Changes before and after a policy to restrict antimicrobial usage in upper respiratory infections in Taiwan

Long-term effects of the global budget program and periodic price adjustment on antibacterial agents: A nationwide decomposition analysis between 2001 and 2016

BACKGROUND

Previous studies have shown that financial strategies are beneficial for improving the appropriate use of antibiotics within a limited period of time. Long-term effects have rarely been explored.

METHODS

This study evaluated the changes in expenditure and prescription patterns of antibacterial agents under the global budget (GB) program and drug price adjustment of a National Health Insurance scheme. Two structural methods, that is, the Laspeyres method and Fisher's Ideal Index decomposition method, were used to illustrate the impacts of price, volume, and drug change.

RESULTS

During the first 5 years of the GB program (ie, 2001-2006), the expenses of antibacterial agents increased by 54.1%, while the volume decreased by 11% to 21.3%. Therapeutic choice was the predominant cause of expense growth. In the second and third 5-year periods (ie, 2006-2011 and 2011-2016), the driving force of therapeutic choice gradually decreased. The antibacterial expense remained stable with a slight increase in prescription volume. Periodic price adjustment contributed steadily to cost containment, by 21.9% to 39.9%.

CONCLUSIONS

The GB program led to a remarkable increase in antibacterial expenses mainly attributed to therapeutic choice, especially in the early stage. In contrast, periodic price adjustment, provided steady benefits to pharmaceutical budget control without a noticeable increase in drug volume.

GPs' Perspective on a Multimodal Intervention to Enhance Guideline-Adherence in Uncomplicated Urinary Tract Infections: A Qualitative Process Evaluation of the Multicentric RedAres Cluster-Randomised Controlled Trial

Urinary tract infections (UTIs) are among the most common reasons patients seeking health care and antibiotics to be prescribed in primary care. However, general practitioners' (GPs) guideline adherence is low. The RedAres randomised controlled trial aims to increase guideline adherence by implementing a multimodal intervention consisting of four elements: information on current UTI guidelines (1) and regional resistance data (2); feedback regarding prescribing behaviour (3); and benchmarking compared to peers (4). The RedAres process evaluation assesses GPs' perception of the multimodal intervention and the potential for implementation into routine care. We carried out 19 semi-structured interviews with GPs (intervention arm). All interviews were carried out online and audio recorded. For transcription and analysis, Mayring's qualitative content analysis was used. Overall, GPs considered the interventions helpful for knowledge gain and confirmation when prescribing. Information material and resistance were used for patient communication and teaching purposes. Feedback was considered to enhance reflection by breaking routines of clinical workup. Implementation into routine practice could be enhanced by integrating feedback loops into patient management systems and conveying targeted information via trusted channels or institutions. The process evaluation of RedAres intervention was considered beneficial by GPs. It confirms the convenience of multimodal interventions to enhance guideline adherence.

Restricting access to antibiotics: The effectiveness of a 'no repeats' government policy intervention

BACKGROUND

Australia has a high rate of antibiotic use. Government policy interventions are one strategy to optimise the use of antibiotics. On 1 April 2020, the Australian Government Department of Health introduced a policy intervention to increase the quality use of four antibiotics.

OBJECTIVES

To assess if the government policy intervention improved the appropriate supply of the four antibiotics amoxicillin, amoxicillin-clavulanic acid, cefalexin and roxithromycin.

METHOD

This study employed a retrospective cohort study design comparing a 10% sample (n = 345,018) of four antibiotics prescribed and dispensed in Australia during a three-month period (May, June, July) in 2019, and again in 2020 (after the policy intervention). The 10% sample of PBS data was obtained from the Australian Government Department of Health. Descriptive statistics, bivariate and multivariable logistic regression analysis were carried out.

RESULTS

The results suggest the policy change improved the appropriate supply of original prescriptions in 2020 compared to 2019 OR = 1.75 (95% CI = 1.68-1.82, p < 0.001), and appropriate supply of repeat prescriptions OR = 1.56 (95% CI = 1.25-1.96, p < 0.001). In 2020, the proportion of appropriate supply of original prescriptions increased by an absolute difference of 1.8% (95% CI = 1.6-1.9%; P < 0.001), and appropriate supply of repeat prescriptions increased by 3.9% (95% CI = 2.2-5.5%; P < 0.001). The total number of antibiotic prescriptions prescribed and dispensed in 2019 (N = 219,960) reduced in 2020 (N = 125,058) after the policy intervention.

CONCLUSION

The study provides evidence for the impact of a government policy intervention to improve the appropriate supply of antibiotics, although some of the reduction in antibiotic use was likely due to the concomitant COVID-19 pandemic. Further research is required to assess the impact of the intervention outside a pandemic.

Effects of a national policy advocating rational drug use on decreases in outpatient antibiotic prescribing rates in Thailand

Objective:

This study examined the effects of a national policy advocating rational drug use (RDU), namely, the ‘RDU Service Plan’, starting in fiscal year 2017 and implemented by the Thai Ministry of Public Health (MOPH), on trends in antibiotic prescribing rates for outpatients. The policy was implemented subsequent to a voluntary campaign involving 136 hospitals, namely, the ‘RDU Hospital Project’, which was implemented during fiscal years 2014-2016.

Methods:

Hospital-level antibiotic prescribing rates in fiscal years 2014-2019 for respiratory infections, acute diarrhea, and fresh wounds were aggregated for two hospital groups using equally weighted averages: early adopters of RDU activities through the RDU Hospital Project and late adopters under the RDU Service Plan. Pre-/post-policy annual changes in the prescribing levels and trends were compared between the two groups using an interrupted time-series analysis.

Results:

In fiscal years 2014-2016, decreases in antibiotic prescribing rates for respiratory infections and acute diarrhea in both groups reflected a trend that existed before the RDU Service Plan was implemented. The immediate effect of the RDU Service Plan policy occurred in fiscal year 2017, when the prescribing level among the late adopters dropped abruptly for all three conditions with a greater magnitude than in the decrease among the early adopters, despite nonsignificant differences. The medium-term effect of the RDU Service Plan was identified through a further decreasing trend during fiscal years 2017-2019 for all conditions in both groups, except for acute diarrhea among the early adopters.

Conclusions:

The national policy on rational drug use effectively reduced antibiotic prescribing for common but questionable outpatient conditions.

Long-Term Surveillance of Antibiotic Prescriptions and the Prevalence of Antimicrobial Resistance in Non-Fermenting Gram-Negative Bacilli

The increasing emergence of multidrug-resistant (MDR) bacteria has been recognized as a public health threat worldwide. Hospitalized patients and outpatients are commonly infected by non-fermenting Gram-negative bacilli (NFGNB), particularly the Acinetobacter calcoaceticus-Acinetobacter baumannii complex (ACB) and Pseudomonas aeruginosa. Antimicrobial agents are critical for treating the nosocomial infections caused by NFGNB. The aim of this study was to assess antimicrobial resistance and the use of antimicrobial agents. The bacterial isolates of 638,152 specimens from both inpatients and outpatients, retrieved from 2001 to 2008 at a medical center in central Taiwan, were examined for their susceptibility to various antimicrobial agents, including cefepime, imipenem, ciprofloxacin, gentamicin, amikacin, meropenem, and levofloxacin. Administrated prescriptions of the monitored antibiotics were analyzed using the Taiwan National Health Insurance Research Database (NHIRD). Our results show that the defined daily doses (DDDs) for cefepime, imipenem, and ciprofloxacin increased with time, and a trend toward reduced antimicrobial sensitivities of both ACB and P. aeruginosa was noticeable. In conclusion, the antimicrobial sensitivities of ACB and P. aeruginosa were reduced with the increased use of antibiotics. Continuous surveillance of antibiotic prescriptions and the prevalence of emerging resistance in nosocomial infections is warranted.

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map

BACKGROUND

Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.

METHODS AND FINDINGS

Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.

CONCLUSIONS

To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.

PROTOCOL REGISTRATION

PROSPERO CRD42017067514.

The Primary Resistance of Helicobacter pylori in Taiwan after the National Policy to Restrict Antibiotic Consumption and Its Relation to Virulence Factors-A Nationwide Study

Objective

The Taiwan Government issued a policy to restrict antimicrobial usage since 2001. We aimed to assess the changes in the antibiotic consumption and the primary resistance of H. pylori after this policy and the impact of virulence factors on resistance.

Methods

The defined daily dose (DDD) of antibiotics was analyzed using the Taiwan National Health Insurance (NHI) research database. H. pylori strains isolated from treatment naïve (N=1395) and failure from prior eradication therapies (N=360) from 9 hospitals between 2000 and 2012 were used for analysis. The minimum inhibitory concentration was determined by agar dilution test. Genotyping for CagA and VacA was determined by PCR method.

Results

The DDD per 1000 persons per day of macrolides reduced from 1.12 in 1997 to 0.19 in 2008, whereas that of fluoroquinolones increased from 0.12 in 1997 to 0.35 in 2008. The primary resistance of amoxicillin, clarithromycin, metronidazole, and tetracycline remained as low as 2.2%, 7.9%, 23.7%, and 1.9% respectively. However, the primary levofloxacin resistance rose from 4.9% in 2000–2007 to 8.3% in 2008–2010 and 13.4% in 2011–2012 (p=0.001). The primary resistance of metronidazole was higher in females than males (33.1% vs. 18.8%, p<0.001), which was probably attributed to the higher consumption of nitroimidazole. Neither CagA nor VacA was associated with antibiotic resistance.

Conclusions

The low primary clarithromycin and metronidazole resistance of H. pylori in Taiwan might be attributed to the reduced consumption of macrolides and nitroimidazole after the national policy to restrict antimicrobial usage. Yet, further strategies are needed to restrict the consumption of fluoroquinolones in the face of rising levofloxacin resistance.

Pediatric invasive pneumococcal disease in Taiwan following a national catch-up program with the 13-valent pneumococcal conjugate vaccine

BACKGROUND

Seven-valent pneumococcal conjugate vaccine (PCV) has been available in Taiwan since late 2005. A national catch-up program was launched in Taiwan in 2013, providing 1 dose of 13-valent PCV to children aged 2-5 years. Here, we report the epidemiology of invasive pneumococcal disease (IPD) in children aged ≤5 years in this setting.

METHODS

We collected demographic and clinical information for pediatric patients (≤5 years) with IPD between 2008 and 2013. The incidence of IPD was estimated. The logs for PCV import into Taiwan were obtained to evaluate the impact of PCV usage on IPD epidemiology.

RESULTS

The overall incidence of IPD in children aged ≤5 years was 15.9 cases per 100,000 person-years. The IPD incidence caused by 7-valent PCV serotypes decreased significantly from 10.0 cases per 100,000 person-years in 2008 to 2.3 cases per 100,000 person-years in 2013. The incidence of IPD caused by serotype 19A increased substantially from 1.7 cases per 100,000 person-years in 2008 to 10.3 cases per 100,000 person-years in 2012, followed by a significant decrease to 5.6 cases per 100,000 person-years in 2013. The significant decrease in the incidence of serotype 19A IPD occurred primarily in children aged 2-5 years.

CONCLUSIONS

The 13-valent PCV catch-up program was associated with a significant decrease in serotype 19A IPD incidence in 2013, primarily in children eligible for the 13-valent PCV immunization. Continued surveillance is necessary to assess the further impact of the national catch-up program on pediatric IPD epidemiology in Taiwan.

Success stories of implementation of antimicrobial stewardship: a narrative review

It has been increasingly recognized that antimicrobial stewardship (AMS) has to be a key component of any efforts that aim to mitigate the current global antimicrobial resistance (AMR) crisis. It has also become evident that AMR is a problem that cannot be tackled by single institutions or physicians, but needs concerted actions at regional, national and supra-national levels. However, it is easy to become discouraged, given the problems that are often encountered when implementing AMS. The aim of this review is to highlight some of the success stories of AMS strategies, and to describe the actions that have been taken, the outcomes that have been obtained, and the obstacles that have been met. Although the best approach to effective AMS remains elusive and may vary significantly among settings, these diverse examples from a range of healthcare contexts demonstrate that effective AMS is possible. Such examples will inform others and encourage them to formally evaluate and share their results with the global stewardship community.

Epidemiology and molecular characterization of macrolide-resistant Streptococcus pyogenes in Taiwan

Our multicenter nationwide surveillance data indicated that erythromycin (ERY) resistance among group A Streptococcus (GAS) isolates in Taiwan declined from 53.1% in 1998 and 2000 to 14.6% in 2002 and 2004 and 10.7% in 2006 to 2010 (P < 0.01). The present study aimed to assess the epidemiology of GAS in Taiwan and identify factors associated with ERY resistance. All 127 ERY-resistant (ERY(r)) isolates and 128 randomly selected ERY-susceptible (ERY(s)) isolates recovered from 1998 to 2010 were emm typed. ERY(r) isolates were also characterized by ERY resistance phenotype and mechanisms and pulsed-field gel electrophoresis (PFGE). Multilocus sequence typing was performed on selected ERY(r) isolates. The predominant emm types in ERY(r) isolates were emm22 (n = 33, 26.0%), emm12 (n = 24, 18.9%), emm4 (n = 21, 16.5%), and emm106 (n = 15, 11.8%). In ERY(s) isolates, emm12 (n = 27, 21.9%), emm1 (n = 18, 14.1%), emm106 (n = 16, 12.5%), and emm11 (n = 9, 7.1%) predominated. The most common ERY resistance phenotype was the M phenotype (resistant to macrolides) (70.9%), with all but one isolate carrying mef(A), followed by the constitutive macrolide-lincosamide-streptogramin B resistance (cMLSB) phenotype (26.8%), with isolates carrying erm(B) or erm(TR). ERY(r) isolates of the emm12-sequence type 36 (ST36) lineage with the cMLSB phenotype were mostly present before 2004, while those of the emm22-ST46 lineage with the M phenotype predominated in later years. Recovery from respiratory (throat swab) specimens was an independent factor associated with ERY resistance. emm1 and emm11 GAS isolates were significantly associated with ERY(s), while emm22 was detected only in ERY(r) GAS. In addition, emm106 isolates were prevalent among the abscess/pus isolates, whereas emm12 isolates were strongly associated with a respiratory (throat) origin. In addition to identifying factors associated with ERY resistance in GAS, our study provides helpful information on the changing GAS epidemiology in Taiwan.

High rates of multidrug resistance in Enterococcus faecalis and E. faecium isolated from inpatients and outpatients in Taiwan

Longitudinal national data on resistance in Enterococcus faecalis and E. faecium from different sources in Taiwan are rare. The present study analyzed data from the Taiwan Surveillance of Antimicrobial Resistance program to address this issue. Between 2002 and 2010, a total of 1696 E. faecalis and 452 E. faecium isolates were studied. Although these 2 species together comprised similar percentages of all enterococci in each study year (94.1-97.2%, P = 0.19), the proportion of E. faecium increased from 12.4% in 2002 to 27.3% in 2010 (P < 0.001). The most noteworthy change in susceptibilities of these 2 species was vancomycin resistance in E. faecium (VREfm), which increased from 0.3% in 2004 to 24.9% in 2010 (P < 0.001). VREfm prevalence differed significantly between geographic regions, patient age groups, and locations. Multidrug resistance was very common in both species even in isolates from outpatients (82.7% for E. faecalis and 98.1% for E. faecium), at rates similar to those from intensive care unit (ICU) and non-ICU patients (80.5-80.9% in E. faecalis and 97.2-98.6% in E. faecium). Nonsusceptibility to linezolid was <0.5% in both species. All tested isolates were susceptible to daptomycin. Continuous surveillance of VRE prevalence and survey of community reservoirs of multidrug-resistant enterococci are warranted.

Prevalence of antimicrobial resistance in Helicobacter pylori isolates in Taiwan in relation to consumption of antimicrobial agents

During 1998-2004, a total of 218 Helicobacter pylori isolates were obtained from patients who were randomised to receive one of the following regimens in a medical centre in Taiwan: lansoprazole, amoxicillin and clarithromycin (LAC) therapy; or lansoprazole, metronidazole and clarithromycin (LMC) therapy. In the LMC group, resistance rates for metronidazole and clarithromycin reduced from 48.6% (1998-2000) to 20.4% (2001-2004) (P<0.05) and from 13.5% to 6.3% (P<0.05), respectively. Analysis of annual antimicrobial consumption found that metronidazole use was slowly decreased both in the total population and in gastrointestinal disease patients. The per-protocol analysis revealed a higher eradication rate for patients using LMC therapy in 2001-2004 (82.6% vs. 75.0%), whilst there was similar efficacy for LAC therapy (84.8% vs. 84.2%). This observation suggests an effective programme to control H. pylori antibiotic resistance and hence elevate its cure rate.

The impact of an intensive antimicrobial control program in a Taiwanese medical center

OBJECTIVE

The study evaluates the short term impacts of an intensive control program for the appropriate us of antimicrobials, and to provide a novel strategy for antimicrobial control in inpatient wards in Taiwan.

METHOD

In September 2002, a dual intensive antimicrobial control program was implemented within a 921-bed medical center in Taiwan. The study sample included all patients admitted to the medical center during the basal period (October-December 2001) and the intervention period (October-December 2002), where at least one type of parenteral antimicrobial was administered. The sample comprised of 5046 patients during the basal period and 5054 patients during the intervention period.

MAIN OUTCOME MEASURE

Analysis of the impact of the intensive antimicrobial control program was undertaken by comparing clinical outcomes, parenteral antimicrobial consumption and bacterial susceptibilities, before and after the establishment of the intensive antimicrobial control program.

RESULTS

No statistical differences were found between the basal and intervention periods with regard to either the demographic variables, such as age and gender, or the incidence of nosocomial infections. The clinical outcomes, including length of stay in the medical center, mortality and readmission rates, were also similar for both periods. As compared to the basal period, the consumption of parenteral antimicrobials--in defined daily doses (DDDs) per 100 patient days (PDs)--declined by 13.2% during the intervention period (71.2 vs. 61.8). There were significant increases in the susceptibilities of Pseudomonas aeruginosa to both amikacin and ciprofloxacin, and Serratia spp. to ciprofloxacin (P < 0.05), while all others remained stable.

CONCLUSION

This study reports positive responses to intensive antimicrobial control measures among health professionals within a Taiwanese medical center. Following the implementation of the intensive control program, both prescriptions and consumption levels of parenteral antimicrobials were reduced without compromising the clinical outcomes of patients, while the susceptibility patterns of bacterial organisms mostly remained stable. Long-term control of parenteral antimicrobials under such a program may well produce significant benefits for inpatients through the overall rationalization of antimicrobial usage, leading to potential reductions in both the incidence of adverse effects and the burden of resistant organisms. A method of incorporating this intensive control program into a computerized prescription order system is currently under construction.

Changes in macrolide resistance among respiratory pathogens after decreased erythromycin consumption in Taiwan

Measures to alleviate the growing problem of macrolide resistance in Taiwan resulted in a decrease in macrolide consumption, from 0.629 defined daily doses/1000 inhabitants per day (DIDs) in 1999 to 0.301 DIDs in 2003 (a reduction of 52%). A linear relationship was observed between the decline in erythromycin consumption and the decline in erythromycin resistance in Streptococcus pyogenes (46% in 1999 vs. 17% in 2003; p < 0.001) and azithromycin resistance in Haemophilus influenzae (31% in 2000 vs. 0% in 2003; p < 0.001). However, the rate of erythromycin resistance in Streptococcus pneumoniae showed a continued increase, from 80.2% in 1999 to 92% in 2003.

Decreasing rates of resistance to penicillin, but not erythromycin, in Streptococcus pneumoniae after introduction of a policy to restrict antibiotic usage in Taiwan

A 16% decline in rates of penicillin resistance in Streptococcus pneumoniae isolates in Taiwan between 1998--1999 (25%) and 2001 (9%) was associated with a 46% decrease in total penicillin and other cephalosporin usage in 2001 compared with 1999. However, erythromycin resistance in S. pneumoniae remained high (94%), despite a 45% decrease in macrolide consumption between 1999 and 2001.

Etiology of community acquired pneumonia among adult patients requiring hospitalization in Taiwan

BACKGROUND

There has not been a comprehensive multi-center study investigating the microbial profile of community acquired pneumonia (CAP) in Taiwan.

METHODS

A prospective study of adult CAP patients requiring hospitalization between December 2001 and April 2002 was carried out in 13 hospitals in Taiwan. Etiology was determined based on laboratory data from blood and sputum cultures plus serology from paired serum and urine antigen detection tests.

RESULTS

Etiology was assigned to 99 (58.9%) of the 168 patients having the most complete data for etiology determination, with mixed infection in 21 (12.5%) patients. More than half (51.8%) of the patients were>60 years and 63.7% of the patients were males. The most common etiologic agent was Streptococcus pneumoniae (40, 23.8%), the majority (60%, 24 cases) of which was detected by positive urine antigen test. Other common agents included Mycoplasma pneumoniae (24, 14.3%), Chlamydia pneumoniae (12, 7.1%), Influenza A virus (11, 6.5%), Klebsiella pneumoniae (8, 4.8%) and Haemophilus influenzae (8, 4.8%). The prevalence of S. pneumoniae and M. pneumoniae was highest in patients>60 years (25/87, 28.7%), and<44 years (12/59, 19%), respectively; while K. pneumoniae comprised a larger proportion (4/22, 18%) in the 45-59 years group.

CONCLUSIONS

S. pneumoniae was the most common etiology agent in adult patients hospitalized due to CAP in Taiwan and the spectrum of other major pathogens was similar to studies conducted elsewhere in the world. Empiric treatment recommendations developed in other parts of the world may be appropriately adapted for local use after taking into account local resistance profiles. Our data also support the recommendation that urine antigen test be added as an adjunct to adult CAP etiology diagnosis protocol.