What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India

Identification, mapping, and self-reported practice patterns of village doctors in Sitakunda subdistrict, Bangladesh

Background

Informally trained health care providers, such as village doctors in Bangladesh, are crucial in providing health care services to the rural poor in low- and middle-income countries. Despite being one of the primary vendors of antibiotics in rural Bangladesh, village doctors often have limited knowledge about appropriate antibiotic use, leading to varied and potentially inappropriate dispensing and treatment practices. In this study, we aimed to identify, map, and survey village doctors in the Sitakunda subdistrict of Bangladesh to understand their distribution, practice characteristics, clinical behaviours, access to technologies, and use of these technologies for clinical decision-making.

Methods

Using a 'snowball' sampling method, we identified and mapped 411 village doctors, with 371 agreeing to complete a structured survey.

Results

The median distance between a residential household and the closest village doctor practice was 0.37 km, and over half of the practices (51.2%) were within 100 m of the major highway. Village doctors were predominately male (98.7%), with a median age of 39. After completing village doctor training, 39.4% had completed an internship, with a median of 15 years of practice experience. Village doctors reported seeing a median of 84 patients per week, including a median of five paediatric diarrhoea cases per week. They stocked a range of antibiotics, with ciprofloxacin and metronidazole being the most prescribed for diarrhoea. Most had access to phones with an internet connection and used online resources for clinical decision-making and guidance.

Conclusions

The findings provide insights into the characteristics and practices of village doctors and point to the potential for internet and phone-based interventions to improve patient care and reduce inappropriate antibiotic use in this health care provider group.

Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study

OBJECTIVE

Antibiotic misuse includes using them to treat colds and influenza, obtaining them without a prescription, not finishing the prescribed course and sharing them with others. Although drug providers are well positioned to advise clients on proper stewardship practices, antibiotic misuse continues to rise in Ethiopia. It necessitates an understanding of why drug providers failed to limit such risky behaviours. This study aimed to explore drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia.

SETTING

The study was conducted in rural Haramaya district and Harar town, eastern Ethiopia.

DESIGN AND PARTICIPANTS

An exploratory qualitative study was undertaken between March and June 2023, among the 15 drug providers. In-depth interviews were conducted using pilot-tested, semistructured questions. The interviews were transcribed verbatim, translated into English and analysed thematically. The analyses considered the entire dataset and field notes.

RESULTS

The study identified self-medication pressures, non-prescribed dispensing motives, insufficient regulatory functions and a lack of specific antibiotic use policy as the key contributors to antibiotic misuse. We found previous usage experience, a desire to avoid extra costs and a lack of essential diagnostics and antibiotics in public institutions as the key drivers of non-prescribed antibiotic access from private drug suppliers. Non-prescribed antibiotic dispensing in pharmacies was driven by client satisfaction, financial gain, business survival and market competition from informal sellers. Antibiotic misuse in the setting has also been linked to traditional and ineffective dispensing audits, inadequate regulatory oversights and policy gaps.

CONCLUSION

This study highlights profits and oversimplified access to antibiotics as the main motivations for their misuse. It also identifies the traditional antibiotic dispensing audit as an inefficient regulatory operation. Hence, enforcing specific antibiotic usage policy guidance that entails an automated practice audit, a responsible office and insurance coverage for persons with financial limitations can help optimise antibiotic use while reducing resistance consequences.

Inappropriate antibiotic access practices at the community level in Eastern Ethiopia

Access to antibiotic medications is critical to achieving the Sustainable Development Goal for good health and well-being. However, non-prescribed and informal sources are implicated as the most common causes of inappropriate antibiotic access practices, resulting in untargeted therapy, which leads to antibiotic resistance. Hence, knowing antibiotic access practices at the community level is essential to target misuse sources. In this study, 2256 household representatives were surveyed between July and September 2023 to examine their antibiotic access practices. Of 1245 household members who received antibiotics, 45.6% did so inappropriately. Non-prescribed antibiotic access was more common among urban residents and individuals not enrolled in health insurance schemes. This means of antibiotic access was also more common among individuals concerned about distance, drug availability, and healthcare convenience at public facilities. In addition, women and rural individuals were more likely to get antibiotics from unauthorized sources. Unrestricted antibiotic dispensing practices in urban areas enabled their non-prescribed access, while unlicensed providers prevailed with this access practice in rural areas. In this regard, personal behaviors and healthcare-related gaps such as the lack of health insurance, inconvenience, and drug unavailability have led community members to seek antibiotics from unofficial and non-prescribed sources. Targeting the identified behavioral and institutional factors can enhance antibiotic access through prescriptions, hence reducing antibiotic resistance.

Evaluatıon of forensic medical aspects of medical interventions and damages caused by unauthorized persons

BACKGROUND

Medical interventions are procedures that are conducive to creating danger on people's life and body immunity due to their characteristics. We aimed to raise awareness and make contributions by revealing the fact that serious bodily and mental harms occur due to medical interventions by the ones who do not have the authority to perform.

METHODS

We evaluated 210 cases appealled to our institution between the years of 2017 and 2022 who suffered damage after medical interventions by people who do not have any authorization or license. The damages that occurred in the cases were evaluated in terms of medical and legal aspects. Analysis of the data were done with SPSS 25.0 for Windows and the statistical alpha significance level were accepted as p < 0.05.

RESULTS

76.7% of the cases were women, 87.1% were young individuals under the age of 40 Of the medical interventions, 91.9% were for aesthetic/cosmetic purposes (laser epilation, tattoo removal, botox, dermapen, cold lipolysis), 8.1% were for therapeutic purposes (bone setter intervention, tooth extraction/prosthesis, intramuscular injection, cupping pull) was found. It was found that 87.1% of the medical interventions were performed in beauty salons, 12.9% in hairdressers, home, medical markets, pharmacies and dental clinics.

CONCLUSIONS

All over the world and in our country, serious bodily and mental injuries occur in people after medical interventions by unauthorized persons. Therefore, it is necessary to see this situation as an important problem, and raise awareness in the society to make legal arrangements.

Antibiotic dispensing practices among informal healthcare providers in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

The rise of antimicrobial resistance represents a critical threat to global health, exacerbated by the excessive and inappropriate dispensing and use of antimicrobial drugs, notably antibiotics, which specifically target bacterial infections. The surge in antibiotic consumption globally is particularly concerning in low-income and middle-income countries (LMICs), where informal healthcare providers (IPs) play a vital role in the healthcare landscape. Often the initial point of contact for healthcare-seeking individuals, IPs play a crucial role in delivering primary care services in these regions. Despite the prevalent dispensing of antibiotics by IPs in many LMICs, as highlighted by existing research, there remains a gap in the comprehensive synthesis of antibiotic dispensing practices and the influencing factors among IPs. Hence, this scoping review seeks to map and consolidate the literature regarding antibiotic dispensing and its drivers among IPs in LMICs.

METHODS AND ANALYSIS

This review will follow the Joanna Briggs Institute guideline for scoping review. A comprehensive search across nine electronic databases (MEDLINE, EMBASE, SCOPUS, Global Health, CINAHL, Web of Science, LILACS, AJOL and IMSEAR) will be performed, supplemented by manual searches of reference lists of eligible publications. The search strategy will impose no constraints on study design, methodology, publication date or language. The study selection process will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The findings on antibiotic dispensing and its patterns will be synthesised and reported descriptively using tables, visuals and a narrative summary. Additionally, factors influencing antibiotic dispensing will be elucidated through both inductive and deductive content analysis methods.

ETHICS AND DISSEMINATION

Ethical approval is not required for scoping reviews. The findings will be disseminated through peer-reviewed publications and presentations at relevant conferences.

Challenges in the distribution of antimicrobial medications in community dispensaries in Accra, Ghana

INTRODUCTION

The dispensation of medicines in some low- and middle-income countries is often carried out by private vendors operating under constrained conditions. The aim of this study was to understand the challenges reported by employees of dispensaries, specifically, chemical and herbal shops and pharmacies in Accra, Ghana. Our objectives were twofold: (1) to assess challenges faced by medicine vendors related to dispensing antimicrobials (antibiotic and antimalarial medications), and (2) to identify opportunities for improving their stewardship of antimicrobials.

METHODS

Data were collected in 79 dispensaries throughout Accra, in 2021, using a survey questionnaire. We used open-ended questions, grounded on an adapted socioecological model of public health, to analyze these data and determine challenges faced by respondents.

RESULTS

We identified multiple, interlocking challenges faced by medicine vendors. Many of these relate to challenges of antimicrobial stewardship (following evidence-based practices when dispensing medicines). Overall, medicine vendors frequently reported challenges at the Customer and Community levels. These included strained interactions with customers and the prohibitive costs of medications. The consequences of these challenges reverberated and manifested through all levels of the socioecological model of public health (Entity, Customer, Community, Global).

DISCUSSION

The safe and effective distribution of medications was truncated by strained interactions, often related to the cost of medicines and gaps in knowledge. While addressing these challenges requires multifaceted approaches, we identified several areas that, if intervened upon, could unlock the great potential of antimicrobal stewardship. The effective and efficient implementation of key interventions could facilitate efforts spearheaded by medicine vendors and leverage the benefits of their role as health educators and service providers.

CONCLUSION

Addressing barriers faced by medicine vendors would provide an opportunity to significantly improve the provision of medications, and ultimately population health. Such efforts will likely expand access to populations who may otherwise be unable to access medications and treatment in formal institutions of care such as hospitals. Our findings also highlight the broad range of care provided by shopkeepers and vendors at dispensaries. These findings suggest that the meaningful engagement of dispensaries as valued conduits of community health is a promising pathway for interventions aiming to improve antimicrobial stewardship.

"Just as curry is needed to eat rice, antibiotics are needed to cure fever"-a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India

OBJECTIVES

To understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West Bengal in India.

DESIGN

Qualitative study using focus group discussions and in-depth interviews.

SETTING

Two contrasting village clusters in South 24 Parganas district, West Bengal, India. Fieldwork was conducted between November 2019 and January 2020.

PARTICIPANTS

98 adult community members (42 men and 56 women) were selected purposively for 8 focus group discussions. In-depth interviews were conducted with 16 community key informants (7 teachers, 4 elected village representatives, 2 doctors and 3 social workers) and 14 community health workers.

RESULTS

Significant themes at the individual level included sociodemographics (age, gender, education), cognitive factors (knowledge and perceptions of modern antibiotics within non-biomedical belief systems), affective influences (emotive interpretations of appropriate medicine consumption) and economic constraints (affordability of antibiotic courses and overall costs of care). Antibiotics were viewed as essential fever remedies, akin to antipyretics, with decisions to halt mid-course influenced by non-biomedical beliefs associating prolonged use with toxicity. Themes at the community and health system levels included the health stewardship roles of village leaders and knowledge brokering by informal providers, pharmacists and public sector accredited social health activists. However, these community resources lacked sufficient knowledge to address people's doubts and concerns. Qualified doctors were physically and socially inaccessible, creating a barrier to seeking their expertise.

CONCLUSIONS

The interplay of sociodemographic, cognitive and affective factors, and economic constraints at the individual level, underscores the complexity of antibiotic usage. Additionally, community leaders and health workers emerge as crucial players, yet their knowledge gaps and lack of empowerment pose challenges in addressing public concerns. This comprehensive analysis highlights the need for targeted interventions that address both individual beliefs and community health dynamics to promote judicious antibiotic use.

The healthcare field as a marketplace: general practitioners, pharmaceutical companies, and profit-led prescribing in Pakistan

Incentivisation of general practitioners (GPs) by pharmaceutical companies is thought to affect prescribing practices, often not in patients' interest. Using a Bourdieusian lens, we examine the socially structured conditions that underpin exchanges between pharmaceutical companies and GPs in Pakistan. The analysis of qualitative interviews with 28 GPs and 13 pharmaceutical sales representatives (PSRs) shows that GPs, through prescribing medicines, met pharmaceutical sales targets in exchange for various incentives. We argue that these practices can be given meaning through the concept of 'field' - a social space in which GPs, PSRs, and pharmacists were hierarchically positioned, with their unique capacities, to enable healthcare provision. However, structural forces like the intense competition between pharmaceutical companies, the presence of unqualified healthcare providers in the healthcare market, and a lack of regulation by the state institutions produced a context that enabled pharmaceutical companies and GPs to use the healthcare field, also, as space to maximise profits. GPs believed the effort to maximise incomes and meet socially desired standards were two key factors that encouraged profit-led prescribing. We conclude that understanding the healthcare field is an important step toward developing governance practices that can address profit-led prescribing.

Monitoring of antimicrobial usage among adult bovines in dairy herds of Punjab, India: A quantitative analysis of pattern and frequency

The present study aimed to evaluate the antimicrobial usage (AMU) pattern in dairy herds of Punjab, India. The on-farm quantification of AMU in adult bovine animals by the manual collection of empty drug containers ("bin method") along with the records of the treatment was carried out in 38 dairy farms involving 1010 adult bovines for 1 year from July 2020 to June 2021. The farm owners were asked to record the antibiotic treatments as well as to deposit empty antibiotic packaging/vials into the provided bins placed at the farms. A total of 14 different antibiotic agents in 265 commercial antibiotic products were administered to the dairy herds during the study. A total of 179 (67.55%) administered products contained antimicrobials of "critical importance" as per the World Health Organization (WHO). Mastitis (54.72%), followed by the treatment of fever (19.62%), reproductive problems (15.47%), and diarrhea (3.40%) accounted for the majority of drugs administered in the herds during the study period. The most commonly used antibiotics were enrofloxacin (89.47% herds; 21.51% products), followed by ceftriaxone (50% herds; 12.83% products), amoxicillin (50% herds; 12.83% products), oxytetracycline (55.26% herds; 11.70% products), and procaine penicillin (47.37% herds; 12.83% products). The highest quantity of AMU [in terms of antimicrobial drug use rate (ADUR)] was observed for ceftiofur, followed by ceftriaxone, procaine benzyl penicillin ceftizoxime, enrofloxacin, cefoperazone, amoxicillin and ampicillin. A total of 125 (47.17%) products contained "highest priority critically important antimicrobials" (HPCIA) and 54 (20.37%) products contained "high priority critically important antimicrobials". In terms of overall number of animal daily doses (nADD), the highest priority critically important antimicrobials (HPCIA) of the WHO such as third-generation cephalosporins and quinolones, respectively accounted for 44.64 and 22.35% of the total antibiotic use in the herds. The bin method offers an alternative to monitoring AMU as a more accessible approach for recording the actual consumption of antimicrobials. The present study, to the best of our knowledge, is the first of its kind to provide an overview of the qualitative and quantitative estimate of AMU among adult bovines from India.

Pharma-cartography: Navigating the complexities of antibiotic supply to rural livestock in West Bengal, India, through value chain and power dynamic analysis

Antibiotic resistance threatens provision of healthcare and livestock production worldwide with predicted negative socioeconomic impact. Antibiotic stewardship can be considered of importance to people living in rural communities, many of which depend on agriculture as a source of food and income and rely on antibiotics to control infectious diseases in livestock. Consequently, there is a need for clarity of the structure of antibiotic value chains to understand the complexity of antibiotic production and distribution in community settings as this will facilitate the development of effective policies and interventions. We used a value chain approach to investigate how relationships, behaviours, and influences are established during antibiotic distribution. Interviews were conducted with key informants (n = 17), value chain stakeholders (n = 22), and livestock keeping households (n = 36) in Kolkata, and two rural sites in West Bengal, India. Value chain mapping and an assessment of power dynamics, using manifest content analysis, were conducted to investigate antibiotic distribution and identify entry points for antibiotic stewardship. The flow of antibiotics from manufacturer to stockists is described and mapped and two local level maps showing distribution to final consumers presented. The maps illustrate that antibiotic distribution occurred through numerous formal and informal routes, many of which circumvent antibiotic use legislation. This was partly due to limited institutional power of the public sector to govern value chain activities. A 'veterinary service lacuna' existed resulting in livestock keepers having higher reliance on private and informal providers, who often lacked legal mandates to prescribe and dispense antibiotics. The illegitimacy of many antibiotic prescribers blocked access to formal training who instead relied on mimicking the behaviour of more experienced prescribers-who also lacked access to stewardship guidelines. We argue that limited institutional power to enforce existing antibiotic legislation and guide antibiotic usage and major gaps in livestock healthcare services make attempts to curb informal prescribing unsustainable. Alternative options could include addressing public sector deficits, with respect to both healthcare services and antibiotic provision, and by providing resources such as locally relevant antibiotic guidelines to all antibiotic prescribers. In addition, legitimacy of informal prescribers could be revised, which may allow formation of associations or groups to incentivise good antibiotic practices.

One Health approaches adapted in low resource settings to address antimicrobial resistance

Inter-disciplinary collaborations are now considered as key factors for integrated health system strengthening. Its application in the domain of One Health needs more milestones to achieve. Other than the human health sector, the antimicrobials are used in food animals and aquaculture for therapy, prophylaxis and growth promotion which significantly contributes to the development of antimicrobial resistance. It is the high time to develop a sustainable collaboration between the concerned sectors of One Health for a resilient health system. The domain of One Health not only mitigates the emergence of antimicrobial resistance but also helps in realizing the surveillance and epidemiology of zoonotic diseases, and the control of public health emergencies such as COVID-19. The review identified the key One Health strategies adapted by India, the exemplary low resource settings, to address antimicrobial resistance and zoonosis.

Genome-Based Multi-Antigenic Epitopes Vaccine Construct Designing against Staphylococcus hominis Using Reverse Vaccinology and Biophysical Approaches

Staphylococcus hominis is a Gram-positive bacterium from the staphylococcus genus; it is also a member of coagulase-negative staphylococci because of its opportunistic nature and ability to cause life-threatening bloodstream infections in immunocompromised patients. Gram-positive and opportunistic bacteria have become a major concern for the medical community. It has also drawn the attention of scientists due to the evaluation of immune evasion tactics and the development of multidrug-resistant strains. This prompted the need to explore novel therapeutic approaches as an alternative to antibiotics. The current study aimed to develop a broad-spectrum, multi-epitope vaccine to control bacterial infections and reduce the burden on healthcare systems. A computational framework was designed to filter the immunogenic potent vaccine candidate. This framework consists of pan-genomics, subtractive proteomics, and immunoinformatics approaches to prioritize vaccine candidates. A total of 12,285 core proteins were obtained using a pan-genome analysis of all strains. The screening of the core proteins resulted in the selection of only two proteins for the next epitope prediction phase. Eleven B-cell derived T-cell epitopes were selected that met the criteria of different immunoinformatics approaches such as allergenicity, antigenicity, immunogenicity, and toxicity. A vaccine construct was formulated using EAAAK and GPGPG linkers and a cholera toxin B subunit. This formulated vaccine construct was further used for downward analysis. The vaccine was loop refined and improved for structure stability through disulfide engineering. For an efficient expression, the codons were optimized as per the usage pattern of the E coli (K12) expression system. The top three refined docked complexes of the vaccine that docked with the MHC-I, MHC-II, and TLR-4 receptors were selected, which proved the best binding potential of the vaccine with immune receptors; this was followed by molecular dynamic simulations. The results indicate the best intermolecular bonding between immune receptors and vaccine epitopes and that they are exposed to the host’s immune system. Finally, the binding energies were calculated to confirm the binding stability of the docked complexes. This work aimed to provide a manageable list of immunogenic and antigenic epitopes that could be used as potent vaccine candidates for experimental in vivo and in vitro studies.

Crossover-Use of Human Antibiotics in Livestock in Agricultural Communities: A Qualitative Cross-Country Comparison between Uganda, Tanzania and India

Antibiotic use in animal agriculture contributes significantly to antibiotic use globally and is a key driver of the rising threat of antibiotic resistance. It is becoming increasingly important to better understand antibiotic use in livestock in low-and-middle income countries where antibiotic use is predicted to increase considerably as a consequence of the growing demand for animal-derived products. Antibiotic crossover-use refers to the practice of using antibiotic formulations licensed for humans in animals and vice versa. This practice has the potential to cause adverse drug reactions and contribute to the development and spread of antibiotic resistance between humans and animals. We performed secondary data analysis of in-depth interview and focus-group discussion transcripts from independent studies investigating antibiotic use in agricultural communities in Uganda, Tanzania and India to understand the practice of antibiotic crossover-use by medicine-providers and livestock-keepers in these settings. Thematic analysis was conducted to explore driving factors of reported antibiotic crossover-use in the three countries. Similarities were found between countries regarding both the accounts of antibiotic crossover-use and its drivers. In all three countries, chickens and goats were treated with human antibiotics, and among the total range of human antibiotics reported, amoxicillin, tetracycline and penicillin were stated as used in animals in all three countries. The key themes identified to be driving crossover-use were: (1) medicine-providers' and livestock-keepers' perceptions of the effectiveness and safety of antibiotics, (2) livestock-keepers' sources of information, (3) differences in availability of human and veterinary services and antibiotics, (4) economic incentives and pressures. Antibiotic crossover-use occurs in low-intensity production agricultural settings in geographically distinct low-and-middle income countries, influenced by a similar set of interconnected contextual drivers. Improving accessibility and affordability of veterinary medicines to both livestock-keepers and medicine-providers is required alongside interventions to address understanding of the differences between human and animal antibiotics, and potential dangers of antibiotic crossover-use in order to reduce the practice. A One Health approach to studying antibiotic use is necessary to understand the implications of antibiotic accessibility and use in one sector upon antibiotic use in other sectors.

Qualitative Study on Antimicrobial Usage and Resistance in the Dairy Chain: A Situation Analysis and Solutions by Stakeholders from Punjab, India

The rising prevalence of antimicrobial resistance in animal foods and injudicious antibiotic use in the dairy sector pose significant threats to public health. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with a strategic sample of four stakeholder groups (114 participants) associated with antibiotic usage in the dairy sector of Punjab. The FGDs were conducted among veterinarians (n = 56), para-veterinarians (n = 28), and KIIs were conducted among chemists (n = 18) and dairy quality managers (n = 12) during 2020-2021. FGDs and qualitative interviews of various stakeholders depict existing risk practices in the fields that may promote antimicrobial resistance. The present study revealed that widely prevalent quackery (treatment practices carried out by unauthorized persons without any recognized diploma/degree) and self-treatment by farmers, over-the-counter availability of antibiotics, low veterinarian per animal ratio, and lack of awareness among the society about the potential public health effects of antimicrobial resistance were the main risk factors for injudicious antibiotic use in the dairy sector. The present study involved a comprehensive approach targeting the stakeholders in the dairy sector and their reflections on judicious antimicrobial usage and antimicrobial resistance adapted to the dairy farming of Punjab. There is an urgent need for the advocation of policies that consider the specific challenges faced by the dairy sector to simultaneously improve access to veterinary services as well as strengthen antibiotic stewardship.

What are the Tuberculosis Care Practices of Informal Healthcare Providers? A Cross-Sectional Study from Eastern India

India is the highest Tuberculosis (TB) burden country, accounting for an estimated 26 % of the global burden of disease. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan (NSP) for TB elimination (2017-2025). However, Informal Healthcare Providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilised in the National TB Elimination Program (NTEP) of India. Non-prioritisation of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment, and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilising the retrospective case study method. A total 203 IPs participated who reported seeing at least one confirmed TB patient in six months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices which have consequences for achieving India's National Goal of TB elimination.

How conflicts of interest hinder effective regulation of healthcare: an analysis of antimicrobial use regulation in Cambodia, Indonesia and Pakistan

Background

There has been insufficient attention to a fundamental force shaping healthcare policies—conflicts of interest (COI). We investigated COI, which results in the professional judgement of a policymaker or healthcare provider being compromised by a secondary interest, in relation to antimicrobial use, thereby illuminating challenges to the regulation of medicines use more broadly. Our objectives were to characterise connections between three groups—policymakers, healthcare providers and pharmaceutical companies—that can create COI, and elucidate the impacts of COI on stages of the policy process.

Methods

Using an interpretive approach, we systematically analysed qualitative data from 136 in-depth interviews and five focus group discussions in three Asian countries with dominant private healthcare sectors: Cambodia, Indonesia and Pakistan.

Findings

We characterised four types of connections that were pervasive between the three groups: financial, political, social and familial. These connections created strong COI that could impact all stages of the policy process by: preventing issues related to medicines sales from featuring prominently on the agenda; influencing policy formulation towards softer regulatory measures; determining resource availability for, and opposition to, policy implementation; and shaping how accurately the success of contested policies is reported.

Interpretation

Our multicountry study fills a gap in empirical evidence on how COI can impede effective policies to improve the quality of healthcare. It shows that COI can be pervasive, rather than sporadic, in influencing regulation of medicine use, and highlights that, in addition to financial connections, other types of connections should be examined as important drivers of COI.

Availability, Prices and Affordability of Antibiotics Stocked by Informal Providers in Rural India: A Cross-Sectional Survey

Providers without formal training deliver healthcare and antibiotics across rural India, but little is known about the antibiotics that they stock. We conducted a cross-sectional survey of such informal providers (IPs) in two districts of West Bengal, and assessed the availability of the antibiotics, as well as their sales volumes, retail prices, percentage markups for IPs and affordability. Of the 196 IPs that stocked antibiotics, 85% stocked tablets, 74% stocked syrups/suspensions/drops and 18% stocked injections. Across all the IPs, 42 antibiotic active ingredients were stocked, which comprised 278 branded generics from 74 manufacturers. The top five active ingredients that were stocked were amoxicillin potassium clavulanate (52% of the IPs), cefixime (39%), amoxicillin (33%), azithromycin (25%) and ciprofloxacin (21%). By the WHO's AWaRe classification, 71% of the IPs stocked an ACCESS antibiotic and 84% stocked a WATCH antibiotic. The median prices were in line with the government ceiling prices, but with substantial variation between the lowest and highest priced brands. The most affordable among the top five tablets were ciprofloxacin, azithromycin, cefixime and amoxicillin (US$ 0.8, 0.9, 1.9 and 1.9 per course), and the most affordable among the syrups/suspensions/drops were azithromycin and ofloxacin (US$ 1.7 and 4.5 per course, respectively), which are mostly WATCH antibiotics. IPs are a key source of healthcare and antibiotics in rural communities; practical interventions that target IPs need to balance restricting WATCH antibiotics and expanding the basket of affordable ACCESS antibiotics.

Understanding Internal and External Drivers Influencing the Prescribing Behaviour of Informal Healthcare Providers with Emphasis on Antibiotics in Rural India: A Qualitative Study

Globally, Antibiotic resistance is a major public health concern, with antibiotic use contributing significantly. Targeting informal healthcare providers (IHCPs) is important to achieve universal health coverage and effective antibiotic stewardship in resource-constrained settings. We, therefore, aimed to analyse the internal and external drivers that influence IHCPs' prescribing behaviour for common illnesses in children under five, with an emphasis on antibiotic use in rural areas of India. A total of 48 IHCPs participated in focus group discussions. Thematic framework analysis with an inductive approach was used, and findings were collated in the theoretical framework based on knowledge, attitude, and practice model which depicted that the decisions made by IHCPs while prescribing antibiotics are complex and influenced by a variety of external and internal drivers. IHCPs' internal drivers included the misconception that it is impossible to treat a patient without antibiotics and that antibiotics increase the effectiveness of other drugs and cure patients faster in order to retain them. Formal healthcare providers were the IHCPs' sources of information, which influences their antibiotic prescribing. We found when it comes to seeking healthcare in rural areas, the factors that influence their choice include 'rapid cure', 'cost of treatment', 'distance' and '24 h availability', instead of qualification, which may create pressure for IHCPs to provide a quick fix. Targeted and coordinated efforts at all levels will be needed to change the antibiotic prescribing practices of IHCPs with a focus on behaviour change and to help resolve misconceptions about antibiotics.

Recent advances in nanoparticles as antibacterial agent

Recently, the rapid increase in antibiotic-resistant pathogens has caused serious health problems. Researchers are searching for alternative antimicrobial substances to control or prevent infections caused by pathogens. Different strategies are used to develop effective antibacterial agents, and in this respect, nanoparticles are undoubtedly promising materials. Nanoparticles act by bypassing drug resistance mechanisms in bacteria and inhibiting biofilm formation or other important processes related to their virulence potential. Nanoparticles can penetrate the cell wall and membrane of bacteria and act by disrupting important molecular mechanisms. In combination with appropriate antibiotics, NPs may show synergy and help prevent the developing global bacterial resistance crisis. Furthermore, due to characteristics such as enhanced biocompatibility and biodegradability, polymer-based nanoparticles enable the development of a wide range of medical products. Antibacterial applications of nanoparticles range from antimicrobial synthetic textiles to biomedical and surgical devices when nanoparticles are embedded/loaded/coated into different materials. In this review, the antibacterial mechanisms of nanoparticles and their potential for use in the medical field are discussed.

Marketing and Distribution System Foster Misuse of Antibiotics in the Community: Insights from Drugs Wholesalers in India

Antibiotic misuse is one of the major drivers of antimicrobial resistance (AMR). In India, evidence of antibiotic misuse comes largely from retailers as well as formal and informal healthcare providers (IHCPs). This paper presents the practices and perspectives of drug wholesalers, a critical link between manufacturers and last-mile dispensers. Four experienced wholesalers and an ex-State Drug Controller (ex-SDC) were interviewed in depth, using semi-structured guides in the National Capital Region of Delhi, India, between November 2020 and January 2021. Four main findings were that wholesalers (i) have limited knowledge about wholesale licensing and practice regulations, as well as a limited understanding of AMR; (ii) directly supply and sell antibiotics to IHCPs; (iii) facilitate medical representatives (MRs) of pharmaceutical companies and manufacturers in their strategies to promote antibiotics use in the community; and (iv) blame other stakeholders for unlawful sale and overuse of antibiotics. Some of the potential solutions aimed at wholesalers include having a minimum education qualification for licensing and mandatory Good Distribution Practices certification programs. Decoupling incentives by pharmaceutical companies from sales targets to improve ethical sales practices for MRs and optimize antibiotic use by IHCPs could alleviate wholesalers’ indirect actions in promoting antibiotic misuse.

"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India

Smallholder farms are the predominant livestock system in India. Animals are often kept in close contact with household members, and access to veterinary services is limited. However, limited research exists on how antibiotics are used in smallholder livestock in India. We investigated antibiotic supply, usage, and their drivers in smallholder livestock production systems, including crossover-use of human and veterinary antibiotics in two rural sites in West Bengal. Qualitative interviews were conducted with key informants (n = 9), livestock keepers (n = 37), and formal and informal antibiotic providers from veterinary and human health sectors (n = 26). Data were analysed thematically and interpreted following a One Health approach. Livestock keepers and providers used antibiotics predominantly for treating individual animals, and for disease prevention in poultry but not for growth promotion. All providers used (highest priority) critically important antimicrobials for human health and engaged in crossover-use of human antibiotic formulations in livestock. Inadequate access to veterinary drugs and services, and a perceived efficacy and ease of dosing of human antibiotics in animals drove crossover-use. Veterinary antibiotics were not used for human health due to their perceived adverse effects. Given the extent of usage of protected antibiotics and crossover-use, interventions at the community level should adopt a One Health approach that considers all antibiotic providers and livestock keepers and prioritizes the development of evidence-based guidelines to promote responsible use of antibiotics in animals.

Antimicrobial resistance in low- and middle-income countries: current status and future directions

Introduction: Rising rates of antimicrobial resistance (AMR) globally continue to pose agrave threat to human health. Low- and middle-income countries (LMICs) are disproportionately affected, partly due to the high burden of communicable diseases.Areas covered: We reviewed current trends in AMR in LMICs and examined the forces driving AMR in those regions. The state of interventions being undertaken to curb AMR across the developing world are discussed, and the impact of the current COVID-19 pandemic on those efforts is explored.Expert opinion: The dynamics that drive AMR in LMICs are inseparable from the political, economic, socio-cultural, and environmental forces that shape these nations. The COVID-19 pandemic has further exacerbated underlying factors that increase AMR. Some progress is being made in implementing surveillance measures in LMICs, but implementation of concrete measures to meaningfully impact AMR rates must address the underlying structural issues that generate and promote AMR. This, in turn, will require large infrastructural investments and significant political will.