BACKGROUND AND OBJECTIVES:While microbiology tests can guide management of infectious diseases, little is known about the prevalence of testing around the time of antibiotic initiation in long-term care facilities (LTCFs). The objectives of this study were to investigate prevalence and factors associated with microbiology testing around the time of antibiotic initiation, and subsequent treatment pathways in LTCFs. METHODS:This retrospective cohort study included individuals aged ≥65 years who entered a LTCF in three Australian states between 1 January 2017 and 30 June 2019, and received a systemic antibiotic (n = 36 977). Prevalence of microbiology testing in the 14 days pre- and 7 days post-antibiotic initiation, and treatment pathways 14 days post-initiation, were determined. Multivariable logistic regression determined adjusted odds ratios (aORs) and 95% confidence intervals (95%CIs) for factors associated with testing. RESULTS:In total 15 407 (41.7%) individuals were tested around the time of antibiotic initiation, ranging from 22.9% (n = 585/2551 residents) of macrolide initiators to 79.3% (n = 413/521) of nitrofurantoin initiators. Individuals with urinary tract infections on LTCF entry (aOR 1.24, 95%CI 1.10-1.40) or initiating trimethoprim (aOR 2.80, 95%CI 2.50-3.13) were more likely to be tested. Males (aOR 0.81, 95%CI 0.77-0.85), and residents who received cephalosporins (aOR 0.75, 95%CI 0.68-0.84), penicillins (aOR 0.49, 95%CI 0.45-0.55), or with airways disease (aOR 0.87, 95%CI 0.82-0.91) had lower odds of testing. Among those tested, 14.5% (n = 2238) had a second dispensing of the same antibiotic, 11.4% (n = 1 751) switched antibiotic therapy and 5.9% (n = 904) were hospitalized within 14 days. CONCLUSIONS:With four in ten residents tested, and lower prevalence within certain resident subgroups, this study suggests a high dependence on initiating empiric therapy in LTCFs.

The objective of this study is to determine whether primary care electronic health record (EHR) data are sufficiently complete and plausible to support automated audits of antimicrobial prescribing quality.Cross-sectional descriptive assessment of antimicrobial auditing-related fields in Patron, a large Australian primary care EHR dataset with 3.5 million patients from 129 consenting general practices. Data from 2018 to 2022 were evaluated using the Harmonized Data Quality Assessment Terminology and Framework, covering conformance, completeness, and plausibility.Thirty-one fields (137,776,804 rows; 1,406,364 patients across 116 practices) were assessed. Value conformance and plausibility were high for most core audit variables, including demographics, antimicrobial name, dose, allergy status, and visit date. Prescribing indication was incompletely captured (13-27% completeness), and allergy severity was recorded in 26% of allergy entries. Vendor-level heterogeneity contributed substantially to variation in field completeness.Australian primary care EHR data capture the core structured elements required for automated antimicrobial prescribing audits, enabling assessments of spectrum suitability, microbiology mismatch, and prescribing prevalence. Incomplete and inconsistent documentation of indication and allergy severity necessitates the use of proxy fields or inference for more complex evaluations. Greater standardization across EHR systems is required to enhance the scalability and clinical utility of automated audits in primary care.

Background: There is increasing awareness of the importance of antimicrobial stewardship in long-term care settings internationally. Despite this, there is little robust surveillance data on the quality of prescribing in this setting to help target interventions. In Australia, nursing homes are known as residential aged care homes (RACHs). The Aged Care National Antimicrobial Prescribing Survey (Aged Care NAPS) is a national, standardized audit program enabling Australian RACHs to monitor antimicrobial use and provide feedback on prescribing practices. Since 2016, the program has collected detailed prescribing data but has not made an explicit assessment on prescribing quality. With revision to Australian national prescribing guidelines, we now have the potential to use this data to assess concordance with guidelines. Methods: All Australian RACHs are eligible and invited annually to participate in the Aged Care NAPS. A single-day point prevalence audit is the primary methodology adopted. Antimicrobial prescribing data are collected by auditors at participating RACHs and entered into an online platform. All residents present on the survey day were included in the audit. Retrospective analysis of Aged Care NAPS data collected between 1 January 2020 and 31 December 2024 was undertaken. Guideline concordance was evaluated for the five most common indications (cystitis, tinea, non-surgical wound infection, pneumonia and cellulitis), using the Therapeutic Guidelines: Antibiotic 16th edition and Dermatology 4th and 5th editions. Results: A total of 41,786 prescriptions from 1,408 RACHs were audited during the study period. The five most common indications accounted for 37.4% of all prescriptions. Incorrect antimicrobial choices were common, such as cefalexin and roxithromycin for pneumonia, and amoxicillin-clavulanic acid and doxycycline for cellulitis. Prevalence of dosing errors ranged from 3.4% (trimethoprim for cystitis) to 78.0% (amoxicillin for pneumonia). Cefalexin was frequently prescribed and commonly incorrectly dosed (70.3% in cystitis, 72.8% in non-surgical wound infections, 68.2% in cellulitis). Over 40% of prescriptions for the top five antimicrobials for each indication exceeded recommended treatment durations, ranging from 41.7% (amoxicillin for cystitis) to 96.8% (ketoconazole for tinea). Prescribing for tinea often exceeded six months and included non-recommended pro re nata (PRN) prescriptions. Conclusion: The Aged Care NAPS shows promise as a tool to monitor the quality of antimicrobial prescribing in long-term care facilities. This analysis has identified targets for improving antimicrobial prescribing, focusing on choice, dosing and duration.

Background Management of E faecium bloodstream infections (BSIs) remains debated, particularly the clinical impact of vancomycin resistance, the role of follow-up cultures, and optimal therapeutic regimens. This study aimed to reach expert consensus on these unresolved clinical domains and identify priorities for future research. Methods We first conducted a systematic review and meta-analysis in January 20, 204 focusing on four predefined areas: mortality in E faecium BSIs compared with other BSIs, mortality in vancomycin-resistant enterococci (VRE)-BSIs compared with vancomycin-susceptible enterococci-BSIs, management of catheter-related E faecium BSIs, and 4) optimal antibiotic therapy for VRE-BSIs. These results informed a three-round Delphi process involving a panel of experts. An iterative approach was adopted: 16 initial questions developed from the systematic review (6-point Likert scale) were refined across rounds based on expert feedback. Consensus was defined as at least 80% agreement or disagreement. Findings 13 statements were generated across three broader domains. Regarding clinical outcomes and diagnostics, experts agreed that mortality is heavily influenced by comorbidities; thus, therapeutic assessment should rely on clinical trends and inflammatory markers, with follow-up blood cultures used to confirm eradication. Catheter-related BSI should be managed with device removal and short-course (<7 days) antibiotics in selected uncomplicated cases. For therapeutic management, teicoplanin is preferred for vanB VRE-BSI. For vanA VRE-BSI, both linezolid and high-dose daptomycin (>9 mg/kg per day) are effective, reserving daptomycin-based combinations for challenging cases (deep-seated infections and/or high Minimum Inhibitory Concentrations). Finally, future trials evaluating the impact of antimicrobial therapy should use Desirability-of-Outcome-Ranking analysis; the in-vitro potential of oritavancin justifies targeted randomized trials to define its clinical efficacy in VRE-BSI. Interpretation This paper delineates current evidence and expert consensus on management of E faecium BSI while identifying crucial knowledge gaps to guide future clinical research. Funding None.

Abstract Background The National Infection Surveillance Program for Aged Care (NISPAC) is a new standardised and streamlined infection and antimicrobial use surveillance tool for Australian Residential Aged Care Homes (RACHs). As a part of the program development and implementation, it was identified that the cost of NISPAC implementation in Australian RACHs was currently unknown, and the objective of this study was to determine this cost from the perspective of the Australian Aged Care setting. Methods The cost of implementation included those of the three coordinating bodies, as well as the individual RACHs who participated in the NISPAC program implementation. Development and implementation resources and costs for the coordinating bodies were determined over a 3 year period and then attributed equally across the participating RACHs. Participating RACHs (n = 69) reported the resources and cost of NISPAC implementation over a 5 month period, and this included salary and non-salary costs (2 months pre-implementation and 3 months of implementation). Costs for the participating RACHs were added to the costs of the coordinating bodies to determine the total cost per RACH. The price year for the analysis was 2024. Results The total implementation cost for the three coordinating bodies was $AUD1,869,279, resulting in a mean cost attributed per RACH of $AUD27,091 (SD $AUD0). The mean cost of RACH staff time for the intervention during the pre-implementation planning phase was $276.18 (SD $AUD219.55), and during the implementation phase was $AUD1,146.47 ($AUD1,003.48). The mean cost of NISPAC implementation per RACH was $AUD28,805 (SD $AUD1,137). Conclusion The novel NISPAC was a relatively low-cost infection and antimicrobial use surveillance program to implement in RACHs. Future studies are required to establish the cost-effectiveness of the program. Keywords: Infection, surveillance and cost analyses

Introduction Infections are a leading cause of non-relapse mortality following chimeric antigen receptor T-cell therapy (CAR-T) and bispecific antibody (BsAb) therapies. However, infection data from clinical trials are often incomplete, lack pathogen-level detail and rarely capture late infectious complications. This CAR-T treatment in Lymphoma: Analysis of Risk of Infection following Therapy (CLARITY) study aims to generate real-world, longitudinal infection data with extended follow-up to characterise infection timing, including late events and inform risk prediction in patients with lymphoma and myeloma receiving novel immunotherapies.Methods and analysis CLARITY is a multicentre observational cohort study across six Australian centres enrolling adults treated with CAR-T or BsAb therapies. A co-designed REDCap (Research Electronic Data Capture) instrument captures infections classified as microbiologically defined, clinically defined or fever of unknown origin, using internationally standardised definitions. Patients were enrolled between 2019 and 2023, with at least 2 years follow-up per patient, allowing time-updated data on immunosuppressive exposures, haematological recovery and prophylaxis. Multivariable regression and landmark analyses will estimate infection incidence and identify dynamic risk factors over time. Incidence rate ratios will assess prophylaxis effectiveness. Data integrity is supported by central adjudication and site-level audits.Ethics and dissemination The study has received a waiver of consent (HREC/PMCC/89002) and was co-designed by haematology and infectious diseases investigators. Findings will be disseminated through peer-reviewed publications, scientific meetings and national guideline committees to inform infection prevention and late effects surveillance in immunotherapy-treated populations.

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.

Routine fluoroquinolone (FQ) prophylaxis may increase the risk of antimicrobial resistance, microbiome disruption, and Clostridioides difficile infection in patients receiving chimeric antigen receptor T-cell (CAR-T) therapy for hematological malignancy. In Australia, FQ prophylaxis is not routinely used. We evaluated the etiology of early fever following CAR-T to better understand the incidence of infections, particularly bloodstream infections, in a cohort not receiving FQ prophylaxis. This bicentric Australian retrospective study included adults receiving standard-of-care CD19 CAR-T therapy for DLBCL (2019 to 2023). The primary outcome was the cause of sustained fever (≥38.0°C on ≥1 days) from infusion to day 30. Recurrent fever required ≥72 h afebrile before a new fever. Infections were classified as microbiologically confirmed, clinically defined, or fever syndrome per consensus criteria. About 204 adults (median age 64 years, IQR: 57 to 71) received tisagenlecleucel (50%) and axicabtagene (50%), after a median of 3 prior therapies (interquartile range [IQR]: 3 to 4). Sustained fever occurred in 131/204 patients (64%), comprising 161 episodes. Of these, 36 (21%, 28pts) were microbiologically confirmed infections, 14 (9%, 14pts) were clinically defined infections, and 110 (69%, 108pts) were fevers of unknown origin. Bacteremia occurred in 7/204 patients (3.4%; 9 events), with one fatal polymicrobial bacteremia. Other microbiologically confirmed infections included C. difficile (7/36), URTI (13/36) and invasive fungal infection (5/36). Risk factors for early microbiologically confirmed infection in univariate analysis included axicabtagene product (hazard ratio [HR] = 2.5, P = .019), grade ≥3 immune-cell associated neurotoxicity (HR = 3.4, P = .012), and prolonged neutropenia (absolute neutrophil count ≤ .5 × 10⁹/L for ≥14 days; HR = 3.7, P = .014). Early bacteremia rates remain low without routine FQ prophylaxis. Initial sustained fevers are predominantly noninfectious. Our data do not support universal FQ prophylaxis in CAR-T therapy.

BACKGROUND:We evaluated whether a daily nasal spray of interferon-alpha (IFN-α) would reduce the incidence of COVID-19 or community-acquired respiratory viral infections in adult cancer patients. METHODS:In this multicenter, randomized, double-blinded, placebo-controlled trial, participants were randomized 1:1 to receive daily 40 000 IU IFN-α nasal spray or normal saline placebo. Participants who developed influenza-like symptoms self-collected nasal swabs for PCR testing of SARS-CoV-2, influenza A/B, respiratory syncytial virus, parainfluenza, adenovirus, seasonal coronavirus, picornavirus, human metapneumovirus, and/or SARS-CoV-2 rapid antigen testing. Co-primary endpoints were incidence of COVID-19 and/or other respiratory viruses ≤90 days of randomization. RESULTS:Four hundred and thirty-three participants were randomized to IFN-α (n = 217) or placebo (n = 216). The incidence of COVID-19 was lower in the IFN-α group versus placebo (8.3% vs 14.4%), indicating a 40% reduced risk of infection (relative risk [RR]: .60; 95% credible interval [CrI]: .33-.97). Other respiratory viral infection incidence was 5.1% and 5.1% in both groups (RR: 1.12; .43-2.34). In the per-protocol cohort (n = 389), the incidence of COVID-19 in IFN-α and placebo groups was 7.7% and 16.0% (RR: .50; .26-.84) with other respiratory virus incidence of 4.6% and 5.7%, respectively. Subgroup analysis demonstrated lower COVID-19 in the IFN-α group for ages <65 years (RR: .48; .20-.92), female sex (RR: .44; .19-.85), and COVID-19 vaccinated (RR: .50; .26-.82), but no difference by underlying malignancy. No differences were observed in secondary endpoints of severity, hospitalization, and mortality. IFN-α was well tolerated and safe. CONCLUSIONS:IFN-α nasal spray prophylaxis reduced the incidence of COVID-19 among adult cancer patients. CLINICAL TRIALS REGISTRATION:ClinicalTrials.gov identifier: NCT04534725 (ANZCTR: ACTRN12620000843954).

OBJECTIVES:Assessing antimicrobial prescribing is foundational to antimicrobial stewardship (AMS) programs to enable targeted interventions, however data assessing its impact on prescribing appropriateness are lacking. Using data from the National Antimicrobial Prescribing Survey Program, we aimed to evaluate the impact of repeated auditing on appropriateness and examine differences in hospital and prescription characteristics, including against the World Health Organization AWaRe classifications. METHODS:This multicentre, national observational cohort study analysed annual point-prevalence audits conducted by Australian hospitals between 2014 and 2023. Local AMS clinicians assessed appropriateness using standardized definitions considering spectrum, dosing, route and duration. Descriptive analyses examined prescribing patterns, and a logistic mixed model estimated odds ratios (ORs) for the association between years of auditing participation and appropriateness. RESULTS:A total of 543 hospitals contributed data, of which 67 participated across all 10 years. Most hospitals were public (68.5%), low acuity (68.9%) and from major cities (48.6%). A total of 276 212 antimicrobial prescriptions were analysed. Aggregate appropriateness was 73.7% and was lowest for AWaRe Access category antimicrobials (102 502/146 017, 70.2%) compared with Watch (58 751/80 053, 73.4%) and Reserve (1011/1170, 86.4%) antimicrobials. Hospitals participating in any number of subsequent years had increased odds of appropriateness compared with first-time participants (range OR, 1.11; 95% CI, 1.02-1.22 to OR, 1.22; 95% CI, 1.04-1.43), with the greatest differences observed in hospitals participating across all 10 years. This was statistically significant in the public but not private hospital subgroup. Lower appropriateness was observed for regional (0.77; 95% CI, 0.68-0.87) or remote (0.60, 95% CI, 0.45-0.79) compared with major city hospitals and for surgical prophylaxis (0.28, 95% CI, 0.27-0.29) compared with nonsurgical prophylaxis prescriptions. CONCLUSIONS:Using a unified definition, appropriate antimicrobial prescribing was significantly higher with repeated auditing, reinforcing its importance as a fundamental AMS strategy. Targeted interventions are required to address poor appropriateness in regional and remote hospitals, surgical prophylaxis, and amongst Access antimicrobials.

Abstract Background Microbiology testing can guide infectious disease management and antimicrobial selection, including for older people living in long-term care facilities (LTCFs), who are at high risk of infectious diseases. However, insufficient and excessive microbiology testing can contribute to inappropriate antimicrobial use. The study examined national trends, co-testing, and LTCF variation in microbiology testing. Methods This national repeated cross-sectional study included individuals aged 65–105 years residing in Australian LTCFs between 2009 and 2019. The annual age and sex standardised (i) proportion of individuals with a microbiology test and (ii) number of tests performed/100 resident-years were determined. Annual changes were estimated using adjusted rate ratios (aRRs) with 95% confidence intervals (CIs) from Poisson or negative binomial models. Co-testing and LTCF variation in 2019 were also evaluated. Results Among the 547,067 studied residents, the median age at study entry was 84 years and 65.8% were women. Proportion of microbiology testing increased from 50.2% (95%CI 49.8–50.5) in 2009 to 59.4% (95%CI 59.0-59.7) in 2019 (aRR 1.02, 95%CI 1.01–1.02). Urine tests were the most frequently requested microbiology test, increasing from 40.9% (95%CI 40.5–41.2) to 44.9% (95%CI 44.5–45.2) during 2009–2019 (aRR 1.01, 95%CI 1.01–1.01). Nucleic acid amplification tests (NAATs) increased from 3.4% (95%CI 3.3–3.5) to 17.9% (95%CI 17.7–18.1) (aRR 1.21, 95%CI 1.21–1.21). In 2019, there were 1,614 (58.6%) LTCFs where the adjusted proportion of microbiology testing fell within the 95%CI range around the population mean. Faecal, Cryptosporidium/Giardia , and Clostridioides difficile/C.toxin tests were commonly performed concurrently with NAATs. Conclusions Over an 11-year period, microbiology testing increased. Eight out of ten residents were tested at least once during their LTCF stay, and considerable facility variation in testing was observed. Diagnostic stewardship targeting commonly requested microbiology tests (e.g., urine tests) could optimise antimicrobial use in LTCFs.

BACKGROUND:Antimicrobials are an adjunctive therapy in clinical dentistry. In dentoalveolar surgery, antimicrobials are not routinely required for surgical prophylaxis. This retrospective analysis of the Australian Surgical National Antimicrobial Prescribing Survey (Surgical NAPS) dataset aimed to evaluate the guideline compliance and appropriateness of antimicrobial prescribing for dentoalveolar procedures in Australian hospitals. METHODOLOGY:Deidentified Surgical NAPS data for dentoalveolar procedures (tooth extractions and implant placements) between 2016 and 2022 were extracted. Procedures outside the scope of a general dentist were excluded. Prescribed antimicrobials for surgical prophylaxis, including procedural prophylaxis doses and post-procedural prescriptions, were assessed for guideline compliance and appropriateness according to the Surgical NAPS algorithm. RESULTS:1345 surgical episodes with dental procedures were included. This comprised 1077 procedural prophylaxis doses and 555 post-procedural prescriptions. Of the post-procedural prescriptions, 478 (86%) were for prophylaxis. Guideline compliance was demonstrated in 35.3% of procedural doses and 14.6% of post-procedural prescriptions. Rates of appropriateness were 33.5% for procedural doses and 12.6% for post-procedural prescriptions. Most procedural doses and post-procedural prescriptions were deemed inappropriate as they were not required (72.5% and 93.0%, respectively). CONCLUSIONS:Suboptimal guideline compliance and appropriateness of antibiotic prescribing for dentoalveolar surgery reinforces the need for antimicrobial stewardship interventions.

Chemotherapy/immune checkpoint inhibitor (ICI) therapy is increasingly standard of care for a range of cancers. Increasing numbers of emergency cancer presentations mean alternative pathways are required to ensure sustainable services and improve outcomes. Febrile neutropenia (FN) is common in patients treated with chemotherapy/ICI therapy. Risk stratifying patients with FN is essential to personalise acute management and optimise use of healthcare resources. Management of patients with low-risk FN in an outpatient setting is proven to be safe and effective. The MASCC score is well validated for risk stratification in FN, and patients with a score ≥ 21 are likely to be suitable for outpatient management. It has not been validated in patients treated with combined chemotherapy/ICI regimens. This MASCC position paper outlines an approach for acute ambulatory management of low-risk FN in this cohort and produces ten position points. A literature search was performed up to the 31st May 2025 for outpatient management of FN in patients treated with chemotherapy/ICI therapy. Only one paper met the criteria highlighting the need for prospective and real-world data. Patients treated with a MASCC score < 21 are high risk and require standard neutropenic sepsis management. Empirical usage of high-dose steroids in patients presenting with FN on chemo/ICI therapy with grade ≥ 3 diarrhoea and/or transaminitis is not recommended. Patients treated with chemotherapy/ICI therapy with low-risk FN should be treated on the same pathway as those treated with chemotherapy alone with inclusion criteria adapted to recognise their eligibility. ICI-mediated neutropenia should be considered in patients receiving combined chemotherapy/ICI therapy when the timing of presentation is unanticipated or there is a failure of neutrophil recovery with persistent grade 3/4 neutropenia 10 days following administration. Initial treatment of suspected ICI-mediated neutropenia is to commence high-dose steroids and consider short-acting G-CSF.

Objectives:Surveillance of antimicrobial prescribing quality is a core element of national antimicrobial resistance containment strategies. The National Antimicrobial Prescribing Survey (NAPS) programme was implemented in Bangladesh, Bhutan, and Nepal under the Fleming Fund-supported Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia project to strengthen national surveillance and stewardship capacity. The programme comprises setting-specific modules using standardized indicators including documentation quality, guideline concordance, and appropriateness. Methods:Between September 2024 and September 2025, Hospital NAPS point-prevalence audits were conducted in Bangladesh and Nepal, and Surgical NAPS was piloted in Bhutan. Audits were conducted in two phases to enable local interventions between rounds, incorporating stakeholder engagement, structured auditor training, and central quality assurance. Results:Ten hospitals completed audits encompassing 1299 patients (Hospital NAPS), 236 procedures (Surgical NAPS), and 2308 prescriptions. The programme produced baseline prescribing appropriateness data for the first time to inform stewardship priorities across district to tertiary settings. Key enablers included national engagement and establishment of antimicrobial stewardship committees; barriers included incomplete documentation, infrastructure limitations, and coordination challenges. Conclusion:The NAPS programme demonstrated feasibility across diverse health system contexts in three South-East Asia Region countries. Sustained leadership, routine practice integration, local ownership, and committed cross-institutional collaboration are critical for long-term stewardship impact.

Objectives This study examined the incidence of hospitalizations for urinary tract infections (UTIs) and associated factors among residents of long-term care facilities (LTCFs) during the first 12 months of their LTCF stay. Design Population-based retrospective cohort study. Setting and participants This study included people aged ≥65 years who first entered an LTCF between 2015 and 2018 using data from the Registry of Senior Australians National Historical Cohort. Methods The cumulative incidence of hospitalizations of UTI in the 12 months following LTCF entry was evaluated. Individual, facility, medicine, and service utilization-related factors associated with hospitalizations for UTIs were investigated. A Fine-Gray model was used to estimate subdistribution hazard ratios (sHRs) and 95% CIs. Results Of the 180,858 people included from 2464 LTCFs, 59.7% (n = 107,914) were female, with a median age of 85 years. The cumulative incidence of hospitalizations for UTIs in the 12 months after LTCF entry was 3.7% (95% CI 3.7-3.8). Factors associated with a higher rate of hospitalizations for UTIs included long-term urinary catheter use (sHR 3.39, 95% CI 3.16-3.65), history of hospitalizations with UTI (sHR 2.33, 95% CI 2.21-2.46), preferred language other than English (sHR 1.38, 95% CI 1.28-1.48), diabetes (sHR 1.29, 95% CI 1.22-1.37), high (sHR 1.30, 95% CI 1.19-1.41) or medium (sHR 1.21, 95% CI 1.11-1.32) need for assistance with activities of daily living, cerebrovascular disease (sHR 1.14, 95% CI 1.08-1.20), and urinary incontinence (sHR 1.08, 95% CI 1.01-1.15). Conclusions and implications A considerable burden of UTI-associated hospitalizations was observed in Australian LTCFs, which can be minimized through implementing effective UTI prevention, detection, and management strategies.

BACKGROUND:Around half of children admitted to hospital receive intravenous (IV) antibiotics, contributing to higher costs, vascular access complications and longer hospital stays. A single-site pilot in a tertiary Australian paediatric hospital implemented nationally endorsed Australasian Stewardship of Antimicrobials in Paediatrics (ANZPID-ASAP) IV-to-oral antibiotic switch guidelines, improving timely switch rates from 64% to 82%. Following this success, a broader study is planned to assess the feasibility of scaling this approach across hospitals of varying types and sizes within NSW, Australia. AIMS:The HOMEFREE study hypothesises that implementation of an IV-to-oral antibiotic switch programme based on endorsed guidelines and supported by audit and feedback will increase the proportion of hospitalised children transitioned to oral therapy or antibiotic cessation within 24 h of meeting eligibility criteria. The study will evaluate both effectiveness and implementation feasibility across tertiary paediatric and general hospitals in metropolitan and rural/regional settings. This paper presents the study protocol. METHODS:Participating sites will select context-appropriate interventions to support guideline-concordant prescribing, informed by shared learning during the prospective phase. Effectiveness will be assessed using prospective audits, with key outcomes including timely guideline-concordant IV-to-oral switch and hospital length of stay. Implementation feasibility will be evaluated using the Consolidated Framework for Implementation Research through surveys of local project committee members conducted before and after 12 months of audit and feedback. CONCLUSIONS:This study will assess the effectiveness and feasibility of translating and scaling best-practice IV-to-oral antibiotic switch guidelines for children in real-world hospital settings.

BACKGROUND:Cutaneous T-cell lymphomas (CTCLs) are rare with distinct diagnostic challenges. Equitable access to cancer care is a recognized priority, internationally. To date, the geospatial distribution of CTCL has not been definitively studied. Understanding the incidence and geographical distribution of patients with CTCL are critical first steps towards the ultimate goal of equity of care. Geospatial analyses also allow the opportunity to explore environmental causative factors: for CTCL, the contribution of solar ultraviolet (UV) radiation on causation remains unclear. OBJECTIVES:We investigate geospatial patterns of CTCL incidence across Australia, compare with all rare cancers, and consider solar UV exposure on causality and diagnosis rates. METHODS:All CTCL diagnoses (1 January 2000 to 31 December 2019) were obtained from the nationwide dataset. Areas of residence were collected according to nationally approved definitions. Bayesian spatial incidence models were applied. Geospatial distributions were visually analysed. RESULTS:The CTCL age-standardised incidence rate was 7.7 (95% confidence interval 7.4-7.9) per million people per year in Australia. Diagnostic disparity was seen between Australian states/territories, with lower diagnosis rates in rural/remote and socioeconomically disadvantaged areas. Incidence exceeded the national average within more densely populated capital cities. Visual comparisons of the geospatial distribution of CTCL revealed marked discordances with the geospatial patterns of all rare cancers and solar UV in Australia. CONCLUSIONS:Geographical heterogeneity in CTCL exists across Australia. Incidence reflects population density. Geospatial patterns of CTCL differ substantially from all rare cancers, with implications for the unique diagnostic challenges and unmet needs of this patient population. The distribution of CTCL across Australia does not support a causative link with UV exposure. Further global evaluation of geospatial patterns is warranted.

Background: Since 2013, the Australian Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) has provided a standardized framework for hospitals to assess the quality of antimicrobial prescribing. As part of the program’s continuous quality improvement, a revised appropriateness algorithm was developed and is scheduled for implementation in 2025. This study aims to validate this algorithm by evaluating accuracy and inter-rater reliability (IRR) in assessing guideline concordance and appropriateness. Methods: A prototype of the revised assessment algorithm was developed using Qualtrics®, including an assessment of antimicrobial-level guideline concordance, appropriateness and reasons for non-optimal prescribing, as well as overall indication-level guideline concordance and appropriateness. An eLearning module was developed to ensure consistency of training for assessors. Fourteen clinical vignettes (ten general and four specialist) across a range of real-world clinical scenarios and with varying levels of complexity were developed. Gold standard assessments were determined by an independent group of infectious diseases (ID) and antimicrobial stewardship (AMS) clinicians. Existing Hospital NAPS users were invited to participate. General vignettes were split into two equal groups and assigned to assessors in an alternating manner. Those with expertise in haematology/oncology or paediatrics were assigned additional specialist vignettes. Results were analyzed for accuracy against the gold standard, and for IRR using Fleiss’ Kappa coefficient. Results: A total of 102 assessors, across a range of professions, remoteness areas and years of auditing experience, completed their assigned vignettes. Assessors correctly identified the antimicrobial regimen for auditing in 91.9% of assessments, with incorrectly identified assessments excluded. A total of 681 antimicrobial-level and 534 indication-level assessments were analyzed. Figure 1 summarizes the accuracy and IRR for the main outcome measures of guideline concordance and appropriateness. Accuracy and IRR were higher for appropriateness compared with guideline concordance, and at the overall indication-level compared with the antimicrobial-level. Auditors correctly identified all gold-standard reasons for non-optimal prescribing in 68.3% of assessments. Across all measures, accuracy and IRR was higher amongst assessors with specialist ID/AMS experience compared to those without, from metropolitan compared with regional settings, and amongst those with 4 or more years of auditing experience. Pharmacists without ID/AMS expertise scored as highly as doctors and pharmacists with ID/AMS expertise. Conclusion: The revised Hospital NAPS algorithm provides a valid measure of guideline concordance and appropriateness. Higher accuracy and IRR were observed for appropriateness compared with guideline concordance, highlighting the importance of appropriateness as a measure for stewardship surveillance in reflecting quality of patient care.

INTRODUCTION:Diagnostic stewardship, the optimization of diagnostic testing to improve patient outcomes, is a rapidly evolving field; however, data relating to immunocompromised hosts are scarce. AREAS COVERED:This review examines recent advances in diagnostic stewardship and explores best practice principles for key clinical scenarios in immunocompromised patients, including febrile neutropenia, central nervous system infections, invasive fungal infections, cytomegalovirus, and Clostridioides difficile infection. EXPERT OPINION:Key challenges remain, including optimizing test utilization without compromising patient safety, interpreting advanced diagnostics in the context of immunosuppression, and demonstrating cost-effectiveness. A multidisciplinary approach incorporating both diagnostic and antimicrobial stewardship principles is essential to improve outcomes in this complex patient population. Future research should focus on prospective evaluation of diagnostic stewardship interventions and their impact on clinical and economic outcomes in immunocompromised hosts.