Introduction
The spread of antimicrobial resistance (AMR) represents a significant global public health threat with increased rates of resistance being observed in both the hospital and community settings. 1 The growing burden of AMR has led to increased rates of hospitalization, longer hospital stays, higher treatment complications, and significant economic impact on the health system. Reference Wozniak, Dyda, Merlo and Hall2 In Australia, the AMR burden is exceedingly high in remote settings where ongoing monitoring and disease surveillance have historically been limited. Reference Ralph, Holt and Islam3
Healthcare delivery challenges in remote areas result in significant delays in microbiological diagnostics compared with urban settings. These delays mean many patients may wait up to 5 days or more for directed antimicrobial therapy after the initial diagnostic test, provided it was accessible to begin with. Reference Cuningham, Anderson and Bowen4 In rural and remote Australia, workforce constraints mean remote area nurses and Aboriginal health practitioners often take on the role of primary care providers. To support timely access to medicines, these staff are authorized to supply and administer certain medicines providing they follow specified treatment protocols approved by the Northern Territory Chief Health Officer, such as the Central Australian Rural Practitioners Association (CARPA) manuals. Reference Pennington, Clark and Knight5 Although, Aboriginal health practitioners are authorized to supply antibiotics, <1% actually do so as part of their practice. Reference Cuningham, Anderson and Bowen4 This is in contrast to urban clinics, where general practitioners are the main prescribers of antibiotics. Reference Whiteing, Barr and Rossi6 Additionally, there are no routine antibiograms produced in Australia for primary care, limiting the available data healthcare providers can access to inform empiric antimicrobial prescriptions.
In response to the identified need for regional and remote healthcare practitioners to access local AMR data at the point of care, the HOTspots Surveillance and Response Program was established in 2018. In 2019, following extensive engagement with local clinicians and policy, the HOTspots digital surveillance platform was launched in clinical practice. 7 AMR surveillance data from HOTspots are provided to the national AMR surveillance system—Antimicrobial Usage and Resistance in Australia program 8 . In response to these positive actions in monitoring and responding to AMR in regional and remote Australia, we aimed to address the knowledge gap and evaluate the data and information needs of clinicians and policymakers working to reduce the AMR threat in these settings.
Methods
Design
A qualitative study design was used to assess transcribed semi-structured interviews (n = 13) utilizing interpretive description techniques.
Study setting and participants
This study was conducted in remote Australia. Interview participants were end users of AMR data and included laboratory/pathology data custodians, healthcare providers responsible for clinical management of AMR patients, policymakers responsible for strategic response to AMR, and public health practitioners responsible for population-level disease control.
Data collection
Data from transcribed semi-structured interviews conducted in 2019 as part of an evaluation of an AMR surveillance system were reviewed to identify comments that related to data use and information needs of the interview participants.
Data coding and analysis
Interviews were recorded and transcribed verbatim. Interview transcripts were reviewed independently by 2 authors (M.E and T.W) who extracted preliminary themes. A process of interpretive description, a method of intellectual inquiry whereby researchers constantly question and reconsider their findings, was then undertaken with 3 authors (M.E, T.W, and L.H). The independently coded data was critically analyzed using this framework until a consensus on themes was reached.
Ethical considerations
This study received ethical approval from the Human Research Ethics Committee of the NT Department of Health and Menzies School of Health Research (approval number 2019-3425).
Results
13 semi-structured, individual and group interviews lasting between 8 and 45 minutes were conducted with a total of 18 participants. Our analysis identified 5 key themes: (1) data needs, (2) data governance and management, (3) data confidence, (4) ability to act on evidence including resourcing, and (5) technology challenges (Table 1).
Table 1. Identified themes and challenges of clinicians and policymakers to support action on AMR in remote Australia
Note. AMR, antimicrobial resistance; CARPA, Central Australian Rural Practitioners Association; MRSA, methicillin-resistant Staphylococcus aureus; AHP, Aboriginal health practitioner; RAN; Remote Area Nurse.
Discussion
In remote Australia, clinicians and policymakers face the challenge of supporting a patient population with a disproportionately high burden of chronic disease and infectious diseases and an exceedingly high burden of AMR. Reference Bowen, Daveson, Anderson and Tong9 This study highlights the need for reliable, local, and geographically representative data to guide effective clinical and policy decision-making in the face of the unique challenges of regional and remote Australia. We identified 3 crucial challenges—limited workforce, delayed confirmation of causative pathogen, and frequent shortages of antibiotics.
Remote Australia faces significant challenges due to a limited workforce and high staff turnover. Reference Wakerman, Humphreys and Russell10,Reference Russell, Zhao and Guthridge11 In these regions, the primary healthcare workforce consists mainly of remote area nurses and Aboriginal health practitioners, with support from visiting medical staff. These healthcare professionals follow local treatment guidelines such as the CARPA manual. Timely access to local AMR data to inform clinical practice is crucial and is most practical when integrated into local treatment guidelines and clinical pathways, such as the Primary Health Network Health Pathways.
In remote areas of Australia, the distance between community clinics and diagnostic laboratories often leads to significant delays in receiving antimicrobial susceptibility test results. This means clinicians must make the difficult choice of an antibiotic at the point of care prior to receiving the antimicrobial susceptibility results. To support their clinical judgment, it is important to provide accessible data on the region’s AMR patterns. This helps ensure the optimal choice of antibiotics when local diagnostic capabilities are limited.
Lastly, we identified that healthcare professionals in regional and remote Australia often struggle to maintain a steady supply of medications including antibiotics. Due to geopolitical unrest and disrupted supply chains, shortages of critical antibiotics have become more common in Australia. Reference Khumra, Mahony and Devchand12 Participants in this study noted issues such as supply shortages, challenges with stockpiling, and fluctuations in stock rotation costs in their clinics and local pharmacies. Providing policymakers and those in charge of medicines management with region-specific AMR data can help them assess the need for specific antibiotics to treat their local patient population. This would aid early preparation and facilitate seeking alternative antibiotic supply chains in the event of potential shortages.
This study is limited to the views of participants which may not be representative of all the views of healthcare professionals within regional and remote Australia. There was an unequal representation of health policymakers in our study, and only 1 was included in the analysis. However, the study had a good representation of clinical participants, who face significant challenges in responding to AMR in regional and remote Australia.
Conclusion
This study is the first to examine the AMR data and information needs of healthcare professionals working in regional and remote Australia. Understanding healthcare professionals’ perspective of what data and information needs they have will ensure that local surveillance systems such as HOTspots meet the needs of the end users. These findings will guide the integration of AMR surveillance data into clinical practice, prescribing guidelines, and policy decisions to strengthen local and national response to the AMR threat.
Acknowledgments
We thank the AMR responders who participated in this study.
Author contributions
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1. Dr Matthew Eustace assisted with framing the study, data analysis, and interpretation, drafted the initial manuscript, and reviewed and revised the manuscript in association with co-authors.
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2. A/Prof Lisa Hall assisted with framing the study, interpreted data, and reviewed and revised the manuscript.
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3. A/Prof Bhavini Patel assisted with reviewing and revising the manuscript.
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4. Dr Teresa Wozniak conceptualized and designed the study, interpreted data, and reviewed and revised the drafted manuscript.
Financial support
The project is funded by the Australian National Health and Medical Research Council (NHMRC)-funded “Improving Health Outcomes in the Tropical North: A multidisciplinary collaboration (HOT NORTH),” GNT1131932.
Competing interests
All authors report no conflicts of interest relevant to this article.
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