2016/LSIF/FOR/007 Improving Antimicrobial Use and Awareness in Korea

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1 2016/LSIF/FOR/007 Improving Antimicrobial Use and Awareness in Korea Submitted by: Asia Pacific Foundation for Infectious Diseases Policy Forum on Strengthening Surveillance and Laboratory Capacity to Fight Healthcare Associated Infections and Antimicrobial Resistance Ha Noi, Viet Nam December 2016

2 Improving antimicrobial use and awareness in Korea Doo Ryeon Chung, MD, PhD Professor of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Chief, Division of Infectious Diseases Director, Center for Infection Prevention and Control, Samsung Medical Center Secretary General, Asia Pacific Foundation for Infectious Diseases (APFID)

3 2 Outline Korean Healthcare System Appropriateness of antimicrobial usage Antimicrobial stewardship in the community Antimicrobial stewardship in hospitals Awareness

4 Korean Healthcare System 3 Tertiary Hospital 44 ( 400 beds) General Hospital 273 (100~399 beds) Hospital 1,287 (30~99 beds) Clinic 27,325 (<30 beds) June, 2010

5 Korean Healthcare System 4 85% of patients received unnecessary hospital services

6 Chun CB, et al. Health system review. Rep. of Korea. Health Systems in Transition 2009;11(7) Health care system in Korea 5 Medical service provider Public sector 10% Private sector 90%

7 Korean Healthcare System National Health Insurance 1989 Universal Health Insurance

8 National Health Insurance System 7 National Health Insurance Service Ministry of Health and Welfare Health Insurance Review & Assessment Service

9 Korean Healthcare System Pharmaceutical Policy Reform: Separation of prescription and dispensation of drugs in outpatient care

10 9 Outline Korean Healthcare System Appropriateness of antimicrobial usage Antimicrobial stewardship in the community Antimicrobial stewardship in hospitals Awareness

11 Antimicrobial usage in Korea 10 Total antimicrobial consumption for human use in Korea 35 Antimicrobial consumption for human use in Korea DDD/1,000 habitants/day OECD average Korea Ministry of Health & Welfare

12 Antimicrobial usage in Korea Sale of antibiotics Through the pharmacy Without prescription : 48.7% of total antibiotic consumption A report from the Korea Institute for Health and Social Affairs

13 Antimicrobial usage in Korea 12 Proportion of episodes prescribing antibiotics for URI (viral diseases) 90 Policy reform Proportion (%) Jan 2000 Jan 2001 P<0.001 Park S, Soumerai SB, et al. Health Policy Plan. 2005;20:302-9

14 Antimicrobial stewardship in hospitals Assessment of antibiotic use for surgical prophylaxis Preliminary assessment A retrospective study in Korea in 2004 only 0.8% of the patients who underwent a major surgery received appropriate prophylactic antibiotics. (Choi WS, et al. Infect Control Hosp Epidemiol 2007;28: ) Use within 1 h before incision (%) Use of AG (%) Use of 3 rd G Cepha. (%) Combined use (%) Antibiotics at discharge (%) Avg. days of antibiotics

15 14 Outline Korean Healthcare System Appropriateness of antimicrobial usage Antimicrobial stewardship in the community Antimicrobial stewardship in hospitals Awareness

16 Antimicrobial stewardship in the community No antibiotics without doctor s prescription since 2000 Consumption of antibiotics : Decrease by about 30% A report from the Korea Institute for Health and Social Affairs

17 Antimicrobial stewardship in the community 16 Total antimicrobial Antimicrobial consumption for for human use use in Korea in Korea 35 DDD/1,000 habitants/day OECD average Separating drug prescription from dispensing Korea Ministry of Health & Welfare

18 Antimicrobial stewardship in the community Pharmaceutical policy reform in 2000 Change in proportion of episodes prescribing antibiotics for URI (viral diseases) after policy reform Policy reform Proportion (%) Jan 2000 Jan 2001 P<0.001 Park S, Soumerai SB, et al. Health Policy Plan. 2005;20:302-9

19 Antimicrobial stewardship in the community Assessment of antibiotic prescription for URI Change in proportion of episodes prescribing antibiotics for acute URI after opening the data for each hospital to the public Clinics Hospitals General Hospitals Tertiary Hospitals

20 Antimicrobial stewardship in the community Assessment of antibiotic prescription for URI 19

21 Domestic strategy and action plans 20 Goals Antimicrobial consumption 20% Antibiotic prescription rate for URI 50% Antibiotic prescription rate for respiratory disease 20% Enforcement of assessment of appropriateness of antibiotic use Development and distribution of antibiotic treatment guidelines

22 Treatment guideline for acute URI in children 21 Treatment guideline for acute URI in children (KCDC, Nov. 2016)

23 22 Outline Korean Healthcare System Appropriateness of antimicrobial usage Antimicrobial stewardship in the community Antimicrobial stewardship in hospitals Awareness

24 Antibiotic Treatment Guidelines 23 Community-acquired pneumonia Urinary tract infection Cardiovascular infection Gastrointestinal infection Skin and soft tissue infection Bone and joint infection Central nervous system infection Sepsis

25 Antimicrobial stewardship in hospitals Assessment of antibiotic use for surgical prophylaxis Preliminary assessment Use within 1 h before incision (%) Use of AG (%) Use of 3 rd G Cepha. (%) Combined use (%) Antibiotics at discharge (%) Avg. days of antibiotics

26 Antimicrobial stewardship in hospitals Assessment of antibiotic use for surgical prophylaxis 25

27 54 hospitals with ID specialists On-line survey, % 13% Hospital beds >1,000 beds 501-1,000 beds beds 65% Kim B, Pai H, et al. J Korean Med Sci 2016;31: Dec 07, 2016 ANTIMICROBIAL STEWARDSHIP. 대한의료관련감염관리학회연수강좌 26

28 54 hospitals with ID specialists On-line survey, % Number of ID specialist 32% 6% 60% One Two Three or four Five or six Kim B, Pai H, et al. J Korean Med Sci 2016;31: Dec 07, 2016 ANTIMICROBIAL STEWARDSHIP. 대한의료관련감염관리학회연수강좌 27

29 2006 (n=44) 2012 (n=40) 2015 (n=50) ASPs 95.5% 87.5% 92.6% Restriction on antibiotic use Selected reporting of antimicrobial susceptibility results 7 (16.7) 7 (20.0) 16 (32.0) Automatic stop order 17 (40.5) 26 (52.0) Formulary restriction 10 (23.8) 7 (20.0) 9 (18.0) Restriction on inappropriate antibiotic combination 15 (30.0) Restriction on long-term antibiotic use 23 (46.0) Computerized system for control 26 (59.1%) 34 (85.0%) 50 (100%) Dec 07, 2016 Kim B, Pai H, et al. J Korean Med Sci 2016;31:

30 Dec 07, 2016 Kim B, Pai H, et al. J Korean Med Sci 2016;31:

31 Antimicrobial stewardship in hospitals Computerized decision support system Asan Medical Center 2002 Korea University Anam Hospital 2003 Samsung Medical Center (optional) 11 out of 44 tertiary hospitals 2003 Seoul National University Bundang Hospital & SNUH 2005 Dongkuk Univ. Ilsan Hospital 2006 Hallym University Medical Center (5 hospitals) 2008 Samsung Medical Center (new ver.)

32 Korean Healthcare System 31 Tertiary Hospital 44 ( 400 beds) General Hospital 273 (100~399 beds) Hospital 1,287 (30~99 beds) Healthcare Accreditation System Assessment of antibiotic prescription for URI Assessment of surgical antibiotic prophylaxis Antibiotic sub-committee Antibiotic restriction Clinic 27,325 (<30 beds) June, 2010

33 Samsung Medical Center, Seoul, Korea 2,000-bed tertiary hospital Affiliated with Sungkyunkwan University School of Medicine 11 ID physicians (6 faculties & 5 fellows) 4 Ped. ID physicians (1 faculty & 3 fellows) 2 Clinical microbiologists 1 Pharmacist Antimicrobial Stewardship Committee

34 33 Antimicrobial formulary restriction Determining antimicrobials requiring approval Antimicrobial Stewardship Committee Samsung Medical Center Reviewing antimicrobial usage data Reviewing antimicrobial resistance of major pathogens

35 Approval systems in SMC 34 Carbapenems Glycopeptides Linezolid Amikacin Aztreonam Arbekacin Colistin Tigecycline

36 35

37 Samsung Antibiotic Prescription System (SAPS) 36 Empiric Prophylactic Definitive Prev. orders Date Adv. reactions Search Remarks duration d Dx. Diagnosis for empiric therapy Target organisms Antimicrobials Select Antimicrobials Order Adults

38 Samsung Antibiotic Prescription System (SAPS) 37 Empiric Prophylactic Definitive Prev. orders Date Adv. reactions Search Remarks duration d Dx. Diagnosis for empiric therapy Target organisms Antimicrobials Antimicrobials Select Order Adults

39 Samsung Antibiotic Prescription System (SAPS) 38 Empiric Prophylactic Definitive Prev. orders Search Diagnosis for empiric therapy Date Remarks Adv. reactions duration d Dx. Target organisms Antimicrobials Antimicrobials Select Order Adults Code Product Antimicrobial Content Unit Dose Freq. Interval AG Dialysis Order

40 Samsung Antibiotic Prescription System (SAPS) 39 Selection of Antimicrobials Others Reason for choosing others

41 Samsung Antibiotic Prescription System (SAPS) Prophylactic antibiotics 40 Empiric Prophylactic Definitive Search Operation or procedure Prev. orders

42 Samsung Antibiotic Prescription System (SAPS) 41 Prophylactic antibiotics Empiric Prophylactic Definitive Prev. orders Search Operation or procedure duration d

43 Samsung Antibiotic Prescription System (SAPS) Definitive antibiotic therapy 42 Empiric Prophylactic Definitive Prev. orders Culture requested Culture report Select antibiotics

44 Samsung Antibiotic Prescription System (SAPS) Definitive antibiotic therapy 43 Empiric Prophylactic Definitive Selection of antibiotics based on susceptiblity Select antibiotics

45 Samsung Antibiotic Prescription System (SAPS) Total Third G cephalosporin Aminoglycoside Vancomycin Huh KM, Chung DR, et al. Am J Infect Cont 2016;44:e145-e152

46 Samsung Antibiotic Prescription System (SAPS) ESBL + E. coli Meropenem-resistant Pseudomonas aeruginosa MRSA Huh KM, Chung DR, et al. Am J Infect Cont 2016;44:e145-e152

47 46 Outline Korean Healthcare System Appropriateness of antimicrobial usage Antimicrobial stewardship in the community Antimicrobial stewardship in hospitals Awareness

48 Q1) Do you think taking antibiotics improve the condition of having a cold? Q2) When your ill symptoms improve after taking prescribed antibiotics, do you think it is okay to stop taking antibiotics? Q3) Have you ever taken any antibiotics that have been kept at home for treating fever without visiting a doctor? 71.4% 80.4% 28.1% 67.4% 77.3% 31.0% 66.6% 74.4% 29.6% [Song JH. KFDA. 2010] [Song JH. KCDC. 2012] [APFID. 2015]

49 48 Public Campaign The Korean Society of Infectious Diseases The Korean Society for Chemotherapy Supported by Korea CDC The Korean Society of Pediatric Infectious Diseases Asia Pacific Foundation for Infectious Diseases (APFID)

50 Public Campaign

51 Public Campaign

52 Public Campaign

53 Public Campaign e-learning

54 Public Campaign e-learning

55 Public Campaign Education of school nurses

56

57

58 Summary 57 Pharmaceutical policy reform separating prescription and dispensation of drugs, assessment and public reporting of antibiotic prescription rate for URI and surgical antibiotic prophylaxis for each institution have been very effective to improve antibiotic usage. Antimicrobial stewardship programs in hospitals, mostly dependent on restriction and approval system have been used in most tertiary hospitals and a small proportion of general hospitals. Computerized decision support system for antibiotic prescription has been developed and utilized successfully in some tertiary hospitals. Public campaign for appropriate antibiotic use has been launched and will be in alignment with implementation of domestic action plans.

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