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Objectives: To report the quarterly incidence of hospital‐identified Clostridium difficile infection (HI‐CDI) in Australia, and to estimate the burden ascribed to hospital‐associated (HA) and community‐associated (CA) infections. Design, setting and patients: Prospective surveillance of all cases of CDI diagnosed in hospital patients from 1 January 2011 to 31 December 2012 in 450 public hospitals in all Australian states and the Australian Capital Territory. All patients admitted to inpatient wards or units in acute public hospitals, including psychiatry, rehabilitation and aged care, were included, as well as those attending emergency departments and outpatient clinics. Main outcome measures: Incidence of HI‐CDI (primary outcome); proportion and incidence of HA‐CDI and CA‐CDI (secondary outcomes). Results: The annual incidence of HI‐CDI increased from 3.25/10 000 patient‐days (PD) in 2011 to 4.03/10 000 PD in 2012. Poisson regression modelling demonstrated a 29% increase (95% CI, 25% to 34%) per quarter between April and December 2011, with a peak of 4.49/10 000 PD in the October–December quarter. The incidence plateaued in January–March 2012 and then declined by 8% (95% CI, − 11% to − 5%) per quarter to 3.76/10 000 PD in July–September 2012, after which the rate rose again by 11% (95% CI, 4% to 19%) per quarter to 4.09/10 000 PD in October–December 2012. Trends were similar for HA‐CDI and CA‐CDI. A subgroup analysis determined that 26% of cases were CA‐CDI. Conclusions: A significant increase in both HA‐CDI and CA‐CDI identified through hospital surveillance occurred in Australia during 2011–2012. Studies are required to further characterise the epidemiology of CDI in Australia.

ObjectivesHospital-acquired bloodstream infections are known to increase the risk of death and prolong hospital stay, but precise estimates of these two important outcomes from well-designed studies are rare, particularly for non-intensive care unit (ICU) patients. We aimed to calculate accurate estimates, which are vital for estimating the economic costs of hospital-acquired bloodstream infections.DesignCase–control study.Setting9 Australian public hospitals.ParticipantsAll the patients were admitted between 2005 and 2010.Primary and secondary outcome measuresRisk of death and extra length of hospital stay associated with nosocomial infection.ResultsThe greatest increase in the risk of death was for a bloodstream infection with methicillin-resistant Staphylococcus aureus (HR=4.6, 95% CI 2.7 to 7.6). This infection also had the longest extra length of stay to discharge in a standard bed (12.8 days, 95% CI 6.2 to 26.1 days). All the eight bloodstream infections increased the length of stay in the ICU, with longer stays for the patients who eventually died (mean increase 0.7–6.0 days) compared with those who were discharged (mean increase: 0.4–3.1 days). The three most common organisms associated with Gram-negative infection were Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumonia.ConclusionsBloodstream infections are associated with an increased risk of death and longer hospital stay. Avoiding infections could save lives and free up valuable bed days.

Background The development of antimicrobial resistance, which is partially attributable to the overuse and/or misuse of antibiotics in health care, is one of the greatest global public health challenges. In Sub-Saharan African (SSA) countries, non-prescribed dispensing of antibiotics in community drug retail outlets (CDROs) has been flagged as one of the contributing factors for the widespread misuse of antibiotics in the community. Objective The current review aimed to estimate the proportion of non-prescription antibiotics requests or consultations that resulted in provision of antibiotics without a valid prescription among CDROs in SSA region, and describe the type of antibiotics dispensed. Methods A literature search was conducted using PubMed, CINAHL, Scopus and Google Scholar. We also searched reference lists of relevant articles. Random effect model meta-analysis was employed to determine the pooled proportion of over the counter sale of antibiotics. Subgroup and meta-regression was undertaken to explore the potential cause of heterogeneity in effect size across studies. Results Of 671 total citations retrieved, 23 met the inclusion criteria (seven cross-sectional questionnaire-based surveys and 16 cross-sectional client-based studies). The overall pooled proportion of non-prescription antibiotics requests or consultations that resulted in supply of antibiotics without prescription was 69% (95% CI 58–80). Upper respiratory tract infections and/or acute diarrhoea were the most frequently presented case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed antibiotics to treat those symptoms. Conclusions Non-prescribed dispensing of antibiotics was found to be a common practice among CDROs in several SSA countries. Ease of access to and overuse of antibiotics can potentially accelerate the emergence of resistance to antibiotics available in the region. Our review highlights the need for a stringent enforcement of existing policies and/or enacting new regulatory frameworks that would regulate antibiotic supply, and training and educational support for pharmacy personnel (e.g. pharmacists, pharmacy assistants) regarding judicious use of antibiotics and the importance of antimicrobial stewardship.

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BackgroundInfluenza vaccination is a commonly used intervention to prevent influenza infection in healthcare workers (HCWs) and onward transmission to other staff and patients. We undertook a systematic review to synthesize the latest evidence of the direct epidemiological and economic effectiveness of seasonal influenza vaccination among HCW.MethodsWe conducted a systematic search of MEDLINE/PubMed, Scopus, and Cochrane Central Register of Controlled Trials from 1980 through January 2018. All studies comparing vaccinated and non-vaccinated (i.e. placebo or non-intervention) groups of HCWs were included. Research articles that focused on only patient-related outcomes or monovalent A(H1N1)pdm09 vaccines were excluded. Two reviewers independently selected articles and extracted data. Pooled-analyses were conducted on morbidity outcomes including laboratory-confirmed influenza, influenza-like illnesses (ILI), and absenteeism. Economic studies were summarized for the characteristics of methods and findings.ResultsThirteen articles met eligibility criteria: three articles were randomized controlled studies and ten were cohort studies. Pooled results showed a significant effect on laboratory-confirmed influenza incidence but not ILI. While the overall incidence of absenteeism was not changed by vaccine, ILI absenteeism was significantly reduced. The duration of absenteeism was also shortened by vaccination. All published economic evaluations consistently found that the immunization of HCW was cost saving based on crude estimates of avoided absenteeism by vaccination. No studies, however, comprehensively evaluated both health outcomes and costs of vaccination programs to examine cost-effectiveness.DiscussionOur findings reinforced the influenza vaccine effects in reducing infection incidence and length of absenteeism. A better understanding of the incidence of absenteeism and comprehensive economic program evaluations are required to ensure the best possible management of ill HCWs and the investment in HCW immunization in increasingly constrained financial environments. These steps are fundamental to establish sustainability and cost-effectiveness of vaccination programs and underpin HCW immunization policy.

ObjectiveIn recent years, there have been considerable increases in both the utilisation and reported harms of prescription opioids in Australia. This report details the development of adaptable resources, implementation and the evaluation of pilot projects that optimise oxycodone prescribing and introduce concepts of opioid stewardship into hospital settings. MethodsAn adaptable suite of resources, based on principles of implementation science, was developed and used to facilitate the projects. Local prescribing practice audits of oxycodone guided the development of context-sensitive educational strategies that were piloted and evaluated in a repeat audit. The primary outcome was the proportion of oxycodone prescriptions indicating tailored prescribing practices. In emergency departments (EDs), a prescription was considered tailored if it was for ≤10 tablets. In surgery, tailored prescriptions were those given to patients who had required opioids in the 24h before discharge. ResultsCumulative results of the pilot projects in three EDs demonstrated improved rates of tailored oxycodone prescribing on discharge (62% vs 90%; P<0.0001). In the surgical setting of one hospital, tailored prescribing increased significantly (from 76% to 91%; P=0.013) and was accompanied by a halving of the proportion of patients receiving oxycodone prescriptions (36% vs 18%; P<0.001). ConclusionsThe implementation of facilitated, adaptable, prescriber-led quality improvement projects significantly improved tailored oxycodone prescribing practices and provides a platform to advance further opioid-related practice improvement in Australia. What is known about the topic?The increasing trend in opioid prescribing, misuse, harm and death in Australia, and the potential for hospital prescribing to contribute to long-term opioid use, is well known. Recent changes to the Pharmaceutical Benefits Scheme are designed to help better identify patients who need oxycodone on discharge and the quantity to prescribe, rather than default prescribing. However, how to implement tailored prescribing has not been described in detail in the Australian literature. What does this paper add?This paper adds to the mass of literature describing the ‘problem’ of opioid prescribing by providing a ‘solution’ in the form of evidence for the implementation of a facilitated and adaptable quality improvement strategy in emergency and surgical settings. The focus is not on a reduction of opioids, but rather on providing tailored pain management and opioid prescribing. What are the implications for practitioners?This paper provides a practical, pragmatic and achievable starting point for other Australian practitioners to adapt the described processes and take the first steps towards opioid stewardship in their setting.

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