AMR Control in the Philippines · AMR Control in the Philippines NCGM Department of International Trials Dr. Anton アンㇳンVillanueva, Regional Manager

AMR Control in the PhilippinesNCGM Department of International Trials

Dr. Anton アンㇳン Villanueva, Regional Manager

© 2018 National Center for Global Health and Medicine 2

Disclaimer

These Power Point slides are the intellectual property of NCGM under the copyright laws.Used by permission. All rights reserved. NCGM and the NCGM logo are registeredtrademarks of the National Center for Global Health and Medicine.

©2018 NCGM | CCS | Department of International Trial

© 2019 National Center for Global Health and Medicine https://www.who.int/bulletin/volumes/89/5/11-088435/en/


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WHO 6-Point Policy to Combat AMR

https://www.who.int/bulletin/volumes/89/5/11-088435/en/

❑1. Finance a national plan

❑2. Strengthen surveillance and laboratories

❑3. Ensure access to quality medicines

❑4. Regulate and promote the rational use of medicines

❑5. Enhance infection prevention and control

❑6. Innovate with research and development

© 2018 National Center for Global Health and Medicine © 2019 National Center for Global Health and Medicine


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© 2018 National Center for Global Health and Medicine

AMR Control Workflow in the Philippines

• 1. The Philippine Action Plan to Combat AMR

• 2. Antimicrobial Stewardship Program in Hospitals

• 3. National Antibiotic Guidelines



Co-Chairs:Department of Health（DOH）Department of Agriculture（DOA)

Members:Department of Science and TechnologyDepartment of Trade and IndustryDepartment of Interior and Local Government

Strategy

One Health Approachhttp://www.pidsphil.org/pdf/2016/16LEC-09-Philippine-Action-Plan-to-Combat-Antibiotic-Resistance-Celia-Carlos.pdf

1. The Philippine Action Plan to Combat AMR

2012 – country situation analysis2014 – ‘Administrative Order no.42’

2015


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Implemented WHO’s 6 Recommendations

https://www.who.int/bulletin/volumes/89/5/11-088435/en/

❑1. Finance a national plan

❑2. Strengthen surveillance and laboratories

❑3. Ensure access to quality medicines

❑4. Regulate and promote the rational use of medicines

❑5. Enhance infection prevention and control

❑6. Innovate with research and development


2015 Philippine Action Plan to Combat AMRExpand Antibiotic Resistance Surveillance, National Referral Centers, ISO 15189

Improve PFDA registration, Post-Marketing Surveillance of essential medicines

2017 National Antibiotic Guidelines (Health)

2018 National Antibiotic Guidelines (Agriculture)

2016 Antimicrobial Stewardship Program in Hospitals (2016), ISO 9001:2015

2013 Establish unified Philippine National Health Research System



❑ Key Philippine Strategy #7:



Working GroupAntimicrobial Stewardship Steering CommitteeNational Antibiotic Guidelines CommitteeUniversity of the Philippines – Pharmacy

https://www.slideshare.net/phicna2005/doh-antimicrobial-stewardship-program-in-hospitals-manual-of-procedures-mop-2016

DOH Offices:Health Facility Development BureauHealth Facilities and Services Regulatory BureauPhilippine Health Insurance Corporation

Professional Associations:Pediatric Infectious Disease SocietyPhilippine College of PhysiciansHospital Infection Control SocietyHospital Infection Control Nurses AssociationSociety for Microbiology and Infectious Disease

Pilot Hospitals:Research Institute of Tropical Medicine, Baguio

General (Northern Luzon), Jose B. Lingad (Pampanga, Central Luzon), Rizal Medical (Southern Luzon), Vicente Sotto (Cebu, Visayas), Corazon Montelibano (Bacolod, Visayas), Northern Mindanao, Southern Philippines Medical

Development Partner: WHO country office, WPRO

2. AMS in Hospitals




Working Group:Society for Microbiology and Infectious DiseasesHospital Infection Control SocietyPediatric Infectious Disease SocietyPharmacists AssociationFormulary Executive CouncilResearch Institute for Tropical MedicineNational Center for Disease Prevention and ControlUP College of MedicineNational Epidemiology CenterNational Center for Health Facilities Development

DOH Offices:

Disease Prevention and Control Bureau

Epidemiology BureauFood and Drug AdministrationHealth Facilities Development Bureau

Professional Associations:

Pediatric Infectious Disease, Nephrology, Family Physicians, Ophthalmology,

Pediatric Pulmonologists, Coalition Against Tuberculosis, Chest Physicians, Internists, Surgeons, Dentists, Dermatology, Hospital Infection Control, Neurology, Obstetrics and Gynecology, Orthopedics, Pediatrics, Pharmacists, Microbiology and Infectious Disease, Nephrology, Newborn Medicine, Otolaryngology Head and Neck Surgery, Pediatric Gastroenterology Hepatology and Nutrition, Pediatric Surgeons, Urology

Hospitals:

Philippine Children’s Medical Center

Research Institute of Tropical MedicineSan Lazaro HospitalThe Medical CityUniversity of the Philippines-General Hospital

Development Partner: WHO country office, WPRO

2018

https://pharmadiv.doh.gov.ph/antimicrobial-resistance/nag-guidelines

3a. NAG (DOH)

https://pharmadiv.doh.gov.ph/antimicrobial-resistance/nag-guidelines



Department of Agriculture （DOA)Technical Working Group

Bureau of Animal IndustryNational Meat Inspection ServiceNational Dairy AuthorityPhilippine Carabao CenterBureau of Fisheries and Aquatic Resources2018

3b. NAG (DOA)

https://www.oie.int/amr2018/wp-content/uploads/2018/11/Part-1_-iAMResponsible-Philippines.pdf

https://www.oie.int/amr2018/wp-content/uploads/2018/11/Part-1_-iAMResponsible-Philippines.pdf



Core Elements of National AMS Program

1 LEADERSHIP

2 POLICIES GUIDELINES PATHWAYS

3 SURVEILLANCE

4 ACTION

5 EDUCATION

6 PERFORMANCE

EVALUATION





1 LEADERSHIP

AMS Program Leadership in Hospitals

Chief of Hospital

Medical Director

PTCPharmacy & Therapeutics

CommitteeAMSAntimicrobial Stewardship

Committee

IPCInfection Prevention &

Control Committee

AMS TeamAMS Clinician

AMS Clinical PharmacistExecutive

MicrobiologyLaboratory Department


⌂ Advocacy, capacity-building, infrastructure




AMS Team Roles & Responsibilities

AMS Team Roles & Responsibilities

AMS Clinician0.5 FTE* per hospitalInfectious Disease SpecialistAMS-trained

-which antimicrobials in formulary-leads AMS activities, guidelines-approves restricted antimicrobials-educates staff on proper use

AMS Clinical Pharmacist1 FTE:100 beds

-assists lead-enforces compliance-educates pharmacy staff-identifies cases for review-provide drug information (on dosing, interactions, adverse reactions)-evaluates prescribing behavior

Executive1 FTE per hospital

-provides administrative support-assists in monitoring AMS program-prepares reports


*FTE = full-time (employee) equivalent




Antimicrobial Use under AMS Program

RESTRICTED4th generation cephalosporins,aztreonam,carbapenems,colistin,vancomycin,linezolid,IV* antifungals (except fluconazole)

MONITORED3rd generation cephalosporins,fluoroquinolones,aminoglycosides,clindamycin

ALL OTHER

Pre-Authorization by IDS** or AMS Clinician

Audit and Feedback by AMS Team

Point-of-Care interventions:de-escalation

IV-to-PO*** switch(by AMS Team)

7th Day Automatic Stop

antimicrobials with rejected interventions

2 POLICIES GUIDELINES PATHWAYS


*IV = intravenous**infectious disease specialist***per orem (by mouth)

⌂Re-training, Organizational control




General Algorithm toward De-escalation


Clinical suspicion of infection

Orders (cultures if possible)

Initiation of empiric therapy

AP reviews 48-72 hours

Switch to narrow spectrum

Stop antimicrobialsContinue antimicrobials

De-escalation

Review by AMS Team/IDS

Microlabsends (+)

asap+ -

+ -

Re-evaluate evidence

⌂Quality Management System, rapid diagnostics




Antimicrobial Resistance Surveillance Program


3 SURVEILLANCE

Sentinel units upload daily via WHONET

per Clinical Laboratory Standards Institute (CLSI)

using MIC (Vitek and gradient E-test) and disk

diffusion

Research Institute of Tropical Medicine uses

whole genome sequencing

Department of HealthEpidemiology Bureau and

National Center for Disease Prevention and Control

AMS Team/Hospital disseminates local

monthly antibiogram among practitioners

⌂Laboratory Quality, Healthcare Software

ARSP reportable pathogens

Enterococcus faecium

E. Faecalis

Staphylococcus aureus

Methicillin-resistant S. aureaus

Streptococcus pneumoniae

Acinetobacter baumanii

Eschericia coli

Haemophilus influenzae

Klebsiella pneumoniae

Neisseria gonorrhoeae

Pseudomonas aeruginosa

Salmonella enterica

Non-typhoidal Salmonella

Shigella





⌂Human Resources, Training & Development, Information Communication Technology

https://arsp.com.ph/activities/ https://arsp.com.ph/activities/ https://arsp.com.ph/arsp-2018-annual-report-data-summary-is-now-available-for-download/

https://arsp.com.ph/activities/


https://arsp.com.ph/arsp-2018-annual-report-data-summary-is-now-available-for-download/




⌂Strategies: prevention, rapid diagnostics, new generics, innovations, repurposing, combinations

https://arsp.com.ph/activities/ https://arsp.com.ph/arsp-2018-annual-report-data-summary-is-now-available-for-download/






⌂ Strategies: prevention, rapid diagnostics, new generics, innovations, repurposing, combinations

https://arsp.com.ph/activities/ https://arsp.com.ph/arsp-2018-annual-report-data-summary-is-now-available-for-download/





Intervention against Inappropriate Use


4 ACTION

Reason for Inappropriateness Description

No infection Started/continued antimicrobial despite lack of signs, symptoms, or evidence (e.g., virus)

Wrong choice Based on guidelines

Wrong dose Specific patient characteristics

Wrong route Used IV when oral is possible

Wrong duration Used longer than in guideline

Intervention

Discontinue

Escalate/De-escalate

Optimize regimen

Switch

Discontinue

⌂ enforcement of administrative sanctions and criminal penalties



© 2018 National Center for Global Health and Medicine https://www.slideshare.net/phicna2005/doh-antimicrobial-stewardship-program-in-hospitals-manual-of-procedures-mop-2016

5 EDUCATION




Device: SteraMist (Beverly Hills, US) disinfectant for sterilization of health facility

Purpose: Expand to the Philippine market and then ASEAN through a Clinical Trial in San Lazaro Hospital which should determine effectivity against microorganisms in the TB ward and on Filipino healthcare workers before/after spraying (2018)

Strategy: PPP by approaching DOH

Results: To Be Discussed

AMR Research case (medical device)


Take Home

Messages

Unmet Needs Priorities in AMR

◆ Preventive therapies & devices.

◆ New generic drugs,

◆ Repurposing of medicines,

◆ Innovative combinations.

◆ Lower cost quality equipment,

◆ More rapid diagnostic kits,

◆ Medical software apps,

◆ Health data management apps.




NCGM Dept of International Trials Public Relations

Contact: [email protected]

For the Collaboration Request Form : http://ccs.ncgm.go.jp/050/050/index.html

Strategies

mailto:[email protected]

© 2018 National Center for Global Health and Medicine 30

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Documents

AMR Control in the Philippines · AMR Control in the Philippines NCGM Department of International Trials Dr. Anton アンㇳンVillanueva, Regional Manager