Antibiotic stewardship in South East Asia

2017-09-22

In a series of papers in the BMJ, invited authors summarize the most recent developments regarding antimicrobial resistance in the South East Asian region. In these countries, antibiotic use is high and policies are either absent or poorly implemented.

Here we highlight two of these articles focusing on antibiotic use and stewardship. They give good examples and may provide inspiration to other low- and middle-income countries.

In a commissioned series of articles in the BMJ , invited authors summarize the most recent developments regarding antimicrobial resistance in the South East Asian region. The articles cover topics such as environmental issues, policy, surveillance of resistance and antibiotic stewardship. However, at the core of any interventions aimed at reducing antimicrobial resistance lie situation analyses on country level: how big is the problem, what policies and structures are in place and how are they implemented?

Antibiotic use and resistance

A major force driving the emergence of antibiotic resistance is use. Every time an antibiotic is used a by a patient, a selective pressure is exerted on the bacteria encountering the antibiotic.

When a bacterial infection is treated with antibiotics, the gain caused by curing the patient is obviously considered greater than the risk of selecting for resistance. However, if the patient does not have an infection caused by bacteria, the gain disappears, leaving only the selective pressure. The more antibiotics are used, the greater and more extensive the selective pressure. Thus it is very important that antibiotics are used restrictively.

Antibiotic use in South East Asia

One of the articles in the BMJ series focuses on the use of antibiotics in the region. The authors reviewed published situation analyses and extracted the data found. In public sector primary care facilities, antibiotic use was very high – up to 67% of all outpatients were given antibiotics. In upper respiratory tract infections, which are mostly of viral origin rather than bacterial, antibiotic use ranged from 20% up to 100% of patients (median 65%). In contrast, Swedish quality indicators state that less than 20% of patients with acute bronchitis should receive antibiotics, although it should be noted that the goal has not been achieved.

Antibiotic policies in South East Asia

Most of the countries reviewed had no AMR strategies or other key policies in place, which could probably affects antibiotic prescription rates. Also, antibiotics were available without prescription in all countries, so many patients have probably not gone to a public primary health care facility, but rather to a pharmacy to buy antibiotics without a diagnosis from a physician.

The authors highlight political will and a blame-free environment as important factors in creating the situation reports. The purpose of situation analyses is to identify weaknesses in the systems and potential solutions to overuse.

Tackling antimicrobial resistance in Thailand

Another paper in the collection focuses on Thailand, presenting the work with their national action plan. The authors focus on the burden of antimicrobial resistance, antibiotic use, reviewing existing policies and the national collaboration with the WHO. Thailand found that 88 000 infections were attributable to antimicrobial resistance, directly costing around $70-170 million, with an estimated additional indirect cost of at least $1100 million due to morbidity and premature deaths.

The national action plan has ambitious goals of reducing the morbidity due to antimicrobial resistance with 50% and antibiotic use by 20% in humans and 30% in animals. The goals are to be achieved by improving infection prevention and antibiotic stewardship, regulating distribution and increasing public awareness. Monitoring and evaluation of the goals will be based on the WHO joint external evaluation tool, including measures for resistance surveillance defined in the Global Antibiotic Surveillance System, GLASS

The authors conclude that the work needs sustained political support, including funding and permanent structures to oversee implementation. A main requirement identified is to improve existing monitoring and reporting systems as well as improving cross-talk between systems to be able to reliably estimate morbidity and mortality.

Time for action

Achieving low rates of unnecessary use of antibiotics requires work on several levels: political, financial, management and hands on in hospitals and farms. The article series gives good examples and may provide inspiration to other low- and middle-income countries in their efforts. As each country is different, it is important to make the plan tailored to national situations and make sure to allocate sufficient resources to carry out the intent of the plans.