An action plan to enhance antimicrobial stewardship in rural hospitals: maximising connections.

Abstract

Background: Antimicrobial stewardship (AMS) programs promote the appropriate use of antibiotics and slow antibiotic resistance. There is an absence of specific strategies to support rural and regional (rural) hospitals to deliver AMS programs. The aim of this research program was to develop an action plan for enhancing AMS practices in the rural setting.

Methods: Strategies or approaches for the delivery of AMS programs in rural hospitals were identified through key informant interviews with AMS innovators. Focus groups with health professionals with day-to-day AMS responsibilities explored the contemporary barriers and enablers for rural AMS programs. The interview and focus group transcripts were analysed using the framework method. Antibiotic prescribing patterns in rural hospitals were compared to those in major-city hospitals through analysis of the 2014–16 National Antimicrobial Prescribing Survey (NAPS) data.

Results: Key informant interviews with 15 participants from various professional disciplines generated three recommendations to better support AMS programs in rural hospitals: use hospital accreditation to drive direct resource allocation; provide greater support to develop AMS network arrangements; and refinement of traditional roles within AMS programs to create new partnerships. The focus groups, involving 22 participants from various professional disciplines, identified six contemporary factors unique to the rural setting that impacted on AMS program delivery: a culture of independence and self-reliance by local clinicians; personal relationships; geographical location of the hospital influencing antibiotic choice; local context (such as resistance patterns); inability to meaningfully benchmark performance; and lack of resources. The NAPS analysis (n=47,876) highlighted that, compared to major-city hospitals, inappropriate antibiotic prescribing was higher in rural hospitals for cellulitis (25.7% v 19.0%, p=<0.001), high-risk infections such as Gram positive bacteraemia (12.6% v 6.5%, p=0.004) and empiric therapy for sepsis (26.0% v 12.0%, p<0.001).

These findings were synthesised to create an action plan for enhancing AMS practices in rural hospitals, including to:

adopt a true one-health approach with coordinated initiatives and messaging between acute, primary, aged, dental and veterinary care and the community develop shared resources to improve antibiotic prescribing in commonly encountered infections such as cellulitis evaluate existing rural AMS programs in Australia to define the organisational conditions and intensity of input required to foster practice change. Conclusions: An action plan for enhancing AMS practices in rural hospitals was formulated through a program of interlinked research. The action plan requires strong collaboration between researchers, communities and clinicians in the various sectors where antibiotics are prescribed.