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What influences
antibiotic prescribing
and use
in South(east) Asia?
Erika Vlieghe, MD PhD
Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp
Department of Tropical Medicine, University Hospital Antwerp
Antibiotic resistance world wide
2
Molton, Clin Infect Dis 2013
Antibiotic resistance world wide
Gram negative
resistance…
3
Molton, Clin Infect Dis 2013
Global spread of resistant S. Typhi
Source: WHO
ESBL-producing E. coli in Asia
Resistan
ce
%
Korea
10-25%
Japan
10-25%
China
>50%
Hong Kong
25-50%
Taiwan
10-25%
Philippines
10-25%
Thailand
25-50%
Vietnam
>50%
Malaysia
10-25%
Singapore
25-50%
Indonesia
25-50%
India
Sri Lanka
Saudi Arabia
>50%
?
<1%
Korea
China
1-5 %
Japan
Saudi
Arabia
Taiwan
HK
5-10 %
10-25 %
Vietnam
Philippines
India
Indonesia
Malaysia
Sri Lanka
Thailand
25-50 %
> 50 %
unknown
Singapore
25-50%
1st APEC
Expert Forum
Source: Hsueh PR, 2012
No clear diagnosis: AB started
Self-medication
What are causes of resistance?
Dose too low
Substandard drugs
Treatment too short/too long
Unnecessary combinations
Irrational use of antibiotics
The vicious circle of resistance
WHO 2012 ‘Options for action’
• Surveillance
• Bacterial resistance
• Antibiotic use
• Infection prevention
• Rational drug use = stewardship, policy
• Innovation (drugs, diagnostics, vaccines)
• Political support
Rational antibiotic use
• 4 D’s:
Drug choice
Dose
Duration
De-escalation
Early appropriate AB 
better survival chances
Need:
Evidence
&
Guidelines
• Presence of strategies
– National/local policies & guidelines
– Regular consumption data audit and feedback
– Early start of education on AB resistance
• Socio-economic factors
– Reimbursement policies & health care organisation
– Influence of pharmaceutical industry
• Socio-cultural factors
– Defensive society  Defensive prescribing: uncertainty avoidance
– Hierarchical  Egalitarian societies
– Catholic Protestant religion?..
• Presence of strategies
– National/local policies & guidelines
– Regular consumption data audit and feedback
– Early start of education on AB resistance
• Socio-economic factors
– Reimbursement policies & health care organisation
– Influence of pharmaceutical industry
• Socio-cultural factors
– Defensive society  Defensive prescribing: uncertainty avoidance
– Hierarchical  Egalitarian societies
– Catholic Protestant religion?..
First rough estimate: AB sales data
Source: GARP
More refined quantitative data:
hospital usage data  benchmarking
500
Other J01
400
Vancomycin J01XA
DDD/100 bed-days
Carbapenem J01DH
300
Tetracyclines J01A
200
Quinolones J01M
Penicillins J01C
100
Macrolides J01F
0
Cephalosporins J01DA
Hospital
Antibiotic consumption for systemic use (J01) by ATC class in 15 hospitals in 2008
Slide: Heiman Wertheim, OUCRU Hanoi, VN
More refined quantitative data:
hospital usage data  benchmarking
But what is behind these different prescription patterns?
And how to change (decrease) them…?
500
Other J01
400
Vancomycin J01XA
DDD/100 bed-days
Carbapenem J01DH
300
Tetracyclines J01A
200
Quinolones J01M
Penicillins J01C
100
Macrolides J01F
0
Cephalosporins J01DA
Hospital
Antibiotic consumption for systemic use (J01) by ATC class in 15 hospitals in 2008
Slide: Heiman Wertheim, OUCRU Hanoi, VN
Awareness of AB resistance among Lao prescribers
Quet et al, submitted
Perceived barriers for good AB prescription
practices (n=60 physicians, South India)
Unavailability of antibiotics
78,0%
Local medical shopkeeper sells antibiotic
18,3%
61,7%
High workload
20,0%
56,6%
Pateints ask to prescribe
36,6%
50,0%
Lab reports not in time
45,0%
46,6%
Poor quality antibiotics
41,6%
No support from higer-ups
40,0%
Not much awareness on resistance
21,6%
Promotion & living problems present
20,0%
33,3%
46,6%
41,6%
68,3%
53,3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
strongly & somewhat agreed
strongly & somewhat disagreed
no opinion & not answered
Krishna Sushma, Master Thesis MPH 2014
Perceived barriers for good AB prescription
practices (n= 58 pharmacists, South India)
Indent takes long arrival
No support from higher-ups
Not trained well at job
High wok load
No much awareness abt resistance
Local medical shopkeeper sells
Doctors don’t take my suggestion
No place for stock and storage
Unavailability of required antibiotics
Not my domain
Poor quality antibiotics dispensed
Poor preserving conditions for antibiotics
20,0%
63,8%
15,0%
62,2%
28,3%
60,3%
25,0%
55,2%
45,0%
44,8%
28,3%
43,6%
25,80%
30,0%
43,6%
45,0%
39,6%
53,3%
36,2%
41,6%
31,0%
36,20%
33,3%
29,3%
55,0%
25,9%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Strongly & somewhat agree
No opinion & not answered
Strongly & somewhat disagree
KAP surveys in LMIC: common denominator
• ‘AB resistance is a problem world wide but less so
in my personal practice’
• Poor knowledge on antibiotics and resistance
patterns
• Limited sources of information, treatment
guidelines
• Openness for innovative ways of information,
training, guidance
KAP surveys in LMIC: common denominator
• ‘AB resistance is a problem world wide but less so
in my personal practice’
But…
desirableon
answers
& conflicting
results
•Socially
Poor knowledge
antibiotics
and resistance
patterns
What
is the best local strategy?
Need for more in-depth insight
•…Limited sources of information, treatment
guidelines
• Openness for innovative ways of information,
training, guidance
India
• Mixed methods study in public system in
Tumkur district (Sushma Krishna)
• IDI among all types of prescribers in BangaloreTumkur area (Annelies Post, poster …)
Low quality of care drives AB use
Over- or underaccess to antibiotics…?
“Govt supply is limited madam. In the budget, antibiotics costly. We
cannot order, burden for us. So, when infection routine happens, people
buy outside”, said the pharmacist.
Need for information and guidance
“Guidelines(pauses). . .We actually have to make guidelines.. . . higher side people at
teaching institutions, to frame there”, physician
“Actually we had developed one antibiotic policy format from internet in view of
accreditation happening, but it did not come into effect, was just on papers(laughs). .. By
that time, thing got cancelled”
The influence of ‘Big Pharma’
Doctors’ image and generational conflict
Cambodia – work in progress
• KAP survey among 19 hospitals across
Cambodia
• IDI and FGD
– Prescribers
– Dispensers/pharmacists
– Patients and relatives
– Agricultural sector (peasants, industry, MoH)
Pts request for
‘drugs’, not for
AB!
‘VIP antibiotics
for VIP patients’
Low levels of
knowledge
and
awareness
Lack of access
to drugs and
diagnostics
Use+++ in
food
animal
sector
Lack of
regulation
Discussing National Antibiotic Resistance 5-year plan
(Phnom Penh, June 2014)
To conclude…
• Common (‘ubiquitous’) observations local flavours
• Blame game: prescribers-dispensers-patients-govmt
• Over- versus under-access…
– to antibiotics
– to diagnosis
– to quality health care
• Training, information, CME
– Vacuum  taken over by pharmaceutical companies
• Potential of social media and communication technology