Aura 2016: first Australian report on antimicrobial use and resistance in human health

7.2 Next steps for the AURA Surveillance System

Additional reports on specific focus areas for AMR and AU will supplement AURA 2016 and will be released throughout the year. The Australian Commission on Safety and Quality in Health Care (the Commission) will continue a multifaceted, collaborative approach to achieving a comprehensive AU and AMR surveillance system that provides valuable data to inform action to prevent and contain AMR. Work is already under way through the Commission’s AURA coordinating unit to improve data analysis and interpretation at the national level, and to respond to issues, such as inappropriate surgical prophylaxis, that have been highlighted in this report.

The Commission will work with its partners to increase surveillance coverage across geographical areas (states and territories; and urban, regional, rural and remote areas), patient settings (primary care, residential aged care and hospitals) and hospital types.

The work undertaken to establish the AURA Surveillance System, and to develop AURA 2016, has also provided a focus for activity that will achieve greater representativeness, acceptability, comparability and quality of the data.

Key activities to enhance the system and reporting include:

continuing work with stakeholders on the harmonisation of susceptibility testing systems to improve data quality and comparability; similar challenges are reported in the development of the World Health Organization’s Global Antimicrobial Resistance Surveillance System

increasing hospital participation and scope of surveillance for the Australian Group on Antimicrobial Resistance (AGAR), the National Antimicrobial Prescribing Survey (NAPS) and the National Antimicrobial Utilisation Surveillance Program (NAUSP)

reviewing defined daily doses and other measures, to improve opportunities for reports to compare surveillance and allow benchmarking between hospitals

reviewing options for casemix and infection rate adjustments for occupied-bed days in hospitals; this might be achieved by assessing the proportion of cases with pneumonia, sepsis or specific types of surgery

facilitating increased access to NAUSP reports by all participating hospitals, as well as identifying opportunities to improve benchmarking at the state and territory level, and potentially in clinical settings such as oncology/haematology and renal units

benchmarking and comparing peer group hospitals or healthcare networks to improve appropriate AU

reviewing specific aspects of antimicrobial prescribing under the Pharmaceutical Benefits Scheme to assess opportunities for improving appropriateness of AU in the community, in partnership with NPS MedicineWise

continuing to develop best practice in data governance, and ethics and privacy issues, as key enablers of a sustainable surveillance system.

National alert system for critical antimicrobial resistances

A priority component of AURA is to improve the utility of surveillance data, where gaps have been identified. The surveillance of critical antimicrobial resistances (CARs) and timely reporting of these resistances is one such gap, as there is no formal means to inform health systems of these developments. The Commission has therefore established a national alert system for CARs.

CARs are resistance mechanisms that are known to have a high impact on the effectiveness of last-line antimicrobial agents. CARs are currently relatively low in number across Australia, but they can result in significant illness and death in healthcare facilities and in the community when they do emerge. The emergence and spread of KPC-2-producing Klebsiella pneumoniae in Victoria has highlighted the challenge of timely recognition of the location and spread of CARs in Australia. Overseas experience has shown that this particular CAR has high capacity for amplification and spread, and can cause significant mortality.^66,67

Susceptibility data for some CARs has been captured through a small number of state-based surveillance programs for multidrug-resistant organisms. Data is also captured through existing national programs, such as the National Notifiable Diseases Surveillance System and AGAR. However, none of these systems provide comprehensive data on all of the relevant CARs that should be monitored, nor do they provide timely or structured advice to health services and jurisdictions to minimise the spread of organisms with CARs.

A structured and coordinated system to identify and communicate information about CARs is a key requirement for managing the emergence and spread of AMR in Australia. The system provides an efficient and responsive mechanism to describe the common protocols for testing isolates of potential CARs, as well as processes for recording and transferring information about confirmed CARs through a web portal for reporting, in near real time.

The CARs to be reported are listed in Table 7.1, and are drawn from the list of priority organisms and antimicrobials for targeted surveillance and national reporting under the AURA Surveillance System. The list was developed by the Commission, in consultation with members of the AURA Project Reference Group. The CARs will be reviewed and updated regularly in the context of the latest available evidence on critical resistances to emerge in Australia and overseas.

How the alert system works

If an initial laboratory test indicates a possible CAR, an isolate is sent to a designated confirming laboratory for testing. Confirming laboratories have clear definitions of resistance, based on genotypic or phenotypic testing methods. A handbook has been provided to confirming laboratories to detail all aspects of the alert system processes.

The confirming laboratory notifies the originating laboratory of both positive and negative results in the usual manner. In addition, it uses the web portal to record and send organism data and some demographic data on confirmed CARs to the Commission. The system then communicates CAR alerts to designated stakeholders by email or SMS so that appropriate local, state or territory, and national responses can be initiated. This allows timely action to be taken for appropriate infection control and containment, as well as proactive prevention strategies across the health system.

Table 7.1 Critical antimicrobial resistances for Australia

Organism	Critical resistance
Enterobacteriaceae	Carbapenemase production or ribosomal methylase production
Enterococcus species	Linezolid nonsusceptibility
Mycobacterium tuberculosis	Multidrug resistance (rifampicin resistance)
Neisseria gonorrhoeae	Ceftriaxone or azithromycin nonsusceptibility
Salmonella species	Ceftriaxone nonsusceptibility
Shigella species	Multidrug resistance
Staphylococcus aureus	Vancomycin, linezolid or daptomycin nonsusceptibility
Streptococcus pyogenes	Penicillin reduced susceptibility

The Commission is responsible for coordination and oversight of the system. In addition to the alerts, it will produce analytic reports to inform policy and program development. These reports will be provided to the states and territories, and will also be available in future national reports on AU and AMR.

The Commission began operating this system in March 2016, and is currently working with the states and territories, as well as public and private laboratories, to ensure that the system is fully operational and achieving its potential by mid-2016.