Epidemiology of antimicrobial resistance in patients presenting at 3 sentinel surveillance hospitals in Chiang Mai province, Thailand, April 2017 – January 2018 : a thesis presented in partial fulfilment of the requirements for the degree of Master of Public Health at Massey University, School of Health Sciences, Collage of Health, Massey University, Palmerston North, New Zealand

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Antimicrobial resistance (AMR) defined as microorganisms including bacteria, viruses, fungi, and parasites have the ability to resist the effect of antimicrobial drugs is a serious global public health problem which is apparently increasing. The consequences of AMR include health and economic impacts. The World Health Organization has launched a global action plan on AMR to encourage countries to tackle the crisis of AMR urgently. Thailand approved a national strategic plan on AMR and the Bureau of Epidemiology established a surveillance system on AMR at 6 sentinel hospitals in 4 provinces including 3 sentinel hospitals in Chiang Mai. Study I described the epidemiological characteristics of sepsis patients infected with a pathogen with AMR bacterial infection in 3 sentinel hospitals in Chiang Mai, April 2017 – January 2018. Study II was conducted to examine differences between characteristics of patients by AMR status for all bacterial infections and identify potential risk factors for AMR and for death among the patients in Chomthong hospital, Chiang Mai, April – October 2017. Data from patients infected with bacteria (both AMR and non-AMR) from Chomthong hospital was used in the analyses in Study II. Descriptive statistics were used to present prevalence, incidence, proportion, mean with standard deviation, median with interquartile range. Age-adjusted morbidity rates were calculated for each district. Univariate and multivariate analysis was performed to examine associations between potential risk factors and the outcome. Results were presented as odds ratio (OR) and adjusted OR. Inferential statistics was done to determine p-values and 95% confidence intervals. A backward stepwise approach was performed to select potential risk factors in the multivariate analysis. The results reveal that there were 148 sepsis patients infected with eight selected AMR pathogen over the study period from 3 sentinel hospitals. Overall prevalence of sepsis patients infected with a pathogen with AMR in Chiang Mai province may be higher than 9.2 cases per 100,000 population and Case fatality rate (CFR) for sepsis patients infected with a pathogen with AMR was 23% (34/148). The percentage of female patients overall was 51.3%. The median of age of the patients in the three hospitals ranged from 64.0 to 68.0 years. The highest percentage of the AMR organisms was E. coli accounting for approximately 56.8%. About forty percent (53/132) of sepsis patients infected with a pathogen with AMR were hospital-acquired infection (HAI). About one-third of sepsis patients infected with a pathogen with AMR in Nakornping occurred in rainy season in Thailand. In Chomthong hospital, 62% (13/21) of A. baumannii isolates were multidrug resistant (MDR), which was defined as resistance to ≥ 1 antibiotic agent in ≥ 3 antibiotic classes, following by E. coli isolates 42.2% (89/211), K. pneumoniae isolates 37% (25/67), and P. aeruginosa isolates 31% (13/41). Underlying disease, HAI, and E. coli infection were risk factors for AMR infection for which the adjusted ORs were 2.66 (95%CI 1.13 – 6.25), 4.39 (95%CI 1.84 – 10.48), and 10.69 (95%CI 4.47 – 25.55) respectively. HAI, MDR infection, and sepsis were risk factors for death during hospitalisation period which the adjusted ORs were 3.05 (95%CI 1.08 – 8.65), 3.95 (95%CI 1.30 – 12.00), and 4.62 (95%CI 1.51 – 14.11) respectively. Antimicrobial resistance was still a problem in Chiang Mai. Public health sectors should take an AMR to be an important issue to increase resources including workforce, budget, and equipment support to the surveillance system. Strengthening HAI prevention and control programme could reduce the occurrence of AMR and death during the patients’ hospitalisation.