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Carlo Perrone is a research physician based at the Mahidol Oxford Tropical Medicine Research Unit and is the head of the Chiang Rai Clinical Research Unit in Chiangrai, Thailand

Help us understand…about you and you work 

The challenges we face include the following:

  • Which infectious diseases are most common in the region?
  • How should we treat them?
  • Which strategies and biomarkers would be most effective and convenient in directing antibiotic treatment ?
  • And to better understand scrub typhus, the most common treatable cause of undifferentiated acute febrile illness in the region. How do we improve its diagnosis and treatment, thereby reducing its burden. 

We have studied the epidemiology of undifferentiated febrile illnesses in the region, we are now conducting a randomised trial to find out how to best treat scrub typhus, this and other studies will gather important information on diagnostics and pathophysiological disease features.

We are engaging with community health workers and community health volunteers to raise the awareness of scrub typhus and reduce its burden. A previous project focused on antibiotic usage in primary care units, this information, together with the results of the GRAM project, will help identify areas in which improvement can be made and help to plan future antibiotic stewardship interventions.

AMR is fascinating because it exemplifies the extraordinary adaptability of microorganisms, and indirectly of all living creatures. The increasing threat it poses also  brings out some of the flaws in human societies, who tend to underestimate (or even ignore) slow paced threats irrespective of their magnitude or their potential consequences.

Help us understand… about your collaboration with the GRAM project

Together with Chiangrai Prachanukroh Hospital microbiology and IT departments we gathered the results of all positive blood and CSF cultures from 2017 - 2019 as well as the characteristics of the corresponding hospital admissions, we merged the data so the isolates could be contextualised with the hospital diagnosis and the antibiotic therapy that was prescribed.

Thailand Is a country where antibiotic resistance constitutes a dramatic problem, nonetheless, the country’s public health measures in the past have been extremely successful in tackling issues such as HIV, birth control and in limiting the availability of antimalarial drugs without a doctor’s prescriptions. As the country now considers AMR a priority, we are in a unique position to see what kind of impact aimed interventions can have in a middle-income setting, potentially setting an example for other countries struggling with similar problems.

I am interested in the drivers of antibiotic resistance and in how policies and practices can help reduce AMR burden. Most of the scientific literature on AMR (and in general) is generated by a small portion of the world, so the solutions and strategies proposed might not be applicable to the majority of the globe’s population. In my opinion it is essential to try and estimate AMR burden globally, find global solutions and delineate global strategies that can be adapted into local realities. Additionally, as the COVID-19 pandemic has made dramatically clear, infectious diseases know no borders and will spread from one region to another if left un-tackled.

Help us understand... the context of AMR

It is increasingly common for patients with multi-drug resistant (MDR) sepsis to occupy intensive care beds for long periods of time, the use of second- or third-line antibiotic treatments is also very common. Consequently, risks of antibiotic related toxicity, treatment costs and death rates due to AMR bacteria are rising as well.

In a recent publication, it was estimated that over 40% of 45,209 deaths due to hospital-acquired infections in Thailand were due to MDR bacteria (Lim et al., 2016). Antibiotics can be purchased freely at local pharmacies in Thailand and are readily prescribed by general practitioners. While access to antibiotics is effective, there is limited knowledge by the population of what antibiotics are and how they differ from anti-inflammatory drugs. The consequences of overuse are also not known by the general population. The free access to antibiotics and how their inappropriate use can impact population health.

The most helpful tools to address AMR in Thailand would be to develop clear, evidence based local guidelines on who should receive antibiotics and which class and making sure these guidelines are understood followed by all entities who can provide antibiotics, including pharmacies. Also, inform the general population on the risks of antibiotic misuse. 

How has your laboratory been affected by the covid-19 pandemic?

Clinical studies involving patient contact and work in the laboratory have been intermittently paused based on local transmission risk. Overall Thailand has been affected less than most western countries and the limitations on activities have not been as dramatic. It is also likely, and has already happened, especially in the early phases of the epidemic, that patients with COVID-19 or suspected COVID-19 will receive antibiotics they don't need (eg Azithromycin).

Help us understand...your perspective on the global picture and the future

The global AMR community should focus on community data, on antibiotic usage outside large hospitals and the perception in the general population to inform and try to involve the community in the search for solutions to inappropriate antibiotic usage.

In 5 - 10 years time I imagine in hospitals the number of deadly infections caused by multi-resistant organisms will increase, if this is the case, eventually it will reach a point where the need for urgent action will be obvious, this would drive antibiotic research, policy improvement and general awareness. Hopefully the latter three will increase without the need for MDR disease burden to reach dramatic levels.

The biggest threat to getting AMR under control are socio-economic factors that make excessive antibiotic use likely. For example subjects that cannot afford the loss of a days work or many visits to the doctor. Similarly physicians or healthcare workers who have insufficient resources for a watch and wait approach (re-schedule a visits in 3 days, remote follow up) will be more likely to over-prescribe antibiotic therapy.

Carlo.jpg From left to right: 

Nipaphan Kanthawang, Nidanuch Tasak, Carlo Perrone, Nongyao Kattha, Ploypatcha Kaewwiset and Areerat Thaiprakhong