promoting responsible use of antibiotics from local evidence to policy and practice. visanu...

Promoting Responsible Use of Antibiotics : Promoting Responsible Use of Antibiotics : From Local Evidence to Policy and PracticeFrom Local Evidence to Policy and Practice

VisanuVisanu ThamlikitkulThamlikitkul, MD, MDFaculty of Medicine Faculty of Medicine SirirajSiriraj Hospital Hospital

MahidolMahidol University, Bangkok, ThailandUniversity, Bangkok, Thailand

Thailand AMR Containment ProgramThailand AMR Containment Program

0.6% of GDP0.6% of GDP

Thailand AMR Containment Program 2012 Thailand AMR Containment Program 2012 -- 20162016Donors :Donors : National & International Funding AgentsNational & International Funding Agents ThaiThai HealthHealth PromotionPromotion FoundatioFoundation (n (ThaiHealthThaiHealth)) Health Systems Research Institute (HSRI)Health Systems Research Institute (HSRI) Faculty of Medicine Faculty of Medicine SirirajSiriraj HospitalHospital Government Pharmaceutical Organization (GPO)Government Pharmaceutical Organization (GPO) International Development Research Center (IDRC)International Development Research Center (IDRC)

Target Groups :Target Groups : ““One HealthOne Health”” or or ““EcoHealthEcoHealth”” ApproachApproach

““ONE HEALTHONE HEALTH””

Thailand AMR Containment Program 2012 Thailand AMR Containment Program 2012 -- 20162016

Logo & Slogan of AMR Containment Campaign (English)


Logo & Slogan of AMR Containment Campaign (Thai)

Responsible Use of Antibiotics

Sanitation & Hygiene

Infection Control Measures


I. Develop Fundamental Systems ( 8 Actions)I. Develop Fundamental Systems ( 8 Actions)I. Develop Fundamental Systems ( 8 Actions)

II. Conduct Research & Development (5 Actions)II. Conduct Research & Development (5 Actions)II. Conduct Research & Development (5 Actions)

877 Communities in Thailand877 Communities in Thailand

III. Implement AMR Containment Bundles III. Implement AMR Containment Bundles in 4 Prototype Communities (2 Actions)in 4 Prototype Communities (2 Actions)


Thailand AMR Containment Program 2012 Thailand AMR Containment Program 2012 -- 2016 2016 II. Research & Development Building Block (5 Actions)II. Research & Development Building Block (5 Actions)•• One of the actions is to generate & implement local evidence One of the actions is to generate & implement local evidence for A) promoting responsible use of antibiotics and B) efficientfor A) promoting responsible use of antibiotics and B) efficientpractices for infection control in local context of limitedpractices for infection control in local context of limited--resource settingresource setting An example of An example of promoting responsible use of antibiotics in promoting responsible use of antibiotics in local context of limitedlocal context of limited--resource setting is Responsible Use of resource setting is Responsible Use of Antibiotics in URI & DiarrheaAntibiotics in URI & Diarrhea

AAntibioticntibiotic UUsese for URI and Acute Diarrhea in for URI and Acute Diarrhea in LowLow-- and Middleand Middle--Income Countries (1980 Income Countries (1980 -- 2006)2006)

60%60%

65%65%

Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea

•• Healthcare CenterHealthcare Center Antibiotic Prescription RateAntibiotic Prescription RateURI Acute DiarrheaURI Acute Diarrhea

University HospitalsUniversity Hospitals 72%72%--80% 45%80% 45%--70%70% National Children Hospital 79% National Children Hospital 79% 35% 35% General & Regional HospitalsGeneral & Regional Hospitals 60% 50% 60% 50% Private hospitals & clinics >90% >90%Private hospitals & clinics >90% >90% Drug stores >90% Drug stores >90% >90%>90%•• Commonly Used AntibioticsCommonly Used Antibiotics Amoxicillin, CoAmoxicillin, Co--amoxiclavamoxiclav, , AzithromycinAzithromycin, , ClarithromycinClarithromycin, ,

NorfloxacinNorfloxacin, , LevofloxacinLevofloxacin, Ciprofloxacin, , Ciprofloxacin, CeftriaxoneCeftriaxone

What we do in Thailand !What we do in Thailand !

•• ExistingExisting Local EvidenceLocal Evidence Thai patients with URI are caused by bacteria in 7.9%Thai patients with URI are caused by bacteria in 7.9% Bacterial URI can be predicted by clinical featuresBacterial URI can be predicted by clinical features Thai patients with acute diarrhea are caused by pathogenic Thai patients with acute diarrhea are caused by pathogenic bacteria that required antibiotics in less than 1%bacteria that required antibiotics in less than 1%

(J Med Assoc Thai 2011;94:545 & 2006;89:1178)(J Med Assoc Thai 2011;94:545 & 2006;89:1178) Amoxicillin had no benefit for fever and sore throat due to Amoxicillin had no benefit for fever and sore throat due to nonnon--exudativeexudative pharyngotonsillitispharyngotonsillitis in Thai patients in Thai patients

((IntInt J Infect J Infect DisDis 2000;4:702000;4:70--4)4) FluoroquinoloneFluoroquinolone use is risk factor of inducing ESBL in Thais use is risk factor of inducing ESBL in Thais

(Southeast Asian J (Southeast Asian J TropTrop Med Public Health 2005;36:1503Med Public Health 2005;36:1503--9)9)

Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea What we know based on existing local evidencesWhat we know based on existing local evidences

Do –---- Know Gap !Do Do ––-------- Know Gap !Know Gap !

•• Antibiotics should be given to <10% of patients with URI or Antibiotics should be given to <10% of patients with URI or acute diarrhea and overuse of antibiotics should be avoidedacute diarrhea and overuse of antibiotics should be avoided

•• Additional Local EvidenceAdditional Local Evidence To determine appropriate target rate of antibiotic use and To determine appropriate target rate of antibiotic use and safety of patients who receive no antibiotics safety of patients who receive no antibiotics Multifaceted interventions in a tertiary care hospitalMultifaceted interventions in a tertiary care hospital Train healthcare providers on management of URI & acute Train healthcare providers on management of URI & acute diarrheadiarrhea Clinical Practice Guidelines (CPG) for physiciansClinical Practice Guidelines (CPG) for physicians Educational media for patients and their relativesEducational media for patients and their relatives Contact all patients via telephone to determine their clinical Contact all patients via telephone to determine their clinical responses on day 3 after receiving careresponses on day 3 after receiving care Reminder healthcare providersReminder healthcare providers’’ performance on antibiotic performance on antibiotic prescription rate once a monthprescription rate once a month


•• Antibiotic use rates before and after interventionsAntibiotic use rates before and after interventions 1,241 episodes of URI1,241 episodes of URI

BEFOREBEFORE AFTERAFTER

13%13%19%19%

75%75%

210 episodes of Acute Diarrhea210 episodes of Acute Diarrhea


•• Clinical responses on day 3 after receiving care Clinical responses on day 3 after receiving care URI (N=1,241)URI (N=1,241)

CuredCured ImprovedImproved Not ImprovedNot Improved ATB (13%)ATB (13%) 39% 39% 60%60% 1%1% No ATB (87%)No ATB (87%) 37% 37% 62% 62% 1%1%

Acute Diarrhea (N=210)Acute Diarrhea (N=210)Cured Cured ImprovedImproved Not ImprovedNot Improved

ATB (19%)ATB (19%) 68% 68% 30%30% 2%2% No ATB (81%)No ATB (81%) 69% 69% 31%31% --

No significant difference in clinical responses No significant difference in clinical responses in patients with and without antibiotics !in patients with and without antibiotics !

J Med Assoc Thai 2014;97 J Med Assoc Thai 2014;97 SupplSuppl 3:S133:S13--9.9.


•• National Health Security Office (NHSO) that is responsible National Health Security Office (NHSO) that is responsible for Universal Health Coverage Scheme (UCS) for 47 million for Universal Health Coverage Scheme (UCS) for 47 million Thais Thais •• NHSO have adopted ATB use rate for outNHSO have adopted ATB use rate for out--patients with URI patients with URI and diarrhea as criteria for and diarrhea as criteria for ““PayPay--forfor--Performance (P4P)Performance (P4P)”” for all for all healthcare facilities under UCShealthcare facilities under UCS since fiscal year 2013 since fiscal year 2013 NHSO allocated 1.6 million $US for NHSO allocated 1.6 million $US for ““P4PP4P”” according to according to antibiotic prescription rates of URI and diarrheaantibiotic prescription rates of URI and diarrheaAntibiotic Prescription Rate Amount of Additional PaymentAntibiotic Prescription Rate Amount of Additional Payment

<<20%20% FullFull21% 21% -- 40%40% PartialPartial

>40%>40% NoNo

Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & DiarrheaFrom Local Evidence to From Local Evidence to PolicyPolicy

•• Promoting responsible use of antibiotics in practices under Promoting responsible use of antibiotics in practices under P4P policyP4P policy Education and training for healthcare providersEducation and training for healthcare providers Media Media -- CPG for healthcare providers & brochures for clientsCPG for healthcare providers & brochures for clients ToolsTools•• Overall means of antibiotic prescription rates for URI and Overall means of antibiotic prescription rates for URI and diarrhea in 892 hospitals were decreased from 50%diarrhea in 892 hospitals were decreased from 50%--60% (2012) 60% (2012) to 35%to 35%--40% (40% (2013 to 2014) after implementing incentive policy 2013 to 2014) after implementing incentive policy (P4) and educational & training(P4) and educational & training•• The target mean of antibiotic prescription rate for URI and The target mean of antibiotic prescription rate for URI and diarrheadiarrhea is 20%is 20%•• Additional policies and measures are neededAdditional policies and measures are needed

Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & DiarrheaFrom Local Evidence to Policy From Local Evidence to Policy to Practiceto Practice

•• Addition Policies and MeasuresAddition Policies and Measures Antibiotic use rate for outAntibiotic use rate for out--patients with URI and diarrhea is patients with URI and diarrhea is one of the quality criteria for accreditation and reone of the quality criteria for accreditation and re--accreditation accreditation of hospitals in Thailand of hospitals in Thailand Antibiotic use rate for outAntibiotic use rate for out--patients with URI and diarrhea patients with URI and diarrhea should be one of the criteria to renew the license for healthcarshould be one of the criteria to renew the license for healthcare e services of private clinics & private hospitalsservices of private clinics & private hospitals Healthcare purchasers should reimburse direct medical cost Healthcare purchasers should reimburse direct medical cost for URI & diarrhea as for URI & diarrhea as ““fee schedulefee schedule”” instead of instead of ““feefee--forfor--serviceservice””

Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & DiarrheaFrom Local Evidence to Policy to Practice to From Local Evidence to Policy to Practice to PolicyPolicy

Promoting Responsible Use of Antibiotics : Promoting Responsible Use of Antibiotics : From Local Evidence to Policy and PracticeFrom Local Evidence to Policy and Practice

VisanuVisanu ThamlikitkulThamlikitkul, MD, MDFaculty of Medicine Faculty of Medicine SirirajSiriraj Hospital Hospital

MahidolMahidol University, Bangkok, ThailandUniversity, Bangkok, Thailand

Thailand AMR Containment ProgramThailand AMR Containment Program

promoting responsible use of antibiotics from local evidence to policy and practice. visanu...

Health & Medicine

amr containment bundlesiii

conduct research development

local evidenceone

fundamental systems

practicefrom local evidence

prototype communities

acute diarrhea infor

thailand877 communities