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  1. 1. Antimicrobial Awareness Week 2020 Insert your organisation’s name here Insert presenter’s name here #worldantimicrobialawarenessweek
  2. 2. Overview •Antibiotics are vital life-saving medicines •Antimicrobial resistance is both a global and local problem •The link between antibiotic use and resistance •Addressing antimicrobial resistance in Australia •Antimicrobial stewardship (AMS) •Antimicrobial Awareness Week
  3. 3. 18 – 24 November Fixed dates regardless of the first day of the week Aims to encourage best practice in relation to antibiotic use, among the general public, health workers and policy makers to prevent and contain the spread of antimicrobial resistance. Antimicrobial Awareness Week in Australia
  4. 4. • Narrow spectrum antibiotics work against a limited group of bacteria ⎻ Lower resistance potential • Broad spectrum antibiotics work against a larger group of bacteria • Overuse of unnecessarily broad spectrum antibiotics can drive antimicrobial resistance Broad vs Narrow Spectrum Antibiotics Bacteria A Bacteria B Bacteria C Bacteria D Bacteria E Bacteria F Bacteria G Antibiotic 1 Antibiotic 2 Antibiotic 3 Antibiotic 4 Antibiotic 5 Antibiotic 6 Antibiotic 7 Antibiotic 8 Antibiotic 9 Antibiotic 10 It is preferable to narrow spectrum antibiotics wherever possible
  5. 5. The primary purpose of the PAL is to promote improved prescribing by reducing the total quantity of antibacterial use. The PAL can be used to describe reductions in a way that identifies preferred or quality use in terms of AMR and AMS Priority Antibacterial List for Antimicrobial Resistance Containment
  6. 6. Access Review - Curb Review - Contain amoxicillin amoxicillin–clavulanic acid amikacin ampicillin azithromycin aztreonam benzathine benzylpenicillin cefaclor cefepime benzylpenicillin cefalexin ceftaroline chloramphenicol cefalothin ceftazidime dicloxacillin cefazolin ceftazidime–avibactam doxycycline cefotaxime ceftolozane–tazobactam flucloxacillin cefoxitin colistin gentamicin ceftriaxone daptomycin metronidazole cefuroxime doripenem minocycline clarithromycin ertapenem nitrofurantoin ciprofloxacin fosfomycin phenoxymethylpenicillin clindamycin imipenem–cilastatin procaine benzyl penicillin erythromycin linezolid streptomycin fidaxomicin meropenem sulfamethoxazole– trimethoprim lincomycin moxifloxacin tetracycline norfloxacin pivmecillinam tinidazole piperacillin–tazobactam polymixin B tobramycin rifampicin pristinamycin trimethoprim rifaximin tigecycline roxithromycin sodium fusidate spiramycin teicoplanin vancomycin Priority Antibacterial List for Antimicrobial Resistance Containment
  7. 7. • Antimicrobial resistance (AMR) occurs when bacteria, parasites, viruses or fungi change to protect themselves from the effects of antimicrobial drugs designed to destroy them. • This means previously effective antimicrobial drugs (e.g. antibiotics) used to treat or prevent infections may no longer work. • The World Health Organization (WHO) has identified AMR as ‘one of the biggest threats to global health’. • The Australia’s National Antimicrobial Resistance Strategy - 2020 and Beyond was released and is Australia’s national AMR strategy. What is antimicrobial resistance (AMR)?
  8. 8. • Antibiotics treat infections caused by bacteria • Modern medicine, especially surgery and cancer treatments, depends on effective antibiotics to minimise the risk of infection − Currently, antibiotics reduce post-operative infection rates to below 2% − Without effective antibiotics, this could increase to around 40% to 50%. Up to 30% of these patients could die from resistant bacterial infections − The risk of mortality without access to effective antibiotics may make some treatments and surgical procedures too risky to continue • Antimicrobial resistance results in substantial financial cost for patients and healthcare systems. Why are antibiotics and antimicrobial resistance important?
  9. 9. Antimicrobial Resistance
  10. 10. • In general, the impact of medications are limited to the patient taking them • Use of antibiotics has an impact not just for the patient using them but the global community as well Antibiotics are a unique medicine
  11. 11. • Antimicrobial resistance is a natural phenomenon • Overuse, misuse and inappropriate use of antibiotics may accelerate this • The delivery of more complex health care which may require longer use of antibiotics • Prolonged hospitalisation • The potential impact of surgical procedures undertaken overseas • Resistant pathogens can now spread easily − during hospitalisation if infection prevention is poor − potential for cross-border transmission through increased travel. How has antimicrobial resistance developed?
  12. 12. Where do we use antibiotics? USA UK • Humans ⎻ Community ⎻ Hospital • Animals ⎻ Pets ⎻ Livestock • Agriculture ⎻ Crops ⎻ Aquaculture
  13. 13. Resistance is not new
  14. 14. Resistance is getting worse 2013 2015 Carbapenem-resistant Enterobacteriaceae
  15. 15. Antibiotic use in Australia Figure 3.15: Annual total-hospital antibiotic usage rates (DDD/1,000 OBD) in Principal Referral Hospitals contributing to NAUSP, 2017 0 200 400 600 800 1,000 1,200 1,400 1,600 M7 G4 A9 P6 I7 S4 F3 W6 D8 L8 O2 K3 U2 P4 J8 G5 G8 V5 D2 B2 T4 M6 W5 H9 H7 F8 Z9 G2 U7 G3 Antibiotic usage rate (DDD/1,000 OBD) Contributor code
  16. 16. Antibiotic use in Australia, 2017
  17. 17. • Trends in sales of recently launched antibiotics discourage pharmaceutical companies to invest in their research and development Decline in antibiotic production
  18. 18. Robust monitoring and evaluation are needed in order to measure progress towards the delivery of the global action plan on antimicrobial resistance (GAP) objectives, and help identify key achievements and persisting gaps across human, animal, plant, food, and environment sectors in efforts to tackle antimicrobial resistance Antimicrobial Resistance – Global Response
  19. 19. In March 2020, the Australian Government released the second antimicrobial resistance strategy Australia’s National Antimicrobial Resistance Strategy - 2020 and Beyond to guide the response to the threat of antimicrobial misuse and resistance. Objectives: Australia’s response to antimicrobial resistance
  20. 20. The AURA Surveillance System: ⎻ Coordinates the integration of data from a range of sources on antimicrobial use and antimicrobial resistance ⎻ Contributes significantly to the development and implementation of health strategies to respond to, monitor and prevent antimicrobial resistance in Australia Surveillance of Antimicrobial Use and Resistance in Australia (AURA)
  21. 21. • In Australia, antimicrobial resistance also affects aged care homes and the community. High levels of antibiotic use in the community (which includes primary and aged care) is a growing concern • Australia is better placed than many countries to respond to antimicrobial resistance through having: - The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System - The National Alert System for Critical Antimicrobial Resistances – CARAlert (as part of AURA) - The Australian Government’s National Antimicrobial Resistance Strategy 2015-2019 - Initiatives developed and implemented by states and territories, and the private sector Australia’s response to antimicrobial resistance
  22. 22. Surveillance of Antimicrobial Use and Resistance in Australia (AURA) National Notifiable Diseases Surveillance System National Neisseria Network OrgTRx The AURA National Coordination Unit is responsible for the AURA Surveillance System. Funding for AURA is provided by the Australian Government, and state and territory health departments. Multiple partners contribute data.
  23. 23. • Australia has very high usage of antibiotics in the community ⎻ 41.5% of individual Australians received an antibiotic in 2017 ⎻ Australia remains in the top 25% of countries with the highest community usage compared with European countries and Canada • For the first time since the late 1990s, the rate of antibiotic dispensing under the PBS/RPBS has declined • High levels of inappropriate prescribing were found in ⎻ Respiratory tract infections including COPD ⎻ Amoxicillin–clavulanic acid and cefalexin use AURA 2019 Key Findings – Antibiotic use in the Community
  24. 24. Aged Care Prescribing in Australia, 2018 LINK
  25. 25. Antimicrobial Resistance in Australia, 2017
  26. 26. • Treatment failures • Recurring infections • Longer hospital stays • Longer recovery times • A higher risk of mortality or long term implications • Significant financial cost of treatment Patient impact of antimicrobial resistant infections Watch Glen’s Story here Preventing infections is everybody's business
  27. 27. • Which infections are we seeing? [Insert surveillance data, i.e. what is the most common cause of bacteraemia in your facility] • What are our susceptibility and resistance patterns? ⎻ [Insert hospital data] ⎻ [Numbers of cases] ⎻ [Examples of cases] • Are there local antimicrobial resistance issues? • What are local rates of MRSA, C diff? • Do you have access to a local antibiogram? Antimicrobial resistance locally – What is happening in our health service?
  28. 28. • This is a placeholder for a local example of a patient who experienced a resistant bacterial infection at your healthcare facility • Insert a case study (optional) • You may want to detail the: − diagnosis and the method of diagnosis − bacterium that was resistant to the preferred antibiotic − medications used to treat the bacterial infection − time, resources and people involved to treat the infection − impact on the patient, the patient’s life and patient’s family − immediate, medium or long-term health implications (if any). Patient story
  29. 29. Monitoring of Critical Antimicrobial Resistance (CARAlert) Link to latest CARAlert Report Species Critical resistance Acinetobacter baumannii complex Carbapenemase-producing Candida auris – Enterobacterales Carbapenemase-producing, and/or ribosomal methyltransferase-producing Enterobacterales Transmissible colistin resistance Enterococcus species Linezolid resistant Mycobacterium tuberculosis Multidrug-resistant (resistant to at least rifampicin and isoniazid) Neisseria gonorrhoeae Ceftriaxone non-susceptible or azithromycin non-susceptible Salmonella species Ceftriaxone non-susceptible Shigella species Multidrug-resistant Staphylococcus aureus Vancomycin, linezolid or daptomycin non- susceptible Streptococcus pyogenes Penicillin reduced susceptibility Pseudomonas aeruginosa Carbapenemase-producing
  30. 30. • Resistance mechanisms to ‘last-line’ antibiotics • 2,979 results – January 2017 to December 2018 • Azithromycin- or ceftriaxone-nonsusceptible Neisseria gonorrhoeae was the most frequently reported in 2017 (48% of isolates) • Carbapenemase producing Enterobacterales (CPE) were the most frequently reported in 2019 (49% of isolates) • Over three-quarters of all CARs were from clinical specimens including urine, wound, blood Critical Antimicrobial Resistances (CAR)
  31. 31. The National Antimicrobial Utilisation Surveillance Program (NAUSP) is a partner in AURA and collects data on antimicrobial use. Factors that are likely to have contributed to reduced use include: • Increased capacity of local, state and territory, and national AMS programs • Changes in clinical practice • More effective adoption of recommendations in Therapeutic Guidelines: Antibiotic. Aggregate Hospital Antibiotic Use 2017 (NAUSP) Figure 3.1: Annual total-hospital aggregate antibiotic usage rate (DDD/1,000 OBD) in NAUSP contributor hospitals, 2007–2017
  32. 32. • Insert local antibiotic use data (if available) • Include information about your contributions to National Antimicrobial Usage Surveillance Program (NAUSP) • Insert NAUSP data. Local Antibiotic Use
  33. 33. Whilst antimicrobial utilisation is a good measure for the success of antimicrobial prescribing interventions it does not assess why the antimicrobial was used. Utilisation: how much we use? Appropriateness: was it a good choice? Utilisation vs Appropriateness
  34. 34. • National Antimicrobial Prescribing Survey (NAPS) - In 2017, 22.4% of all prescriptions from all participants were deemed “inappropriate” (n= 24,987 prescriptions) Appropriateness of prescribing in Australia
  35. 35. • Does your healthcare facility audit appropriateness of prescribing? • What tools are used (e.g.. National Antimicrobial Prescribing Survey [NAPS], jurisdictional audit tools) • If participating in NAPS, insert your healthcare facilities results here: • Consider − results compared to national results − Time series data − how the your facility’s NAPS results have contributed to your AMS program. Appropriateness of prescribing at our hospital
  36. 36. May increase risk of adverse effects, including: ⎻ AMR (current and future patients) ⎻ Antimicrobial allergy ⎻ Treatment failure ⎻ Toxicity (e.g. ototoxicity) ⎻ Clostridioides difficile (formely called Clostridium difficile) ⎻ Increased health care costs (i.e. length of stay) Why is inappropriate use important? Reason Yes (%) No (%) Not specified (%) Spectrum too broad 21.9% 46.3% 31.8% Incorrect dose or frequency 20.1% 50.9% 29.0% Antimicrobial not required 17.5% 49.8% 32.7% Incorrect duration 16.5% 51.0% 32.5% Spectrum too narrow 6.6% 58.8% 34.6% Incorrect route 5.2% 60.6% 34.3% n = 5,864 Reasons for a reported prescription being assessed as inappropriate, Hospital NAPS contributors, 2017
  37. 37. • In 2017, a large proportion of the Australian population had at least one antimicrobial dispensed under the PBS (41.5%, n = 10,215,109) Antibiotics in primary care – Pharmaceutical Benefit Scheme (PBS) Figure 3.24: Quantity of antibiotics dispensed under the PBS/RPBS (DDD/1,000 inhabitants/day), 2013–2017
  38. 38. • The Antimicrobial Medicines Dispensing from 2013–14 to 2017–18 report out today also has some encouraging findings, with a downward trend in national antimicrobial dispensing rates, which fell 13.3% over five years. • Australia’s antimicrobial prescription rate remains high by international standards, and is double that of comparable OECD countries such as The Netherlands and Sweden Antibiotics in Primary Care
  39. 39. • In 2017, only 33.4% of antibiotics prescribed had the reason for the prescription recorded • An indication for antibiotic use could not be identified for 30% of prescriptions • Patients still received antibiotic prescriptions for influenza/upper respiratory tract infections ⎻ But antimicrobials are not generally recommended for these conditions Antibiotics in primary care – NPS MedicineWise Medicine Insight
  40. 40. • Variation raises concerns about equity and safety and appropriateness of care • There is marked variation in use of antibiotics − between states − between hospitals  different sizes  within the same size • The reasons for this are not well understood • Also marked variation in community dispensing of antibiotics in 2016-17 − The magnitude of variation was 4.5 times − A reduction in the rate of antimicrobial prescriptions nationally by 9% compared to 2013-14 Understanding Variation
  41. 41. Antimicrobial Stewardship isn’t about “not using antimicrobials” but rather “identify that small group of patients who really need antibiotic treatment and then explain, reassure and educate the large group of patients who don’t” • Stewardship means to protect something • AMS is a systematic approach to optimising the use of antimicrobials • Goals of AMS are to: ‒ improve patient outcomes / patient safety ‒ reduce antimicrobial resistance ‒ reduce costs. • AMS works hand-in-hand with infection prevention and control, and environmental cleaning strategies Antimicrobial Stewardship (AMS)
  42. 42. Safety – bring up to the minimum acceptable and sustainable standard Quality – aspiring to the best possible quality and effectiveness of care Equity – ensuring every patient regardless of their cultural or linguistic background has the same experience of care Has the right patient received the right antibiotic, at the right time, at the right dose, via the right route for the right duration? Is there a systematic approach to ensure each patient using antimicrobials is managed with the principles of AMS? Does your organisation keep up to date with the latest evidence and strive to innovate and implement that standard of care? Antimicrobial Stewardship (AMS) – Safety, Quality and Equity dimensions
  43. 43. A Critical Balance Risk of toxicity and adverse drug reactions
  44. 44. Antimicrobial Stewardship = least harm to current/future patients Right dose
  45. 45. • Clear organisational structure and governance • Executive and clinical leadership • AMS advisory committee • Multidisciplinary clinical AMS team • Expert advice from − infectious diseases experts − microbiologists − pharmacists • Education and training − prescribers, pharmacists, nurses − consumers • Information technology resources. Enablers for effective for AMS Programs - Hospitals
  46. 46. Essential strategies for AMS Programs - Hospitals Pre-prescription Post-prescription Formulary management Direct patient input e.g. AMS Round Restriction System Audit and Feedback Guidelines Monitor appropriateness – National Antimicrobial Prescribing Survey (NAPS) Education Monitor utilisation – National Antimicrobial Utilisation Surveillance Program (NAUSP) Antibiograms (susceptibility of microogranisms to antimicrobials) Education Selective reporting of susceptibility testing Electronic solutions - eMeds – automatic stops Confirming patient’s allergy status IV to Oral switch
  47. 47. Insert information on your AMS service: ⎻ Structure, governance – who is responsible? ⎻ Who leads AMS activities? ⎻ Who is on your local AMS team? ⎻ What AMS activities are undertaken? ⎻ What AMS activities are you / your department involved in? Antimicrobial Stewardship in our healthcare facility AMS Team Microbiologist Infectious Diseases Specialist Antimicrobial Stewardship Pharmacist Infection Control Nurses AMS Pharmacy Technician
  48. 48. • In the community ⎻ General Practice  Not prescribing antibiotics for colds and flu  Delayed prescribing  Shared decision making  Public declarations in the practice about conserving antibiotics ⎻ Pharmacies  Offering symptomatic support for cold and flu Antimicrobial Stewardship – not just for hospitals
  49. 49. • In the home ⎻ Not taking antibiotics that haven’t been prescribed for you ⎻ Discarding old antibiotic medicines appropriately • In industry ⎻ Investing in research and development for antimicrobials
  50. 50. • COVID-19 pandemic has presented many additional challenges (including antimicrobial shortages) for managing patients with infections • It is even more important to prevent infections and reduce inappropriate antibiotic use • Key message: ⎻ Explain to patient that antibiotics do not prevent or treat COVID- 19 but can cause adverse effects, allergic reactions, drug interactions and increase risk of future resistant infections AMS during COVID-19
  51. 51. • New Chapters! ⎻ General Practice – Published! ⎻ In the Care of Children – Published! ⎻ Aboriginal and Torres Strait Islander Populations – on the way AMS in Australian Health Care Book
  52. 52. National Safety and Quality Health Service Standards
  53. 53. • Always use the most current version ⎻ Currently version 16, 2019 ⎻ Now only in online format • Check hospital intranet • A ‘go to’ reference, especially where there are limited local guidelines • Learn more ⎻ www.tg.org.au ⎻ click ‘Products’, then ‘Antibiotic’ Therapeutic Guidelines: Antibiotic
  54. 54. • Use this slide to highlight any AMS initiatives your organisation has completed recently • This may be ⎻ A new guideline ⎻ A new audit ⎻ A new service or multidisciplinary team success
  55. 55. Insert information on AAW in your health service: • Join the conversation on social media: ⎻ Hashtags  #worldantimicrobialawarenessweek  #WAAW  #AntibioticResistance  #AMR ⎻ @ACSQHC • Local activities and contact people • Include information about local activities Local Antibiotic Awareness Week Activities
  56. 56. Ideas! • Get Creative  • Pick a target area • Examples • IV to Oral Switch • Penicillin Allergy • Surgical Prophylaxis
  57. 57. Antimicrobial resistance: ⎻ occurs when an organism evolves and develops resistance to an antimicrobial that should inhibit or destroy it ⎻ is reducing the effectiveness of antimicrobials to treat infections ⎻ is happening now • Few new antimicrobials are being developed • The misuse, overuse, and inappropriate use of antimicrobials contributes to antimicrobial resistance • Antimicrobial stewardship works hand in hand with prevention and control strategies to help address antimicrobial resistance. Key messages
  58. 58. • NPS MedicineWise/ACSQHC Antimicrobial Prescribing Modules - https://learn.nps.org.au/mod/page/view.php?id=4282 • Future Learn - https://www.futurelearn.com/courses/antimicrobial- stewardship • Stanford AMS Course - http://errolozdalga.com/medicine/pages/OtherPages/AntibioticRevi ew.ChanuRhee.html • MAD-ID Course - http://mad-idtraining.org/certification/ • Infections in Surgery Course - https://infectionsinsurgery.org/management-of-intra-abdomianl- infections-free-online-course/ • WHO Course - https://openwho.org/courses/AMR-competency Online Resources for AMS
  59. 59. References Slide Number Website 4 https://www.reactgroup.org/toolbox/understand/antibiotics/ 6 https://www.safetyandquality.gov.au/publications-and-resources/resource-library/priority-antibacterial-list- antimicrobial-resistance-containment 10 Image - https://www.researchgate.net/figure/Total-deaths-projected-by-2050-attributable-to-antimicrobial-resistance- AMR-every-year_fig2_340990507 11 Image - http://blog.nus.edu.sg/singaporesling/2016/11/16/the-resistible-rise-of-antibiotic-resistance/ 13 Image courtesy of CDC / Melissa Brower Centers for Disease Control and Prevention Public Health Image Library http://phil.cdc.gov/phil/home.asp 14 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/843129/English_Sur veillance_Programme_for_Antimicrobial_Utilisation_and_Resistance_2019.pdf https://www.nejm.org/doi/full/10.1056/nejmp1311479 15 https://www.businessinsider.com.au/alexander-fleming-predicted-post-antibiotic-era-70-years-ago-2015-7
  60. 60. References Slide Number Website 16 https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/carbapenem-resistant- enterobacteriaceae-risk-assessment-april-2016.pdf 17 Source: The Antimicrobial Resistance Standing Committee (2013) National Surveillance and Reporting of Antimicrobial Resistance and Antibiotic Usage for Human Health in Australia. 18 AURA 2019 Report - https://www.safetyandquality.gov.au/aura-2019 19 AURA 2019 Report - https://www.safetyandquality.gov.au/aura-2019 20 Butler M, Blaskovich M, Cooper M. Antibiotics in the clinical pipeline in 2013. J. Antibiot 2013;66: 571-591 21 Lee Ventola C. The Antibiotic Resistance Crisis Part 1: Causes and Threats. P T 2015 Apr; 40(4): 277–283 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378521/ Fernandes V, Martens E. Antibiotics in late clinical development. Biochemical Pharmacology 2017 June 1; 133: 152-163 https://www.sciencedirect.com/science/article/pii/S0006295216303082 22 https://apps.who.int/iris/handle/10665/325006
  61. 61. References Slide Number Website 23 https://www.amr.gov.au/resources/australias-national-antimicrobial-resistance-strategy-2020-and-beyond 24 AURA 2019 Report - https://www.safetyandquality.gov.au/aura-2019 28 https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial-use-and-resistance-australia- surveillance-system-aura/antimicrobial-prescribing-australian-residential-aged-care 29 https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial-use-and-resistance-australia-surveillance- system-aura/community-antimicrobial-resistance/australian-group-antimicrobial-resistance 30 YouTube - Glen’s Story - https://www.youtube.com/watch?v=RIsBB6TmZvA 33 https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial-use-and-resistance-australia-surveillance- system/national-alert-system-critical-antimicrobial-resistances-caralert 34 https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial-use-and-resistance-australia-surveillance- system/national-alert-system-critical-antimicrobial-resistances-caralert
  62. 62. References Slide Number Website 35 NAUSP 2018 Report - https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial- use-and-resistance-australia-surveillance-system-aura/hospital-antimicrobial-use/antimicrobial-use-australian- hospitals 38 NAPS 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/naps- 2/?section=4 40 NAPS 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/naps- 2/?section=4 41 Goff D.A, File T.M, The risk of prescribing antibiotics “just-in-case” there is infection, Seminars in Colon and Rectal Surgery 29 (2018), 44-48 https://www.sciencedirect.com/science/article/abs/pii/S1043148917300763 42 AURA 2019 Report - https://www.safetyandquality.gov.au/aura-2019 43 safetyandquality.gov.au/antimicrobials-report-2020 45 https://www.safetyandquality.gov.au/our-work/healthcare-variation
  63. 63. References Slide Number Website 46 Verheij TJ. The antibiotic revolution should be more focused. Br J Gen Pract. 2009;59(567):716-717. doi:10.3399/bjgp09X472557 - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751913/ 48 Ohio Society of Health-System Pharmacists (2016 Annual Meeting). Meet the Antimicrobial Stewardship Pharmacists https://c.ymcdn.com/sites/www.ohioshp.org/resource/resmgr/AM_2016_Slides/4BoyleCraftetal- MeettheAntim.pdf 53 https://www1.health.gov.au/internet/main/publishing.nsf/Content/Nudge-vs-Superbugs-behavioural-economics-trial-to- reduce-overprescribing-antibiotics-June-2018 56 https://www.tg.org.au/news/antibiotic-summary-table/ 57 https://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/antimicrobial-stewardship/ 58 https://www.safetyandquality.gov.au/publications-and-resources/resource-library/antimicrobial-stewardship-australian- health-care-2018 59 https://www.safetyandquality.gov.au/sites/default/files/2019-06/AURA-2019-Consumer-resource-Trifold-Brochure-Do-I- really-need-Content-from-Literally-Inspired.pdf https://www.nps.org.au/medical-info/consumer-info/antibiotic-resistance-the-facts
  64. 64. References Slide Number Website 60 https://www.safetyandquality.gov.au/standards/nsqhs-standards/preventing-and-controlling-healthcare- associated-infection-standard/antimicrobial-stewardship 61 https://www.safetyandquality.gov.au/our-work/clinical-care-standards/antimicrobial-stewardship-clinical-care- standard/ 62 https://www.tg.org.au/ 64 https://thepulse.org.au/2017/11/14/what-is-the-future-of-antibiotics/ 65 Acknowledgement: Toronto East Health Network
  65. 65. Safetyandquality.gov.au Twitter.com/ACSQHS Youtube.com/user/ACSQHC