___________________________________________________________________________
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