To investigate the use of rifampicin vials in Australian operating theaters (OT) to determine the method of administration and rationale for use.

Retrospective (2022 and 2023) OT usage data for rifampicin 600 mg vials were analyzed to compare trends in use between Australian hospitals and between jurisdictions. An audit of rifampicin vials used in OT during 2023 was conducted at a large tertiary hospital.

Fifty-nine of 248 hospitals (24%) contributing data to the National Antimicrobial Utilisation Surveillance Program recorded OT use of rifampicin vials during 2022 and 2023. Excluding hospitals with no usage, the median use was 7 vials/annum/per hospital (IQR: 2–32). A wide variation in use was seen between Australian states and territories. An audit of OT use in 2023 at a large tertiary hospital found poor documentation of topical use; in most cases, documentation was in the operation note only, with no documentation on the medication charts, medical notes, or the anesthetic record. Of 33 rifampicin vials used in 2023, documented topical use was identified for 10 individual patients only, 4 of whom had a confirmed Staphylococcus aureus infection (1 methicillin-resistant and 3 methicillin-susceptible).

Off-label, topical use of rifampicin during surgery is not uncommon in some Australian hospitals despite limited evidence of safety or efficacy. Given the potential for resistance, surgical use of rifampicin should be restricted to a named-patient basis, under the guidance of an infectious disease specialist/clinical microbiologist. Documentation of all medication use is recommended for patient safety.

The frameworks used by Health Technology Assessment (HTA) agencies for value assessment of medicines aim to optimize healthcare resource allocation. However, they may not be effective at capturing the value of antimicrobial drugs.

To analyze stakeholder perceptions regarding how antimicrobials are assessed for value for reimbursement purposes and how the Australian HTA framework accommodates the unique attributes of antimicrobials in cost-effectiveness evaluation.

Eighteen individuals representing the pharmaceutical industry or policy-makers were interviewed. Interviews were transcribed verbatim, coded, and thematically analyzed.

Key emergent themes were that reimbursement decision-making should consider the antibiotic spectrum when assessing value, risk of shortages, the impact of procurement processes on low-priced comparators, and the need for methodological transparency when antimicrobials are incorporated into the economic evaluation of other treatments.

Participants agreed that the current HTA framework for antimicrobial value assessment is inadequate to properly inform funding decisions, as the contemporary definition of cost-effectiveness fails to explicitly incorporate the risk of future resistance. Policy-makers were uncertain about how to incorporate future resistance into economic evaluations without a systematic method to capture costs avoided due to good stewardship. Lacking financial reward for the benefits of narrower-spectrum antimicrobials, companies will likely focus on developing broad-spectrum agents with wider potential use. The perceived risks of shortages have influenced the funding of generic antimicrobials in Australia, with policy-makers suggesting a willingness to pay more for assured supply. Although antibiotics often underpin the effectiveness of other medicines, it is unclear how this is incorporated into economic models.