7 November 2014 amr@health.gov.au RE: Developing a National Antimicrobial Resistance Strategy for Australia The Society of Hospital Pharmacists of Australia (SHPA) is the national professional organisation for over 3,000 pharmacists, pharmacists in training, pharmacy technicians and associates working across Australia s health system. SHPA is the only professional pharmacy organisation with a core base of members practising in public and private hospitals and other health service facilities. SHPA is committed to facilitating the safe and effective use of medicines, which is the core business of pharmacists, especially in hospitals. SHPA supports pharmacists to meet medication and related service needs, so that both optimal health outcomes and economic objectives are achieved for Australians, as individuals, for the community as a whole and for healthcare facilities within our systems of healthcare. SHPA welcomes this discussion for a national antimicrobial resistance strategy to address what is a priority global health issue. SHPA has previously written to the Australian Commission for Safety and Quality in Health Care (ACSQHC) with respect to antimicrobial stewardship. Dr David Kong, a SHPA member, is also the SHPA representative on the ACSQHC s Antimicrobial Stewardship Advisory Committee. Strategy Goal and Objectives The proposed goal of the Strategy is to slow the development and spread of antimicrobial resistance (AMR) and conserve the effectiveness of antimicrobials. Is this an appropriate and realistic goal for Australia to commit to working towards? Yes, this is an appropriate and realistic goal for Australia and should be recognised as a National Health Priority Area (NHPA) by the Australian Institute of Health and Welfare (AIHW). AMR is a significant global health issue which has implications on the treatment and transmission of diseases, as well as impacting on additional health care costs associated with AMR. The proposed objectives of the Strategy are to prevent infections and the spread of resistant infections, improve surveillance, and improve the appropriate use of antimicrobials through action across the seven key elements of IPC, surveillance, AMS, communication and education, international engagement, research and development and governance. Are these proposed objectives and the scope of the key elements sufficient to enable Australia to achieve the goal of the strategy? If not, what additional objectives or key elements are needed to ensure a comprehensive national response to AMR? Yes, the proposed objectives and the scope of the key elements appear to be adequate to achieve the goal of the Strategy. Adequate resources, national leadership and extensive stakeholder representation (including but not limited to State and Territory health departments, NPS MedicineWise, public and private hospitals, medical and allied health professional organisations, colleagues from Agriculture and Veterinary settings) are required to achieve these goals. The Society of Hospital Pharmacists of Australia Mailing address: PO Box 1774 Collingwood 3066 Victoria Australia Office location: Suite 3, 65 Oxford Street Collingwood 3066 Victoria Australia T: 61 3 9486 0177 F: 61 3 9486 0311 E: shpa@shpa.org.au W: www.shpa.org.au
Infection Prevention and Control (IPC) Are the identified IPC gaps an accurate reflection of the current situation in Australia? Are there other gaps that have not been captured here? Are the proposed actions for IPC appropriate to address the identified gaps? What other actions should be considered? The proposed actions for IPC with respect to Human Health should also specifically mention vaccinations. Universal precautions in clinical and community care settings should always be observed to prevent transmission of blood-borne viruses. This is particularly important as the demographics of the aged care population increasingly have higher rates of HIV, Hepatitis C and other blood-borne viruses. The paper is silent on sexually transmitted infections (STIs), and actions to control and prevent the spread of STIs - STIs should be at the forefront of IPC. HIV has been a global health priority for the past few decades and continues to be. A recent development the health sector is facing is the emergence of antibiotic resistant gonorrhoea. How could each action be progressed? Which organisations and/or professional groups should be involved in progressing these actions? What role could your organisation or profession play in implementing and/or supporting the actions described above? All professions registered with the Australian Health Practitioners Regulation Agency (AHPRA) should be involved in IPC. As mentioned previously, extensive stakeholder engagement is required for any national AMR strategy to be effective and achieve objectives. State and Territory health departments, NPS MedicineWise, public and private hospitals, medical and allied health professional organisations and consumer groups should all be involved. SHPA currently has a factsheet on antimicrobial stewardship which aims to guide hospitals and health services that wish to implement AMS programs and highlights the role of pharmacists as part of the required collaborative approach. SHPA also has an infectious diseases Committee of Speciality Practice (COSP) which discusses matters pertaining to AMR. The Chair of the SHPA s infectious diseases COSP is Dr David Kong, who is also SHPA s representative on ACSQHC s Antimicrobial Stewardship Advisory Committee (ASAC). SHPA would be prepared to develop or participate in the development of additional material / guidelines as well as continue to contribute within various forums. How can progress on actions be monitored? Are you aware of other existing IPC initiatives that should be considered in the development of the Strategy? 2 P a g e
Antimicrobial Stewardship (AMS) What would be the optimal characteristics of AMS programs to be developed or enhanced in: Primary health care settings? Residential aged care settings? AMS programs in these settings should be developed to reflect AMS programs implemented in hospitals. It is also important that there is greater support for jurisdictional initiatives for AMS. SHPA notes that not all state and territory health departments have coordinated state-wide AMS programs, such as the NSW s Clinical Excellence Commissions Quality Use of Antimicrobials in Healthcare (QUAH). How would AMS programs best be implemented in these settings? What existing arrangements could be used to support the rollout of AMS programs in these settings? What key professional institutions would be involved/could lead? AMS programs should be tailored to the specific needs and characteristics of local settings for optimal outcomes. As such, there is a need to engage key stakeholders to provide national coordination in this area. The ACSQHC, Antimicrobial Resistance Standing Committee (ARSC) and ASAC already exist and have the expertise in order to lead and inform AMS programs nationally. Therefore, it will be important to involve and/or partner with key professional bodies, such as the Australian Medical Association (AMA), Australian Nursing and Midwifery Federation (ANMF), Allied Health Professionals Australia (AHPA) and SHPA to name a few, to facilitate the engagement and education of the professions which they represent. Strategies to engage the broader health workforce will also need to be considered. State and territory health departments should liaise and share research, information and ideas to improve each other s practices. For example, in 2012, a database for Victorian hospital AMS contacts to facilitate sharing of AMS activity and information was established. We have heard anecdotally from our members that resourcing the implementation of AMS programs in some states / territories have been a challenge. A trend observed in hospitals setting up AMS programs is that funding is only approved for a short term (i.e. six months) with cost-saving as the primary objective. However, AMS programs need to have a long term vision in order to achieve the expected results including improved patient outcomes, slowing the development of resistance and the potential for cost savings through more appropriate use of antimicrobials. Are there opportunities to improve the regulation that supports the appropriate use of antibiotics? Currently, state and territory legislation dictates that prescribers can prescribe antimicrobials (with repeat prescriptions) with a script validity of up to one year. However, in most cases, antimicrobials are used to treat infections which should be managed within an acute time frame, such that a script that is valid for one year is not required. SHPA suggests that thought be given to limiting the script validity of a range of antimicrobials be explored, to only allow repeat prescriptions of antibiotics if it is justified by evidence. Furthermore, the cost of many antibiotics has fallen in price due to patent expiry and price disclosure. Anecdotally, we have observed that prescribers have been circumventing the Pharmaceutical Benefits Scheme (PBS) Authority system which limits the prescription of some antibiotics for specific indications, by prescribing these medicines privately. In doing so, they do not attract a PBS subsidy, but because of the price, is not an impost to the patient. This practice facilitates the inappropriate use of antibiotics and contributes to AMR. However, currently it is difficult to understand the significance of 3 P a g e
this problem as data on private prescriptions are not collected. It would be beneficial for the Department to investigate in order to assess the breadth of this issue. Some hospitals have systems where prescribers must retrospectively or prospectively seek approval from the pharmacy department to prescribe certain antimicrobials as an initiative to reduce the inappropriate use. Currently, policy objectives and implementation can differ at each hospital, and it would be beneficial for a more coordinated policy approach which would result in a consistent AMS program implementation across the hospital sector. Additionally, whilst hospitals are required to adhere to the National Safety and Quality Health Service Standards, Standard 3: Preventing and Controlling Healthcare Associated Infections, the design of and implementation of AMS programs can vary, and will depend upon the available resources. Is there a need to develop national prescribing guidelines, similar to those in human health, for animal health and agriculture? Yes. Should the use of antibiotics as growth promoters in food animals be more closely regulated, reduced or phased out completely? Yes. Communication and Education What areas has Australia performed well in with education about AMR? Where are the areas for improvement? SHPA suggests that knowledge and competency of AMR and AMS could be improved by having increased focus on these topics in undergraduate and postgraduate curriculums for health science degrees. Prescriber competency in antimicrobials should also be an element of medical intern and other prescriber training programs. In addition, this should be accompanied by regular review of prescribers competency to prescribe antimicrobials throughout their career, to ensure that health professionals are prescribing antibiotics according to current evidence and in line with best practice. Australia currently has several modules to support the appropriate prescribing of antimicrobials delivered by NPS MedicineWise. What are the top three priority areas for action on education and communication? Educating prescribers and other health professionals of the need to use antimicrobials appropriately and judiciously, as well as the global threat concerned with AMR. Prescribers need to decide whether antimicrobial therapy is always required, or whether supportive and symptomatic treatment will deliver the same health outcomes Educating consumers to raise awareness of the need to use antimicrobials appropriately and about other strategies endorsed by the National Hand Hygiene Initiative (NHHI) What channels of communication and approaches are likely to be most effective? A range of communication activities and approaches should be appropriately tailored to the target audience. It is important that these activities are consistently and regularly reinforced, which could utilise similar strategies like, for example, the annual Antibiotic Awareness Week currently hosted by the ACSQHC. 4 P a g e
How could GPs, pharmacists and veterinarians be further supported to reinforce messages about AMR, appropriate antibiotic use and infection prevention and control? There should be simple and accessible material for health professionals to reinforce and promote AMS practices. For example, GPs as well as other prescribers of medicines, could benefit from a simple prescribing tool which guides appropriate antimicrobial prescribing after a diagnosis has been made. Any activity would need engagement from relevant bodies such as NPS MedicineWise, AMA, Pharmaceutical Society of Australia (PSA), the Pharmacy Guild of Australia and SHPA. What types of education would be most beneficial in reducing inappropriate antibiotic prescribing (e.g. training on AMR, training on prescribing antibiotics for specific conditions, training on communicating with patients/clients)? Effective education and training should be targeted to the specific audience and guided by the intended outcome. As discussed earlier, prescriber competency in antimicrobials should be an element of prescriber training programs; accompanied by regular review of prescriber s competency to prescribe antimicrobials throughout their career, and to ensure that health professionals are prescribing antibiotics according to current evidence in line with best practice. It is also worthwhile educating health professionals and consumers about the emerging upward trend of superbugs which are resistant to antimicrobial therapy, and the global threat that this poses. It should be reinforced that every person has a role to play in combating AMR by being judicious and informed about the use of antimicrobials. International Engagement How could Australia best engage with countries leading the way on responses to AMR, to ensure that we learn from the experience of others and implement initiatives that are known to be efficient and effective? Ensure that there is consistent and strong leadership at a national level, which actively engages with health departments abroad which have established national AMS programs. This will allow Australia to learn from international experiences and tailor local AMS programs to suit its priorities. Patterns of AMR differ slightly in each country; however the principles of AMS programs are generally adaptable in any country s healthcare system. How could Australia best support and collaborate with other countries in the region on initiatives to address AMR? Australia can actively engage countries in the region through a forum to discuss AMR issues (eg. WHO, and other existing strategies). Australia can also lead expanded surveillance activities of resistance patterns within the region, and build capacity by sharing our resources and giving access to tools developed within Australia for other countries within the region. Research and Development For your area of expertise, what are the AMR research and development priorities? The development and support of programs which promote optimal dosing of antimicrobials to prevent emergence of resistance should be encouraged. This will facilitate effective antibiotic use (i.e. appropriate dosing) and extend the life of currently available antimicrobial agents. This may also include the need to develop appropriate tools for paediatric settings. 5 P a g e
There is also a need to have more coordinated research and fostered collaborations between scientists that study exposure response relationships for antibiotics and resistance, and clinicians who can turn that information into dosing strategies and guidelines. A dedicated call for funding should be considered, particularly one which focuses on the patient groups where much of the resistance is generated (intensive care unit patients, cystic fibrosis, burns patients, transplant recipients). From an AMS perspective, this research can be rapidly translated into clinical care once the research has been supported. Who may be best placed to lead a priority-setting process and the development and coordination of a national research agenda for AMR? The National Health and Medical Research Council (NHMRC), in partnership with the ACSQHC, ASAC and ARSC. How can greater private sector investment in AMR-related research and development, including research taking a One Health approach, be supported and encouraged? Private hospitals and private health insurance companies will realise that AMR is a significant impost on patient and hospital costs, and that an active role in AMS is in line with their commercial interests. How can the sharing of AMR research findings, particularly with the private sector and internationally, be better supported so that new knowledge is actively converted to better practices, policies and new technologies? What mechanisms are available, or could be developed, to support increased investment in the discovery and development of new antibiotics and other technologies? Ensure adequate funding of major research universities and institutions and encourage crossinstitutional collaboration through the provision of grants and financial incentives to achieve results. It is important to ensure there is ongoing investigation of any potential new indications of older medicines. Governance What consideration should be given to identifying, establishing and maintaining key partnerships to support achievement of the goal and objectives of the Strategy? It is imperative that federal, state and territory health departments, along with Primary Healthcare Networks (replacing Medicare Locals from 1 July 2015) and Local Hospital Networks, are in the same conversation together. Having programs which have different objectives operating across the country is counter-intuitive and national oversight is needed. Australia should also engage with countries in the region to share ideas and implement strategies to address AMR. What strategies may be effective in supporting AMR governance arrangements at the national, jurisdictional and local levels? What jurisdiction and local governance arrangements are you aware of that could be better linked into a broader national structure? Any strategy will likely need directives by federal, state and territory governments. Primary Healthcare Networks would be good candidates to provide governance and monitoring of AMS activities locally, and report back to government on progress and issues. 6 P a g e
What non-statutory instruments (e.g. standards, codes of practice, guidelines) are you aware of that may underpin activities under the Strategy that are administered by professional bodies or industry? Some antimicrobial stewardship resource materials have been made available on ACSQHC s website, however there are more resources in which SHPA could help gather. (http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/antimicrobialstewardship/resource-materials/) What voluntary restrictions on antibiotic use in food producing animals are in place and how effective are they? How could the arrangements administered by industry and/or professional bodies be maximised to support the strategy? It is necessary to ensure that industry and professional bodies are coordinated in their approach to implement the Strategy, and that adequate support is offered should any issues arise. If you would like to discuss the issues raised in this submission or require further information please contact Jerry Yik (JYik@shpa.org.au or 03 9486 0177). Yours sincerely, Helen Dowling Chief Executive Officer (BPharm,DipHospPharmAdmin,GDipQIHCare,FSHP,AICD) 7 P a g e