Antimicrobial Stewardship in Thailand

Assistant Professor Kumthorn Malathum

Faculty of Medicine Ramathibodi Hospital,

Mahidol University, Thailand

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Antimicrobial Stewardship: DefinitionAntimicrobial Stewardship: Definition

Coordinated interventions designed to improve

and measure the appropriate use of [antibiotic]

agents by promoting the selection of the optimal

[antibiotic] drug regimen including dosing[antibiotic] drug regimen including dosing,

duration of therapy, and route of administration

Barlam TF Et al CID; 2016;62(10):e51–e77

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Barlam TF. Et al. CID; 2016;62(10):e51–e77

Antimicrobial Stewardship: BenefitAntimicrobial Stewardship: Benefit

Improved patient outcomes, Reduced adverse events

Improvement in rates of susceptibilities Improvement in rates of susceptibilities to targeted antibiotics

Optimization of resource utilization

Barlam TF Et al CID; 2016;62(10):e51–e77

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Barlam TF. Et al. CID; 2016;62(10):e51–e77

RecommendationsRecommendations

Preauthorization and/or prospective audit and feedback interventionsinterventions

Interventions designed to reduce the use of antibiotics associated with a high risk of CDIassociated with a high risk of CDI

Dedicated pharmacokinetic (PK) monitoring and adjustment programadjustment program

Interventions to increase use of oral antibiotics Reduce antibiotic therapy to the shortest effective

duration

4Barlam TF. Et al. CID; 2016;62(10):e51–e77

Core element of ASPCore element of ASP

Leadership commitment – national, some h it lhospitals

Accountability and drug expertise Accountability and drug expertise Physician and pharmacist with formal training in

infectious diseases and/or antibiotic stewardshipinfectious diseases and/or antibiotic stewardship

CDC Core Elements of Hospital Antibiotic Stewardship Programs 2014. Available at h // d / /h l h /i l i / l h l

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http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Core element of ASPCore element of ASP

Leadership commitment – national, some h it lhospitals

Accountability and drug expertise Accountability and drug expertise Physician and pharmacist with formal training in

infectious diseases and/or antibiotic stewardshipinfectious diseases and/or antibiotic stewardship 200 full-trained infectious disease physicians

30 li i l h i t ith i f ti di t i i 30 clinical pharmacist with infectious disease training

CDC Core Elements of Hospital Antibiotic Stewardship Programs 2014. Available at h // d / /h l h /i l i / l h l

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http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Key supportKey support

Infection preventionists and hospital epidemiologists epidemiologists

Quality improvement staff ± Laboratory staff , ? Lab quality

Information technology staff competency? Information technology staff , competency? Nurses , unclear role

CDC Core Elements of Hospital Antibiotic Stewardship Programs 2014. Available at h // d / /h l h /i l i / l h l

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http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Key supportKey support

Infection preventionists and hospital epidemiologists epidemiologists

Quality improvement staff ± Laboratory staff , ? Lab quality

Information technology staff competency? Information technology staff , competency? Nurses , unclear role

CDC Core Elements of Hospital Antibiotic Stewardship Programs 2014. Available at h // d / /h l h /i l i / l h l

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http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

Mind setMind set Just to be on the safe side, let’s put him on a (broad-spectrum) antibioticspectrum) antibiotic.

A i h i dAcute fever without localizing signs

Azithromycin and cefdinir were prescribed as home med

Suspected Dengue infection

as home med.

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Mind setMind set Just to be on the safe side, let’s put him on a (broad-spectrum) antibioticspectrum) antibiotic.

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Aim at minimizing the use of antibiotic inuse of antibiotic in common community-acquired infections not requiring such q gagents

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ASU: Antibiotic Smart UseASU: Antibiotic Smart Use

WHO-supported Begun in 2007 in a central province with

600 k population, 14 community hospitals600 k population, 14 community hospitals Has now embed in the National Rational

Drug Use scheme, resulting in wider deployment of the activityp y y

1. J Med Assoc Thai 2014; 97 (Suppl. 3): S13-S19, Full text. e-Journal: http://www.jmatonline.com

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2. J Med Assoc Thai 2015; 98 (10): 974-84 Full text. e-Journal: http://www.jmatonline.com

Clinical Infectious Diseases 2006; 42:768–75

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TeamTeam

1 ID physician 1hospital id i l i t

1clinical microbiologist

epidemiologist 1 IC specialistmicrobiologist

4 pharmacists 1 IC specialist 1 computer system

2 internists analyst

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Apisarnthanarak A., et al. CID 2006

ActivityActivity

Feedback Antibiotic order forms

Obligatory requirement for procuring the Obligatory requirement for procuring the drug from the pharmacy

Bedside discussion among the pharmacists clinical microbiologist andpharmacists, clinical microbiologist, and attending physicians

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Apisarnthanarak A., et al. CID 2006

Outcomes: decreased resistanceOutcomes: decreased resistance

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Apisarnthanarak A., et al. CID 2006

Example of computer-assisted p pantimicrobial prescription control

Derived from “Antibiotic Order Form” Allow initial empirical therapy

Aim at carbapenem Aim at carbapenem Very broad spectrum Increasing carbapenem-resistant Increasing use of carbapenem Increasing use of carbapenem Logistically feasible

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Initial order will be process for 3 day supply then a renewal3-day supply, then a renewal is required

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R i ti d 3• Renew prescription on day 3• Only “specific therapy” or ID staff prescribing are allowed• Specific therapy will be determined by the program which

links to Microbiology Report and look for “carbapenemlinks to Microbiology Report and look for carbapenem-susceptible only” pathogen

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The use of carbapenem in hospitalThe use of carbapenem in hospital

100

120

Use rate (DDD/1000 Pt-day)

80

100

60

20

40

0

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2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 20162005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

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Large scale implementation of ASPLarge scale implementation of ASP

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Opportunity and ChallengesOpportunity and Challenges

Appropriate use of antimicrobial agent is a major component in the National AMR strategymajor component in the National AMR strategy

Physicians’ mind set “just to be on the safe side, let’s put them on antibiotics”

Laboratory support for physicians Laboratory support for physicians Lack of human resources in variety of

disciplinediscipline

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Thank you for your attentionThank you for your attention

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