Antimicrobial Stewardship: Navigating The Challenges

Antimicrobial Stewardship (AMS) is a set of coordinated strategies aimed at improving the use of antimicrobial medications in the primary treatment of infection. These are such drugs as antibiotics, antifungals, antivirals and antiparasitics. The primary aim of AMS is to ensure these drugs are used only, when necessary, the correct drug is chosen at the right dose and duration, and that prescribing practices are continuously monitored and improved. AMS is particularly important in aged care because older adults are often more susceptible to infections due to a weakened immune system and other underlying health conditions. The high use of antimicrobials in these settings significantly increases the risk of Antimicrobial Resistance (AMR). Here, bacteria, viruses, fungi, and parasites develop resistance to the medications used to treat them, leading to harder-to-treat infections, prolonged illness, and increased risk of mortality.

This is a consistently reported obstacle to the effective management of antimicrobial usage in aged care.

• Financial Constraints: Many aged care facilities operate with tight budgets, making it difficult to allocate resources specifically for AMS initiatives over the day-to-day running of the facility. The complex funding models used in aged care can hinder the demonstration of an immediate return on investment required to secure dedicated funding for AMS. Prioritising AMS can be a challenge with extra financial pressures such as maintaining staffing levels and upgrading facilities.

• Staffing Shortages: Many facilities face significant staffing shortages, leaving the existing workforce overstretched. Implementing a new program into a facility such as AMS, requires dedicated time and effort for the additional tasks required. Activities such as reviewing prescriptions, providing staff education, and collecting data, appear as an added burden to busy facility staff and managers alike. Many facilities, particularly smaller ones or those in rural and remote areas, lack the resources to employ dedicated AMS personnel , specialist nurses or pharmacists available to champion and monitor AMS initiatives. This means the AMS responsibilities often fall to existing staff who may already have a full workload with resident care duties.
  
• Diagnostic Limitations: Inadequate access to accurate diagnostic tools can hinder effective AMS implementation. This can lead to “guesswork prescribing” and an over-reliance on broad-spectrum antibiotics when treatment of an infection is understood to require immediate action. This contributes more significantly to the development of antibiotic resistance compared to targeted, narrow-spectrum antibiotics. Furthermore, access to clinical pharmacists and infectious disease specialists can be limited, especially in rural and remote areas. Pharmacists play a vital role in reviewing medication charts and advising on antibiotic use, infectious disease specialists provide guidance on complex cases and AMS policies. The data deficit, including limited data on infection indications when prescribing antibiotics and a lack of surveillance on non-prescription antimicrobials, further compounds this issue.

Despite these limitations, some Australian facilities have taken steps to address this challenge. This includes facility leadership prioritising AMS within their budgets, forming strategic partnerships with larger healthcare networks or universities for additional resources and expertise, and introducing innovative technology solutions to streamline processes even with limited staff.

Resistance from healthcare professionals within the facility to adopting AMS programs is another significant hurdle.

• Habitual Prescribing Practices: Healthcare professionals may rely on familiar, dated prescribing practices rather than familiarising themselves with, and adopting new, evidence-based guidelines promoted by AMS.

• Lack of Awareness and Education: Not all staff members fully understand the importance of reducing antibiotic use and the serious consequences of antimicrobial resistance. A lack of knowledge about AMS principles and the rationale behind prudent antibiotic use can lead to resistance.

• Consequences of Staff Resistance: Resistance among staff can lead to continued inappropriate antibiotic prescribing, increasing infection risks for residents and directly contributing to higher rates of antimicrobial resistance. This can undermine all the goals of AMS programs and jeopardise patient safety.
  
  

To overcome staff resistance, facilities have implemented several effective strategies. Regular training and educational sessions are required to clearly explain the importance of responsible antibiotic use and update staff on the latest guidelines. Providing decision-support tools can make it easier for staff to follow AMS guidelines consistently. Implementing audits of antibiotic prescribing, providing feedback loops, and offering positive reinforcement can encourage and reinforce positive changes in prescribing practices. Engaging different staff groups with tailored education that aligns with their roles is also essential. Furthermore, clear, easily understood and consistent communication with residents and their families about the importance of correct antibiotic use is vital. Their expectations and misconceptions also need to be considered, and correct information explained. All these points are vital for fostering a culture of stewardship.

Coordinating AMS efforts across different healthcare disciplines within aged care facilities presents a considerable challenge.

1. What exactly is antimicrobial stewardship?

Antimicrobial stewardship involves coordinated efforts to promote responsible antibiotic use—to reduce unnecessary prescriptions & combat antibiotic resistance effectively!

2. Why is AMS particularly important in aged care?

Older adults have weaker immune systems, making them vulnerable targets. Improper antibiotic usage increases risks significantly, making effective stewardship essential!

3. How can small facilities with limited budgets implement effective AMS?

Small facilities should focus on leadership prioritisation combined with strategic partnerships offering additional resources/expertise alongside adopting the affordable tech solutions available today!

4. What role do nurses play in successful AMS programs?

Nurses serve as frontline advocates promoting responsible prescribing practices; they're instrumental educators fostering awareness among colleagues & ensuring adherence consistently throughout daily routines!

5. Are there any government resources available supporting AMS initiatives?

Absolutely! The Australian government provides various educational tools/resources including self-assessment guides & national surveillance programs like NAPS specifically designed to support facility-level improvements nationwide.

In conclusion, implementing effective AMS programs in Australian aged care facilities is a complex undertaking due to limitations in resources and expertise, staff resistance to change, and the inherent complexities of multidisciplinary coordination. Overcoming these challenges is essential to protect the health and well-being of elderly residents and to combat the growing threat of antimicrobial resistance. By acknowledging these hurdles and collaboratively working towards innovative solutions, Australian aged care facilities can continue to make progress in antimicrobial stewardship. The Australian government also provides various educational tools and resources, including national surveillance programs like NAPS, to support facility-level improvements nationwide.

This blog is based on Australian information, but most is relevant to the New Zealand aged-care facility.

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