1. TBS November 4, 2014 1 |1 | AMR and appropriate use of antimicrobials Nicola Magrini and Jane Robertson Policy, Access and Use Team, EMP TBS 4 November 2014

2. TBS November 4, 2014 2 |2 | Optimize use  Regulatory mechanisms for new antibiotics  Effective low-cost tools for diagnosis and susceptibility testing  Access to medicines accompanied by measures to protect continued efficacy  Code of practice

3. TBS November 4, 2014 3 |3 | Optimizing use of antimicrobials Policy makers and regulators (Government level) Providers and health professionals Public and patients Producers and distributors Payers

4. TBS November 4, 2014 4 |4 | Policy makers and regulators Registration and licensing of dispensing outlets Ensuring that access to antimicrobials is prescription only Marketing authorization only for effective, safe, quality- assured antimicrobials; avoid illogical combinations of agents Adequate human and financial resources to manage AMR Developing indicators to monitor and evaluate the use of antimicrobial agents, and assess impact of AMR strategies Identify and eliminate perverse economic incentives

5. TBS November 4, 2014 5 |5 | Policy makers and regulators II – health system Establish infection control programs Develop guidelines and formularies for hospital setting D&T Committees to monitor activities/use of antimicrobials Support multi-disciplinary antibiotic stewardship programs Limit pharmaceutical industry activities in hospitals Ensuring access to appropriate laboratory facilities for testing with timely reporting of results Dissemination of AMR surveillance reports

6. TBS November 4, 2014 6 |6 | Providers and health professionals Undergraduate, postgraduate education programs on the appropriate use of antimicrobials and disease prevention Awareness and use of STGs, limited medicines formularies Raising awareness of industry promotion; what may be in accord with PI may not be appropriate for the setting and local resistance patterns Role in educating patients on appropriate antimicrobial use Audit/feedback of prescribing and dispensing, peer review Linking ongoing registration to commitments to CME

7. TBS November 4, 2014 7 |7 | Public and patients Education on the appropriate use of antimicrobials Importance of preventing infection including immunization Hand-washing, good food hygiene to reduce transmission Encourage appropriate health-care seeking behaviour; manage expectations of a prescription for an antimicrobial Identifying alternatives to antimicrobials for symptom relief Discouraging self-initiation of treatment Encouraging adherence to prescribed regimens

8. TBS November 4, 2014 8 |8 | Producers and distributors Requiring compliance with international codes of practice for industry and/or developing local codes of practice Regulations for direct-to-consumer advertising and advertising on the internet Monitoring compliance of promotional activities Normal business models cannot apply for new antimicrobials – want to limit sales to preserve efficacy

9. TBS November 4, 2014 9 |9 | Payers Opportunities to influence how antimicrobials are financed and used Reimbursement for selected medicines/clinical conditions –Restrictions for critical antimicrobials –Some agents only initiated by infectious disease specialists –Limit duration of treatment without specialist review In resource-limited settings may be issue of adequate procurement of appropriate antimicrobials for the public sector

10. TBS November 4, 2014 10 | Addressing AMR Complex and difficult; involves behaviour change Multi-faceted interventions are needed Commitment at all levels