Abstract
Antimicrobial resistance (AMR) is a major global public health threat. One of the principal drivers of AMR is the
inappropriate use of antimicrobial agents. Therefore, antimicrobial stewardship programs (ASPs) play a critical
role in promoting appropriate antimicrobial use and slowing the emergence and spread of antimicrobial
resistance in Thailand. However, implementation of ASPs remains challenging in many hospitals because of
limited numbers of trained personnel and insufficient organizational infrastructure to support stewardship
activities.
Between 2019 and 2021, the research team from the Faculty of Medicine Siriraj Hospital conducted the
Expanded AMS program Phase IV in three provincial hospitals—Sa Kaeo Crown Prince Hospital, Surin Hospital,
and Surat Thani Hospital—with funding from the Health Systems Research Institute (HSRI). The project focused
on strengthening ASPs through three core interventions: (1) development of hospital antimicrobial resistance
surveillance using the GLASS antibiogram, (2) implementation of evidence-based clinical practice guidelines
(CPGs) for common infectious diseases, and (3) antibiotic authorization programs. Each hospital's infectious
diseases physician served as the project leader. The project successfully reduced inappropriate antimicrobial
use and significantly improved the quality of patient care.
Building upon the success of Phase IV, the research team implemented The Expanded AMS Program
Phase V (2024–2026) to expand these successful ASP strategies to smaller general hospitals within the same
health regions. The program continued to focus on the three key interventions—GLASS antibiograms, clinical
practice guidelines, and antibiotic authorization—implemented with technical support from experienced model
hospitals. The participating hospitals were organized into two regional networks:
1. Northeastern Region: Kalasin Hospital, Maha Sarakham Hospital, Roi Et Hospital; Supported by Surin
Hospital (model hospital)
2. Southern Region: Chumphon Khet Udomsak Hospital, Krabi Hospital, Takuapa Hospital; Supported
by Surat Thani Hospital (model hospital)
Analysis of the three project components yielded the following key findings:
1. GLASS Antibiogram Project
Implementation of GLASS antibiograms provided a more comprehensive understanding of local antimicrobial
resistance patterns. Susceptibility profiles varied considerably according to the site of infection and between
community-acquired and hospital-acquired infections, even for the same bacterial species. Incorporating these
locally derived microbiological and epidemiological data into hospital-specific treatment guidelines enabled
more accurate empirical antibiotic recommendations and facilitated more targeted interventions against
antimicrobial resistance.
2. Clinical Practice Guideline (CPG) Project
Locally adapted clinical practice guidelines proved to be practical, feasible, and readily accepted within
participating hospitals, with minimal barriers to implementation. The intervention significantly improved the
appropriateness of antimicrobial prescribing. Although it did not reduce overall antimicrobial consumption, it
demonstrated a trend toward reduced in-hospital mortality.3. Antibiotic Authorization Project
Implementation of antibiotic authorization programs, supported by experienced stewardship teams, was
resource-intensive and posed operational challenges, particularly in hospitals without infectious diseases
specialists. Nevertheless, the intervention reduced both the overall duration of antimicrobial therapy and the
duration of use of targeted broad-spectrum antibiotics. It also showed trends toward improved clinical outcomes
and lower rates of secondary infections.
Overall, the findings demonstrate that implementing antimicrobial stewardship programs in secondarylevel general hospitals through three core strategies—GLASS antibiograms, clinical practice guidelines, and
antibiotic authorization—can reduce inappropriate antimicrobial use while improving the quality of patient care.
The research team anticipates that the lessons learned from this project can be successfully scaled up to other
hospitals throughout Thailand, particularly those without infectious diseases specialists or established
antimicrobial stewardship programs. The model of mentorship and technical support provided by more
experienced hospitals offers a practical and sustainable approach for strengthening antimicrobial stewardship
capacity nationwide.
