Improving Use of Medicines

Appropriate use of medicines is a major building block of all health systems and can be used as a tracer of service delivery. During the last six years, the Health Systems and Policy research group has made major contributions in relation to measuring, understanding, and improving antimicrobial adherence.

The thematic area also addresses the global threat of antibiotic resistance by conducting research, training, and policy dialogues aiming at improved use of antibiotics by consumers and providers, both at a global and local level. In addition, the area will also further develop research on antibiotics and the environment, especially in water sources.

Group members

Research Projects

Epidemiological surveillance of Legionnaires’ disease. A study of determinants of surveillance quality in the European Union

Emmanuel Robesyn

Legionnaires’ disease is notifiable in the European Union but is expected to be widely under-diagnosed and under-reported, resulting in a disease surveillance that does not reflect well true disease occurrence.

The research project aims to better understand the variation in Legionnaires’ disease reporting rates, based on study of two major determinants: travel, a determinant of the disease, and diagnostic intensity, a determinant of the surveillance quality.

The research will assess how variation in travel and diagnostic intensity affect the temporal and spatial disease reporting incidence. It is hypothesized that statistical modelling of these factors can provide a better understanding of how the reported data reflect true disease occurrence.

The results will allow to better estimate the incidence of the disease, the extent of under-diagnosis and under-reporting, and the role of the determinants.

Evaluation of an exercise-based cardiac rehabilitation program for patients with chronic heart failure in China

Xiankun Chen (Sharon), Gaetano Marrone

Chronic heart failure (CHF) is a major and growing public health problem and poses economic burden on the society. There is a need for a safe, equipment-free, low-cost, and easily implemented exercise-based cardiac rehabilitation program for CHF patients in China. Baduanjin exercise, translated as ‘eight silken movements’, is one of the most common forms of traditional Chinese exercise and it could have value to be integrated into a exercise-based cardiac rehabilitation program for CHF patients, together with education, evaluation and consultancy. Accordingly, the BESMILE-HF program applying the Baduanjin exercise as the central component, has been developed in Guangdong Provincial Hospital of Chinese Medicine which is one of the largest hospitals of Chinese medicine in China.

This project is to evaluate the efficacy and acceptability of BESMILE-HF program in patients with CHF in China, and it will be based on a randomized controlled trial and a qualitative study.

Headquarter of GDHTCM

Infection-related hospitalizations in Chinese patients with chronic kidney disease: Prevalence, clinical consequences, resistance to antibiotics and the role of physical activity

Cecilia Stålsby Lundborg

Chronic kidney disease (CKD) is a global public health problem, due to its high prevalence, high rate of complications, high health care costs and poor outcomes. Among patients with CKD, infection is the second leading cause of mortality and hospitalization. Higher rates of infection and greater use of antibiotics might contribute to the emergence of resistant pathogens, placing the global population at risk.

The aim of the study is to examine in-hospital consequences, antibiotic use in patients with CKD to address the burden from infection-related hospitalization, and to explore the role of physical activity as a potential mean of reducing risk of hospitalizations due to cardiovascular events or infections in this population.

The data will be collected from Guangdong Provincial Hospital of traditional Chinese Medicine (GDHTCM).

GDHTCM is a tertiary care hospital, located in the south of China in Guangzhou city, Guangdong province, is one of the oldest and largest hospital groups of traditional Chinese medicine (TCM) in China. It has four hospital branches located in different districts of Guangzhou city, with a total of 3,150 beds. Over 90,000 patients are admitted to GDHTCM each year, and considering population estimates that over 9,000 patients may have CKD.

Innovations in the health system: interventions for improved treatment of infectious diseases in children in rural Uganda

Cecilia Stålsby Lundborg (PI), Jaran Eriksen*, Senia Rosales-Klintz* (* contact person)

Under-five mortality (U5M) is high in Uganda, and reduction has been slow, 90 children out of 1000 die before their fifth birthday with infections as the leading cause of death. Children may have poor access to health facilities or receive poor quality of care with inappropriate diagnosis and treatment. Antimicrobial and especially antibiotic resistance is globally considered one of the most severe threats to public health. One reason for development and spread of resistance is inappropriate use of antimicrobials. In Uganda, the public health system which has the primary obligation of providing health care has difficulties delivering the evidence-based and affordable interventions that could save two thirds of the children dying today. The private sector has stepped in but poor quality of care in private, as well as public health care is an important determinant of mortality. In this research partnership we will address research questions that can assist in creating evidence for the Ugandan health system to enable possibilities for high quality child health care.

The scientific research questions we will address fall broadly under the following areas,

  1. how to develop, implement and evaluate simplified and field-adapted screening tools for monitoring of antibiotic and antimalarial use at community level,
  2. how to determine prevalence, distribution and antibiotic resistance patterns of tracer bacteria isolated from children,
  3. how to develop, implement, and evaluate context specific antibiotic stewardship programs in the public and private sectors as part of institutional quality-improvement and safety initiative
  4. how to determine the optimal dosing of antimalarial drugs for children and develop evidence-based dosage recommendations
  5. how can quality of care for children with malaria, pneumonia and diarrhoea be improved in the private sector
  6. how to adapt and evaluate point-of-care test (POCT) for rapid detection of pathogens causing infections and how to develop and evaluate a complementary automated data analysis system, using mobile phone technology for image acquisition and a data base for results analysis and reporting
  7. how to develop, implement and evaluate the effectiveness of e.g. smartphones with respiratory timers for improved management of paediatric respiratory infections and improving clinical decision support.

These questions will be answered by in robust studies using qualitative and quantitative research including randomized controlled trials in rural Uganda. The results from the research will directly inform policy-making in the Ugandan health system and lead to better quality of care and subsequent increased survival of children.

Validation and implementation of rapid diagnostic methods for multidrug-resistant tuberculosis in Honduras


Gloved hand holding a test tube with purple color.
Positive results for the nitrate reductase assay. This is a low-cost non-commercial method for detection of multidrug-resistant to implemented in Honduras as result of our ongoing collaboration.

Senia Rosales Klintz

This collaborative project focuses on the dissemination of knowledge generated within previous bilateral collaborations between Honduras and Sweden. Our consortium, comprising Karolinska Institutet, the Public Health Agency of Sweden and Universidad Nacional Autonoma de Honduras, has been working within the field of Tuberculosis (TB) diagnostics and molecular epidemiology during the last 20 years.

The purpose of this collaborative research project is to support the improvement and expansion of tuberculosis (TB) diagnostic capacity in Honduras, building upon our previous results and by further develop joint research strategies.

Microbiology sample.


Cecilia Stålsby Lundborg, Oliver Dyar

The Sino-Swedish Integrated Multisectorial Partnership for Containment of Antibiotic Resistance is a collaborative effort between Sweden and China to minimize emergence and dissemination of antibiotic resistance.

The aim is to minimize emergence and dissemination of antibiotic resistance (ABR), a holistic one-health approach is called for at national and international levels. The project aims to:

Increase basic knowledge of the complex routes of dissemination of ABR between sectors (humans, animals, the environment)
Increase basic knowledge of factors contributing to irrational use of antibiotics in humans and animals
Integrate this new knowledge with existing evidence to design and pilot interventions aiming to limit development and spread of ABR
Promote adequate infection prevention and control and access to effective antibiotics for humans and animals for improved public and animal health, and consequently efficient, sustainable animal food production.

Molecular investigations will map and correlate the occurrence of ABR clones in humans (commensal, clinical isolates), animals (household, farm animals), food, drinking water and the environment (water, sewage, manure). Antibiotic residues will be mapped as well as AB use (humans and animals), perceptions, knowledge, attitudes and practice among key stakeholders (community members, farmers, health care providers, animal health advisors).

The project continues an ongoing collaboration coordinated by SMI and Zhejiang University and will be conducted in Shandong Province, China, and includes additional partners with human medicine-, animal-, food- and environmental competence.

Student Prepare

Cecilia Stålsby Lundborg, Oliver Dyar, Cecilia Lindsjö

Student-PREPARE (PREscriber Perspectives on Antibiotic use and Resistance Education) is a survey on antibiotic education for all final year medical students in Europe. The study is coordinated by ESGAP (the ESCMID Study Group for Antibiotic Policies).

The study has the goal of finding ways to improve education on antibiotic use and antibiotic resistance. Junior doctors are responsible for much antibiotic prescribing, which is why it is so important to support their undergraduate education on the prudent use of antibiotics. The results of this survey are intended to identify if there is a perceived need for further education, and to guide clinicians and lecturers responsible for curriculum and course development across Europe. A forty point questionnaire was developed, and has now been answered by more than 10,000 students across Europe.

The study has strong connections to the Improving use of medicines subgroup. Professor Cecilia Stålsby Lundborg is a member of the scientific committee for the study, and the country coordinator for Sweden. Dr Oliver Dyar is the coordinator for the overall European project. The Swedish part is assisted by Cecilia Lindsjö.

Waste water sample collection in vietnamese hospitals.

Antibiotic resistance: implications of hospital practices for public health -A study from Vietnam

Lien La Thi Quynh, Ashok Tamhankar, Cecilia Stålsby Lundborg

The aim of this project is to explore hospital practices in relation to antibiotic resistance in hospital wastewater. Hospitals are high users of antibiotics and thus hospital wastewater can contain large amounts of antibiotics that can allow generation of antibiotic-resistant bacteria. In high-income countries hospital wastewater undergoes treatment to remove contaminants. In low and middle income countries (LMICs), however, hospital wastewater is often not treated and enters the environment contaminated with antibiotics and antibiotic resistant bacteria. Such water can get released into water bodies, wherefrom it might be used for irrigation or later come into water used for household purposes, resulting into infections by resistant organisms in humans and animals.

Another possibility is horizontal gene transfer from bacteria harbouring resistance genes to susceptible bacteria. Specifically the project explores the perceptions of hospital staff regarding infection control, analyse antibiotic prescribing in hospitals, determine antibiotic residues in hospital wastewater in relation to the antibiotic use of the hospitals and antibiotic resistance patterns of E. coli isolated from hospital wastewater before and after treatment. The settings are the rural Ba Vi hospital (220 beds) and the urban Thanh Nhan hospital (520 beds) in Hanoi.

Examiners room with a small bed and a lot of tools and supplies on the shelves.

MASPIC – Maltese Antibiotic Stewardship Programme in the Community

Erika Saliba, Senia Rosales, Cecilia Stålsby Lundborg

The MASPIC project aims to improve antibiotic prescription for respiratory tract infections (RTI) by family doctors through a behaviour change intervention. It encompasses several components, including:

I: Developing a better understanding of family doctors’ views, experiences and perceptions on antibiotic prescribing for RTI

II: Exploring the views and perceptions of other stakeholders, namely pharmacists and caretakers of school-going children.

III: Developing and evaluating a behaviour change intervention targeting family doctors’ antibiotic prescribing practices for RTI

IV: Monitoring family doctors’ antibiotic prescribing practices when consulting patients with RTI

By gaining a better understanding of the underlying mechanisms of antibiotic prescribing for RTI in the community, we seek to design an effective intervention and tool for future initiatives where the goal is to ameliorate antibiotic prescribing in the community, both in Malta and other similar settings. The project is planned to continue at least until 2018.

Pills spilling out of a jar and over a form that reads RX.
Drug therapy acne vulgaris.

Systemic drug therapy for treatment of acne vulgaris in adolescents – a Norwegian prescription database study

Ingvild Odsbu, Cecilia Stålsby Lundborg

Acne vulgaris is affecting 80-85% of all teenagers. Tetracyclines are recommended as first choice for severe acne vulgaris, and - if not sufficient effect - isotretinoin could be prescribed. Both therapy options have disadvantages; tetracycline use gives side effects like phototoxicity, influences the normal gut microbiota and contributes to antibiotic resistance, and isotretinoin is a teratogen highly likely to cause birth defects. In recent years, systemic drug therapy for severe acne vulgaris is more frequent, and isotretinoin has exhibited the greatest increase.

The aim of the project is to investigate the prescribing of systemic drug therapy for the treatment of severe acne vulgaris in adolescents by use of prescribed drug data from the Norwegian Prescription Database. The project is done in collaboration with the Norwegian Institute of Public Health, Oslo, Norway.

Research support

  • Swedish Research Council


ReAct: Action on Antibiotic Resistance

Göran Tomson

KI is a co-founder of React, an independent global network addressing the threat of antimicrobial resistance. Since its start in 2005, React has become a strong voice on antibiotic resistance (ABR) policy in the global arena, including advocacy and the “innovation track”, i.e. pushing politically for a new business model to facilitate and reinvigorate research and development for new, effective antibiotics. Research results have been packaged for decision makers, with political leadership by the Swedish Ministry of Health. The ongoing policy dialogue is both local and global.

Norwegian Institute of Public Health, Oslo, Norway

About our group