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2016/LSIF/FOR/008

Antimicrobial Stewardship in Viet Nam - Turning Challenges into Opportunities

Submitted by: Pham Ngoc Thach University of Medicine

Policy Forum on Strengthening Surveillance and Laboratory Capacity to Fight Healthcare Associated Infections and Antimicrobial

ResistanceHa Noi, Viet Nam

14-15 December 2016

Antimicrobial Stewardship in Viet Nam

Turning challenges into opportunities

A/Prof Le thi Anh Thu, MD, PhD President, HCMC Infection Control Society

Chief, Infection Control Department, Cho Ray Hospital Chief lecturer, Pham Ngoc Thach University of Medicine

Resistance of pathogens causingHAI in 3 tertiary hospitals and 14

provincial hospitals, 2013

Common Pathogens

Acinetobacter baumannii

Pseudomonas aeruginosa

Escherichia coli

Klebsiella spp.

Coagulase N Staphylococus

S. Aureus

Enterococcus spp

Candida Albicans

Negative Gram / Positive Gram: 2/1

50 - 97.8 % MRSA

36-83.3% CNS resistant to Methicilline

> 60% E. Coli, K. Pneumoniae ESBL+ MDR A.baumannii > 80 %

Situation of antimicrobial resistance in Viet Nam

Carbapenem resistant A. Baumannii

VN: 60-79%

• In Human Use

• In Agriculture and the Environment

Challenges High rate of inappropriate AB use

Challenges High rate of AB use

VN: 62%

• Inappropriate rate of AB use patients are reported as high as > 60 % – 99-100% surgery patients are prescribed AB 5-7

days after operations – AB in surgery patients contribute to 50% of total

AB used in hospitals • AB contribute to more than 60 % of total

treatment costs in hospitals

Challenges High rate of inappropriate prescribed AB use

MOH 2010

Challenges High Rate of Healthcare Associated Infections

Incidence per 1000 devices -days

VAP 24.5

CLABSI 7.1

CAUTI 11.5

HAI rate, A (n=177), 63.8% HAI rate, C

(n=210), 61.0% HAI rate, K (n=108), 57.4%

HAI rate, M (n=135), 37.8%

HAI rate, N (n=161), 36.0%

HAI rate, I (n=94), 13.8%

HAI rate, F (n=413), 3.9%

HAI rate, E (n=181), 37.0% HAI rate, G

(n=316), 31.3% HAI rate, B

(n=139), 23.0% HAI rate, J

(n=120), 21.7% HAI rate, H (n=118), 17.8% HAI rate, D

(n=179), 15.1% HAI rate, L

(n=162), 6.2%

HAI rate in adult ICUs

Province

Central

Prevalence of HAI in hospitals : 3%-7.5% (2015) HAI prevalence in ICUs in 16 hospitals (2013): 29.1% pediatric 33.3%, adult 27.3%

Phu et al, 2013 Thu et al, 2016

Challenges Difficulty in establishing Infection Control Overloading of patients is common, especially in

public, tertiary hospitals

Challenges Difficulty in establishing Infection Control Poor infrastructure, insufficient equipment to ensure

infection control Contaminated environment (surface, air, water)

100 100137.5

250

525

387.5

712.5

512.5

312.5

225 225

787.5

450

575637.5

487.5

0

100

200

300

400

500

600

700

800

900

PM1 PM2 PM3 PM4 PM5 PM6 PM7 PM8 PM9 PM10 PM11 PM12 PM13 PM14 PM15 PM16

Required limit

Microbiology sampling of operating theatre at a tertiary hospital, 2015

Turning challenges into opportunities – How to establishing AMS effectively in the

healthcare facilities ?

Right

Patient Drug Time Dose Duration

+

Infection Control

Antimicrobial Stewardship Program

Ministry of Health Level

- Co-operate with other Ministries to control AB use in human, agriculture and environment

- Training, education, communication in communities and healthcare settings

- Support resources for improving microbiology capacity and infrastructure of infection control

AMS program should involve

Simões AS, et al. Front Microbiol. 2016;7:855.

Hospital level

AMS Intervention Intervention Physicians Pharmacy Microbiology AMS team

leader 1 Syndrome-based clinical

pathway, include appropriate diagnostic testing

Comply with pathway

Cooperate Provide the methods and interpretative

result

Leading the development of pathways

2 Development of local Guideline for empirical therapy and prophylaxis (promote antibiotic diversity and monotherapy)

Cooperate Unit specific antibiogram

Guideline development

leader

3 Proactive audit/feed back Receive feedback

Antibiotic use

Antibiogram Provide feedback

5 Education Lead Lead

4 Antibiotic usage data - Compile antibiotic

usage data

- Provide feedback

Asia Pacific AMS expert meeting Nov 2016

AMS Intervention No Intervention Other

physicians Pharmacy Microbiology AMS team

leader 6 Formulary restriction Comply to the

guidelines Audit - Evaluate

audit data

7 IV to oral switching Decision maker, based on

clinical condition

Guidance -

-

8 Dose optimization Comply Guidance -

9 De-escalation and antibiotic time out

Evaluate the patient regularly

Automatic stopping

Selective reporting of

antibiotic susceptibility

10 Pre-authorization of certain antibiotics

Lead

Lead

11 Active surveillance testing

Reporting results

Request

Asia Pacific AMS expert meeting Nov 2016

Commitment of doctors to prescribe AB appropriately

Hospital level Improving Infection Control

• System change:

– Invest more instruments – Improve infrastructure

• Establish policies and procedures for prevention of HAIs

• Continuous training • HAIs surveillance

outbreak investigation • Intervention programs

Overall, 2007, 20.5

Overall, 2008, 31.2

Overall, 2009, 36.8

Overall, 2010, 45.6

Overall, 2011, 56.7

Overall, 2012, 77.8

Doctors, 2007, 16.3

Doctors, 2008, 28.6

Doctors, 2009, 32.4

Doctors, 2010, 41.2

Doctors, 2011, 59.2

Doctors, 2012, 79.2

Nurses, 2007, 22.6

Nurses, 2008, 33.2

Nurses, 2009, 37.2

Nurses, 2010, 47.2

Nurses, 2011, 54.3

Nurses, 2012, 77.6 OverallDoctorsNurses

Hand Hygiene compliance rate

Before program

After program

P

% inappropriate AB use (%) 52.4

22.1 <0.001

% inappropriate AB prophylaxis use in surgery (%)

94.2 33.1 <0.0001

Monotherapy (%) 30.0 48.8 0.001

Microbiology culture done (%) 27.5 51.5 <0.001 Mean DOT of AB 20.4 16.8 0.002 DDDs/1000 bn-ngày 1607.18 1495.32 0.001

CRH 2015

Some achievements An example of successful AMS program

Some achievements An example of successful AMS program

0,67 Trước can thiệp, Cepha 2, 4

944,3

Trước can thiệp, Cepha 4, 233

Trước can thiệp, Carbapenem, 52

152,8

263,4

579,8

Trước can thiệp, Vanco, 53 Sau can thiệp, Cefazolin, 66 9,5

447,5

55,5

333,5 331,8

112,2

335,6

Sau can thiệp, Vanco, 245

Trước can thiệp Sau can thiệp Before program After program

Average number of DDDs of AB/month before and after ASP

Cho ray hospital, 2015

Comparison rate of carbapenamase gene of Gram negative bacteria before and after AMS

Before ASP After ASP

CRH 2015

26

Yes, we can

Turning challenges into opportunities?

Thank you