START Trial

Increasing the appropriate use of antibiotics in residential aged care facilities and understanding the transmission of antimicrobial-resistant microbes.

In 2013, Professor Peleg and his team discovered that more than a third of residents in nursing homes across Australia carried antibiotic-resistant bacteria. Half of those were prescribed antibiotics in the three months prior. Studies have found that a staggering 50 to 80 per cent of residents in aged care facilities will be prescribed an antibiotic, however only one in three will be necessary.

In response to this worrying statistic, a National trial in residential aged care facilities has been established to find out the extent of antibiotic resistant bacteria, and how best practice antibiotic use can assist to control the rise of superbugs.

A team of infection and aged care specialists and trial design experts will coordinate this unique trial to include 72 nursing homes nationally reaching more than 7000 aged care residents, making it one of the largest in the world. The nurse-led antimicrobial best-practice will monitor levels of antibiotic resistant bacteria in nursing home residents. Resident movement to and from hospitals will also be tracked, to determine the degree to which hospital attendance may increase the superbug load in nursing homes.

The trial is designed for the efficient and timely roll-out of necessary interventions so that best practice can be introduced quickly. The long term benefits of the trials are to improve overall practice in nursing homes and thus improve the general health of older people.

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START Project

START =Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance

Background

The World Health Organisation has identified antimicrobial resistance as one of the greatest threats to human health, with overuse and misuse of antimicrobials driving this process. In residential aged care facilities (RACFs), antimicrobials are often prescribed inappropriately. Although antimicrobial stewardship programs are well established in the hospital setting, few programs exist in RACFs and their impact on antimicrobial use and resistance has not been well-explored.

Aims

The START project will implement and evaluate the impact of a nurse-led bundled antimicrobial stewardship program on the appropriateness of antimicrobial use in RACFs.

The project will also explore the impact of resident movement on the spread of antimicrobial resistance and model the transmission of antimicrobial resistance.

Study design

The nurse-led antimicrobial stewardship intervention will be implemented in a stepped-wedge randomised controlled trial. The trial will be conducted in collaboration with Bupa Aged Care Australia and include 14 RACFs over 18 months.

Methods

The antimicrobial stewardship intervention will comprise a nurse-led care and education bundle to support appropriate antimicrobial use. This will include education, guidelines, documentation, and audit and feedback.

The intervention will first be pilot tested across 2 RACFs and revised prior to implementation across 14 RACFs in a randomised controlled trial. Following the trial, the intervention will be rolled out nationally across Bupa RACFs.

Outcome measures

Primary outcomes include the proportion of residents prescribed an antimicrobial and the total number of days of antimicrobial therapy.

Secondary outcomes include the number of courses of antimicrobials prescribed, the incidence of carriage of drug-resistant bacteria and other health-care associated infections, change in antimicrobial susceptibility profiles, incidence of resident transfer to hospital, and all-cause mortality.

Funding

Australian Government Medical Research Future Fund (MRFF) Tackling Antimicrobial Resistance Program

Trial Registration

ClinicalTrials.gov registration number: NCT03941509

Further information

Please contact the START Project Coordinator:

Natali Jokanovic

Department of Infectious Diseases

Monash University and the Alfred Hospital

Level 2, 85 Commercial Road, Melbourne VIC 3004

Phone: +61 3 9903 0087

Email: Natali.Jokanovic@monash.edu


START Project Research Team

Principal investigator

Professor Anton Peleg, Department of Infectious Diseases, Monash University and the Alfred Hospital

Co-investigators

Associate investigators and

other project team members

Dr Trisha Peel,

Department of Infectious Diseases,

Monash University and the Alfred Hospital

Dr James Trauer,

School of Public Health and Preventive Medicine,

Monash University

Dr Andrew Stewardson,

Department of Infectious Diseases,

Monash University and the Alfred Hospital

Professor Marilyn Cruickshank,

University of Technology Sydney

Professor Allen Cheng,

Department of Infectious Diseases,

Monash University and the Alfred Hospital

Dr Tim Spelman,

Burnet Institute

Professor Sarah Hilmer,

Departments of Clinical Pharmacology and Aged Care,

Royal North Shore Hospital and The University of Sydney

Professor Daniel Wilson,

University of Oxford

Professor Yun-Hee Jeon,

School of Nursing and Midwifery,

The University of Sydney

Dr Nicola De Maio,

University of Oxford

Associate Professor Rhonda Stuart,

Monash Infectious Diseases, Monash Health

Denise Harisiou,

Bupa Australia

Professor Terry Haines,

School of Primary and Allied Health Care,

Monash University

Maureen Berry,

Bupa Australia

Professor Kathryn Holt,

Department of Infectious Diseases,

Monash University and the Alfred Hospital

Associate Professor Annette Schmiede,

Bupa Health Foundation

 

Dr Natali Jokanovic,

Department of Infectious Diseases,

Monash University and the Alfred Hospital

 

Janine Roney,

Department of Infectious Diseases,

Monash University and the Alfred Hospital