Medicine (RMH) - Theses
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ItemAntibiotic Stewardship in Australian rural hospitals( 2021)Australia has a high per capita consumption of antibiotics. Much of this antibiotic use is inappropriate or unnecessary, contributing to poor patient outcomes such as unresolved infection or antibiotic-related side effects. Antibiotic stewardship (AMS) programs in hospitals are a component of a multi-faceted approach to optimise antibiotic use. Compared to AMS programs in metropolitan hospitals, significant gaps exist in our knowledge about AMS programs operating in lower resource settings, such as regional, rural and remote (rural) hospitals. While the literature describes some models to increase local capacity for AMS or access to infectious diseases advice, this wisdom is predominately derived from small studies in international hospitals. Therefore, this PhD sought to address the paucity of information on optimising AMS programs in Australian rural hospitals. First, it was necessary to establish whether there was unwanted variation in antibiotic prescribing in Australian rural hospitals. An analysis of National Antimicrobial Prescribing Survey (NAPS) data from 2014-2016 found that inappropriate antibiotic prescribing was higher in rural hospitals compared to metropolitan hospitals. A sub-analysis identified cellulitis and some high-risk infections (such as sepsis) as priority areas for action. To address this unwanted variation in antibiotic prescribing, an in-depth understanding of the barriers, enablers and potential models for AMS programs in the Australian rural setting was required. These were identified through a series of focus groups and key informant interviews with hospital staff and AMS innovators respectively. Synthesis of the findings of these studies revealed specific considerations for the delivery of AMS programs in rural hospitals that differ from metropolitan hospitals. This included a culture of independence and self-reliance by local clinicians, interconnected work-life relationships, geographical location of the hospital influencing antibiotic choice, inability to meaningfully benchmark performance and a lack of resources (leading to key person dependencies and the risk of burnout). Network arrangements were recognised as an important way to build capacity. The aforementioned work led to the conceptualisation of a multi-centre study which utilised two of the findings; a) that cellulitis was a condition where antibiotic prescribing in rural hospitals could improve and b) that AMS network approaches should be facilitated. The study co-designed, implemented and evaluated a cellulitis management plan (including a consumer leaflet) in three Victorian rural hospitals. Although unable to show a statistically significant improvement in antibiotic appropriateness after the introduction of the cellulitis management plan, patient satisfaction with the information provided about cellulitis increased when the consumer leaflet was received. The study was a compelling example of how health services and consumers can work together to create shared resources and improve the consumer experience. This PhD has identified that to optimise AMS in the rural setting, more Australian rural hospitals must share their AMS program structures and outcomes so that the organisational conditions and intensity of input required to have real impact on antibiotic prescribing practices can be established. Given the unique connectedness that exists in rural communities, there is the opportunity to adopt a true one health approach and create new partnerships across acute, primary, aged, dentistry and veterinary sectors to collectively improve antibiotic prescribing.