COMMON CHALLENGES IN
CONTAINING
ANTIMICROBIAL RESISTANCE
Budiono Santoso
Personal background & introduction
Clinical
Pharmacologist Academician &
researcher Gadjah Mada
University 1977 - 1999
Former Team Leader in Pharmaceuticals &
Health Technology WHO Western Pacific
Regional Office 1999 - 2013
Professionals in medicines area
- INRUD
- US Pharmacopeia - IUPHAR Clinical
Pharmacology - WHO Expert
ANTIMICROBIAL RESISTANCE
What are the issues ?
´ Increasing incidence of resistance
´ Antibiotics
´ Anti parasitic
´ Antifungals
´ Anti HIV/AIDS
´ Well documented in different settings, both developed and developing countries.
´ Different levels of awareness and commitment
SILENT EPIDEMICS
with
Leading infectious killers, global, millions of
deaths
(WHO surveillance 1998)
0 0.5 1 1.5 2 2.5 3 3.5 4
ARI AIDS Diarrhoeal diseases
TB Malaria
´
Malaria -
choroquine resistance in
81/92 countries
´
Tuberculosis :
0-22 % primary MDR
´
HIV/AIDS :
0-25 % primary
resistance to at least one
anti-retroviral
´
Pneumonia and bacterial
meningitis
´
0-70 % penicillin resistance
S.pneumoniae
´
Diarrhoea: shigellosis
´
10-90% ampicillin resistance
´
5-95% cotrimoxazole resistance
´
Hospital infections :
0-70%
S.
Global Surveillance report 2014
´
“ ….. The data reviewed for the report reveals serious problems and worsening trends in antimicrobial resistance in some nations in the Southeast Asian region”.
Jeopardizing the future treatment of
´ Pneumonia and meningitis
´ Shigellosis
´ Sepsis including neonatal sepsis
´ Hospital infections
´ Urinary tract infections
´ Post surgery infections
´ Gonorrhea
´ Malaria
´ TB
´ Cancer chemotherapy
Antimicrobial Resistance -
WHO Global surveillance report 2014
Indonesia
(%)
Malaysia (%)
Thailand (%) Philippines (%)
E Coli
Resistance to 3rd generation
cephalosphorins
10 (ctx) 13.8 (cro)
14.9 (caz); 18 (cro); 20 (ctx) 30.5 (caz); 41.4 (cro); 42.7 (ctx) 26.7 Klebsiella pneumoniae
Resistance to 3rd generation cephalosporins 53.3 (ctx); 67.2 (cro) 21.1 (cro); 20.8 (caz); 24 (ctx) 37.4 (caz); 40.3 (cro); 41.1 (ctx) 30 Staphylococcus aureus: Resistance to methicilline (MRSA)
-
17.3 21.6 (cef);
24.2 (oxa)
54.9
Streptococcus pneumoniae: Resistance, or
non-susceptibility, to penicillin
- 17.5 47 43 Shigella species:
Resistance to fluoroquinolones
Antimicrobial resistance in Indonesia
( AMRIN STUDY, 2000 – 2005)
´
E Coli Resistance (43%)
´
Ampicillin - 34 %
´
Co-trimoxazole - 29 %
´
Chloramphenicol - 25 %
Hospital infections
( n = 781 )
´
E Coli Resistance ( 81 %)
´
Ampicillin - 73 %
´
Co-trimoxazole - 56 %
´
Chloramphenicol - 43 %
´
Cyprofloxazine - 22 %
´
Gentamycin - 18 %
Community infections
( n = 2494)
Antimicrobial Resistance –
What could be the impacts ?
Prolonged
Treatment &
Treatment failure
increased
morbidity &
Mortality
Escalating
healthcare cost
& reduced
access and
coverage
Potential loss of effective therapy in
World Health Organization
Essential Medicines and Pharmaceutical Policy
Cost ratio of alternative drugs to 1st line antimicrobials:
2
nd, 3
rd, and 4
thline drugs may be 2 to 90 times costlier
0 10 20 30 40 50 60 70 80
Gonorrhoea Malaria Shigellosis Pneumonia
2nd 3rd
4th Cost ratio to
1st line drug
Alternative drugs
Source: WHO model formulary and relevant WHO clinical guidelines on the WHO website 2004, and Management Sciences for Health's 2004 International Drug Price Indicator Guide
Cost per
patient with 1st
line drug
Survival after pneumococcus pneumoniae with
sepsis before and after the discovery of penicillin
Antimicrobial Resistances
Possible risk factors
Uncontrolled distribution of antimicrobials
Substandard quality of antimicrobials
products Overuse,
indiscriminate use,
under-dosage by providers and
consumers
The use of antimicrobials for
human in veterinary and
World Health Organization
Essential Medicines and Pharmaceutical Policy
Total antibiotic use (DDD/1000 population/day)
40 30 20 10 0
P
e
n
ic
il
li
n
-r
e
si
st
a
n
t
S.
p
ne
um
o
ni
a
e
(
%
)
60 50 40 30 20 10 0 USA UK Sweden Spain Portugal Norway Netherlands Luxemburg Italy Ireland Iceland Greece Germany France Finland Denmark Canada Belgium Austria AustraliaAlbrich, Monnet and Harbarth, Emerg Infect Dis.; 2004; 10(3):514-7
Antimicrobial Resistance
What need to be done ?
´ Improve AMR monitoring and surveillance
´ Enforce regulation
´ Quality production of antimicrobial products
´ Quality surveillance
´ Controlled distribution
´ Quality use of antimicrobials
´ Antimicrobials usage surveillance
´ Antibiotic policy as part of national medicines policy
´ Advocacy and information for providers and consumers
Antimicrobial resistance
What have been done at global, regional and
national levels?
´ Global & regional levels
´ Intercountry consultation at regional and global level
´ Inter-partners consultation – donors, industries, non governmental institutions, academic institutions.
´ WHO Global Strategy for Containment of Antimicrobial Resistance, 2001
´ WHO Global Action on Antimicrobial Resistance 2015
´ National level
´ National training & workshop on AMR
´ National action plan for Containment of Antimicrobial Resistance.
´ Subnational/institutional/hospital levels
´ Implementing relevant actions : surveillance, RDU, hospital policy etc ?
´ Community levels
WHO Global Strategy for Containment
of Antimicrobial Resistance 2001
National Task Force to coordinate 67 interventions in
six key areas
1. Strengthen surveillance capabilities
2. Improve use of antimicrobials
3. Improve access to appropriate antimicrobials
4. Reduce disease burden & spread of infection
5. Enforce regulations & legislation
WHO Global Action Plan on
Antimicrobial Resistance (2015)
Framework for National Action Plan,
with 5 objectives
1. To improve awareness and understanding on AMR
2. To strengthen the knowledge and evidence base through surveillance and research,
3. To reduce the incidence of infection through effective sanitation, hygiene and infection prevention,
4. To optimize the use of antimicrobial medicines for human and animal health,
World Leaders Commit To Act on
Antimicrobial Resistance, September 2016
´ Antimicrobial Resistance included in the UN Agenda for Sustainable Development.
´ One Health
´ Human Health
´ Animal health
´ Environmental Health
´ http://www.un.org/
sustainabledevelopment/blog/
What lessons learnt from other priority
international agenda ?
´ Millennium Development Goals (MDG)
´ Non achievement of target in neonatal mortality
´ Non achievement of target in maternal mortality
´ What lessons learnt ?
´ Sense of ownership ?
´ Inter sector collaboration & everybody responsibility meaning nobody
responsibility
Success story (1)
Antibiotics Smart Use Program in Thailand
´ Collaborative project supported by Thai FDA and WHO, involving 80 hospitals and health centers, started in 2007.
´ Promote rational use of antibiotics
´ “No antibiotics for non-bacterial infection”
´ Research and advocacy
´ URI, acute diarrhea and simple wound.
´ Principles
´ Bottom up approach
´ Multi facet intervention
´ Inter sectors collaboration
STRAMA SWEDEN
Strategic Program Against Antimicrobial
Resistance
´ Started in 2007 involving 21 subnational health authorities
´ At the national level
´ National Board of Health and Welfare (national regulatory body)
´ Swedish Institute for Infectious Disease control
´ STRAMA group
´ STRAMA at the local level ´ Clinical microbiology
´ Infections control
´ Clinic for infectious diseases
´ Mandatory drug committee
´ Country medical officer.
´ Consensus & problem solving solution
´ Mission - Planning and testing
intervention on Rational Use of Medicines
´ INRUD network 30 groups from Asia, Africa, Latin America, Eastern Europe and WHO
´ Harvard Medical School, Karolinska Institutet, University of Boston,
´ Secretariat Management Sciences for Health (MSH) di USA.
´ Launched in Yogyakarta, 1989
J Quick, B Santoso D. Bimo, Ross Degnan, R Laing, KK Kafle, Azad Choudhury,
David Ofori Adjei, Biola Mabadeje etc.
Indonesia contribution
´ Interactive Group Discussion involving providers and
consumers (IGD)
´ Mothers Active Learning Module for critical assessment of ads
(CBIA)
´ MTP (monitoring training and
planning ) – micro-level instrument to improve quality use
What are the way forwards?
´ Whole society engagement
´ Prevention first
´ Access
´ Sustainability
´ Incremental target for improvement
WHO, 1915
´ Focused on actions
implementation at subnational/ hospital/community levels
´ Strengthen surveillance of high risk conditions
´ Networking between referral hospitals and districts hospitals
´ Community education on drugs/ antimicrobials.
