Antibiotic dispensing in Egyptian community pharmacies: an observational study

Phenotypic and genotypic characterization of commensal staphylococci isolated from young volunteers in Alexandria, Egypt

Nasally colonized staphylococci carry antibiotic resistance genes and may lead to serious opportunistic infections. We are investigating nasal carriage of Staphylococcus aureus and Staphylococci other than S. aureus (SOSA) among young volunteers in Egypt to determine their risk potential. Nasal swabs collected over 1 week in June 2019 from 196 volunteers were cultured for staphylococcus isolation. The participants were interviewed to assess sex, age, general health, hospitalization and personal hygiene habits. Identification was carried out using biochemical tests and VITEK 2 automated system. Disc diffusion and minimum inhibitory concentration tests were performed to determine antibiotic susceptibility. Screening for macrolide resistance genes (ermA, ermB, ermC, ermT and msrA) was performed using polymerase chain reaction. Thirty four S. aureus and 69 SOSA were obtained. Multi-drug resistance (MDR) was detected among most staphylococcal species, ranging from 30.77% among S. hominis to 50% among S. epidermidis. Phenotypic resistance to all tested antibiotics, except for linezolid, was observed. Susceptibility to rifampicin, vancomycin and teicoplanin was highest. ermB showed the highest prevalence among all species (79.41% and 94.2% among S. aureus and SOSA, respectively), and constitutive macrolide-lincosamide-streptogramin B (MLSB) resistance was equally observed in S. aureus and SOSA (11.11% and 16.22%, respectively), whereas inducible MLSB resistance was more often found in S. aureus (77.78% and 43.24%, respectively). The species or resistance level of the carried isolates were not significantly associated with previous hospitalization or underlying diseases. Although over all colonization and carriage of resistance genes are within normal ranges, the increased carriage of MDR S. aureus is alarming. Also, the fact that many macrolide resitance genes were detected should be a warning sign, particularly in case of MLSB inducible phenotype. More in depth analysis using whole genome sequencing would give a better insight into the MDR staphylococci in the community in Egypt.

Assessment of knowledge, attitudes, and practices among community pharmacists in Lahore regarding antibiotic dispensing without prescription: A cross-sectional study

OBJECTIVES

The irrational dispensing practices are responsible for antibiotic abuse and the spread of antibiotic resistance. Thus, the present study aims to evaluate the knowledge, attitudes, and practices of community pharmacists (CPs) regarding dispensing antibiotics without prescription (DAwP).

METHOD

A descriptive, cross-sectional study was conducted between March 1, 2023, and March 31, 2023, in community pharmacy settings of Lahore, Pakistan. A self-administered and pretested questionnaire was used for the data collection. Logistic regression analysis was used to determine the factors associated with the practices of community pharmacists. Data were analyzed using SPSS (version 26) and MS Office (2016).

RESULTS

Among 359 respondents, many strongly agreed/agreed with the statements "DAwP is contributing to the development of antimicrobial resistance" (83%, n = 298) and "Antibiotic resistance has become a public health issue" (81.9%, n = 249). Overall, most of the community pharmacists claimed that the unwillingness of patients to visit physicians for non-serious infections (75.2%, n = 270) and good knowledge of pharmacists about the use of antibiotics (51%, n = 183) were the most common reasons attributable to dispensing of antibiotics without prescription. Cephalosporin (n = 260, 72.4%), penicillin (n = 254, 70.8%), and tetracyclines (n = 170, 47.4%) were the most commonly dispensed classes of antibiotics without prescription due to cold, flu and diarrhea. Most community pharmacists never/sometimes warn patients about the potential side effects of medicines (79.1%, n = 284). Logistic regression analysis revealed that community pharmacists 31-40 years of age (OR = 0.568, 95%CI = 0.348-0.927, p-value = 0.024) were significantly less associated with poor practices of dispensing antibiotics without prescription (DAwP) while those who were 'Managers' (OR = 4.222, 95%CI = 2.542-7.011, p-value = <0.001), had 3-5 years of experience (OR = 2.241, 95%CI = 1.183-4.243, p-value = 0.013), dispensed ≤25 antibiotics per day (OR = 12.375, 95%CI = 5.177-29.583, p-value = <0.001), were more likely to be associated with poor practices of dispensing of antibiotics without prescription.

CONCLUSION

The community pharmacists had adequate knowledge, positive attitudes, and poor practices towards DAwP. Demographical factors such as age, job status, and work experience were the determinants of community pharmacists' practices towards dispensing antibiotics without prescription (DAwP). Hence, a multifaceted approach, including educational interventions, is needed to reduce the dispensing of antibiotics without prescription (DAwP).

Bacterial Diversity and Antibiotic Resistance Patterns of Community-Acquired Urinary Tract Infections in Mega Size Clinical Samples of Egyptian Patients: A Cross-Sectional Study

BACKGROUND

 Community-acquired urinary tract infection (UTI) is one of the most common infectious diseases nowadays. Alarming increased levels of antimicrobial resistance are developing globally which limit treatment options and may lead to life-threatening problems.

AIM

Our study aimed to collect surveillance data on non-hospitalized Egyptian UTI cases and to develop strategies against multidrug-resistant pathogens (MDR). According to our knowledge, this is the first study to screen this high number (15,252 urine samples) in a short period (three months), providing valuable data on resistance profiles in non-hospitalized Egyptian UTI patients.

METHODS

A total of 15,252 urine samples were collected from different patients. Positive cultures were identified using a semi-quantitative method. Kirby-Bauer's disc diffusion method was used for antibiotic susceptibility testing, the double disc diffusion method was used for extended-spectrum beta-lactamases-producing strains, and the Chi-square test was used for statistical data processing.

RESULTS

The results showed 61% positive cultures, females accounted for 67.5%. Infants and elderly patients showed the highest positive cultures (74.4% and 69.2%, respectively). Despite Escherichia coli being the most common uropathogen (47.19%), Klebsiella species(24.42%) were the most MDR and extended-spectrum β-lactamase (ESBL)-producing organisms. E. coli and Klebsiella spp. displayed increased resistance to cephalosporins (75% and 81%, respectively). In contrast, both organisms displayed high sensitivity to carbapenems. Unlike Klebsiella spp., E. coli was highly sensitive (92%) to first-line treatment (nitrofurantoin) for UTI. Moreover, trimethoprim/sulfamethoxazole showed higher sensitivity rates compared to other nations.

CONCLUSION

 Despite Escherichia coli being the most often identified bacteria in our isolates Klebsiella spp. displayed higher resistance to the majority of tested antibiotics. Fortunately, trimethoprim/sulfamethoxazole significantly increased sensitivity, especially against E. coli. However, both species showed high rates of cephalosporin resistance. Moreover, It is important to promote Egypt's national action plan for antimicrobial resistance in collaboration with the World Health Organization, especially in the community to minimize the chance of bacterial resistance in the Egyptian community.

Health literacy, knowledge, household disposal, and misuse practices of antibiotics among UAE residents: a nationwide cross-sectional study

BACKGROUND

The study aimed to evaluate health literacy, knowledge, household disposal, and misuse practices of antibiotics among the United Arab Emirates (UAE) residents.

RESEARCH DESIGN AND METHODS

An observational cross-sectional study was conducted between May 1st and August 31st, 2022. The study encompassed a sample of 1074 participants.

RESULTS

Participants involved in a medical field (OR: 1.98, 95% CI: 1.45-2.69, p < 0.001) were more likely to have adequate health literacy. Most participants rarely (n = 315; 29.33%) or sometimes (n = 292; 27.19%) sought help from a doctor or pharmacist with reading the instructions and leaflets of antibiotics. A bachelor`s degree was associated with a reduced odds ratio of self-medication with antibiotics (OR: 0.46, 95% CI: 0.29-0.75, p = 0.002). Only 10.61% of unneeded antibiotics were returned to the pharmacy, 79.42% were disposed of at home and 10% were disposed of using other disposal practices.

CONCLUSIONS

Higher levels of adequate health literacy were observed in those involved in the medical field and those with higher educational levels. The prevalence of self-medication with antibiotics among the UAE population was low. These findings highlight the importance of improving health literacy, promoting responsible antibiotic use, and encouraging proper disposal practices among the population.

Biosynthetic gene cluster signature profiles of pathogenic Gram-negative bacteria isolated from Egyptian clinical settings

Biosynthetic gene clusters (BGCs) are a subset of consecutive genes present within a variety of organisms to produce specialized metabolites (SMs). These SMs are becoming a cornerstone to produce multiple medications including antibacterial and anticancer agents. Natural products (NPs) also play a pivotal role in enhancing the virulence of ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), which represent a global health threat. We aimed to sequence and computationally analyze the BGCs present in 66 strains pertaining to three different ESKAPE pathogenic species: 21 A. baumannii, 28 K. pneumoniae, and 17 P. aeruginosa strains recovered from clinical settings in Egypt. DNA was extracted using QIAamp DNA Mini kit and Illumina NextSeq 550 was used for whole-genome sequencing. The sequences were quality-filtered by fastp and assembled by Unicycler. BGCs were detected by antiSMASH, BAGEL, GECCO, and PRISM, and aligned using Clinker. The highest abundance of BGCs was detected in P. aeruginosa (590), then K. pneumoniae (146) and the least in A. baumannii strains (133). P. aeruginosa isolates shared mostly the non-ribosomal peptide synthase (NRPS) type, K. pneumoniae isolates shared the ribosomally synthesized and post-translationally modified peptide-like (RiPP-like) type, while A. baumannii isolates shared the siderophore type. Most of the isolates harbored non-ribosomal peptide (NRP) BGCs with few K. pneumoniae isolates encoding polyketide BGCs. Sactipeptides and bottromycin BGCs were the most frequently detected RiPP clusters. We hypothesize that each species' BGC signature confers its virulence. Future experiments will link the detected clusters with their species and determine whether the encoded SMs are produced and cause their virulence. IMPORTANCE Our study analyzes the biosynthetic gene clusters (BGCs) present in 66 assemblies from clinical ESKAPE pathogen isolates pertaining to Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa strains. We report their sequencing and assembly followed by the analysis of their BGCs using several bioinformatics tools. We then focused on the most abundant BGC type in each species and we discussed their potential roles in the virulence of each species. This study is pivotal to further build on its experimental work that deciphers the role in virulence, possible antibacterial effects, and characterization of the encoded specialized metabolites (SMs). The study highlights the importance of studying the "harmful" BGCs and understanding the pathogenicity and virulence of those species, as well as possible benefits if the SMs were used as antibacterial agents. This could be the first study of its kind from Egypt and would shed light on BGCs from ESKAPE pathogens from Egypt.

Assessment of Dispensing Malpractice in Community Drug Retail Outlets in South Gondar Zone, Northwest Ethiopia: A Simulated Patient Experience

Background

Pharmacy professionals in community drug retail outlets, as the most accessible personnel for the community, are engaged in consultation and responding to health problems in addition to filling prescriptions. In doing so, different dispensing malpractices are observed and much is not known on the issue in Ethiopia.

Objective

The study aimed at assessing dispensing malpractice at pharmacies, drug stores and drug vendors in South Gondar zone.

Methodology

A cross-sectional study design with a descriptive approach was applied from April 1 to June 30. The data was collected using the simulated patient method. Seven prescription-only medicines and a diarrheal case were requested during visit. All drug retail outlets in South Gondar zone that were in service during data collection were visited.

Results

Almost all prescription-only medications were dispensed without prescription at all community drug retail outlets. Of all the dispensaries, 19 (82.6%) provided a partial dosage regimen of amoxicillin. Presence of fever and pregnancy status were asked about by dispensers in only 8% and 20% of visits for diarrhea, respectively. Medication history was also rarely requested. Medication was dispensed in 80% of visits for diarrhea, all of which included antimicrobials. Oral rehydration salt was considered in only two (10%) dispensaries.

Conclusion

Dispensing medications without a prescription is common in community drug retail outlets in South Gondar zone in Amhara Regional State. Our findings also showed that detailed assessments of patients' signs and symptoms are not performed properly by the dispensers to understand the diarrheal case. Training of pharmacy professionals and strict regulatory control are needed.

Application of a novel lytic Jerseyvirus phage LPSent1 for the biological control of the multidrug-resistant Salmonella Enteritidis in foods

Non-typhoidal Salmonella is the tremendously predominant source of acquired foodborne infection in humans, causing salmonellosis which is a global threat to the healthcare system. This threat is even worse when it is combined with the incidence of multidrug-resistant Salmonella strains. Bacteriophage therapy has been proposed as a promising potential candidate to control a diversity of foodborne infective bacteria. The objective of this study designed to isolate and characterize lytic phages infecting zoonotic multi-drug resistant and strong biofilm producer Salmonella enterica serovar Enteritidis EG.SmE1 and then apply the isolated phage/s as a biocontrol agent against infections in ready-to-eat food articles including milk, water, apple juice, and chicken breasts. One lytic phage (LPSent1) was selected based on its robust and stable lytic activity. Phage LPSent1 belonged to the genus Jerseyvirus within the Jerseyvirinae subfamily. The lysis time of phage LPSent1 was 60 min with a latent period of 30 min and each infected cell burst about 112 plaque-forming units. Phage LPSent1 showed a narrow host range. Furthermore, the LPSent1 genome did not encode any virulence or lysogenic genes. In addition, phage LPSent1 had wide pH tolerance, prolonged thermal stability, and was stable in food articles lacking its susceptible host for 48 h. In vitro applications of phage LPSent1 inhibited free planktonic cells and biofilms of Salmonella Enteritidis EG.SmE1 with a lower occurrence to form phage-resistant bacterial mutants which suggests promising applications on food articles. Application of phage LPSent1 at multiplicities of infections of 100 or 1000 showed significant inhibition in the bacterial count of Salmonella Enteritidis EG.SmE1 by 5 log10/sample in milk, water, apple juice, and chicken breasts at either 4°C or 25°C. Accordingly, taken together these findings establish phage LPSent1 as an effective, promising candidate for the biocontrol of MDR Salmonella Enteritidis in ready-to-eat food.

Extent of cardiovascular medications dispensing practice without a prescription: Self-reported and simulated patient-based study at community pharmacies in Northwest Ethiopia

BACKGROUND

Critical actions are required for the proper administration of medications to patients with cardiovascular diseases. However, there has been an increase in irrational use of cardiovascular drugs. The purpose of this study was to determine the extent of non-prescription cardiovascular medicine dispensing practices at community drug retail outlets (CDROs) in Gondar, Northwest Ethiopia.

METHODS

A cross-sectional survey and simulated patient-based visits were employed at the CDROs in Gondar City, Northwest Ethiopia between June 1 and July 20, 2022. The cross-sectional component that assessed the self-reported practices used a standardized self-reported questionnaire. A simulated patient (SP) case scenario, using different tracer prescriptions only for cardiovascular medications, allowed for the observation of real-world dispensing procedures. SPSS version 22 was used for the data entry and analysis.

RESULTS

The cross-sectional study approached 76 CDROs, and 71 of them agreed to take part (93.4% response rate). More than half of the respondents (53.5%) were males, with a mean (SD) age of 33.5 ± 9.1 years. Overall, the current self-reported survey showed that 59.2% of the participants provided cardiovascular drugs without a prescription. A total of 213 simulated visits were conducted. Considering all SP scenarios, the percentage of cardiovascular drugs dispensed without a prescription increased to 88.7%. Besides, more than 90% of pharmacists did not demand the SP to have a prescription, did not advise them to visit doctors or clinics, and did not inquire as to whom the medication was required.

CONCLUSION

A significant proportion of CDROs dispensed cardiovascular medications without a prescription. The findings highlight the disparity between self-reported and actual CDRO practices. Additionally, nearly all of the CDROs approached made it simple to obtain cardiovascular medications. Stakeholders could adherently follow the CDROs' practices to improve their proper dispensing procedures.

Community Pharmacists' Knowledge, Attitude, and Nonprescription Dispensing Practices of Antibiotics: An Explorative Study in a Selected City of South India

Objective

This study aimed to assess the community pharmacists' knowledge of antibiotics, their attitude toward antibiotic usage and antibiotic resistance, and their nonprescription dispensing practices of antibiotics.

Methods

A cross sectional-questionnaire-based study was conducted among 75 community pharmacists practicing in a selected city of South India. Data on their age, years of experience, and educational qualifications were obtained. A modified, 33-items, prevalidated structured questionnaire was used to assess the community pharmacists knowledge, attitude, and nonprescription antibiotic dispensing practices knowledge, attitudes and practices (KAP). The responses obtained were expressed in descriptive statistics. The association between years of experience and their KAP was assessed using Pearson's correlation.

Findings

Most pharmacists (60%) agreed that antibiotics are used for bacterial infections, and 35% believed that antibiotics could be given for pain and inflammation. Fourty-one percentage of pharmacists agreed that dispensing antibiotics without prescription increases the risk of antibiotic resistance. Seventy-two percentage agreed that they are responsible for taking a prominent role in antimicrobial resistance and infection-control programs in healthcare. Only 46% of pharmacists stated that they always dispensed antibiotics only with a prescription, and 56% dispensed antibiotics for longer than the doctor prescribed. Amoxicillin, metronidazole, and cephalexin were the most commonly dispensed antibiotics without a prescription. The most common reason for dispensing antibiotics without a prescription was the fear of losing customers.

Conclusion

The study identified an average KAP interquartile range 1 among community pharmacists, indicating a lack of awareness of antibiotic resistance and dispensing antibiotics without a prescription.

Characterization and Isolation of the Major Biologically Active Metabolites Isolated from Ficus retusa and Their Synergistic Effect with Tetracycline against Certain Pathogenic-Resistant Bacteria

Globally, pathogenic microbes have reached a worrisome level of antibiotic resistance. Our work aims to identify and isolate the active components from the bioactive Ficus retusa bark extract and assess the potential synergistic activity of the most major compounds' constituents with the antibiotic tetracycline against certain pathogenic bacterial strains. The phytochemical screening of an acetone extract of F. retusa bark using column chromatography led to the identification of 10 phenolic components. The synergistic interaction of catechin and chlorogenic acid as the most major compounds with tetracycline was evaluated by checkerboard assay followed by time-kill assay, against Bacillus cereus, Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumonia, and Salmonella typhi with fraction inhibitory concentration index values (FICI) of 0.38, 0.43, 0.38, 0.38, 0.38, and 0.75 for catechin and 0.38, 0.65, 0.38, 0.63, 0.38, and 0.75 for chlorogenic acid. The combination of catechin and chlorogenic acid with tetracycline significantly enhanced antibacterial action against gram-positive and gram-negative microorganisms; therefore, catechin and chlorogenic acid combinations with tetracycline could be employed as innovative and safe antibiotics to combat microbial resistance.

Local accessory gene sharing among Egyptian Campylobacter potentially promotes the spread of antimicrobial resistance

Campylobacter is the most common cause of bacterial gastroenteritis worldwide, and diarrhoeal disease is a major cause of child morbidity, growth faltering and mortality in low- and middle-income countries. Despite evidence of high incidence and differences in disease epidemiology, there is limited genomic data from studies in developing countries. In this study, we aimed to quantify the extent of gene sharing in local and global populations. We characterized the genetic diversity and accessory-genome content of a collection of Campylobacter isolates from the Cairo metropolitan area, Egypt. In total, 112 Campylobacter isolates were collected from broiler carcasses (n=31), milk and dairy products (n=24), and patients suffering from gastroenteritis (n=57). Among the most common sequence types (STs), we identified the globally disseminated host generalist ST-21 clonal complex (CC21) and the poultry specialists CC206, CC464 and CC48. Notably, CC45 and the cattle-specialist CC42 were under-represented, with a total absence of CC61. Core- and accessory-genome sharing was compared among isolates from Egypt and a comparable collection from the UK (Oxford). Lineage-specific accessory-genome sharing was significantly higher among isolates from the same country, particularly CC21, which demonstrated greater local geographical clustering. In contrast, no geographical clustering was noted in either the core or accessory genome of CC828, suggesting a highly admixed population. A greater proportion of Campylobacter coli isolates were multidrug resistant compared to Campylobacter jejuni. Our results suggest that there is more horizontal transfer of accessory genes between strains in Egypt. This has strong implications for controlling the spread of antimicrobial resistance among this important pathogen.

Clostridioides difficile infection in Africa: A narrative review

Clostridioides (Clostridium) difficile infection (CDI) places a burden on healthcare facilities worldwide. Most research studies have been concentrated in high-income countries in North America, Europe, Asia and Australia, where C. difficile is the leading cause of diarrhoea associated with antimicrobial use. This narrative review summarises African CDI studies, focussing on reports published in the last 20 years. Although relatively sparse, the data suggest that CDI is an important cause of diarrhoea on the continent. African CDI patient populations are often younger than in European and North American settings, probably due to the high prevalence of co-morbid conditions such as tuberculosis, particularly in sub-Saharan Africa. Strain typing data are rare and where reported generally limited to single sites and institutions. Despite challenges, including a lack of facilities and awareness, there is a need for further investigation to more accurately determine the true burden of disease caused by C. difficile in Africa.

Antimicrobial Use and Management of Childhood Diarrhea at Community Drug Retail Outlets in Eastern Ethiopia: A Matched Questionnaire-Based and Simulated Patient-Case Study

Introduction

Antimicrobial agents have saved millions of lives worldwide. However, inappropriate use has become a global concern leading to the emergence and spread of antimicrobial resistance (AMR). In this regard, the dispensing practices of pharmacy professionals in the community drug retail outlets (CDROs) plays a central role. Therefore, this study was aimed to assess the knowledge and dispensing practices of pharmacy professionals in the management of childhood diarrhea in CDROs of Eastern Ethiopia.

Methods

A community based cross-sectional study was conducted in 100 randomly selected CDROs in Eastern Ethiopia from 1 August to 30 September 2020. Data were collected with a structured questionnaire matched with a simulated patient case. Descriptive statistics were employed to summarize variables. Cohen's Kappa was analyzed to measure the degree of agreement between questionnaire-based and simulated patient-based methods. Binary logistic regression analysis was conducted to determine factors associated with inappropriate dispensing practice.

Results

Majority of the participants were aged 25-34 years (median: 29 years). High proportion of them were male (65%) and had work experiences of two or more years. Majority (61%) of the professionals were knowledgeable about AMR. Out of 2886 scores, 745 scores were agreed on Cohen's Kappa interrater agreement scale with the overall percent agreement between the two methods being 26.0%. Besides, about 67% of dispensing practices to the simulated patient case was found inappropriate. On the multivariate analysis, insufficient knowledge of retailers on AMR was significantly associated with the inappropriate dispensing of antimicrobial agents.

Conclusion

A considerable proportion of retailers had insufficient knowledge regarding the emergence and spread of AMR. Only a quarter of their questionnaire-based knowledge response agreed with simulated-patient-based actual practice, indicating weak agreement between the two methods and high level of inappropriate practice. Besides, insufficient knowledge of retailers was significantly associated with their inappropriate dispensing of antimicrobials.

Antibiogram Screening and Detection of Virulence-Associated Genes in Brucella Species Acquired from Cattle in South Africa's Eastern Cape Province

Brucellosis is a widespread zoonotic illness, and it poses serious public health and economic risks. The purpose of this investigation is to look at the antimicrobial susceptibility of unpasteurized milk, blood, and lymph node specimens from cattle, goats, and sheep, as well as to identify virulence-associated genes. In this investigation, a total of 123 isolates were examined. The activity of 15 antimicrobials against Brucella pathogens were assessed using the Kirby−Bauer disk diffusion technique. Nine virulence factors were detected with polymerase chain reaction analysis. Five antibiotics were 100% effective against Brucella isolates. A high level of resistance (100%) was documented with streptomycin, penicillin, and seven more antibiotics. Doxycycline resistance was found in 12% of goat isolates, and tetracycline resistance was found in 21% and 44% of goat and sheep isolates, respectively. Multiple antibiotic resistance (MAR) index >0.2 was found in 38.2% (47/123) of Brucella isolates. VecC and BetB, two B. abortus genes, were confirmed to be comparable. The findings of this study suggests that Brucella spp. are reservoirs of antibiotic resistance in the Eastern Cape Province. As such, they represent a potential pool of antibiotic genes that might be transferred to other pathogens in the community, and thus continue to pose a healthcare hazard.

Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia

In Saudi Arabia, there are concerning rates of non-compliance with pharmaceutical regulations prohibiting the pharmacy dispensing of prescription-only medications without a physician prescription. This is the first study in the Middle East which examines physicians’ perceptions regarding misuse of codeine, listed as a narcotic, controlled, and prescription-only drug. The CODEMISUSED survey was adapted to the Saudi Arabian context and pilot tested, prior to cross-sectional administration to physicians in Riyadh, Jeddah, Abha, and Jazan (n = 105). Descriptive statistics (frequencies and percentage) present physician level of agreement, neutrality, and disagreement with statements regarding codeine prescribing, patient awareness and use, online and community pharmacy availability, and dependence. The study indicates concern by physicians regarding patient intentional use of codeine to enhance mood, misuse patterns, lack of awareness around habit-forming use and iatrogenic dependence, and sourcing via illegal dispensing. It underscores the imperatives to address pharmacy compliance with pharmaceutical regulatory controls, implement enhanced pharmacovigilance, and improve awareness around safe use.

Efficacy of three lytic bacteriophages for eradicating biofilms of multidrug-resistant Proteus mirabilis

Proteus mirabilis is one of the most frequent causes of catheter-associated urinary tract infections (CAUTIs) owing to its capability to colonize and develop crystalline multidrug-resistant (MDR) biofilms. Here, we report the isolation and partial characterization of three novel bacteriophages, vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, which were active against the planktonic form and biofilms of the MDR P. mirabilis strain ES01, isolated from CAUTIs in Egypt. The antibiotic susceptibility profile of the P. mirabilis isolates showed resistance to most of the antibiotics tested. The isolated phages were identified morphologically using TEM, and each appeared to have myovirus-like morphology. The three phages displayed strong lytic activity and a narrow host range, and they were stable at different ranges of temperatures and pH values. One-step growth kinetics showed a lysis time of 180 min with a burst size of 99.6, 95, and 86 PFU/cell for phage vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, respectively. The three phages exhibited different digestion patterns using different restriction enzymes. The genome size was estimated to be 59.39 kb, 62.19 kb, and 52.07 kb for phage vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c, respectively. A phage cocktail including the three phages showed a potential ability to reduce and eradicate a biofilm formed by the MDR Proteus mirabilis EG-ES1. Accordingly, a phage cocktail of vB_PmiM-ES1a, vB_PmiM-ES1b, and vB_PmiM-ES1c is considered a promising candidate for use as a biocontrol agent against MDR Proteus mirabilis bacteria.

Medical Devices-Related Counseling Practices Among Community Pharmacists: A Nationwide Cross-Sectional Study from Saudi Arabia

Objective

The current study was conducted to assess medical devices-related counseling practices among community pharmacists in Saudi Arabia.

Methodology

This was a cross-sectional study conducted among community pharmacists from Saudi Arabia using a convenience sampling technique. An online questionnaire based on Google forms was used to collect data. Descriptive and inferential analyses were conducted using SPSS statistics 22. Student t-test, one way ANOVA, and Pearson correlation statistics were used where applicable. Results with a p-value of <0.05 were considered statistically significant.

Results

One thousand and six community pharmacists responded to the survey. Males’ rating of their ability to operate medical devices was significantly higher than females (overall average score of 3.8 versus 3.5, p=0.033). As years of experience increased there were slight but significant increases in the overall scores on ability to operate medical devices (p=0.002) and confidence to counsel patients about the devices (p=0.032). Those who got a board certification used devices for self-treatment significantly more than their counterparts (on average 6.9 devices versus 5.2, p=0.003). Those who received clinical training reported higher rates of ability to use/operate devices (p=0.011), confidence to counsel patients on devices (p=0.001), and counseling practice (p=0.044) than those who did not receive clinical training.

Conclusion

The present study revealed good to very good self-reported medical devices-related counseling practices. There is a need for more future rigorous research to evaluate pharmacists' actual practice in this area. Pharmacy educators and CPD programs should pay attention to updating pharmacists’ knowledge and skills and improve their contribution to medical devices supportive services.

Efficacy and safety of azithromycin in Covid-19 patients: A systematic review and meta-analysis of randomized clinical trials

Azithromycin (AZM) is commonly used in Covid‐19 patients based on low‐quality evidence, increasing the risk of developing adverse events and antimicrobial resistance. The current systematic review and meta‐analysis investigated the safety and efficacy of AZM in treating Covid‐19 patients using published randomized controlled trials. Google Scholar, PubMed, Scopus, Cochrane Library, Clinical Trials.gov, MEDLINE, bioRxiv and medRxiv were searched for relevant studies. The random‐effects model was used to pool estimates using the Paule–Mandel estimate for heterogeneity. The odds ratio and raw difference in medians were used for dichotomous and continuous outcomes, respectively. The analysis included seven studies with 8822 patients (median age, 55.8 years; 61% males). The risk of bias was assessed as ‘low’ for five of the seven mortality results and as ‘some concerns’ and ‘high’ in one trial each. There were 657/3100 (21.2%) and 1244/5654 (22%) deaths among patients randomized to AZM and standard of care, respectively. The use of AZM was not associated with mortality in Covid‐19 patients (OR = 0.96, 95% CI 0.88–1.05, p = 0.317 based on the random‐effect meta‐analysis). The use of AZM was not associated with need for invasive mechanical ventilation (OR = 0.96, 95% CI 0.49–1.87, p = 0.85) and length of stay (Δ = 1.11, 95% CI −2.08 to 4.31, p = 0.49). The results show that using AZM as routine therapy in Covid‐19 patients is not justified due to lack of efficacy and potential risk of bacterial resistance that is not met by an increased clinical benefit.

Antibiotic misuse and compliance with infection control measures during COVID-19 pandemic in community pharmacies in Egypt

BACKGROUND

Globally, antibiotics misuse by the public has been reported in the era of COVID-19, despite the discouraging instructions of the World Health Organization, especially for mild cases.

OBJECTIVE

Is to describe this antibiotic misuse and its contributing factors. Also, to measure the pharmacists' application of infection preventive practices during the pandemic.

METHODS

A cross-sectional study was conducted among randomly selected Egyptian community pharmacists (Center, East, Delta, and Upper Egypt) using a questionnaire and direct interviews from 1 to 30 August 2020. The questionnaire consisted of two parts, the first covered pharmacist's demographic data and their application of basic infection preventive practices (eg, wearing face masks, regular hand sanitization, etc), and the other part was related to antibiotic dispensing patterns. Data were descriptively analyzed and the impact of participant experience on the responses was evaluated using the χ² test.

RESULTS

From 480 randomly selected Egyptian community pharmacists, 413 (87%) consented to participate in the study. 86.7% of the participants were keen to wear face masks (n = 358) and 86.2% kept regular hand sanitization (n = 356); whereas, 46.9% (n = 194) maintained adequate antibiotic stock supply during the pandemic. Nearly 67% (n = 275) of the pharmacists reported that patients were more likely to be given antibiotics for showing any sign or symptom of COVID-19 infection, and 82% (n = 74 278) of the dispensed antibiotics were given upon physician recommendation. Azithromycin, Ceftriaxone, and Linezolid were the major antibiotics dispensed to COVID-19 presumptive patients Azithromycin was given to ~40% of presumptive patients showing only mild or moderate symptoms for 5-10 days. Additionally, antibiotic combinations were given to 74% (n = 62 479) of home-isolated patients for a maximum of 2 weeks.

CONCLUSIONS

Pharmacists applied suitable sanitation and infection control protocols. Meanwhile, antibiotics were dispensed heavily during this pandemic without proper clinical indication and for long durations supporting the idea of antibiotic misuse.

Knowledge, attitudes, and practices regarding antibiotic use and resistance among community pharmacists: a cross sectional study in Jordan

Background Antibiotic resistance is a global threat and burden on healthcare systems. One major factor contributing to this problem is inappropriate use of antibiotics, which comprises suboptimal use, misuse, abuse, and dispensing errors. Another important factor is dispensing antibiotics without medical prescription. Many studies considered pharmacists as healthcare providers accountable for this malpractice. Objectives To investigate community pharmacists' knowledge, attitudes, and practices in relation to antibiotic dispensing, antibiotic resistance and antibiotic stewardship. Setting Community pharmacists selected from different areas in Amman/Jordan. Subjects were selected based on their availability and accessibility. Methods A descriptive cross-sectional survey of community pharmacists was conducted between May to October 2019, using a structured, validated, and pilot-tested questionnaire. A four-part systematic survey consisting of biography, knowledge, practice and attitude domains was used. Main outcome measure community pharmacist knowledge, practices and attitudes regarding antibiotic use and resistance. Results Of 150 community pharmacists approached, 114 completed and returned the questionnaire (response rate 76%). More than 83.3% perceived antimicrobial resistance as a global problem. A substantial percentage (59.7%) educate patients about issues of inappropriate antibiotics use. Almost half the participants (44.7%) agreed that implementing antimicrobial stewardship would result in better outcomes. Conclusion It is crucial to improve the curriculum in schools of pharmacy, emphasizing on interprofessional education and developing customized interventions. Regulations on dispensing antibiotics without prescription should be enforced. Policy makers need to implement antimicrobial stewardship and encourage the use of public educational interventions in community pharmacy.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Dispensing of antibiotics in community pharmacy in Iraq: a qualitative study

Objective

This study aimed to understand the dispensing practice of antibiotics in community pharmacy in Iraq, in addition to explore the community pharmacists' perception about dispensing antibiotics without prescription.

Methods

A qualitative design was conducted on community pharmacists in Baghdad, Iraq. Pharmacists were selected conveniently from different gender, age group, pharmacy type and years of experience. Face-to-face semi-structure interview was used with all the pharmacists to get in-depth understanding about their dispensing practice of antibiotics without prescription in community pharmacy. The data was coded and classified for thematic analysis.

Results

This study found that dispensing of antibiotics without prescription was a common practice in community pharmacy. Pharmacists' perception towards dispensing antibiotics without prescription was associated with the medical condition, safety and efficacy of antibiotics, patients request antibiotics by name, emergency cases, regular customer, promotions from pharmaceutical companies, saving time and cost, brand medications, and poor healthcare services. In addition, there were inadequate knowledge about antibiotic resistance and lack of awareness about antibiotic stewardship leading to inappropriate dispensing practice.

Conclusions

Community pharmacists have poor perception towards dispensing antibiotics without prescription. Educational interventions about antibiotics use focusing on community pharmacists are needed. This will help to optimize the practice of dispensing of antibiotics in the community. In addition, training programs about antibiotic resistance are important to enhance pharmacists' understanding about antibiotic stewardship.

Rodrigues D, Figueiras A, Zapata-Cachafeiro M, Roque F, Herdeiro MT. Antibiotic Dispensation without a Prescription Worldwide: A Systematic Review

Antibiotic resistance still remains a major global public health problem and the dispensing of antibiotics without a prescription at community pharmacies is an important driver of this. MEDLINE, Pubmed and EMBASE databases were used to search and identify studies reporting the dispensing of non-prescribed antibiotics in community pharmacies or drugstores that sell drugs for human use, by applying pharmacy interviews/questionnaires methods and/or simulated patient methods. Of the 4683 studies retrieved, 85 were included, of which 59 (69.4%) were published in low-and middle-income countries. Most of the papers (83.3%) presented a percentage of antibiotic dispensing without a prescription above 60.0%. Sixty-one studies evaluated the active substance and the most sold antibiotics without a prescription were amoxicillin (86.9%), azithromycin (39.3%), ciprofloxacin (39.3%), and amoxicillin-clavulanic acid (39.3%). Among the 65 articles referencing the diseases/symptoms, this practice was shown to be mostly associated with respiratory system problems (100.0%), diarrhea (40.0%), and Urinary Tract Infections (30.8%). In sum, antibiotics are frequently dispensed without a prescription in many countries and can thus have an important impact on the development of resistance at a global level. Our results indicate the high need to implement educational and/or regulatory/administrative strategies in most countries, aiming to reduce this practice.

Microbial Resistance Movements: An Overview of Global Public Health Threats Posed by Antimicrobial Resistance, and How Best to Counter

Antibiotics changed medical practice by significantly decreasing the morbidity and mortality associated with bacterial infection. However, infectious diseases remain the leading cause of death in the world. There is global concern about the rise in antimicrobial resistance (AMR), which affects both developed and developing countries. AMR is a public health challenge with extensive health, economic, and societal implications. This paper sets AMR in context, starting with the history of antibiotics, including the discovery of penicillin and the golden era of antibiotics, before exploring the problems and challenges we now face due to AMR. Among the factors discussed is the low level of development of new antimicrobials and the irrational prescribing of antibiotics in developed and developing countries. A fundamental problem is the knowledge, attitude, and practice (KAP) regarding antibiotics among medical practitioners, and we explore this aspect in some depth, including a discussion on the KAP among medical students. We conclude with suggestions on how to address this public health threat, including recommendations on training medical students about antibiotics, and strategies to overcome the problems of irrational antibiotic prescribing and AMR.

Serotypes and Antimicrobial Susceptibility of Nasopharyngeal Isolates of Streptococcus pneumoniae from Children Less Than 5 Years Old in Egypt

Purpose

Streptococcus pneumoniae (S. pneumoniae) is the etiology of severe and life-threatening infections in children less than 5 years old. Though pneumococcal conjugate vaccines (PCVs) are effective in the prevention of pneumococcal infections, yet they are not included in the National Immunization Program in Egypt pending the identification of pathogenic serotypes. As S. pneumoniae colonization of the pharynx predisposes to pneumonia and invasive pneumococcal disease (IPD) caused by the colonizing serotypes, identification of the nasopharyngeal (NP) serotypes can be a surrogate to the invasive serotypes. In this study, we aimed to 1. Identify the serotypes and antimicrobial susceptibility testing (AST) of Streptococcus pneumoniae colonizing the nasopharynx of Egyptian children younger than 5 years in two successive winter seasons. 2. Correlate the identified serotypes with vaccine coverage of the 13-valent conjugate pneumococcal vaccines (PCV13). 3. Compare the serotypes and AST of S. pneumoniae from NP to those of IPD that were routinely identified in our clinical laboratory during the study period.

Materials and Methods

The study was conducted in two successive winter seasons (December 2015–March 2016; December 2016–March 2017). We enrolled 334 children, aged 6 months to 5 years, attending the outpatient general clinics of Cairo University Children Hospital, excluding those with fever, signs of infection, history of antibiotic intake or hospitalization in the preceding month. We tested NP swabs for S. pneumoniae by culture and real-time PCR. Serotyping was performed by sequential multiplex PCR for all positive samples. AST was done to S. pneumoniae isolates by Vitek-2™ (BioMérieux, Marcy-L’Etoile, France). We included routinely detected S. pneumoniae from sterile body sites during the study period, and identified their serotypes and AST.

Results

PCR was positive for pneumococci in 217 out of 334 pharyngeal swabs (65%), including 186 typable samples. The most common serotypes were serotypes 1, 6ABC, 19 F, 5 and 18ABC. By culture, we isolated only 110 out of 334 pharyngeal swabs (32.9%). The theoretical coverage of the PCV13 vaccine for the detected serotypes was 77.4%. The AST of NP isolates revealed low susceptibility rates to all antimicrobials except for vancomycin, linezolid, levofloxacin and clindamycin. During the study period, we identified 40 IPD; 21 identified by PCR and 19 by culture. The commonest pneumococcal serotypes were 1, 18ABC, 6ABC and 5. The PCV13 coverage was 75%. By Vitek-2, the isolates showed 100%, 100%, 94.7%, 89.5%, 84.2%, 84.2% and 78.9% susceptibility to vancomycin, linezolid, clindamycin, levofloxacin, penicillin, cefotaxim and erythromycin, respectively.

Conclusion

Based on the serotype vaccine coverage and the emerging antimicrobial resistance of S. pneumoniae, PCVs will be valuable to Egyptian children.

How accurate is the diagnosis of rheumatic fever in Egypt? Data from the national rheumatic heart disease prevention and control program (2006-2018)

Rheumatic heart disease (RHD) as a chronic sequela of repeated episodes of acute rheumatic fever (ARF), remains a cause of cardiac morbidity in Egypt although it is given full attention through a national RHD prevention and control program. The present report reviews our experience with subjects presenting with ARF or its sequelae in a single RHD centre and describes the disease pattern over the last decade. A cross-sectional study was conducted in El-Mahalla RHD centre between 2006 and 2018. A total of 17014 individual were enrolled and evaluated. Diagnosis ARF was based on the 2015 revised Jones criteria and RHD was ruled in by echocardiography. The majority of the screened subjects were female (63.2%), in the age group 5-15 years (64.6%), rural residents (61.2%), had primary education (43.0%), and of low socioeconomic standard (50.2%). The total percentage of cases presenting with ARF sequelae was 29.3% [carditis/RHD (10.8%), rheumatic arthritis (Rh.A) (14.9%), and Sydenham's chorea (0.05%)]. Noticeably, 72% were free of any cardiac insult, of which 37.7% were victims of misdiagnoses made elsewhere by untrained practitioners who prescribed for them long term injectable long-acting penicillin [Benzathine Penicillin G (BPG)] without need. About 54% of the study cohort reported the occurrence of recurrent attacks of tonsillitis of which 65.2% underwent tonsillectomy. Among those who experienced tonsillectomy and/or received BPG in the past, 14.5% and 22.3% respectively had eventually developed RHD. Screening of family members of some RHD cases who needed cardiac surgery revealed 20.7% with undiagnosed ARF sequalae [RHD (56.0%) and Rh.A (52.2%)]. Upon the follow-up of RHD cases, 1.2% had improved, 98.4% were stable and 0.4% had their heart condition deteriorated. Misdiagnosis of ARF or its sequelae and poor compliance with BPG use may affect efforts being exerted to curtail the disease. Updating national guidelines, capacity building, and reliance on appropriate investigations should be emphasized. Since the genetic basis of RHD is literally confirmed, a family history of RHD warrants screening of all family members for early detection of the disease.

Implementation of the WHO Approved "Tailoring Antimicrobial Resistance Programs (TAP)" Reduces Patients' Request for Antibiotics

The misuse of antibiotics is a worldwide public health concern. Behavioral Intervention programs that aim to reduce patients' own request for antibiotics during their visit to primary care clinics is an attractive strategy to combat this problem. We tested the effectiveness of a behavioral modification method known as the Tailoring Antimicrobial resistance Programs (TAP) in reducing the request for antibiotics by patients visiting primary care clinics for mild upper respiratory tract infections (URTIs). A stratified cluster randomized design with two groups pre-post, comparing intervention with the control, was conducted in six health centers. TAP was implemented for eight weeks. Request for antibiotics was assessed before (period 1) and after introducing TAP (period 2). The percentage of patients or their escorts who requested antibiotics in period 1 was 59.7% in the control group and 60.2% in the intervention group. The percentage of patients who requested antibiotics did not significantly change between period 1 and 2 in the control group, who continued to receive the standard of care. The above percentage significantly decreased in the intervention group from 60.2% to 38.5% (p < 0.05). We conclude that behavioral change programs including TAP are a viable alternative strategy to address antibiotic misuse in Jordan.

Socioeconomic Inequality in Self-Medication in Iran: Cross-Sectional Analyses at the National and Subnational Levels

Background

Self-medication (SM) is a public health concern globally. This study aimed to measure socioeconomic inequality in SM and identify its main determinants among Iranian households.

Methods

A total of 38,859 households from the 2018 Household Income and Expenditure Survey (HIES) were included in the study. Data on SM, household size, age, gender and education status of the head of household, monthly household’s expenditures (as a proxy for socioeconomic status), health insurance coverage and living areas and provinces were obtained for the survey. The concentration curve and the normalized concentration index (C_n) were used to quantify the magnitude of socioeconomic inequality in SM among Iranian households. The C_n was decomposed to identify the main determinants of socioeconomic inequality in SM in Iran.

Results

The results indicated that 18.2% (95% confidence interval [CI]: 17.7% to 18.5%) of households in Iran had SM practice in the past month. The results suggested a higher concentration of SM among the rich households (C_n= 0.0466; 95% CI= 0.0321 to 0.0612) in Iran. The concentration of SM among high SES households was also found in urban (0.0311; 95% CI=0.0112 to 0.0510) and rural (= 0.0513; 95% CI=0.0301 to 0.0726) areas. SM was concentrated among the rich households in Tehran, Qom, Esfahan, Ardebil, Golestan, and Sistan and Baluchestan provinces. In contrast, a higher concentration of SM was found among the poor households in Semnan, North Khorasan, Kerman, Bushehr, and South Khorasan provinces. The decomposition revealed SES of household, itself, as the main contributing factor to the concentration of SM among the wealthy households.

Conclusion

This study demonstrated that SM is more concentrated among socioeconomically advantaged households in Iran. Thus, effective evidence-based interventions should be implemented to improve awareness about SM and its negative consequences. Further studies are required to investigate the consequences of SM practice among people.

Community knowledge and practices regarding antibiotic use in rural Mozambique: where is the starting point for prevention of antibiotic resistance?

BACKGROUND

Antibiotic misuse and other types of unnecessary use of antibiotics can contribute to accelerate the process of antibiotic resistance, which is considered a global concern, mostly affecting low-and middle-income countries (LMICs). In Mozambique there is limited evidence on community knowledge and practices regarding antibiotics and antibiotic resistance. As part of the ABACUS project, this paper describes knowledge and practices of antibiotic use among the general population in the semi-rural district of Manhiça to inform evidence-based communication intervention strategies for safer antibiotic use.

METHODS

The study was conducted in Manhiça, a semi-rural district of Southern Mozambique. Sixteen in-depth interviews and four focus group discussions (FGDs) were conducted with community members to explore lay knowledge and practices regarding antibiotics and awareness of antibiotic resistance. The qualitative data was analysed using a combination of content and thematic analysis. The SRQR guidelines for reporting qualitative studies was performed.

RESULTS

Although participants did not hold any consistent knowledge of antibiotics, their visual recognition of amoxicillin (distinct red yellow capsule) was acceptable, but less so for different types and brands of antibiotics. The majority of participants were aware of the term 'antibiotic', yet the definition they gave was rarely backed by biomedical knowledge. Participants associated antibiotics with certain colours, shapes and health conditions. Participants reported common habits that may contribute to resistance: not buying the full course, self-medication, sharing medicines and interruption of treatment. Most had never heard of the term 'antibiotic resistance' but were familiar with the phenomenon. They often understood the term 'resistance' as treatment failure and likened 'resistance' to non-compliance, ineffective medication, disease resistance or to an inability of the physical body to respond to it.

CONCLUSION

There is a broad understanding of the importance of medication compliance but not specifically of antibiotic resistance. In addition, there is a recognized gap between knowledge of responsible drug compliance and actual behaviour. Future qualitative research is required to further explore what determines this behaviour. The existing ability to visually identify amoxicillin by its distinct red and yellow appearance is informative for future awareness and behavioural change campaigns that may incorporate visual aids of antibiotics.

Antimicrobial activity of certain natural-based plant oils against the antibiotic-resistant acne bacteria

The unceasing emerging of multidrug-resistant bacteria imposes a global foremost human health threat and discovery of new alternative remedies are necessity. The use of plant essential oil in the treatment of many pathogenic bacteria is promising. Acne vulgaris is the most common skin complaint that fears many people about their aesthetic appearance. In this work we investigated the antibacterial activity of some plant oils against acne-inducing bacteria. Three bacterial isolates were identified from Egypt, biochemically and by means of 16s rRNA gene typing, and were designated as Staphylococcus aureus EG-AE1, Staphylococcus epidermidis EG-AE2 and Cutibacterium acnes EG-AE1. Antibiotic susceptibility test showed resistance of the isolates to at least six antibiotics, yet they are still susceptible to the last resort Vancomycin. In vitro investigations of eleven Egyptian plant oils, identified tea tree and rosemary oils to exhibit antibacterial activity against the antibiotic-resistant acne isolates. Inhibition zones of 15 ± 0.5, 21.02 ± 0.73 and 20.85 ± 0.76 mm was detected when tea tree oil applied against the above-mentioned bacteria respectively, while inhibition zones of 12.5 ± 1.5, 15.18 ± 0.38 and 14.77 ± 0.35 mm were detected by rosemary oils. Tea tree and rosemary oils exhibited bacteriostatic and bactericidal activity against all the strains with MICs/MBCs ranging between 39-78 mg/L for tea tree oil and 39-156 mg/L for rosemary oil. All the isolates were killed after 4 and 6 h upon growing with 200 mg/L of tea tree and rosemary oils, respectively. Additionally, gas chromatography mass spectrometry (GC/MS) profiling identified and detected a variable number of antimicrobial compounds in both oils.

The impact of law enforcement on dispensing antibiotics without prescription: a multi-methods study from Saudi Arabia

Background: Dispensing of antibiotics without a prescription (DAwP) has been widely practised among community pharmacies in Saudi Arabia despite being illegal. However, in May 2018, the law and regulations were enforced alongside fines. Consequently, we wanted to evaluate the impact of these changes.Methods: A study was conducted among 116 community pharmacies in two phases. A pre-law enforcement phase between December 2017 and March 2018 and a post-law enforcement phase one year later. Each phase consisted of a cross-sectional questionnaire-based survey and a simulated client method (SCM) approach. In the SCM, clients presented with either pharyngitis or urinary tract infections (UTI). In SCM, for each phase, all 116 pharmacies were visited with one of the scenarios.Results: Before the law enforcement, 70.7% of community pharmacists reported that DAwP was common with 96.6% and 87.7% of participating pharmacies dispensed antibiotics without a prescription for pharyngitis and UTI respectively. After the law enforcement, only 12.9% reported that DAwP is still a common practice, with only 12.1% and 5.2% dispensing antibiotics without prescriptions for pharyngitis and UTI respectively.Conclusion: law enforcement was effective. However, there is still further scope for improvement. This could include further educational activities with pharmacists, physicians and the public.

Identification, Genotyping and Antimicrobial Susceptibility Testing of Brucella spp. Isolated from Livestock in Egypt

Brucellosis is a highly contagious zoonosis worldwide with economic and public health impacts. The aim of the present study was to identify Brucella (B.) spp. isolated from animal populations located in different districts of Egypt and to determine their antimicrobial resistance. In total, 34-suspected Brucella isolates were recovered from lymph nodes, milk, and fetal abomasal contents of infected cattle, buffaloes, sheep, and goats from nine districts in Egypt. The isolates were identified by microbiological methods and matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF MS). Differentiation and genotyping were confirmed using multiplex PCR for B. abortus, Brucella melitensis, Brucella ovis, and Brucella suis (AMOS) and Bruce-ladder PCR. Antimicrobial susceptibility testing against clinically used antimicrobial agents (chloramphenicol, ciprofloxacin, erythromycin, gentamicin, imipenem, rifampicin, streptomycin, and tetracycline) was performed using E-Test. The antimicrobial resistance-associated genes and mutations in Brucella isolates were confirmed using molecular tools. In total, 29 Brucella isolates (eight B. abortus biovar 1 and 21 B. melitensis biovar 3) were identified and typed. The resistance of B. melitensis to ciprofloxacin, erythromycin, imipenem, rifampicin, and streptomycin were 76.2%, 19.0%, 76.2%, 66.7%, and 4.8%, respectively. Whereas, 25.0%, 87.5%, 25.0%, and 37.5% of B. abortus were resistant to ciprofloxacin, erythromycin, imipenem, and rifampicin, respectively. Mutations in the rpoB gene associated with rifampicin resistance were identified in all phenotypically resistant isolates. Mutations in gyrA and gyrB genes associated with ciprofloxacin resistance were identified in four phenotypically resistant isolates of B. melitensis. This is the first study highlighting the antimicrobial resistance in Brucella isolated from different animal species in Egypt. Mutations detected in genes associated with antimicrobial resistance unravel the molecular mechanisms of resistance in Brucella isolates from Egypt. The mutations in the rpoB gene in phenotypically resistant B. abortus isolates in this study were reported for the first time in Egypt.

Prevalence Of Self-Medication With Antibiotics Among Residents In United Arab Emirates

Background

Self-Medication with antibiotics is a human practice and attitude in which an individual uses antibiotics to treat self-diagnosed symptoms. The self-medication with antibiotics is a common practice among residents in the UAE.

Purpose

The present study aimed to determine the prevalence of self-medication of antibiotics among residents in the UAE population to determine its associated risk factors and to increase awareness regarding the abuse of antibiotics.

Patients and methods

Three hundred and fifteen participants from different public places in Abu Dhabi, Dubai and Sharjah,UAE received the validated questionnaire over the five-month study period. Collected data were analyzed using SPSS statistical software and the Chi-square test to assess the relationships between categorical variables.

Results

Of 315 participants, 31.7% (n=100) of the respondents reported the use of non-prescription antibiotics within a three-month study period. Self-medication with antibiotics was significantly associated with ethnicity and employment. The participants reported their previous experience with the disease (69; 21.9%), as the main reason for self-medication with antibiotics. The primary sources of antibiotics were those purchased from community pharmacies (70; 22.2%) and household (21; 6.7%).

Conclusion

Our study showed a high prevalence of self-medication behaviour even with the enforcement of the new legislation regarding the prohibition of selling antibiotics without a prescription. Therefore, there is a need to raise public awareness towards the safe use of antibiotics in our community.

Assessment of Temporary Community-Based Health Care Facilities During Arbaeenia Mass Gathering at Karbala, Iraq: Cross-Sectional Survey Study

Background

Arbaeenia mass gathering (MG) in Karbala, Iraq, is becoming one of the largest MGs in the world. The health care infrastructure in Iraq is inadequately prepared to serve the health needs of the millions of pilgrims.

Objective

This study aimed to describe the temporary health care facilities installed and run by the local community to provide health care services to Arbaeenia pilgrims in Karbala, Iraq.

Methods

A survey was conducted in all community-based health care facilities located along part of Najaf to Karbala road within Karbala governorate. A structured questionnaire was answered through an interview with the workers and direct observation. Data were collected on staff profile, type of services provided, use of basic infection control measures, medical equipment, drugs and supplies, and the most commonly encountered medical problems.

Results

The total number of health care facilities was 120, staffed by 659 workers. Only 18 (15.0%, 18/120) facilities were licensed, and 44.1% (53/120) of the workers were health professionals. The health care workers provided different services including dispensing drugs (370/1692, 21.87%), measuring blood pressure and blood sugar (350/1692, 20.69%), and caring for wounds and injuries (319/1692, 18.85%). Around 97% (116/120) health facilities provided services for musculoskeletal disorders and only 16.7% (20/120) provided services for injuries. The drugs available in the clinic were analgesics, drugs for gastrointestinal and respiratory diseases, and antibiotics, with an availability range of 13.3% to 100.0%. Infection control practices for individual protection, environmental sanitation, and medical waste disposal were available in a range of 18.1% to 100.0%.

Conclusions

Community-based health care facilities experienced a profound shortage of trained human resources and medical supplies. They can significantly contribute to health services if they are adequately equipped and follow standardized operation procedures.

Knowledge, attitudes and practices regarding antibiotic use in Maputo City, Mozambique

Background

Irrational use of antibiotics is a major driver of antimicrobial resistance (AMR) worldwide. Sub-Saharan Africa, where the risk of spread of AMR is highest, lacks data on the knowledge, attitudes and practices regarding antibiotic prescription and use. This is the first study in Mozambique to address this gap.

Methods

A cross-sectional study was conducted in 2016 in 1091 adults (age ≥18 years) living in five districts in peri-urban areas of Maputo City. Three stage cluster sampling was used to select the households. A semi-structured questionnaire was used to collect information on the knowledge, attitudes and practices regarding antibiotics and their use and socio-demographic data.

Results

Of the 1091 participants, 20.9% (228/1091) had used non-prescribed antibiotics. Most of the non-prescribed antibiotics were purchased in pharmacies (199/228; 87.3%). The proportion of use of non-prescribed antibiotics was higher in those who purchased from informal markets (82.6%; 14/17) and home stores (66.7%; 12/18), compared to pharmacies (24.6%; 199/810) (p = 0.000). Variables significantly associated with use of non-prescribed antibiotics were male gender (p = 0.004), living in the Central A (p<0.001), Aeroporto B (p<0.001) or 25 de Junho (p<0.001) neighborhoods, purchase of antibiotics in informal markets (p<0.002) or obtaining from home stores (p = 0.026), not completing the course (p<0.001) and having poor knowledge on the use of antibiotics (p<0.001). Main reasons for use of non-prescribed antibiotics were a perception that there was no need to attend a health facility (26.8%), followed by someone else’s advice (7.7%), symptoms similar to a previous episode (6.2%) and poor quality of care in health facilities (6.7%).

Conclusions

Our study shows for the first time that knowledge regarding antibiotics is poor in Maputo City. Purchase of non-prescribed antibiotics is a common practice and most are sold in pharmacies, indicating deficient inspection. Interventions to reinforce adherence by pharmacies to current legislation for dispensing antibiotics, combined with community education are urgently needed.

Photothermal versus photodynamic treatment for the inactivation of the bacteria Escherichia coli and Bacillus cereus: An in vitro study

The widespread occurrence of microbial pathogens, including multidrug-resistant (MDR) bacteria, has ignited research efforts to discover alternative strategies to combat infections in patients. Recently, photodynamic therapy (PDT) and photothermal therapy (PTT) have been proposed for the inactivation of pathogens. Although PDT and PTT are very promising antipathogenic tools, further effort is needed to determine their real impact on pathogens apart from the effects of individual elements involved in the photodynamic/photothermal processes, i.e., light, photosensitizers (PSs), and nanoparticles. Accordingly, in the current study, toluidine blue O (TBO) and gold nanoparticles (GNP) were used as generators of reactive oxygen species (ROS) and hyperthermia in the presence of light, respectively. Escherichia coli (E. coli) and Bacillus cereus (B. cereus) bacteria were chosen as examples of gram-negative and gram-positive bacteria, respectively. Before the bactericidal activity of PDT was assessed, the aggregation of TBO and its effect on the growth of both strains of bacteria were studied. Additionally, E. coli and B. cereus were exposed to a range of doses of 633 nm helium-neon laser light to investigate its effect. In a separate set of experiments, the bactericidal activity of PTT was assessed after the effects of GNP and green light (530 nm) had been assessed. The results showed that PDT and PTT should be considered useful tools for bacterial eradication even when the light, PSs, and nanoparticles are each used at doses safe for bacterial growth. Moreover, different photodynamic responses were observed for E. coli and B. cereus, and light from a 633 nm laser and a 530 nm light-emitting diode (LED) showed disparate responses when applied alone to both bacteria.

Egyptian community pharmacists' attitudes and practices towards antibiotic dispensing and antibiotic resistance; a cross-sectional survey in Greater Cairo

BACKGROUND

Antibiotic resistance is an increasing worldwide crisis. In Egypt, it is prohibited by law to dispense antibiotics with no prescription; however, there are no active and enforced governmental policies and laws to regulate such a process. This has led to increased antibiotic dispensing and consumption.

AIMS

To assess some basic knowledge and attitudes towards antibiotic resistance and the practice of antibiotic dispensing among Egyptian community pharmacists in Greater Cairo.

METHODOLOGY

An observational cross-sectional self-administrated survey targeting licensed community pharmacists in Greater Cairo, Egypt. The survey was validated by both face and content validation.

RESULTS

Exactly 531 pharmacists were invited to join the survey, and only 461 pharmacists agreed to participate. Approximately half of the participants (51.2%) were considered to have good basic knowledge regarding antibiotic use and antibiotic resistance. The majority (74%) of the respondents strongly agreed that antibiotics are over-prescribed in Egypt, and almost all of them (90%) were hoping the Ministry of Health could publish guidelines for antibiotic dispensing in Egypt. Male pharmacists were more likely to engage and communicate with either patient or prescriber during the antibiotic dispensing process compared to females.

CONCLUSION

The Egyptian Ministry of Health should regulate and monitor the process of dispensing antibiotics without a prescription with law enforcements. Moreover, community pharmacists should have more awareness on the consequences of the problem of antibiotic dispensing without a prescription, regardless of the business profit behind it.

Knowledge, attitude, and practice of self-medication with antibiotics among community residents in Addis Ababa, Ethiopia

Background: Self-medication with antibiotics, which may cause significant antibiotic resistance, is predominant in developing countries. The aim of this study is to assess the knowledge, attitude, and practice of self-medication with antibiotics among community residents in Ethiopia. Methods: A cross-sectional study design was conducted from June to August 2017. Knowledge-Attitude-Practice questionnaire was developed and distributed to eligible household respondents in Addis Ababa and its surrounding area. Logistic regression analysis was used to identify factors associated with self-medication with antibiotics. Results: Among the 605 invited participants, 595 respondents were participated in this study (response rate = 98.3%) and 67.3% of the respondents had reported self-medication with antibiotics in the past 6 months. The median score of knowledge about antibiotics was 3 (Inter quarter range: 2-4) of a maximum possible score of 6 and the median score of attitude was 19 (Inter quarter range: 16-22) from a maximum of 29. Self-medication with antibiotics was significantly associated with age, educational status, and average monthly income of the communities. Conclusions: Respondents have inadequate knowledge and inappropriate practice toward rational use of antibiotics. Policies such as restricting the purchase of antibiotics without a medical prescription and educating appropriate use of antibiotics are urgently needed.

Evaluation of antibiotic dispensing practice in community pharmacies in Jordan: A cross sectional study

It is well known that the emergence of antibiotic resistance is linked to the misuse and overuse of antibiotics. Misuse includes self-medication and the inappropriate use of antibiotics because of improper dosage or improper duration than recommended. This study investigated three patterns of dispensing antibiotics in a sample of community pharmacies in Jordan. This included dispensing antibiotics by prescription or over-the-counter either by direct request or upon a pharmacist’s recommendation. The antibiotics dispensed were evaluated in terms of indication, appropriateness of dose, and duration of treatment based on the empirical treatment suggested by selected references: Lexicomp (2017) and UptoDate (2017) and the manufacturer’s recommendations. Of the 457 antibiotics dispensed, almost one third were without prescription. Of the antibiotics dispensed with prescription or without prescription, 31.5% and 24.6% respectively were appropriate dosage and duration (p = 0.002). In the three patterns of dispensing, beta lactam antibiotics were the most commonly dispensed. In addition, it was noticed that there was a tendency to prescribe or dispense higher generations of antibiotics to cases that could have been treated with lower generation or safer antibiotics. Furthermore, 12.2% of the antibiotics were dispensed to treat infections that are not indicated for them. In conclusion, a significant proportion of antibiotics are dispensed without prescription in Jordan. Moreover, a considerable proportion of prescribed antibiotics were inappropriate for the conditions concerned. This indicates the importance of enforcing the Jordanian regulations prohibiting the dispensing of nonprescription antibiotics and the implementation of continuous education to physicians and pharmacists to increase awareness about the emergence of antibiotic resistance.

Quality of Community Pharmacy Practice in Antibiotic Self-Medication Encounters: A Simulated Patient Study in Upper Egypt

Antibiotic misuse, either by patients or healthcare professionals, is one of the major contributing factors to antimicrobial resistance. In many Middle Eastern countries including Egypt, there are no strict regulations regarding antibiotic dispensing by community pharmacies. In this study, we examined antibiotic dispensing patterns in Egyptian community pharmacies. About 150 community pharmacies were randomly chosen using convenience sampling from the five most populous urban districts of Minia Governorate in Egypt. Two simulated patient (SP) scenarios of viral respiratory tract infection requiring no antibiotic treatment were used to assess the actual antibiotics dispensing practice of. Face-to-face interviews were then conducted to assess the intended dispensing practice. Descriptive statistics were calculated to report the main study outcomes. In 238 visits of both scenarios, 98.3% of service providers dispensed amoxicillin. Although stated otherwise in interviews, most pharmacy providers (63%) dispensed amoxicillin without collecting relevant information from presenting SPs. Findings showed high rates of antibiotic misuse in community pharmacies. Discrepancies between interviews and patient simulation results also suggest a practice‒knowledge gap. Corrective actions, whether legislation, enforcement, education, or awareness campaigns about antibiotic misuse, are urgently needed to improve antibiotic dispensing practices in Egyptian community pharmacies.

Patients' Perspective And Usefulness Of Pictograms In Short-Term Antibiotic Therapy - Multicenter, Randomized Trial

PURPOSE

To evaluate the practical utility of pharmaceutical pictograms in routine practice in community pharmacy. The primary outcome (composite endpoint) consisted of three elements: i) complete use of the whole package of medication, ii) taking the recommended dose twice a day, and iii) subjective assessment of patients' perspective on medical information about antibiotic therapy obtained during the pharmacy consultation measured by Net Promoter Score in scale from 1 to 10 where 1 is the lowest and 10 the highest possible rating.

PATIENTS AND METHODS

A multicenter, randomized controlled study was conducted. Community pharmacies (n = 64) which agreed to participate in the study were assigned to one of two groups: i) study - providing an antibiotic with pictograms placed on the external packaging of the medicinal product containing information about drug regimen (n = 32); or ii) control - providing an antibiotic according to usual pharmacy practice (n = 32). Two semi-structured interviews were performed. Data were collected from 199 patients with a mean age ± SD of 45.5 ± 17.0 years.

RESULTS

In the control group, 15.7% of participants discontinued therapy before using the whole package compared with 13.4% of participants in the study group. In the control group, 81.3% of patients reported that they always took the medication twice a day as recommended by their healthcare providers compared with 80.4% of patients in the study group. The Net Promoter Score was higher for pharmacy practice with than without pictograms (71.3% vs 51.5%, respectively, p<0.005). The chance that a patient was an advocate of pharmaceutical services (scores 9 and 10) was twice as likely in the case of pharmaceutical practice supported by pictograms (p<0.02). The composite endpoint was achieved more frequently in the population using pictograms, however this difference was not statistically significant (p<0.34).

CONCLUSION

The pharmaceutical pictograms are readily accepted by patients and could prove to be a valuable support for pharmacists in conducting pharmaceutical care. Further representative research is needed to evaluate the true effectiveness of this solution.

"You could lose when you misuse" - factors affecting over-the-counter sale of antibiotics in community pharmacies in Saudi Arabia: a qualitative study

Background

The sale of antibiotics without a prescription poses a global public health concern. Antibiotics dispensed without a prescription are largely recognised as a cause of antibiotic misuse and overuse which may result in antibiotic resistance, recurrent infection, increased cost and adverse effects of treatment. There have been no qualitative studies to explore the reasons for over-the-counter (OTC) sale of antibiotics, despite the fact that non-prescription sale of antibiotics are increasing in Saudi Arabia.

Methods

Qualitative interviews were conducted with community pharmacists living in the Eastern Province of Saudi Arabia using face-to-face, open-ended questions. Interviews were audio-recorded and transcribed verbatim. The interview transcripts were analysed using thematic analysis and NVivo 10 software.

Results

All participants declared that antibiotics were frequently sold without a medical prescription on an OTC basis. The main reasons for OTC sale of antibiotics were found to be related to the ease of access to community pharmacies compared to other healthcare services, expertise and knowledge of pharmacists and patients’ trust, misconceptions and inappropriate practices of the public towards antibiotic use, customer pressure, pharmacists’ need to ensure business survival and weak regulatory enforcement mechanism. These are presented in more detail below by using illustrative quotes from participants’ transcripts.

Conclusions

The non-prescribed sale of antibiotics is still a common practice in Saudi Arabia, despite being a problem. The results of this study highlight the need to design interventions to promote rational use of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3753-y) contains supplementary material, which is available to authorized users.