Results from the 2014-2015 National Antimicrobial ... · Results from the 2014-2015 National Antimicrobial Prescribing Survey (NAPS) Dr Rod James National Centre of Antimicrobial

Results from the 2014-2015

National Antimicrobial

Prescribing Survey (NAPS)

Dr Rod James

National Centre of Antimicrobial Stewardship

at the Peter Doherty Institute

Outline

• Introduction

– Background

– Development of data collection tools and

website

• Results

– Participating hospitals

– Data analysis – focus on NSW

• Future directions

Introduction to

the NAPS

Background

• Antimicrobial Prescribing Survey (APS)

• Developed by Melbourne Health AMS

research team

• Aim – to develop a tool for qualitative and

quantitative assessment of antimicrobial

prescribing at an individual hospital

level

Background

• Flexible, practical and generalisable

• Suit needs of a variety of auditors

• The act of auditing – associated with

reflection and improved practice

Aims and limitations

• Aims

1. Quality improvement tool to help assess own

practice

2. Provide data to allow some simple

comparisons to be made between hospitals

3. Provide feedback on utilisation of guidelines

as well as gaps

Aims and limitations

• Limitations

1. Sampling

• Not always a randomised sample

• Only ‘keen’ hospitals participate

• ? better prescribers

2. ‘Benchmarking’

• Difficult to provide completely accurate

comparisons

• Need to disclose limitations

The results described in the report were obtained from a pilot of a new, web-based National

Antimicrobial Prescribing Survey implemented during Antibiotic Awareness Week in November

2013.

The authors advise caution in the interpretation and extrapolation of these data, and the

results should be interpreted in the context of several limitations:

1. Sampling and selection bias: hospitals included were not a randomised sample. Any

health care facility was able to participate if they wished to, hence these results may be

skewed by selection bias.

2. Survey methodology – participating facilities were able to choose their own method of

data collection (eg point-prevalence survey, random sample, targeted patient types)

and we did not ask them to nominate which they had used. Therefore, we were unable

to determine an accurate denominator in all cases.

3. Validation of audit tool and the assessment of appropriateness: individual auditors at

each participating facility were responsible for determining the appropriateness of each

antimicrobial prescription. An algorithm and detailed instructions were provided,

however this tool has not yet been validated. An inter-rater correlation study is

currently underway to determine consistency of assessment between assessor types.

Data collection

• For more consistent data collection, also

developed a set of training tools:

– definitions for each data entry field

– a unique indication list

– guidelines to assist with the assessment of

appropriateness

– a set of worked case examples

Data Collection Form

Guidelines

Indications List

Website – www.naps.org.au

Reporting

• 5 main components: 1. Dashboard

• Display key indicators

2. Filterable reports

• Antimicrobial usage

• Detailed assessment of prescription

3. ‘Benchmarking’ comparisons

• Needed approval from facilities

• De-identified

4. Time series analysis

5. Data Export

Dashboard

Filterable Reports

Benchmarking

Benchmarking

Time Series

Participation

Rates

Participating hospitals

APS 2011

32 hospitals

APS 2012

76 hospitals

NAPS 2013

152 hospitals

NAPS 2014

248 hospitals

Funding type Public Private Public Private Public Private Public Private

30 2 66 10 133 19 197 51

Location

major city 22 35 65 87

inner regional 6 14 46 62

outer regional 2 14 14 34

remote 0 3 6 10

very remote 0 0 2 4

Number of prescriptions 2, 523 5, 185 13, 111 19, 944


State Funding type Number State total

ACT Public 1

2 Private 1

NSW Public 71

79 Private 8

NT Public 2

2 Private 0

QLD Public 26

36 Private 10

SA Public 9

15 Private 6

VIC Public 63

80 Private 17

WA Public 25

34 Private 9

Total Public 197

248 Private 51


Public Hospitals

Peer Group Number of hospitals Total number

in each category

Percent of all hospitals in

category, 2014

Percent change from 2013

2013 2014 Absolute Relative

Principle referral 48 61 93 65.6 +14.0 +27.1

Specialist women’s and children’s 6 8 11 72.7 +18.2 +33.3

Large hospitals- Major city 11 18 23 78.3 +30.4 +63.6

Large hospitals - Regional and remote 9 11 20 55.0 +10.0 +22.2

Large hospitals - Group 1 12 17 30 56.7 +16.7 +41.7

Large hospitals - Group 2 13 22 58 37.9 +15.5 +69.2

Small acute hospitals - Regional 9 25 117 21.4 +13.7 +177.8

Sub-acute and non-acute hospitals 6 7 65 10.8 +1.5 +16.7

Small acute hospitals - Remote 7 10 41 24.4 +7.3 +42.9

Multi-purpose services 5 5 79 6.3 0.0 0.0

Rehabilitation 2 2 8 25.0 0.0 0.0

Other non-acute 3 3 12 25.0 0.0 0.0

Psychiatric hospital 0 1 19 5.3 +5.3c nac

Un-peered and other 2 7 201 3.5 +2.5 +250.0

Total 133 197 777 25.4 +8.2 +48.1

Public Peer Groups

Peer Group NSW National Percent

Principle referral 25 61 41%

Specialist women’s and children’s 3 8 38%

Large hospitals- Major city 8 18 44%

Large hospitals - Regional and remote 3 11 27%

Large hospitals - Group 1 8 17 47%

Large hospitals - Group 2 7 22 32%

Small acute hospitals - Regional 7 25 28%

Sub-acute and non-acute hospitals 2 7 29%

Small acute hospitals - Remote 0 10 0%

Multi-purpose services 0 5 0%

Rehabilitation 2 2 100%

Other non-acute 3 3 100%

Psychiatric hospital 1 1 100%

Un-peered and other 2 7 29%

Total 71 197 36%

Pubic Remoteness

Remoteness NSW National Percent

Major cities 37 87 43%

Inner regional 22 62 35%

Outer regional 12 34 35%

Remote 0 10 0%

Very Remote 0 4 0%

Total 71 197 36%

NSW Data

Key Performance Indicators

Key Indicator NSW 2013 NSW 2014 National

2013

National

2014

Indication documented (Best practice >95%)

71% 76% 71% 74%

Surgical prophylaxis given >24hrs (Best practice <5%)

48%* 50%* 42%* 36%*

Compliance with

guidelines

Compliant

(Therapeutic Guidelines

& local guidelines)

59% 52% 60% 56%

Directed Therapy - 11% - 10%

Non-compliant 26% 27% 23% 24%

No guideline available 9% 5% 11% 5%

Not assessable 6% 4% 6% 5%

Appropriateness

Appropriate

(optimal & adequate) 69% 70% 71% 72%

Inappropriate

(suboptimal & inadequate) 26% 26% 23% 23%

Not assessable 5% 4% 6% 5% * where surgical prophylaxis was selected as the indication

Key Performance Indicators

Key Indicator NSW 2014 Public Private National

2014

Indication documented (Best practice >95%)

76% 79% 37% 74%

Surgical prophylaxis given >24hrs (Best practice <5%)

50%* 51%* 48%* 36%*

Compliance with

guidelines

Compliant

(Therapeutic Guidelines

& local guidelines)

52% 52% 55% 56%

Directed Therapy 11% 12% 5% 10%

Non-compliant 27% 26% 34% 24%

No guideline available 5% 5% 2% 5%

Not assessable 4% 5% 4% 5%

Appropriateness

Appropriate

(optimal & adequate) 70% 71% 58% 72%

Inappropriate

(suboptimal & inadequate) 26% 25% 38% 23%

Not assessable 4% 4% 4% 5% * where surgical prophylaxis was selected as the indication

Inappropriateness by

Remoteness

Remoteness Inappropriate Total prescriptions Percent

Major cities 1064 4449 24%

Inner regional 341 1337 26%

Outer regional 110 371 30%

Remote 0 0 0%

Very remote 0 0 0%

Grand Total 1515 6157 25%

Top 15 indications

106

107

116

131

182

196

198

199

203

213

249

266

493

693

814

0 100 200 300 400 500 600 700 800 900

Osteomyelitis - Bacterial

Sepsis: directed therapy (Gram positive bacteraemia includes…

Febrile neutropaenia - Bacterial

Pneumonia: hospital acquired (HAP) - Bacterial

Wound infection: surgical - Bacterial

Medical prophylaxis - Fungal

Pneumonia: aspiration - Bacterial

Medical prophylaxis - Bacterial

Sepsis: empirical therapy (organism unknown) - Bacterial

Indication Unknown - Pathogen Unknown

Chronic obstructive pulmonary disease (COPD): infective exacerbation -…

Cellulitis/Erysipelas - Bacterial

Urinary tract infection (UTI) - Bacterial

Surgical prophylaxis - Bacterial

Pneumonia: community acquired (CAP) - Bacterial

Top 15 Inappropriate

Indications

18

20

27

28

30

34

43

44

48

68

74

103

133

197

371

0 50 100 150 200 250 300 350 400

Osteomyelitis - Bacterial

Bronchitis - Bacterial

Wound infection: non-surgical - Bacterial

Cholecystitis - Bacterial

Medical prophylaxis - Bacterial

Pneumonia: hospital acquired (HAP) - Bacterial

Pneumonia: aspiration - Bacterial

Sepsis: empirical therapy (organism unknown) - Bacterial

Wound infection: surgical - Bacterial

Indication Unknown - Pathogen Unknown

Cellulitis/Erysipelas - Bacterial

Chronic obstructive pulmonary disease (COPD): infective exacerbation -…

Urinary tract infection (UTI) - Bacterial

Pneumonia: community acquired (CAP) - Bacterial

Surgical prophylaxis - Bacterial

Top 15 Antimicrobials

150

169

184

185

189

212

220

270

272

389

395

408

439

571

752

0 100 200 300 400 500 600 700 800

Nystatin

Trimethoprim-sulfamethoxazole (Bactrim)

Ciprofloxacin

Gentamicin

Doxycycline

Benzylpenicillin

Vancomycin

Flucloxacillin

Azithromycin

Cephalexin

Piperacillin-tazobactam (Tazocin)

Amoxycillin-clavulanic acid (Augmentin or Augmentin Duo Forte)

Metronidazole

Cephazolin

Ceftriaxone

Top 15 Inappropriate

Antimicrobials

31

31

36

36

37

41

52

53

77

108

122

132

182

226

227

0 50 100 150 200 250

Amoxycillin

Ampicillin

Benzylpenicillin

Vancomycin

Doxycycline

Gentamicin

Ciprofloxacin

Flucloxacillin


Azithromycin

Metronidazole


Cephalexin

Cephazolin

Ceftriaxone

Antimicrobials for CAP by

inappropriateness

1

1

1

1

1

1

2

2

2

2

2

2

3

4

6

6

7

10

14

16

27

41

45

0 5 10 15 20 25 30 35 40 45 50

Cefepime

Erythromycin

Gentamicin

Lincomycin

Moxifloxacin

Vancomycin

Cefaclor

Cephazolin

Ciprofloxacin

Clindamycin

Metronidazole

Ticarcillin-clavulanic acid (Timentin)

Ampicillin

Cephalexin

Amoxycillin

Benzylpenicillin


Clarithromycin

Doxycycline

Roxithromycin


Azithromycin

Ceftriaxone

Antimicrobials for SAP by

inappropriateness

1

1

1

1

2

3

4

4

5

5

6

10

10

10

19

26

30

86

147

0 20 40 60 80 100 120 140 160

Benzylpenicillin


Ticarcillin-clavulanic acid (Timentin)

Trimethoprim-sulfamethoxazole (Bactrim)

Chloramphenicol

Trimethoprim

Cefaclor

Clindamycin

Ampicillin

Ciprofloxacin

Flucloxacillin


Gentamicin

Vancomycin

Cefalothin

Ceftriaxone

Metronidazole

Cephalexin

Cephazolin

Reasons for inappropriate

SAP prescribing

3

4

8

16

25

60

81

172

0 20 40 60 80 100 120 140 160 180 200

Allergy mismatch

Microbiology mismatch

Spectrum too narrow

Spectrum too broad

Incorrect route

Incorrect dose/fequency

Antimicrobial not indicated

Incorrect duration

Future

Directions

Future Directions

• Further improvements to the NAPS

website and database

• User training and credentialing

• Sharing, reporting and ownership of data

• More comprehensive reporting and

benchmarking functionality

• Further recruitment of hospitals

Aged Care NAPS

Aged Care NAPS

Surgical NAPS

Surgical NAPS

Further NAPS

• Veterinary NAPS

• General Practice NAPS

• Modules

– Indication / antimicrobial audits

– Vancomycin / gentamicin dosage

– IV to oral switch

– Quick NAPS

Acknowledgements

• Melbourne Health, Peter Doherty Institute for Infection and Immunity – A/Prof Karin Thursky – Director National Centre for Antimicrobial Stewardship

– A/Prof Kirsty Buising – Deputy Director National Centre for Antimicrobial Stewardship

– Ms Caroline Chen – Project Manager, Antimicrobial pharmacist

– Dr Noleen Bennett – Project Officer, Infection control consultant

– Ms Sonia Koning – Project Officer, Antimicrobial pharmacist

– Mr Simon Burrell – Database Manager

– Mr Roland Laguitan – IT Analyst

– Mr Xuebing Yang – Software developer

– Mr Danish Sultan – Software developer

• Australian Commission on Safety and Quality in Health Care – Ms Kathy Meleady – Director, Commonwealth Programs

– Ms Liz Metelovski – Senior Project Officer

– Prof John Turnidge – Senior Medical Advisor

www.naps.org.au

[email protected]

(03) 9342 9415

http://www.naps.org.au/

mailto:[email protected]

Thank You

Results from the 2014-2015 National Antimicrobial ... · Results from the 2014-2015 National Antimicrobial Prescribing Survey (NAPS) Dr Rod James National Centre of Antimicrobial

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