Antibiotic Control Policies in South Korea, 2000-2013

Association between exposure to antibiotics during pregnancy or early infancy and risk of autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children: population based cohort study

OBJECTIVE

To evaluate the association between antibiotic use during pregnancy or early infancy and the risk of neurodevelopmental disorders in children.

DESIGN

Nationwide population based cohort study and sibling analysis.

SETTING

Korea's National Health Insurance Service mother-child linked database, 2008-21.

PARTICIPANTS

All children live born between 2009 and 2020, followed up until 2021 to compare those with and without antibiotic exposure during pregnancy or early infancy (first six months of life).

MAIN OUTCOMES MEASURES

Autism spectrum disorder, intellectual disorder, language disorder, and epilepsy in children. After 1:1 propensity score matching based on many potential confounders, hazard ratios with 95% confidence interval were estimated using Cox proportional hazard models. A sibling analysis additionally accounted for unmeasured familial factors.

RESULTS

After propensity score matching, 1 961 744 children were identified for the pregnancy analysis and 1 609 774 children were identified for the early infancy analysis. Although antibiotic exposure during pregnancy was associated with increased risks of all four neurodevelopmental disorders in the overall cohort, these estimates were attenuated towards the null in the sibling analyses (hazard ratio for autism spectrum disorder 1.06, 95% confidence interval 1.01 to 1.12; intellectual disorder 1.00, 0.93 to 1.07; language disorder 1.05, 1.02 to 1.09; and epilepsy 1.03, 0.98 to 1.08). Likewise, no association was observed between antibiotic exposure during early infancy and autism spectrum disorder (hazard ratio 1.00, 0.96 to 1.03), intellectual disorder (1.07, 0.98 to 1.15), and language disorder (1.04, 1.00 to 1.08) in the sibling analyses; however, a small increased risk of epilepsy was observed (1.13, 1.09 to 1.18). The results generally remained consistent across several subgroup and sensitivity analyses, except for slightly elevated risks observed among children who used antibiotics during very early life and those who used antibiotics for more than 15 days.

CONCLUSIONS

In this large cohort study, antibiotic exposure during pregnancy or early infancy was not associated with an increased risk of autism spectrum disorder, intellectual disorder, or language disorder in children. However, elevated risks were observed in several subgroups such as children using antibiotics during very early life and those with long term antibiotic use, which warrants attention and further investigation. Moreover, antibiotic use during infancy was modestly associated with epilepsy, even after control for indications and familial factors. When prescribing antibiotics to pregnant women and infants, clinicians should carefully balance the benefits of use against potential risks.

Principles and practices of antimicrobial stewardship programs in Korea

This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.

Quantitative and qualitative evaluation of antimicrobial usage: the first step for antimicrobial stewardship

The identification of antimicrobial use patterns is essential for determining key targets for antimicrobial stewardship interventions and evaluating the effectiveness thereof. Accurately identifying antimicrobial use patterns requires quantitative evaluation, which focuses on measuring the quantity and frequency of antimicrobial use, and qualitative evaluation, which assesses the appropriateness, effectiveness, and potential side effects of antimicrobial prescriptions. This paper summarizes the quantitative and qualitative methods used to evaluate antimicrobials, drawing insights from overseas and domestic cases.

Effects of implementing a clinical pathway on antibiotic prophylaxis for patients who underwent an elective surgery

A reduction in the unnecessary use of antibiotic prophylaxis can prevent antibiotic resistance and adverse drug events. We aimed to evaluate the effects of implementing clinical pathways (CPs) on adherence to a systematic and appropriate duration of antibiotic prophylaxis. We identified 61 eligible CPs and a total of 44,062 patients who underwent elective surgeries associated with CPs. The Poisson mixed model with an interrupted time-series analysis frame was applied to the patient-level data. This enabled a comparison of the adherence rate before and after CP implementation. Furthermore, we examined the effect of application or completion of CP on the adherence rate after implementation. Adherence to the antibiotic prophylaxis guideline substantially increased (incident rate ratio [IRR] 8.05; 95 confidence interval [CI] 2.64-24.55), compared with that before implementation. Following the implementation into the electronic entry system, we observed an improved adherence not only in CP completion but also in attempted CP execution (IRR of the executed but not completed cases 1.54; 95% CI 1.17-2.04; IRR of the executed and competed cases, 1.94; 95% CI 1.4-2.69). The implementation of CP into the electronic prescribing system was associated with a significant increase in the appropriate use of antibiotic prophylaxis among patients who underwent elective surgeries. The results suggest that a computer-assisted CP system for electronic health records could improve antibiotic adherence without significant expense.

Changes in antibiotic consumption patterns after the implementation of the National Action Plan according to the Access, Watch, Reserve (AWaRe) classification system

OBJECTIVE

The Korean government published the first National Action Plan (NAP) on antimicrobial resistance (AMR) in August 2016, followed by a second plan in November 2021. The objective of this study was to analyze changes in antibiotic use patterns after the implementation of the NAP in South Korea.

METHODS

We analyzed National Health Insurance claims data for hospitals and clinics from January 2011 to December 2020. Consumption was measured using a defined daily dose per 1000 inhabitants per day (DID). We analyzed data for each year, dimension, and category of the Access, Watch, Reserve classification system by the World Health Organization. Monthly inpatient and outpatient antibiotic use were calculated, and an interrupted time-series (ITS) analysis to assess the trend in antibiotic use was conducted.

RESULTS

The consumption of antibiotics increased from 25.78 DID in 2011 to 29.06 DID in 2016, then decreased in 2017 after the implementation of the NAP on AMR. The watch group showed a temporal decrease after the implementation of the NAP; however, these figures increased until 2019, and the reserve group showed a downward trend beginning in 2017. According to the ITS analysis, the level (β₂) and the slope of the trend (β₃) of total antibiotic use decreased by 0.17 and 0.001, respectively. After implementation of the NAP, antibiotic use was reduced from 7.18 DID in 2016 to 4.84 DID in 2017 for amoxicillin and beta-lactamase inhibitors, 0.86 DID to 0.70 DID for ciprofloxacin, and 0.66 DID to0.66 DID for levofloxacin.

CONCLUSION

After the implementation of the NAP in South Korea, antibiotic use in terms of total antibiotics and fluoroquinolone in the watch and reserve groups decreased. Further policies to improve the use of antibiotics in the watch and reserve groups are needed.

Stepwise Expansion of Antimicrobial Stewardship Programs and Its Impact on Antibiotic Use and Resistance Rates at a Tertiary Care Hospital in Korea

To optimize antibiotic use, the US CDC has outlined core elements of antimicrobial stewardship programs (ASP). However, they are difficult to implement in limited-resource settings. We report on the successful implementation of a series of ASP with insufficient number of infectious diseases specialists. We retrospectively collected data regarding antibiotic administration and culture results of all patients admitted to a tertiary care teaching hospital, Seoul National University Bundang Hospital (SNUBH), from January 2010 to December 2019. Trends of antibiotic use and antibiotic resistance rates were compared with those from Korean national data. Trend analyses were performed using nonparametric, two-sided, correlated seasonal Mann–Kendall tests. Total antibiotic agent usage has significantly decreased with ASP implementation at SNUBH since 2010. National claim data from tertiary care hospitals have revealed an increase in the use of all broad-spectrum antibiotics except for third-generation cephalosporins (3GC). In contrast, at SNUBH, glycopeptide and fluoroquinolone use gradually decreased, and 3GC and carbapenem use did not significantly change. Furthermore, the rate of colonization with methicillin-resistant Staphylococcus aureus showed a consistently decreasing trend, while that with 3GC- and fluoroquinolone-resistant Escherichia coli significantly increased. Unlike the national rate, the rate of colonization with antibiotic resistant-Klebsiella pneumoniae did not increase and that of 3GC- and fluoroquinolone-resistant Pseudomonas aeruginosa significantly decreased. Stepwise implementation of core ASP elements was effective in reducing antibiotic use despite a lack of sufficient manpower. Long-term multidisciplinary teamwork is necessary for successful and sustainable ASP implementation.

IMPORTANCE Antimicrobial stewardship programs aimed to optimize antibiotic use are difficult to implement in limited-resource settings. Our study indicates that stepwise implementation of core antimicrobial stewardship program elements was effective in reducing antibiotic use in a tertiary care hospital despite the lack of sufficient manpower.

Association between antibiotics use and diabetes incidence in a nationally representative retrospective cohort among Koreans

Numerous studies have reported that antibiotics could lead to diabetes, even after adjusting for confounding variables. This study aimed to determine the causal relationship between antibiotics use and diabetes in a nationally representative cohort. This retrospective cohort study included adults aged 40 years or older who were enrolled in the Korean National Health Insurance Service-Health Screening Cohort. Antibiotic exposure was assessed from 2002 to 2005 and newly diagnosed diabetes mellitus was determined based on diagnostic codes and history of antidiabetic medication use from 2006 to 2015. Multivariate Cox proportional hazards model was used to assess the association between antibiotic use and diabetes incidence. The mean age of the 201,459 study subjects was 53.2 years. People who used antibiotics for 90 or more days had a higher risk of diabetes (adjusted hazard ratio [aHR] 1.16, 95% confidence interval [CI] 1.07–1.26) compared to non-users. Those who used five or more classes of antibiotics had a higher risk of diabetes than those who used one antibiotic class (aHR 1.14; 95% CI 1.06–1.23). The clear dose-dependent association between antibiotics and diabetes incidence supports the judicious use of antibiotics in the future.

Impact of antibiotic usage on extended-spectrum β-lactamase producing Escherichia coli prevalence

An increase in antibiotic usage is considered to contribute to the emergence of antimicrobial resistance. Although experts are counting on the antimicrobial stewardship programs to reduce antibiotic usage, their effect remains uncertain. In this study, we aimed to evaluate the impact of antibiotic usage and forecast the prevalence of hospital-acquired extended spectrum β-lactamase (ESBL)—producing Escherichia coli (E. coli) using time-series analysis. Antimicrobial culture information of E. coli was obtained using a text processing technique that helped extract free-text electronic health records from standardized data. The antimicrobial use density (AUD) of antibiotics of interest was used to estimate the quarterly antibiotic usage. Transfer function model was applied to forecast relationship between antibiotic usage and ESBL-producing E. coli. Of the 1938 hospital-acquired isolates, 831 isolates (42.9%) were ESBL-producing E. coli. Both the proportion of ESBL-producing E. coli and AUD increased over time. The transfer model predicted that ciprofloxacin AUD is related to the proportion of ESBL-producing E. coli two quarters later. In conclusion, excessive use of antibiotics was shown to affect the prevalence of resistant organisms in the future. Therefore, the control of antibiotics with antimicrobial stewardship programs should be considered to restrict antimicrobial resistance.

Antibiotics in surface water of East and Southeast Asian countries: A focused review on contamination status, pollution sources, potential risks, and future perspectives

This review provides focused insights into the contamination status, sources, and ecological risks associated with multiple classes of antibiotics in surface water from the East and Southeast Asia based on publications over the period 2007 to 2020. Antibiotics are ubiquitous in surface water of these countries with concentrations ranging from <1 ng/L to hundreds μg/L and median values from 10 to 100 ng/L. Wider ranges and higher maximum concentrations of certain antibiotics were found in surface water of the East Asian countries like China and South Korea than in the Southeast Asian nations. Environmental behavior and fate of antibiotics in surface water is discussed. The reviewed occurrence of antibiotics in their sources suggests that effluent from wastewater treatment plants, wastewater from aquaculture and livestock production activities, and untreated urban sewage are principal sources of antibiotics in surface water. Ecological risks associated with antibiotic residues were estimated for aquatic organisms and the prevalence of antibiotic resistance genes and antibiotic-resistant bacteria were reviewed. Such findings underline the need for synergistic efforts from scientists, engineers, policy makers, government managers, entrepreneurs, and communities to manage and reduce the burden of antibiotics and antibiotic resistance in water bodies of East and Southeast Asian countries.

Association of class number, cumulative exposure, and earlier initiation of antibiotics during the first two-years of life with subsequent childhood obesity

BACKGROUND

Despite the possible association between antibiotic overuse and childhood obesity, studies on this association are lacking in Asia. This study aimed to determine whether there is an association between the number, duration of antibiotic exposure, timing of antibiotics initiation and childhood obesity.

METHODS

In this retrospective cohort study, Korean children born between January 1, 2008 and December 31, 2012, who underwent government-provided health examinations at age 4-6 and 30-36 months, were included. The main outcome was obesity (body mass index in 95th percentile) at 30-36 months. The exposure variable was antibiotic prescription during the first 24 months of life. The number, prevalence, and odds ratio (OR) of obese children based on antibiotic exposure were analyzed using logistic regression.

RESULTS

Of 31,733 children, 31,457 (99.1%) children used antibiotics and 2843 (9%) were obese at 30-36 months. There was a clear dose-response relationship between obesity and number of antibiotic classes, cumulative days, and earlier antibiotic initiation. Children who used five or more antibiotic classes had higher odds of obesity than those who used only one class (OR 1.42, 95% CI 1.12-1.8). Children with >180 days of antibiotic exposure had higher risk of obesity than those with 1-30 exposure days (OR 1.40, 95% CI 1.19-1.64). Children with earlier initiation of antibiotics had higher risk of obesity (OR 1.15 per 6 months, 95% CI 1.08-1.22).

CONCLUSION

Increased number of antibiotic classes, longer duration of antibiotic prescription and earlier antibiotic initiation before 24 months was associated with childhood obesity at 30-36 months. This South Korean retrospective study supports judicious use of antibiotics in the first 24 months of life to avoid the potential risk of childhood obesity. Future studies need to be performed to confirm or refute the results presented herein.

Development of Antibiotic Classification for Measuring Antibiotic Usage in Korean Hospitals Using a Modified Delphi Method

In 2019, a project designed to develop a system for measuring and comparing antibiotic usage in hospitals was launched in Korea. As part of this project, we developed a means to classify antibiotic usage in Korean hospitals using a modified Delphi method. In results, the following categories of antibiotic classification were accepted for use in Korean hospitals: 1) broad-spectrum antibacterial agents predominantly used for hospital-onset infections in adults, 2) broad-spectrum antibacterial agents predominantly used for community-acquired infections in adults, 3) antibacterial agents predominantly used for resistant gram-positive infections in adults, 4) narrow-spectrum beta-lactam agents in adults, 5) antibacterial agents predominantly used for extensive antibiotic resistant gram-negative bacteria in adults, and 6) total antibacterial agents.

Impact of national interventions to promote responsible antibiotic use: a systematic review

BACKGROUND

Global recognition of antimicrobial resistance (AMR) as an urgent public health problem has galvanized national and international efforts. Chief among these are interventions to curb the overuse and misuse of antibiotics. However, the impact of these initiatives is not fully understood, making it difficult to assess the expected effectiveness and sustainability of further policy interventions. We conducted a systematic review to summarize existing evidence for the impact of nationally enforced interventions to reduce inappropriate antibiotic use in humans.

METHODS

We searched seven databases and examined reference lists of retrieved articles. To be included, articles had to evaluate the impact of national responsible use initiatives. We excluded studies that only described policy implementations.

RESULTS

We identified 34 articles detailing interventions in 21 high- and upper-middle-income countries. Interventions addressing inappropriate antibiotic access included antibiotic committees, clinical guidelines and prescribing restrictions. There was consistent evidence that these were effective at reducing antibiotic consumption and prescription. Interventions targeting inappropriate antibiotic demand consisted of education campaigns for healthcare professionals and the general public. Evidence for this was mixed, with several studies showing no impact on overall antibiotic consumption.

CONCLUSIONS

National-level interventions to reduce inappropriate access to antibiotics can be effective. However, evidence is limited to high- and upper-middle-income countries, and more evidence is needed on the long-term sustained impact of interventions. There should also be a simultaneous push towards standardized outcome measures to enable comparisons of interventions in different settings.

Trends in the use of antibiotics among Korean children

Inappropriate antibiotic use is the most important factor causing increased bacterial resistance to antibiotics, thus affecting patient outcomes. Multidrug-resistant bacteria have become a serious public health threat, causing significant morbidity and mortality worldwide. In Korea, the burden of antibioticresistant bacteria has become an important public health issue. There is increasing evidence of overuse and misuse of antibiotics in Korea, as observed in cohorts with large sample sizes. Antibiotic use among children should receive particular attention because of the frequency of community-associated infections among this population and the elevated risk of transmission. Recent studies from Korea have demonstrated that the use of broad-spectrum antibiotics, either for inpatient or outpatient treatment, has increased among many age groups, especially children. In this review, we aim to describe the patterns of antibiotic prescription and evaluate recent trends in antibiotic use among children. Coordinated efforts toward communication and education in order to address misunderstandings regarding antibiotic use, involving interprofessional antimicrobial stewardship programs, are required in the near future.

Increased use of third-generation cephalosporin antibiotics in the outpatient setting in Korean children and adolescents

BACKGROUND

Antimicrobial resistance is a concern to public health, and controlling antibiotic use is therefore important. This study analyzed the trend in outpatient antibiotic prescriptions in children and adolescents in Korea.

METHODS

Using National Prescribing Sample data from the Korea Health Insurance Review and Assessment Service between 1 January 2010 and 31 December 2014, we analyzed outpatient systemic antibiotic (anatomical therapeutic chemical [ATC] J01) prescriptions in patients aged 2-17 years. The antibiotic rate was defined as the proportion of all outpatient prescriptions for antibiotics. We calculated absolute and relative differences with 95%CI between 2010 and 2014 in the antibiotic rate by age group (2-6, 7-11, and 12-17 years) and the percentage of antibiotic prescriptions by antibiotic class. Seven of the most commonly used antibiotic drugs were identified based on defined daily dose.

RESULTS

A total of 7 261 176 prescriptions were written for 1 039 756 pediatric patients between 2010 and 2014. The antibiotic rate in all patients increased from 34.8% in 2010 to 70.4% in 2014, resulting in the relative difference of 102.1% (95%CI: 101.7-102.5). Extended spectrum penicillins were the most commonly prescribed antibiotic class, accounting for 40.0-41.0% of all antibiotic prescriptions. The use of third-generation cephalosporins increased steeply with the relative difference of 55.7% (95%CI: 55.2-56.2). Amoxicillin/clavulanate, an extended spectrum antibiotic drug, was the predominately used antibiotic drug but the use of cefpodoxime, a third-generation cephalosporin, increased by 96%.

CONCLUSIONS

The use of outpatient antibiotics, especially third-generation cephalosporins, has increased in children and adolescents in Korea.

Changes in Antimicrobial Usage Patterns in Korea: 12-Year Analysis Based on Database of the National Health Insurance Service-National Sample Cohort

National antimicrobial usage and prescription patterns during the 12 years from 2002 to 2013 were analyzed using the National Health Insurance Service-National Sample Cohort. Antimicrobial usage was analyzed by major illness, sex, age, area of residence, income rank, diagnosis, and type of medical institution for each year. Total antimicrobial prescriptions increased from 15.943 daily defined dose (DDD)/1,000 inhabitants/day in 2002 to 24.219 in 2013. In 2013, 72% of total prescriptions were administered in clinics. Antimicrobials were most frequently prescribed to children younger than 10 years, followed by adults aged 70 years or older and those aged 60-69 years. Penicillins and cephems were the most popular classes of antimicrobial used. In 2013, 48% of total antibiotic usage (11.683 DDD/1,000 inhabitants/day) was due to respiratory diseases. After the Korean government has implemented a series of healthcare policies, antibiotic prescription decreased for the treatment of upper respiratory infection, the causative agents are mostly viruses.