Country perspectives
Opening with an overview on developments over the past year, Mr Adrian Shephard from RB highlighted three recent activities that indicate progress towards tackling the issue of AMR:
1. In May new guidance on the treatment of Acute Sore Throat was published by NICE in the UK. This guidance specifically encouraged GPs to stop the routine dispensing of antibiotics and reserve these drugs for patients whose symptoms indicate they will truly benefit
2. On a Global scale, the WHO and their partners such as the World Organisation for Animal Health (OIE) have united under the One Health approach to take collective action to minimize the emergence and spread of AMR by promoting the prudent and responsible use of antimicrobial agents
3. The five pillars set out in the Global Action Plan to address AMR are being translated into National Action Plans (NAPs) in different countries across the world.
The major battleground in the community continues to be
the inappropriate prescribing of antibiotics for self-limiting respiratory tract infections
Mr Shephard reflected that the increase in the number of countries who have now published NAPs to counter inappropriate antibiotic use is remarkable. There was a huge surge in 2017 that continued into early 2018. We now see the majority of the countries have a NAP and within those plans there are commonalities around the five pillars from the WHO
Italy
High levels of antibiotic consumption remains an issue in Italy, said Dr Sessa. A report published in July this year indicated a slight but continuous decrease in the use of antibiotics. However, there are important regional differences with markedly higher antibiotic consumption in southern Italy.
The objective of the Italian National Plan against AMR is a 10% reduction in the of use antibiotics in the community, a 5% reduction in hospital patients, and a 30% reduction in animals in the space of three years
In November 2017, a prominent financial newspaper in Italy published a booklet about AMR, titled “An Ongoing Emergency”, which explained the relevance of the problem to the public and also the associated economic burden. It was made available to all medical doctors, dentists, veterinarians, pharmacists and biologists.
In addition, Italy continues to run an AMR awareness campaign every October that involves a huge diversity of media channels. This includes all principle newspapers in Italy, radio and cinema advertisements, so-called “dynamic” advertising on buses, a toll-free number for people and HCPs, and a plethora of educational posters and leaflets displayed inside GP and hospital waiting rooms.
In summary, Dr Sessa concluded that Italy is fully engaged in the fight against AMR and is committed to reduce antibiotic consumption to avoid overuse.
Netherlands
Dr van der Velden began the Netherlands, update with a quote from Edith Schippers, the previous Dutch Minister of Health, who has made combating AMR one of her main goals. A couple of years ago Ms Schippers announced a plan to decrease unnecessary antibiotic use in the Netherlands by 50%. This announcement helped raise AMR awareness in the Netherlands and initiated a programme to address the inappropriate use of antibiotics. The strategy included facilitating and organising antibiotic surveillance and stewardship, not only in primary care, but also in secondary care and in long-term care facilities, which are often forgotten in context of antibiotic overuse.
The new indication-linked quality indicators, together with the education provided were greatly appreciated by GPs.
In the pilot for primary care, the systematic surveillance of antibiotic use was initiated, beginning with new quality indicators, explained Dr van der Velden. Previously, antibiotic use was measured as the number and type of antibiotics per practice. This lacked the indication for prescribing, making it difficult to interpret whether usage was appropriate. The new quality indicators were presented to GPs during educational meetings, during which guidelines, new scientific insight and patient/ doctor communication were also discussed.
Subsequently, tools were developed that nowadays allow the collection of information from practices’ electronic medical records in a standardized manner, to enable transparent and uniform calculation of the outcomes of the quality indicators. Dr van der Velden also recently obtained further funding to start training regional teams, support practices collect the outcomes for the indicators and provide further education. The next steps are to roll this out in two of the 12 large regions of the Netherlands. This represents the first step towards the national implementation of these processes to gather this information from the GP system, calculate the outcomes and provide education on a regular basis.
United Kingdom
There is a great deal of work being done in the UK around AMR and the correct use of antibiotics, said Dr Duerden. Dame Sally Davies, the Chief Medical Officer for England, has taken a national lead across the UK on this topic and it has become her priority to address the problem. In addition, Public Health England have done a considerable amount of work on the issue and there are also frequent articles in the press criticizing doctors for being too liberal with the use of antibiotics.
Dr Duerden cautioned that although there is a focus on addressing AMR in the UK, this is made difficult by the already high GP workload and the scarcity of available resources for general practice. This is further compounded not only by the potential of Brexit negatively affecting pharmacy supplies, but also by signs that the antibiotic development pipeline is not as robust as people think it might be.
In September, NICE published draft guidance on the use of antibiotics for acute cough. Fundamentally this guidance indicated that doctors should recommend, where possible, non-drug treatments to patients who present with a cough. This guidance included recommendations such as the use of honey, herbal remedies such as pelargonium and cough medicines containing the antitussive dextromethorphan.
NICE also published draft guidance on the use of antibiotics for sore throat. This guidance uses clinical assessment criteria to decide whether the patients are likely to benefit from antibiotics or not, based on the probability of them having Streptococcus. In addition, the guidance contains useful information on self-management and refers to evidence that medicated lozenges can help reduce pain.
Beyond the guideline update, there has been increased surveillance on the usage of antibiotics. Dr Duerden confessed that while previously sceptical, that there is increasing evidence of a change in clinical practice. Whether looking at the overall volume of prescribing or the prescription of items such co-amoxiclav, cephalosporins and quinolones in relation to other antibiotics, Dr Duerden concluded there is now data that strongly suggest a reduction in the overall usage of antibiotics in the UK.
Australia
Over the last five years, the lead organisation in Australia, NPS MedicineWise, has had a remit to address antimicrobial stewardship, said Mr Bell. To date, the NPS has focused on health professional education, especially with regards RTIs, urinary tract infections, and skin and soft tissue infections. Last year at the annual conference of the Pharmaceutical Society, there was particular focus on antimicrobial stewardship. In addition, the Chief Medical Officer, John Turnage, also discussed the appropriate length of courses for antibacterial therapy and concluded that despite recent news, it seems that most consumers believe that you must finish the course of antibiotics.
Every year during the cold and flu season, NPS MedicineWise in conjunction with the medical practitioner and pharmacy groups, have campaigns aimed at consumers in workplaces, schools and childcare centres. Mr Bell explained that despite World Antibiotic Awareness Week (WAAW) not occurring at the most appropriate time in the southern hemisphere, they continue to run on-going campaigns to coincide with this global initiative.
We have seen some benefits insofar as how the campaign has gone over the last five years, but there is certainly still a long way to go
The results of this five-year campaign have been encouraging, but not fantastic, concluded Mr Bell. There has been an increase in the consumer perception of what antibiotics do from 53% to over 70%. However, most parents believe upper respiratory tract symptoms in children should last no longer than one week and if they do, then you should start antibiotics. With regards to the number of antibiotic prescriptions, a recent publication showed a 14% total reduction in the number of dispensed antibiotics during the time period from 2004 through 2014/15.
South Africa
South Africa was amongst the first countries in Africa to develop a National Action Plan, this is called the National Antimicrobial Resistance Strategy Framework, said Prof Essack. This plan was recently updated, and the new 2017-2024 action plan now includes a strong One Health component.
Part of the implementation strategy is a stewardship guideline. Regional training centres have been established where people from provincial hospitals are trained on how to implement an antimicrobial stewardship programme. There are pockets of excellence in various provinces throughout the country, such as the Western Cape, said Prof Essack.
South Africa has also adopted the Antibiotic Guardian initiative from the UK and will be implementing pledges in time for WAAW this year. In addition, they will soon be publishing the first surveillance report, demonstrating that it is possible to take data from both the public and private sectors in South Africa and publish as one consolidated report.
From a regional perspective, Prof Essack explained that the Africa Centres for Disease Control and Prevention (CDC) has published its own AMR framework. The Regional Action Plan brought together the Africa CDC, the regional Food and Agricultural Organisation of the United Nations (FAO) office, the regional World Organisation for Animal Health (OIE) office, the WHO, React Africa, the African Ecumenical Pharmaceutical Network and several others such as the African Society of Laboratory Medicine. This Regional Action Plan is currently in an intense phase of consultation and is expected to reach consensus soon.
One of the challenges Africa faces is that a number of different organizations are working in the same countries, trying to address the same issues necessitating review and rationalization of efforts. Therefore, Prof Essack emphasized the importance of each agency finding its own niche to avoid duplicating activities.
On a Global level, Prof Essack described how she has been working with the WHO on education and awareness. A competency framework for nurses, doctors, pharmacists and laboratory technicians has been developed. A stewardship toolkit adapted specifically for low and middle income countries is also in development with the aim of piloting this in a couple of countries that were also involved in the development of the National Action Plan.
Russia
On 25th September 2017, the Russian National Action Plan was established in two parts that cover the time periods from 2017-2020 and from 2020-2030, Prof Kozlov explained. This plan describes seven major pillars that include the development of professional education and emphasise the importance of collaboration.
Consequently Russia is in the early stages of implementation and one of the first tasks to draw up a roadmap for the roll-out of this new initiative. This is a very poignant moment, as it will be the first time when different constituencies such as the Minister of Health and the Minister of Agriculture within the Russian Confederation will need to work together.
Regarding international collaboration, Russia is continuing to assist Russian-speaking colleagues within the former USSR as part of their mandate. Russia also has a good, long-term relationship with the UK. For example there is a joint exhibition between the Wellcome Trust and the Natural History Museum of Moscow on microbial life to raise public awareness.
One of the specific parts in which we achieved probably the biggest success is actually professional education, because it’s a separate entity within the initial action plan, and we are in the late stages of approval from the professional standard of medical microbiology.
To complement the efforts to improve professional education, Russia has also initiated mass media campaigns. This was prompted by recent outbreaks of infections such as measles, which attracted substantial attention towards the role of antimicrobials and therefore provided the opportunity to work with Russian newspapers in order to educate consumers on AMR.
Prof Kozlov concluded that the major focus for Russia over the next few years will be to communicate the action plan and implement it effectively to achieve the maximum benefit possible within the timeframe.
USA
Dr Burgoyne explained how the CDC increased funding for AMR for two years in a row. In 2016 $160 million was dedicated to AMR, $163 million in 2017, and there are hopes this trend will continue into 2018.
The majority of this funding is distributed to individual states to run their own AMR campaigns such as educational programs for school children and billboard advertisements. In addition, there are regular articles in national newspapers such as the Wall Street Journal and the New York Times, talking about resistance and the need to appropriately use antibiotics.
The news reports are warning everybody, including consumers, but physicians are still caving to their patients and giving them the antibiotic when they ask for it
Despite these initiatives, there is still a significant amount of pressure on physicians to prescribe antibiotics. Some of this pressure comes from the need to generate high patient satisfaction scores in order to receive maximum reimbursement from health plans and achieve bonus. Not only do consultations take longer when explaining the reasons for not prescribing an antibiotic but also often the patient leaves dissatisfied. This provides an incentive to capitulate to patient demands even if this means overprescribing antibiotics.
Dr Burgoyne explained that from a pharmacist perspective in the US there isn’t a great deal of time spent educating patients about appropriate use of antibiotics. This is likely because pharmacies are extremely busy, often filling 600-700 prescriptions per day. Therefore, if a prescription comes in for an antibiotic, it often gets filled with no discussion nor comment from the pharmacist.
Dr Burgoyne concluded that this may be a learning that the US could take from the GRIP initiative and re-engage with pharmacists to educate them about the impact that inappropriate antibiotic use has on AMR."
Ireland
The situation in Ireland is very similar to the UK in terms of the pressure on GPs, the increased patient demand for consultations and the requirement to fit more patient appointments into the day, stated Dr Noonan. However, the Out of Hours structure in Ireland is very different and sees all patients from 6pm to 8am on weekdays and at weekends. There was a directive issued earlier this year, advising doctors to prescribe antibiotics for any patient who had either already recently seen their GP, or who seemed to be particularly adamant for an antibiotic prescription. The motivation for this was to increase patient satisfaction and reduce litigation. Expressing frustration, Dr Noonan explained that this is likely to negatively affect the relationship between the patient and their regular doctor and increase the overall number of antibiotic prescriptions.
There has been a dramatic increase in the number of consultations over the last two to three years, largely because all children under the age of six are now seen for free. Consequently, this has also increased the usage of antibiotics in that age group. These changes in practice are surprising, given that Ireland already has an AMR Stewardship program. The website antibioticprescribing.ie gives guidelines for the correct treatment of specific bacterial infections that doctors are supposed to reference before they prescribe an antibiotic.
From a patient perspective, the patient website undertheweather.ie provides advice on how to manage self-limiting conditions including RTI and provides patients with realistic expectations of symptom duration. Efforts to educate patients on how to use antibiotics continue and is accompanied by advice on medical tourism to dissuade patients from buying antibiotics abroad at a discounted price and bringing them home for later use.
Despite having an AMR programme in operation in Ireland, there was a directive issued in one of the largest out of hours co-ops that essentially said in order to increase patient satisfaction and reduce complaints, we would recommend that all doctors prescribe antibiotics for patients who have already been seen by their own doctor
Brazil
In 2010 the National Health Surveillance Agency in Brazil introduced a new regulation to prevent the sale of antibiotics to patients that lack a prescription. Since this change there has been some data to indicate a decrease in antibiotic use by as much as 70%, however Prof Pignatari emphasized the need for better data in order to draw firm conclusions.
Currently the majority of official government programmes in Brazil are focused on preventing hospital-acquired infections rather than providing advice on the use of antibiotics in the community setting. This is to tackle the relatively high levels of nosocomial infections by resistant bacteria in Latin American countries compared to Europe and the US. Consequently, stewardship programmes exist predominantly for hospitals rather than the community. In Brazil it is common for the patient to go the emergency room (ER) rather than the GP for an initial consultation. Therefore there is particular effort to educate ER doctors and hospital pharmacists to lower the rate of antibiotic prescriptions.
Most of the effort from the official government programs is for hospitals, not for the community - specifically to tackle nosocomial infections
Germany
Currently around 45% of all encounters between a patient with a RTI and a physician result in an antibiotic prescription. Although this is a 10% reduction in antibiotic prescribing compared to previous years, the prescription of broadspectrum antibiotics remains far too high.
The German National Action Plan is called the Deutsche Antibiotika Resistenzstrategie (DART) initiative and continues to gain momentum. As an example, Dr Altiner explained they are currently in the middle of one of the largest educational programmes for physicians in ambulatory care. This involves more than 2,500 practices and covers almost half of Germany. In addition, over 2,500 practices recently completed an online educational programme that focused on doctorpatient communication.
Another program gaining momentum is the discussion on health literacy. Dr Altiner reflected that changes in prescribing behaviours are not entirely due to improvements in HCP education, but also due to a generation shift in GPs in Germany that results in a different prescription style and a change in patient demands.
Dr Altiner concluded by reflecting that one of the big challenges in Germany is the difficulty in obtaining timely prescribing data. Ideally prescribers should be provided with almost immediate prescription feedback, however there remain many barriers to achieving this in Germany.
The German national plan to reduce antibiotic or to improve antibiotic use is gaining momentum. We’ve never seen as many projects on antibiotic use and prescribing as today
Mexico
Antibiotic resistance is no longer a threat, it is a clear and present danger requiring concerted actions at a global level. However, Dr Caretta explained that the level of danger varies by geography due to rates of resistance and main causative agents differing between countries. In industrialised countries the primary issue is AMR in hospitals, whereas in less developed countries such as Mexico, the main problem is in community acquired infections.
Giving some context on Mexico, Dr Caretta described it as a middle-income country with a fairly good human development index and representing a significant economy in Latin America. However Mexico has grave challenges regarding social mobility and corruption, with more than 53 million people living in poverty with no access to healthcare systems or education. This presents a difficult environment to develop strategies to address AMR.
One of the main milestones in regulating antibiotic prescriptions in Mexico was the implementation of a policy to prevent pharmacists providing antibiotics to patients without a prescription. In Latin America, Chile was the first country to implement this policy in 1999. In 2005, Colombia partially followed suit by regulating the OTC sales of antibiotics but only in the capital city. Initially the Mexican government was hesitant to initiate a similar policy due to economic reasons. However, after a particularly bad H1N1 influenza epidemic and associated mortality there was an upsurge in pressure to implement new policies.
Consequently in 2010, a policy was implemented that enforced the prohibition of antibiotic sales without prescription. This policy introduced punitive measures against pharmacies and drugstores that sold antibiotics without a prescription and meant they could face losing their business licence. Five years later, a study showed a 34% decrease in the use of antibiotics in private practice in Mexico.
Antibiotic resistance is no longer a threat, it is a clear and present danger
However, the situation in Mexico presents many additional challenges to tackling AMR. In addition to inadequate infrastructure and overcrowding in cities, Mexico has a fragmented healthcare system. There is a private healthcare system, a public healthcare system and a parallel healthcare system. The parallel system is made by businessmen who buy pharmacies and hire general practitioners to write scripts for people that cannot pay for medical attention. In these facilities, the prescription of antibiotics is often inappropriate, and driven by patient desires instead of physician knowledge and advice.
In order to implement successful policies in Mexico it is important to understand both health and socioeconomic issues. It is also important to work with all stakeholders not only the GPs and specialists, but also with the public. Dr Caretta concluded that the combination of policy change and education initiatives can result in a significant reduction in the inappropriate use of antibiotics as long as HCPs are also given appropriate training and resources to convince patients that they don’t necessarily need antibiotics.
Thailand
Thailand is a country of over 60 million people where antibiotic use accounts for approximately 20% of total drug use and antibiotic usage continues to increase each year. Dr Tongrod explained this is because antibiotics continue to be freely available for purchase at the pharmacy without a prescription. Recent publications have further emphasized AMR as a major and urgent health problem in Thailand both in terms of patient mortality and cost to the healthcare system.
In 2008, the Thai FDA initiated the Antibiotic Smart Use (ASU) program with support from the WHO. This programme focused on three common ailments; sore throat, acute diarrhoea and simple wounds, and provided tools to educate both prescribers and patients. After two years, hospitals had reduced antibiotic use by almost 30%. This program has been publically endorsed by the Prime Minister of Thailand who is visible on poster campaigns with the quote, “I don’t want to see Thai people ill and dying from irrational drug use”.
The National Action Plan to combat AMR runs from 2017 to 2021 and details six key strategies to achieve a distinct set of goals:
50% reduction in AMR morbidity
20% reduction in antimicrobial consumption in humans
20% increase in public awareness on AMR, and antimicrobial use
30% reduction of antimicrobial use in animals
Antibiotic use in Thailand accounts for about 20% of all the drugs in Thailand. Their use is also increasing and if you ever go to Thailand you can buy antibiotics from the pharmacy without a prescription
In Thailand, most pharmacies will provide a mirror and flashlight to enable patients to examine their sore throat themselves. This provides the pharmacist with an opportunity to explain that there is no need to use antibiotics for viral infections. Whilst working for the Faculty of Pharmaceutical Sciences at Huachiew Chalermprakiat University (HCU), Dr Tongrod developed the HCU Sore Throat application. This is a self-diagnosis tool that enables the patient to take a photo of their sore throat, assess a symptom checklist that uses the McIsaac sore and read a leaflet providing advice on whether they need an antibiotic. This tool won several awards including from the Ministry of Public Health. Based on this success, Dr Tongrod has developed a second version of this application that includes a video about self diagnosis for sore throat and provides information on symptomatic relief.
With regards to future plans, the action plan for ASU includes the development of guidelines for pharmacy, development of a self-screening card, and the launch an education programme together with the Pharmaceutical Association of Thailand. Dr Tongrod concluded by confirming that they will continue to develop the HCU Sore Throat Application for use by patients to help differentiate between viral and bacterial infections to avoid the inappropriate use antibiotics.