Antimicrobial Stewardship Clinical Care Standard

When treating a patient with suspected sepsis¹ or another life-threatening infection, administer appropriate empiric antimicrobials as soon as possible. There should be prompt access to the appropriate antimicrobials.

Obtain clinical specimens as appropriate, but do not delay administration of antimicrobials and do not wait for results of investigations. When results are received, immediately reassess the treatment.

If there is no immediate access to the appropriate antimicrobials, arrange for immediate transfer of the patient to an acute care facility; for example, ambulance transfer to a hospital. This is relevant in community settings or for some rural hospitals. 

End-of-life care

When considering the administration of antimicrobials for patients with life-threatening or serious infections, the patient’s advance care plan should be considered. Safe and high-quality end-of-life care should be aligned with the values, needs and wishes of the individual, and their family or carers. For ethical reasons, it is important not to harm patients approaching the end of life by providing burdensome investigations and treatments that can be of no benefit.²

Ensure that relevant clinical pathways and an appropriate local antimicrobial formulary are available so that clinicians can give optimal antimicrobial treatment promptly and within recommended time frames to patients with life-threatening infections. 

Infections can be serious and may be life threatening. Examples of these conditions include: 

• Sepsis (when the body’s response to an infection injures its own tissues and organs)
• Meningitis (an infection of the tissues lining the brain)
• Necrotising fasciitis (a serious infection from a flesh-eating bacteria).

If you are unwell with a serious infection, you will be given appropriate medicine to treat the infection without delay.

The Commission’s Sepsis Clinical Care Standard is relevant to this quality statement.

Prescribe an antimicrobial according to the current Therapeutic Guidelines or locally endorsed guidelines, including the appropriate active ingredient, dose, formulation, route and frequency of administration, and duration for the patient’s clinical condition.

Prescribe, dispense and administer antimicrobials in line with local antimicrobial formularies and restrictions, where available, including those applied to broad-spectrum antimicrobials.

Consider the individual patient’s characteristics, such as age, weight, renal function, allergies, other medicines prescribed and other health conditions.

Ensure clinicians have access to and use the current Therapeutic Guidelines and evidence-based, locally endorsed guidelines when prescribing antimicrobials.

Ensure clinicians have access to and use the local antimicrobial formulary, as required, and that it is evidence based. Monitor adherence with the antimicrobial formulary, including broad-spectrum antimicrobials.

If you are prescribed a medicine for an infection, your clinician will discuss which medicine is best for you, based on national or local recommendations. Your clinician should also consider any allergies and other health conditions you may have, as well as the cause of your infection. 

Locally endorsed guidelines

Therapeutic Guidelines: Antibiotic provides national, evidence-based guidelines for antimicrobial use in Australia.³ It is regularly revised, with interim targeted updates made in response to significant changes in evidence and practice, which may be triggered by feedback from the healthcare community. However, in some cases, evidence-based and local adaptations that have been through a formal, robust endorsement process may be more relevant to local patterns of antimicrobial resistance or to specific patient populations requiring a localised approach or with highly specialised diagnoses out of the scope of Therapeutic Guidelines. It is important to ensure that local adaptations of guidelines are based on Therapeutic Guidelines. Any deviation should be accompanied by a clear rationale based on published clinical evidence and local epidemiology, and documented and endorsed by a governing body. Endorsing bodies may include peer review from a drug and therapeutics committee, an antimicrobial stewardship committee, a medicines advisory committee, or equivalent. 

For more information about the requirements of locally endorsed guidelines and antimicrobial formularies, including restriction lists, see page 9 of the Antimicrobial Stewardship Clinical Care Standard.

• Quality statement 2 has indicators for local monitoring.
• Access to Therapeutic Guidelines (Fact sheet): This fact sheet provides clinicians with guidance on how to access the Therapeutic Guidelines for information on the appropriate prescribing of medicines. The updated mobile app for Therapeutic Guidelines is now available to download - view the user guide for more information.

Before prescribing, dispensing or administering an antimicrobial, consider the patient’s previous adverse reactions to medicines. Check the healthcare record and ask the patient about their previous adverse reactions, including the active ingredient(s), date the adverse event occurred, nature and severity of the reaction (including how it was managed), and where they recorded it, such as on an allergy bracelet or a medicines list. If any of the essential elements for assessing an adverse reaction are unknown (see below), this should be explicitly documented in the patient’s healthcare record.

The essential elements for assessing an adverse reaction are the:

• Patient’s description of the event (what happened to the patient)
• Nature of the reaction (diagnosis of the reaction)
• Active ingredient(s) thought to have caused the adverse reaction
• Assessment of likelihood (certainty it was caused by the active ingredient)
• Severity of event (consequence to the patient, for example hospitalisation)
• Date and location of the care (because the original record may have more detail).

Assess the likelihood of the adverse reaction being caused by the active ingredient(s). Factors relevant to your decision about whether to use an antimicrobial or not include the potential for the adverse reaction to recur and the likely consequences to the patient. Use information about the patient’s adverse reaction history, along with evidence-based guidelines, to assess the most appropriate antimicrobial to use. Review the accuracy of the documentation and update the patient’s healthcare record.

Communicate any changes to a patient’s adverse reaction or allergy status to the patient and their regular clinician (for example, in My Health Record or a discharge summary for the general practitioner). It may also be necessary to update the patient’s medicines list.

If a patient experiences a new adverse reaction to an antimicrobial, document the essential elements (as above) in the patient’s healthcare record. Any new or suspected adverse reactions should also be recorded in the organisation-wide incident reporting system and reported to the Therapeutic Goods Administration.⁴

Ensure processes are in place to support clinicians to document adverse reactions to medicines that are reported or experienced by a patient in the patient’s healthcare record. 

The essential elements to document for an adverse reaction are the:

• Patient’s description of the event (what happened to the patient)
• Nature of the reaction (diagnosis of the reaction)
• Active ingredient(s) thought to have caused the adverse reaction
• Assessment of likelihood (certainty it was caused by the active ingredient)
• Severity of event (consequence to the patient, for example hospitalisation)
• Date and location of the care (because the original record may have more detail).

Ensure processes are in place for clinicians to review and update information about patients’ adverse reactions to medicines in their healthcare records at each encounter including the My Health Record system.

Ensure guidelines are available for clinicians to assess adverse reactions to antimicrobials and to use the most appropriate antimicrobial when required.

Ensure relevant information about adverse reactions to medicines is available for clinicians to provide to patients.

Ensure processes are in place to review adverse reactions to antimicrobials in the organisation-wide incident reporting system and report them to the Therapeutic Goods Administration.⁴

Adverse reactions are any unwanted effects of a medicine. Many adverse reactions are expected side effects of medicines, and can range from mild to severe. An ‘allergic reaction’ is one type of adverse reaction.

If you have ever had an unwanted response to a medicine used to treat an infection, even if it was many years ago, talk to your clinician. They will ask you about what happened to find out whether it was because of the medicine, how severe it was and what it means for your care. As a result, your treatment may change and your healthcare record will be updated. Important changes will be communicated to you and your regular doctor.

If you have had an adverse reaction to a medicine, it is important that this information is added to your healthcare record. You can also review and update your information in your My Health Record. Carry a list of your medicines with you, and make sure that it includes the most up-to-date information about your previous adverse reactions to medicines, including allergies.

Obtain appropriate samples for microbiology testing when clinically indicated and before starting antimicrobial therapy whenever possible. This ensures that treatment can be specific for the infecting organism, and that the most appropriate narrow-spectrum antimicrobial is used.

For patients with a life-threatening or serious infection (such as sepsis), obtain clinical specimens as appropriate but start administering antimicrobials as soon as possible. Reassess the treatment as soon as the test results are available.

Follow guidelines for appropriate microbiological testing, such as Therapeutic Guidelines.

Ensure clinicians have access to and use the current Therapeutic Guidelines and evidence-based, locally endorsed guidelines for clinically appropriate microbiological testing.

Ensure systems are in place for clinicians to take samples for microbiology testing before starting antimicrobial therapy, when clinically indicated, and for the results to be available to clinicians in a timely manner.

Before you are given medicines to treat an infection, your clinician will try to find out what is causing the infection. This will help them to decide which medicine is best for you. You may need to have a sample taken – for example, from your blood (a blood test), urine (a urine test) or a wound (wound swab) to find out what kind of microbe (sometimes known as a bug) is causing the infection. It may be important to start treating the infection straight away, before you have the test results. However, your medicine can be changed later if needed. 

Discuss with the patient the expected progression of the infection and the potential benefits and harms of the treatment options, which may or may not include antimicrobials. This discussion should consider the patient’s preferences and needs.

If antimicrobials are not needed, reassure the patient and inform them of other treatments that can help with symptoms.

If antimicrobials are needed, discuss with the patient the importance of using antimicrobials as prescribed, how long to take them, any potential adverse effects, any potential drug interactions with existing medicines, and when the treatment will be reviewed or ceased.

Provide verbal and/or written information and resources to the patient about their treatment options and their antimicrobial therapy. Document in the patient’s healthcare record what patient information was conveyed, including the provision of written information such as a consumer medicine information sheet, and the outcome of the shared decision making process. Examples include a hospital discharge referral, or an outpatient clinic note.

Ensure systems are in place for clinicians to provide patients and/or their carers with information and advice on antimicrobial treatment options.

Ensure systems are in place so that clinicians discuss with patients and/or their carers the need to take antimicrobials as prescribed, how long to take them, any potential side effects and whether their treatment requires review.

Provide high-quality written patient materials and resources for use by clinicians and patients.

Monitor patient understanding of information provided for antimicrobial therapy and evidence of shared decision making, for example, qualitative patient surveys, patient-reported experience measures, patient-reported outcome measures and/or measuring uptake of shared decision making tools. See Appendix C of the Antimicrobial Stewardship Clinical Care Standard for more information.

Ensure processes are in place to ensure information is communicated to the patient at transitions of care (such as on referral in a community setting, or on admission to or discharge from hospital) about their treatment options and antimicrobial plan.

If you have an infection, or are at risk of developing an infection, your clinician will talk to you about your treatment options. This may mean taking medicines depending on the type or risk of infection you have. Your clinician will explain the possible benefits and harms (the good things and bad things) that might happen.

If you decide to take the medicine, your clinician will give you instructions about what you need to do. It is important that you follow these instructions correctly so that the medicine can work to fight your infection. Talk to your clinician if you are not sure what do, or if you have questions.

Some medicines may have side effects. Understanding the possible side effects can help you know what to expect.

Some other things that you need to know about the antimicrobial medicine are:

• when to start the medicine
• how many times a day to take, use or apply the medicine
• whether to take tablets or capsules with food or on an empty stomach
• how the medicine will affect other medicines you use
• what the potential side effects are
• signs or symptoms of when to seek urgent care, depending on the type or risk of infection
• when to stop the medicine. 

You may need another appointment with your clinician to check that the medicine is working.

When prescribing antimicrobials, document the indication, active ingredient, dose, frequency and route of administration, intended duration, and a review plan in the patient’s healthcare record. If required, document any plans for therapeutic drug monitoring.

Ensure a system is in place so that when clinicians prescribe antimicrobials, they document the clinical reason, active ingredient, dose, frequency and route of administration, intended duration and a treatment review plan in the patient’s healthcare record. Where electronic healthcare records are being used, incorporate flags and reminders into the record management system to support documentation in all relevant fields or consider making them mandatory fields. 

Your healthcare record contains information about your antimicrobial therapy. This includes information on:

• the medicines you have been prescribed (active ingredients)
• why they were prescribed and by whom
• when they were prescribed
• the dose
• what form of the medicine you use (such as tablets or an injection)
• how often you have them
• how long to use them for
• any plans to review your treatment.

If antimicrobials are prescribed, review the patient’s progress to assess whether ongoing treatment is needed. If the patient is on intravenous agents, consider oral options to reduce hospital-acquired infections. Ensure the antimicrobial agent and dose are appropriate for the site of the infection and patient parameters (such as renal function).

If microbiological tests are ordered, review the results within 24 hours of them being available, and use this information to consider whether changing or stopping antimicrobials is appropriate.

When prescribing a broad-spectrum antimicrobial, review the patient’s clinical status and any microbiology results to determine whether the patient’s treatment can be switched to a more narrow-spectrum agent to reduce potential patient harms and the risk of developing antimicrobial resistance.

Ensure systems are in place so clinicians regularly review patients who are prescribed antimicrobials, as appropriate to the clinical condition and healthcare setting. In hospital, this includes ceasing antimicrobials when no longer necessary, and reviewing within 48 hours from the first prescription. In the community, this includes communicating with the consumer about signs and symptoms for re-presentation to the clinician or a hospital.

Ensure systems are in place so clinicians review microbiology test results as soon as they are available and use the information to guide antimicrobial treatment decisions. Where electronic healthcare records are in place, consider incorporating flags and reminders into the record management system where possible.

Ensure processes are in place to support clinicians changing from broad-spectrum antimicrobials to appropriate narrow-spectrum agents once the pathogen and its susceptibilities are known, or after review of the patient’s clinical condition and diagnosis. Consider having processes in place to flag potential parenteral to oral switch for antimicrobials.

If you are prescribed a medicine for an infection, your clinician should regularly check that you still need the medicine and that it’s the best medicine for you. If tests have been done to find out what kind of infection you have, your clinician should review these results as soon as they are available. When your infection has improved, it may be appropriate to stop or change how you use this medicine (for example, changing from an injection, infusion or drip to a medicine you take by mouth).

If the cause of your infection is unclear, you may be prescribed a medicine that works against different types of infections. You may need to have tests (such as a blood or urine test) to check if the medicine is working. Depending on the test results, your treatment may need to continue, change or stop.

Prescribe, dispense and administer surgical antimicrobial prophylaxis according to the recommendations outlined in the current Therapeutic Guidelines or locally endorsed guidelines. Consider the patient’s clinical condition (for example, colonisation with a multidrug-resistant organism, or patient allergies).

Avoid prescribing antimicrobials post-procedurally, as prolonged antimicrobial use is not usually required. Prescribe according to guidelines with respect to the choice of antimicrobial, dose and optimal timing and consider the route of administration; topical antimicrobials are not recommended for surgical prophylaxis.³ Avoid using off-label routes of administration for antimicrobials such as irrigations, pastes, washes or topical applications for surgical prophylaxis without evidence-based guidelines.

Ensure systems are in place for clinicians to provide appropriate antimicrobial therapy to patients undergoing surgery or a procedure. Ensure these systems are based on the current Therapeutic Guidelines or evidence-based, locally endorsed guidelines.

Ensure systems and processes are in place to allow for the clear documentation of peri-procedural antimicrobial active ingredient, dose, administration time and incision time.

Assess adherence to guidelines regularly as part of a quality improvement approach. Ensure systems are in place to meet the health service organisation’s requirements for surgical antimicrobial prophylaxis, as part of the National Safety and Quality Health Service Preventing and Controlling Healthcare-Associated Infection Standard.

Before a surgical procedure, medicines may be given to you to reduce the risk of an infection. The prescription will be based on national or local recommendations. After having a surgical procedure, antimicrobials are not usually needed unless you have an infection.

Therapeutic Guidelines: Antibiotic provides national, evidence-based guidelines for antimicrobial use in Australia.³ It is regularly revised, with interim targeted updates made in response to significant changes in evidence and practice, which may be triggered by feedback from the healthcare community. However, in some cases, evidence-based and local adaptations that have been through a formal, robust endorsement process may be more relevant to local patterns of antimicrobial resistance or to specific patient populations requiring a localised approach or with highly specialised diagnoses out of the scope of Therapeutic Guidelines. It is important to ensure that local adaptations of guidelines are based on Therapeutic Guidelines. Any deviation should be accompanied by a clear rationale based on published clinical evidence and local epidemiology, and documented and endorsed by a governing body. Endorsing bodies may include peer review from a drug and therapeutics committee, an antimicrobial stewardship committee, a medicines advisory committee, or equivalent. 

For more information about the requirements of locally endorsed guidelines and antimicrobial formularies, including restriction lists, see page 9 of the Antimicrobial Stewardship Clinical Care Standard.

• Access to Therapeutic Guidelines (Fact sheet): This fact sheet provides clinicians with guidance on how to access the Therapeutic Guidelines for information on the appropriate prescribing of medicines. The updated mobile app for Therapeutic Guidelines is now available to download - view the user guide for more information.
• Surgical Antibiotic Prophylaxis Improving Practice Infographic
• Approaches to surgical site infection surveillance: For acute care settings in Australia