Antimicrobial Stewardship In Austalian Health Care 2018

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Antimicrobial Stewardshipin Australian Health Care2018

Published by the Australian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth Street, Sydney NSW 2000Phone: (02) 9126 3600Fax: (02) 9126 3613Email: 978-1-925665-40-6 Australian Commission on Safety and Quality in Health Care 2018All material and work produced by the Australian Commission on Safety and Quality in Health Care (the Commission)is protected by copyright. The Commission reserves the right to set out the terms and conditions for the use of suchmaterial.As far as practicable, material for which the copyright is owned by a third party will be clearly labelled. The Commissionhas made all reasonable efforts to ensure that this material has been reproduced in this publication with the full consentof the copyright owners.With the exception of any material protected by a trademark, any content provided by third parties and where otherwisenoted, all material presented in this publication is licensed under a Creative Commons Attribution–NonCommercial–NoDerivatives 4.0 International licence.Enquiries about the licence and any use of this publication are welcome and can be sent to Commission’s preference is that you attribute this publication (and any material sourced from it) using the followingcitation:Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship in Australian Health Care 2018.Sydney: ACSQHC; 2018DisclaimerThe content of this document is published in good faith by the Commission for information purposes. The documentis not intended to provide guidance on particular healthcare choices. You should contact your healthcare provider forinformation or advice on particular healthcare choices.This document includes the views or recommendations of its authors and third parties. Publication of this documentby the Commission does not necessarily reflect the views of the Commission, or indicate a commitment to a particularcourse of action. The Commission does not accept any legal liability for any injury, loss or damage incurred by the use of,or reliance on, this document.

Antimicrobial Stewardshipin Australian Health Care2018

AcknowledgementsAntimicrobial Stewardship in Australian Health Care2018 has been developed through the contributionsof many individuals and organisations who arecommitted to improving antimicrobial use inhospitals and reducing the risk of harm to patientsfrom inappropriate antimicrobial prescribing.The Australian Commission on Safety and Qualityin Health Care wishes to thank the followingcontributing authors for their expertise and timegiven to the writing of this publication: Dr Tara Anderson – Infectious Diseases Physicianand Clinical Microbiologist, Medical Advisor– Infection Prevention and Control, RoyalHobart Hospital, and Specialist Medical Advisor– Tasmanian Infection Prevention and ControlUnit (particularly Chapter 2) Dr Noleen Bennett – National Centre forAntimicrobial Stewardship (particularlyChapter 12) Associate Professor Kirsty Buising – NationalCentre for Antimicrobial Stewardship(particularly Chapters 3 and 6) Clinical Associate Professor Susan Benson– PathWest Laboratory Medicine, WesternAustralian Department of Health and Universityof Western Australia (particularly Chapter 9) Dr Celia Cooper – SA Pathology, SA Health(particularly Chapters 5 and 8) Dr Jonathan Dartnell – NPS MedicineWise(particularly Chapters 7 and 10) Ms Margaret Duguid – Australian Commission onSafety and Quality in Health Care (contributionto all Chapters) Conjoint Associate Professor John Ferguson– Hunter New England Local Health District(particularly Chapter 9) Ms Fiona Gotterson – Australian Commission onSafety and Quality in Health Care (particularlyChapters 3, 5 and 12) Dr David Kong – Ballarat Health Services andCentre for Medicine Use and Safety, MonashUniversity (particularly Chapter 11) Associate Professor David Looke – InfectiousDiseases Physician and Clinical Microbiologist,Princess Alexandra Hospital; and AssociateProfessor, University of Queensland (particularlyChapter 6) Professor Graeme Nimmo – PathologyQueensland, Queensland Health (particularlyChapter 9) Professor Lisa Pulver – NPS MedicineWise(particularly Chapters 7 and 10) Professor Debra Rowett – NPS MedicineWise(particularly Chapters 7 and 10) Professor Karin Thursky – National Centrefor Antimicrobial Stewardship (particularlyChapter 4) Professor John Turnidge – AustralianCommission on Safety and Quality in HealthCare (particularly Chapters 1 and 3) Dr Helen Van Gessel – Albany Hospital(particularly Chapter 2) Dr Morgyn Warner – SA Pathology, SA Health(particularly Chapter 1) Dr Jeanie Yoo – NPS MedicineWise (particularlyChapter 10).The Commission also wishes to extend its thanks tothe following individuals who have provided theirconsidered advice in the review of the content of thisbook: Dr Philippa Binns – public health physician andgeneral practitioner Professor Chris Del Mar – Centre for Research inEvidence-Based Practice, Bond University Dr Kylie Easton – NPS MedicineWise Associate Professor Thomas Gottlieb - Senior StaffSpecialist, Microbiology & Infectious Diseases, ConcordHospital Dr Malene Hansen – Centre for Research inEvidence-Based Practice, Bond University Ms Dorothy Harrison – consumer representativereviewer Ms Aine Heaney – NPS MedicineWise Ms Elaine Lum – Institute of Health andBiomedical Innovation, Faculty of Health,Queensland University of Technology Dr Amanda McCullough – Centre for Research inEvidence-Based Practice, Bond University Dr Geoffrey Playford - Director, InfectionManagement Services, Princess Alexandra Hospital Associate Professor Owen Robinson - InfectiousDiseases Physician, Royal Perth Hospitaliii

Ms Vanessa Simpson – NPS MedicineWise Dr Andrew Staib - Emergency Medicine,Princess Alexandra Hospital Dr Clair Sullivan - Consultant Endocrinologist andMedical Informatician, Princess Alexandra Hospital.A number of Commission staff were also involved inthe writing and review of this publication, and theCommission wishes to acknowledge: Ms Debbie Carter Professor Marilyn Cruickshank Dr Nicola Dunbar Dr Robert Herkes Ms Eliza McEwin Adjunct Professor Kathy Meleady Adjunct Professor Debora Picone AM Ms Naomi Poole Ms Lucia Tapsall Mr Michael Wallace.In addition, the Commission wishes to acknowledgethe members of the Society of Hospital Pharmacistsof Australia Infectious Diseases Committee ofSpecialty Practice for their contribution in reviewingthis publication; and the staff of Biotext for theirexpert review, editing and design services.iv

ContentsAcknowledgements iiiSummary 1Key issues 3The challenge The response Australian framework for AMS Essential elements of antimicrobial stewardship This publication Aim Structure Chapter 1: Evidence for antimicrobial stewardship 33334447Acronyms and abbreviations 101.1Introduction 111.2Challenge and impact of antimicrobial resistance framework for antimicrobial stewardship l standards and guidelines National Antimicrobial Resistance Strategy Antimicrobial stewardship in the states and territories Therapeutic Guidelines Surveillance of antimicrobial use and resistance in Australia Education and awareness raising Antimicrobial stewardship research Professional societies and organisations Antimicrobial use between antimicrobial use and resistance Consequences of antimicrobial resistance Factors contributing to unnecessary and inappropriate antimicrobial use Antimicrobial use in Australia Harmful effects of antimicrobial use Antimicrobial stewardship antimicrobial stewardship Evidence to support the benefits of antimicrobial stewardship Unintended consequences of antimicrobial stewardship programs 12131414171717181920202121212122222427References 29Appendix A: Examples of antimicrobial stewardship (AMS) activities and resourcesin Australian states and territories 34 v

Chapter 2: Establishing and sustaining an antimicrobial stewardship program 35Acronyms and abbreviations 382.1Introduction 392.2Essential elements of antimicrobial stewardship programs 402.3Structure and governance 412. stewardship committee and team stewardship committee Antimicrobial stewardship team 4548Antimicrobial stewardship program plan Safety and quality improvement Governance Executive leadership Clinical leadership Assessing readiness to implement an antimicrobial stewardship program or intervention Reviewing existing policies and prescribing guidelines Reviewing local data on antimicrobial use and resistance Determining priority areas for antimicrobial stewardship activities Identifying effective interventions Defining measurable goals and outcomes Documenting and implementing the antimicrobial stewardship plan Educating the workforce Developing and implementing a communication plan Sustaining the antimicrobial stewardship program 49535556575859596060Resources 61References 63Appendix A: Examples of successful and sustained antimicrobial stewardship programs 66Chapter 3: Strategies and tools for antimicrobial stewardship 75Acronyms and abbreviations 783.1Introduction 793.2Prescribing guidelines 813. guidelines Local guidelines Promoting guideline uptake Tools and resources to support guideline implementation Education and feedback Antimicrobial stewardship care bundles Formularies and approval systems formulary State and territory formularies Hospital formularies Antimicrobial approval systems 8181828283838383848485vi

3.4Post-prescription reviews should perform reviews in hospitals? Which patients should be reviewed? What should be included in the feedback? How should feedback be provided? Prescription review at transitions of care Post-prescription reviews in the community setting Point-of-care interventions therapy based on results from microscopy and other rapid tests Directing therapy based on culture and susceptibility test results Optimising dosing Limiting toxicity Changing the duration of therapy Switching from intravenous to oral delivery Escalating to formal expert clinical review 878789898990909191919192929293Resources 94References 95Chapter 4: Information technology to support antimicrobial stewardship 99Acronyms and abbreviations 1024.1Introduction 1034.2Electronic clinical decision support systems 1111121134.3Data collection and reporting 1144.4Telehealth 115Resources 117References 118Chapter 5: Antimicrobial stewardship education for clinicians 123Acronyms and abbreviations 1265.1Introduction 1275.2Key elements of antimicrobial stewardship education 1285. Passive decision support systems and smartphone apps Electronic approval systems Electronic surveillance and infection prevention systems Electronic prescribing and medication management systems Advanced decision support systems Implementing electronic clinical decision support systems for antimicrobial stewardship Electronic clinical decision support in primary care Audiences Principles of education on antimicrobial stewardship Antimicrobial stewardship competencies and standards 128129129vii stewardship education for different groups and stages of the pharmaceutical industry Evaluation of educational activities Undergraduate training Early-career development Continuing education and professional development Education and training for antimicrobial stewardship teams Specialist training Education resources Websites and online learning resources Educators 131132132132133134136137137137137138Resources 139References 140Appendix A: Managing conflicts of interest and relationships with thepharmaceutical industry – further reading and links 143Appendix B: Example of a ‘Did you know’ email for clinicians 144Chapter 6: Measuring performance and evaluating antimicrobialstewardship programs 147Acronyms and abbreviations 1506.1Introduction 1516.2Key elements of antimicrobial stewardship measurement 1526. should be measured? Measurement approaches Structure measures Community 1521521521521546.4Process measures 1546.5Outcome measures 1556. patient outcomes Improved patient safety Reduced resistance Reduced costs Qualitative and other related measures of program activity 1561561561571576.6Balancing measures 1576.7Surveillance of antimicrobial use 1586. the volume of antimicrobial use in hospitals Measuring the volume of antimicrobial use in the community Reporting and monitoring use data at the local level Auditing the quality of antimicrobial prescribing 6.8.1Auditing prescribing in hospitals 158160161164164viii prescribing in the community Quality improvement audits Reporting, feedback and use of data service organisation reports State and territory reports National reports Use of data for benchmarking 166167168168168168169Resources 171References 172Chapter 7: Involving consumers in antimicrobial stewardship 177Acronyms and abbreviations 1807.1Introduction 1817.2Consumer awareness and expectations 1827. messages and communication understanding of when antimicrobials are needed Consumer awareness and understanding of antimicrobial resistance Previous experience of antimicrobials Reassurance Health literacy Communication with consumers in different settings and circumstances Consumer resources and tools the consultation During the consultation After the consultation Reaching and engaging consumers nationally Antibiotic Awareness Week 182182183183183183185186186187188188190Resources 191References 192Chapter 8: Role of the infectious diseases service in antimicrobialstewardship 195Acronyms and abbreviations 1988.1Introduction 1998.2Leadership 1998. advice 8.4Participating in the antimicrobial stewardship team and committees Implementing and maintaining antimicrobial policies and guidelines Specific situations requiring infectious diseases physician expertise Support for external organisations Support for formularies and approval systems 200201201202203204ix Approval systems Prescription review with feedback stewardship team rounds Conflicting advice 2042042052052058.6Monitoring antimicrobial use and evaluating interventions 2068.7Liaison 2078. within hospitals Interacting with the pharmaceutical industry Role in education 207207208Resources 209References 209Chapter 9: Role of the clinical microbiology service in antimicrobialstewardship 213Acronyms and abbreviations 2169.1Introduction 2179.2Overview of the diagnostic testing process 2179.3Pre-analytical phase: microbiology process 2189. phase: microbiological analytical practice of test reporting and integration with antimicrobial stewardship programs Reporting and interpreting results Cascade reporting Communicating critical results Specific situations that need clinical microbiology service expertise diagnostics and testing Antimicrobial susceptibility testing Post-analytical phase: microbiology reporting diagnostic tests Collecting and transporting samples Commenting on specimen quality Support for high-risk units Cumulative antibiogram analysis Signal and critical antimicrobial resistances (CARs) Therapeutic drug monitoring and review Linking microbiology results with electronic prescribing Measuring performance of the clinical microbiology service as part of theantimicrobial stewardship program Role in education 8228229Resources 230References 231x

Chapter 10: Role of prescribers in antimicrobial stewardship 237Acronyms and abbreviations 24010.1 Introduction 24110.2 Prescriber concerns and influences 24210. perspectives on antimicrobial resistance Policies and guidelines Diagnostic uncertainty Influence of others Prescribers in aged care Non-medical prescribers 10.3 Prescriber strategies 10.3.1 Antimicrobial stewardship prescribing principles 10.3.2 Prescribing in specific situations 10.4 Prescriber resources and tools 10.4.1 Guidelines and antimicrobial information 10.4.2 Antimicrobial Stewardship Clinical Care Standard 10.4.3 Education and professional development 242242243243244244245245246247247247247Resources 248References 249Chapter 11: Role of the pharmacist and pharmacy services inantimicrobial stewardship 253Acronyms and abbreviations 25611.1 Introduction 25711.2 Pharmacists and antimicrobial stewardship 25711.2.1 Activities in different settings 11.2.2 Pharmacy managers 11.2.3 Roles of antimicrobial stewardship pharmacists 11.3 Leadership 11.3.1 Promoting uptake and compliance with national standards for antimicrobial stewardship 11.3.2 Developing and maintaining antimicrobial guidelines 11.4 Expert advice 11.4.1 Providing expert advice to clinicians, patients and carers 11.4.2 Participating in antimicrobial stewardship ward rounds 11.4.3 Initiating point-of-care interventions 25826126226226326326326326326411.5 Formularies and approval systems 26411.6 Monitoring antimicrobial use and evaluating interventions 26411.7 Liaison 26511.8 Education 265 11.8.1 Antimicrobial stewardship education for pharmacists 11.8.2 Pharmacists’ role in education 265267xi

Resources 268References 269Appendix A: Examples of training and educational opportunities for AMS pharmacists 271Chapter 12: Role of nurses, midwives and infection control practitionersin antimicrobial stewardship 273Acronyms and abbreviations 27612.1 Introduction 27712.2 Nursing and midwifery practice and antimicrobial stewardship 27712.3 Facilitating nursing and midwifery involvement 28012. for nursing and midwifery involvement Promoting a safety culture Education Resources and tools 12.4 Advanced and specialist practice roles 12.4.1 Nurse practitioners 12.4.2 Infection control practitioners 280282283284285285286Resources 289References 290Glossary 293Glossary 295References 303xii

SummaryAntimicrobial Stewardshipin Australian Health Care2018

SummaryKey issuesThe challengeAntimicrobial resistance (AMR) is an issue ofgreat significance for health care in Australia andhas been declared a significant threat to humanhealth. Infections with pathogens resistant toantimicrobials lead to prolonged or serious illness,escalation in therapy with associated healthcarecosts, hospitalisation or death. With few newantimicrobials coming onto the market in theforeseeable future, the options for treating resistantinfections are becoming increasingly limited.High levels of antimicrobial use and inappropriateuse of antimicrobials cause increasing AMRand other patient harms. Australia’s use ofantimicrobials is high compared with other highincome countries. In 2015, almost 40% of patientsadmitted to Australian hospitals were prescribedan antimicrobial, and in the community 45%of the population were dispensed one or moreantimicrobials during the year. Around onethird to one-half of this antimicrobial use wasconsidered inappropriate. That is, antimicrobialswere prescribed for conditions that did notrequire antimicrobial treatment – such as acuteundifferentiated upper respiratory tract infection,acute tonsillitis, or acute otitis media – or wereprescribed inappropriately or suboptimally; forexample, using a poor choice of antimicrobial, orsuboptimal dose, route or duration.The responseAntimicrobial stewardship (AMS) promotes optimalantimicrobial prescribing. AMS programs have beenshown to reduce unnecessary and inappropriateuse of antimicrobials, reduce patient morbidityand mortality, and reduce bacterial resistance ratesand healthcare costs. AMS is considered an integralcomponent of patient safety and an importantstrategy for preserving the effectiveness of thoseantimicrobials currently available.Australian framework for AMSIn Australia, AMS programs are required by theNational Safety and Quality Health Service (NSQHS)Preventing and Controlling Healthcare-AssociatedInfection Standard, and supported by the AustralianCommission on Safety and Quality in Health CareAntimicrobial Stewardship Clinical Care Standard,the Antimicrobial Use and Resistance in Australia(AURA) Surveillance System, and the work of manygovernment and non-government organisations,health service organisations, professional bodiesand research organisations. Australia’s first NationalAntimicrobial Resistance Strategy 2015–2019 aimsto implement effective AMS practices across humanand animal health and agriculture sectors.Essential elements of antimicrobialstewardshipSuccessful AMS programs in human healthare multidisciplinary, and operate within anorganisation’s governance systems with the supportof the organisation’s executive. They comprise asuite of coordinated strategies and interventions topromote the optimal use of antimicrobials, tailoredto patients’ needs. The essential elements andstrategies for AMS programs are outlined in the boxbelow.Although much of the experience in AMS has beenin the hospital sector, the benefits of the use ofAMS interventions to influence antimicrobial use incommunity settings, such as primary care and agedcare homes, are significant for patients, consumersand residents. There is considerable experience ofAMS in hospitals across all peer groups, in rural andremote areas, and in private hospitals. Summary 3

This publicationAimThis publication is designed to provide cliniciansand managers working in all healthcare sectors withthe evidence, expert guidance and tools they need toinitiate and sustain AMS activities in a diverse rangeof practice settings – hospitals (public and private,metropolitan and rural), primary care and aged carehomes. It describes the roles of those responsiblefor establishing and implementing AMS programs,as well as how prescribers, pharmacists, infectioncontrol practitioners, nurses and midwives cancontribute to program success by incorporating AMSprinciples within their clinical practice.StructureThis publication summarises current evidenceabout AMS strategies and interventions, and theirimplementation, and each chapter begins with asummary of the key points relevant to the topic.Chapters 1–7 provide strategies for implementingand sustaining AMS. These chapters includeguidance on establishing and sustaining AMSprograms, strategies and interventions that changeprescribing behaviour, use of electronic clinicaldecision support systems, clinician education,monitoring of antimicrobial use and evaluationof program outcomes, and strategies for engagingconsumers in AMS.Chapters 8–12 examine the roles of the differentclinicians in AMS. These chapters focus on theroles and responsibilities that clinicians canhave in formal AMS programs, as well as howclinicians can incorporate AMS principles intotheir clinical practice. Chapters cover infectiousdiseases physicians; clinical microbiology services;prescribers; pharmacists; and nurses, midwives andinfection control practitioners.The publication will continue to evolve withadditional chapters to follow that address AMSin specific settings such as primary care. As newresources become available, they will be added ashyperlinks to the resources section in each chapteror to the appendices.4 Summary

Essential elements and strategies for antimicrobial stewardshipprogramsStructure and governanceOverall accountability for antimicrobialstewardship (AMS) is defined by anorganisation’s corporate and clinicalgovernance.The NSQHS Standards require health serviceorganisations to implement systems for thesafe and appropriate prescribing and use ofantimicrobials as part of an AMS program.The program should include an AMS policyand have an antimicrobial formulary thatincludes restriction rules and approvalprocesses. The program will also benefitfrom: Implementing formulary† restriction andapproval systems that include restrictingbroad-spectrum and later-generationantimicrobials to patients in whom theiruse is clinically justified Reviewing antimicrobial prescribing, withintervention and direct feedback to theprescriber Implementing point-of-care interventions(including directed therapy, intravenousto-oral switching and dose optimisation) Ensuring that the clinical microbiologyservice–– provides guidance and support foroptimal specimen collection Establishing a multidisciplinary AMS teamthat includes, at least, a lead doctor andpharmacist–– targets reporting of clinicallymeaningful pathogens and theirsusceptibilities Ensuring ongoing education and trainingfor prescribers, pharmacists, nurses,midwives and consumers about AMS,antimicrobial resistance and optimalantimicrobial use.–– uses selective reporting of susceptibilitytesting results–– generates location-specificantimicrobial susceptibility reports(antibiograms) annuallyEssential strategiesThe essential strategies that sit within theAMS governance structure are: Providing access to and implementingclinical guidelines* consistent withTherapeutic Guidelines: Antibiotic thattake into account local microbiology andantimicrobial susceptibility patterns Monitoring antimicrobial use andoutcomes, and reporting to clinicians andmanagement.*†Guidelines include clinical pathways and care bundles.Refers to institutional formularies; in the community,the Pharmaceutical Benefits Scheme and theRepatriation Pharmaceutical Benefits Scheme act as theformulary. Summary 5

1Evidence for antimicrobial stewardshipAntimicrobial Stewardshipin Australian Health Care2018

Chapter contentsAcronyms and abbreviations 101.1Introduction 111.2Challenge and impact of antimicrobial resistance framework for antimicrobial stewardship l standards and guidelines National Antimicrobial Resistance Strategy Antimicrobial stewardship in the states and territories Therapeutic Guidelines Surveillance of antimicrobial use and resistance in Australia Education and awareness raising Antimicrobial stewardship research Professional societies and organisations Antimicrobial use between antimicrobial use and resistance Consequences of antimicrobial resistance Factors contributing to unnecessary and inappropriate antimicrobial use Antimicrobial use in Australia Harmful effects of antimicrobial use Antimicrobial stewardship antimicrobial stewardship Evidence to support the benefits of antimicrobial stewardship Unintended consequences of antimicrobial stewardship programs 12131414171717181920202121212122222427References 29Appendix A: Examples of antimicrobial stewardship (AMS) activities and resourcesin Australian states and territories 34

Acronyms and l resistanceAMSantimicrobial stewardshipAURAAntimicrobial Use and Resistance in AustraliaCIconfidence intervalCommissionAustralian Commission on Safety and Quality in Health CareESBLextended-spectrum β-lactamaseIRRincidence rate ratioMRSAmethicillin-resistant Staphylococcus aureusNAPSNational Antimicrobial Prescribing SurveyNAUSPNational Antimicrobial Utilisation Surveillance ProgramNHMRCNational Health and Medical Research CouncilNSQHS StandardsNational Safety and Quality Health Service StandardsRACGPRoyal Australian College of General Practitioners10 Chapter 1: Evidence for antimicrobial stewardship

Key points The growing problem of antimicrobialresistance (AMR) presents a threat topublic health and patient safety.antimicrobial choice, dose and durationselected to optimise clinical outcomesand minimise adverse consequences. Antimicrobial-resistant infections can leadto prolonged or serious illness, escalationin therapy (and associated healthcarecosts), hospitalisation or death. In Australia, AMS programs are requiredby the National Safety and Quality HealthService Standards, which are mandated forall hospitals in Australia. Other healthcare interventions, such assurgery and oncology treatments, are alsothreatened by AMR because antimicrobialsare essential to those interventions. AMS initiatives in human health settingsare also supported by the AntimicrobialStewardship Clinical Care Standard. The decreasing pipeline of newantimicrobials limits options for treatinginfections. High levels of antimicrobial use andinappropriate use of antimicrobials areassociated with increasing AMR. Reducing inappropriate antimicrobial useis an important strategy to preserve theeffectiveness of antimicrobials. Antimicrobial stewardship (AMS)programs have been shown to improvethe appropriateness of antimicrobial use,reduce patient morbidity and mortality,and reduce bacterial resistance rates andhealthcare costs. Effective AMS is a suite of coordinatedstrategies that aims to ensure thatantimicrobials are prescribed accordingto ev

Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129

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