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India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.

ObjectivesThis study responds to calls for greater focus on nursing roles, and the need for nursing integration within the antimicrobial optimisation agenda. The objective of this study was to explore Australian hospital nurses’ views on antimicrobial resistance and antimicrobial stewardship (AMS) in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimisation within hospital settings.DesignQualitative one-on-one, semistructured interviews. Interview transcripts were digitally audio-recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory.SettingFour hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states.Participants86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages.ResultsFindings were organised into three thematic domains: (1) the current peripheral role of nurses in AMS; (2) the importance of AMS as a collaborative effort, and current tensions around interprofessional roles and (3) how nurses can bolster antimicrobial optimisation within AMS and beyond.ConclusionNursing staff are central to infection management within the hospital and are thus ideally located to enhance antibiotic optimisation and contribute to AMS governance. However, without increased interprofessional cooperation, education and integration in the AMS agenda, as well as addressing organisational/resource constraints in the hospital, the nursing role in stewardship will remain limited.

BackgroundAustralia has unrestricted access to direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment. In order to increase access to treatment, primary care providers are able to prescribe DAA after fibrosis assessment and specialist consultation. Transient elastography (TE) is recommended prior to commencement of HCV treatment; however, TE is rarely available outside secondary care centres in Australia and therefore a requirement for TE could represent a barrier to access to HCV treatment in primary care.ObjectivesIn order to bridge this access gap, we developed a community-based TE service across the Sunshine Coast and Wide Bay areas of Queensland.DesignRetrospective analysis of a prospectively recorded HCV treatment database.InterventionsA nurse-led service equipped with two mobile Fibroscan units assesses patients in eight locations across regional Queensland. Patients are referred into the service via primary care and undergo nurse-led TE at a location convenient to the patient. Patients are discussed at a weekly multidisciplinary team meeting and a treatment recommendation made to the referring GP. Treatment is initiated and monitored in primary care. Patients with cirrhosis are offered follow-up in secondary care.Results327 patients have undergone assessment and commenced treatment in primary care. Median age 48 years (IQR 38–56), 66% male. 57% genotype 1, 40% genotype 3; 82% treatment naïve; 10% had cirrhosis (liver stiffness >12.5 kPa). The majority were treated with sofosbuvir-based regimens. 26% treated with 8-week regimens. All patients had treatment prescribed and monitored in primary care. Telephone follow-up to confirm sustained virological response (SVR) was performed by clinic nurses. 147 patients remain on treatment. 180 patients have completed treatment. SVR data were not available for 19 patients (lost to follow-up). Intention-to-treat SVR rate was 85.5%. In patients with complete data SVR rate was 95.6%.ConclusionCommunity-based TE assessment facilitates access to HCV treatment in primary care with excellent SVR rates.

Surgical antibiotic prophylaxis (SAP) is a common area of antimicrobial misuse. The aim of this study was to explore the social dynamics that influence the use of SAP. 20 surgeons and anaesthetists from a tertiary referral hospital in Australia participated in semi-structured interviews focusing on experiences and perspectives on SAP prescribing. Interview data were analysed using the framework approach. Systematic analysis of the participants’ account of the social factors influencing SAP revealed four themes. First, antibiotic prophylaxis is treated as a low priority with the competing demands of the operating theatre environment. Second, whilst guidelines have increased in prominence in recent years, there exists a lack of confidence in their ability to protect the surgeon from responsibility for infectious complications (thus driving SAP over-prescribing). Third, non-concordance prolonged duration of SAP is perceived to be driven by benevolence for the individual patient. Finally, improvisation with novel SAP strategies is reported as ubiquitous, and acknowledged to confer a sense of reassurance to the surgeon despite potential non-concordance with guidelines or clinical efficacy. Surgical-specific concerns have thus far not been meaningfully integrated into antimicrobial stewardship (AMS) programmes, including important dynamics of confidence, trust and mitigating fear of adverse infective events. Surgeons require specific forms of AMS support to enact optimisation, including support for strong collaborative ownership of the surgical risk of infection, and intra-specialty (within surgical specialties) and inter-specialty (between surgery, anaesthetics and infectious diseases) intervention strategies to establish endorsement of and address barriers to guideline implementation.

Background: Antimicrobial therapy for intra-abdominal infections is often inappropriately prolonged. An intervention addressing factors influencing the duration of intravenous antibiotic use was undertaken. This study reports the antibiotic prescribing patterns before and after the intervention and a qualitative analysis of the experience of the intervention. Methods: Quantitative: A retrospective audit of patients with complicated intra-abdominal infection before and after a multifaceted persuasive intervention was performed. Qualitative: Semi-structured interviews were performed to evaluate which elements of the intervention were perceived to be effective. Results: An intervention including collaborative inter-specialty and inter-professional educational meetings, and education of all professional streams was undertaken. Quantitative: Twenty-three patients before and 22 patients after the intervention were included. The total duration of antibiotics decreased significantly following the intervention (9.2 versus 6.6 days P = 0.02). The duration of intravenous antibiotics did not change significantly (5.4 versus 4.5 days, P = 0.06). Qualitative: Eighteen health-care professionals participated. Thematic analysis indicated that a collaborative approach between senior surgical and infectious disease specialists in the pre-intervention stage led to perceived ownership and leadership of the intervention by the surgical team, which was thought critical to the success of the intervention. Conversely, the ability of nurses and pharmacists to influence antibiotic practice was considered limited and a poster promoting the intervention was perceived as ineffective. Conclusion: Consultant leadership and specialty ownership of the process were perceived to be critical in the success of the intervention. Antibiotic stewardship programs which address social factors may have greater efficacy to optimize antimicrobial prescribing.

Background Surgical antibiotic prophylaxis (SAP) is a critical area to optimize to reduce the escalation of antimicrobial resistance. This article explores the ways by which interpersonal relationships influence SAP decision making. Methods Twenty surgeons and anesthetists participated in in-depth semistructured interviews on SAP prescribing. Results were analyzed using the framework approach. Results Analysis revealed 3 ways by which interpersonal relationships influence SAP: relationship dynamics between the surgeon and the anesthetist determine appropriateness of SAP, particularly operative risk ownership; perceived hierarchies within, and between, surgical and anesthetist specialties influence antibiotic prescribing decisions; and surgical distance from the antimicrobial stewardship team, which influences use of antimicrobial stewardship principles. Conclusions Interventions to optimize SAP are more likely to be effective in enacting sustained change if they consider the interpersonal and social contexts, including issues of familiarity and cohesiveness, hierarchical patterns, and sense of place within a team. Significant relational dynamics in SAP decision making are centered around risk; that is, personal/reputational risk to different professional groups and ownership of risk for individual patient outcomes. Risk must therefore be considered for sustainable SAP optimization interventions.

Diarrhoea that occurs during or after recent travel is predominantly infectious in nature; however, in atypical or prolonged cases a broader range of aetiologies for diarrhoea must be considered, and a careful history and examination may reveal clues to more sinister causes of diarrhoea. We report two cases in which a recent travel history and a positive stool culture or polymerase chain reaction testing for bacterial pathogens delayed the diagnosis of ulcerative colitis. As a result of severe inflammatory bowel disease, colectomy was the final result in both cases. Early consideration of causes other than infection for traveller's diarrhoea may prevent unnecessary morbidity in young patients.

The looming global antibiotic crisis, and the need to curtail over-use, has been positioned variously as a medical problem, an urgent public health concern, and an issue of governance and political will. But few questions have been raised in terms of its economic drivers. Specifically, how infection management—and the problematic of antimicrobial resistance—may be deeply embedded in economic imperatives and relations of labour. Drawing on interviews with 31 health professionals (doctors, nurses, pharmacists) from a private hospital in Australia, we explore their accounts of the dynamics of care and the economic imperatives in (and beyond) infection management. We argue that market-driven forces create a distinct set of obligations that could undermine the local and global antibiotic optimisation agenda. Given the increasingly privatised landscape of healthcare in Australia and internationally, exploring the nexus of economics and practice will be vital in retaining antibiotics for the future.

The growing global concern around antimicrobial mis-use and proliferating resistance has resulted in increasing interest in optimising antibiotics, particularly in hospitals. While the agenda to tighten antibiotic use has been critically explored in metropolitan settings, the dynamics of rural and remote settings have remained largely unexplored. Drawing on 30 interviews with doctors, nurses, and pharmacists in a remote Australian hospital, we focus on the pertinence of setting, and its importance for contextualising and potentially achieving antibiotic optimisation. Building on previous work on the dynamics of locale and core-periphery relations, here we consider how antimicrobial practice is deeply embedded in experiences of being on the geographical periphery, and crucially, at the periphery of (established) knowledge.

Objectives This study aimed to examine how hospital doctors balance competing concerns around antibiotic use and resistance, with a focus on individual care versus broader public health considerations. Methods Sixty-four doctors across two hospitals in Australia participated in semi-structured interviews about their perspectives on antibiotic resistance and prescribing decisions. Results were analysed using the framework approach. Results The first theme focused on the significance of antimicrobial resistance (AMR) and the role of hospital doctors. Participants did not perceive resistance to be central to clinical decision-making, and externalised the resistance threat. They perceived themselves as separated from the issue of escalating resistance, viewing the key drivers to be overseas use, use in agriculture, and community prescribing. The second theme was around balancing risks. Immediate clinical risks were described as prioritised over long term population risk. Participants described concern around reputational and legal risks, which were perceived to be associated with under-prescribing of antibiotics. Over-prescribing was described by participants to be easier and without perceived immediate risk to them or to patients. Conclusion Hospital doctors perceived antimicrobial resistance as externally produced and described clinical concerns taking precedence in individual antibiotic decisions. These dual processes mean that a population health model has limited traction in the hospital context. The externalisation of resistance leads to a sense of futility in changing practice, which combines with the pressures of acute medicine to prioritise immediate patient outcomes. Such dynamics are leading to antibiotic optimisation as a low or absent priority in hospital clinician antibiotic decision-making.

Background The treatment of pulmonary infections is one of the largest indications for antibiotics in human health care, offering significant potential for antibiotic optimization internationally. This study explores the perspectives of pulmonary clinicians on antibiotic use in hospital pulmonary infections. Methods Twenty-eight pulmonary doctors and nurses from 2 hospitals participated in semi-structured interviews focusing on their experiences of antibiotic use. Results Barriers to antibiotic optimization in pulmonary infections were identified. Clinical barriers are as follows. The first is differentiating pneumonia vs chronic obstructive pulmonary disease: differentiating pulmonary diagnoses was reported as challenging, leading to overtreatment. The second is differentiating viral vs bacterial: diagnostic differentiation was perceived to contribute to excess antibiotic use. The third is differentiating colonization vs pathogen: the interpretation of ambiguous results was reported to lead to under- or overprescribing depending on the perspective of the treating team. Social barriers are as follows. The first is the perception of resistance: antibiotic resistance was not perceived as an immediate threat. The second is the perceived value of antibiotic clinical guidelines: there was mistrust in antibiotic guidelines. The third is hospital hierarchies: hierarchical structures had a significant influence on prescribing. Conclusions Substantial barriers to antibiotic optimization in pulmonary infections were identified. To facilitate change in antibiotic use there must be a systematic understanding and interventions to address specific clinical issues. In the case of pulmonary medicine, significant identified issues, such as mistrust in clinical guidelines and diagnostic challenges, need to be addressed.

Given the global crisis of antimicrobial resistance, the continued misuse of antibiotics is perplexing, particularly despite persistent attempts to curb usage. This issue extends beyond traditional “wastage” areas, of livestock and community medicine, to hospitals, raising questions regarding the current principles of hospital practice. Drawing on five focus group discussions, we explore why doctors act in the ways they do regarding antibiotics, revealing how practices are done, justified, and perpetuated. We posit that antibiotic misuse is better understood in terms of social relations of fear, survival and a desire for autonomy; everyday rituals, performances, and forms of professional etiquette; and the mixed obligations evident in the health sector. Moreover, that antibiotic misuse presents as a case study of the broader problematic of defensive medicine. We argue that the impending global antibiotic crisis will involve understanding how medicine is built around certain logics of practice, many that are highly resistant to change.

Antibiotic resistance poses a significant global threat, yet clinically inappropriate antibiotic use within hospitals continues despite the implementation of abatement strategies. Antibiotic use and the viability of existing antibiotic options now sit precariously at the nexus of political will, institutional governance and clinical priorities ‘at the bedside’. Yet no study has hitherto explored the perspectives of managers, instead of focusing on clinicians. In this article, drawing on qualitative interviews with hospital managers, we explore accounts of responding to antimicrobial resistance, managing antibiotic governance and negotiating clinical and managerial priorities. We argue that the managers’ accounts articulate the problematic nexus of measurement and accountability, the downflow effects of political will, and core tensions within the hospital between moral, managerial and medical authority. We apply Bourdieu’s theory of practice to argue that an understanding of the logics of practice within the ‘hospital management classes’ will be critical in efforts to protect antibiotics for future generations.

Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over four million people worldwide. There are multiple reports of prolonged viral shedding in people infected with SARS-CoV-2 but the presence of viral RNA on a test does not necessarily correlate with infectivity. The duration of quarantine required after clinical recovery to definitively prevent transmission is therefore uncertain. In addition, asymptomatic and presymptomatic transmission may occur, and infectivity may be highest early after onset of symptoms, meaning that contact tracing, isolation of exposed individuals and social distancing are essential public health measures to prevent further spread. This review aimed to summarise the evidence around viral shedding vs infectivity of SARS-CoV-2., Highlights • Viral shedding has been demonstrated up to 63 days after symptom onset. • The distinction between viral shedding and infectivity is important for the development of quarantine guidelines and policy. • There is an earlier peak in viral load in SARS-CoV-2 than seen in SARS. • Quantitative viral loads are higher in the nose than the throat. • It is likely that asymptomatic and presymptomatic transmission is occurring.

Much has been written about the problem of antimicrobial resistance (AMR) and the action required to rein in this emerging global health threat. Addressing AMR is often operationalised as requiring ‘behavior change’ of clinicians and of patients, in combination with improving the drug development pipeline. Few have approached AMR as a challenge fundamentally embedded within the cultural fabric of modern societies and the (varied) ways they are organised economically, socially and politically. Here, drawing on a decade of work across a range of health contexts, we approach the problem of AMR as one of values and culture rather than of individual behavior. We reframe AMR as a social and political concern resulting from a confluence of factors and practices including: temporal myopia, individualisation, marketisation, and human exceptionalism. To effectively tackle AMR, we advocate solidaristic models that espouse collective responsibility and recognise relative opportunity to act rather than a continuation of the individualistic behavioural models that have, so far, proven largely ineffective.

ObjectivesTo assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance.DesignThe Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation.SettingThe study was undertaken at three hospitals (one regional, two metropolitan) in Australia.ParticipantsSAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods.InterventionQSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing.ResultsThe site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance.ConclusionsThe barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Objectives The 2014–15 Ebola outbreak in West Africa highlighted the challenges many hospitals face when preparing for the potential emergence of highly contagious diseases. This study examined the experiences of frontline health care professionals in an Australian hospital during the outbreak, with a focus on participant views on information, training and preparedness, to inform future outbreak preparedness planning. Study design Semi-structured interviews were conducted with 21 healthcare professionals involved in Ebola preparedness planning, at a hospital in Australia. Methods The data were systematically coded to discover key themes in participants' accounts of Ebola preparedness. Results Three key themes identified were: 1) the impact of high volumes of—often inconsistent—information, which shaped participants' trust in authority; 2) barriers to engagement in training, including the perceived relative risk Ebola presented; and finally, 3) practical and environmental impediments to preparedness. Conclusions These clinicians' accounts of Ebola preparedness reveal a range of important factors which may influence the relative success of outbreak preparedness and provide guidance for future responses. In particular, they illustrate the critical importance of clear communication and guidelines for staff engagement with, and implementation of training. An important outcome of this study was how individual assessments of risk and trust are produced via, and overlap with, the dynamics of communication, training and environmental logistics. Consideration of the dynamic ways in which these issues intersect is crucial for fostering an environment that is suitable for managing an infectious threat such as Ebola., Highlights • Outbreak communication needs to be rigorously controlled for consistency and transparency at all levels. • Risk perception is influenced by lack of trust in the communication provided. • Assessment of training effectiveness and feasibility for outbreak threats should include frontline clinicians. • Dynamics of communication and mistrust can strongly influence the ability of an organisation to implement best practice.

We are likely moving rapidly toward a post-antibiotic era, as a result of escalating antimicrobial resistance, rapidly declining antibiotic production and profligate overuse. Hitherto research has almost exclusively focused on doctors’ prescribing, with nurses’ roles in antibiotic use remaining virtually invisible. Drawing on interviews with 30 nurses, we focus on nurses as brokers of doctors’ antibiotic decisions, nursing capacity to challenge doctors’ decisions, and, “back stage” strategies for circumnavigating organizational constraints. We argue that nurses occupy an essential and conscious position as brokers within the hospital; a subject position that is not neutral, facilitates (short-term) cohesion, and involves the pursuit of particular (preferred) nursing outcomes. Illustrating how authority can be diffuse, mediated by institutionalized praxis, and how professionals evade attempts to govern their practice, we challenge the reification of physician prescribing power, arguing that it may work against the utilization of nurses as important stakeholders in the future of antibiotics.

Summary Background The role of infectious diseases (ID) and clinical microbiology (CM) in hospital settings has expanded in response to increasing antimicrobial resistance, leading to widespread development of hospital antimicrobial stewardship (AMS) programmes, the majority of which include antibiotic approval systems. However, inappropriate antibiotic use in hospitals continues, suggesting potential disjunctions between technical advice and the logics of antibiotic use within hospitals. Aim To examine the experiences of doctors in a UK hospital with respect to AMS guidance of antibiotic prescribing, and experiences of a verbal postprescription antibiotic approval process. Methods Twenty doctors in a teaching hospital in the UK participated in semi-structured interviews about their experiences of antibiotic use and governance. NVivo10 software was used to conduct a thematic content analysis systematically. Findings This study identified three key themes regarding doctors' relationships with ID/CM clinicians that shaped their antibiotic practices: (1) competing hierarchical influences limiting active consultation with ID/CM; (2) non-ID/CM consultants' sense of ownership over clinical decision-making and concerns about challenges to clinical autonomy; and (3) tensions between evidence-based practice and experiential-style learning. Conclusions This study illustrates the importance of examining relations between ID/CM and non-ID/CM clinicians in the hospital context, indicating that AMS models that focus exclusively on delivering advice rather than managing interprofessional relationships may be limited in their capacity to optimize antibiotic use. AMS and, specifically, antibiotic approval systems would likely be more effective if they incorporated time and resources for fostering and maintaining professional relationships.

© 2015, © The Author(s) 2015. Misuse of antibiotics in hospitals in Australia and internationally is common. The combination of multi-resistant organisms and continued misuse of antibiotics is contributing to a predicted ‘antimicrobial perfect storm’ in the coming decades. Attempts to influence doctors’ use of antibiotics have seen limited success internationally, yet few studies have explored the potential social factors driving current practices within hospitals and the interpersonal processes that underpin persistent ‘suboptimal’ antibiotic use. In this qualitative study of hospital-based Australian doctors we explore some of these dynamics including: the role of clinical uncertainty and ambivalence; experiences of immediate risk; interpersonal and intra-professional pressure; and the role of localised norms and ‘craft groups’ in driving antibiotic practices. We argue that the development of a sociological understanding of antibiotic misuse in the hospital sector (and beyond) is vital for progress to be made in protecting antibiotics for future generations.

Ebola has previously been predominantly isolated to African nations, with limited impact in OECD countries. In 2014 Ebola gained international visibility, based largely on the threat of it ‘moving west’. Here we examine a group of Australian health professionals’ accounts of the Ebola threat including their fears around exposure; the moralities underpinning their responses; the role of othering in framing the threat; and the significance of relations of mistrust. We posit that the threat of Ebola unsettled professional expectations (duty, sacrifice and exposure to risk), rights (choice and safety) and certainty (evidence or knowledge to guide practice). In making sense of the 2014 Ebola threat, the participants articulate dilemmas around human value, the contingency of professional duty and care, and transnational responsibility.

Objectives: Escalating antimicrobial resistance worldwide necessitates urgent optimization of antimicrobial prescribing to preserve antibiotics for future generations. Early intravenous (iv) to oral switch campaigns are one strategy that hospital-based antimicrobial stewardship programmes can incorporate to minimize inappropriate antibiotic use. Yet, iv antibiotics continue to be offered for longer than is clinically indicated, increasing hospital length of stay, increasing costs and placing patients at risk (e.g. cannula-related infections). This study aims to identify why this inappropriate prescribing trend continues. Methods: Twenty doctors (9 females and 11 males) working at a teaching hospital in north-east England participated in semi-structured interviews about their experiences of antibiotic use. NVivo10 software was used to conduct a thematic content analysis of the full interview transcripts driven by the framework approach. Results are reported according to COREQ guidelines. Results: Decisions around the choice of iv over oral antibiotics were influenced by three key issues: (i) consumerism, i.e. participants were concerned about the risk of litigation or complaints if patient expectations were not met; (ii) hierarchy of the medical team structure limited opportunities for de-escalation of antibiotics; and (iii) iv antibiotics were perceived as more potent and having significant mythical qualities, which participants acknowledged were not necessarily evidence based. Conclusions: The iv to oral switch interventions should tailor strategies to demystify iv versus oral antibiotic efficacy, engage consumers around the negative effects of iv antibiotic overuse and examine strategies to streamline team decision-making. Addressing these issues has the potential to reduce inappropriate antibiotic use and resistance.

Coxiella burnetii infection is not known to involve directly the kidneys. Kidney injury associated with Q fever usually manifests in the setting of chronic infection or endocarditis with development of immune complex deposition. Acute kidney injury (AKI) in the context of acute Q fever infection may be more pathologically heterogeneous. We describe two cases of severe AKI secondary to acute Q fever infection, each with marked differences in pathological characteristics, and clinical course.

© 2019 Royal Australasian College of Physicians The antibiotic optimisation imperative is now ubiquitous, with national policy frameworks in Organisation for Economic Co-operation and Development (OECD) countries incorporating the requirement for antimicrobial stewardship within healthcare services. Yet in practice, the optimisation agenda often raises complex ethical- and practice-based dilemmas. Antibiotic use at the end of life is multidimensional. It includes balancing complex issues, such as accuracy of prognostic estimates, benevolence to the individual versus the broader public health, personalised value judgement of time and quality of life and the right to treatment versus the right to die. It also occurs in an emotional context where the clinician and patient (and their family) collectively confront mortality. This provides a scenario where amplification of the already strong social and behavioural forces that drive overuse of antibiotics in many other clinical settings may occur. It therefore offers an important case for illustrating how antibiotic optimisation may be limited by social, value-based and ethical dilemmas.

Background Antimicrobial resistance is increasing and there is an urgent international imperative to optimise use within hospitals. Antibiotic use at the end of life is frequent in the hospital setting, but data on use in Australian hospitals in this context is limited, and optimisation is complicated by clinical/diagnostic, ethical and humanistic considerations. As yet there is little data available on baseline use in hospital end of life settings, an empirical gap we sought to begin to fill here. Methods A retrospective review of antibiotic use in patients who died in a Queensland hospital between January 2015 and July 2015. Results One hundred and thirty-seven patients were included, of which 73 were male (53.3%) and the median age was 81 years. Of these patients, 86 received antibiotics at the end of life. The most common antibiotic prescribed was piperacillin/tazobactam (41.9%). The most common site of infection was pulmonary (32.8%). Of 86 patients prescribed antibiotics, 29 patients (33.7%) received antibiotics after futility was documented. 83 patients (96.5%) were administered their antibiotics intravenously. Conclusion Antimicrobial use at the end of life is frequent, with greater than one third of the patients who died in hospital having their antibiotics continued after discussion of futility. Antimicrobial use in this setting is complex with significant clinical, social and ethical considerations which need to be addressed if antibiotic optimization in this area (and more broadly in the hospital) is to be achieved.

Summary Background Antibiotic optimization is an urgent international issue. Regulatory frameworks, including the requirement to have a functioning antimicrobial stewardship (AMS) programme, are now ubiquitous across the hospital sector nationally and internationally. However, healthcare is ultimately delivered in a diverse range of institutional settings and social contexts. There is emerging evidence that implementation of antibiotic optimization strategies may be inappropriate or even counterproductive to attempts to optimize in atypical healthcare settings. Aim To document the experiences and perspectives of clinical staff in a remote healthcare setting in Australia with respect to antimicrobial use, and strategies for optimization in that environment. Methods Semi-structured qualitative interviews were conducted with 30 healthcare professionals, including doctors, nurses and pharmacists, from a remote hospital in Queensland, Australia. Findings Four themes were identified from the analysis as key challenges to antibiotic optimization: (i) AMS as externally driven, and local knowledge sidelined; (ii) perceptions of heightened local population risks, treatment failure and the subsequent pressure to over-use of antimicrobials; (iii) interprofessional relationship dynamics including medical hierarchical structures perceived as a barrier to AMS; (iv) a clinical workforce dominated by transient locum staff and other process issues were perceived as significant barriers. Conclusion The perceptions of healthcare professionals in this site lead to the conclusion that antimicrobial regulations and practice improvement strategies more generally are unlikely to succeed if they fail to accommodate and respect the context of care, the resource and structural constraints of the setting, and the specificities of particular populations (and subsequent clinical ‘know-how’).

Summary Background Suboptimal antibiotic use in respiratory infections is widespread in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimizing the use of respiratory antibiotics, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived. Aim To explore the perceptions of hospital respiratory clinicians on AMS in respiratory medicine. Methods In-depth interviews were conducted with 28 clinicians (13 doctors and 15 nurses) from two hospitals in Australia. Data were analysed thematically using the framework approach. Findings Four key barriers to the integration of AMS processes within respiratory medicine, from the participants' perspectives, were identified: 1. Clinical ownership of common respiratory infections by the respiratory team is perceived to be challenged by AMS processes. 2. AMS processes conflict with traditional hierarchies and consultation etiquette in respiratory medicine. 3. Barriers to respiratory nursing engagement in AMS include lack of knowledge/education and perceived restrictions to their role. 4. AMS processes result in significant interspecialty and interprofessional challenges that may undermine antibiotic optimization. Conclusions AMS processes are introduced in hospitals with established social structures and knowledge bases. This study found that AMS in respiratory medicine challenges and conflicts with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.

Highlights • Rhodococcus equi infection primarily causes pneumonia but can disseminate to cause disease in virtually any human tissue. • Increasing recognition that this pathogen can cause disease in both immunocompetent and immunocompromised hosts. • Two cases of invasive R. equi infection at both ends of the spectrum in terms of susceptibility and severity of disease. • High index of suspicion in a broad range of settings and communication with microbiologist is essential for early diagnosis., Rhodococcus equi is a gram positive bacterium most commonly presenting clinically as pneumonia, however can disseminate to cause disease in virtually any human tissue. Although it is predominantly an opportunistic pathogen, a number of case series have described infection occurring among individuals with a normal immune system. We describe two cases of Rhodococcus equi infection which highlight the diversity of disease presentations of this rare organism.

Background Antibiotic treatment options for common infections are diminishing due to the proliferation of antimicrobial resistance (AMR). The impact of Antimicrobial Stewardship (AMS) programs seeking to preserve viable antibiotic drugs by governing their use in hospitals has hitherto been limited. Pharmacists have been delegated a critical role in antibiotic governance in AMS teams within hospitals but the experience of pharmacists in influencing antibiotic use has received limited attention. In this study we explore the experiences of pharmacists in antibiotic decision-making in two Australian hospitals. Methods We conducted 19 semi-structured interviews to explore hospital-based pharmacists’ perceptions and experiences of antibiotic use and governance. The analysis was conducted with NVivo10 software, utilising the framework approach. Results Three major themes emerged in the pharmacist interviews including (1) the responsibilities of pharmacy in optimising antibiotic use and the interprofessional challenges therein; (2) the importance of antibiotic streamlining and the constraints placed on pharmacists in achieving this; and (3) the potential, but often under-utilised expertise, pharmacists bring to antibiotic optimisation. Conclusions Pharmacists have a critical role in AMS teams but their capacity to enact change is limited by entrenched interprofessional dynamics. Identifying how hospital pharmacy’s antibiotic gatekeeping is embedded in the interprofessional nature of clinical decision-making and limited by organisational environment has important implications for the implementation of hospital policies seeking to streamline antibiotic use. Resource constraints (i.e. time limitation and task prioritisation) in particular limit the capacity of pharmacists to overcome the interprofessional barriers through development of stronger collaborative relationships. The results of this study suggest that to enact change in antibiotic use in hospitals, pharmacists must be supported in their negotiations with doctors, have increased presence on hospital wards, and must be given opportunities to pass on specialist knowledge within multidisciplinary clinical teams. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1290-0) contains supplementary material, which is available to authorized users.

Background Gender differences vary across geographical settings and are poorly reported in the literature. The aim of this study was to evaluate demographics and clinical characteristics of participants from the Australian HIV Observational Database (AHOD), and to explore any differences between females and males in the rate of new clinical outcomes, as well as initial immunological and virological response to antiretroviral therapy. Methods: Time to a new clinical end-point, all-cause mortality and/or AIDS illness was analysed using standard survival methods. Univariate and covariate adjusted Cox proportional hazard models were used to evaluate the time to plasma viral load suppression in all patients that initiated antiretroviral therapy (ART) and time to switching from a first-line ART to a second-line ART regimen. Results: There was no significant difference between females and males for the hazard of all-cause mortality [adjusted hazard ratio: 0.98 (0.51, 1.55), P = 0.67], new AIDS illness [adjusted hazard ratio: 0.75 (0.38, 1.48), P = 0.41] or a composite end-point [adjusted hazard ratio: 0.74 (0.45, 1.21), P = 0.23]. Incident rates of all-cause mortality were similar between females and males; 1.14 (0.61, 1.95) vs 1.28 (1.12, 1.45) per 100 person years. Virological response to ART was similar for females and males when measured as time to viral suppression and/or time to virological failure. Conclusion: This study supports current Australian HIV clinical care as providing equivalent standards of care for male and female HIV-positive patients. Future studies should compare ART-associated toxicity differences between ART-associated toxicity differences between men and women living with HIV in Australia.

BackgroundLife expectancy has increased for newly diagnosed HIV patients since the inception of combination antiretroviral treatment (cART), but there remains a need to better understand the characteristics of long-term survival in HIV-positive patients. We examined long-term survival in HIV-positive patients receiving cART in the Australian HIV Observational Database (AHOD), to describe changes in mortality compared to the general population and to develop longer-term survival models.MethodsData were examined from 2,675 HIV-positive participants in AHOD who started cART. Standardised mortality ratios (SMR) were calculated by age, sex and calendar year across prognostic characteristics using Australian Bureau of Statistics national data as reference. SMRs were examined by years of duration of cART by CD4 and similarly by viral load. Survival was analysed using Cox-proportional hazards and parametric survival models.ResultsThe overall SMR for all-cause mortality was 3.5 (95% CI: 3.0-4.0). SMRs by CD4 count were 8.6 (95% CI: 7.2-10.2) for CD4ConclusionObserved mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors. These rates did not vary much by duration of treatment. Changes in mortality with age were similar to those in the Australian general population.