Courtney Ierano

Background and objectives: Antimicrobial stewardship initiatives are designed to improve the appropriateness of antimicrobial use and thereby maximize benefits and minimize risks. Currently, there is no shared understanding of appropriate use. Qualitative research with key stakeholders in human and animal health is critical to inform a One Health definition and to support global stewardship efforts. Methods: Four qualitative focus groups were held in 2024 with livestock producers, consumers, healthcare professionals and policymakers to examine factors affecting antimicrobial use and stewardship. A thematic analysis methodology informed by grounded theory was adopted, capturing themes as they emerged directly from the data. Results: Thematic analysis identified two themes:Structural and economic barriers; in animal health, consumer demand for free-range or antibiotic-free produce conflicted with practical antimicrobial use. This was compounded by differences between large and small livestock enterprises and regulatory constraints around off-label antimicrobial use. In human health, time pressure, limited access to review appointments and conflicting consumer–prescriber expectations influenced antimicrobial decision-making.Information access and education; participants identified gaps in antimicrobial stewardship education for livestock producers, limited public understanding of appropriate use and underused communication channels to support consistent context-specific messaging. Conclusion: This study highlights how participants understood appropriate antimicrobial use across One Health sectors and the structural, economic, informational and educational factors they perceived as shaping whether it could be achieved in practice. Establishing contextualized, consensus definitions is essential for measuring prescribing quality, benchmarking practice and targeting stewardship interventions. These findings will inform an international Delphi process to develop practical, implementable One Health definitions of appropriate use.

Sexually transmitted infections (STIs) place a substantial burden on outpatient health care and are a key focus for antimicrobial stewardship due to rising antimicrobial resistance. Suboptimal treatment can result in ongoing transmission, reinfection and complications, such as pelvic inflammatory disease. Evaluating prescribing quality is essential to improve patient care and support stewardship efforts. This review synthesises evidence on antimicrobial prescribing quality for STIs and identifies gaps to inform targeted interventions for this unique but critical setting. This PRISMA-ScR scoping review searched Ovid MEDLINE and Embase for English-language studies published from 2015 to May 2025 assessing antimicrobial prescribing quality for STIs in outpatient settings. Results were summarised descriptively; no formal critical appraisal was undertaken. Fifteen studies assessing antimicrobial prescribing quality for STIs in outpatient settings were included, predominantly from high-income countries, and focused on Neisseria gonorrhoeae and Chlamydia trachomatis. Substantial heterogeneity was observed in analytic units, denominators and outcome definitions, limiting comparability across studies. Prescribing quality was primarily assessed against national guidelines, although approaches varied from antimicrobial choice alone to multi-criteria and all-or-nothing assessments, with inconsistent terminology used throughout. Reported guideline concordance varied widely, with generally higher concordance for chlamydia than gonorrhoea. Antimicrobial prescribing for STIs in outpatient settings is both understudied and highly variable. Despite increasing global policy emphasis on antimicrobial stewardship, there are no standardised frameworks to support routine auditing in this setting. Developing standardised auditing approaches would improve surveillance, support stewardship efforts and identify opportunities to optimise prescribing practices across a broader range of STIs.

In this international, multicenter prospective study, implementing penicillin direct oral challenge (DOC) using a digital toolkit was acceptable, feasible, and sustainable. Audit and feedback increased activity, particularly among pharmacists. Safety was maintained across heterogeneous DOC protocols, validating a pragmatic, scalable approach that supports local adaptation.

Objective: To analyze antimicrobial prescribing practices in Australian emergency departments (ED), identifying prescribing areas requiring improvement. This aims to inform antimicrobial stewardship (AMS) strategies to enhance antimicrobial prescribing quality. Design: Retrospective analysis of the Hospital National Antimicrobial Prescribing Survey (NAPS) data set. Setting: EDs in public and private Australian hospitals (n = 652). Participants: Hospitals (n = 652) that participated in the Hospital NAPS from 2013 to 2022. Methods: Data were collected by trained auditors from participating hospitals with the use of a standardized auditing tool, the Hospital NAPS. Data from 2013 to 2022 were analyzed descriptively. Variables assessed included guideline compliance and appropriateness by antimicrobial and indication, and reasons for inappropriateness. Results: There were 3,098 antimicrobial prescriptions from EDs included for analysis. Guideline compliance (63.5%) and appropriateness (70.4%) in EDs were lower compared to overall prescribing practices from all departments. The most commonly prescribed antimicrobial was ceftriaxone (16.9%, n = 523), and the most common indication was empiric prescribing for community-acquired pneumonia (16.0%, n = 497). Amoxicillin-clavulanic acid (53.2%, n = 99), and acute exacerbation of chronic obstructive pulmonary disease (54.3%, n = 57), were the antimicrobial and indication with the lowest rates of appropriateness respectively. Ceftriaxone prescribing also had a low rate of appropriateness (62.3%, n = 326). Selection of antimicrobials with too broad of a spectrum was the most common reason for inappropriateness (40.2%). Conclusion: Antimicrobial prescribing quality in EDs warrants improvement. Recommended targets for AMS interventions are the excessive and inappropriate use of broad-spectrum antimicrobials such as ceftriaxone and amoxicillin-clavulanic acid in common respiratory and urinary tract infections.

Background: Oral amoxicillin‐clavulanic acid, a broad‐spectrum antimicrobial and one of the most commonly prescribed antimicrobials in Australia, has demonstrated poor prescribing guideline compliance and appropriateness. This may have inadvertent impacts on patient care and safety, from adverse drug reactions to antimicrobial resistance. Intravenous (IV) amoxicillin‐clavulanic acid was first registered in Australia in 2017, reflecting a subsequent and immediate increase in use. There is a need to assess the quality of such prescribing.Aim: To describe the quality of IV amoxicillin‐clavulanic acid prescriptions through assessing guideline compliance and appropriateness of use in Australian hospitals.Method: A retrospective data analysis of IV amoxicillin‐clavulanic acid prescriptions from the Hospital National Antimicrobial Prescribing Survey database between 2013 and 2021. The main outcomes measured were guideline compliance and appropriateness. Ethical approval was granted by the Melbourne Health Human Research Ethics Committee (HREC/74195/MH‐2022).Results: The proportion of prescriptions for IV amoxicillin‐clavulanic acid, compared to all other antimicrobials, increased from 0.02% (2013) to 2.3% (2021). Guideline compliance and appropriateness have overall decreased (by 18.9% and 16.7%, respectively). Over time, national guidelines predominantly replaced local guidelines as the primary guideline source for prescribing. The most common reason for inappropriateness was unnecessarily broad spectrum of activity (39.5%).Conclusion: Intravenous amoxicillin‐clavulanic acid prescribing continues to increase throughout Australian hospitals, with notable reductions in guideline compliance and appropriateness. Since 2019, the increase in these outcomes coincided with updated national prescribing guidelines, evident by prescribers utilising national over local guidelines. These findings reinforce the concept that antimicrobial stewardship initiatives, including auditing, robust national guidelines and education, are crucial to optimise IV amoxicillin‐clavulanic acid prescribing.

Purpose of review: This review aims to discuss the current state of surgical antimicrobial prophylaxis (SAP) evidence for surgical site infection prevention. Despite decades of research, knowledge gaps persist in identifying optimal SAP regimens. Recent findings: Recent randomised controlled trials highlight ongoing heterogeneity in study design. Key new findings support the use of oral preoperative SAP for colorectal surgery and advise against the use of SAP for transperineal prostate biopsy. There is growing evidence for culture-based SAP over empiric use for transrectal prostate biopsy. Contentious issues remain regarding topical antimicrobials for cardiac procedures involving sternotomy, the necessity of SAP for wire lumpectomy and laparoscopic cholecystectomy for both mild or moderate acute cholecystitis. Procedures where SAP is not indicated, yet research is still being conducted on this topic include dental implants and clean orthopaedic procedures. Summary: Research efforts continue with numerous trials published and registered to determine optimal SAP regimens. However, many efforts are suboptimal due to poor statistical design and redundant questions already answered by existing literature. To improve practice and influence surgeons prescribing behaviour future RCTs should be well powered, with large sample sizes across multiple sites, focusing on clinically relevant questions.

Background and Objectives: The National Antimicrobial Prescribing Survey (NAPS) is a novel digital antimicrobial auditing program. The Hospital NAPS, released in 2013, is used to monitor antimicrobials prescribed within a facility and identify targets for quality improvement initiatives. Since...