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Assessment Title: Measuring Antimicrobial Prescribing Patterns Methods in Aged Care Facilities in Australia — Literature Review

Measuring Antimicrobial Prescribing Patterns Methods in Aged Care Facilities in Australia




Antimicrobial resistance is one of the threats facing human health as it reduces effectiveness to prevention and treatment of an assortment of infections (1-6). The Aged Care National Antimicrobial Prescribing Survey (acNAPS) (1) noted that antimicrobial resistance reduces effectiveness of antimicrobial use against bacteria, viruses, parasites, and fungi as well as common infections such as urinary tract infections and pneumonia (p. vi). Therefore, inappropriate use of antimicrobials was of concern especially in residential aged care facilities (RACFs) where the residents have an increased chance of contracting antimicrobial resistance-based infection. The threat is magnified by possible cross-transmission (6-10). The potential outcome of antimicrobial resistances promotes the need for action in all settings in which antimicrobials are in use toward successful control of decreased effectiveness and resulting infections.

Australia has identifiable programs focusing on addressing the prevalence of antimicrobial resistance and promoting sustainable and standardized use of antimicrobials. For instance, acNAPS, the National Antimicrobial Prescribing Survey (NAPS), and National Center for Antimicrobial Stewardship (NCAS) are among units working toward collection of annual data that may be used to design improved interventions to promote appropriate antimicrobial use among the aged population. This literature review consolidates information about the different programs, and their outcomes as a way to inform future action on the use of antimicrobials in aged care.


The aim of the literature review is to compare and contrast the antimicrobial surveillance programs in Australia. In particular, the review explores how the programs measure the prescribing patterns of antimicrobials, the approaches to data collection among patients, facility / residential records, and among the staff members. Additionally, it highlights the timeframe used in the data collection, target population and sample size, and approaches to data collection and analysis as well as the outcome of the findings. The literature review considers the different programs available within Australia and other reports from academic or practitioner researchers that have examined the conduct and effectiveness of these programs.

Search Strategy

The information search involved collection of literature from databases, Google, and survey sites. The search terms used in the process included: prescribing antimicrobials in aged care facilities, measuring antimicrobial prescribing patterns, methods of prescribing antimicrobials, and antimicrobials use programs. Search limits included the use of teams such as Australia, aged care facilities, and aged care residential. The databases used in the search included ProQuest, MEDLINE, and PubMed as well as Google Scholar. All these databases allow for the delineation of cases based on the set limits including a specified timeframe.

The inclusion and exclusion of literature for the literature reviewwas based on six characteristics, namely types of study, credibility of publication, origin of publication, population of interest, type of data used and period of publication. When doing a general World Wide Web on Google, it is apparent that there is much literature on microbial prescribing patterns methods among the aged. Therefore, it was important to identify a way to limit the search and ensure the literature included is relevant to the larger topic and its objective. The six characteristics provided a strategy to remain relevant to the topic while sieving through the information. The first consideration was origin of the data included and the publication. As the study is specific to aged care facilities in Australia, the literature included fully reflected this in its originality. Therefore, the data collected for the literature review came from sites specific to programs in Australia such asacNAPS, NAPS, NAUSP, and PBS/RPBS, and then supported by peer-reviewed publications that targeted the Australian population, whether the aged or caregivers of the aged.

The information included was either primary data especially in the peer-reviewed articles or secondary data especially for the institutional reports such as in acNAPS. Articles included reported on research conducted with Australia and with specified sample size and population. The institutional reports are published for Australia. Finally, the literature included must be published within the last five years, allowing for current practices. The assumption is that literature published more than five years ago may not contain current practices especially considering the topic relates to health practices, which are changing based on upcoming evidence. As research continues in the areas of prescription and pharmacology, it becomes paramount that practices also change to fit evidence based activities. This informed the choice of a five year term for inclusion and exclusion of publications. Agreeably, older articles may be included but only for historical value if necessary. The expectation is to include about 40 articles within Australia, including peer-reviewed articles, grey articles, and institutional reports.


The literature review led to the identification of six prescription measurement programs in Australia, namely NAUSP, NAPS, acNAPS. ROGS, Medicine Insight, and PBS/RPS, which have publications supporting their work and the outcomes. Different authors have also examined the work completed in these programs. The following sections underscore the roles of each of these programs, identifying the program, its method, target population, data classification and restrictions, and a comparison of how each program relates to others, later presented in a table format.

The National Antimicrobial Prescribing Survey

The National Antimicrobial Prescribing Survey (NAPS) represents a coordinated multi-disciplinary team dedicated to surveys within the Australian Health Care Facilities with the goal of assessing the antimicrobial prescribing practices (12) . The surveillance ultimately offers antimicrobial stewardship strategies in different settings including tertiary, rural, regional, aged care, general practice, and animal health sectors. The target is to facilitate policy formulation and practice in the use of antimicrobials for humans and animals.

NAPS has released different reports on their surveillance among the 2014 (13) and 2015 (14) National Antimicrobial Prescribing Survey that offer insight into how the survey functions and the type of data received. The survey incorporates the findings from 129 voluntary participating hospitals from Australia(13). The survey started in 2011 and is incorporated in the National Safety and Quality Health Service Standards, which introduced a requirement for all hospitals to assess their antimicrobial use (14). The survey continues to grow with increasing number of hospitals participating, and has been able to become a standardised auditing tool for quantity and quality control for antimicrobial prescribing in Australian hospitals (15). As identified in the 2015 report, the expectations of NAPS is that through continued auditing, facilities will promote reflection thus leading to improved practice, safety and client care (14).

The interpretation of the NAPS results is affected by a number of limitations noted in the reports, including sampling and selection bias, whereby the hospitals inclusion was not randomised as participation is voluntary and thus the results may not be representative of all the facilities in Australia. James and colleagues supported the possible gap in the representation of data across facilities, noting that results show less auditing and review in regional facilities due to lack of specialist infectious diseases support and other resources compared to metropolitan hospitals (16). Therefore, the findings in NAPS may show a greater representation of metropolitan hospitals compared to other areas. Second, the assessment is subjective as auditors have the prerogative to establish the assessment for appropriateness of antimicrobial prescribing with assistance with the NAPS if needed. Third, the 2014 and 2015 reports which present data collected in the previous year, use different categories based on revisions done in methodology and selection of participants.

The 2014 NAPS was largely led by drug specialists (60.8%), disease control experts and medical attendants (18.8% consolidated), and specialists (16.1%). Between the auditors, dependability shows that appropriateness of practices appraisals were mostly embraced by on-location or remote AMS groups and clinical specialists. However, there were some changes in approach that took place between the 2013 (13) and 2014 (14) reviews. What has been observed is that not all the information from the fields was the same in the two studies; which may suggest that special concerns should be raised in regard to the specific areas as reported in the annual report for the two years. The findings of NAPS in the two years of study showed that about 24.3% of prescriptions were non-compliant and 23.0% inappropriate (15). The facilities are yet to achieve best practices level, as they rated 74.0% on average, with specific rating for the highest prescriptions in 2014 being 63.1% to 76.9% for cephazolin, ceftriaxone, metronidazole, piperacilin-tazobactam, and amoxicillin-clavulanic acid.

The findings of the NAPS are specific to the health facilities, but as noted in the 2015 report the Australian Commission on Safety and Quality in Health Care in collaboration with the National Centre for Antimicrobial Stewardship is working toward expansion of NAPS into aged care module, and improvement of antimicrobial stewardship in residential aged care facilities (14). The Australian Commission on Safety and Quality in Health Care has thus developed the acNAPsInfographic to promote aged care facilities to participate in acNAPS and to develop antimicrobial stewardship strategies and promote appropriate antimicrobial prescribing (17). The Infographic identifies the threat of resistance coming from unnecessary prescribing of antimicrobials, noting that 32% of prescribed cases have no documented reason, and 65% prescriptions have no documented review or stop date. Additionally, 31% have an over 6 months prescription, 20% show prescriptions without an identifiable infection based on signs and symptoms, and 18% have unspecified skin infection (18).


The Australian Government Department of Human Services (DHS) gathers information from the Medicare drug store claims database on antimicrobial administration through the Pharmaceutical Benefits Scheme (PBS) and the Repatriation Pharmaceutical Benefits Scheme (RPBS). The Information is submitted to DHS specifically by drug stores or by patients who have been recommended a PBS/RPBS intervention through Medicare administration. As stated by Rello et al. (19)The Australian Government Department of Health examinations PBS/RPBS processes the information in order to illuminate the cost concerns and process improvement. It is observed that more medication use data is required for various purposes including pharmocol-observation and assessment of activities for quality utilization of prescriptions.

As Sabuncu et al. (20) observes, Information captured by the PBS/RPBS is broad. According to the survey report, Around 30 million antimicrobials drugs were prescribed in 2014, which is estimated at 13% of the aggregate PBS and RPBS medication prescriptions. The Department of Health of late administers Antimicrobials medication through the Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme usage (21) (22), the emerging report produced the framework for the evaluation of the 2014 information incorporated into the AURA 2016 report.

The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System focus on reconnaissance for antimicrobial use and resistance in public health facilities (20). The Data collected in regard to the antimicrobial use and its suitability is sourced from the National Antimicrobial Prescribing Survey, the Aged Care National Antimicrobial Prescribing Survey, the National Antimicrobial Utilization Surveillance Program, the NPS Medicine-Wise Medicine-Insight program, the Annual Report on taxpayer-supported organizations and the Pharmaceutical Benefits Scheme. Data on antimicrobial resistance is sourced from the Australian Group on Antimicrobial Resistance, the Queensland Health OrgTRx framework, the National Neustria Network, the National Notifiable Diseases Surveillance System and Sullivan Nicolaides Pathology. However, it is observed that the Coordination of information and data from the different sources should be analysed by point of interest of the information sources, techniques, and reason for the gathering of the information, additionally, it should include all the consideration undertaken when utilizing the information. This permits successful coordination, efficient examination, and precise reporting that should inform the local, state, and national wellbeing frameworks. The program should also consider the expansion of the methodology to capture a wider population.

Medicine-Insight program

Nolan and O’Malley (23), has noted that NPS Medicine-Wise as of now works through the national project called Medicine-Insight, which gathers longitudinal clinical information from general practices. The information incorporates utilization of prescriptions, exchanging of pharmaceuticals information, signs for endorsing, adherence to rules, and pharmocol-vigilance to bolster post market reconnaissance of medication use in essential care, it also bolster general practices’ change in quality utilization of drugs and medicinal tests. Jörgensen et al. (24) noted thatthe project plans to bolster changes in endorsing designs by giving local information to general practices, to better comprehend where there might be variety and open door for development. The Medicine-Insight project is a deliberate system, which gathers de-recognized general expert desktop clinical information. A free information administration board supervises the task.

The data availed in this report is anchored on general practice clinical information gathered from volunteer practices enlisted to the Medicine-Insight program (25). The project’s information set has been developed and the work is in advanced stages. It is assist to create abilities and limit in information investigation and report presentation. The survey report outcomes relies on 182 works done by over 1005 general practitioners and 1 264 232 patients. The information is drawn from the primary recording of clinical information from 1 January to 31 December 2014. Although the project has fundamentally been extended, the initial assessment has demonstrated that the information is broadly illustrative and consistent with the Ministry of Health recommendations.

Ochoa et al (26) recognised that issues that should be considered when deciphering the Medicine-Insight information include the fact that the general practices included are not a randomized examples, Data is sourced from therapeutic records, and depends on a fitting level of fulfilment and precision inside the records. Infrequently visits to patients, master medicines and tests are excluded. However, it has been observed that The Prescription information can fluctuate from apportioning information, as not all interventions are administered; therefore, the information may not relate totally with PBS information.

In 2015, the NCAS created and guided a NAPS module for private elderly Aged Care NAPS (acNAPS) (1). The module, however, operates on the same approach as NAPS. Surveys were changed to focus on private aged care benefits and utilized the McGeer contamination criteria70 as an intermediary for evaluation of suitability. The larger parts of evaluators were medical professionals (57.5%) or medical attendants (35.6%), followed by drug specialists (11.0%), more than 33% of evaluators were enlisted to direct the survey across the private establishment.

An aggregate of 186 Participants offices took part in the survey, with representation from across the six states. However, Neither the Australian Capital Territory nor the Northern Territory took part in the pilot study. The greater parts of medical establishment were government owned (75.8%). The Commission is working with NCAS to grow NAPS into other elderly wellbeing divisions. The initial step will be develop a committed elderly care module, called acNAPS, with the aim of enhancing AMS operations in the private elderly care setting. The Commission has built up the acNAPS Info-graphic to empower private elderly care facilities to take an interest in acNAPS and to embrace AMS methodologies to enhance suitable antimicrobial surveillance.

The 2015 acNAPS pilot study was corroboration between the National Center for Antimicrobial Stewardship (NCAS), the Commission, the Guidance Group, and the VICNISS Coordinating Center. NCAS, the Guidance Group, and VICNISS together utilize drug resistant illnesses specialists, disease control professionals, disease transmission specialists, clinical microbiologists, master drug specialists, and data innovation officers who can give master direction on AMS. The aim of the acNAPS pilot study was to create and execute a feasible and institutionalized quantitative review instrument to screen diseases and antimicrobial use in Australian RACFs (1). The broad objective of the acNAPS is to bolster AMS in RACFs through the monitoring the predominance of diseases and antimicrobial prescription at the local, state, and national level in a supportable manner the program also set out to establish acNAPS as an annual reporting component for AMR in elderly care institutions.


The yearly Report on Government Services (RoGS) gives data on the value, adequacy, and effectiveness of taxpayer driven organizations in Australia. This report was covers the period between 27 January — 4 February 2016. It has been observed that ROGS ought to be refined in order to meet contemporary execution estimation needs, and be empowered to be more dynamic in meeting future needs. Additionally, ROGS needs to adjust to supplement the new NPRS and IGA. As Lim, Kong and Stuart observes (9) the government agency mandates include ensuring the respectability of the execution information it gathers and holds and Exercising stewardship over the information, to a certain degree, through the support of the Steering Committee (9). It is also charged with Ensuring that execution variables are significant, justifiable, convenient, practically identical, officially straightforward, savvy, exact and progressive, in line with the standards for execution markers set out under the Intergovernmental Agreement on Federal Financial Relations additionally, the agency is expected to Keep abreast with the global advancements in the prescription administration including the estimation and reporting of taxpayer driven organizations arrangement (27).


The National Antimicrobial Utilization Surveillance Program (NAUSP) was initiated in July 2004. It has been observed that the number of hospitals has increased significantly since the presentation of the NSQHS S in 2011 (28). The report incorporated information from 148 Australian hospitals (128 open and 20 private) The 128 public hospitals facilities had 79% of total beds in Australian hospitals. All Australian Principal Referral hospitals are incorporated into this report. The report followed the Standardized usage density rates, which takes into account the World Health Organization’s Anatomical Therapeutic Synthetic (ATC) norms for Characterized Daily Doses (DDD). The denominator is the metric of inpatient ‘Possessed Bed Days’ (OBDs), a subterranean antimicrobial usage reporting, taking into account DDD, which informs the appraisal and the correlation of aggregate — healing center use, as a rate. This report covers antimicrobial use for the period July 2014 to June 2015, with the total yearly rate for elderly care units anti-microbial use by 148 givers was 923 DDD/1000 OBDs (29).

Similarities and differences between the programs

Type of surveillance



The program advances the proper utilization of antimicrobials, while reducing the rise in antimicrobial resistance.

The program Develops and execute a manageable strategy to gauge the predominance of diseases and the suitability of antimicrobial prescription (30)

The program differs with the other initiatives by assist in showing concordance with the Australian

Aged Care Accreditation Standards for Infection Control and Medication Management.

Medicine insight

Medicine insight program advocates for quality change in taking interest general practices and addresses the reduction in prescribing antimicrobial agents.

Educating future wellbeing arrangement and supporting a practical PBS. 

ROGS addresses the Clinicians, administration officials and supervisors, teachers and suppliers. The program utilizes the standards and ten vital components of the Consensus Statement as a manual for enhancing the security and nature of end-of-life consideration.

The program offers Frameworks and structures for elderly care and great end-of-life consideration work in collaboration with those reacting to clinical decay.

The program Provides a preview of medicine outlines and patient records which have been evaluated for propriety of antimicrobial endorsing, and consistence with rules.

The NAPS is facilitated by a multi-disciplinary group at the National Center for Antimicrobial Stewardship, and is conveyed by the Guidance bunch. This review has been used since 2011 and has as of now helped several Australian Health Care Facilities to evaluate their antimicrobial prescription practices (31)

The program also provides important data on the use of antimicrobials inside Australia and is supported by the Australian Commission on Safety and Quality in Health Care.


To access pharmaceutical advantages under this course of action a patient must go to a corroborating facility.

The program recommends only a medical expert giving restorative treatment, or a maternity specialist giving birthing assistance treatment, or an attendant professional giving attendant specialist treatment inside a participating open clinic may recommend PBS sponsored pharmaceutical from a healing facility(32)

The program offers Unrestricted access to medical benefits unbounded on the sponsored sign for prescription.

Restricted benefits Medicines accessible for the treatment of specific signs In the event that the solution is endorsed outside the PBS-determined sign, prescribers are required to attend private elderly care facilities (33)

An powerful remedy is required for certain confined solutions and for situations where a higher dose or the amount of the drug is required than the most extreme endorsed on the PBS prescriptions, which require the prescriber to get phone endorsement from DHS or Department of Veterinarians’ Affairs (DVA) before apportioning is allowed Prescriptions do not require earlier endorsement from DHS or DVA, yet a streamlined power code must be given on the remedy.

Private healing facilities are excluded in the AIHW peer gathering(34)

Pharmacists are included gathering information from inpatients issued antimicrobials and affirmation information

In general terms, the local, state, and the Australian Government give a large portion of the assets to open healing facilities. Private doctor’s facilities are essentially financed by private medical coverage and out-of-pocket instalments by patients(35)

Governments for the most part store crisis office and outpatient administrations, while conceded persistent administrations are regularly supported by private (non-government) sources, and additionally government source

Discussion and Conclusion

Data from Australia suggests that surveillance and measuring antimicrobial use and associated infectious syndromes in residential aged care facilities remains the most effective way to understand how prescription is completed, and thus possible effectiveness (2) (11). As shown by Bennett et al. (11) estimation of the infection burden within the aged care facilities in relation to microbiologic testing requires establishment of surveillance criteria that can assess non-routine prescriptions, and their impact. The recognition of the challenges associated with the identification of the routine and non-routine prescriptions prompts the assessment of current surveillance programs in Australia. In conclusion, the programs available in Australia have an effective system in antimicrobial prescription assessment although their developments depend on the target group such as hospital facilities. Their applicability to aged care thus depends on how well they may be adopted to such facilities.


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