Review Article

Meeting the challenge for effective antimicrobial stewardship programs in regional, rural and remote hospitals – what can we learn from the published literature?

AUTHORS

name here
Jaclyn Bishop1
MPH, PhD Fellow, National Centre for Antimicrobial Stewardship *

David CM Kong2 PhD, Chief Investigator, National Centre for Antimicrobial Stewardship

Thomas R Schulz3 MBBS, Associate Investigator, National Centre for Antimicrobial Stewardship

Karin A Thursky4 MD, Director, National Centre for Antimicrobial Stewardship

Kirsty L Buising5 MD, Deputy Director, National Centre for Antimicrobial Stewardship

AFFILIATIONS

1 National Centre for Antimicrobial Stewardship, Doherty Research Institute, 792 Elizabeth St, Melbourne, VIC, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Department of Medicine, Royal Parade, Melbourne, VIC, Australia; and Pharmacy Department, Ballarat Health Services, Drummond St, Ballarat, VIC, Australia

2 National Centre for Antimicrobial Stewardship, Doherty Research Institute, 792 Elizabeth St, Melbourne, VIC, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Department of Medicine, Royal Parade, Melbourne, VIC, Australia; Pharmacy Department, Ballarat Health Services, Drummond St, Ballarat, VIC, Australia; and Centre for Medicine Use and Safety, Monash University, 381 Royal Parade, Parkville, VIC, Australia

3 National Centre for Antimicrobial Stewardship, Doherty Research Institute, 792 Elizabeth St, Melbourne, VIC, Australia; and Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Melbourne, VIC, Australia

4, 5 National Centre for Antimicrobial Stewardship, Doherty Research Institute, 792 Elizabeth St, Melbourne, VIC, Australia; University of Melbourne, Faculty of Medicine, Dentistry and Health Sciences, Department of Medicine, Royal Parade, Melbourne, VIC, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital, 300 Grattan St, Melbourne, VIC, Australia

ACCEPTED: 9 January 2018


early abstract:

Objective: Antimicrobial resistance (AMR) has been recognised as an urgent health priority, both nationally and internationally. Australian hospitals are required to have an Antimicrobial Stewardship (AMS) program, yet the necessary resources may not be available in regional, rural or remote hospitals. This review will describe models for AMS programs that have been introduced in regional, rural or remote hospitals internationally and showcase achievements and key considerations that may guide Australian hospitals in establishing or sustaining AMS programs in the regional, rural or remote hospital setting.

Methods: A narrative review was undertaken based on literature retrieved from searches in Ovid Medline, Scopus, Web of Science and the grey literature. Cited and cited-by searches were undertaken to identify additional papers. Papers were included if they described an AMS program in the regional, rural or remote hospital setting (defined as a bed size less than 300 and located in a non-metropolitan setting).

Results: Eighteen papers were selected for inclusion. The AMS initiatives described were categorised into models designed to address two different challenges relating to AMS program delivery in regional, rural and remote hospitals. This included models to enable regional, rural and remote hospital staff to manage AMS programs in the absence of on-site infectious diseases (ID) trained experts. Non-ID doctor-led, pharmacist-led and externally-led initiatives were identified. Lack of pharmacist resources was recognised as a core barrier to the further development of a pharmacist-led model. The second challengewas access to timely off-site expert ID clinical advice when required. Examples where this had been overcome included models utilising visiting ID specialists, telehealth and hospital network structures. Formalisation of such arrangements is important to clarify the accountabilities of all parties and enhance the quality of the service. Information technology was identified as a facilitator to a number of these models. The variance in availability of information technology between hospitals and cost limits the adoption of uniform programs to support AMS.

Conclusion: Despite known barriers, regional, rural and remote hospitals have implemented AMS programs. The examples highlighted show that difficulty recruiting ID specialists should not inhibit AMS programs in regional, rural and remote hospitals, as much of the day-to-day work of AMS can be done by non-experts. Capacity building and the strengthening of networks are core features of these programs. Descriptions of how Australian regional, rural and remote hospitals have structured and supported their AMS programs would add to the existing body of knowledge sourced from international examples. Research into AMS programs predominately led by GPs and nursing staff will provide further possible models for regional, rural and remote hospitals.