7th July 2017, Volume 130 Number 1458

Sharon J Gardiner, Jane A Pryer, Eamon J Duffy

Antimicrobial resistance is a recognised threat to modern medicine,1 and is a growing concern in New Zealand.2 Antimicrobial stewardship (AMS), a collection of co-ordinated strategies that aims to optimise the use of antimicrobials (ie, right drug, right indication, right dose, right duration and right route), can slow further development of this threat. Hospital-based AMS interventions have the potential to reduce development of Clostridium difficile-associated diarrhoea, and colonisation or infection with resistant organisms (eg, vancomycin-resistant Enterococcus faecalis) as well as decrease mortality, length of stay and cost.4 Internationally, it is widely recommended that hospitals initiate AMS programmes, and advice is available to guide implementation.5–7

An international response to antimicrobial resistance is being co-ordinated by the World Health Organization through the Global Action Plan.1 As a member state, New Zealand has committed to delivering a national plan, including implementation of AMS as a key objective, by May 2017.8 In 2013, the Health Quality and Safety Commission (HQSC) published a scoping paper on AMS, which provided qualitative feedback from key stakeholders around the country.9 Subsequently, AMS programmes have been implemented in some of New Zealand’s public hospitals with reported data primarily confined to the volume of antimicrobials used.10 AMS requirements for hospital accreditation exist through the New Zealand Standard 8134.3:2008 for Infection Prevention and Control.11 However, the standard is a generic document to address basic principles and systems, and there has been no formal assessment across public hospitals of how AMS practices are being delivered. In order to formulate and deliver an effective plan, with appropriate resource planning for secondary care, it is necessary to understand the current status of AMS in New Zealand. This survey aimed to determine the structures, resources and practices in place for AMS in public hospitals currently. It was conducted on behalf of the Healthcare Associated Infections Governance Group (Ministry of Health, New Zealand).12

Methods

International recommendations for core components of hospital AMS programmes5,7 were used as the basis for survey development. The preliminary survey questions were organised under the headings of governance and personnel, audit and surveillance, and key AMS interventions. The survey design was largely quantitative, with multiple choice options available. Free text areas were included for additional comments as required. The intent was to capture the breadth of AMS activities in our public hospitals as succinctly as possible, while allowing opportunity for comment around key issues such as perceived challenges in implementing an AMS programme. The Healthcare Associated Infections Governance Group12 provided input into the survey content, and it was piloted in three DHBs before finalising.

In June 2016, the Chief Executive Officers for each of New Zealand’s 20 DHBs were invited to participate in this survey. They were asked to provide a single response for their respective DHBs by liaising with relevant parties such as infectious diseases (ID) physicians, pharmacists, clinical microbiologists and infection prevention and control (IPC) staff. PDF versions of the survey were provided to facilitate discussion between staff and at committees. However, it was requested that the final survey for each DHB be submitted electronically (SurveyMonkey Inc, Palo Alto, California, USA: www.surveymonkey.com). Non-responding DHBs were followed up over the subsequent three months to ensure a response was received for each DHB.

Results are presented descriptively and largely anonymously. However, details of key AMS resources (personnel) in each DHB are described by name, as are efforts around regional collaboration.

Results

Responses were obtained from all 20 DHBs, with most (85%) primary respondents being pharmacists (11/20) or ID physicians (6/20).

Governance and personnel

Committees

All DHBs reported having an IPC committee (20/20), most had a drugs and therapeutics committee (18/20), and half had a dedicated AMS committee (10/20) (Table 1). Eleven DHBs indicated that they had up to three additional committees relevant to AMS, most involving safety and/or quality (10 of the 16 additional committees across the 11 DHBs). Responsibility for hospital antimicrobial activities resided with the AMS committee (10/20), the IPC committee (5/20), the drugs and therapeutics committee (3/20) or the ‘infection team’ (1/20). One DHB (1/20) had no committee responsible for antimicrobial activities.

Table 1: Governance and personnel.

Committees

Hospital-based committees concerned with AMS at each DHB*

Infection prevention and control

20 (100%)

Drugs and therapeutics**

18 (90%)

Antimicrobial stewardship

10 (50%)

Additional committee or team relevant to AMS

11 (55%)

  • Safety and/or quality (10 committees in eight DHBs)
  • Infection team (1)
  • Infection prevention & control subcommittee for antibiotic advice (1)
  • Medicines Governance committees (adults) (1)
  • Medicines Governance committees (paediatrics) (1)
  • Preferred Medicines List (1)
  • Medicines Utilisation Committee (1)

Committee primarily responsible for co-ordinating activities related to optimising antimicrobial use

Antimicrobial stewardship

10 (50%)

Infection prevention and control

5 (25%)

Drugs and therapeutics

3 (15%)

Other committee relevant to AMS:

2 (10%)

  • Infection team (1)
  • No committee (1)

Frequency of committee meetings

Fortnightly

2 (10%)

Monthly

11 (55%)

Every two months

5 (25%)

Every three months

1 (5%)

Not applicable (no committee responsible for antimicrobial activities)

1 (5%)

Strategic plan

Formal written strategic plan for AMS at the DHB

No

15 (75%)

Yes

5 (25%)

  • Reviewed annually (1), every two years (2), not known/unclear (2)
  • Signed off at corporate level (3)
  • Refers to New Zealand Health & Disability Infection Control standards NZS 8134.3.6:2008 Standard 6 for antimicrobial usage (3)

Budget

Presence of a dedicated budget for AMS activities (excluding salaries)

No

20 (100%)

Yes

0 (0%)

Policies

Antimicrobial prescribing and management policy/guideline in place

No

2 (10%)

Yes

18 (90%)

Regional AMS

Involvement in regional AMS activities, eg, shared guidelines

No

9 (45%)

Yes

11 (55%)

*One or more responses were able to be selected by respondent.
**One committee covered both drugs & therapeutics and quality & safety, and is included as a separate count for the respective committee types. 

Membership of the 19 committees charged with responsibility for antimicrobial activities was diverse (Figure 1). Pharmacy (18/19), nursing (17/19), clinical microbiology (15/19), IPC (15/19) and ID (12/19) were most frequently represented. Most committees (16/19) had representation from pharmacy plus ID physician and/or clinical microbiologist, and around half (9/19) had all three disciplines present. Medical specialities other than ID and clinical microbiology were included in more than half of the committees (11/19), with general medicine being most frequently included (9/19) and other specialities including surgery having comparatively low representation (4/19) (Figure 1). Most of the committees (18/19) met at least two monthly (Table 1). Reporting pathways were not clear, but dedicated AMS committees (7/10) typically reported to the drugs and therapeutics committee and/or IPC committees as the initial ‘upwards’ step. The most frequent activities undertaken by the committees were empiric guideline development, audit and monitoring, and evaluation of antimicrobial use (occurring in 68–79% of committees) (Figure 2).

Figure 1: Disciplines on committees responsible for antimicrobial usage.

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Figure 2: Types of activity undertaken by committee responsible for antimicrobial usage.

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Lead clinicians and pharmacists

Eleven DHBs (55%) had a lead AMS pharmacist, with nine having dedicated salaried full-time equivalents (FTEs) for the role (Table 2). Six of the latter positions were full time (0.9–1.0 FTE), and three were part time (≤0.6 FTE). The six full-time positions resided in the six largest DHBs (based on bed number), ie, Canterbury, Auckland, Waitemata, Counties-Manukau, Waikato and Capital & Coast, and five of these DHBs also had tertiary hospitals. The seventh largest DHB and the remaining DHB to have a tertiary hospital (Southern) did not have an AMS pharmacist.

Table 2: Key AMS resources in each DHB (from largest to smallest based on total bed number).

DHB

Ministry of health data

DHB response

No. beds

Certified Public Hospital Providers*

(No. beds)

Acute beds

Lead clinician**

Lead pharmacist

AMS Committee

Y/N

FTE

Y/N

FTE

Y/N

Canterbury

1,463

Christchurch (811), Ashburton (48), Burwood (276)***, Hillmorton (144), Princess Margaret (52)***, Tuarangi (39), Kaikoura (21), Rangiora (16), Oxford (15), Waikari (11), Darfield (10), Ellesmere (10), Lincoln (7), Chatham Islands (3)

800

Y (ID)

0.1–0.2

Y

0.9–1.0

Y

Auckland

1,329

Auckland City (1,124), Auckland DHB X 3 Units – Mental Health (96), Buchanan Rehabilitation (40), Greenlane (31), Rehab Plus (28), Pitman (10)

800

Y (ID)

-

Y

0.9–1.0

Y

Waitemata

1,154

North Shore (670), Waitakere (283), Mason Clinic (106), Elective Surgery (30), He Puna Waiora (39), Wilson Centre (26)

830

Y (ID)

-

Y

0.9–1.0

Y

Counties Manukau

937

Middlemore (745), Manukau Surgery (78), Pukekohe (34), Auckland Spinal Rehabilitation (20), Tamaki Oranga (20), Botany Downs (12), Franklin Memorial (18), Papakura Obstetric (10)

900

Y (ID)

-

Y

0.9–1.0

Y

Waikato

904

Waikato (620), Henry Rongomau Bennett (97), Thames (52), Matariki (32), Rhoda Read (32), Tokora (21), Te Kuiti (16), Taumaranui (14), Ward OPR1 (15), Puna Whiti (5)

600

Y (Mic)

 

-

Y

0.9–1.0

N

Capital & Coast

764

Wellington (484), Kenepuru (131), Porirua (118), Wellington (Mental Health) (29), Kapiti Health (2)

470

Y (ID/Mic)

0.1–0.2

Y

0.9–1.0

Y

Southern

710

Dunedin (400), Wakari (120), Southland (176), Lakes District (14)

465

Y (ID)

-

N

-

Y

Bay of Plenty

444

Tauranga (369), Whakatane (69), Opotiki (6)

350

N

-

N

-

N

Hawkes Bay

384

Hawke’s Bay (364), Wairoa (12), Central Hawkes Bay (8)

400

Y (ID)

0.3–0.4

Y

0.3–0.4

N

Mid Central

358

Palmerston North (330), Horowhenua (28)

250

Y (ID)

-

Y

0.5–0.6

Y

Nelson-Marlborough

350

Nelson (191), Wairau (100), Mental Health Admissions (26), Tipahi St (13), Alexandra (12), Murchison (8)

165

Y (ID)

0.3–0.4

N

-

N

Hutt Valley

322

Hutt Valley (322)

210

Y (ID)

0.1–0.2

Y

0.5–0.6

Y

Northland

320

Whangarei (249), Kaitaia (32), Bay of Islands (20), Dargaville (19)

300

Y (Mic)

0.1–0.2

N

-

N

Lakes             

228

Rotoroa (201), Taupo (27)

120

N

-

N

-

N

Taranaki

208

Taranaki Base (194), Hawera (14)

220

N

-

N

-

N

West Coast

161

Grey Base (114), Buller (32), Reefton Health (15)

78

Y (GM)

-

Y

-

N

Whanganui

172

Whanganui (172)

130

N

-

N

-

N

South Canterbury

133

Timaru (133)

131

Y (Mic)

0.1–0.2

N

-

Y

Tairawhiti

115

Gisborne (115)

100

N

-

N

-

N

Wairarapa

85

Wairarapa (85)

75

Y (ID)

0.1–0.2

Y

-

Y

*www.health.govt.nz/your-health/certified-providers/public-hospital       
**ID = infectious diseases physician, Mic = clinical microbiologist, GM = general medicine physician, N/G = not given.                         
***from inpatient occupancy data
Shaded area indicates DHBs with tertiary-level care hospitals. 

Fifteen of 20 (75%) DHBs had a clinician lead for AMS activities (Table 2). These clinicians were reported as specialists trained in ID (10/15), clinical microbiology (3/15), dual trained in ID and microbiology (1/15) or general medicine (with experience in ID) (1/15). Eight DHBs had dedicated full-time equivalents (FTEs) for the clinician lead, these were all less than 0.4 FTE, with most (6/8) having no more than 0.2 FTE.

Figure 3 shows dedicated AMS pharmacist and lead clinician time in each of the 20 DHBs, expressed per 100 acute bed days (self-defined). Horizontal lines depict Australian recommendations for AMS pharmacist and lead clinician time.5 Accepting the challenges with defining acute beds, four DHBs met or exceeded recommendations for clinician time (Hawkes Bay, Hutt Valley, South Canterbury and Wairarapa), and one DHB approximated recommended pharmacist time (Hutt Valley). One DHB met recommendations for both pharmacist and clinician time (Hutt Valley).

Figure 3: Number of lead clinician and AMS pharmacist FTEs per 100 acute bed days. 

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Strategic plan, budget and antimicrobial prescribing policy

Five DHBs (25%) had formal written strategic plans for AMS (Table 1).11 Most DHBs (18/20) had antimicrobial prescribing and management policies (Table 1), with the most frequently included topic being guidelines for antimicrobial prescribing (18/18) (Figure 4). Excluding salaries, no DHB had a budget specifically for AMS activities such as campaigns or information technology (Table 1).

Figure 4: Antimicrobial policy content.

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Regional AMS activities

Eleven DHBs participated in regional activities, primarily shared antimicrobial guidelines. Three lower North Island DHBs (Capital & Coast, Hutt Valley and Wairarapa) had a working ‘3DHB’ guideline, while the three Auckland metropolitan DHBs (Auckland, Counties-Manukau and Waitemata) had regional community guidelines and aimed for consolidation of hospital guidelines where possible. The five South Island DHBs (Canterbury, Nelson-Marlborough, South-Canterbury, Southern, West Coast) had formed a South Island Hospital Antimicrobial Guidelines Group to produce joint antimicrobial guidelines.

Barriers to implementing an AMS programme

Most DHBs (19/20) reported barriers to implementing AMS programmes, with inadequate resourcing (staffing, IT support, software, budget and time) as the key issue. Eleven DHBs explicitly stated staffing was a barrier, eg:

  • “No onsite infectious diseases consultant. No onsite microbiologist. No formal pathway for referral to these specialists. No formal medical lead for [AMS]. No dedicated pharmacist lead for [AMS]”,
  • “No dedicated infectious disease FTE or pharmacy FTE towards antimicrobial stewardship”.

Lack of senior clinician buy-in and/or challenges in reaching agreement was the second most common theme, eg:

  • “Drs are often confrontational when pharmacy ask for ID approval of restricted [antibiotics]”,
  • “…many staff do not see AMS as a priority”. 

Audit and surveillance

Twelve DHBs (60%) indicated they described antimicrobial usage by at least one metric, most commonly defined daily doses (11/12) and costs (8/12). Eight DHBs had regular reporting schedules of three, six or 12 monthly (Table 3). Most DHBs (16/20) produced an antibiogram (Table 3), but not all made these available to prescribers (13/16). All DHBs had defined surveillance programmes for multi drug-resistant organisms, surgical site infections and central-line associated blood stream infections, and most (75%) tracked cases of Clostridium difficile infections (15/20).

Table 3: Audit and surveillance.

Metrics

Metrics used to describe antimicrobial use (consumption)*

Number of grams of antimicrobials used (Defined Daily Dose, ie, ‘DDD’)

11 (55%)

Direct expenditure on antimicrobials (purchasing costs)

9 (45%)

Counts of antimicrobials administered to patients per day (Days of Therapy, ie, ‘DOT’)

1 (5%)

Not done

8 (40%)

Frequency of reporting on antimicrobial use (eg, as costs or DDDs) to hospitals or clinical areas

Monthly

0 (0%)

3 monthly

2 (10%)

6 monthly

2 (10%)

12 monthly

4 (20%)

Never

8 (40%)

Other

4 (20%)

  • Only when requested (2 of 4)
  • Work in progress (2 of 4)

Antibiogram (cumulative antimicrobial susceptibility report)

Available at the DHB

No

4 (20%)

Yes

16 (80%)

How is the antibiogram disseminated*

DHB intranet

9 (45%)

Hardcopy, eg, booklet or bulletin

3 (15%)

E-mail

7 (35%)

Poster

0 (0%)

Not applicable

4 (20%)

Multidrug resistance organisms and healthcare associated infections

Defined and documented surveillance programmes at the DHBs*

Monitoring of MDRO occurrence, eg, methicillin resistant S. aureus

20 (100%)

Surgical site infection

20 (100%)

Central-line associated bloodstream infection

20 (100%)

Clostridium difficile infection

15 (75%)

Catheter associated urinary tract infection

3 (15%)

None

0 (0%)

Other

3 (15%)

  • Hospital-acquired S. aureus blood stream infection (2 DHBs)
  • Hospital-acquired blood stream infections (1 DHB)
*One or more responses were able to be selected by respondent. 

Key AMS interventions

Antimicrobial guidelines

Nineteen DHBs had their own antimicrobial guidelines, with nine having all of the treatment guidelines listed, and most (19/20) having guidelines for meningitis, sepsis, skin and soft tissue infections, and community-acquired pneumonia (Table 4). Guidelines were reviewed every one (6/19), two (7/19) or three years (6/19), and were predominantly published on the intranet (19/19).

Table 4: Antimicrobial guidelines.

Guidelines

Presence of DHB specific antimicrobial guidelines

Yes

19 (95%)

No

1 (5%)

Frequency of DHB guideline review

Every year

6 (30%)

Every two years

7 (35%)

Every three years

4 (20%)

Other

2 (10%)

  • last review 3–4 years prior, involved in regional guidelines (1)
  • ‘as required’ (1)

Not applicable

1 (5%)

Resources used to develop DHB guidelines*

Local microbiology and antimicrobial susceptibility patterns

16 (80%)

Therapeutic Guidelines of Australia ‘Antibiotic’

14 (70%)

Expert opinion

15 (75%)

Key consensus guidelines, eg, Infectious Diseases Society of America

13 (65%)

The Sanford Guide to Antimicrobial Therapy

12 (60%)

UpToDate

11 (55%)

New relevant research published on the topic

11 (55%)

BPAC (NZ) Antibiotics–choices for common conditions

9 (45%)

Other, eg, another DHB’s guideline

11 (55%)

Not applicable (no guidelines)

1 (5%)

Presentation of guidelines to clinical staff*

DHB intranet

19 (95%)

Lanyard cards (eg, summary of key guidelines)

7 (35%)

Hardcopy

5 (25%)

Mobile devices – PDF (1), mobile friendly internet site (1), ‘App’ (3)

4 (20%)

Internet

2 (10%)

Posters (eg, summary of key guidelines)

2 (10%)

Other – e-book (1), verbal education sessions, eg, grand rounds (2)

3 (30%)

Not applicable

1 (5%)

Antimicrobial guidelines encouraged for use at DHB*

Your own DHB’s guidelines

19 (95%)

BPAC (NZ) antibiotics – choices for common conditions

3 (15%)

Another DHB’s guidelines – ADHB (1), CCDHB (1), CDHB (3), Waikato (2)

5 (25%)

Starship hospital guidelines

3 (15%)

Sanford guide to antimicrobial therapy

2 (10%)

UpToDate

2 (10%)

Therapeutic Guidelines of Australia ‘Antibiotic’

0 (0%)

*One or more responses were able to be selected by respondent. 

Audits

Nineteen DHBs (one DHB did not respond to this question) performed at least one antimicrobial audit in the preceding 12 months, with a median of three audits (range: one to five) undertaken. Six DHBs reported conducting point prevalence studies. The most frequently investigated indication- and antimicrobial-focused audits involved community-acquired pneumonia (six DHBs) and gentamicin (four DHBs), respectively. Nine audits were undertaken in eight DHBs on surgical prophylaxis, but it is unclear whether these were separate to the monitoring required as part of the Health Quality and Safety Commission (HQSC) Surgical Site Infection Improvement programme.

Restricted antibiotics

PHARMAC requires that some antimicrobials (eg, ciprofloxacin, vancomycin) have ID or clinical microbiology approval for use, via specific-patient consultation or through compliance with a DHB guideline. In the absence of a guideline, 11 DHBs allowed the restricted antimicrobial to be started without approval with endorsement required for continuation, three DHBs required approval pre-initiation and three had a hybrid of these two courses of action (ie, prior approval within working hours but post-approval after hours). Three DHBs appeared to have different approaches, ie, “AMS review on a regular basis”, “theoretically requires clinical microbiologist consultation” or “not enforced, ad hoc by individual pharmacists”. In terms of access to restricted antimicrobials, most DHBs (17 of 19 that responded to this question) dispensed restricted antimicrobials for specific patients, with some having ward stocks in high use areas such as intensive care. In these DHBs, after-hours access to restricted antimicrobials is via emergency drug cupboards (or similar) or the on-call pharmacists. Two DHBs implied restricted antimicrobials were more readily available as ward stock.

Other AMS interventions

Three DHBs reported having AMS ward rounds (Table 5), although only two of these appeared to be distinct from an ID consult and bacteraemia service. Both of these sites involved an AMS pharmacist and at least one ID doctor or clinical microbiologist, with rounds undertaken one to four times weekly. Referrals were received from doctors or pharmacists, with other triggers for review, including use of specific antimicrobials (eg, carbapenems).

Table 5: AMS interventions (n=20 DHBs, unless otherwise specified).

Presence of AMS ward rounds (exclude ID consults, bacteraemia services)

No

17 (85%)

Yes

3 (15%)

Policy requiring documentation of the indication for antimicrobial use on the drug chart

No

16 (80%)

Yes

4 (20%)

Procedure for review of appropriateness of antimicrobials at specified time frames post-prescription

No

12 (70%)

Yes

8 (40%)

Direct personalised communication about how to improve antimicrobial prescribing

No

13 (65%)

Yes

7 (35%)

Methods of providing education on AMS activities to clinical staff in previous 12 months (n=18)*

Grand rounds

12 (67%)

Regular teaching slots, eg, for undergraduate students

11 (61%)

Bulletins – electronic

8 (44%)

Bulletins – hardcopy

4 (22%)

Local AMS intranet/internet site

4 (22%)

Other – irregular teaching (1), intranet (1), medical staff orientation (1)

3 (17%)

Not done

1 (6%)

Disciplines provided with AMS education (18 responses)*

Registered medical officers

16 (89%)

Pharmacists

15 (83%)

Nurses

13 (72%)

Senior medical officers

12 (67%)

Nurse prescribers

5 (28%)

Midwives

3 (17%)

Pharmacist prescribers

2 (11%)

Dentists

1 (6%)

Other – medical students (1), GPs (1), medical & nursing students (1)

3 (17%)

Not applicable

1 (6%)

*One or more responses were able to be selected by respondent. 

Other AMS interventions (Table 5) included a policy for the indication to be documented on the drug chart (4/20), or the requirement to review appropriateness of antimicrobials at a specific time post-prescription (8/20). No feedback was sought within the survey on the likely compliance with these guidelines but no DHB included audit of these policies among the audits undertaken in the preceding 12 months (Table 5). Education on AMS activities was reported to be given to clinical staff (mainly doctors and pharmacists) in the preceding 12 months at 17 DHBs, with grand grounds (12/17), regular teaching slots (11/17) and electronic bulletins (8/17) the most common format for information (Table 5). Seven DHBs (35%) had provided direct personalised communication about how to improve antimicrobial prescribing.

Figure 5: Guidelines for empiric treatment and for prophylaxis in place in the 20 DHBs.

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Nine DHBs provided additional comments with two-thirds signalling enthusiasm to undertake AMS activities, but a struggle to obtain sufficient resources, eg:

  • “We would love to do more formal AMS work but major restriction is time. We would welcome a requirement for AMS activities and better still FTE for DHBs as has been developed in Australia. It would be beneficial if such requirements are implemented at clinician level as well as organisation level to encourage buy in from senior clinicians in denial of the role of AMS and specialist knowledge and skills of the infection service” and
  • “The pharmacy department are keen to play a role in AMS, however, find that we do not have the manpower to provide an efficient service. Being a small DHB we do not have a specialist ID consultant on site and therefore find it challenging to question the use of unnecessary antibiotics.”

Discussion

No other class of drugs has revolutionised medicine as much as the antimicrobials. However, their ability to prevent and cure infection is diminishing, with the burgeoning emergence and spread of resistant organisms. New Zealand has been relatively insulated from this issue, but the last two decades have seen a clear increase in the prevalence of resistant organisms, which can cause infections that are harder to treat, resulting in prolonged hospital stays, increased mortality and greater healthcare costs. One of the key drivers for resistance is antimicrobial use, both appropriate and inappropriate. International research13 and local studies10,14 indicate that New Zealand has high antimicrobial use compared with other developed countries, and that this primarily resides within the community sector and is increasing. This increase in use of antimicrobials in New Zealand contrasts with the decrease seen in the UK,15 which has a national strategy and programme in place for antimicrobial resistance and AMS. New Zealand must follow suit.

This survey of AMS practices in New Zealand public hospitals provides an opportunity to compare current activities against international best practice. Overseas authorities advise that AMS programmes are implemented in all acute care hospitals,5,16 with recommendations for core components of successful programmes outlined in key documents.7 In order to be accredited in Australia,17 hospitals should have “safe and appropriate antimicrobial prescribing [as] a strategic goal of the clinical governance system” with

  1. presence of an AMS programme,
  2. availability of antibiotic guidelines,
  3. monitoring of antimicrobial usage and resistance,
  4. ongoing efforts to improve AMS.

More specific clinical care standards, such as appropriate microbiological sampling, timely review of antimicrobial prescriptions and patient education support this.18

If current practice in New Zealand is compared against Australian hospital accreditation requirements, then a starting place is whether or not we have AMS programmes in place. At the core of a successful AMS programme is the personnel, which should, in the New Zealand context, include both an AMS pharmacist and a lead clinician (ideally an ID physician or clinical microbiologist) at a minimum. Funding for AMS pharmacists in nine of our DHBs and for lead clinicians in eight DHBs (four DHBs had both) is positive and signals some leadership support. However, only one of our DHBs met Australian recommendations for number of pharmacist and clinician FTE per 100 acute beds,5 suggesting that even DHBs with dedicated staff are underpowered to achieve the mission of effective AMS. Perhaps the greater issue is that a number of DHBs lack any suitable access to either an ID physician or a clinical microbiologist, and struggle to have any AMS activity at all.

It is reassuring that half of our DHBs have dedicated AMS committees. Tasking other committees (eg, drugs and therapeutics) with antimicrobial activities is probably reasonable in smaller DHBs provided that appropriate staff are present and sufficient time and thought is dedicated to the subject. Support from national or regional centres would encourage this development. Pleasingly, almost all DHBs (18/20) had a policy for antimicrobial prescribing in place (although compliance with these policies is not known), but only five had a formal strategic plan for AMS. The lack of strategic plans is perhaps understandable given there is no national strategy or direction to tie into and poor access to data to identify areas to improve.

All but one DHB (ie, 95%) stated that they have their own antimicrobial guidelines. Current New Zealand standards11 indicate that antibiotic guidelines should be consistent with local resistance data, discourage use of certain antibiotics and have clear recommendations for dose, timing and duration of surgical prophylaxis. Sixteen of the DHBs (80%) used local microbiology and susceptibility patterns to inform guideline development, and surgical prophylaxis guidelines were reported present in 17 DHBs. Australian standards19 indicate that clinicians should have access to national guidelines. Unlike Australia, which has five times the population and nearly 30 times the land mass, New Zealand does not have national guidelines due to issues such as lack of funding, resourcing and central commitment to support this work. A move towards regional guidelines is, however, a positive step that will facilitate prescribing consistency. It will also allow more accurate comparisons of prescribing practice between DHBs and help identify opportunities for learning from AMS interventions that improve prescribing.

Monitoring of antimicrobial usage and resistance is the third of four action points in the Australian national standards. All of our 20 DHBs reported monitoring for antimicrobial resistant organisms, but this is not surprising given that they are driven by national standards “surveillance shall be conducted on multi-resistant organisms”11 and supported centrally by the Institute of Environmental Science and Research (ESR) and the Health Quality and Safety Commission (HQSC). Antimicrobial usage was understandably less well-monitored, with no standard or central support, with only 12 DHBs (60%) describing monitoring antimicrobial usage in some form. Clear national guidance on the format of data collection and co-ordination of activities is required to facilitate this process. There is inter-DHB willingness to standardise process with collaborative work on antimicrobial usage already published.10 However, this work only investigates one aspect of antimicrobial use (inpatients) and consideration of other aspects of hospital antimicrobial use (eg, outpatient home IV therapy, discharge scripts) must also be considered with input from PHARMAC and the Pharmaceutical Collection database.

The fourth point in the Australian national standards relates to ongoing efforts to improve AMS. New Zealand’s early development with AMS programmes shows via this survey that all DHBs have areas to improve on.

This paper is the first to describe quantitatively the extent of AMS activities in New Zealand public hospitals. It signals some positive steps, with dedicated AMS committees in half of our DHBs and employment of AMS pharmacists in nine DHBs. However, it is clear that our national standards for antimicrobial use in healthcare require updating to reflect international best practice and to ensure AMS, which is still very much in its infancy in New Zealand hospitals, becomes a priority for our DHBs. There does need to be some flexibility in how AMS programmes look across New Zealand, to reflect variation in size of hospitals and DHBs, however, core elements can be established and agreed. Further, it is important to recognise that the bulk of human antimicrobial use in New Zealand does not reside with hospital inpatient prescribing. Emphasis must focus upon community antimicrobial use. The introduction of AMS programmes into New Zealand hospitals in recent years is positive, but is merely a start of the efforts required in New Zealand. To meet international standards for AMS and promote appropriate use of DHB resources and engagement with primary care, national leadership with government commitment to funding and resourcing is required.

Summary

Antimicrobial resistance is a growing problem in New Zealand and means that antimicrobials are becoming less effective. Antimicrobial stewardship (co-ordinated strategies to help optimise the use of antimicrobials) can slow the progression of resistance. This survey shows that antimicrobial stewardship is in its infancy in New Zealand’s public hospitals, with only around half of our DHBs employing dedicated pharmacists and doctors to help optimise antimicrobial prescribing. Practices to improve antimicrobial prescribing (eg, audit, teaching, guideline development) are highly variable from DHB to DHB. National co-ordination is needed to help DHBs develop effective programmes to help preserve antimicrobials for future use.

Abstract

Aim

To determine what antimicrobial stewardship (AMS) practices exist in New Zealand public hospitals.

Method

A quantitative survey based on recommended components of hospital AMS programmes was sent to the 20 DHBs in June 2016.

Results

Ten of the 20 DHBs had an AMS committee, nine had dedicated AMS pharmacist full-time equivalents (FTEs) and eight had lead clinician FTEs. Only one DHB met FTE recommendations for AMS pharmacists and two for clinicians (0.3 and 0.1 FTEs per 100 acute beds, respectively). All DHBs had conducted at least one antimicrobial audit in the preceding 12 months, most had their own antimicrobial guidelines (19/20) and prescribing policies (18/20), and 12 reported on antimicrobial usage by at least one metric (eg, defined daily doses). Staff education on AMS had been given at most DHBs in the previous year, but only three reported having AMS ward rounds. All DHBs had surveillance programmes for resistant organisms and most produced antibiograms (16/20). All reported barriers to implementation of an AMS programme.

Conclusion

Hospital AMS programmes are in their infancy in New Zealand, with wide variation in practices seen. National co-ordination is required to assist DHBs in developing effective programmes to improve antimicrobial use.

Author Information

Sharon J Gardiner, Antimicrobial Stewardship Pharmacist, Departments of Pharmacy, Infectious Diseases and Clinical Pharmacology, Canterbury District Health Board; Jane A Pryer, Senior Advisor, Protection Regulation and Assurance, Ministry of Health; Eamon J Duffy, Antimicrobial Stewardship Pharmacist, Departments of Pharmacy and Infectious Diseases, Auckland District Health Board, and member of Healthcare Associated Infections Governance Group, Ministry of Health.

Correspondence

Sharon J Gardiner, Department of Infectious Diseases, Christchurch Hospital, PB 4710, Christchurch.

Correspondence Email

sharon.gardiner@cdhb.health.nz

Competing Interests

Nil.

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