See full Report of the workshop for details - ReAct

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See full Report of the workshop for details - ReAct

Workshop Six: Antimicrobial resistance and rational use of antibiotics

Convenors Mary Murray, Niyada Kiatying‐AngsuleeRapporteursMichael Chai, Debra Rowett

Workshop Participants from Indonesia, Australia, India, Kiribati, American Samoa, Samoa,

Vanuatu, Tonga, Cook Islands, Tuvalu, India, Netherlands, Nepal, New Zealand, Philippines,

Bangladesh, Korea, China, Mongolia, and Malaysia (37 participants)

Introduction

Antimicrobial resistance occurs with antiviral (HIV), antiparasitic(malaria) and antibacterial

medicines(TB and common bacterial diseases). While resistance has been addressed to an

extent in HIV, Malaria and TB, resistance to antibiotics for other bacterial diseases has had

relatively little attention. The workshopfocused onantibiotic resistance (ABR).

ABR is not a specific disease but a problem concerning a medicine that is no longer working

against bacteria that cause many common diseases. For example, blood infections,

gonorrhoea, typhoid fever, pneumonia and various surgical infections are becoming

untreatable due to increasing resistance. In some parts of the world, the situation is already

critical. Resistance also threatens many medical procedures such as major surgery, safe

childbirth, care of preterm neonates, and cancer treatment. ABR is a global problem affecting

everyone, but vulnerable populations with the highest infectious disease burden pay the

highest price having least access to current and future interventions to manage ABR. As first

line antibiotics fail, the cost for treatment by second or third line antibiotics increases

dramatically. For example the cost for treating resistant typhoid in Pakistan in 2004roseby

200‐3,000% depending on the antibiotic, using up the annual hospital drug budget in 2 weeks.

How did we get to this position? Antibiotics have been used inappropriately for a long time in

humans, animals and plants. Bacteria are very adaptive. To develop resistant genes is a

natural response to survive. The more we use antibiotics, especially unnecessarily and in a

wrong manner, the more pressure on bacteria to develop resistance. Resistance genes travel.

Bacteria actively share their genes and hence resistance moves through ecosystems, ESBL

even being found in migratory birds in the Antarctica. Global travel and trade increases the

rate of spread of resistance genes. Poor sanitation and hygiene also contribute to the spread

of infection and resistance.

The extent of the problem and burden associated with AMR has been underestimated due to

limitations of available data. Complicating and increasing the urgency of the problem is the

fact that there are almost no new antibiotics in the present R&D pipeline. So, as resistance

grows, we are literally running out of effective treatments. Should solutions to the

development of new antibiotics be found, they are likely to be extremely expensive and how

will they become accessible to all those that need them?. More fundamentally, what will

guarantee that they can be preserved for a reasonable time to treat infection if the present

way we use antibiotics continues? At societal level there seems to have been little or no

planning around how the cost structures involved for using existing second or third line, last

resort or future new antibiotics will be managed.

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The effort of the past 20 years highlights that there has been growing awareness of the

problem of AMR but that, like an iceberg, only the tip was visible, but perhapsonlynow a sense

of the depth of the problem is being realised. The ‘timeline of endeavour’ representing years

of hard work across many countries on AMR shows a recent concentration of effort.

Workshop participants were encouraged to think differently and innovatively ‐ tostop

spinning within the circle (Thai saying), unlike ‘think outside the square’ (western saying) but

both imploring those in this field to think differently if we are to find a timely solution.

“If change is to occur then it will need to occur at the community, professional and policy

levels and there will need to be strong advocacy if the system is to change. We need to

galvanise the community to hold us all accountable for AMR.”

Workshop objectives

To strengthen attention to AMR as an issue to be implemented within NMP.

To identify the main challenges/barriers/gaps to developing and implementing effective

strategies to contain AMR, and integrate AMR into NMP.

What are the AMR challenges participants face in their countries?

Participants were invited to provide individual written responses to the following questions:

Describe one main challenge you face in taking action on AMR.

Why did you choose this challenge to share?

Which country are you from?

What are the main issues regarding AMR in your country?

The responses below, in the participants own words as far as possible, show the range of

issues and have been grouped under broad headings.

Having the public (ie the community and media) believe it is a real and urgent problem that is

important for them

o Lack of knowledge, attitude and practice of the community towards antimicrobial use

o Getting consumers to understand why AB are not often needed

o Real issue vs conspiracy theory vs boring topic

o Surveillance of antibiotic use in the community (both human and animals)

o Communicatingand implementing findings of research

Lack of expertise of prescribers / Standard Treatment Guidelines

o Unavailability of antimicrobial use guidelines at a local level at the point of care/clinical

decision making

o Prescribers prescribe irrespective of guidelines

o Ensuring principles are applied consistently for all prescribers including non medical

prescribers

o Prescribers are concerned about complaints by patients in case infections not cured

o Indiscriminate use of AB by physicians as well as unauthorised prescribers

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o

lack of laboratory microbiology and expertise in microbiology in health providers

Promotion of rational use to policy makers

o Cannot convince Ministry of Agriculture to reduce AB use in cattle

o Requires intersectoral commitment, coordination, partnership

o Requires evidence of impact of AMR and also success of interventions to change AB use and

reduce AMR

o That AMR is seen as a potential problem rather than as a real and actual problem facing

patients and practice

o Lack of regulatory power and resistance of Governments to regulate

o Development of a funded national AMR policy that is comprehensive an includes use of AB in

animals

o Coordinated action so that opportunities in the health system can be used to address rational

use of AB eg when decision support systems being built (eg hospital approval processes are

included in the design phase)

o Maintaining old patent expired AB on the register to ensure supply plus actual maintenance of

supply

o Prescribing practices which are very much influenced by pharmaceutical promotion

o Limited Budgets and adequate funding for public education and awareness

Participants highlighted different reasons as to why they had chosen a particular challenge to

share, for many it was based on the extent of the problem and the potential for change. It was

emphasized that this needs to be a community led change with greater data collected to

provide the evidence on antibiotic use (misuse) to inform intervention programs.

“One group/sector alone cannot achieve adequate impact and sustained activity”

“The time is right to make a change”

A review of the responses regarding the main issues of AMR in the respondent’s country

revealed many similarities. There were consistent issues relating to the high rates of

prescribing by qualified doctors and non medical prescribers alike, accessibility of antibiotics

without a prescription over the counter, community expectation for a ‘quick fix’, veterinary

use of antibiotics – perverse incentives and no control, antibiotics in agriculture, no database

for antibiotic use in the community

Groupwork

Three work groups each focused on one level of society/health system. Community, Policy,

and Professional (hospital/academic/research) levels were each conceptualised as interacting

systems as described below in the headings introducing each work group) The workshop

participants joined one of three groups depending on their interest and expertise. They were

encouraged to brainstorm the issues but then to choose one to delve intomore deeply in

regard to barriers and ways forward for real change, rather than simply identifying a range of

barriers and general solutiosn..The following reflects the feedback from each of the groups.

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Community level – key stakeholder groups and individuals and the interactions

at the community and primary care level.

7 Participants (Indonesia,

Australia, India, Kiribati)

including those who had

contributed posters on

consumer and health

professional attitudes,

practices and perceptions of

AB use in the community.

This group emphasised the ongoing challenges of AB overuse and misuse in both public and

private sectors including wrong indication, wrong AB, wrong dose and wrong duration. The

impact of over‐the‐counter (OTC)ABs (without prescription) from private retail pharmacistsin

the developing world was ongoing. Pharmacists copy GP prescribing patterns – if a GP is giving

ciprofloxacin for diarrhoea then pharmacists copy their model and give ciprofloxacin OTC to

patients. Hence the doctor’s behaviour is a strong influence on the practice of otherhealth

providers (multiplier effect). This includes nurses who give paracetamol and amoxycillin when

a patient presents with a fever. There is limited or no time for counselling patients that they

don’t need an AB for acute diarrhea or fever. Theperception is that it takes less time to just

give the AB.

“Patients demand AB because they paid money or travelled long distances –‘ we need somestrong

medicine so we can go to back to work as quickly as possible’”

It is important to understand that the patient is not necessarily asking for AB –people’s

practical reality,their ‘fear’ about infection/microbes and cultural belief about how to keep

going and be protected are also involved. The group considered it important to implement

standard treatment guidelines (STG), pharmacist education and encourage political

commitment and a multidisciplinary approach.However the most important area was to make

the issue real and personal for consumers/citizens either through story or pictorial

approaches which touch people’s emotions – resistance is in the bug, not in you, so if your

child is sick and the bug is resistant to AB then your child may not get well and die.

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The group emphasized the need to educate patients to ask at least onequestion of the doctor

and pharmacist: “Do I really need an AB?”Strengthen the confidence of consumers/citizens to

ask this question with posters in doctor’s surgeries, in outpatients department and clinics

reminding them to ask this question. The group noted the example of polio which is more

straight forward as people can see the need. Therefore we need to make resistance more real

to the community, to make it a more visible problem.

Professional secondary and tertiary health institution level – key stakeholder

groups and individuals and the interactions at the hospital, academic teaching

and research level.

13 Participants (American

Samoa, Samoa, Vanuatu,

Tonga, Cook Islands, Tuvalu,

India, Netherlands, Nepal,

New Zealand)

This groupacknowledged much overlap with the previous group comments but emphasised

that in many countries there was no monitoring for antimicrobial use, no microbiology

laboratory support, no AMR data to inform policies and procedures, and, in some countries,

there were no AB treatment guidelines at all. They restated that there was both under

treatment with a lack of expertise and knowledge of the service provider (microbiology, AB

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dose, duration, selection, form) and also inappropriate use of antibiotics whereby prescribers

are resistant to evidence‐based practice and continue to do what they have always done.

The patient demand for antibiotics was significant also and reflected their perceptions and

health beliefs.“I need amoxycillin, or cotrimoxazole based on previous experience when AB fixed the

infection in 2 days”

Other issues included: availability of AB without prescription in both community and hospital

and no restriction of sellers of antibiotics; AB use in animal feeds, e.g. poultry; no infection

control committee in place; sanitation, hygiene can still be a problem with inappropriate

disposal of infected materials; limited development of new Abs; Surgical prophylaxis;

unavailability of first line drugs forcing use of quinolone and cepaholsporin, for example;

Influence of pharmaceutical companies; strengthen regulatory & Ministry of Health strategies.

Enablers

Having local sensitivity data – informs drug choice selection and patterns of AMR

Strong microbiology department, Infection Control policy makers, active DTC

Making AB treatment guidelines available in every country

Evidence base to support management treatment guidelines

Prescribing restriction levels for access to AB (ie Level 4 ID specialist)

Empirical escalation and de‐escalation

Research into innovative practices to change behaviour

Regular auditing and monitoring of AM use and of how strategies are working

Education for all stakeholders including patients

Policy to govern public and private prescribing – expanded to regional and global levels.

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National or central government level (and decentralised state or province) –

key stakeholder agencies and individuals,including business,and the

interactions in the political and policy machinery process.

14 participants

(Australia,

Philippines,

Bangladesh,

Korea,

China,Mongoli

a,

Netherlands,

This group identified similar points to those of the other groups but emphasised the

importance of encouraging people to do what they know they should do but don’t!

Professionals need to understand that they do not act in isolation and that their actions can

have far reaching impacts at all three levels. The goal is to strengthen the ethos that no

physician practises in isolation. Their practice influences others –physicians and patients alike.

There is a clear need for a National committee on AMR which has resources (dollars and

political will) to coordinate activities, to conduct surveillance, provide education to help

people to do the right thing. Then at a local/regional level areneeded local Infection control

committees, surveillance, education, AB guidelines. Policy needs to be linked into incentives

and sanctions, as education,while useful,doesn’t work for all.Surveillance needs to be linked in

to practice incentive payments and sanctions (professional and financial). Similarly, if AB are

being offered/sold by pharmacists then those pharmacists need to be accredited and part of

ongoing monitoring and audit processes

National education health promotion campaigns need to be conducted under the auspices of

national policy. A regulatory process regarding AB use also needs to apply in veterinary

practice and agriculture, to ensure that different classes of AB are used. It was acknowledged

that this is not simple, but that this area still needs policy, surveillance, regulation and

sanctions; Industry less of a problem more responsible.

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Enablers

Story, media and evidence

o Surveillance and good data are needed and then to be translated into human stories –

ie a routine hip replacement resistance organism might lead to implant removal and

pus oozing for months, useless floppy leg as a result

Media will need to play an important role – disaster stories help make get issue onto the

front page. In India the NDM story made the front pages of newspapers and was linked to

medical tourism – people come to India for surgery. This resulted in a task force being set

up.Public policy to reinforce AMR

AMR needs to be in the school curriculum so children go home to discuss with parents and

doctors as part of public education

Need to engage not only the Minister for Health butalso the Minister for Education

Policy in Philippines is‘no prescription no AB’ but is not followed by the pharmacy; needs

local level commitment by local officials

Data about financial burden to Government needs to cost the side effects of AMR – need

better data on financial burden of AMR

Who will advocate? All in the room!

A conceptual map of a worldwide network based on ReAct’s network and its connections with

other networks was displayed. Participants wanted to be connected in a network.

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Conclusions from discussion of group work results:

Countries represented in the workshop were very diverse. They reported different types of

barriers at different levels within the countries. Where enablers exist (such as surveillance

data, treatment guidelines, regulations) theyare not adequately connected on common

platforms locally or nationally. There is little or no policy support. Even where there is policy,

there is little or no commitment, resources or machinery for implementation or enforcement.

In many of the Pacific island nations, there are no guidelines available. In many places there

are no microbiological facilities present and so even if guidelines exist, there is no possibility

to gather local sensitivity data and match local guidelines to results.

Stronger efforts to engage and strengthen community understanding and advocacy was

proposed including empowering people to ask their doctor and pharmacists whether they

really needed antibiotics. Likewise efforts are needed to make doctors aware of how their

prescribing for symptoms such as fever may set the pattern that will be copied for years to

come for similar symptoms by patients and pharmacists alike for self‐purchased medicines,

including antibiotics. Proposals made in the workshop included:


Build partnerships, raise awareness and strengthen collaboration among all stakeholders

to address the growing challenge of antibiotic resistance. Simple and easy programs to

educate the public regarding resistance and the use of antibiotics through various media at

specific locations – tell stories that engage people emotionally – make resistance VISIBLE.

Encourage people to ask ‘Do I really need antibiotics?’

National Prescribing Service, Australia, is running a 5 year campaign on resistance encouraging

every Australian to become a resistance fighter.


Strengthen the ethos that no physician is practising in isolation but that their practice

influences others: physicians and patients alike

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Build networks to join people together. ReAct and other global

networks are beginning to collaborate in regions. There was a

strong feeling in the room that it is important to be part of a

regional network.

‘How can we get the pacific islands onto the networking

map?’ asks Natane fromTuvalu after the workshop







Link researchprojects with research training in order topromote

research in the field of ABR for necessary evidence.

Review and revise all undergraduate health related education programs with the aim of

increasing students' skills in rational prescribing and dispensing of antibiotics.

Develop an ethos of independent continuing education amongst health professionals.

Institute government (MoH) regulation of the interactions between pharmaceutical

industries, doctors and pharmacists.

Focus on the mechanism for action– the national policy platform, represented by the

community of stakeholders serving as a review panel, agreeing upon the monitoring and

evaluation methodology and time frame to measure outcomes and impacts and propose

course corrections. Replicate this at local/regional levels.

Policy needs to be linked into incentives and sanctions because education,while

useful,doesn’t work for all.Surveillance needs to be linked in to practice incentive payments

and sanctions (professional and financial).Accredit, and audit pharmacists who sell ABs.

Participants discussing

group proposals

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