Research projects - IUM

Improving Use of medicine

PRevalence and factOrs associated with POlypharmacy and Self-medication among the Elderly population residing in six major Indian cities (PROPOSE)

Saibal Das

The proportion of the elderly population (age ≥60 years) in India is 10.1%. The elderly population is often exposed to the risk of unsafe medication practices, including polypharmacy and self-medication, causing considerable harm. This study aims to estimate the prevalence and factors associated with polypharmacy and self-medication among elderly patients residing in six major Indian cities (New Delhi, Mumbai, Chennai, Kolkata, Indore, and Guwahati) and to assess the patient and prescriber-reported qualitative factors behind such medication practices. Six hundred elderly patients living in households in six cities will be recruited. Their socio-demographic details, medical history, and medication history will be recorded. The prevalence of polypharmacy and self-medication; medication adherence; adverse drug reactions; associated socio-demographic factors; and knowledge, attitude, and practice of patients will be evaluated. A contextual definition of polypharmacy will be derived. Then, thirty patients taking polypharmacy or self-medication and eighteen allopathic prescribers will be interviewed to understand factors and social determinants associated with polypharmacy and self-medication in the same population. The insights generated related to such unsafe medication practices among elderly patients in Indian urban community settings could help in improvising customized interventional plans to mitigate this preventable problem.

This study will be performed in collaboration with the Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden and the Indian Council of Medical research-Centre for Ageing and Mental Health, Kolkata, India.


Antibiotic prescription patterns, trends, and prescribing behaviour in LMICs, focusing on India: challenges and efficient interventions to reduce antibiotic resistance.

Kristina Skender

The aim is to: (i) investigate 10 years’ antibiotic prescription patterns and trends in orthopaedic and surgery departments, (ii) assess the incidence and identify risk factors for SSIs in operated patients, and to identify antibiotic susceptibility patterns, (iii) explore surgeons’ antibiotic prescribing behaviour in two Indian private-sector hospitals, (iv) assess and rank the effectiveness of various interventions to ensure appropriate antibiotic prescribing by the primary care physicians from LMICs.

This research project would employ the combination of quantitative and qualitative methods, as well as network meta-analysis

Adherence to dietary recommendations and its clinical consequences in patients with chronic kidney disease.

Ouyang Wenwei

Although previous studies showed adherence to the nutrition guidelines may have the effect on thwarting CKD progression, a better psychological status and reduce the risk of complications in CKD patients, the current evidence is still contradictory. 

Project describes the nutritional status, guideline adherence and evaluate the association between adherence to dietary recommendation and renal related outcomes in non-dialysis CKD patients in Southern China.

The specific research questions are: (1) Study-1: What are the dietary characteristics of CKD patients and how do their diets comply with relevant China national guidelines in Southern China? (2) Study-2: Is there any association between self-efficacy and dietary guideline adherence in Chinese CKD patients, consider social support as a moderator (study 2) (3) Study-3: Whether adherence to different dietary quality scores (aMED, DASH, CHEI, HEI-2005) and their key components at baseline predicts a better habitual sleep at 1 year in CKD population? (4) Study-4: Is diet potassium restriction associated with low risk of hyperkalemia independently of comorbidities and medications?

In a word, although nutrition management has been recommended in CKD guidelines, it is still in its infancy in China. Better knowledge about the topic may highlight the need for CKD patients and healthcare professionals to facilitate lifestyle change, manage symptoms, and offer rational support.


The strategies and achievements of antibiotic resistance governance in China across healthcare system

Ding Yang

China is one of the countries with the largest consumption of antibiotics and the most serious bacterial resistance in the world. In the past decade, the Chinese government continuously took actions to combat antibiotic resistance (ABR). These actions could be divided into three stages: controls of medicine use, clinical ABR surveillance, and multi-sectional governance (including animal and environment). After many years of governance, what progress has been made in the governance of ABR in China, what problems still exist, and how to timely adjust the strategies and measures according to the changes are significant topics that need to be paid attention to. The sub-studies in this PhD will describe and analyze China’s policies for containing ABR, then according to the results of the policy analysis, explore the achievements and challenges of ABR governance in China in the past decade from the perspective of hospital, primary healthcare facility and retail pharmacy, using Shandong Province as a proxy for all of mainland China. In addition, the sub-studies will help to provide a comprehensive insight to improve the measures against ABR in China.


Bronchiectasis exacerbations a global public health challenge - detecting interactions between microbiome, pathophysiology, and clinical characterization

Yuanyuan Wang

This project will investigate the role of the pulmonary microbiome (the gut microbiome might also be involved if appropriate), and its interactions with the host immune response in patients with bronchiectasis in Guangzhou, China.  Both retrospective and prospective studies will be conducted to address research questions, including the detection of airway microbial compositions by laboratory culture and molecular biology methods; the evaluation of potential immune system reaction, particularly when associated with microbiome change or bronchiectasis exacerbations; and the development of a predictive instrument from respiratory symptom changes to exacerbations.


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
Headquarter of GDHTCM. Photo: Private

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,

  • how to develop, implement and evaluate simplified and field-adapted screening tools for monitoring of antibiotic and antimalarial use at community level,
  • how to determine prevalence, distribution and antibiotic resistance patterns of tracer bacteria isolated from children,
  • 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
  • how to determine the optimal dosing of antimalarial drugs for children and develop evidence-based dosage recommendations
  • how can quality of care for children with malaria, pneumonia and diarrhoea be improved in the private sector
  • 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
  • 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

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.

Photo: Private


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.

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.

Photo: Private

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.

Photo: Private

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.

Photo: Private

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