ISBN 978-4-909675-37-8

Contents

Preface ........................................................................................................................................................

02

Executive Summary ....................................................................................................................................

03

Opening ......................................................................................................................................................

04

I

05

National Action Plan on Antimicrobial Resistance in Japan .....................................
Kazuhiro Kamata M.D
Tuberculosis and Infectious Diseases Control Division, Health Service Bureau,
Ministry of Health, Labour and Welfare, Government of JapanII

The Actions of China in Containing Antimicrobial Resistance ................................. 10
Weiguo Zhu M.D.,CPHIMS
Vice Senior, Division of General Internal Medicine /Deputy Director, Department of Information Management General Internal Medicine,
Peking Union Medical College HospitalIII

AMR Situation in Vietnam .....................................................................................................

24

Dr. Truong Thien Phu
Head of Microbiology Department, Cho Ray Hospital
Dr. Nguyen Phuc Tien
The Department of Microbiology of Cho Ray HospitalIV

Anti-Microbial Resistance in India .....................................................................................

34

Dr. Thandavarayan Murali
Senior Assistant Professor, Pediatric Emergency Department
Institute of Child health and Hospital for Children
Dr. Thirumalaikumarasamy Sivaraman
Senior Assistant Professor, Pediatric Intensive Care
Institute of Child health and Hospital for Children

V

Anti-Microbial Resistance Situation in Egypt .................................................................

48

Dr. Yasser Kandeel
Head of Infection Control Department, Egyptian Ministry of Health and Population
Dr. Aly Shalaby
Lecturer and Clinical Lead for the SNICU / Pediatric Surgery Department
Cairo University Specialized Pediatric Hospital

VI

JICA’s Efforts on Responding to AMR ..............................................................................

57

Sangnim Lee, R.N., MPH
Health Advisor, Health Group 2, Human Development Department,
Japan International Cooperation Agency (JICA)

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

1

Preface

Health problems of great concern in the world today would include cancer, cerebrovasculardisease, and pneumonia. The issue of Antimicrobial Resistance (AMR) is currently considered
to be a small problem compared with these major health concerns. However, it is estimatedthat the number of people who die because of AMR will exceed the number of deaths fromcancer within the next few decades if we ignore the problem. AMR is an issue that requires
urgent action.
Moreover, it is not necessarily the developed countries that will see many people lose theirlives to AMR. Rather, it is predicted that the problem will be more serious in emerging anddeveloping countries. In these countries, standards of medical and health care are gradually
improving as their economies develop. However, AMR could place a substantial clinical burden
on medical facilities. The problem will become a major obstacle to medical treatment in eachcountry and hinder the development of medical facilities unless we address the problem now.
AMR is a global issue. In order to tackle it, each country needs to gather together and share
their knowledge and experience to find a resolution. However, each country’s efforts are notalways presented as papers or covered by the media. Therefore, it is extremely difficult for
us to obtain information on the efforts each country is making. Fortunately, however, we wereable to have an opportunity to discuss measures against AMR with people from the countries
that participated in JICA’s training course. We learned about the current AMR situation as
well as the initiatives in each country. This document is a report describing the information weshared at the workshop. The report will give you a clear understanding of how serious AMR isin the context of each country, and how these countries are studying and trying to deal withthe problem. In this sense, this report is an important document that is of academic value. I
hope that the workshop where participants of the training course shared their knowledge andexperience has served as the first step toward developing effective measures to combat AMR
in each country.

Norio Omagari

Director, Disease Control and Prevention Center,
National Center for Global Health and Medicine

2Executive Summary

Health care-associated infections (HCAI) and related deaths, together with increased costs
due to extended hospitalization and medical treatment, have become serious problems both indeveloped and developing countries.
In particular, antimicrobial resistance is one of the biggest threats to global health and foodsecurity. Antimicrobial resistance is rising to dangerously high levels in all parts of the world.
We have to tackle this problem with not only health professionals but also policy makers, thehealthcare industry and the agriculture sector.
Japan International Cooperation Agency (JICA) and National Center for Global Health andMedicine (NCGM) have conducted a Program for the Specialist of Healthcare-AssociatedInfection Control and Prevention since 2003 for the hospital administrators and the persons incharge of HCAI control in their respective institutions, as well as trainers for their staff regarding
HCAI control.
Participants shall have opportunities in Japan to understand the principles and practices of
HCAI control through a series of lectures, workshops and site visits, and moreover to formulate
an action plan to solve the problems related to HCAI control in their respective countries andhospitals.
Leveraging the opportunity of the program and WHO World Antibiotic Awareness Week
2016, JICA and NCGM organized Knowledge Co-creation Session "Sharing Experiences ofAntimicrobial Resistance."
As speakers, representatives from JICA, Ministry of Health, Labour and Welfare,
Government of Japan and participants of the abovementioned program from four countries(China, Vietnam, India and Egypt) made presentations on the Experiences of Antimicrobial
Resistance.
Lastly, we appreciate all participants and persons involved for their effort and collaboration
for this successful session and we hope that the session will nurture mutual collaboration
among participating countries and Japan by sharing knowledge and experiences in HCAI
control now and in the future.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

3

Opening
Coodinator

Moderator

Jun Moriyama

Norio Omagari

National Center for Global Health and Medicine

National Center for Global Health and Medicine

Bureau of International Health Cooperation,

Jun Moriyama: Ladies and gentlemen, now wewould like to start the Knowledge Co-Creation
Program and sharing experiences of antibiotic
resistance. I would like to welcome you all andthank you all for your presence. I am Jun Moriyama
from the Bureau of International Health Corporation.
First, let me introduce you all to the program. Thissession on antimicrobial resistance (AMR) is oneof the Japan International Cooperation Agency(JICA) programs for the specialists in healthcare
associated infection control and prevention. This is
the concept of our program.
This program aims to make action plan for
implementing more effective policies for infection
control and prevention in their own facilities.
In particular, antibiotic resistance is one of

Director, Disease Control and Prevention Center,the biggest threats to global health. It can affectanyone, of any age, and in any country. Tackling
the antibiotic resistance is high priority for us. We
have planned this session today as it is the World
Antibiotic Awareness Week.
Participants from China, Egypt, India, andVietnam will talk about their country’s current
situation and challenges against AMR. The speakerfrom Japan is in charge of AMR measures in the
Ministry of Health and JICA. Thereafter, we would
like to discuss about AMR measures.
Now, I would like to introduce Dr. Omagari,
Director, Disease Control and Prevention Center,
National Center for Global Health and Medicine.
Today, he is the chairman of the session.

Course Contents
Sharing the experiences and processes of HCAI Prevention and Control in Japan	
ImplemenBng  Partner:  NaBonal  Center  for  Global  Health  and  Medicine	Japanese  Health  System	

Universal  Health  Coverage,  Surveillance  ,  Tuberculosis,  Medical  Waste  Management.	
Principles  of  HCAI  PrevenBon  and  Control	Outsourcing  	・Clinical  Laboratory
・Medical  Waste  Management

・5S  Management
・Architectural  Engineering
・AnBmicrobial  Stewardship・Health  management  of  Healthcare  staﬀ
・  Surveillance

HCAI  PrevenBon  and  control  in  NCGM	AcBviBes  in  each  Department
・ InfecBon  Control  and            PrevenBon  ・ Pharmacy
・ Clinical  Laboratory
・ Central  Medical  Supply
・ Medical  Engineer
・ Radiology
・ AcBviBes  of  ICU,  ER  and            General  Ward	

Knowledge
Co-­‐creaBon

HCAI  PrevenBon  and  control    in  Yurin  Hospital(Mid-­‐size)	
・Experience  of  the  outbreak  in      Yurin  Hospital・Staﬀ  EducaBon  Regional  Network	
・ InfecBon  Control  Network  in              Nagasaki  Prefecture
・Experience  of  the  outbreak  in    
    Nagasaki  University  Hospital

Making Action Plan in your own country	
4

I

I

National Action Plan on Antimicrobial Resistance in Japan

National Action Plan on
Antimicrobial Resistance in Japan
Kazuhiro Kamata M.D
Tuberculosis and Infectious Diseases Control Division, Health Service Bureau,
Ministry of Health, Labour and Welfare, Government of Japan

Dr. Omagari: Thank you very much. Today, we
have six speakers and we have about 20 minutes
for their presentation.
I would like to introduce our first speaker, andour first speaker is Dr. Kamata from Japan. He
is actually from the tuberculosis and infectious
disease control division, Ministry of Health, Laborand Welfare. So Dr. Kamata please get to the
podium and start your presentation.
Thank you, Chairperson Dr.
Dr. Kamata:Omagari. I am from the Ministry of Health, Laborand Welfare, Government of Japan. Great honor
to have this opportunity to present Japanesechallenges to combat AMR. Today, I would like totalk mainly regarding two points: first, the current
status of antibiotic use and second, National Action
Plan in Japan, which was launched in April thisyear. In last May, Japan was host to G7 Summit in
Ise-Shima. For almost five years, AMR has been
discussed in the international meetings such as
World Health Organization and G7 Summit; in May
2015, the World Health Assembly endorsed the
Global Action Plan on AMR and asked all member
states to develop a relevant national action plan
within two years. But what is the problem and what
happened due to AMR?

Deaths  a2ributable  to  AMR
2013	
2050	

An#microbial	
  Resistance:	
  Tackling	
  a	
  crisis	  for	
  health	
  and	
  wealth	
  of	
  na#ons,	
  the	
  O’Neill	
  Commission,	
  UK,	  December	
  2014	

This is one report to answer this question. The
UK has estimated that deaths due to AMR reached
10 million worldwide by 2015, and gross domestic

product of $1,000 trillion will be lost if no measure
will be taken in the future, so AMR is a threat to
global health security.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

5

Human  An9bio9c  Use  per  Person  (2010)

Japan	

Reference:	
  Van	
  Boeckel	
  TP	
  et	
  al.,	
  Lancet  Infect  Dis.	
  2014;	
  14:	
  742-­‐50.	

Next, I talk about consumption. This slide
shows the total consumption of antibiotics in 2010.
The more color dark red, the more antibiotics are

consumed. According to this research, Japan isplaced in the middle or lower in the world.

An9bio9c  Use  Growth  Rate  from  2000  to  2010

Reference:	
  Van	
  Boeckel	
  TP	
  et	
  al.,	
  Lancet  Infect  Dis.	
  2014;	
  14:	
  742-­‐50.	

This is a trend indicating growth rate ofantibiotic usage from 2000 to 2010. Blue-coloredcountries have lower growth rate, and Japan’s
place in these blue-colored countries means

6decrease in growth rate of antibiotic usage from
2.5% to 4% in 10 years. Furthermore, this provides
the details of antibiotic consumption in Japan
compared with in European countries.

I

National Action Plan on Antimicrobial Resistance in Japan

  Comparison  of  An9bio9c  Use  (2012)  セファロスポリン、その他のβラクタム	
Cephalosporins,  other  beta-­‐lactams	

キノロン	
Quinolones	

Greece	  Romania	  Belgium	
  Cyprus	  France	  Luxembourg	  Italy	
  Ireland	
  Portugal	
  Malta	
  Iceland	  Croa#a	  Spain	
  United	  Kingdom	
  Slovakia	
  Poland	  Finland	  Bulgaria	
  Czech	
  Rep.	
  Norway	  Denmark	
  Lithuania	
  Germany	
  Slovenia	  Sweden	  Austria	  Hungary	
  Latvia	  Estonia	  Netherlands	  Japan	
  Macrolides,  others	
マクロライド等	Penicillins	
ペニシリン	

Others	
その他	

15.8	
0	
  

5	
  

10	
  

15	
  

20	
  

25	
  

30	
  

Average  Daily  An9bio9c  Consump9on  per  1,000  popula9on  	

Japan is shown at the bottom, with 15.8 (Defined
daily doses/1,000 inhabitants/day). Once again,
we can find that the total usage of antibiotics inJapan is lower. However, as you can see, Japan
has certain characteristics. The proportion isdifferent. Light blue area means that the usage of35	
  penicillin in Japan is smaller compared with othercountries, and the usage of oral antibiotics such as
cephalosporin, which is blue and colored red andgreen, is frequent in Japan. These trends are risky
situation to produce newly resistant bacteria as
well as for livestock.

An9bio9c  Use  for  Livestock  in  Japan6	

It shows the total amount of antimicrobial used
for livestock in Japan. It is decreasing in these
10 years because the Minister of Agriculture
implemented a new guideline for the prudent

use of antibiotics for veterinarians and farmers.
Moreover, they establish risk assessment for thesechemicals for human health in collaboration with
the Ministry of Health and food safety committee.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)7

6  Areas  and  Goals  of  AMR  Na9onal  Ac9on  Plan
Fields	 Goals	 1	  Public	
  Awareness	
  and	
  Educa#on	
  Improve	
  Public	
  Awareness	
  and	
  Understanding,	
  and	
  Promote	
  Educa#on	
  and	  Training	
  of	
  Professionals	 2	  Surveillance	
  and	  Monitoring	 Con#nuously	
  Monitor	
  An#microbial	
  Resistance	
  and	
  Use	  of	
  An#microbials,	
  and	  Appropriately	
  Understand	
  the	
  Signs	
  of	
  Change	  and	  Spread	
  of	
  An#microbial	
  Resistance	 3	  Infec#on	
  Preven#on	
  and	
  Control	
  	  Prevent	
  the	  Spread	
  of	
  An#microbial-­‐resistant	  Organisms	
  by	
  Implemen#ng	
  Appropriate	
  Infec#on	
  Preven#on	
  and	
  Control	
 4	
  Appropriate	
  Use	  of	
  An#microbials	
  	
 Promote	  Appropriate	
  Use	  of	
  An#microbials	
  in	
  the	
  Fields	
  of	
  Healthcare,	
  Livestock	
  Produc#on	
  and	  Aquaculture	
 5	
  Research	
  and	  Development	 Promote	  Research	
  on	
  An#microbial	
  Resistance	
  and	
  Foster	  Research	
  and	  Development	
  to	
  Secure	
  the	
  Means	  to	
  Prevent,	
  Diagnose	
  and	  Treat	  the	
  An#microbial-­‐resistant	  Infec#ons	
 6	  Interna#onal	
  Coopera#on	 Enhance	
  Global	
  Mul#disciplinary	  Countermeasures	
  against	
  An#microbial	
  Resistance	 Given these findings, the National Action Plan
on AMR was developed by a ministerial meeting
to promote countermeasures against AMR in
Japan. Our National Action Plan has a structurethat aims at six areas as you can see on thisslide. First is public awareness and education,
second is surveillance monitoring, third is infection
prevention and control, fourth is the appropriate

use of antimicrobials, and fifth is research anddevelopment. These fields, one to five are basicallythe same as in the WHO Global Action Plan in
2015; however, the last one, field six, international
cooperation is original in the Japan action plan
to fulfil Japan responsibility for international
cooperation.

Outcome  Indices  for  The  Ac9on  Plan 	
Propo9on  of  resistant  isolates  of  speciﬁc  indicator  microorganisms

Humans	

Indicator	

2014	

2020  (Target)	

Penicillin-­‐resistance	
  in	
  Streptocuccus  penumoniae	

48%	

15%	
  or	
  Less	Fluoroquinolone	
  resistance	
  in	
  Echerichia  coli	

45%	

25%	
  or	
  Less	

Methicillin	
  resistance	
  in	
  Staphylococcus  aureus	

51%	

20%	
  or	
  Less	carbapenem	
  resistance	
  in	
  Pseudomonas  aeruginosa	

17%	

10%	
  or	
  Less	

Carbapenem	
  resistant	  in	
  Escherichia  coli/Klebsiella  pneumoniae	

0.1-­‐0.2%	

0.2%	
  or	
  Less	  (same	
  level	
  as	
  of	
  2014)	

Animals

Tetracycline	
  resistance	
  in	
  Escherichia  coli	

45%	

33%	
  or	
  Less	

Third	
  genera#on	
  cephalosporin	
  resistance	  in	
  Escherichia  coli	

5%	

same	
  level	
  as	
  G7	

ﬂuoroquinolone	
  resistance	
  in	
  Escherichia  coli	

5%	

same	
  level	
  as	
  G7	

An9microbial  Use  for  humans    (average  amount  of  an9microbials  used  per  day  per  1,000  popula9on)
Indicator	

2014	

2020(Target)	

Total	

15.8	Decreased	
  by	
  33%	Oral	
  Cephalosporins,	
  Fluoroquinolones,	
  Macrolides	

11.6	

Decreased	
  by	
  50%	

Amount	
  of	
  intravenous	
  an#microbials	
  used	  1.2	

Decreased	
  by	
  20%	In the National Action Plan, we set a numeral
target in both fields of human and animals. We
know it is quite challenging, but we need to clearly8express the commitment to combat AMR. Afterthe National Action Plan was developed, we havetaken some action as you can see on this slide.

I

Ac9ons  taken• November	
  as	
  Japan	
  An#bio#c	
  Awareness	
  month	  –	
  Na#onal	  Council	
  on	
  Countermeasures	
  against	
  AMR	
  	
  	
  
on	
  November	
  1	
  
	
  
• Commigee	
  set	  up	
  for	  AMR	  in	
  MHLW	  • Mul#-­‐sectorial	
  commigee	
  being	
  set	
  up	
  	
  
	
  	
  	
  	
  for	  One-­‐Health	
  surveillance	
  	
  
	
  	
  	
  	
  with	  Ministry	
  of	
  the	  Environment	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Ministry	
  of	
  Agriculture,	  Forestry	
  and	
  Fisheries	  	
  • Guideline	
  being	
  developed	
  for	
  an#microbial	
  stewardship	
  National Action Plan on Antimicrobial Resistance in Japan

The World Antibiotic Awareness Week is held inthis week. In the last few slides, I will talk about thecurrent state of public awareness.

An#bio#cs	
  are	  not	
  eﬀec#ve	  	
  against	
  cold	  and	  ﬂu	
  ?	

This is Yahoo! Japan awareness survey thatshows antibiotics are effective or not effective
against cold and flu. Do you know this result or can

you imagine? Just over half of respondents gave
the correct answer that antibiotics are not effectivein these cases.

Do	
  you	
  know	
  AMR	  ?	

There is another question in the same Yahoo!
Japan awareness survey, “Do you know what isAMR?” Accordingly, 60% responded that they
don’t know or they know only the term AMR.
This is the current situation in Japan. AMR isa transboundary and cross-country global healthissue. Japan supports global countermeasures
adapted by WHO both at high level and root levels
and takes action to support the implementation of
the Global Action Plan on AMR.
This is the end of my presentation. Thank you
for your kind attention.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)9IIThe Actions of China
in Containing
Antimicrobial Resistance
Weiguo Zhu M.D.,CPHIMS
Vice Senior, Division of General Internal Medicine /Deputy Director, Department of Information Management General Internal Medicine,
Peking Union Medical College Hospital

Dr. Omagari: Now I would like to introduce oursecond speaker, second speaker is Dr. Zhu. He
is from China and he is a Vice Senior Division ofGeneral Internal Medicine and also Deputy Director
Department of Information Management, Peking
Union Medical College Hospital.

q Not specialized in AMR, but grab sth. to

In the U.S., it‘s easy to buy a gun,but hard to buy antibiotics,
but in China,
it was just the opposite.

share.
q Stands for no one else ,but my self!

There is one saying in the U.S.—it is easy to
buy a gun but difficult to buy antibiotics; in China,
it is just the opposite.
Peking Union Medical College Hospital

Peking Union Medical College Hospital

Good afternoon and thankDr. Zhu(China):
you JICA. It is my honor to be here giving a talk,and this is my title. I wish to clarify two points that
I am not specialized in AMR, but I actually got
something to share with you guys. Second one isbecause I do not ask for commission from hospital,
so here I will stand for nobody else but for myself.

1

How bad is it？

2

Where is the way out？

3

What am I expecting?

I will have three topics today, how bad is it andthen where is the way out, what I am expecting.
Peking Union Medical College Hospital

10

II

■■ How bad is it?
First, I would like to show our respect to thisyoung man; because of him, we know the exact
amount of antibiotics used in China through

The Actions of China in Containing Antimicrobial Resistancethe work they published in this article in theenvironmental science and technology.

The map indicates that every year, the total
usage of antibiotics is 162,000 tons per year. Thisis a map of the pollution around the river of China,
and here is the – the left side is the total amount,and the right side is per square meter or per
kilometer, it is the average amount.

Peking Union Medical College Hospital

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

11

Five antibiotics are commonly used in China
according to his research.
qAmoxicillinqFlorfenicolqLincomycin
qPenicillinqNorfloxacin

Peking Union Medical College Hospital

Peking Union Medical College Hospital

Peking Union Medical College Hospital

12

II

The Actions of China in Containing Antimicrobial Resistance

There is one saying, “no comparison, noharm.” We can see that in China, UK, and USA,the number of antibiotics used is about six times
compared with that in other countries such as U.S.
and Canada, about 149 unique gene mutations arecaused by resistance to antibiotics.

149

Peking Union Medical College Hospital

AMR CONTROL 2015

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

13

q The prevalence of MRSA in tertiary hospitals is approximately
50%q More than 80% of S. aureus, Streptococcus pneumoniae, andStreptococcus pyogenes were resistant to macrolides andclindamycinq Among Gram-negative bacteria, approximately 70% of
Escherichia coli isolates were resistant to ciprofloxacin andapproximately 60% were resistant to third-generation
cephalosporins.
q Carbapenem-resistance was seen in 20%– 35% of P. aeruginosaand in more than 50% of Acinetobacter baumannii.

Peking Union Medical College Hospital

AMR CONTROL 2015

It doesn’t matter, because pharmaceuticalcompanies will develop more new antibiotics.

We have MRSA and other issues, VRE or VRSP.
Someone says that it doesn’t matter because
pharmaceutical companies will develop more newantibiotics, but that is not true.
For pharmaceutical companies at the very
beginning, actually if we have 10,000 compound,

The worst thing is that no
more new kinds of antibiotics
have been developed

Peking Union Medical College Hospital

14

then to the next pre-clinical period it will be 250
components, and then when we move to clinical
trials, only five compound can be chosen and thenfinally only one, it takes about seven or eight years
to get one new kind of compound.

The worst thing is that no more new kinds ofantibiotics have been developed since 1987, which
is another threat.

II

In 2011, the Chinese government
began a three-year special campaign forrational antibiotic use centered on the

The Actions of China in Containing Antimicrobial Resistance

1. The roles, responsibilities and liabilities of healthadministrative authorities, medical institutions,
hospital task forces and all categories of healthcare professionals in detail.
2. Stewardship: to build professional teams,
implement staff training, and establish and improve“Administrative Regulations for theClinical Use of Antibiotics”.

the technological systems supporting rational
antibiotics use.
3. Indicators & Surveillance
4. Legal responsibilities
Peking Union Medical College Hospital

Peking Union Medical College Hospital

关于抗菌药物临床应用管理有关问题的通知
2009年3月23日（卫办医政发 〔 2009〕38号）

关于印发《全国抗菌药物联合整治工作方案》的通知
2010年12月15日（卫办医政发〔2010〕111号）

卫生部办公厅关于做好全国抗菌药物临床应用专项整治活动的通知2011年4月18日（卫办医政发〔2011〕56号

卫生部办公厅关于继续深入开展全国抗菌药物临床应用专项整治活动的通知

These are those outlines, translating toEnglish would be easier here, so those roles,
responsibilities, liabilities, and some facilities, andthe third one is indicators and surveillance, andfour is legal responsibilities.

2012年3月5日（卫办医政发〔2012〕32号）

抗菌药物临床应用管理办法
2012年4月24日（卫生部令第84号）

关于进一步开展全国抗菌药物临床应用专项整治活动的通知2013年5月6日（卫办医政发〔2013〕37号）

国家卫生计生委办公厅关于做好2014年抗菌药物临床应用管理工作的通知
国卫办医函〔2014〕300号

国家卫生计生委办公厅、国家中医药管理局办公室关于进一步加强抗菌药物临床应用管
理工作的通知国卫办医发〔2015〕42号■■ What is the way out?
Where is the way out? Like countries such
as Japan and other countries, the Chinese
government just began a three-year special
campaign for national antibiotic use centered on
the Ministry of Regulations for this clinical use ofantibiotics in 2011. These are all the regulations,actually it is not from 2011, but starting from– actually there was a SARS breakout at thattime, after that actually, so these are all thoseregulations.

Peking Union Medical College Hospital

1. 组织机构和职责
2. 抗菌药物临床应用管理
3. 监督管理
4. 法律责任

Peking Union Medical College Hospital

Here are some examples, these are theguidelines from the government regarding theantibiotics usage, which is published, and we takethat for example.

Peking Union Medical College Hospital

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

15

Special Abx

Restrictive Abx

Non-restrictive Abx

Peking Union Medical College Hospital

We classify antibiotics into three kinds of levels,and here nonrestrictive antibiotics. These kindsof antibiotics can be prescribed by resident or byattending every physician in the hospital, and thesecond one will be the restrictive antibiotics thatcan only be prescribed by attending – and those
who get the right after the examination of antibiotic

use test. The top one, the last one is special
antibiotics, for example, independent. Such kindsof antibiotics cannot be used freely and randomly.
They should be applied by clinicians and thenthere would be ID, infectious disease team on callto review those physician orders and then give thepermission to use that.

Peking Union Medical College Hospital

The advanced surveillance is one thing, but
the inspection is another important issue. The
government will send a team on inspection, we callthat fly check. This is an example of our hospital.

16

Actually we met with those teams nine times thewhole year. It comes from different labels, somefrom the government, some from local government,
some from MoH and surveillance.

II

The Actions of China in Containing Antimicrobial Resistance

AMR CONTROL 2015

Peking Union Medical College Hospitalq At the national level, the proportion of
outpatients receiving antibiotic prescriptions
dropped from 22% to 14.7% from 2010 to 2012.
q The proportion of inpatients receiving
antibiotics decreased from 68.9% to 54%,
antibiotic prophylaxis in surgical procedures
decreased from 95% to 44.6%, and combined

Actually things are changing for the better.
This is 2006 and then 2010, 2011, 2012, and an
inpatient or outpatient pays that prescription, theamount of that, and then it is decreased a lot.
These are our exact numbers, for example, theprescription of the outpatients regarding thoseusing antibiotics dropped from 22% to 14.7% up to
two years of the program and other numbers.

antibiotic treatment with two or more agentsdecreased from 37% to 30%.
Peking Union Medical College Hospital

AMR CONTROL 2015q550,000 square metersq54 clinical and related sub-specialties
qOver 4000 faculties, 600 professors andassociate professorsqOutpatient Visit: 17000 persons/day, 3.5
million /yearqInpatient Beds: 2000
Peking Union Medical College Hospital

Peking Union Medical College Hospital

Regarding our hospital, this hospital was
founded in 1921 by Rockefeller as a teaching
hospital of Peking Union Medical College. This is
our new building actually, and it ranks number one
among the best hospitals in China for continuously
about seven years.

This is a general information. We have 54
clinical departments and over 4,000 faculties and17,000 visits per day.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

17

Hospital infection control management model

Three level

Control HAI,
Assure Medical safety

Hospital
Infection
Management
Committee

Hospital Levell 监督 审查l 指导 咨询l 提供建议 完善体系
All Departmentsl 监督 检查l 培训 宣传

Office of
Hospital
Infectionl 走进临床 服务临床Part-time dept.
Infection
Management
Staff

This is the Infection Control Committee, this is
the hospital level, and then the office. I am gladthat I am one of the members in the group, andother members come from the office of medical
affairs, from the pharmaceutical department, fromnursing, from the labs, and from the IT department;
I am from general internal medicine and also IT
department.

The Departmentl 执行 落实l 督促 检查l 发现问题 解决问题

Peking Union Medical College HospitalIn our hospital, usually, we will have theframework of the management infrastructure.

Peking Union Medical College Hospital

These are our rules about environment use, andhere is about the hand washing.

Handwashingn Hand hygiene-Self Examn Hand hygiene- Hospital Exam

Peking Union Medical College HospitalThis is the self-reporting result of hand washingrate, and here is the supervising or just checkingof those result, and there is a gap you see that.

18

Here you see 98%, but this is 85%, there is a gap
between self-reporting and supervising.

II

Peking Union Medical College Hospital

The Actions of China in Containing Antimicrobial ResistancePeking Union Medical College Hospital

Another thing we do is prescription review for
antibiotic prescription. I mean the hospital willusually once a month or once a week will review

those antibiotic prescriptions to reveal what is the
optimal usage and what is not optimal. This is asystem to support that.

Things are changing too.
门诊患者
主要控制指标
住院患者
抗菌药物处方比（2013年全部达标） 抗菌药物使用率%例%I类切口手术
预防使用
抗菌药物比例%

抗菌药物
使用强度

要求控制指标

≤60%

≤20%

≤30%

≤40

2011年6月

55.84%

8.60%

62.23%

37.68

2012年6月

44.44%

5.65%

41.51%

41.65

2013年6月

36.20%

2.79%

21.48%

33.48

2014年6月

37.30%

2.80%

24.30%

38.10

2015年6月

35.55%

2.58%

23.02%

36.70

2010年 5月我院医院感染现患率为6.67% （抗菌药物专项整治活动前）
2012年12月我院医院感染现患率为6.66% （抗菌药物专项整治活动后）
2013年12月我院医院感染现患率为6.33%
2015年管理目标：
2014年 5月我院医院感染现患率为5.66%
保持达标 避免反弹
2015年 5月我院医院感染现患率为5.16%
内涵管理 规范合理
整体处于平稳水平，符合国家<10%的要求。

Peking Union Medical College HospitalThings are changing too-MDRq MDR Measures：q Isolation CPOEq Isolation post/tagq Ward or Bedq Hand sanitizer beside the bedq Reserved thermometer,
stethoscope, sphygmomanometerq Ward Round or Procedure at lastn 2015 is stepping down, even comparing to 2014n Mostly ESBL(+) E Coli., MRSCoN、PDR-ABA

Peking Union Medical College HospitalThings are changing. This is the year, forexample, here is the inpatient antibiotic user rate,
the percentage just dropped down from 55% to35.5%, and it has dropped for MTR too, and these
are the measures we took.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

19

for example, quinolones are antibiotics that areused very often, too often in animals, so the soil,
the earth is contaminated, and next one domestic
and international cooperation will be there.

Peking Union Medical College Hospitalq Within the hospital: Team workq Hospital & Pharmaceutical Companyq Healthcare providers to human & animalsq Domestic & Internationalq Involve IT staffs in your infection control teamq Be generous to invest in IT, including software,
hardware and personnel, productive

Peking Union Medical College Hospital■■ What am I expecting?
What I am expecting and also challenging is
my own opinion just like advocate, AMR cannot bedone only by healthcare workers like us, it should
be in cooperation from various fields such aspolicymakers, farmers, vegetarians, patients, andhere I would like to say cooperation is number one
expectation.
Even though in hospital, we will cooperate as ateam against this AMR, and then second one will
be in the hospital and the pharmaceutical company
because they want to sell more medications
antibiotics, that is in conflict actually.
And then the third one healthcare providers
to humans and animals, though there are not somuch research just we talk about that, but in China,

20q Integrate system in your workflow instead of
adding extra work to physicians or nursesq Data flow out of your system instead of being
collectedq ……
Peking Union Medical College Hospital

And number two, IT, I hope that IT canempower the work we are doing. In China, actually
there is one item in the policy. The hospital should
use IT to improve the optimal use as written in
here. From my own experience, I would like to givesome suggestions. First, involve IT staff in yourinfection control team if possible, and second, be
generous to investing in IT, including software,
hardware, and personnel. Sometimes it will be
more productive than adding ___.

II

Third, integrate system in your workflow insteadof adding extra work to physicians or nurses.
For example, we just write down for the first time
and then ask them to input that to the system thesecond time, that is not what we want to do. Fourthis data because these days I am hearing too many

The Actions of China in Containing Antimicrobial Resistancetypes of data are connecting, but my opinion isa little bit different, data should flow out of yoursystem instead of being connected. It takes time.
Third, I hope the map to become whole green in
the map. Thank you.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

21

Q&A
Dr. Omagari: Thank you very much. Anycomments or questions?

Dr. Zhu (China): Yes, you cannot buy that
actually, except the over the counters.

JICA: How do you see the progress of yourinnovative to control the use of the antimicrobials inyour hospital?

Male Speaker 2: How can I motivate the people?
They can buy if they think that they are sufferingfrom fever.

Dr. Zhu (China): Thank you for your question.
Actually, it is a comment actually I think –teamwork is very important, including not only
physicians, nurses, and office but also other kindsof pharmaceutical members and labs and lab
technicians, and also the awareness, I do not talkabout that because Monday I talked about how
training and awareness of such kind of a serious
problem is very important. You cannot solve a
problem without seeing it first, so that is very
important, and the second one is the system.
Actually, because I am not a specialized AMR
doctor, and before I came here, I just went to theoffice to see the person in charge, and I asked
questions about what are those three strong points
we do in our hospital. Her answer just shocked me.
She said IT. IT not only connects data but helps
physicians, nurses, and other staffs to do theirwork, not only the efficient but also the feedback isa surveillance and that is my own feeling about theopinion. Thank you.

Male Speaker 3: I think it is a national countermeasure to do that actually. In China or in any
other country, I think that there should be a policy
to guarantee that if the store or the physician justgives the antibiotics, not optimal, so they will bepunished by the government or by some officials.

Dr. Nahid (Bangladesh): I am Dr. Nahid from
Bangladesh. I will question not only you but allof you from other countries expect Bangladesh.
In your country, is it possible to buy an antibiotic
without prescription as in our country?
Dr. Zhu (China): Maybe I can clear first andthen the rest. Maybe you noticed that I used theword “was” in the second slide. Remember that“was” in China is the same thing actually and not
your situation, but after we realized that problem
with the government just – there is a ban to saythat no antibiotic can be bought from the drug
store without a prescription. Nowadays, it is very
restrictive. I think that policymakers can do that.
Male Speaker 1: Any rule from physician – anyrule to combat this problem, is there any rule?

22

Ms. Pem Zam (Bhutan): I want to share the drug
experiences. We are very new – it is a very new
subject, AMR, and then this has been some otherproblem in the department of medical services, but
as our friend from Bangladesh said, like especiallyin Bhutan it is very unique because we do nothave private practices, and we have a handful ofpharmacy shops, but then since we have a verystrong regulatory office called drug and regulation,
they have a mandate and none of these private
pharmacies are allowed to sell antibiotic, except
few multivitamins or maybe some painkillers but
not the antibiotic at all. Thank you.
Dr. Sivaraman (India): My name is Dr. Sivaraman.
I am from India. I have a comment to make. As
she said, legislation is going to bring down thisOver the counters and we can have legislation tostop selling antibiotics without a prescription, but
it is very difficult to monitor this in a huge country
like India, which has a huge population and many
medical shops; it is not humanly possible for thecontrolling authority to monitor this. One thing ispublic awareness.
You can increase awareness among peopleof all this communication and through gadgets,you can spread this awareness that antibiotic
is not a panacea for disease. Antibiotic is notan equivalent treatment for fever, the thing is
to increase awareness among population that
antibiotic is not for everything. Second thing
is no amount of legislation or punishment isgoing to change people. The thing is you haveto change the attitude of the people by giving

IImore information about why it should not be
used, what are the effects on future generation;these are the important points in reducing AMR,
and it is not going to happen overnight. It needssustained effort from all the stakeholders, from thegovernment, medical personnel, pharmacy, andall the people involved in combating AMR, then

The Actions of China in Containing Antimicrobial Resistanceonly we can see a visible change in few years or
down the line, so this is the most important point as
Dr. Nahid has indicated. Unless they change andunless people’s attitude change, you cannot makea change in the Over the counters preparation orOver the counters selling of antibiotics. Thank you.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

23

III

AMR Situation in Vietnam
Dr. Truong Thien Phu
Head of Microbiology Department, Cho Ray Hospital

Dr. Nguyen Phuc Tien
The Department of Microbiology of Cho Ray Hospital

Dr. Omagari: I would like to invite our third
speaker. He is from Vietnam; Dr. Phu, and he is
the head of the Department of Microbiology of Cho
Ray Hospital in Vietnam, it belongs to the Ministryof Health of Vietnam.
REPORT  OF  ANTIBIOTIC  USAGE  AND  RESISTANCE  IN  15  HOSPITALS  FROM  2008-­‐2009

BACTERIA  FROM  15  HOSPITALS  2009
Samples:	
  -­‐Blood	  -­‐Spinal	
  ﬂuid	  -­‐Sputum	  -­‐Pus	  -­‐Urine	
  
	
  

24

Dr. Phu (Viet Nam): Thank you very much Dr.
Omagari. I will just share some experiences about
the situation of AMR in Vietnam.

First, I want to introduce the study of Ministry of
Health in 2008 to 2009 because I don’t have thenew data, only 2008, 2009, because they havesupport from Sweden; until now they don’t have thefunds to do, they collect the data from 15 hospitals
from the north to the south of Vietnam, eighthospitals in the north, three hospitals in the middle,
and four hospitals in the south. My hospital is Cho
Ray hospital.

III

AMR Situation in Vietnam

BACTERIA  FROM  15  HOSPITALS  IN  2009This is the data of the bacteria from 15 hospitals
and sample from blood, spinal fluid, sputum post,
and five most common bacteria are Acinetobacter,E. coli, and Klebsiella, Pseudomonas, andStaphylococcus aureus.

ANTIBIOTIC  RESISTANCE  OF  COMMON  BACTERIA

We conducted survey in the north, in the
middle, and in the south of Vietnam, about many
bacteria, and about the antimicrobial system,
red is Pseudomonas, and green Acinetobacter,purple is Klebsiella, and blue is E. coli, and thisis cephalosporin and this is third generation
cephalosporin, this is a Aminoglycoside andfluoroquinolones and you see almost they resist
over 30% just carbapenem

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

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ANTIBIOTIC  RESISTANT  OF  S.AUREUS

ANTIBIOTIC  RESISTANT  OF  K.PNEUMONIAE

ANTIBIOTIC  RESISTANT  OF  E.COLI

About resistance of Staphylococcus aureus,
and this is the resistance, and this is the name ofthe hospital, and this is my hospital. The resistant26

staphylococcus aureus and oxacillin is about 20%.
And about resistant of Klebsiella pneumoniae,
in my hospital also resist with ceftriaxone orIIIcotrimoxazole, but sensitive with imipenem – andantibiotic resistance of E. coli and also resist withcotrimoxazole. Pseudomonas resistance is about

AMR Situation in Vietnam

40% of ceftazidime and ciprofloxacin and 20% for
imipenem.

ANTIBIOTIC  RESISTANT  OF  ACINETOBACTER  SPP.

Acinetobacter is resistant to ceftazidime,
ciprofloxacin, gentamycin, and imipenem over
50%, and the data is different between hospital.

ESBL  (+)  OF  E.COLI  AND  KLEBSIELLA  SP.

At that time, I think the data is not very confident
because we don’t use the machine to identify or
make sensitivity; about ESBL, 49% of E. coli and
58% of Klebsiella.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

27

Distribution of bacteria of Cho Ray in 2015
Bacteria 2015 (n = 13.526)
9.2%

A. baumannii
20.5%
E. coli

13.5%

S. aureus

14.3%

19.2%

K. pneumoniae
P. aeruginosa

This is the data of my hospital in 2015. I think
we are confident with the data because now we
use the machine to identify the bacteria and makedrug sensitivity; in 2015, we isolate about 13,526
bacteria, and almost done this Acinetobacterbaumannii 20.5%, and the second one is E. coli,
19.2%, and the third is Staphylococcus aureus
14.3%, and the fourth is Klebsiella pneumoniae
13.5%, and 9.2% for Pseudomonas.

Antibiotic resistant of A. baumannii%R A. baumannii 2015 (n=2.772)
100	
  
90	
  
80	
  
70	
  
60	
  
50	
  
40	
  
30	
  
20	
  
10	
  
0	
  

28

III

AMR Situation in Vietnam

Antibiotic resistant of E. coli
%R E. coli 2015 (n=2.596) ESBL 50%
90	
  
80	
  
70	
  
60	
  
50	
  
40	
  
30	
  
20	
  
10	
  
0	
  

Antibiotic resistant of S. aureus%R S.aureus 2015 (n=1.930)
100	
  
90	
  
80	
  
70	
  
60	
  
50	
  
40	
  
30	
  
20	
  
10	
  
0	
  

Antibiotic resistant of K. pneumoniae80	
  %R K. pneumoniae 2015 (n=1.824) ESBL
53%

70	
  
60	
  
50	
  
40	
  
30	
  
20	
  
10	
  
0	
  

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

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Antibiotic resistant of P. aeruginosa
R% P. aeruginosa 2015 (n=1.237)
100	
  
90	
  
80	
  
70	
  
60	
  
50	
  
40	
  
30	
  
20	
  
10	
  
0	
  

30

About antibiotic resistance Acinetobacter in
2007, 172 of Acinetobacter, they resist with almost
the antibiotic with colistin and rifampicin. About
E. coli, our resistant with antibiotics, and sensitive
with imipenem, meropenem, and tigecycline.
Staphylococcus aureus also resist with many
antibiotics, but we have many antibiotics to use forstaphylococcus aureus. And about K. pneumoniae
also resistance is high, especially is ertapenem,
meropenem, and imipenem significantly increasedin this year, year-by-year if compared with 2008
or 2009, now our resistance is over 30%. About
Pseudomonas aeruginosa, the resistance is over
30% for almost all antibiotic and just 2% for colistin.

Problems

Anti-resistance strategies• Easy	  to	
  buy	
  anLbioLc	
  in	
  pharmacy	
  (w/o	  prescripLon).	
  • Unsuitable	
  using	  anLbioLc	
  in	
  argiculture.	
  • Using	  anLbioLc	
  for	
  children	
  with	  mild	  respiratory	
  infecLon.	
  • Unsuitable	
  using	  prevenLve	
  anLbioLc	
  in	
  surgery.	
  • Overload	
  of	
  hospital	
  and	
  old	
  infrastructure.	
  • Lack	  of	
  ﬁnancial.	
  § Repairing	
  infrastructure	
  and	
  anL-­‐overload.	
  § Training	
  in	
  the	
  use	  of	
  anLbioLcs	
  in	
  hospitals	
  § Risk	
  straLﬁcaLon	
  § AnLbioLc	
  Usage	
  guidelines	
  (base	  on	
  microbiological	
  
data	
  of	
  hospital)	
  § PrevenLve	
  anLbioLcs	
  in	
  surgery	
  § Monthly	
  mulL	
  resistant	
  bacteria	
  report	  § The	  monthly	
  report	
  of	
  hospital	
  infecLons	  § Comment	
  medical	
  record	
  use	  of	
  anLbioLcs	
  § Maintaining	
  handwashing	  	  § IsolaLon,	
  infecLon	
  control	
  in	  hospital

The problem of my country I think is, like China
before, easy to buy the antibiotic in a pharmacy
without prescription; although the Ministry of Healthhave a law, it is very easy to buy.
It is unsuitable to use antibiotic in agriculture,
for children with mild respiratory infection, and as
prevention antibiotic in surgery; every surgery they
use antibiotic, and the most problem I think is a lotof the hospital and all infrastructure, and so like thefinancials to make the survey.

I think the strategy for anti-resistant to repairing
the infrastructure and anti-overload and training
in the years of antibiotic in hospital, researchstratification, antibiotic usage guidelines basedon the microbiological data of hospital, preventive
antibiotic in surgery and mostly multiresistantbacteria report, monthly reports of hospital
infections and comment medical record use ofantibiotic, maintaining the hand washing andisolation infection control in hospital.

III

AMR Situation in Vietnam

Step  1:  System  change    	
  

Hand	
  saniLzers	
  available	
  at	
  the	  point	
  of	
  care	  for	
  staﬀ,	
  paLents	
  and	  their	
  family	
  	
  	
  	
  

Access	  to	
  safe,	  conLnuous	
  water	  supply,	
  soap	  and	
  towels	  In the infection control department, we have astrategy to solve a problem. First system change,
set hand sanitizer available at the point of care ofstaff, patient and their family, and access to safe,
continuous water supply, soap and towels, andtraining.

Step  2:  Training  and  EducaSon  The hand wash education for nurse and doctor
through the machine, check microbes in hand
before and after practicing of washing hand.

Check	  microbes	
  in	
  hand	  before	
  and	
  a_er	
  pracLcing	
  of	
  washing	
  hand	  	
  Onsite	  lecture	
  and	
  pracLce	
  	
  	
  

Step  3:  ObservaSon  and  feedback    
	
  

Hand	
  Hygiene	
  compliance	
  is	
  measured,	
  reported	
  and	  moLvated	  Observation and feedback, and they go to visit
to work and to see how the nurse maintain hygieneand hand hygiene compliance is measured,reported, and motivated.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

31

Step  4:  Reminders  in  the  workplace	
  Variety	
  of	
  posters,	
  pamphlets,	
  sLckers,	
  gi_s..	
  	
  Step four is reminders at the workplace. We
have many panel for our hand wash and increase
washed hand, and don’t let the bacteria grow up.

Step  5:  InsStuSonal  safety  climate	
  
	
  
	
  	
  	
  

	
  
Asia  Paciﬁc  Hand  Hygiene  Award  2013

AcLviLes	
  of	
  hand	  hygiene	
  compeLLon	
  ceremonies	
  Step five we have some contest about infection
control.

Hand  Hygiene  Program  since  2007    Success  Hand hygiene compliance gradually increased
90

Overall

77.8
79.2
77.6

80

Doctors
Nurses

70
60
50
40
30
20

20.5
22.6
16.3

31.2
33.2
28.6

36.8
37.2
32.4

45.6
47.2
41.2

56.7
59.2
54.3

Overall HAI rate decreased significantly
12
10

10
0

8
2007

2008

2009

2010

2011

2012

6
4
2
0

Hospitalacquired
infections

9.6
7.7

4.6

5.4
3.2

1.6
0.7
0.6
2007

2.1
1.1
0.8

Nosocomial
Pneumonia

7.6

6.5
5.2
3.1

5.6
3.5
2.7

4.7
3.2
2.3

Surgical Site
Infections

4.3
2.6
2.1

1
0.9
0.8
0.8
0.6
0.5
0.5
0.4
0.3
0.3
0.3
0.2
0.1
0
0
2008 2009 2010 2011 2012

CatheterrelatedUrinary
Tract
Infections

They got Asia Pacific Hand Hygiene Award
2013. Thank you very much for your time.

32

III

AMR Situation in Vietnam

Q&A
Dr. Omagari: Thank you very much. Do you haveany comments or questions?
Dr. Sivaraman (India): Thank you for the nicepresentation. My question is there is unusually highnumber of Acinetobacter in every department, andmost of them are MDR, I can see only colistin issensitive to it. You get Acinetobacter everywhere,
and responding only to a very toxic drug, hope
they treat this and is there any environmental
reason for this? Acinetobacter everywhere not
only one department orthopedics, ICU, respiratory
ward, everywhere there is Acinetobacter, andmost of them are resistant organism. I think there
is something – there is a common source ofAcinetobacter, any comments about it?

Dr. Phu (Viet Nam): Yes, that is the problem of
my hospital. A lot of Acinetobacter baumannii, but
I think because of over load of my hospital, andsometimes two patients in one bed in many wards,
so we cannot solve the problem until we canisolate the case, and we also use the colistin in that
case.
Dr. Omagari: Any other questions or comments?
...Thank you. I have visited his hospital more thana couple of times and it is a very busy hospital,
big hospital. However, his hospital is the central
hospital in the south side of Vietnam, so sickpatients go down to his hospital, so that is why they
don’t have enough.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

33

IV

Anti-Microbial Resistancein India
Dr. Thandavarayan Murali

Senior Assistant Professor, Pediatric Emergency Department
Institute of Child health and Hospital for Children

Dr. Thirumalaikumarasamy Sivaraman

Senior Assistant Professor, Pediatric Intensive Care
Institute of Child health and Hospital for Children

Dr. Omagari: Our fourth speaker is from India, Dr.
Murali. He is a senior assistant professor and alsoin pediatric emergency medicine from the Instituteof Child Health and Hospital for Children.
Dr. Murali: Good afternoon to everyone. I would
like to thank JICA for giving us an opportunity toparticipate in this program and to make us to work
effectively than before. Thank you very much. As
usual, it is not my formal presentation. I thought
it is between our member. It is just a simple
presentation. I will try to do my best.

AnEmicrobial	
  Resistance	
  in	
  India	
  
	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  Major  public  health  problem
	  Important	
  concern	
  for	  the	
  public	
  health	
  authoriEes	
  at	
  global	  level	  	  InfecEous	
  disease	
  burden	
  is	
  high	  	  Inappropriate	
  and	
  irraEonal	
  use	  of	
  anEmicrobial	
  agents	
  
	
  
Over	
  the	
  Counter	
  availability	
  and	  	
  self	
  medicaEon	
  by	
  paEents	  AMR in India is a major public health problem. It
is not only in India, it is a global problem, what weare facing now, it is almost like a world war, may
be antibiotic world war we have to fight. Definitely,
we have to win. It should be a multidisciplinary
approach, and the burden of the infectious disease34

is very high in India, and we have inappropriate andirrational use of anti-microbial agent, not only by
the doctors, it is by the patient, most common they
have self-medication and the drugs are getting overcounter, and overcrowding in the hospital.
	  Overcrowding	  in	
  Hospital	
  
	
  
Lack	
  of	
  isolaEon	
  faciliEes	
  for	
  paEents	
  with	  MDRO	
  
	
  
	
  
Burden	  of	
  poor	  sanitaEon	
  and	
  malnutriEon	
  exacerbates	
  these	  condiEons	
  
	
  
	
  AnEbioEcs	
  are	
  used	  widely	
  in	
  food	  animals	
  as	
  growth	  promoters	
  and	  to	
  prevent	
  and	
  treat	  infecEon.	
  	
  One bed, two patients, is it possible, I don’tknow, we have maybe 30 bed, we have 140
patients sometimes in epidemic, so we find it very
difficult, but usually one bed for one patient only,
others have to lie down. So this overcrowding in
hospital causes multiresistant organism. Lackof isolation facility for patient with multiresistantorganism and burden of poor sanitation andmalnutrition exaggerate this condition. Antibiotics
are widely used in animal husbandry as a growthpromoter. This is now a burden for us to haveantimicrobial resistant and even multidrug resistantorganism.

IV

These are the factors contributing to the AMR,
among which the environmental factor is moredangerous because we are most concerned about
our patient factor, drug-related factor, and ourdoctor factor, but what about the environmental
factors? Environmental factors are now going to
be a very major contribution along with this patient
factor. We have to focus on this in managing thisAMR.

Factors	
  contribuEng	
  to	
  AMR	
  Environment  factors

Prescrip6on  relatedAMR
Pa6ent  factors

Anti-Microbial Resistance in India

Drug  related  factorIndian	  Scenario	
  An6bio6c  Consump6on/Billion  SU-­‐2010

US	
  

7	
  

China	  10	
  India	
  

13	
  

0	
  

2	
  

4	
  

6	
  

8	
  

10	
  

12	
  

14	
  

AnEbioEc	
  ConsumpEon/Billion	
  SU	
  

This is the Indian scenario. The largest
consumption of antibiotic has been compared withthe countries; India, China, and the U.S. where theyfound that India is consuming around 13 billion
standard unit of antibiotic in 2010 strategy where

it is alarming. As my colleague Dr. Shivraman
from India has said, antibiotic is not antipyretic,that is what we as pediatrician believe and we will
not give antibiotic as an initial treatment for any
fever case, but this is very alarming, and it is now
pushing to the death end.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

35

This is on the article on antibiotic misuse. You
can see that 53% of patient use antibiotic without
prescription, so it is available over counter and
18% save unused antibiotic for later, so theyusually take it for two days, after it improves thenif they come for next visit, we will ask, have you
taken for five days, no doctor, it has improvedby two days why should I take it for five days, so
now this contributes to the 18%, 47% will change
doctor if we don’t prescribe antibiotic. Now thatis what our Bangladesh friend is asking, if I am
not giving antibiotic what this person will do, we
better leave the person, let him go to some otherplace that will be the better option. Further, 25%of physicians give antibiotic to children with any
fever, so that is what they think it is antipyretic,
23% among this it is too less antibiotic unit in suchcases. We have seen many cases who come to

our OPD by practice where they will give antibiotic,
for example, ceftriaxone, and injection gentamicin
for URI, one-day fever, cold and cough, what
happened, these people go to the other doctor andasks for suggestion, should I have to continue thisantibiotic for five days, and the other person will
say who told to give all this injection for this simple
URI, then that fellow will stop that also. We arecontributing now toward major cost for antibiotic
resistance.
Further, 25% of physicians advice patients todiscontinue antibiotic once they are better, an
important cause of AMR. The problem in India is
we don’t have sufficient data or surveillance toknow much about AMR, maybe it is limited to somepart, some place, but we are not even fully entered
even in a government setup.

USE  &  ABUSE

This is the antibiotic use and abuse in India. So
you can see that the antibiotics have been used
for long years, so as our friend Dr. Zhu said, theAnEbioEc	
  resistance	
  in	
  India	  36

antibiotic consumption has also reduced, I won’t
make my China to become totally green, but it isallowing us – the consumption is totally increasing
throughout.
With regard to antibiotic resistance in India,
1 million Indian child die in the first four weeks.
Among these – majority of them died due to sepsis
and septic shock, about 30% of these kids die due
to antibiotic resistance.

IV

Furthermore, 30 years discovery of theantibiotic, so we have antibiotic from a long time,
but now we don’t have any newer antibiotic to fightagainst these antimicrobial resistant or multidrug
resistant organism, it is very difficult. We havearound more than 600 new drugs, around 617 new

Anti-Microbial Resistance in India

drugs, but only 15 drugs are known to act against
in a different mechanism what the usually drug
act, so now we are pushed toward a pre-antibiotic
era where you will not have any antibiotic for evena minor illness where it may lead to increased
mortality.

This is a study as carbapenem antibiotic now
become resistant, it is increasing throughout theyear in Indian setup.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

37

Way	
  Forward	
  ?	
  
	
  
	
  Develop	
  and	
  strengthen	
  anEmicrobial	
  policy	  	
  Standard	
  treatment	
  guidelines	  	
  NaEonal	
  plan	
  for	  containment	
  of	
  AMR	  	
  Research	
  related	
  to	
  AMR	  at	
  community	
  and	  hospital	
  level	  	
  So these are some of the studies, we have few
data collection in India where they didn’t study insome part, you can see that only very few places
being concentrated; Delhi, Kolkata, Lucknow,
Puducherry, Nagpur, CMC Vellore, these are all
the good center with good lab support and they
have good computer session and also have agood IT set of people where they collect data andtell what is happening every day and every month.
Here you can see these datas where the organism
has now been, metallo-beta-lactamase is a neworganism, New Delhi metallo-beta-lactamase. It is
resistant to all antibiotics, there is an antibiotic forsuch organism. So, we are now pushing toward
multidrug resistant organism. This is the rate, forexample, you can take Puducherry, you can seethat Klebsiella pneumonia; 93.55% multidrug
resistant and ESBL producer, now we are pushingtoward dangerous zone.

• 	  AnEmicrobial	
  use	
  and	  resistance	
  in	
  ﬁve	
  pilot	  sites	  in	
  India	  (Delhi,	
  Mumbai,	
  Vellore)	
  	
  showed	
  very	
  high	  AMR	
  rates	
  to	
  cotrimoxazole	
  and	  amoxycillin	
  (>70%	
  for	
  H.inﬂuenzae)	
  J	
  Nat	
  Sci	
  Biol	  Med.	
  2013	
  Jul-­‐Dec;	
  4(2):	
  286–291	
  Antibiotic is other study, antimicrobial use andresistant in five pilot study in India; Delhi, Mumbai,
and Vellore showed very high antimicrobial
resistant rate to normal antibiotic more than 70%
for H. influenzae.

38

So, way forward to develop and strengthen
antimicrobial policy, standard of treatment
guidelines, national plan for containment
antimicrobial resistant, and you must have research
related to antimicrobial resistant at community andhospital levels.

          This is our hospital, my working place in thepediatric emergency department, and my chief isabout to intubate that child, to be proud. My chief
Dr. Indumathi santhanam has been trained here
in JICA one year back for a two-month training
in administrative issues. Now we are working as
though we are working in Japan, so there has
been a modification now even in our own personal
behavior and discipline, including that of thedoctor and the staff nurse.

IV

Anti-Microbial Resistance in India

AMR-­‐	
  Our	
  Hospital	  Blood  Culture=1947

346,  18%

1601,  82%Total  number  of  isolates      We have a large volume of cases every day,so this is our antimicrobial resistant data. There isa blood culture, positive cases are around 346,

TOTAL  number  of      Nega6ve  culture

18% for blood culture positivity and among this the
Staphylococcus aureus.

Blood	  Culture	
  Culture  Posi6ve
140	
  
121	
  
120	
  

109	
  

100	
  
80	
  

66	
  

60	
  
40	
  
22	
  
20	
  

No	
  of	
  Isolates	
  

19	
  
4	
  

4	
  

1	
  

0	
  

You can see the Staphylococcus aureus being
the top most and next is the Klebsiella and E. coli.
It is around 35%. It is sensitive 82% for amikacin,
and it is a multidrug resistant – sensitive to

Staphylococcus	
  aureus	
  	
  was	  the	  	
  predominant	
  isolate	  (35%)	  	
  Amikacin	
  (82%)	
  is	
  the	
  most	  	
  eﬀecEve	
  drugs	
  	
  
	
  
MDR:	
  Vancomycin	
  sensiEve	
  
was	
  	
  48%	  &	
  resistant	
  was	
  found	  to	
  be	
  45%	  	
  vancomycin sensitivity was 48%, and resistant now
was found to be 45%. We may not have yet a drug
to treat even this condition.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

39

PUS  &  OTHER  BODY  FLUIDS	
  
	
  
	
  	
  
67,  28%

171,  72%

Total  number  of  isolates      -­‐    Staph	
  aureus	
  	
  was	  the	  predominant	
  isolates	  (53%)  	  Amikacin	
  (76%)	
  was	  the	
  most	
  eﬀecEve	
  drug	  against	
  Staph	  	
  aureus	  	  	  MDR	
  :Vancomycin	
  37%	  isolates	
  are	
  sensiEve	
  and	  resistance.	
  Total  number  of  culture  Nega6ve

Next, the total number of isolate culture
positive is 177 in percent, other body fluids, butstaphylococcal organism will predominate 53%,

and the multidrug resistant for vancomycin is now
30% isolative or sensitive and it is also resistant.

Pus	
  and	  Other	
  Fluid	
  Culture	  NO  of  Posi6vity=248

17,  10%

Staph.aureus  7,  4% 6,  4% 1,  1%

16,  9%Klebsiella  pneumoneae  91,  53%
33,  19%

Coaggulase  nega6ve    Staphylococcus  speciesEsch.coli
Pseudomonas  sp    Streptococcus  sp
Proteus  sp  These are various organisms.

CSF	
  ANALYSIS-­‐247	
  
4,	
  2%	
  

Total  number  of  isolates    243,	
  98%	
  40

Total  number  of  culture  Nega6ve

IVAnti-Microbial Resistance in India

CSF	
  ANALYSIS	
      ISOLATES-­‐4

1,  25%1,  25%1,  25%1,  25%

Klebsiella	
  sp	
  	
  	
  
Acinetobacter	
  	
  sp	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  
E	
  coli	  	  	
  Staphy	  aureus	
  	
  	
  	
  

CSF analysis, we have done for 247 cases
among which the total number of isolate is fourand it is equally distributed one Klebsiella,

Acinetobacter, E. coli, and staphylococcal, till now
there is no multidrug resistant organism we haveisolated.

UTI	  SAMPLE-­‐1002	
  ISOLATES          n  =  364  
300	
  

250	
  

246	
  

200	
  

150	
  

ISOLATES	
  	
  	
  	
  	
  n	
  =	
  364	
  	
  

100	
  
55	
  
50	
  
19	
  
0	
  

Esch.coli	  	
  URINE  CULTURE	  	
  Klebsiella	
  sp	
  	
  

Enterococcus	
  sp	
  	
  

  	
  
	
  
Esc	
  coli	  	
  (65%)	
  was	  the	  predominant	
  	
  isolates	
  SensiEve	
  to	
  Amikacin,	
  the	
  most	  eﬀecEve	
  drug	  	  	  MDR:	
  27%	
  isolates	
  were	  sensiEve,	
  3%	
  MS	
  and	  0.8%	  resistance	
  to	
  Imipenem	
  

8	
  

6	
  

Pseudomonas	
  sp	
  	
  

Proteus	
  sp	
  	
  

The urine sample, the culture positive, the E.
coli being the top most, and it was a prominent
isolate sensitive amikacin, the most effective drug,and 25% isolate sensitive and 3% or medium
sensitive and 0.8% resistant to imipenem.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

41

Throat	  Swab	  5,  29%Total  number  of  isolates      -­‐  5
Total  number  of  culture  Nega6ve

12,  71%

Throat	  Swab	  1,  9%
2,  18%

Klebsiella  sp
Staph.aureus
2,  18%6,  55%

Beta  Hemoly6c  Streptococcus  gp
Pneumococci

The throat swab culture is a different organism.
Here also the most common organism is the betahemolytic streptococcal.

Conclude	  Staph  aureus,  Klebsiella  sp,E  coli  -­‐Common
  56%  of  these  isolates  were  sensi6ve  to  Amikacin  &  ﬂuroquinolones.  
  MDR(24%)-­‐Mul6drug  resistance    to  rou6nely  used  an6bio6cs  such  as  Ampicillin,  Gentamicin,  Amikacin,  Cefotaxime  &  Ciproﬂoxacin
  All  these  MDR  isolates    were  sensi6ve  to  Imipenem,Tigecycline,Colis6n  and  Piptaz	
  42

To conclude my hospital report, Staphylococcus
aureus, Klebsiella, and E. coli are common.
Further, 56% of the isolate sensitive to amikacin
and fluoroquinolones, and the multidrug resistant
24% were routinely used antibiotic such as
ampicillin, gentamicin, amikacin, cefotaxime
and ciprofloxacin, and all this MDR isolates are
sensitive to now at present at least to imipenem,
tigecycline, colistin and piptaz.

IV

Anti-Microbial Resistance in India	
  STATERGIES	  • The	
  Indian	
  Council	
  of	
  Medical	
  Research	
  (ICMR),	
  New	
  Delhi	  • India,	
  has	
  launched	
  the	  AnE	
  Microbial	
  Resistance	  Surveillance	  and	
  Research	
  Network	  (AMRSN)	
  across	
  the	
  country	  in	
  2013	  • Development	
  of	
  an	
  eﬀecEve	
  InfecEon	
  PrevenEon	
  and	
  Control	
  Program-­‐	
  ICC,ICT.	
  • Hand-­‐hygiene	
  and	
  Standard	  PrecauEons	  • AnEmicrobial	
  Stewardship	
  Program	  • MulEdisciplinary	  Approach	  • EducaEonal	
  Programs	
  and	  Strategies	
  

Now we have a national policy. It was first
formed in 2011, now it has been revised, andfor the appropriate use of antimicrobial infectiondisease control program, the government program,
now it has revised for 2016, so it tells about youruse of antimicrobial in a normal situation and also in
drug resistant situations, and we have the initiativeby Indian Council of Medical Research, New Delhi,
it has launched the resistant surveillance andresearch network across the country in 2013.

NaEonal	
  Guidelines	
  Strategies, development of an effective
infectious, preventive and controlled program,so that is what we have come here to learn how
to make it as an effective team leader and to
make it as efficient program and to make ourplan success, to take action plan to have a good
infectious control committee and infectious control
team. Hand hygiene and standard precaution andantimicrobial stewardship program and have amultidisciplinary approach. A single person cannot
do, I think we need a multidisciplinary approachand education program and strategies.

Recommended	
  measures	
  to	
  control	
  spread	  of	
  MulE-­‐drug	
  resistant	  organisms	
  (MDRO)	
  
	
  
	
  i.	
  Improved	
  laboratory	
  detecEon	
  and	
  reporEng	
  of	
  MDR	  	  
	
  ii.	
  Enhanced	
  infecEon	
  surveillance	
  and	  control	
  in	
  ICUs	  	  	  iii.	
  Prevent	
  spread	  by	
  barrier	
  precauEons	
  :	
  Gown	
  and	
  gloves	
  	
  
	
  
iv.	
  Hand	  Washing	
  
	
  	
  
v.	
  Restricted	
  use	  of	
  3rd	
  generaEon	
  cephalosporins	
  and	
  second	
  line	  drugs	
  
	
  	
  

• NoEﬁcaEon	
  • Prophylaxis	
  including	  ImmunizaEon	
  • EﬀecEve	
  IsolaEon	
  • Proper	
  DisinfecEon	  • Data	  CollecEon,	
  Surveillance,	
  Audit	  • IncenEves	
  So, it is a national recommendation to split
the control of multidrug resistant organism,
improve laboratory detection and reportingof mu l t i d ru g r e s i s t a n t , e n h a n c e i n f e c t i o u ssurveillance and control in ICU, prevent spreadby barrier precaution like gloves and gown, handwashing, restrict the use of third generation of
cephalosporins and second-line drugs. Now it has
been the common cause of resistant, inappropriate
use of third generation of cephalosporin for all thecondition.

Notification and prophylaxis including
immunization, effective isolation, proper
disinfection and data collection surveillance andauditing our data, and incentives if they do betterin their work.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

43

MULTI	  DRUG	  RESISTANT	  ORGANISM	
                                            ANTIBIOTICSSIORGANISM

FIRST	
  LINE	  SECOND	
  LINE	
  1	
  Methicillin-­‐	
  Resistant	
  S.	
  aureus	  (MRSA	
  Vancomycin	
  and	  Teicoplanin	  Linezolid.	
  Daptomycin	
  

2	
  

Vancomycin	
  Resistant	
  Enterococcus	
  (VRE)	
  	
  Linezolid	
  Tigecyclin	
  

3	
  

Extended	  Spectrum	  Βeta-­‐Lactamases	
  (ESBL)	
  Producing	
  Enterobacteriacea	  carbapenems	  (Ertapenem,	  Meropenem	
  and	
  Imipenem	
  Piperacillin–Tazobactam	
  and	
  Cefoperazone-­‐	  Sulbactam	
  

4	
  

Carbapenem-­‐	
  Resistant	  Polymyxins,	
  Enterobacteriaceae	
  (CRE)	
  	
   Egecycline	
  &	
  fosfomycin	
  ColisEn	  5	
  These are all the multidrug resistant organism;
methicillin resistant Staphylococcus aureus, wehave vancomycin resistant Enterococci, we haveextended spectrum beta-lactamase producing

Challenges  	  • Strengthening	
  of	
  Surveillance	
  Data	  • Standard	  OperaEng	
  Guidelines	  • Improvement	
  in	
  anEbioEc	
  prescripEon	
  pracEces	  • Over	  the	
  counter	
  sale	  of	
  anEbioEcs	
  • Poor	  sanitaEon,	
  endemic	
  infecEons,	
  malnutriEon	
  • Limited	
  public	
  awareness	
  and	
  government	
  commitment	  • Lack	  of	
  coordinaEon	
  and	
  fragmentaEon	
  of	
  eﬀort	  Disinfectant	  44

enterobacteriaceae and we have carbapenem
resistant enterobacteriaceae. This number is going
to increase if I am not stopping at this point, andwe may not have even this first line of drug aftersome years.

Challenges; strengthen our surveillancedata, and standard operation guideline,
improvement in antibiotic prescription practice
to avoid the over counter sale of antibiotic, toimprove our poor sanitation, epidemic infection
and malnutrition, limited public awareness andgovernment commitment, lack of coordination andfragmentation of effort.

Proper	  Hand	  washing	
  	
  

IV

Anti-Microbial Resistance in India

a universal precaution, wear glove whenever you
prepare any infusions or any procedure and to
training staff. My chief, we don’t have time to go
out for a coffee or to attend any audit meetingor similar because we are in emergency, so thetraining program start here itself, about anything
it can be done in our place, so the infrastructure
can be utilized wherever we are to make it as asufficient program.

BIO	
  MEDICAL	  WASTE	
  MANAGEMENT	  Training	
  Staﬀs	  Team	
  Concept	  Universal	
  precauEons	  These are some of the things if we can use,even I feel after attending three or four days, I felt
it is not related to very highly economic program,
this can be simply done with what we are routinely
doing in our work, if you do effectively our floor
cleaning and the wall cleaning and proper hygiene
technique. Usually in the class, today morning
our staff from – we had morning class session
where she told the most common task of organism,
multidrug resistant antibiotic resistant organism
will be around any wet area. So this is what - if I
go to my place, then I have to look all those things
how to prevent these organism to spreading fromone person to another from a common source. For
regularly cleaning our equipment – and the sterlium
can be used between patient-to-patient, and take

Biomedical waste management is now set up,
and the team concept, multidisciplinary approach,
not only the team concept in my hospital, I think
it is a global issue, you must have international
multidisciplinary approach to manage this situation.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

45

Parents	
  SaEsfacEon	
  NEW	
  JICA	  OPD	  AND	
  
EMERGENCY	  BLOCK,	
  ICH,CHENNAI	  Thank YouTHANK YOU
Patient satisfaction that is what we have comehere to learn. The first day I learned about what
is patient satisfaction. Usually we see it, but when
they stressed up on the patient satisfaction in my
JICA training, then I just recollected and I just put
the photo to show that we may have a good patientsatisfaction when they go. This kids have been
intubated on mechanical ventilator, there will be
under care of ICU, Dr. Shivaraman, and it will cometo us as follow.
This is total thing. How you can get this kind of
quality of neurological intact survival child, goodquality child is – main agenda now is going to be
our antimicrobial resistant organism, so we have tohandle, tackle this situation.

46

The last slide, it is very interesting for me,
it is donated by the JICA to Institute of Child
Health in Egmore. It is around 98 crore project.
It is exclusive for emergency department andoutpatient department. The thing is we have now
got more space, infrastructure, and we have asked
the government to give a manpower, yes, they saidokay, then we told that we need computer session
to all this rooms so that we can have a good datacollection and surveillance, yes, they said, okay,
and we asked for the additional manpower andthings, so it is all being accepted to make our
success – our program to be success. Thank youvery much for giving this opportunity. Thank you.

IV

Anti-Microbial Resistance in India

Q&A
Dr. Omagari: Thank you very much. Now thispresentation is open to comments and questions.
Dr. Sakurada: Thank you very much for the
nice presentation. At NCGM, we have a research
project in Nepal is the neighbor of India, and thepathologists in NCGM identify NDL, but I know
a number of people back and forth between two
countries, so that is a frequent movement of thepeople, and what about animal meat importationand exportation between the neighbors? This is myfirst question. Second question is, do you have any
international friend among some country means
Bangladesh, Nepal, and other countries?
Dr. Murali: There is some regulatory part for thesethings, but it is not as effective. It is still going on,
and that is why we are facing these type of issues.
Regarding the international disciplined approach,but we are now in a fetal phase or just newborn
where we need to have data collection and good
surveillance, so that we can come out and to be apart of multidisciplinary approach.
Male Speaker: Let me add to what Dr. Murali
said. Thanks for the excellent presentation.
Regarding first animal meat. As we all know that
there is an indiscriminate use of antibiotics inanimal veterinarians and in people even who
the animals to increase the weight, so that they
can make more profit, so that is a real issue, andregarding India, Nepal it is a follow spot. We don’t
need to have anything to move around India and
Nepal, so it is difficult, it is difficult to control.
For animals, there might be some quarantine orsomething, but it is not very strict, so there is astrong possibility of infection being transmitted
from Nepal. I have gone to Nepal and I know that
it is very easy to enter Nepal if you are Indian.
You need to have a passport, you just go, show
your ID card, you can enter Nepal, so that is areal issue, but especially in the northern part ofIndia. First, there might be an issue regardingtransmission of antimicrobial resistance. Second,
among SAARC countries, I am not sure because
SAARC is not very active nowadays due to various
issues. As you said, the first government policy
came out in 2011, so hardly five years back, sothat awareness and this came out 2011, and there
was again 2013 guidelines and 2016, but I am notsure about coordination among SAARC countries,
I am not sure about that. I don’t know about any
antimicrobial resistant network or some policy
amongst SAARC country, but there is definitely
a very good – it should be a very good initiative
because the pattern of infection is same andbecause the food they eat and cultural practices
are somewhat similar, so that is a point well taken
which will be represented to the government if wego back, but the other thing is antibiotic use inanimal, transmission to human and soil is probably
bigger, slightly different in different geographicallimits.
Dr. Sakurada: Thank you very much. I have one
more question to Dr. Zhu from China. Fifteen years
back, I visited the border area between China
and Myanmar, and China and Laos, and you
have so many neighbors, and actually the people
very easily cross the border. Daily people from
Myanmar visit China for shopping and if they suffer
serious disease, they visit the hospital in China
and admit. I have a similar question to you. Whatabout such quarantine or control over live animal
and cooked animal meat, including the poultry andhuman movement control.
Dr. Zhu (China): Thank you for the question.
Actually I am not the right person to answer
that, it should be officials. Actually I think that
it is restrictive to bring things through flight orsomething because they will check that. Manythings, many restrictions to check that actually. The
other one is about the communicable diseases, sousually when people come to China from airport,
and then you will get the temperature checked,
and then if he or she is admitted to the hospital, we
will report that to the hospital or to the government,
they will be in the network to surveillance that, somaybe that answers your question. I am not sure
about that. Okay, thank you.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

47

V

Anti-Microbial Resistance
Situation in Egypt
Dr. Yasser Kandeel

Head of Infection Control Department, Egyptian Ministry of Health and Population

Dr. Aly Shalaby

Lecturer and Clinical Lead for the SNICU / Pediatric Surgery Department
Cairo University Specialized Pediatric Hospital

Dr. Omagari: Our fifth Speaker is from Egypt,
Dr. Ali and he is a lecturer and clinical leadfor pediatric surgery department at the Cairo
University and also a specialized pediatric.

Outline•Ministry	
  of	
  Health:	
  •Cairo	
  University	  Specialized	
  Pediatric	  Hospital:	
  • Training	
   on	
   Infec&on	
   Control	
   Standard	
   and	   AMR	   for	  health	   Care	   providers	
   and	   medical	
   students	
   are	  con&nuously	
   conducted	
   in	
   Governmental	
   Health	
  Care	
  SeOngs.	
  • No	
  available	
  data	  on	
  public	
  awareness	
  campaigns	
  to	
  increase	
  awareness	
  on	
  AMR.	
  	
  – Awareness	  – Surveillance	  – AMR	
  reference	
  library	  – Use	  of	
  an&microbials	
  in	
  Egypt	  – Example:	
  Prevalence	
  of	
  MRSA	
  &	
  ESBL	  – Challenges	  – Na&onal	
  Plan	  to	
  combat	
  AMR	  – Background	
  on	
  Hospital	  – Situa&on	
  of	
  AMR	  at	  CUSPH	  • An&biograms	
  • SSI	
  audit	  	
  – Strategy	  of	
  control	
  of	
  AMR	  at	  CUSPH	  – Lessons	
  learned	  Ladies and gentlemen, it is a
Dr. Ali(Egypt):
great honor to be able to speak on behalf of Egypt
in this lovely meeting. My talk is going to be divided
into two sections. Dr. Kandeel is representing the
Ministry of Health, so I will talk about the Egyptian– the overall country status of AMR. Then, I willbe speaking about my own perspective from thehospital where I work and as a pediatric surgeon
in charge of neonatal surgery, I am going to be
speaking very specifically about children andsurgical problems.

48

Awareness  ■■ MOHThe general outline is in the Ministry of Health
we are going to talk about awareness in Egypt,
surveillance, our antimicrobial reference library, theuse of antibiotics, we will give you an example of astudy that was done, then our challenges and ournational plan. Regarding my hospital, I will just givea quick review about what it is about, and then our
antimicrobial resistance in the hospital in general,and our strategy, and we will have a little bit of aconclusion. In the Ministry of Health, generally wetrain all aspects of infection control and we have ahuge project that is going on of which Dr. Kandeel
is the Director, but we don’t have any awareness,
we don’t have any data on the level of publicawareness of antimicrobial resistance.

V

Anti-Microbial Resistance Situation in Egypt

Use	
  of	
  An&microbials	  	
  Surveillance• There	  is	
  surveillance	
  system	
  implemented	
  in	
  	
  
27	
  Governmental	
  hospitals.	
  	
  • There	
  is	
  monitoring	  system	
  for	
  an&bio&c	
  use	  	
  in	
  governmental	
  health	
  care	  facili&es.	
  • An&microbials	
  can	  be	
  sold	  without	
  prescrip&on	  • Standard	
  treatment	
  guidelines	
  available	
  only	  for	
  some	  speciali&es	
  in	
  some	  hospitals.	
  • Use	  of	
  an&bio&cs	
  is	
  monitored	
  in	
  humans	
  	
  	
  

We have about 450 hospitals throughout Egypt
surveying 90 million plus citizens. We currently
have active surveillance on 27 of these hospitals,
and every year we add 20 extra hospitals hoping
to be able to survey all 450. By 2017, we will have
47 hospitals under surveillance, and obviously wehave this monitoring system.

Like many of my colleagues, we have heardthat Over the counters antibiotics are easily
available, this is a huge problem, and we don’t
have standardized treatment guidelines. However,the use of antibiotics in human subjects is jointly
monitored between the Ministry of Health and theMinistry of Agriculture.

AMR  Reference  Laboratory  The  prevalence  rate  of    
MRSA  and  ESβLs  in  ICUs

• There	
  is	
  	
  a	
  Na&onal	
  Reference	  Laboratory	
  for	
  sensi&vity	
  tes&ng	  .	
  • Laboratory	
  quality	
  accredita&on	
  system	
  is	
  in	
  place	  • Par&cipates	
   in	
   External	
   Quality	
   Assessment	
   with	   WHO	  every	  6	  months	  • The	  Infec&on	
  Preven&on	
  and	
  Control	
  Department	  conducted	
  in	
  2013	  in	
  collabora&on	
  with	
  World	
  Health	
  Organiza&on	
  (WHO)	
  a	
  mul&	  cross	
  sec&onal	
  study	  aiming	
  to	
  determine	
  the	  prevalence	
  rate	  of	
  MRSA	  and	
  ESβLs	
  infec&ons	
  and	
  coloniza&on	
  in	
  20	
  ter&ary	
  ICUs	
  in	
  7	
  
Egyp&an	  governorates.	
  • Overall	  prevalence	
  of	
  MDROs:	
  23.2%	
  (N=2969).	
  • 757	
  pa&ents	
  (80.4%)	
  out	  of	
  941	
  pa&ents,	
  use	
  
one	
  or	
  more	  an&bio&cs.	
  We have a national reference laboratory forsensitivity testing, which at the current stateis actually duplicating results, so lots of tests
are sent locally at the local hospital where thepatients are, but they are also sent to the central
laboratory for testing for quality control, but as weare bringing in new automated and online systems
for recording data, we are going to be able to get
rid of this duplication and just have everything in acentralized database. We regularly participate with
the WHO in quality assessment.

I am assuming. I don’t know that the Ministry ofAgriculture is also monitoring the use of antibiotics,
but they monitor it in animals. Part of our joint
efforts with the WHO is this example study that wasdone in seven Egyptian governorates. Basically,
it found that the prevalence of multidrug resistantorganisms is just under 25%.

Challenges
1. Limited	
   na&onal	
   commitment	
   and	   poor	  intersectoral	
  coopera&on.	
  2. Limited	
  public	
  awareness.	
  3. Unauthorized	
  irra&onal	
  public	
  use	  of	
  an&bio&cs.	
  4. Shortage	
  of	
  competent	
  microbiology	
  laboratories.	
  5. Poor	
   surveillance	
   data	   on	
   an&bio&cs	
   use	   and	  resistance.	
  	
  Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)49

Na&onal  Plan  to  combat  AMR6. Inadequate	
   knowledge	
   of	
   health-­‐care	
   providers	  leading	
   to	
   improper	
   prescrip&on	
   and	   dispensing	
  prac&ces.	
  7. Lack	
   of	
   updated	
   treatment	
   guidelines	
   resul&ng	
   in	  the	
  inappropriate	
  prescrip&on	
  of	
  an&bio&cs.	
  8. Poor	
  infec&on	
  control	
  in	
  some	  healthcare	
  seOngs	
  specially	
  the	
  non	
  governorate	
  sector.	
  What are the challenges facing Egypt ingeneral? There is limited commitment. It is sucha big country, so many patients, and there wasn’ta very clear strategy in the past. There are lots ofdifferent sectors, the biggest of which is health andagriculture, and there isn’t much of cooperation
at this stage. Public awareness is limited. We are
not really sure and again like my colleagues were
saying if a doctor doesn’t prescribe antibiotics,
then they are not a good doctor, and some patients
don’t even bother to go to doctors, they can just go
to the pharmacy and pick up a couple of pills andantibiotics, not even a whole course of antibiotics.
There is shortage of the facility, so microbiology,
lab testing, and of course the overall surveillance.
Some of the healthcare providers themselves
aren’t aware of how big the problem is and theyneed to have that kind of training, and we needsolid written guidelines for this SOPs, and we
also have to take care of the bigger picture whichis the whole infection control issue. There is amassive problem again in the Ministry of Healththat is actually going to be centered in Egypt but
surveying all of Africa on infection control.

Na&onal  Plan  to  combat  AMR        Focus  area  1:  Mul&sectoral  coordina&on  and  commitment	  • Strengthen	
  commitment	
  from	  all	
  sectors	
  to	
  the	
  comprehensive	  plan	  on	
  an&bio&cs	
  resistance.	
  50

Focus  area  2:  Surveillance  and  laboratories  capaci&es	  • Strengthen	
  capacity	
  of	
  microbiology	
  laboratories	
  for	
  rapid	
  and	
  reliable	
  diagnos&c	
  tes&ng.	
  • 	
  Establish	
  and	
  maintain	
  an&bio&cs	
  resistance	  surveillance	
  systems.	
  	
  
• 	
  Establish	
  and	
  maintain	
  appropriate	
  systems	  to	
  monitor	
  an&bio&cs	
  use.	
  Na&onal  Plan  to  combat  AMRFocus  area  3:  Prudent  an&bio&cs  use  in  humans	
  • 3.1	
  Promote	
  op&mal	
  an&bio&cs	
  prescribing	
  and	
  use	  in	
  clinical	
  prac&ce.	
  • 3.2	
  Enforce	  prescrip&on-­‐only	
  use	  of	
  an&bio&cs.	
  Na&onal  Plan  to  combat    AMRFocus  area  4:  Infec&on  preven&on  and  control	
  • Strengthen	
  infec&on	
  control	
  prac&ces	
  and	
  processes	
  in	
  hospitals.	
  Focus  area  5:  Research	  • Facilitate	
  basic	
  research	
  on	
  an&bio&cs	
  resistance.	
  Our plan in the Ministry of Health is a five-pointplan. The first one is to strengthen multisecretarialcoordination between the various stakeholders
in the country. The second one is to make surethat the surveillance and the labs are there andlike I said, there is going to be this online systemthat is going to be gathering and pooling datafrom all over the country. The third point is toregulate the use of antibiotics in humans. It isa massive challenge because it is not easy tochange people’s psyche and culture. A lot of
stakeholders are involved. It is not just a matter ofgovernmental policy, there are also, for example,
the pharmaceutical companies that are making
a lot of money by being able to sell these Overthe counters, so we have to consider that if weV

are going to start regulating things. Enforcing aprescription only thing is actually the ideal goal,
but perhaps we might be able to find steps that area little bit closer to that and a little bit more realistic.
The last two points are to get better infection
control in all hospitals and basic research either incombating disease by trying to find new antibiotics
or anything that really will help infection control.

Hospital  Background• Cairo	
  University	  Specialised	
  Pediatric	  Hospital	  • Beds:	
  376	  • Special&es:	
  	
  – Surgery	
  – Pediatrics	  – Emergency	
  Medicine	  – Intensive	  Care	  • Doctors:	
  260	  • Nurses:	
  475	  • Co-­‐medical	
  personnel:	
  780	  ■■ CUSPH
Next is my hospital, the Cairo University
specialized pediatric hospital. It is a 376 bed
hospital that has also an additional 120 intensive
care beds divided in three intensive care units
and the neonatal surgical intensive care units. We
have got four intensive care units in the hospital.
We serve over 450,000 children per year with –from my perspective obviously as a surgeon wedo 14,000 surgeries per year in all the surgical
specialties, so I represent general surgery, but wealso have the cardiothoracic surgery, we have got
neurosurgery, and we have got orthopedic andneurology as well.

Anti-Microbial Resistance Situation in Egypt

Infec&on  Control  CommiVee•

Members:	
  

•

IC	
  Nurses:	
  2	
  

•

Infec&on	
  Control	
  Manual	
  (In	
  Arabic)	
  

•

IC	
  training	
  – Doctors	
  (3)	  – Nurses	
  (3)	
  – Microbiologist	
  (1)	  – Pharmacist	
  (1)	  

– Monitor	
  IC	
  	
  policies	  – Liaise	
  between	
  wards/	
  IC	
  Us/IC	
  commifee	  – Provide	  training	  – IC	
  and	
  An&bio&c	
  Stewardship	  – For	
  everyone	
  except	  Administrators	
  and	
  Pharmacists	  – By	
  Microbiology	
  team	  +	
  IC	
  nurse	  specialists	  We have 260 full-time doctors and just under
500 nurses complemented with just under 800
medical personnel. We have an infection control
committee, comprising – actually this is theteam, the committee is a larger university levelcommittee, so the team is three doctors, three
nurses, a microbiologist, and a pharmacist. Of
the two nurses, we have two dedicated infection
control nurses and their role is mainly to monitor the
infection control policies in the hospital and liaising
between the ward and the different incentive cares
and the team and to provide training for any of thestaff. We have an infection control manual written
in Arabic, obviously it is more accessible for a lotof the nurses. The doctors speak fluent English
because of their training in medicine, but a lot of
the nurses don’t speak English.
Within the infection control, we have theantibiotic stewardship program, of which I
represent the surgical specialties. The trainingrole of infection control team is basically foreverybody except the administrative staff andthe pharmaceutical staff, and it is done by the
microbiology department and the specialized
infection control nurse.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

51

Gram	
  nega&ve	
  organisms	
  	
  Blood	
  culture	  All	
  ICUs	  	
  1st	  January	  	  -­‐	
  	
  30	
  	
  June	  2015.	
    Klebsiella  (87)Pseudomonas    (61)Acinetobacter  (27)Augmen&n
Cefoxi&n

	
  	
  
	
  	
  

	
  	
  
	
  	
  

	
  	
  
	
  	
  

Ce]azidime
Ce]riaxone

	
  	
  
	
  	
  

	
  	
  
	
  	
  

	
  	
  
	
  	
  

Cefotaxime

	
  	
  

	
  	
  

	
  	
  

Cefepime

	
  	
  

	
  	
  

	
  	
  

13	
  (15%)	
  13	
  (15%)	
  
	
  	
  

9	
  (15%)	
  9	
  (15%)	
  
	
  	
  

3	
  (11%)	
  3	
  (11%)	
  
	
  	
  

Pip/  tazobactam  

	
  	
  

	
  	
  

	
  	
  

Gentamycin
Amikacin
Ciprofolxacin
Sulfa-­‐trimethop.

12	
  (14%)	
  13	
  (15%)	
  6	
  (7%)	
  
	
  	
  

30	
  (49%)	
  9	
  (15%)	
  24	
  (39%)	
  
	
  	
  

8	
  (30%)	
  3	
  (11%)	
  8	
  (30%)	
  
	
  	
  

	
  	
  

	
  	
  

	
  	
  

Imipenem
Meropenem
Cefoperazone/sulbctam

Polymyxin  B■■ AMR Situation at CUSPH
The issue in our hospital in terms of antimicrobial
resistance can be gleamed a little bit by the
antibiograms that the microbiology department
presents to us twice a year, for example, if we lookat the gram negative organisms in blood cultures inall the intensive care units, for example, we will findthat the ones that are highlighted in yellow, are theones for example, for Pseudomonas. The higher
sensitivity is only 49% for gentamicin and 39% for
ciprofloxacin. So, that is really bad.

Gram	
  posi&ve	
  organisms	
  	
  Blood	
  culture	  All	
  ICUs	  	
  1st	  January	  	  -­‐	
  	
  30	
  	
  June	  2015.	
    CONS  (196)

MRSA  (27)

Candida  (29)

Fox

	
  	
  

	
  	
  

	
  	
  

Vancomycin

	
  	
  

	
  	
  

	
  	
  

Clindamycin84	
  (43%)	
  12	
  (44%)	
  

	
  	
  

Doxycycline87	  (44%)	
  4	
  (15%)	
  

	
  	
  

Ciproﬂoxacin66	
  (34%)	
  5	
  (19%)	
  

	
  	
  

Amikacin70	
  (36%)	
  5	
  (19%)	
  

	
  	
  

Gentamycin29	
  (15%)	
  1	
  (4%)	
  

	
  	
  

Sulfa-­‐trimethop.

6	
  (3%)	
  

	
  	
  

	
  	
  

	
  	
  

	
  	
  

	
  	
  

erythromycin14	
  (7%)	
  1	
  (4%)	
  

	
  	
  

Teicoplanin32	
  (16%)	
  1	
  (4%)	
  

	
  	
  

GN  200

This is from January to June. This was thefirst half of the year last year, same timeframe but
gram positive organisms. Again, we find that thesensitivity of the antibiotics – the organisms to theantibiotics is also quite low. It doesn’t really changemuch in the second part of the year, so again gramnegative organisms and blood culture. The best
are highlighted in yellow. Again very low number of52

sensitivities, and the same thing for – sorry this is a
mistake in the title, it is gram positive organisms. I
had a lot more data but due to time constraints, we
can – the microbiology department breaks it down
by ICU and by other sources as well, I just chosethe blood culture as an example, but we have got
wound swabs, etc.

V

Anti-Microbial Resistance Situation in EgyptGram	
  nega&ve	
  organisms	
  	
  Blood	
  culture	  All	
  ICUs	  	
  1st	  July	  	  -­‐	  	
  31	  December	
  2015.	
    Klebsiella(108)

Pseudomonas  (38)

Acenito(30)

Augmen&n

	
  	
  

	
  	
  

	
  	
  

Cefoxi&n

	
  	
  

	
  	
  

	
  	
  

Ce]azidime

	
  	
  

	
  	
  

	
  	
  

Ce]riaxone

	
  	
  

	
  	
  

	
  	
  

Cefotaxime

	
  	
  

	
  	
  

	
  	
  

Cefepime

	
  	
  

	
  	
  

	
  	
  

Imipenem22	  (20%)	
  13	
  (34%)	
  11	
  (37%)	
  Meropenem19	
  (18%)	
  11	
  (29%)	
  7	
  (23%)	
  Cefoperazone/sulbctam

	
  	
  

	
  	
  

	
  	
  

Piprac/  tazobactam  TZP

	
  	
  

	
  	
  

	
  	
  

Gentamycin33	
  (13%)	
  7	
  (18%)	
  11	
  (37%)	
  Amikacin26	
  (24%)	
  12	
  (31%)	
  9	
  (30%)	
  Ciprofolxacin26	
  (24%)	
  13	
  (34%)	
  8	
  (27%)	
  

	
  	
  

	
  	
  

	
  	
  

Sulfa-­‐trimethop.

Gram	
  posi&ve	
  organisms	
  	
  Blood	
  culture	  All	
  ICUs	  	
  1st	  July	  	  -­‐	  	
  31	  December	
  2015.	
    CONS  (208)

Staph  aureus  (49)

Vancomycin208	
  (100%)	
  48	
  (98%)	
  Clindamycin96	
  (46%)	
  20	
  (41%)	
  Doxycycline72	  (35%)	
  15	
  (31%)	
  Ciproﬂoxacin72	
  (35%)	
  8	
  (16%)	
  Amikacin104	  (50%)	
  16	
  (33%)	
  Gentamycin28	
  (13%)	
  3	
  (6%)	
  Sulfa-­‐trimethop.

	
  	
  

	
  	
  

GN  200

	
  	
  

	
  	
  

erythromycin

	
  	
  

	
  	
  

Teicoplanin

	
  	
  

	
  	
  

Most  common  organisms  	
  Klebsiella	
  (6):	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  43%	  Pseudomonas	
  (3)	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  21%	  Acinetobacter	
  (2):	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  14%	
  Staph	
  aureus	  (2):	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  14%	  Most  common  organisms  	
  Pseudomonas	
  (7):	
  	
  	
  	
  	
  	
  30%	
  Klebsiella(6)	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  26%	  Acinetobacter=	
  E.coli	
  (2):	
  9%	
  Staph	
  aureus	  (2):	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  	
  9%	
  
	
  

Throughout 2015, the most common organisms
throughout the hospital either in the first half of theyear, which is the top bit or the second half of theyear is pretty much what we see; here we havegot Klebsiella pseudomonas, Acinetobacter titerwhich is what we have been hearing really fromeverybody, so I think we share a common problem.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)53

I put this for laughs and for cries as well. This isalmost a typical result we have from a swab of oneof the patients, and actually this is one of the good
ones where you have a tiny little S at the bottom
there and we are like, yes, we found an antibiotic
which you can use, but very often it is all R, R, R, R
and it is resistant and it is really quite depressive.
Coming from a specialty where I am working with

Outbreak?    
SNICU  SSI  Audit• This	
  audit	  was	  conducted	
  over	  one	
  week	  	  	
  • from	  	
  28/5/2016	
  	
  to	
  	
  4/6/2016	  • Collected	
  data	  taken	
  from	  all	
  SNICU	
  pa&ents:	  • Surgery	  (	  site,date,place,and	
  surgeon)	
  • Already	  	
  prescribed	
  an&bio&cs,	
  either	
  con&nued	
  or	
  changed	
  	
  
• Is	
  there	
  wound	
  infec&on	
  or	
  not?	
  	
  According	  to	
  “Global	  Surg”	  criteria.	
  • Wound	
  swab	  for	
  infected	
  wounds	
  and	  	
  C&S	  	
  results	  To highlight one of these things and again frommy surgical perspective, we had a huge number ofwound infections all of a sudden. Wound infections
in general, SSI on my neonatal surgical unit are a
problem, but they were never a problem like thisweek that we had, so we decided to just audit and
see what we were doing, and so over – just undera week’s period, we just collected data to try andfind out what the problem was. We put a very clear
criteria for defining a wound infection, and if you
have heard of the global surge projects have been
happening for the past few years.

54

children, a lot of the time we have drugs such as
colistin that aren’t even licensed for use in children
besides being toxic and generally they are notlicensed for use in children. We have to use them,and even more specifically, I am working withneonates, and some of them are preterm. We
are using them and we don’t really know what weare doing to these children, so it is quite a hugeproblem.

• Results:	
  
– 	
  	
  Of	
  15	
  postopera&ve	
  pa&ents,10	
  cases	
  had	
  SSI	
  (66%)	
  
– 6	
  of	
  these	  10	
  pa&ents	
  had	
  wound	
  dehiscence	
  (60%)	
  
– 	
  7	
  of	
  these	  10	
  pa&ents	
  had	
  Klebsiella	
  on	
  their	
  wound	
  swab	
  results	
  (70%)	
  
– 3	
  of	
  these	  10	
  pa&ents	
  showed	
  MDR	  on	  their	  sensi&vity	
  results	
  (30%)	
  Their latest project that is being analyzed now
was on actually surgical site infection, so they had
a very clear and nice bulleted definition what asurgical site infection was, so we went and did thisaudit and we found that 15 neonates, 10 of themhad a wound infection, if they didn’t have it at the
beginning of the audit, by the time we finishedauditing, they developed a wound infection, andso 60%. Seven of these were Klebsiella. Now we
wanted to know whether this was an outbreak ornot, but the results from the microbiology lab wereequivocal, so they couldn’t tell us whether this was
the exact same strain or not, but clearly there wasV

a problem. Around 30% of these 10 patients had
multidrug resistant organisms, they were multidrug
resistant.

• 8	
  pa&ents	
  were	  operated	
  in	
  majors	
  (53%)	
  – 5	
  developed	
  wound	
  infec&on	  (62.5%)	
  – 2	
  with	  infec&on	
  died	  (40%)	
  • 7	
  pa&ents	
  were	  operated	
  in	
  the	  ER	  (46%)	
  – 7	
  developed	
  wound	
  infec&on	  (100%)	
  – 1	
  died	  	  (14%)	  	
  Anti-Microbial Resistance Situation in Egypt

the MDR or the AMR is. Our control team meets with
the infection control committee at the university level
twice a year. We have monthly reports on surgicalsite infections and are saying yes, but again likeone of my colleagues was saying, it is an issue ofdata collection. We have some data collection in
the hospital, but we don’t have a very robust way
of collecting all the data, and my colleague from
China was saying it is really the IT that is going to
be able to help us make these decisions, if we pooleverything into a good centralized IT system.

• Awareness	
  campaigns	
  by	
  ICC	
  • An&bio&c	
  Stewardship	
  program	  We have lots of data analyzing this audit again.
It is just one of the things that were looking at,
was it for example, a theater-related issue. We
found that there wasn’t really any major difference
between whether they were operated in one theateror whether they were operated in the emergency
department.

Strategy  of  Control• Surveillance	
  system	  – Twice	
  yearly	
  an&biograms	  – Twice	
  yearly	
  ICC	  at	
  University	
  Level	  – Monthly	
  reports	
  on	
  SSIs	  • Yes,	
  but…	  We need to control this, it is more of an
awakening. We realize if there is a problem and oneof the first steps to solve a problem is to actuallyacknowledge that you have a problem. We haveour surveillance system. We have our antibiograms
happen twice a year to tell us what the magnitude of• An&bio&c	
  Protocol	
  for	  General	
  Surgery	
  (October	  2016)	
  • Repeated	
  audits	
  on	
  SNICU	  – SSI	
  – An&bio&c	
  usage/protocol	  We have awareness campaigns by infection
control committee. Like I said, there is an antibiotic
stewardship program, and we worked really hardover the summer to bring out some guidelines, andI was in charge of the surgical guidelines and I willshow them to you in the next slide. This protocol
was rolled out just in October last year. We havea research candidate who is on my unit on the
neonatal intensive care unit who is monitoring,so we did pre-antibiotic protocol audit to see
what the antibiotic usage was and for how longit was used, and post implementation of the newprotocol, we were going to correlate this of coursewith infections. Naturally, we need to do repeatedaudits for surgical site infection and the usage
protocol.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

55

This is the flowchart for both our prophylactic
guidelines and our treatment guidelines for thesurgical babies. It applies to all of the – we wanted
to keep it simple, so it applies to all the ages ofpediatric surgery. The only difference is when it
comes to neonatal surgery, I don’t know if you

56

can see the small print there, it is probably in yourhand out where it says that we can switch to oral
antibiotics, we don’t switch to oral antibiotics inneonates, we just keep them on IV antibiotics.
Thank you very much.

VI

VI

JICA’s efforts on responding to AMR

JICA’s Efforts on
Responding to AMR
Sangnim Lee, R.N., MPH
Health Advisor, Health Group 2, Human Development Department,
Japan International Cooperation Agency (JICA)

Dr. Omagari: I am inviting our sixth speaker from
JICA, Ms. Lee from the JICA Human Development
Department, and she will talk about a big projectproduced by JICA.

Ms. Lee (JICA): Thank you very much for yourkind introduction Dr. Omagari. Today, I am goingto give a presentation about JICA’s efforts on
responding to AMR.

This slide shows the world map snapshot of
JICA’s ongoing projects for infectious disease
control. A number of projects are conducted in theworld, but my presentation is about a project inVietnam. All participants and special participantsfrom Vietnam, nice to meet you all.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)57

SATREPS	
  Project	  for	  	
  “Determining	
  the	  Outbreak	
  Mechanisms	
  and	  Development	
  of	
  a	
  
Surveillance	  Model	  for	  Multi-­‐Drug	
  Resistant	  Bacteria.”	
  	
  
in	
  Vietnam	
  (Mar	  2012-­‐Mar	
  2017)	
  
Hanoi
Thai	
  BinhNha	
  TrangHo	
  Chi	
  MinhCan	
  Tho

SATREPS	
  (Science	
  and	
  Technology	
  Research	
  Partnership	
  for	
  Sustainable	
  Development)	
  
is	
  	
  a	
  collaboration	  scheme	
  between	
  JICA	  and	
  AMED/JST.

This project is called Determining the Outbreak
Mechanisms and Development of a Surveillance
Model for Multi-Drug Resistant Bacteria. This isa five-year project, and it has been implemented

under the collaboration scheme `SATREPS’
between JICA and Japanese agency called AMED
to promote international joint research.

Organization	
  of	
  the	
  project�
Joint	
  Coordinating	
  Committee	  (JCC)�

�sa�a  �ni���(PI)�

Functional	
  Working	
  Group�

Can  Tho  Univ.�

Institute  of  Public  Health  HCMC�

Binh  Dien  Wholesale  Market  Com.�

Human  Resource  Dev.  
WG�Nha  Trang  Pasteur  Institute�

Anthropology  WG�

Thai  Binh  Univ.  of  Medicine  &  Pharmacy�Pharmacology  WG�

National  Institute  of  Nutrition�

Microbiology  WG��a�ional  Ins�i�u�e  o�  �u��i�ion�(PI)�

Regional  Modules�
4	
  This is an organization chart of the project,
there are project partners from Vietnam and Japan.
From Vietnamese side, there are five institutes anduniversities, and one wholesale market from theprivate sector. These are from Hanoi, Thai Binh,
Ho Chi Minh, Nha Trang and Can Tho. From theJapanese side, there are four universities and one
institute involved in this project, and the principal

58

institute of Japanese side is Osaka University.
Actually I wanted – Professor Yamamoto, the headof this research team of Osaka University, to givea presentation to all of you today, but unfortunately
he works in Osaka today. So, that is why I am
presenting in this way.
The Vietnamese team is led by the National
Institute of Nutrition based in Hanoi.

VI

JICA’s efforts on responding to AMRThe  Project  for  Determining  the  Outbreak  Mechanisms  and  Development  of  a  surveillance  Model  for  Multi�Drug  �esistant  �acteria  �����������������
�Project  Purpose���trengthening  research  capacit�  to  continuousl�  monitor  �M�  bacteria�

(collaboration	
  laboratory,	
  training	
  materials,	
  training,	
  support	
  and	  monitoring	  system,	
  etc.)

Community	
  awareness	
  raising	  	
  Developing	
  a	
  model	  of	
  monitoring	
  AMR/antibiotic	
  residues	
  in	
  foods	  Strengthening	
  research	
  network	  between	  	
  Viet	  Nam	
  and	  Japan	  (manual,	
  data	  archive,	
  training,	
  etc.)

(reduce	  AMR	
  bacteria	
  ,	
  avoid	
  antibiotics	
  abuse,	
  hand	  washing,	
  etc.)



5This project aims to strengthen research
capacity to continuously monitor AMR bacteria
by three main components. The first one isstrengthening the research network between

Vietnam and Japan. The second one is developinga model of monitoring AMR and antibiotic residues
in foods. The third one is community awarenessraising. It is a community intervention program.

【Research	
  outcomes】	
  Antimicrobial-­‐resistant	
  (AMR)	
  Bacteria	
  As	
  A	
  food-­‐related	
  Threat	  in	
  Vietnam	  	
  These are research outcomes. First, more than
60% of residents investigated are colonized with
AMR. It is named ESBL-producing bacteria thatis a target AMR bacteria. Second, more than 50%
of livestock and aquatic food investigated arecontaminated with AMR bacteria (ESBL-producing
bacteria). Third, residual antibiotics were found in
more than 10% of food investigated in Vietnam.
Forth, β -lactam and colistin are widely used in thecommunity.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)59

Prevalence	
  of	
  ESBL-­‐producing	  bacteria	
  in	
  healthy	
  people	  in	
  three	
  cities	
  in	
  Viet	  Nam

are identified by this research. Antibiotic residues
becomes selective pressure of AMR. That is very
important point.
ANTIBIOTICS	
  SUPPLY	  FOR	
  CHICKEN	
  AT	
  A	
  
RURAL	
  VETERINARY	  DRUG	  STORE	
  IN	
  LOCAL	  COMMUNITY	  SYSTEM

＊The	
   prevalence	
   rates	   of	
   ESBL-­‐producing	  E.coli	  in	
  healthy	
  residents	
  in	
  Vietnam	
  is	
  higher	  than	
  that	  in	
  Japan.�

Antibiotics	
  supplied	
  for	
  chicken	
  at	
  a	
  rural	
  veterinary	
  drug	  store	
  
	
  in	
  10	
  months	  	
 Ø More	  than	  half	
  of	
  frequency	
  is	
  combination	
  of	
  antibiotics.	
  Ø More	  than	  half	  of	
  supply	
  includes	
  Colistin.	
  ��

The prevalence of ESBL-producing bacteria
in healthy people investigated in three sites
in Vietnam was higher than that in Japan. The
Vietnamese sites include Hanoi, Thai Binh and Nha
Trang.

Prevalence	
  of	
  ESBL-­‐producing	  bacteria	
  in	
  foods	
  from	  four	  cities	
  in	
  Viet	  Nam	  

Chicken	
  meat	  is	
  more	  frequently	
  contaminated	
  by	
  ESBL-­‐producing	  E.coli.



The next slide shows the antibiotics supply
for chicken at the rural veterinary drug store in
the local community system. More than half of
frequency is the combination of antibiotics andmore than half of supply includes colistin. The useof colistin seems very easy at community level
although colistin is very essential antibiotics. It is
known that the use of colistin is a great risk forthe super bug, so colistin resistance is affected tohuman health.
10	
 Production/	
  Environment	  Wholesale	
  markets	
  Local	  markets	
  Consumers	  

I am mentioning the prevalence of ESBLproducing bacteria in foods from four cities inVietnam. Target food are pork, chicken, fish,and shrimp. Chicken meat is more frequently
contaminated by ESBL producing E. coli.

Antibiotic	
  residues	
  detected	
  in	
  food	  from	  four	  cities	  in	
  Viet	  Nam

About	  10	  percent	
  of	
  the	
  food	  of	
  livestock/ﬁshery	
  origin	
  contain	  residual	
  antibiotics.

Regarding antibiotic residues detected in foodinvestigated from four cities in Vietnam, about 10%of the investigated food of livestock/fishery origin
contained residual antibiotics. Food are alreadysupplied in the market, but still residual antibiotics

60



Both the project’s community intervention
and these important evidences suggest thatthe importance of understanding food chain in
relationship with healthy people with AMR; thefood chain from production level up to dining tableconsumers at home level, and how livestock andfishes contain antibiotics in local community.
In this summer, I visited one project site andwalked in the field. And then I found a big feedstuff
for pork which contains colistin 7%. It seems very
common of containing colistin in these feedstuff foranimals. This project team collected sample fromfood in Wholesale market and local markets. This
study helps to understand why AMR is identified forVI

JICA’s efforts on responding to AMR

Healthy people; such as relation that how people
wash hand properly or how to touch raw meat with
AMR or bacteria and how to cook foods. I want togive more information later.

A	
  food	  monitoring	  system	
  on	
  multi-­‐drug	
  resistant	
  bacteria/antibiotics	
  residues�
Responsible	
  institutions	  Ø National	
  Institute	
  of	
  Nutrition,	
  Hanoi	  Ø Pasteur	
  Institute,	
  Nha	  Trang	  Ø Institute	
  of	
  Public	
  Health,	
  HCMC	  	  * Quarterly	
  sampling	
  (4	
  times	  per	  a	
  year)	
  chicken,	
  pork,	
  ﬁsh	
  and	
  shrimp	
  from	  wholesale	
  markets,	
  supermarkets	
  and	  retail	  markets.	
  * Check	
  ESBL-­‐producing	  E.coli	
  and	
  antibiotic	
  residues	
  (ampicillin)	
  in	
  foods.	
  ���

Next, I am explaining about the developed
food monitoring system on multidrug resistantbacteria and antibiotic residues by this project.
The surveillance system of ESBL producing E.
coli and antibiotic residues, ampicillin, in food has

been established together with National Instituteof Nutrition, Pasteur Institute of Nha Trang andInstitute of Public Health, Ho Chi Minh city as amodel system. System is ready to expand a fullscale system.

Multi-­‐	
  drug	  resistant	
  bacteria	
  surveillance	
  modelØ Sampling	
  quaterlyØ Sample	
  preparation

Ø AnalysisØ ResultData	
  entering/	
  summarization

Laboratory	
  of	
  Microbiology

Laboratory	
  of	
  Chemistry

Manual	  and	
  worksheetsØ

ManualØ ChecklistØ Data sheets

Projects develop a monitoring system and also
developed monitoring manual. The project teamsummarized in the manual about how to sample,

how often, and how to prepare samples, how toanalyze, how to assess the data.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

61

Public	
  health	
  intervention	
  to	
  reduce	  risk	  factors	
  of	
  outbreak	
  and	
  spread	  of	
  antibiotic	
  resistant	
  bacteria	
  in	
  the	
  communityStudy site: Trai hamlet, Chu Minh comm., Ba Vi Dist., Hanoi* Population Bavi district: 265,000; Chu Minh commune: 7,918; Trai Hamlet: 1,000
people* Targeted population: 52 households* 1 commune health station* Period of intervention: Seven months, Aug. 2015 – Mar. 2016

This slide shows the public intervention to
reduce risk factors of outbreak and spread ofantibiotic resistant bacteria in the community. The
target area is Bavi district in Hanoi. The period of intervention was for seven months, because our
project team firstly conducted epidemiologicalmacrobiotics and pharmacological study and thenthey moved to this kind of community intervention.

Intervention	
  research	
  protocol	
  Risk factors
Epidemiology research

KAP researchCommunication Intervention
Plan

Pre/Post evaluation

This is intervention research protocol basedon epidemiological research. This community
intervention identifies the risk factors of community,
such as washing dish inappropriately and cooking
utensils, not using cutting board and knife

62

 

separately, improper handwashing, and usingchemicals/drugs for livestock and for human.
In community, it seems that people easily get
antibiotics without prescription at drugstores.

VI

JICA’s efforts on responding to AMR

Raising	
  awareness	
  of	
  the	
  community	
  through	
  direct	  communication	
  

Hand	
  washing	
  demonstration	
  	
  
for	
  adults. This team conducted KAP research and thencommunity intervention, and evaluated before andafter the interventions. The slide shows the photosof community intervention for raising community
aw a re n e s s t h r o u g h d i r e c t c o m m u n i c a t i o n ,promotion of the proper hygiene practice byutilizing outdoor and indoor posters. Project teamalso demonstrated a right hand washing practice.
For school pupils, they conducted contest aboutknowledge of antibiotic resistant bacteria and how
to wash hands properly. Public speaker systems incommunity were also utilized.

■■ Recommendations from the project togovernment of Vietnam to fight with AMRThis is the recommendation from the project tothe government of Vietnam to fight with AMR. The
wide spread of AMR as what I already explained
based on several researches is probably due
to inappropriate use of antibiotics in agri- andaqua-culture and due to unhygienic handling offood in markets and homes. Recommendations
are to expand the monitoring system, to expand
community interventions, and also to strengthenscientific research. These strongly suggest that`One Health approach’ is necessary in Vietnam,

especially urgent initiatives pertaining to theregulations of antibiotics usage in cooperation
with ministries concerned. It is not only matter of
Ministry of Health, it is also the matter of Ministryof Agriculture and Rural Developments, Ministry ofIndustries. It is intersectional issue. We consider
the relationship among human health, animal
health, food safety and environment. All thesefactors need to be considered to respond to AMR.

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)63�he  Pro�ect  �or  �etermining  the  �utbrea�  Mechanisms  and  �evelopment  o�  �          a  surveillance  Model  �or  Multi��rug  Resistant  Bacteria  ����������������
Science  and  Research  Technology  for  Sustainable  Development  (SATREPS)
Contribute  to  the  National  Action  Plan  to  Combat  AMR  in  Viet  Nam�Animal  Health  Sector�

People  Health  Sector�

Recommend  a  Model  o�  Monitoring  System  �or  Policy  Ma�ers�
Based  on  Scientiﬁc  Evidences�

Strengthening  research  capacity  to  continuously  monitor  AMR  bacteria  �

Developing	
  a	
  model	  of	
  monitoring	
  AMR/antibiotic	
  residues	
  in	
  foods	  Strengthening	
  research	
  network	  between	  	
  Viet	  Nam	
  and	  Japan	
  (collaboration	
  laboratory,	
  training	
  materials,	
  training,	
  support	
  and	  monitoring	  system,	
  etc.)

(manual,	
  data	  archive,	
  training,	
  etc.)



Community	
  awareness	
  raising	  	
  (reduce	  AMR	
  bacteria	
  ,	
  avoid	
  antibiotics	
  abuse,	
  hand	  washing,	
  etc.)

19At the beginning of my presentation, I mentionedthat the project purpose is strengthening research
capacity to continuously monitor AMR bacteria.
However, now this project can recommend themodel of monitoring system for policymakers
of Vietnam based on very important scientificevidences. Also, we are sure that these research

64findings can contribute to the National Action Plan
to combat AMR in Vietnam.
The significant research findings could be
utilized in these policy development. The project
members have had discussions with Ministries. So,
that is all of my presentation. Thank you for yourattention.

VI

JICA’s efforts on responding to AMR

Q&A
Dr. Omagari: Thank you for your presentation. Do you

we have so many common issues like crowdedness

have any comments or questions to this presentation?

of the hospital, lack of surveillance. And we need

Our colleagues from Bangladesh and Bhutan, if

a capacity building microbiology and laboratory,

possible, would you like to make a comment for this

there are common issues. But I have learned a lot

symposium?

of promising project or promising thoughts from this
symposium. Everybody was stressing the importanceDr. Anjuman (Bangladesh): First, it was our luck thatof changing the awareness, especially the community

we got an opportunity to come here. We would like tothat is quite important. They also mentioned about thethank you and JICA for allowing us to come here andcontribution of safety culture toward implementation

gather so much knowledge about infection preventionof the infection prevention control. I was actually

and about AMR bacteria, which is so useful and timely

surprised that so many of us – so many of you aresymposium. I am grateful to you all.

talking about the introduction of the IT system,
information technology to combat AMR. I personally

Dr. Omagari: Thank you. I would like to thank you all –will think about it in terms of how we can do introduce

all the participants and also speakers for participating

IT combat the AMR issue. I would like to close thisin this symposium. Actually, I have learned a lot myself

symposium. Thank you very much.

about the situation of the AMR in each country. We allknow that the issue of the AMR is global. However, theJun Moriyama:

issue of AMR is at the same time based on the context

We would like to close this session. Thank you all forfor each countries, we have different issues, different

your corporation.

Thank you very much Dr. Omagari.

problem, so we have to tackle them. Now we know that

Co-Knowledge Creation Session | Sharing Experiences of Antimicrobial Resistance (AMR)

65

Program for the Specialist of Healthcare-Associated Infection Control and Prevention
Knowledge Co-Creation Session “Sharing Experiences of Antimicrobial Resistance (AMR)”

National Action Plan on Antimicrobial Resistance in Japan
Kazuhiro Kamata M.D
Tuberculosis and Infectious Diseases Control Division, Health Service Bureau,
Ministry of Health, Labour and Welfare, Government of Japan
The Actions of China in Containing Antimicrobial Resistance
Weiguo Zhu M.D.,CPHIMS
Vice Senior, Division of General Internal Medicine /Deputy Director, Department of Information Management General Internal Medicine,
Peking Union Medical College Hospital
AMR Situation in Vietnam
Dr. Truong Thien Phu
Head of Microbiology Department, Cho Ray Hospital
Dr. Nguyen Phuc Tien
The Department of Microbiology of Cho Ray HospitalAnti-Microbial Resistance in India
Dr. Thandavarayan Murali
Senior Assistant Professor, Pediatric Emergency Department
Institute of Child health and Hospital for Children
Dr. Thirumalaikumarasamy Sivaraman
Senior Assistant Professor, Pediatric Intensive Care
Institute of Child health and Hospital for Children
Anti-Microbial Resistance Situation in Egypt
Dr. Yasser Kandeel
Head of Infection Control Department, Egyptian Ministry of Health and Population
Dr. Aly Shalaby
Lecturer and Clinical Lead for the SNICU / Pediatric Surgery Department
Cairo University Specialized Pediatric Hospital
JICA’s Efforts on Responding to AMR
Sangnim Lee, R.N., MPH
Health Advisor, Health Group 2, Human Development Department,
Japan International Cooperation Agency (JICA)

This report was prepared by:
Jun Moriyama
Shinsaku Sakurada

National Center for Global Health and Medicine, Japan
Bureau of International Health Cooperation
1-21-1 Toyama, Shinjuku, Tokyo 162-8655, Japan
Tel: 81-3-3202-7181 / Fax: 81-3-3205-7860
info@it.ncgm.go.jp
http://kyokuhp.ncgm.go.jp/
Issued in March, 2017
©National Center for Global Health and Medicine, Japan All rights reserved.