- Email: [email protected]
The new Korean action plan for containment of antimicrobial resistance
Journal of Global Antimicrobial Resistance 8 (2017) 70–73
Contents lists available at ScienceDirect
Journal of Global Antimicrobial Resistance journal homepage: www.elsevier.com/locate/jgar
Short Communication
The new Korean action plan for containment of antimicrobial resistance Sukhyun Ryu Department of Epidemiology and Medical Informatics, Graduate School of Public Health, Korea University, Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 August 2016 Received in revised form 23 October 2016 Accepted 31 October 2016 Available online 23 December 2016
Background: The Korean national action plan on antimicrobial resistance (AMR) was established on 11 August 2016 by the Korean Ministry of Health and Welfare. Methods and results: This article briefly describes the current status of AMR in Korea and introduces six objectives of the action plan, including the prudent use of antimicrobial medicines, prevention of the spread of AMR, strengthening surveillance programmes, awareness improvement, strengthening research and development, and enhancement of international collaboration. Conclusions: Integrated multisectoral principles are applied to fight AMR more effectively. This 5-year national AMR action plan will be the cornerstone of public health in Korea. © 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.
Keywords: Korea Antimicrobial resistance Action plan Policy
1. Introduction The World Health Organization (WHO) has reported that antimicrobial resistance (AMR), which is associated with increased antibiotic consumption and inappropriate infection control, will become a major public health threat in the near future [1]. Previous Korean studies documented that infections caused by methicillinresistant Staphylococcus aureus (MRSA) resulted in an increased economic burden (1.8-fold) and prolonged hospital stay (1.25-fold) [2]. To mitigate this threat, countries such as Austria, Canada, the UK and the USA have established their own national strategies. As part of the development process of a national strategic plan for the containment of AMR, the Korea Centers for Disease Control and Prevention (KCDC) participated in the WHO’s technical meetings and organised multisectoral meetings to share ideas on national AMR strategies with the One Health concept. In May 2015, the 68th World Health Assembly adopted the global action plan for AMR. As a response to the WHO’s global action plan, the Korean steering committee, which was established during previous multisectoral meeting on national AMR strategies, was organised under the Korean Ministry of Health and Welfare (KMoHW). On 11 August 2016, the KMoHW addressed the new Korean 5-year AMR strategy and action plan [3]. This article describes the major concepts of the
Korean AMR action plan in response to the current status of AMR in the Republic of Korea. 2. Current status of antimicrobial resistance in Korea Antimicrobial consumption in Korea is relatively higher [31.7 defined daily doses (DDD) per 1000 inhabitants per day] compared with other member countries of the Organisation for Economic Co-operation and Development (OECD) (23.7 DDD per 1000 inhabitants per day) [4]. In addition, a recent Korean nationwide surveillance study reported that MRSA has become common (ca. 60% of S. aureus), and the prevalence of imipenemresistant Acinetobacter baumannii and imipenem-resistant Pseudomonas aeruginosa increased from 20% to 62% and from 26% to 42%, respectively, between 2007 and 2013 [5]. From 2003 to 2013, Korea conducted the National Antimicrobial Resistance Safety Control Program, yet the most resistant organisms increased even though the annual investment increased [6]. The lack of awareness and legislation for prudent use of antibiotic prescriptions in medical practice in humans and animals as well as the incomplete surveillance and infection control stewardship programme in the health system is considered major drivers of emerging AMR in Korea. 3. Strategies of the Korean antimicrobial resistance action plan
E-mail address: [email protected] (S. Ryu).
The goal of the Korean national AMR action plan is to improve public safety by (i) reducing the prescription of antibiotic agents by
http://dx.doi.org/10.1016/j.jgar.2016.10.013 2213-7165/© 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.
S. Ryu / Journal of Global Antimicrobial Resistance 8 (2017) 70–73
prudent use and (ii) minimising the spread of AMR in the human (community and healthcare settings) and veterinary sectors. The key objectives with priority areas and measurable indicators are described below and in Table 1.
71
that these programmes considerably reduced the volume of antibiotics prescribed [9,10]. To evaluate physicians’ appropriate use of antibiotic agents, therefore, the evaluation programme will be extended to other types of infectious diseases by the KMoHW.
3.1. Objective 1. Promote the prudent use of antimicrobial medicines A number of studies have shown that AMR in humans is strongly linked with the volume of antimicrobial use in humans and animals [1,7]. To meet this objective, a bundle of measures will be adopted to promote the appropriate use of antibiotic agents. These include strengthening quality evaluation of antimicrobial use in health care, developing guidelines on antibiotic use to support physicians and veterinarians prescribe based on evidence, and offering educational programmes for staff-related antibiotic stewardship both in the human and animal sectors. 3.1.1. Enforce quality evaluation programmes of antibiotic use in health care As the common cold is recognised as one of the most inappropriate reasons for antibiotic prescribing [8], Korea initiated the quality evaluation programme of antimicrobial prescriptions for acute upper respiratory infections since 2006 [9] and surgical antibiotic prophylaxis since 2007 [10]. Previous studies showed
3.1.2. Develop and distribute prescription guidelines on antibiotic use The antibiotics that physicians prescribe for common diseases are often inappropriate [11]. In addition, a report indicated that physicians prescribe broader–spectrum agents more often for common infectious diseases [12]. Since timely access to guidelines is important in clinical practice, the KMoHW will develop a pocket guide, internet prescribing tools and a smartphone application to help health professionals provide adequate and timely antimicrobial treatment [13]. 3.1.3. Enhance appropriate antibiotic use in the animal sector A number of studies have documented that the emergence of AMR is strongly associated with resistant pathogens in animals [14]. The strategy of restriction of antibiotic use in food animals includes (i) classifying all classes of antibiotics used in animals as restricted, (ii) initiating quality evaluation of antibiotic prescribing in veterinary clinics, (iii) establishing a mandatory reporting system for the purchase of antibiotic products and (iv) developing infectious diseases treatment guidelines in animals.
Table 1 Summary of the Korean action plan on antimicrobial resistance (AMR), 2016–2020. Objectives and priority areas
1. Promote the prudent use of antimicrobial medicines - Enforce quality evaluation programmes of antibiotic use - Develop and distribute prescription guidelines on antibiotic use
Indicators
Stakeholders Human sector
Environment sector
Rate of antibiotic prescription in acute respiratory tract infections Rate of antibiotic prescription based on laboratory testing Number of restricted antibiotics in animal sectors
KCDC, HIRA, MoHW
MFAFF, MOF
Rate of washing hands of physicians Rate of nosocomial infections in ICUs
KCDC, MoHW
MFAFF, MOF
KCDC, HIRA, MoHW
MFAFF, MOF, MFDS
- Enhance appropriate antibiotic use in the animal sector
2. Prevent the spread of AMR - Improve institutional policies regarding infection prevention and control - Timely determination of patients infected with resistant pathogens
3. Strengthen the surveillance system - Improve and support AMR surveillance at hospital and community levels
Number of infectious diseases specialists in a hospital Isolation rate of MRSA, VRE and CRE Amounts of antibiotic consumption of humans and animals
- Improve surveillance of antibiotic consumption
4. Improve awareness
Rate of people believing antibiotics help to treat common cold Rate of people quitting antibiotics without physician agreement
KCDC, MoHW
MFAFF, MOF, MFDS
5. Strengthen research and development
Amount of investment
KCDC, MoHW, MSIP, MoSF, MoI
MFDS, MOF
KCDC, MoHW, MoFA, MoSF
MFDS, MFAFF
Number of development of diagnostic kits and new drugs 6. Enhance international collaboration
Amounts of international funds contributed Number of international meetings participated
KCDC, Korean Centers for Disease Control and Prevention; HIRA, Health Insurance Review and Assessment; MoHW, Ministry of Health and Welfare; MFAFF, Ministry for Food, Agriculture, Forestry and Fisheries; MOF, Ministry of Oceans and Fisheries; ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycinresistant enterococci; CRE, carbapenem-resistant Enterobacteriaceae; MFDS, Ministry of Food and Drugs Safety; MSIP, Ministry of Science, ICT and Future Planning; MoSF, Ministry of Strategy and Finance; MoI, Ministry of Interior; MoFA, Ministry of Foreign Affairs.
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3.2. Objective 2. Prevent the spread of antimicrobial resistance Insufficient infection prevention in hospitals is one of the major factors in the emergence of AMR. This is the result of the heavy use of antibiotics in hospitals, especially intensive care units (ICUs), where high-density populations are in frequent contact with medical staff [15]. The high prevalence of MRSA (86.6%) and imipenem-resistant A. baumannii (83.1%) in ICUs is reaching alarming levels in Korea [16].
analyse usage trends and evaluate control programmes. Likewise, the Korean national surveillance programme will examine the antibiotic consumption of humans and animals. In terms of animals, monitoring the population of livestock animals (including cattle, swine, chickens and ducks) will be extended from 400 to 1200, and a national AMR residue detection programme from cow’s milk and fish will be operated by the Ministry for Food, Agriculture, Forestry and Fisheries (MFAFF). 3.4. Objective 4. Improve awareness
3.2.1. Improve institutional policies regarding infection prevention and control Early detection of patients colonised with multidrug-resistant (MDR) pathogens and application of patient isolation procedures are effective measures for preventing the spread of AMR in hospitals. The KMoHW will offer medical institutions introducing isolation rooms for patients with MDR infections economic benefits on a ‘pay for implementation’ basis to limit the financial burden. Furthermore, standardised infection control measures to prevent nosocomial infections will be developed by the KMoHW in 2017. To enhance the infection control capacity of hospitals, the KMoHW will promote infection control stewardship units in midsized hospitals. Furthermore, the staff in these units will be required to acquire certification from the nosocomial infection control programme. The activity of these units will be assessed by the Korean Institution for Healthcare Accreditation. 3.2.2. Timely determination of patients infected with resistant pathogens Urinary catheters and decubitus ulcers are risk factors for infection and spreading of AMR among elderly nursing home residents [17]. Hence, it is important to track patients with antimicrobial-resistant organisms if elderly residents are transferred to acute-care hospitals. An electronic system for tracking patients with vancomycin-resistant S. aureus (VRSA) or carbapenem-resistant Enterobacteriaceae (CRE) will be developed and conducted as a demonstration project in 2017. 3.3. Objective 3. Strengthen the surveillance system A number of reports have emphasised that consumption of antimicrobial agents in food-producing animals is significantly linked to AMR in humans [14]. Therefore, improved surveillance programmes of antibiotic consumption and resistant organisms in humans and animals can support the effectiveness of the AMR containment programme. 3.3.1. Improve and support antimicrobial resistance surveillance at hospital and community levels Since 2007, the KCDC has operated 100 sentinel hospitals and has designated VRSA, MRSA, CRE, vancomycin-resistant enterococci, multiresistant P. aeruginosa and multiresistant A. baumannii as notifiable infectious organisms. Surveillance of VRSA and CRE will be extended to all healthcare facilities by 2017. Furthermore, other resistant organisms (Salmonella,Shigella, Streptococcus pneumoniae, Clostridium difficile and syphilis) will be included in the sentinel surveillance system as per the recommendations of the WHO [18]. Community-based AMR surveillance data have been collected since 2007 as a research project, and the KCDC has been continuously supporting this project to measure AMR at the community level. 3.3.2. Improve surveillance of antibiotic consumption In the European Union, experts of member countries have collected antimicrobial consumption data since 2001 in order to
Political and societal awareness of the AMR threat is critical in order to stimulate intervention programmes to fight against AMR. A previous study showed that only 5% of nationally funded AMR projects conducted between 2003 and 2013 were focused on awareness improvement [6]. Most of the previous reports were surveys measuring public knowledge of AMR as well as publications of antimicrobial treatment guidelines. Educational interventions should be implemented to promote behaviour changes through public campaigns. Hence, the KMoHW will conduct a campaign with messages that will include (i) taking antibiotics in the proper dose and period, (ii) not taking antibiotics for common cold, (iii) ensuring antibiotics are prescribed by doctors and (iv) disposing of unused antibiotics at drug stores or public health centres. To raise awareness of the importance of antibiotics among health professionals, veterinarians and fisheries, AMR will be added as a compulsory component of medical and veterinary education with awareness evaluation programmes. 3.5. Objective 5. Strengthen research and development Novel breakthrough technologies such as rapid diagnostic test kits to determine whether infections are bacterial or viral and indicating specific bacteria with resistance will considerably help physicians to prescribe antimicrobials appropriately [19]. A recent Korean study showed that between 2003 and 2013, the most funding was applied to basic microbial and surveillance research (72.2% of total projects), yet little was applied to research focusing on the area of awareness improvement (5.1%), optimal use of antibiotics (5.6%) and economic evaluation (0.5%) [6]. Basic microbial research programmes will be continuously fostered by targeting AMR, including (i) epidemiological research on transmission, (ii) development of rapid diagnostic kits and (iii) development of new drugs. Assessment of the economic burden of AMR and the effectiveness of infection control programmes in health care will be conducted. 3.6. Objective 6. Enhance international collaboration The increasing number of medical tourists from China is an emerging issue related to AMR in Korea because international travel allows AMR to spread from country to country. To operate a globally standardised surveillance system, Korea joined the Global Antimicrobial Resistance Surveillance System (GLASS) in 2016. In addition, the Republic of Korea, as a leading country of the Global Health Security Agenda and Codex Alimentarius Commission on AMR in 2017, will contribute to global efforts in the fight against AMR. 4. Conclusions Resistance rates and antimicrobial consumption have been increased in Korea. The ability to respond to the emerging threat from AMR depends on strengthening the six objectives areas in the action plan. Multisectoral co-ordination with a One Health concept based on the WHO’s principles is included. This new Korean
S. Ryu / Journal of Global Antimicrobial Resistance 8 (2017) 70–73
national action plan will be the cornerstone of public health for the everlasting war with AMR in Korea. Funding None. Competing interests None declared. Ethical approval Not required. Acknowledgements RS, a former medical officer of the Korea Centers for Disease Control and Prevention, developed the draft of this national action plan. The author expresses his deep gratitude to the Korean Ministry of Health and Welfare to formulate the AMR action plan. The author appreciates the help of Prof. Visanu Thamlikitkul (Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand) and Dr Michael G. Head (Faculty of Medicine, University of Southampton, Southampton, UK) for useful comments during the preparation of the manuscript. References [1] Theuretzbacher U. Global antibacterial resistance: the never-ending story. J Glob Antimicrob Resist 2013;1:63–9. [2] Park EJ. Impact of antimicrobial resistance on economic outcome. Sejong City, South Korea: Korea Institute for Health and Social Affairs; 2006. [3] Ministry of Health and Welfare. National action plan on antimicrobial resistance. Press release August 11. http://www.mohw.go.kr/front_new/al/ sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&page=2&CONT_SEQ=333859. [Accessed 21 August 2016].
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[4] Organisation for Economic Co-operation and Development (OECD). Antimicrobial resistance. OECD; 2016 https://www.oecd.org/els/health-systems/ antimicrobial-resistance.htm. [Accessed 21 August 2016]. [5] Kim HS, Kim JI, Chan C. Monitoring of antimicrobial resistance on non-tertiary hospitals in Korea, 2007–2013. Public Health Wkly Rep 2015;8:1092–5 http:// www.cdc.go.kr/CDC/cms/cmsFileDownload.jsp?fid=31&cid=66231&fieldName=attach1&index=1. [Accessed 21 August 2016]. [6] Ryu S, Head MG, Kim BI, Hwang J, Cho EH. Are we investing wisely? A systematic analysis of nationally funded antimicrobial resistance projects in Republic of Korea, 2003–2013. J Glob Antimicrob Resist 2016;6:90–4. [7] Mayrhofer S, Paulsen P, Smulders F, Hilbert F. Antimicrobial resistance in commensal Escherichia coli isolated from muscle foods as related to the veterinary use of antimicrobial agents in food-producing animals in Austria. Microb Drug Resist 2006;12:278–83. [8] Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory tract infections in the United States. Clin Infect Dis 2001;33:757–62. [9] Yun JM, Shin DW, Hwang S, Cho J, Nam YS, Kim JH, et al. Effect of public disclosure on antibiotic prescription rate for upper respiratory tract infections. JAMA Intern Med 2015;175:445–7. [10] Kim ES, Park SW, Lee CS, Kwak YG, Moon C, Kim BN. Impact of national hospital evaluation program using clinical performance indicators on the use of surgical antibiotic prophylaxis in Korea. Int J Infect Dis 2012;16:e187–92. [11] Simpson SA, Wood F, Butler CC. General practitioners’ perceptions of antimicrobial resistance: a qualitative study. J Antimicrob Chemother 2007;59:292–6. [12] Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005;4:CD003543. [13] Nolan T. A smarter way to practise. BMJ 2011;342:470–1. [14] Marshal BM, Levy SB. Food animals and antimicrobials: impacts on human health. Clin Microbiol Rev 2011;24:718–33. [15] Mammerum AM, Heuer OE. Human health hazards from antimicrobialresistant Escherichia coli of animal origin. Clin Infect Dis 2009;48:916–21. [16] Jeon MH, Kim TH, Kim SR, Chun HK, Han SH, Bang JH, et al. Korean nosocomial infections surveillance system, intensive care unit module report: data summary from July 2012 through June 2013. Korean J Nosocomial Infect Control 2015;20:37–48. [17] Sundvall PD, Elm M, Gunnarsson R, Mölstad S, Rodh N, Jonsson L, et al. Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012. BMC Geriatr 2014;14:30. [18] World Health Organization. Global antimicrobial resistance surveillance system; manual for early implementation. Geneva, Switzerland: WHO; 2015. [19] Kessel AS, Sharland M. The new UK antimicrobial resistance strategy and action plan. BMJ 2013;346:f1601.
Contents lists available at ScienceDirect
Journal of Global Antimicrobial Resistance journal homepage: www.elsevier.com/locate/jgar
Short Communication
The new Korean action plan for containment of antimicrobial resistance Sukhyun Ryu Department of Epidemiology and Medical Informatics, Graduate School of Public Health, Korea University, Anam-ro, Seongbuk-gu, Seoul 02841, Republic of Korea
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 August 2016 Received in revised form 23 October 2016 Accepted 31 October 2016 Available online 23 December 2016
Background: The Korean national action plan on antimicrobial resistance (AMR) was established on 11 August 2016 by the Korean Ministry of Health and Welfare. Methods and results: This article briefly describes the current status of AMR in Korea and introduces six objectives of the action plan, including the prudent use of antimicrobial medicines, prevention of the spread of AMR, strengthening surveillance programmes, awareness improvement, strengthening research and development, and enhancement of international collaboration. Conclusions: Integrated multisectoral principles are applied to fight AMR more effectively. This 5-year national AMR action plan will be the cornerstone of public health in Korea. © 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.
Keywords: Korea Antimicrobial resistance Action plan Policy
1. Introduction The World Health Organization (WHO) has reported that antimicrobial resistance (AMR), which is associated with increased antibiotic consumption and inappropriate infection control, will become a major public health threat in the near future [1]. Previous Korean studies documented that infections caused by methicillinresistant Staphylococcus aureus (MRSA) resulted in an increased economic burden (1.8-fold) and prolonged hospital stay (1.25-fold) [2]. To mitigate this threat, countries such as Austria, Canada, the UK and the USA have established their own national strategies. As part of the development process of a national strategic plan for the containment of AMR, the Korea Centers for Disease Control and Prevention (KCDC) participated in the WHO’s technical meetings and organised multisectoral meetings to share ideas on national AMR strategies with the One Health concept. In May 2015, the 68th World Health Assembly adopted the global action plan for AMR. As a response to the WHO’s global action plan, the Korean steering committee, which was established during previous multisectoral meeting on national AMR strategies, was organised under the Korean Ministry of Health and Welfare (KMoHW). On 11 August 2016, the KMoHW addressed the new Korean 5-year AMR strategy and action plan [3]. This article describes the major concepts of the
Korean AMR action plan in response to the current status of AMR in the Republic of Korea. 2. Current status of antimicrobial resistance in Korea Antimicrobial consumption in Korea is relatively higher [31.7 defined daily doses (DDD) per 1000 inhabitants per day] compared with other member countries of the Organisation for Economic Co-operation and Development (OECD) (23.7 DDD per 1000 inhabitants per day) [4]. In addition, a recent Korean nationwide surveillance study reported that MRSA has become common (ca. 60% of S. aureus), and the prevalence of imipenemresistant Acinetobacter baumannii and imipenem-resistant Pseudomonas aeruginosa increased from 20% to 62% and from 26% to 42%, respectively, between 2007 and 2013 [5]. From 2003 to 2013, Korea conducted the National Antimicrobial Resistance Safety Control Program, yet the most resistant organisms increased even though the annual investment increased [6]. The lack of awareness and legislation for prudent use of antibiotic prescriptions in medical practice in humans and animals as well as the incomplete surveillance and infection control stewardship programme in the health system is considered major drivers of emerging AMR in Korea. 3. Strategies of the Korean antimicrobial resistance action plan
E-mail address: [email protected] (S. Ryu).
The goal of the Korean national AMR action plan is to improve public safety by (i) reducing the prescription of antibiotic agents by
http://dx.doi.org/10.1016/j.jgar.2016.10.013 2213-7165/© 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.
S. Ryu / Journal of Global Antimicrobial Resistance 8 (2017) 70–73
prudent use and (ii) minimising the spread of AMR in the human (community and healthcare settings) and veterinary sectors. The key objectives with priority areas and measurable indicators are described below and in Table 1.
71
that these programmes considerably reduced the volume of antibiotics prescribed [9,10]. To evaluate physicians’ appropriate use of antibiotic agents, therefore, the evaluation programme will be extended to other types of infectious diseases by the KMoHW.
3.1. Objective 1. Promote the prudent use of antimicrobial medicines A number of studies have shown that AMR in humans is strongly linked with the volume of antimicrobial use in humans and animals [1,7]. To meet this objective, a bundle of measures will be adopted to promote the appropriate use of antibiotic agents. These include strengthening quality evaluation of antimicrobial use in health care, developing guidelines on antibiotic use to support physicians and veterinarians prescribe based on evidence, and offering educational programmes for staff-related antibiotic stewardship both in the human and animal sectors. 3.1.1. Enforce quality evaluation programmes of antibiotic use in health care As the common cold is recognised as one of the most inappropriate reasons for antibiotic prescribing [8], Korea initiated the quality evaluation programme of antimicrobial prescriptions for acute upper respiratory infections since 2006 [9] and surgical antibiotic prophylaxis since 2007 [10]. Previous studies showed
3.1.2. Develop and distribute prescription guidelines on antibiotic use The antibiotics that physicians prescribe for common diseases are often inappropriate [11]. In addition, a report indicated that physicians prescribe broader–spectrum agents more often for common infectious diseases [12]. Since timely access to guidelines is important in clinical practice, the KMoHW will develop a pocket guide, internet prescribing tools and a smartphone application to help health professionals provide adequate and timely antimicrobial treatment [13]. 3.1.3. Enhance appropriate antibiotic use in the animal sector A number of studies have documented that the emergence of AMR is strongly associated with resistant pathogens in animals [14]. The strategy of restriction of antibiotic use in food animals includes (i) classifying all classes of antibiotics used in animals as restricted, (ii) initiating quality evaluation of antibiotic prescribing in veterinary clinics, (iii) establishing a mandatory reporting system for the purchase of antibiotic products and (iv) developing infectious diseases treatment guidelines in animals.
Table 1 Summary of the Korean action plan on antimicrobial resistance (AMR), 2016–2020. Objectives and priority areas
1. Promote the prudent use of antimicrobial medicines - Enforce quality evaluation programmes of antibiotic use - Develop and distribute prescription guidelines on antibiotic use
Indicators
Stakeholders Human sector
Environment sector
Rate of antibiotic prescription in acute respiratory tract infections Rate of antibiotic prescription based on laboratory testing Number of restricted antibiotics in animal sectors
KCDC, HIRA, MoHW
MFAFF, MOF
Rate of washing hands of physicians Rate of nosocomial infections in ICUs
KCDC, MoHW
MFAFF, MOF
KCDC, HIRA, MoHW
MFAFF, MOF, MFDS
- Enhance appropriate antibiotic use in the animal sector
2. Prevent the spread of AMR - Improve institutional policies regarding infection prevention and control - Timely determination of patients infected with resistant pathogens
3. Strengthen the surveillance system - Improve and support AMR surveillance at hospital and community levels
Number of infectious diseases specialists in a hospital Isolation rate of MRSA, VRE and CRE Amounts of antibiotic consumption of humans and animals
- Improve surveillance of antibiotic consumption
4. Improve awareness
Rate of people believing antibiotics help to treat common cold Rate of people quitting antibiotics without physician agreement
KCDC, MoHW
MFAFF, MOF, MFDS
5. Strengthen research and development
Amount of investment
KCDC, MoHW, MSIP, MoSF, MoI
MFDS, MOF
KCDC, MoHW, MoFA, MoSF
MFDS, MFAFF
Number of development of diagnostic kits and new drugs 6. Enhance international collaboration
Amounts of international funds contributed Number of international meetings participated
KCDC, Korean Centers for Disease Control and Prevention; HIRA, Health Insurance Review and Assessment; MoHW, Ministry of Health and Welfare; MFAFF, Ministry for Food, Agriculture, Forestry and Fisheries; MOF, Ministry of Oceans and Fisheries; ICU, intensive care unit; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycinresistant enterococci; CRE, carbapenem-resistant Enterobacteriaceae; MFDS, Ministry of Food and Drugs Safety; MSIP, Ministry of Science, ICT and Future Planning; MoSF, Ministry of Strategy and Finance; MoI, Ministry of Interior; MoFA, Ministry of Foreign Affairs.
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3.2. Objective 2. Prevent the spread of antimicrobial resistance Insufficient infection prevention in hospitals is one of the major factors in the emergence of AMR. This is the result of the heavy use of antibiotics in hospitals, especially intensive care units (ICUs), where high-density populations are in frequent contact with medical staff [15]. The high prevalence of MRSA (86.6%) and imipenem-resistant A. baumannii (83.1%) in ICUs is reaching alarming levels in Korea [16].
analyse usage trends and evaluate control programmes. Likewise, the Korean national surveillance programme will examine the antibiotic consumption of humans and animals. In terms of animals, monitoring the population of livestock animals (including cattle, swine, chickens and ducks) will be extended from 400 to 1200, and a national AMR residue detection programme from cow’s milk and fish will be operated by the Ministry for Food, Agriculture, Forestry and Fisheries (MFAFF). 3.4. Objective 4. Improve awareness
3.2.1. Improve institutional policies regarding infection prevention and control Early detection of patients colonised with multidrug-resistant (MDR) pathogens and application of patient isolation procedures are effective measures for preventing the spread of AMR in hospitals. The KMoHW will offer medical institutions introducing isolation rooms for patients with MDR infections economic benefits on a ‘pay for implementation’ basis to limit the financial burden. Furthermore, standardised infection control measures to prevent nosocomial infections will be developed by the KMoHW in 2017. To enhance the infection control capacity of hospitals, the KMoHW will promote infection control stewardship units in midsized hospitals. Furthermore, the staff in these units will be required to acquire certification from the nosocomial infection control programme. The activity of these units will be assessed by the Korean Institution for Healthcare Accreditation. 3.2.2. Timely determination of patients infected with resistant pathogens Urinary catheters and decubitus ulcers are risk factors for infection and spreading of AMR among elderly nursing home residents [17]. Hence, it is important to track patients with antimicrobial-resistant organisms if elderly residents are transferred to acute-care hospitals. An electronic system for tracking patients with vancomycin-resistant S. aureus (VRSA) or carbapenem-resistant Enterobacteriaceae (CRE) will be developed and conducted as a demonstration project in 2017. 3.3. Objective 3. Strengthen the surveillance system A number of reports have emphasised that consumption of antimicrobial agents in food-producing animals is significantly linked to AMR in humans [14]. Therefore, improved surveillance programmes of antibiotic consumption and resistant organisms in humans and animals can support the effectiveness of the AMR containment programme. 3.3.1. Improve and support antimicrobial resistance surveillance at hospital and community levels Since 2007, the KCDC has operated 100 sentinel hospitals and has designated VRSA, MRSA, CRE, vancomycin-resistant enterococci, multiresistant P. aeruginosa and multiresistant A. baumannii as notifiable infectious organisms. Surveillance of VRSA and CRE will be extended to all healthcare facilities by 2017. Furthermore, other resistant organisms (Salmonella,Shigella, Streptococcus pneumoniae, Clostridium difficile and syphilis) will be included in the sentinel surveillance system as per the recommendations of the WHO [18]. Community-based AMR surveillance data have been collected since 2007 as a research project, and the KCDC has been continuously supporting this project to measure AMR at the community level. 3.3.2. Improve surveillance of antibiotic consumption In the European Union, experts of member countries have collected antimicrobial consumption data since 2001 in order to
Political and societal awareness of the AMR threat is critical in order to stimulate intervention programmes to fight against AMR. A previous study showed that only 5% of nationally funded AMR projects conducted between 2003 and 2013 were focused on awareness improvement [6]. Most of the previous reports were surveys measuring public knowledge of AMR as well as publications of antimicrobial treatment guidelines. Educational interventions should be implemented to promote behaviour changes through public campaigns. Hence, the KMoHW will conduct a campaign with messages that will include (i) taking antibiotics in the proper dose and period, (ii) not taking antibiotics for common cold, (iii) ensuring antibiotics are prescribed by doctors and (iv) disposing of unused antibiotics at drug stores or public health centres. To raise awareness of the importance of antibiotics among health professionals, veterinarians and fisheries, AMR will be added as a compulsory component of medical and veterinary education with awareness evaluation programmes. 3.5. Objective 5. Strengthen research and development Novel breakthrough technologies such as rapid diagnostic test kits to determine whether infections are bacterial or viral and indicating specific bacteria with resistance will considerably help physicians to prescribe antimicrobials appropriately [19]. A recent Korean study showed that between 2003 and 2013, the most funding was applied to basic microbial and surveillance research (72.2% of total projects), yet little was applied to research focusing on the area of awareness improvement (5.1%), optimal use of antibiotics (5.6%) and economic evaluation (0.5%) [6]. Basic microbial research programmes will be continuously fostered by targeting AMR, including (i) epidemiological research on transmission, (ii) development of rapid diagnostic kits and (iii) development of new drugs. Assessment of the economic burden of AMR and the effectiveness of infection control programmes in health care will be conducted. 3.6. Objective 6. Enhance international collaboration The increasing number of medical tourists from China is an emerging issue related to AMR in Korea because international travel allows AMR to spread from country to country. To operate a globally standardised surveillance system, Korea joined the Global Antimicrobial Resistance Surveillance System (GLASS) in 2016. In addition, the Republic of Korea, as a leading country of the Global Health Security Agenda and Codex Alimentarius Commission on AMR in 2017, will contribute to global efforts in the fight against AMR. 4. Conclusions Resistance rates and antimicrobial consumption have been increased in Korea. The ability to respond to the emerging threat from AMR depends on strengthening the six objectives areas in the action plan. Multisectoral co-ordination with a One Health concept based on the WHO’s principles is included. This new Korean
S. Ryu / Journal of Global Antimicrobial Resistance 8 (2017) 70–73
national action plan will be the cornerstone of public health for the everlasting war with AMR in Korea. Funding None. Competing interests None declared. Ethical approval Not required. Acknowledgements RS, a former medical officer of the Korea Centers for Disease Control and Prevention, developed the draft of this national action plan. The author expresses his deep gratitude to the Korean Ministry of Health and Welfare to formulate the AMR action plan. The author appreciates the help of Prof. Visanu Thamlikitkul (Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand) and Dr Michael G. Head (Faculty of Medicine, University of Southampton, Southampton, UK) for useful comments during the preparation of the manuscript. References [1] Theuretzbacher U. Global antibacterial resistance: the never-ending story. J Glob Antimicrob Resist 2013;1:63–9. [2] Park EJ. Impact of antimicrobial resistance on economic outcome. Sejong City, South Korea: Korea Institute for Health and Social Affairs; 2006. [3] Ministry of Health and Welfare. National action plan on antimicrobial resistance. Press release August 11. http://www.mohw.go.kr/front_new/al/ sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&page=2&CONT_SEQ=333859. [Accessed 21 August 2016].
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[4] Organisation for Economic Co-operation and Development (OECD). Antimicrobial resistance. OECD; 2016 https://www.oecd.org/els/health-systems/ antimicrobial-resistance.htm. [Accessed 21 August 2016]. [5] Kim HS, Kim JI, Chan C. Monitoring of antimicrobial resistance on non-tertiary hospitals in Korea, 2007–2013. Public Health Wkly Rep 2015;8:1092–5 http:// www.cdc.go.kr/CDC/cms/cmsFileDownload.jsp?fid=31&cid=66231&fieldName=attach1&index=1. [Accessed 21 August 2016]. [6] Ryu S, Head MG, Kim BI, Hwang J, Cho EH. Are we investing wisely? A systematic analysis of nationally funded antimicrobial resistance projects in Republic of Korea, 2003–2013. J Glob Antimicrob Resist 2016;6:90–4. [7] Mayrhofer S, Paulsen P, Smulders F, Hilbert F. Antimicrobial resistance in commensal Escherichia coli isolated from muscle foods as related to the veterinary use of antimicrobial agents in food-producing animals in Austria. Microb Drug Resist 2006;12:278–83. [8] Gonzales R, Malone DC, Maselli JH, Sande MA. Excessive antibiotic use for acute respiratory tract infections in the United States. Clin Infect Dis 2001;33:757–62. [9] Yun JM, Shin DW, Hwang S, Cho J, Nam YS, Kim JH, et al. Effect of public disclosure on antibiotic prescription rate for upper respiratory tract infections. JAMA Intern Med 2015;175:445–7. [10] Kim ES, Park SW, Lee CS, Kwak YG, Moon C, Kim BN. Impact of national hospital evaluation program using clinical performance indicators on the use of surgical antibiotic prophylaxis in Korea. Int J Infect Dis 2012;16:e187–92. [11] Simpson SA, Wood F, Butler CC. General practitioners’ perceptions of antimicrobial resistance: a qualitative study. J Antimicrob Chemother 2007;59:292–6. [12] Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2005;4:CD003543. [13] Nolan T. A smarter way to practise. BMJ 2011;342:470–1. [14] Marshal BM, Levy SB. Food animals and antimicrobials: impacts on human health. Clin Microbiol Rev 2011;24:718–33. [15] Mammerum AM, Heuer OE. Human health hazards from antimicrobialresistant Escherichia coli of animal origin. Clin Infect Dis 2009;48:916–21. [16] Jeon MH, Kim TH, Kim SR, Chun HK, Han SH, Bang JH, et al. Korean nosocomial infections surveillance system, intensive care unit module report: data summary from July 2012 through June 2013. Korean J Nosocomial Infect Control 2015;20:37–48. [17] Sundvall PD, Elm M, Gunnarsson R, Mölstad S, Rodh N, Jonsson L, et al. Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012. BMC Geriatr 2014;14:30. [18] World Health Organization. Global antimicrobial resistance surveillance system; manual for early implementation. Geneva, Switzerland: WHO; 2015. [19] Kessel AS, Sharland M. The new UK antimicrobial resistance strategy and action plan. BMJ 2013;346:f1601.