Advisory AS18/08: Antimicrobial Stewardship and Surgical Prophylaxis

Advisory details

Purpose

To update accrediting agencies of health service organisations’ requirements for the 2021 Preventing and Controlling Infections Standard in the National Safety and Quality Health Service (NSQHS) Standards relating to antimicrobial stewardship, specifically in relation to surgical antimicrobial prophylaxis. 

Issue

The Preventing and Controlling Infections Standard criterion on Antimicrobial Stewardship requires that all health service organisations have an antimicrobial stewardship (AMS) program in place. The relevant sections of the NSQHS Standards Guide for hospitals, Guide for day procedure services, and Guide for Multi-Purpose Services and small hospitals sets out the key tasks required for organisations to implement an AMS program, and specifies actions that incorporate surgical prophylaxis. 

The Australian Commission on Safety and Quality in Health Care has also developed a clinical care standard that describes the care a patient should receive for optimal treatment with antimicrobials. 

Action 3.18.d of the Preventing and Controlling Infections Standard requires health service organisations to incorporate the core elements, recommendations and principles from the current Antimicrobial Stewardship Clinical Care Standard in their AMS program.

Quality statement 8 of the Antimicrobial Stewardship Clinical Care Standard^[1] requires that, if a patient having surgery or procedure requires prophylactic antimicrobials, the prescription is made in accordance with the current Therapeutic Guidelines^[2] (or evidence-based, locally endorsed guidelines). 

Successive National Antimicrobial Prescribing Surveys from 2013 to 2019^[3] show sustained levels of inappropriate prescribing of antimicrobials for surgical prophylaxis in relation to duration, choice of agent and indication. There has been a reduction in the proportion of surgical prophylaxis prescriptions prescribed for longer than 24 hours from 41.8%) in 2013 to 30% in 2019. The target is 5%. 

Requirements

Health service organisations should ensure surgical prophylaxis is included and addressed as part of their AMS program. 

Organisations can monitor their performance using the indicators for quality statements 6 and 8 of the Antimicrobial Stewardship Clinical Care Standard.^[4] Evidence of this includes monitoring antimicrobial use in relation to surgical prophylaxis and taking action in response to issues identified: 

• Indicator 6a: The proportion of prescriptions for which the indication for prescribing the antimicrobial is documented 
• Indicator 6b: The proportion of prescriptions for which the duration, stop date or review date for the antimicrobial is documented
• Indicator 8a: The proportion of patients for whom the perioperative prophylactic antimicrobial is prescribed in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines 
• Indicator 8b: The proportion of patients for whom the perioperative prophylactic antimicrobial dose is prescribed in accordance with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines 
• Indicator 8c: The proportion of patients who are administered prophylactic antimicrobials within the recommended time perioperatively 
• Indicator 8d: The proportion of patients who were prescribed prolonged antimicrobials following a surgery or procedure that is discordant with the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines.

Organisations using evidence-based locally-endorsed guidelines in addition to or in place of Therapeutic Guidelines, are to ensure:

• They comply with the description provided in the AMS Clinical Care Standard
• Can demonstrate local guidelines are based on Therapeutic Guidelines^[5]
• Have documented any deviation from the Therapeutic Guidelines including a clear rationale based on published clinical evidence and local epidemiology
• The organisation’s governing body endorse the guidelines following review of information from peer review processes conducted by a drug and therapeutics committee, an antimicrobial stewardship committee, a medicines advisory committee, or equivalent.

Assessors are to ensure antimicrobial usage and appropriateness of prescribing monitoring is used to inform the ongoing risk assessment for the AMS program. Participation in the National Antimicrobial Prescribing Survey (NAPS)^[6], Surgical NAPS and the National Antimicrobial Utilisation Surveillance Program (NAUSP)^[7] are options for monitoring antimicrobial usage and appropriateness of prescribing. 

Assessors are to ensure that the organisation has taken action in response to issues identified through the monitoring process. 

Assessors are to review compliance with this Advisory in the context of all actions in the two criteria within the Preventing and Controlling Infections Standard: 

• Clinical governance and quality improvement to prevent and control healthcare‑associated infections, and support antimicrobial stewardship
• Antimicrobial stewardship.

Accrediting agencies are to rate actions in the antimicrobial stewardship criterion of the Preventing and Controlling Infections Standard in the Antimicrobial as met, where the health service organisation has complied with the requirements set out in this Advisory.