Complexities involving management and monitoring of vancomycin lead to medication errors including inaccurate dosing, inappropriate timing of sample collection for therapeutic drug monitoring and inappropriate dose adjustments. Early optimisation of vancomycin management reduces mortality, renal injury and other adverse effects. 

Despite availability of guidelines and training, vancomycin management remained suboptimal in four teaching hospitals in a large Queensland Hospital and Health Service (HHS). The uptake of strategies to optimise the management of vancomycin therapy into routine care was identified as an area for improvement. 

The project was conducted in four phases:

1. A baseline audit to identify the nature of the problem and associated determinants informed by stakeholder interviews 
2. Mapping these findings to the Theoretical Domains Framework (TDF) to identify behavioural correlates and modifiers
3. Co-design of the implementation package 
4. Implementing and evaluating the intervention package.

Baseline audits revealed that only a small proportion of vancomycin doses were appropriately prescribed and monitored. Key findings included:

• 26% of cases had the correct loading dose
• 40% of cases had the correct maintenance dose 
• 38% of samples were taken at the appropriate time according to the guidelines 
• 42% of doses were accurately adjusted based on serum vancomycin concentrations and guidelines. 

Focus groups consisting of nurses, pharmacists and doctors were conducted to review the design of the intervention materials, assess their relevance and explore key themes to optimise the management of vancomycin. 

Findings from the focus groups identified key reasons for inappropriate management of vancomycin. These included: 

• Lack of knowledge regarding dosing, administration and monitoring of vancomycin 
• Limited access to user-friendly guidelines
• Reluctance to use guidelines and reliance on prior knowledge by senior staff 
• Limited pharmacy service outside business hours 
• Inconsistent dose verification against guidelines
• Reluctance to contact prescribers to amend orders.

The following feedback from stakeholders informed the development of an intervention package:

• Nurses were protocol-driven and preferred ward-based education activities  
• Pharmacists valued skill development through multidisciplinary support and educational resources  
• Medical officers favoured case-based training with practical components. 

A multi-faceted intervention package was developed for nurses, pharmacists and medical officers which included e-Learning modules, guidelines, lanyards and fact sheets. On-site champions at each facility, supported by the Steering Committee, facilitated the uptake of the intervention package. 

The overall appropriateness of vancomycin prescribing and monitoring improved to 80% for facilities within the four HHSs. 

In one facility, the audits showed improved adherence to dosing recommendations in line with vancomycin guidelines: 

• 92% of loading doses were compliant 
• 90% of maintenance dosing were compliant 

All patients monitored through therapeutic drug monitoring at this facility received dosing recommendations based on the guidelines or advice from the QLD Statewide Antimicrobial Stewardship Service.

Read about the project here: https://doi.org/10.1016/j.sapharm.2024.01.012

Inappropriate antimicrobial prescribing is more prevalent in regional and rural hospitals when compared to urban and metropolitan hospitals. Barriers to delivery of antimicrobial stewardship (AMS) programs in this setting include lack of infectious diseases expertise, limited pharmacy resources and challenges in recruiting staff to regional and remote areas.^1,2 As a result, Toowoomba hospital, the main referral hospital in Darling Downs Hospital and Health Service (DDHHS), often encountered inappropriate durations of antimicrobials for common infections.

Inappropriate antimicrobial prescribing contributes to the emergence of resistance, which causes millions of deaths every year and is forecasted to increase in the future. A prolonged duration of treatment also increases the likelihood of side effects, drug interactions and higher healthcare costs.³

The pharmacists from DDHHS collaborated with the Queensland Statewide Antimicrobial Stewardship Program (QSAMSP) to address the inappropriate duration of antimicrobials for common infections. A retrospective audit tool developed by QSAMSP was utilised to collect baseline data on the duration of common respiratory, urinary and abdominal infections.

Data collected included:

• Type of infection
• Degree of source control (in the setting of abdominal infections)
• Date of initiation and cessation
• Expected duration of therapy 
• Number of excess days of treatment prescribed
• Compliance with the Therapeutic Guidelines: Antibiotic.

The retrospective audit reviewed four months of data. Only 55% of the patients were prescribed antimicrobials according to the Therapeutic Guidelines: Antibiotic recommendations for duration of therapy, compared to the national average of 68%.⁴ 

After discussing the findings, the team identified reasons for inappropriate duration of antimicrobial prescribing. These included:

• Lack of clinician awareness on the latest recommendations in the Therapeutic Guidelines: Antibiotic ­ 
• Lack of education on appropriate antimicrobial prescribing 
• Absence of AMS services resulting in a lack of feedback to clinicians. 

Several strategies were required to improve prescribing and optimise antimicrobial duration of therapy. In collaboration with the AMS physician, AMS pharmacist and resident pharmacist, the team developed: 

• Lanyard cards which included a colour coordinated scale indicating recommended treatment durations for common infections and guidance for intravenous to oral switch
• Education on the recommended duration of antimicrobial therapy, which was delivered to pharmacists, junior and senior medical officers.

A repeat audit following the implementation of the lanyard cards and delivery of education found an improvement in the duration of antimicrobial therapy for common indications, increasing to 72%. There was a reduction in the mean number of excess treatment days across all infections from 1.86 to 0.95 days, with the most significant decrease observed in respiratory infections from 1.64 to 0.11 days.  

Read about the project here:  https://doi.org/10.1002/jppr.1902

In Australia, inappropriate prescribing of antimicrobials is more prevalent in rural and regional areas compared to major metropolitan hospitals.¹ Audits conducted in a Queensland Rural Hospital and Health Service (HHS) identified the prescribing of antimicrobials for respiratory infections, particularly community-acquired pneumonia (CAP) as a potential area for improvement. Key issues included treatment durations exceeding recommended guidelines and high reliance on broad-spectrum agents. 

The Hospital National Antimicrobial Prescribing Survey (NAPS) data shows that in regional and remote facilities, appropriate prescribing of antibiotics for CAP was 73%¹ and the overall appropriateness rate for Australian hospitals was 75%.² 

The HHS, which included four rural hospitals, did not have on-site infectious diseases physicians, clinical microbiologists or antimicrobial stewardship (AMS) pharmacists. However, the HHS is supported by the Queensland Statewide Antimicrobial Stewardship Program (QSAMSP). 

The hospitals collaborated with QSAMSP and nominated on-site champions to deliver an intervention package to support appropriate prescribing of antimicrobials for CAP. An initial retrospective audit was planned to understand trends and identify areas for improvement. The key evaluation measure was the appropriateness of antimicrobial prescribing for baseline and post-implementation phases of the study. 

A retrospective audit was conducted from July 2019 to July 2020, assessing the appropriateness of antibiotic prescribing for CAP at three time points: initial prescription, on transfer to the ward and on discharge. It was found that the overall cumulative appropriateness of antimicrobial prescribing over the three points of care was 35%. This was significantly lower than both the national average for antimicrobial appropriateness and the reported appropriate prescribing rates in rural and remote areas. The audit results demonstrated substantial variability, requiring urgent action for improvement. 

Following the audit, areas identified for improvement included: 

• Optimising treatment duration of antimicrobials 
• Minimising the inappropriate use of broad-spectrum prescriptions 
• Enhancing consumer engagement.

The project team discussed the challenges in prescribing appropriate antibiotics for CAP. Possible contributors included:

• High clinician turnover in rural and remote settings
• Lack of on-site AMS service 
• Clinicians had varying levels of knowledge about the treatment of CAP. 

An intervention package for the management of CAP was developed following review of literature and collaboration with other facilities which had previously developed strategies to improve prescribing of antibiotics in CAP. Interventions included a CAP pathway, duration of therapy guidelines, patient information leaflet, pneumonia flipchart, general CAP fact sheet and clinical education. There was an on-site training during the implementation phase and continued support from AMS champions at each site. AMS champions included clinical pharmacists and senior physicians involved in resource development and implementation. 

The appropriateness of CAP therapy was assessed monthly, with feedback provided to local clinicians. A post-implementation audit revealed the overall appropriateness of antibiotic prescribing improved to 75%, with a decrease in average duration of antibiotic therapy from 8.7 days to 5.5 days. This was in line with the Australian Therapeutic Guidelines.³ Ongoing monitoring to ensure sustained improvements is being conducted using the NAPS audit tool. 

Read about the full project here: http://doi.org/10.1111/ajr.13116

Antibiotic allergy de-labelling has become a focus of international antimicrobial stewardship programs. In Australia, over two million people report an antibiotic allergy, with one in ten in hospitals reporting an allergy to penicillin. As many as 85% of these allergies can be safely tested and de-labelled.³ As outlined in the Antimicrobial Stewardship Clinical Care Standard, antibiotic allergies should be accurately assessed and documented to allow for optimal antimicrobial prescribing. It is known that patients labelled with a penicillin allergy have increased prevalence of Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), and have longer hospital stays.¹ Inaccurate penicillin allergy labels have been associated with increased use of broad-spectrum antibiotic use and inappropriate prescribing.² Due to the success of the Better Care Victoria project that implemented an inpatient antibiotic allergy assessment and de-labelling service at Austin Health and Peter MacCallum Cancer Centre, Safer Care Victoria chose to expand the project to other health services in the state. 

A change package was developed to support other Victorian health services with the roll out of an inpatient penicillin allergy assessment and de-labelling program. 

The core activities undertaken during the planning phase of this project included:  

1. Encouraging health services to collect four weeks of baseline data prior to the project commencement
2. Implementing process mapping to identify key stakeholders for engagement and to determine stages in the patient’s journey where penicillin allergies could be identified, assessed and de-labelled
3. Establishing governance structures and stakeholder engagement mechanisms to enable project success
4. Development of local guidelines, including inclusion criteria for penicillin allergy testing
5. Education for clinicians. 

At the time, limited support and services were available to de-label low risk penicillin allergies in other health services in Victoria. 

Key measures for the project included percentage of patients with:

• No risk of a true penicillin allergy that have their allergy directly de-labelled
• Low risk of a true penicillin allergy that have their allergy de-labelled following an oral challenge
• A documented penicillin allergy in the medical record with the active ingredient, the date of the reaction, its nature and severity specified.

Safer Care Victoria found the following barriers in implementing allergy de-labelling services in Victorian hospitals: 

• Varying levels of clinician knowledge about penicillin allergy labels 
• Lack of expertise and confidence in implementing a penicillin allergy de-labelling service 
• Low priority to assess antibiotic allergies
• Overreporting of penicillin allergies by patients due to experiencing a side effect to a penicillin, childhood reactions, family history, miscommunication and overcaution. 

Safer Care Victoria collaborated with health services to use the Model for Improvement to implement penicillin allergy de-labelling at 12 health facilities including rural, regional and metropolitan hospitals. Safer Care Victoria ran three in-person learning sessions and three health service-based action periods, where changes were tested and adapted. The participating sites maintained contact with each other and Safer Care Victoria, and regularly shared wins, challenges and learnings.

Of the 12 sites, 11 have implemented a guideline to conduct inpatient penicillin de-labelling.

The program has: 

• Achieved a 25% increase in access to comprehensive allergy assessment for hospitalised patients 
• Developed a toolkit to share learnings. 

System benefits:
Safer Care Victoria is partnering with the international Network of Antibiotic Allergy Nations (iNAAN) to form the Check Again Network. The Check Again Network will scale and spread the work of the Collaborative to additional Victorian sites and create the opportunity for services to share wins, challenges, and learnings. 

The Therapeutic Guidelines recommend that following adequate source control, antimicrobial therapy can continue for a further duration of 4 to 7 days for intra-abdominal infections, depending on clinical response.¹ Despite these recommendations, the antimicrobial stewardship (AMS) team at Concord Hospital identified that their surgical patients were often prescribed prolonged courses of broad-spectrum antimicrobials. The AMS Clinical Care Standard states that antimicrobial therapy should be regularly reviewed for ongoing need, appropriate antimicrobial spectrum of activity, dose, frequency and route of administration. Benchmarking found antibiotic plans for these surgical patients often missed the key indicators. 

Concord Hospital participates in the National Antimicrobial Prescribing Survey (NAPS) annually. The results from the latest NAPS were used to establish the extent of the issue and inform strategies to address the high volume of inappropriate antimicrobial use in surgical patients.

Evaluation of the prescribing data found only 60% of antimicrobial prescriptions for colorectal patients were appropriate and just 71.4% of these prescriptions were appropriate for vascular patients. Overall appropriateness was below the overall national principal referral hospital average of 72.9%.

The AMS team explored the underlying drivers for the high rate of inappropriate antimicrobial prescribing in surgical specialties. Through discussions, it was found that: 

• Due to the structure of surgical teams, junior ward-based doctors were the point of first contact and lacked authorisation to make substantial changes to antimicrobial choices
• Limited understanding of surgical procedural resulted in antibiotic de-escalation choices being delayed, undocumented antibiotic durations or review dates, and inter-team conflict
• There was a perception among surgical teams that AMS teams under-appreciate surgical complexities, and antimicrobial prescribing recommendations are based on inadequate parameters and understanding of surgical procedures.

The AMS team initiated weekly collaborative meetings attended by a range of staff, including senior surgical staff from the Vascular, Colorectal and Upper Gastrointestinal (GI) Surgery teams. Discussion focused on the surgical context including recent procedures, relevant microbiology, and devising an antibiotic plan.

The meetings were facilitated by electronic prescribing and an innovative locally developed tool called the Cerner LiveAMS Monitoring Page (AMS mPage). The tool provides a live, direct feed from eMeds into a summary dashboard, enabling identification of all patients on antibiotic therapy. It integrates key information, including microbiology results, medication orders (such as indication, duration, prior antibiotic use and known drug allergies). The tool allowed the AMS and surgical teams to make real-time changes to prescriptions directly from the meeting room. 

The project has achieved:

• Improved rates of appropriate antimicrobial prescribing from 68% appropriateness to 85% to 100% appropriate in the last five years (2019 – 2023) for the surgical specialties 
• Improved patient outcomes
• Increased scope of AMS service.

Other outcomes included: 

• Increased rapport between the surgical department and the AMS team – the meetings are championed by the heads of surgical departments
• Greater collaboration with other surgical departments – the initiative has been extended to include Plastic Surgery and the Breast and Endocrine Surgery units.