Presentation from the 3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, organised by the European Centre of Disease Prevention and Control - Stockholm, 11-13 February 2015

1. 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, MD
Faculty of MedicineFaculty of Medicine SirirajSiriraj HospitalHospital
MahidolMahidol University, Bangkok, ThailandUniversity, Bangkok, Thailand
Thailand AMR Containment ProgramThailand AMR Containment Program

2. 0.6% of GDP0.6% of GDP

3. Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016
Donors :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 MedicineFaculty 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”” oror ““EcoHealthEcoHealth”” ApproachApproach
““ONE HEALTHONE HEALTH””

4. Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016
Logo & Slogan of AMR Containment Campaign
(English)

5. Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016
Logo & Slogan of AMR Containment Campaign
(Thai)

6. Responsible Use of Antibiotics
Sanitation & Hygiene
Infection Control Measures
Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016

7. 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 BundlesIII. Implement AMR Containment Bundles
in 4 Prototype Communities (2 Actions)in 4 Prototype Communities (2 Actions)
Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016

8. Thailand AMR Containment Program 2012Thailand AMR Containment Program 2012 -- 20162016
II. Research & Development Building Block (5 Actions)II. Research & Development Building Block (5 Actions)
•• One of the actions is to generate & implement local evidenceOne 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) efficient
practices for infection control in local context of limitedpractices for infection control in local context of limited--
resource settingresource setting
 An example ofAn example of promoting responsible use of antibiotics inpromoting responsible use of antibiotics in
local context of limitedlocal context of limited--resource setting is Responsible Use ofresource setting is Responsible Use of
Antibiotics in URI & DiarrheaAntibiotics in URI & Diarrhea

9. AAntibioticntibiotic UUsese for URI and Acute Diarrhea infor URI and Acute Diarrhea in
LowLow-- and Middleand Middle--Income Countries (1980Income Countries (1980 -- 2006)2006)
60%60%
65%65%

10. Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea
•• Healthcare CenterHealthcare Center Antibiotic Prescription RateAntibiotic Prescription Rate
URI 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 !

11. •• 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 pathogenicThai 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 toAmoxicillin had no benefit for fever and sore throat due to
nonnon--exudativeexudative pharyngotonsillitispharyngotonsillitis in Thai patientsin Thai patients
((IntInt J InfectJ Infect DisDis 2000;4:702000;4:70--4)4)
 FluoroquinoloneFluoroquinolone use is risk factor of inducing ESBL in Thaisuse 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 !DoDo ––-------- Know Gap !Know Gap !
•• Antibiotics should be given to <10% of patients with URI orAntibiotics 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

12. •• Additional Local EvidenceAdditional Local Evidence
 To determine appropriate target rate of antibiotic use andTo determine appropriate target rate of antibiotic use and
safety of patients who receive no antibioticssafety 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 & acuteTrain 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 clinicalContact 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 antibioticperformance on antibiotic
prescription rate once a monthprescription rate once a month
Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea

13. •• 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
Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea

14. •• Clinical responses on day 3 after receiving careClinical 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)
CuredCured 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 responsesNo significant difference in clinical responses
in patients with and without antibiotics !in patients with and without antibiotics !
J Med Assoc Thai 2014;97J Med Assoc Thai 2014;97 SupplSuppl 3:S133:S13--9.9.
Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea

15. •• National Health Security Office (NHSO) that is responsibleNational Health Security Office (NHSO) that is responsible
for Universal Health Coverage Scheme (UCS) for 47 millionfor Universal Health Coverage Scheme (UCS) for 47 million
ThaisThais
•• NHSO have adopted ATB use rate for outNHSO have adopted ATB use rate for out--patients with URIpatients with URI
and diarrhea as criteria forand diarrhea as criteria for ““PayPay--forfor--Performance (P4P)Performance (P4P)”” for allfor all
healthcare facilities under UCShealthcare facilities under UCS since fiscal year 2013since fiscal year 2013
 NHSO allocated 1.6 million $US forNHSO allocated 1.6 million $US for ““P4PP4P”” according toaccording to
antibiotic prescription rates of URI and diarrheaantibiotic prescription rates of URI and diarrhea
Antibiotic Prescription Rate Amount of Additional PaymentAntibiotic Prescription Rate Amount of Additional Payment
<<20%20% FullFull
21%21% -- 40%40% PartialPartial
>40%>40% NoNo
Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea
From Local Evidence toFrom Local Evidence to PolicyPolicy

16. •• Promoting responsible use of antibiotics in practices underPromoting responsible use of antibiotics in practices under
P4P policyP4P policy
 Education and training for healthcare providersEducation and training for healthcare providers
 MediaMedia -- CPG for healthcare providers & brochures for clientsCPG for healthcare providers & brochures for clients
 ToolsTools
•• Overall means of antibiotic prescription rates for URI andOverall 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 policy2013 to 2014) after implementing incentive policy
(P4) and educational & training(P4) and educational & training
•• The target mean of antibiotic prescription rate for URI andThe 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 & Diarrhea
From Local Evidence to PolicyFrom Local Evidence to Policy to Practiceto Practice

17. •• Addition Policies and MeasuresAddition Policies and Measures
 Antibiotic use rate for outAntibiotic use rate for out--patients with URI and diarrhea ispatients with URI and diarrhea is
one of the quality criteria for accreditation and reone of the quality criteria for accreditation and re--accreditationaccreditation
of hospitals in Thailandof hospitals in Thailand
 Antibiotic use rate for outAntibiotic use rate for out--patients with URI and diarrheapatients 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 healthcaree
services of private clinics & private hospitalsservices of private clinics & private hospitals
 Healthcare purchasers should reimburse direct medical costHealthcare purchasers should reimburse direct medical cost
for URI & diarrhea asfor URI & diarrhea as ““fee schedulefee schedule”” instead ofinstead of ““feefee--forfor--
serviceservice””
Responsible Use of Antibiotics in URI & DiarrheaResponsible Use of Antibiotics in URI & Diarrhea
From Local Evidence to Policy to Practice toFrom Local Evidence to Policy to Practice to PolicyPolicy

18. 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, MD
Faculty of MedicineFaculty of Medicine SirirajSiriraj HospitalHospital
MahidolMahidol University, Bangkok, ThailandUniversity, Bangkok, Thailand
Thailand AMR Containment ProgramThailand AMR Containment Program