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About HKCFP > President’s Message

January 2018

Antimicrobial Resistance (AMR) has caused a media storm over the past two months with a lot of discussions amongst primary care doctors. Being the Chairman of the Advisory Group for Antibiotic Stewardship Programme (ASP) in Primary Care under the umbrella of Centre for Health Protection (CHP), I might be the best person to explain the ins and outs.

The burden of AMR in United States alone (2013) caused more than 23000 deaths, 2 million infections. direct healthcare costs in excess of US$20 billion and loss of productivity at US$35 billion. AMR does not respect country border, and is an international threat. It has been estimated that if no effective measures are implemented by 2050, 10 million annual deaths or one death in every three seconds and loss of 2-3% global GDP accounting to US$ 100 trillion could be incurred. This is the dire number one heath issue we are all facing at the moment.

The first world Antibiotic Awareness Week (AAW) was initiated by the World Health Organization (WHO) started in 2015.

It aims to increase awareness of global AMR and to encourage best practices among the general public, healthcare workers and policy makers to avoid the further emergence and spread of AMR. 13 to 19 November 2017 was the AAW, themed as “Seek advice from a qualified healthcare professional before taking antibiotics”. Appropriate use of antimicrobial agents is one of the essential factors in controlling the emergence of antimicrobial resistance (AMR). To echo the health promotion activities during AAW, the Centre for Health Protection announced the launch of Antibiotic Stewardship Programme (ASP) in Primary Care.

Antibiotic Stewardship is defined as coordinated interventions designed to improve and measure the appropriate use of antibiotics by promoting the selection of the optimal antibiotic regimen including dosage, duration of therapy and route of administration. ASP in Primary Care in UK, US and France results in significant reduction of antibiotic use with no significant change in admissions to hospital, reconsultations or costs.

ASP has been identified as a key measure for reducing unnecessary prescriptions, suppressing AMR emergence, and at the same time controlling medical expenses. The development and implementation of ASP is relatively mature in local hospital settings. However, the support for and promotion of proper use of antimicrobials can be enhanced in the primary health care setting. The Advisory Group is chaired by me and composed of key stakeholders from local experts and academia in the fields of family medicine, microbiology, public health, pharmacology and professional bodies such as the Hong Kong Medical Association, the Hong Kong Doctors Union and healthcare maintenance organizations from the community. We started working in March 2017 for developing a series of evidence-based guidance notes for common infections in primary care. Currently, three guidance notes on acute pharyngitis, acute uncomplicated cystitis in women, and simple (uncomplicated) skin and soft tissue infections have been published and the development of other guidance notes for common infections will continue. In addition, education materials for patients such disease information sheets, posters and pamphlets are also produced to facilitate doctors in explaining the nature of infectious diseases, importance of compliance with doctors’ instructions and advising the public not to use antibiotics indiscriminately.

So how serious is AMR in Hong Kong? According to DH statistics, the number of community-associated methicillin-resistant Staphylococcus aureus (MRSA) cases notified to the CHP has increased five-fold in the past nine years with approximately 1,000 reports annually in the recent three years. Hospital Authority Superbug Report 2011-2016 showed the percentage of isolates cultured to have multi-drug resistant organism:MRSA about 45% and ESBL producing E coli about 35%. What it means is we are near the top of the global AMR league!

So who should take the blame? Certainly not the primary care doctors! The antibiotic prescribing rate for URTI (2014) in Hong Kong was 5-6% (decreased from 8% in 2005; and when compared with 50% in Australia and 80% in China which was one of the lowest in the Asia Pacific region. The liberal use of antibiotic in poultry and cattle imported to Hong Kong has not gone unnoticed. Antibiotics like Cephalosporin which have a shorter half-life are commonly used in cattle farming and untraceable by the time the cattle was sold. However, a local study by the Chinese University of Hong Kong in 2016 on cough showed the antibiotic prescribing pattern: 17.4% in private versus 1.6% in public consultation. The clinicians’ perception of benefit from antibiotic, patients’ request and their expectation, as well as the severity of symptoms are the reasons for antibiotic use. Diagnostic uncertainty is the most common reason for local doctors to prescribe antibiotics to patients with URTI.

The challenges we are facing: Firstly, use of diagnostic tests are not common as cost of laboratory testing and the report timing of specimen culture which will take 3 days make doctors rely heavily on their clinical judgement. Decision to prescribe antibiotics is rarely based on definitive diagnosis. Evidence-based prescribing and dispensing should be the standard of care.

Secondly, the lack of local epidemiology data on resistance pattern of common pathogens especially in private primary care is another hot issue. The establishment of our advisory group is not for compulsory surveillance of antibiotic use in private sector though we will try to work out possible ways to understand the private practice in antibiotic use and to evaluate the effectiveness of programme. We are going to conduct a survey by obtaining feedback from primary care doctors through questionnaires during training sessions. Their views on awareness, usefulness of ASP materials and their frequency of antibiotic prescription for the three diseases in the guidelines will be collected. We have approached HMOs for feasibility to get their data for analysis. Though they have reservation to provide data due to privacy issue, they start to move forward by looking into the antibiotic use in their organisations. The use of electronic channel like eHRSS is not well adopted by primary care doctors for record sharing though this method will progress down the years and should be encouraged. I have heard a microbiologist who recommended taking photos of medication bags and submitting to Department of Health for data collection. This is impractical and can be misleading. The bag is dumb about the clinical presentations, working diagnosis and background situations.

Thirdly, public and patients’ support for reduction of unnecessary antibiotic prescription is essential. The survey by CHP indicates 97% of Hong Kong people agree to non-prescription of antibiotic if doctor explains clearly. Another survey shows a staggering 54% of people misunderstand antibiotic can cure URTI. That is why patient education is of prime importance.

I can summarize the following keys points: 1. Optimisation of antimicrobial use is one of the keys to combat AMR. 2. Enhance surveillance on antimicrobial resistance and antimicrobial use in primary care is an important initiative. 3. Doctors should prescribe antibiotics when indicated and with reference to the latest local prevalence and susceptibility profiles. 4. Development of guidelines to provide doctors with the knowledge and confidence of appropriate standard of antibiotic prescription should be a future direction. 5. Good doctor-patient relationship enhances judicious use of antibiotics by patients through education. 6. Antibiotics are our precious resources and everybody has the responsibility to treasure and prevent its misuse.

Dr. Angus M W CHAN