Antimicrobial resistance in developing countries. Part II: strategies for containment

Antimicrobial resistance among pregnant women with urinary tract infections is on rise: Findings from meta-analysis of observational studies

Pregnant women have a higher risk of urinary tract infections (UTIs) compared to non-pregnant women, making antibiotics necessary for treatment. However, prescribing antibiotics without culture and sensitivity tests may contribute to antimicrobial resistance. A meta-analysis using R was conducted to determine the prevalence of antibiotic resistance patterns in UTIs among pregnant women. We identified observational studies published in the last 10 years and used a random effects model to calculate the pooled prevalence. The prevalence of Gram-negative organisms causing UTIs in pregnant women was 67 %, while Gram-positive organisms were 22 %. The burden of Gram-positive organisms exhibiting antimicrobial resistance was very high at 95 %, primarily to ampicillin. The most common Gram-negative organisms exhibiting antimicrobial resistance were E. coli, Klebsiella, and Pseudomonas aeruginosa, while the most common Gram-positive organisms resistant to antibiotics were Staphylococcus aureus and coagulase-negative Staphylococcus. Sensitivity and culture testing are recommended for effective treatment in pregnant women with UTIs.

Antibiotics use among residents in Eastern Nepal: a community-based mixed method study

Introduction

According to the WHO, more than two-thirds of all antibiotics are used in the community, of which about 30% are used inappropriately. The antimicrobial resistance (AMR) problem is a growing threat to Nepal because of indiscriminate and inappropriate use. However, exact data on the extent of inappropriate use of antibiotics in the community is scarce in Nepal.

Objectives

To know the extent of inappropriate use of antibiotics among the community and their knowledge and practice towards the usage of antibiotics.

Methods

A community-based cross-sectional study was conducted from 20 December 2017 to 20 March 2018 using a purposive sampling technique. A semi-structured questionnaire was used while conducting face-to-face interviews with 336 respondents to find out the knowledge and practice regarding antibiotic use. Investigators took different antibiotics (in all dosage forms) with them to show participants whether they knew and/or used the antibiotics in the last year.

Results

The mean age of respondents with standard deviation was 39.87±13.67 years ranging from 18 to 84 years. Around 35.42% of respondents were farmers and 34.52% were homemakers. 28.87% of respondents were illiterate, 32.44% had primary education and 33.33% had secondary education. Almost half of them (48.51%) think that antibiotics are safe and can be commonly used. So, 43.15% of them preferred taking antibiotics when they had a common cold. The majority of the participants (81.84%) did not have any idea about antibiotic resistance. 94.6% of the respondents used antibiotics inappropriately.

Conclusion

The results of the present study revealed that inappropriate use of antibiotics is high and associated with low earning wages in both males and females in the age group 18-39 years.

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal

BACKGROUND

Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common.

OBJECTIVES

To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal.

METHODS

The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes.

RESULTS

A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices.

CONCLUSION

Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

Physicians' attitudes, knowledge, and practices regarding antibiotic prescriptions

OBJECTIVES

Inappropriate and overuse of antimicrobials, incorrect dosing, and extended duration are some of the leading causes of antibiotic-resistance that have led to the development of antimicrobial resistance (AMR). We aimed to evaluate knowledge, attitudes, and practices regarding rational antibiotic prescribing among physicians in a teaching hospital in Oman, with the goal of identifying knowledge gaps and interventions that could lead to judicious use of antimicrobials and reduce the emergence of resistant organisms METHODS: A cross-sectional study assessing physicians' knowledge of and attitudes towards prescribing antibiotics was conducted at the Royal Hospital from 15 January to 31 March 2020. Likert scales were used to evaluate physicians' awareness and perception of personal performance regarding the care of patients with infections and rational use of antibiotics.

RESULTS

Inadequate hand washing was regarded as the most important factor contributing to AMR (51.6%), followed by widespread use of antibiotics (49%), prescribing broad-spectrum antibiotics (47.3%), lack of effective narrow-spectrum antibiotics (47.3%), inappropriate duration of antibiotic therapy (46.2%), inappropriate empirical choice of antibiotics (45.1%), poor access to information on local antibiotic resistance patterns (40.8%), and inadequate restrictions on antibiotic prescribing (34.4%). Other factors contributing to AMR such as lack of local hospital guidelines on antibiotic usage, random mutations in microbes, patient demands and expectations for antibiotics, and the role of pharmaceutical companies in advertising and promoting use of antibiotics were deemed important by 33.3%, 26.8%, 22.5% and 20.4%, respectively.

CONCLUSIONS

AMR is a global health threat with significant effect on the health system and the economy. Misuse and overuse of antimicrobials remain the main drivers for the development of drug-resistant pathogens. Identifying knowledge gaps and planning interventions that could lead to judicious use of antimicrobials including establishing an Antimicrobial Stewardship Program are of paramount importance in reducing AMR in the twenty-first century and beyond.

Global trend of antimicrobial resistance in common bacterial pathogens in response to antibiotic consumption

The emergence of antimicrobial resistance (AMR) is a growing public health threat worldwide and antibiotic consumption is being increasingly recognized as the main selective pressure driving this resistance. However, global trend in antibiotic resistance in response to antibiotic consumption is not fully understood. In this study, we collected national resistance data on specific resistant pathogens considered by the World Health Organization (WHO) as priority and antibiotic consumption data for 61 countries to assess the global trends in antibiotic resistance of those common bacterial pathogens and their association with antibiotic consumption. The low- and middle-income countries (LMICs) represented the largest hotspots of resistance, which presented relatively higher resistance rates in common bacterial pathogens but lower antibiotic consumption rates compared to high-income countries (HICs). Specifically, we developed the Normalized Antibiotic Resistance/Consumption Index (NARCI) and produced global maps of NARCI to roughly assess the appropriateness of antibiotic consumption across countries and to indicate the potentially inappropriate antibiotic consumption in LMICs compared with HICs. Additionally, we linked antibiotic consumption rates and resistance rates of target pathogens, in conjunction with NARCI and the correlation analysis between antibiotic use and resistance, to inform strategies to alleviate the threat of antibiotic resistance worldwide.

Changing food systems and infectious disease risks in low-income and middle-income countries

The emergence of COVID-19 has drawn the attention of health researchers sharply back to the role that food systems can play in generating human disease burden. But emerging pandemic threats are just one dimension of the complex relationship between agriculture and infectious disease, which is evolving rapidly, particularly in low-income and middle-income countries (LMICs) that are undergoing rapid food system transformation. We examine this changing relationship through four current disease issues. The first is that greater investment in irrigation to improve national food security raises risks of vector-borne disease, which we illustrate with the case of malaria and rice in Africa. The second is that the intensification of livestock production in LMICs brings risks of zoonotic diseases like cysticercosis, which need to be managed as consumer demand grows. The third is that the nutritional benefits of increasing supply of fresh vegetables, fruit, and animal-sourced foods in markets in LMICs pose new food-borne disease risks, which might undermine supply. The fourth issue is that the potential human health risks of antimicrobial resistance from agriculture are intensified by changing livestock production. For each disease issue, we explore how food system transition is creating unintentional infectious disease risks, and what solutions might exist for these problems. We show that successfully addressing all of these challenges requires a coordinated approach between public health and agricultural sectors, recognising the costs and benefits of disease-reducing interventions to both, and seeking win-win solutions that are most likely to attract broad policy support and uptake by food systems.

Antibiotic susceptibility among non-clinical Escherichia coli as a marker of antibiotic pressure in Peru (2009-2019): one health approach

Objective

Antimicrobial resistance is an increasing health problem worldwide with serious implications in global health. The overuse and misuse of antimicrobials has resulted in the spread of antimicrobial-resistant microorganisms in humans, animals and the environment. Surveillance of antimicrobial resistance provides important information contributing to understanding dissemination within these environments. These data are often unavailable in low- and middle-income countries, such as Peru. This review aimed to determine the levels of antimicrobial resistance in non-clinical Escherichia coli beyond the clinical setting in Peru.

Methods

We searched 2009–2019 literature in PUBMED, Google Scholar and local repositories.

Results

Thirty manuscripts including human, food, environmental, livestock, pets and/or wild animals’ samples were found. The analysis showed high resistance levels to a variety of antimicrobial agents, with >90% of resistance for streptomycin and non-extended-spectrum cephalosporin in livestock and food. High levels of rifamycin resistance were also found in non-clinical samples from humans. In pets, resistance levels of 70–>90% were detected for quinolones tetracycline and non-extended spectrum cephalosporins. The results suggest higher levels of antimicrobial resistance in captive than in free-ranging wild-animals. Finally, among environmental samples, 50–70% of resistance to non-extended-spectrum cephalosporin and streptomycin was found.

Conclusions

High levels of resistance, especially related to old antibacterial agents, such as streptomycin, 1st and 2nd generation cephalosporins, tetracyclines or first-generation quinolones were detected. Antimicrobial use and control measures are needed with a One Health approach to identify the main drivers of antimicrobial resistance due to interconnected human, animal and environmental habitats.

•

In livestock and food >90% of streptomycin and cephalosporin resistance was detected.

•

High levels of rifamycin resistance were found in non-clinical samples from humans.

•

High levels to quinolones tetracycline and cephalosporins were detected in pets.

•

Environmental samples showed 50–70% of resistance to cephalosporins and streptomycin.

•

In general, high levels of resistance to ancient antibacterial agents was observed.

Inappropriate supply of antibiotics for common viral infections by community pharmacies in Vietnam: A standardised patient survey

BACKGROUND

This study aimed to evaluate the appropriateness of antibiotic dispensing of private pharmacies in Vietnam.

METHODS

Standardised patient surveys were conducted in randomly selected community pharmacies across 40 districts in Vietnam. Four clinical scenarios were represented by patient actors: (a) an adult requesting treatment for a sibling with a viral upper respiratory tract infection (URTI), (b) a parent requesting treatment for a child with acute diarrhoea, (c) an adult making a direct antibiotic request, and (d) an adult presenting with an antibiotic prescription. We calculated the proportion of interactions that resulted in inappropriate supply of antibiotics and patient advice. Predictors of inappropriate antibiotic supply were assessed.

FINDINGS

Patient actors attended 949 pharmacies, resulting in 1266 clinical interactions. Antibiotics were inappropriately supplied to 92% (291/316) of adults requesting treatment for URTI symptoms, 43% (135/316) for children with acute diarrhoea symptoms and to 84% (267/317) of direct request for antibiotics. Only 49% of pharmacies advised patients regarding their antibiotic use. Female actors were more likely to be given antibiotics than male actors for URTI (aOR 2·71, 1·12-6·60) but not for diarrhoeal disease. Pharmacies in northern Vietnam were more likely than those in southern Vietnam to supply antibiotics without a prescription: for adult URTI (aOR=5·8, 95% CI: 2·2-14·9) and childhood diarrhoea (aOR=3·5, 95% CI: 2·0-6·0) symptoms, but less likely to dispense for direct antibiotics request.

INTERPRETATION

Inappropriate antibiotic supply was common in Vietnamese private pharmacies. Multifaceted measures are urgently needed to achieve WHO's global action plan for the optimal use of antimicrobials.

FUNDING

This study was funded by a grant from the Australian Department of Foreign Affairs and Trade.

Pre-hospital exposures to antibiotics among children presenting with fever in northern Uganda: a facility-based cross-sectional study

Background

The rise in the indiscriminate use of antibiotics has become a major global public health problem and presents the biggest global health challenge in the twenty-first century. In developing countries, caregivers initiate treatment with antibiotics at home before presentation to a health facility. However, there is a paucity of evolving data towards surveillance of this trend in low-income countries. We investigated antibiotic use among febrile children presenting to a tertiary health facility in northern Uganda.

Methods

We conducted a cross-sectional study in a tertiary health facility in northern Uganda between March and September 2021. Children aged 6–59 months with fever were selected using systematic random sampling. A pre-tested interviewer-administered questionnaire was used the collect clinical data from the caregivers. Data were analyzed using SPSS version 23. Descriptive statistics and multiple logistic regression models were applied. P-value < 0.05 was considered for statistical significance.

Results

Eighty-three (39.5%) of the 210 children with fever in this study used antibiotics prior to the hospital visit, 55.4% of which were on a self-medication basis, while 44.6% were empiric prescriptions. The most commonly used antibiotics were amoxicillin 33/83 (39.8%), erythromycin 18 (21.7%), metronidazole 14 (16.9%), ciprofloxacin 13 (15.7%) and ampicillin 6 (7.2%). The main sources of the antibiotics included buying from drug shops 30/83 (36.1%), issuance from clinics (33.7%), remnants at home (12.0%), picking from a neighbour (7.2%) and others (10.8%). The factors associated with antibiotic use among the febrile children were residence (p < 0.001); distance from the nearest health facility (p = 0.005); caregivers’ gender (p = 0.043); cough (p = 0.012); diarrhoea (p = 0.007); duration of fever (p = 0.002); perceived convulsion complicating fever (p = 0.026), and caregivers’ perception that fever (p = 0.001), cough (p = 0.003), diarrhoea (p < 0.001) and any infection (p < 0.001) are indications for antibiotics.

Conclusions

Inappropriate use of antibiotics for childhood febrile illnesses is prevalent in the study setting, facilitated by the ease of access and use of leftover antibiotics. There is a need to address communities’ health-seeking behaviour and the health providers’ practice alike.

Biopolymer Nano-Network for Antimicrobial Peptide Protection and Local Delivery

Antimicrobial resistance (AMR) develops when bacteria no longer respond to conventional antimicrobial treatment. The limited treatment options for resistant infections result in a significantly increased medical burden. Antimicrobial peptides offer advantages for treatment of resistant infections, including broad-spectrum activity and lower risk of resistance development. However, sensitivity to proteolytic cleavage often limits their clinical application. Here, a moldable and biodegradable colloidal nano-network is presented that protects bioactive peptides from enzymatic degradation and delivers them locally. An antimicrobial peptide, PA-13, is encapsulated electrostatically into positively and negatively charged nanoparticles made of chitosan and dextran sulfate without requiring chemical modification. Mixing and concentration of oppositely charged particles form a nano-network with the rheological properties of a cream or injectable hydrogel. After exposure to proteolytic enzymes, the formed nano-network loaded with PA-13 eliminates Pseudomonas aeruginosa during in vitro culture and in an ex vivo porcine skin model while the unencapsulated PA-13 shows no antibacterial effect. This demonstrates the ability of the nano-network to protect the antimicrobial peptide in an enzyme-challenged environment, such as a wound bed. Overall, the nano-network presents a useful platform for antimicrobial peptide protection and delivery without impacting peptide bioactivity.

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.

Antimicrobial Resistance Patterns, Extended-Spectrum Beta-Lactamase Production, and Associated Risk Factors of Klebsiella Species among UTI-Suspected Patients at Bahir Dar City, Northwest Ethiopia

Introduction

Klebsiella species cause pneumonia, UTI, and septicemia in human beings. Beta-lactam drugs are used extensively to treat patients infected with Klebsiella, but most of the Klebsiella species are resistant to third- and fourth-generation cephalosporins and monobactams to which data are scarce in the study area.

Objective

To determine the prevalence, antimicrobial resistance, ESBL production, and associated risk factors of Klebsiella species among UTI-suspected patients in Bahir Dar City, Northwest Ethiopia.

Methods

A multi-institution-based prospective cross-sectional study was conducted from January to May 2019. Midstream urines were collected from 385 patients and inoculated onto CLED and MacConkey agars. Identification of growth was done by a battery of biochemical tests. Antimicrobial resistance and ESBL production patterns were determined by using the disc-diffusion method on Mueller–Hinton agar. Quality of data was maintained by following SOPs and using Klebsiella pneumoniae (ACTT700603). Logistic regression statistical analysis was done using the SPSS, version 25, statistical package. A pvalue ≤ 0.05 was considered statistically significant.

Results

The median age of the study participants was 32 years. Majority of them were female, urban residents, and unable to read and/or write. The total Klebsiella species detected were 38 (9.9%). Of which, 25 (65.8%) were Klebsiella pneumoniae, followed by 6 (15.8%) Klebsiella ozaenae. 20 (80%), 19 (76%), and 19 (76%) Klebsiella pneumoniae showed resistance to amoxicillin/clavulanic acid, ampicillin, and cotrimoxazole, respectively. All K. oxytoca were resistant to ampicillin, and all K. rhinoscleromatis were resistant to cefoxitin and cefotaxime. Klebsiella species that showed resistance to ≥3 antimicrobials were 26 (68%). ESBL-producing Klebsiella species were 10 (26.3%). Patients who had history of antibiotic use, hospitalization, and tight dressing habit had more risk of getting UTI (p < 0.05) than their counterparts.

Conclusions

Overall UTI prevalence in our study was lower than that of previous Ethiopian studies. High MDR and ESBL-producing Klebsiella species were detected. Patients' history of antibiotic use, hospitalization, and tight dressing habit were risk factors for UTI. It calls up for improving prevention/control systems of Klebsiella species.

Natural-product-inspired design and synthesis of thiolated coenzyme Q analogs as promising agents against Gram-positive bacterial strains: insights into structure–activity relationship, activity profile, mode of action, and molecular docking

In an attempt to develop effective and potentially active antibacterial and/or antifungal agents, we designed, synthesized, and characterized thiolated CoQ analogs (CoQ1–8) with an extensive antimicrobial study. The antimicrobial profile of these analogs was determined using four Gram-negative bacteria, three Gram-positive bacteria, and three fungi. Because of the fact that the thiolated CoQ analogs were quite effective on all tested Gram-positive bacterial strains, including Staphylococcus aureus (ATCC® 29213) and Enterococcus faecalis (ATCC® 29212), the first two thiolated CoQ analogs emerged as potentially the most desirable ones in this series. Importantly, after the evaluation of the antibacterial and antifungal activity, we presented an initial structure–activity relationship for these CoQ analogs. In addition, the most promising thiolated CoQ analogs (CoQ1 and CoQ2) having the lowest MIC values on all tested Gram-positive bacterial strains, were further evaluated for their inhibition capacities of biofilm formation after evaluating their in vitro potential antimicrobial activity against each of 20 clinically obtained resistant strains of Gram-positive bacteria. CoQ1 and CoQ2 exhibited potential molecular interactions with S. aureus DNA gyrase in addition to excellent pharmacokinetics and lead-likeness profiles. Our findings offer important implications for a potential antimicrobial drug candidate, in particular for the treatment of infections caused by clinically resistant MRSA isolates.

In an attempt to develop effective and potentially active antibacterial and/or antifungal agents, we designed, synthesized, and characterized thiolated CoQ analogs (CoQ1–8) with an extensive antimicrobial study.

A scoping review of global aminoglycoside antibiotic overuse: A potential opportunity for primary ototoxicity prevention

BACKGROUND

Aminoglycosides are widely used, broad-spectrum antibiotics with significant potential for ototoxicity. Global efforts to prevent ototoxicity must account for aminoglycoside overuse and non-prescription use.

OBJECTIVES

The goals of this study were to a) estimate the prevalence of aminoglycoside overuse by synthesizing evidence on self-medication, over the counter (OTC) availability, and household antibiotic storage for later use, and to report the specific aminoglycosides used and the predictors of overuse, and b) leverage this information to comment on potential risk of ototoxicity.

METHODS

Two systematic search strings were conducted to extract peer-reviewed articles published from 2005 to 2020. The first focused on overuse of aminoglycoside antibiotics. The second focused on potentially ototoxic effects of aminoglycosides related to drug overuse.

RESULTS

A total of 26 articles were included (first search string: n = 21; second search string: n = 5). The prevalence of aminoglycoside self-medication was high and household storage and OTC availability of aminoglycosides was common. Gentamicin was the most commonly overused aminoglycoside. No studies provided information on antibiotic dosing or resultant toxicities, including ototoxicity.

CONCLUSIONS

The limited available evidence indicates that antibiotic overuse (self-medication, home storage, and non-prescription availability) is relatively common, especially in low resource settings, and that aminoglycoside antibiotics comprise a variable, but concerning, proportion of non-prescribed antibiotics. Additional evidence is needed to evaluate the relationship between these dispensing patterns and ototoxicity.

Antimicrobial stewardship: Assessment of knowledge, awareness of antimicrobial resistance and appropriate antibiotic use among healthcare students in a Nigerian University

BACKGROUND

Inappropriate use of antibiotics is a major cause of antimicrobial resistance (AMR). Inadequate knowledge about AMR among healthcare students could affect their practice of antimicrobial stewardship as future healthcare professionals. This study aims to assess the use of antibiotics and knowledge of AMR among future healthcare professionals of a Nigerian University.

METHODS

Respondents' knowledge of antimicrobial resistance, use of antibiotics, and source of antibiotics in the past 12 months was explored using a self-administered questionnaire. Multivariate analyses were used to evaluate the relationship between specific variables and respondents' knowledge.

RESULTS

Of the 939 questionnaires administered to the students, 866 were filled given a response rate of 92.2 %. A total of (765; 88.3 %) of the respondents were aware that antimicrobial resistance makes it harder to eliminate the infection from the body as existing drugs become less effective. In all 824, (95.2 %) of the respondents had use antibiotics in the past 12 months. The use of antibiotics to treat malaria was self-reported by (175; 21.2 %). About half (432; 52.4 %) purchased the antibiotics from community pharmacies, while others obtained their antibiotics from the hospitals (192; 23.3 %), patent medicine stores (150; 18.2 %), and friends and family (50; 6.1 %) in the last 12 months. In all 506, (58.4 %) had good knowledge of antimicrobial resistance. Logistic regression shows that students in 3rd to 6th year 9.29 [AOR = 9.29, 95 % CI: (3.7-22.96)], had greater knowledge of antimicrobial resistance.

CONCLUSIONS

The healthcare students demonstrated a moderate knowledge of AMR. This underscores the need to adopt several educational tactics to introduce the concepts of AMR to the students and ensure there are strict policies to regulate the flow of antibiotics.

Prevalence and patterns of self-medication with antibiotics among visitors of central polyclinic of Kabul, Afghanistan

Objectives

Self-medication with antibiotics is a common public health problem worldwide. It is the main driving factor for the development of microbial resistance. The world is facing the challenge of losing effective antibiotics. The study aim is to determine the prevalence and related factors of self-medication with antibiotics among visitors of a clinic in Kabul, Afghanistan.

Methods

A cross-sectional questionnaire-based survey on a sample of 384 consecutively selected visitors of the Central Polyclinic of Kabul, Afghanistan, was conducted.

Key findings

Approximately 34.9% of the sample self-medicated with antibiotics in the past 12 months. Amoxicillin was the most common antibiotic used for self-medication. The sore throat was a common health problem, and previous experience was the source of recommendation for self-medication. The most common reasons for self-medication with antibiotics were cost-saving, previous experience and lack of time.

Conclusions

Self-medication with antibiotics was prevalent among visitors to the clinic. Patterns of self-medication with antibiotics indicate the inappropriate practice of medicines. Pharmacists, friends and family approve the self-medication with antibiotics.

Magnitude, risk factors and antimicrobial susceptibility pattern of Shigella and Salmonella, among children with diarrhea in Southern Ethiopia: A Cross-sectional Study

Objective:

This study was aimed at identifying Shigella and Salmonella infection, their antibiotic susceptibility pattern and associated risk factors among children with diarrhea who attended Alamura Health Center.

Method:

A facility-based cross-sectional study was conducted on 263 children aged below 14 years with diarrhea. A structured questionnaire was used to collect socio-demographic and clinical data after obtaining the necessary consent from their parents or caretakers. The culture and sensitivity tests were performed using the standard operating procedure of the microbiology laboratory.

Results:

Accordingly, 20/263 (7.6%), 95% confidence interval: 4.4%–11.4% Shigella and 1/263 (0.38%), 95% confidence interval: 0.0%–1.1% Salmonella were isolated. Shigella dysenteriae was dominant 11 (4.2%), followed by Shigella spp. 9 (3.42%) and Salmonella typ 1 (0.38%). The isolates showed 71.4% overall resistance to ampicillin and 61.9% for augmentin and tetracycline, whereas 95.2% of the isolates were sensitive to ciprofloxacin, 85.9% to ceftriaxone and ceftazidime, 81% to gentamycin, 76.2% to chloramphenicol, 66.7% to cefuroxime and 52.4% to cotrimoxazole. The habit of washing hands after toilet use for a while (adjusted odds ratio: 235.1, 95% confidence interval: 20.9–2643.3, p < 0.000) and storing cooked food in an open container for later use (adjusted odds ratio: 36.44, 95% confidence interval: 5.82–228.06, p < 0.000) showed a statistically significant association.

Conclusion:

High level of Shigella and single Salmonella was isolated. Ampicillin, augmentin and tetracycline were resistant and ciprofloxacin, ceftriaxone, ceftazidime, gentamycin, chloramphenicol, cefuroxime and cotrimoxazole were relatively sensitive. Hand-washing after defecation for some time and storing of foods for later use in an open container were statistically associated. Therefore, to alleviate this infection, the concerned body should focus on imparting health education for hand-wash after defecation and storing food in a closed container for later use is mandatory.

Self-medication Behavior with antibiotics: a national cross-sectional survey in Sri Lanka

BACKGROUND

Antibiotic self-medication is common in low- and middle-income countries. This study aimed to evaluate the Sri Lankan public's knowledge about and attitudes toward antibiotic use and self-medication, and factors associated with self-medication.

METHODS

A national cross-sectional, interviewer-administered, survey of a random household sample (N = 1100) was conducted. Factor analysis of the attitudinal items was conducted to investigate the factors associated with antibiotic self-medication.

RESULTS

A response rate of ninety-one percent (n = 998) responded. Knowledge about antibiotics was poor (mean = 12.5; SD = 3.5; (scale 0-27)). Half had previously used an antibiotic once in the past three months. About 11% (108/998) had self-medicated the last time they took antibiotics; mostly obtained from a pharmacy (82%; 89/108). Three attitudinal factors were obtained, explaining 56.1% of the variance. Respondents were less likely to self-medicate if they did not support ease of access to antibiotics from pharmacies (p< 0.001) and situational use of antibiotics (p= 0.001); supported appropriate use of antibiotics (p= 0.003); and had greater knowledge about prescription requirements for antibiotics (p= 0.004).

CONCLUSION

There is limited knowledge about, and a high rate of self-medication with antibiotics.Factors contributing to self-medication could be addressed with appropriate public education campaigns, and policy changes.

Large-scale study validates that regional fungicide applications are major determinants of resistance evolution in the wheat pathogen Zymoseptoria tritici in France

In modern cropping systems, the near-universal use of plant protection products selects for resistance in pest populations. The emergence and evolution of this adaptive trait threaten treatment efficacy. We identified determinants of fungicide resistance evolution and quantified their effects at a large spatiotemporal scale. We focused on Zymoseptoria tritici, which causes leaf blotch in wheat. Phenotypes of qualitative or quantitative resistance to various fungicides were monitored annually, from 2004 to 2017, at about 70 sites throughout 22 regions of France (territorial units of 25 000 km² on average). We modelled changes in resistance frequency with regional anti-Septoria fungicide use, yield losses due to the disease and the regional area under organic wheat. The major driver of resistance dynamics was fungicide use at the regional scale. We estimated its effect on the increase in resistance and relative apparent fitness of each resistance phenotype. The predictions of the model replicated the spatiotemporal patterns of resistance observed in field populations (R² from 0.56 to 0.82). The evolution of fungicide resistance is mainly determined at the regional scale. This study therefore showed that collective management at the regional scale could effectively complete local actions.

Associations between private vaccine and antimicrobial consumption across Indian states, 2009-2017

Vaccines can reduce antibiotic use and, consequently, antimicrobial resistance by averting vaccine-preventable and secondary infections. We estimated the associations between private vaccine and antibiotic consumption across Indian states during 2009-2017 using monthly and annual consumption data from IQVIA and employed fixed-effects regression and the Arellano-Bond Generalized Method of Moments (GMM) model for panel data regression, which controlled for income and public sector vaccine use indicators obtained from other sources. In the annual data fixed-effects model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.22% increase in antibiotic consumption per 1000 people (P < 0.001). In the annual data GMM model, a 1% increase in private vaccine consumption per 1000 under-5 children was associated with a 0.2% increase in private antibiotic consumption (P < 0.001). In the monthly data GMM model, private vaccine consumption was negatively associated with antibiotic consumption when 32, 34, 35, and 44-47 months had elapsed after vaccine consumption, with a positive association with lags of fewer than 18 months. These results indicate vaccine-induced longer-term reductions in antibiotic use in India, similar to findings of studies from other low- and middle-income countries.

Treatment, Persistent Symptoms, and Depression in People Infected with COVID-19 in Bangladesh

Background: Coronavirus disease (COVID-19) has affected people's lives globally. While important research has been conducted, much remains to be known. In Bangladesh, initial treatment (self-administered, hospitalized), persistent COVID-19 symptoms ("long COVID-19"), and whether COVID-19 leads to changes in mental state, such as depressive symptoms, of people are not known. This study aimed to examine treatment, persistent symptoms, and depression in people who had been infected with COVID-19 in Bangladesh. Methods: A cross-sectional survey was conducted on 1002 individuals infected with COVID-19 (60% male; mean age = 34.7 ± 13.9; age range = 18-81 years), with data taken over a one-month period (11 September 2020 to 13 October 2020). A self-reported online questionnaire was used to collect data on socio-demographics, lifestyle, COVID-19 symptoms (during and beyond COVID-19), medication (over-the-counter or doctor-prescribed), and depression (assessed using the Patient Health Questionnaire (PHQ-9)). Results: Twenty-four percent of participants self-medicated with over-the-counter medicine when they were first diagnosed with COVID-19. Self-medication was higher among female vs. male respondents (29.6% vs. 20.2%, respectively, p = 0.002). A minority (20%) reported that they experienced persistent COVID-like symptoms after recovering from COVID-19. The most reported persistent symptoms were diarrhea (12.7%) and fatigue (11.5%). Forty-eight percent of participants were categorized as having moderate to severe depression. Based on multivariate regression analysis, depression during COVID-19 was positively associated with lower family income, poor health status, sleep disturbance, lack of physical activity, hypertension, asthma/respiratory problems, fear of COVID-19 re-infection, and persistent COVID-19 symptoms. Conclusions: The findings suggest a need for appropriate interventions for COVID-19 patients to promote physical and mental wellbeing.

The use of non-prescribed antibiotics; prevalence estimates in low-and-middle-income countries. A systematic review and meta-analysis

Background

The global increase in the utilization of non - prescribed antibiotics (NPA), is concerning, with high persistence within the low and middle-income countries (LMICs). With a negative impact on the health of individuals and communities the use of NPA paves the way to the  propagation of superbugs that potentially predisposes to changes in bacterial resistance patterns, antibiotic resistance (AR) and antimicrobial resistance (AMR). This study aimed at estimating through a systematic review and meta-analysis, the prevalence of NPA utilisation and describe its primary sources in LMICs.

Methods

The study is a systematic review and meta-analysis which study protocol was registered in PROSPERO (CRD42017072954). The review used The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.  The studies searched in databases were deemed eligible if reported evidence of practices of self-medication with antibiotics (SMA) and the prevalence of NPA utilisation within adult participants from LMICs, published between 2007 to 2017. The pooled analyses were carried out using Meta XL statistical software. The pooled prevalence was calculated with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Quality in Prognosis Studies (QUIPS) tool.

Results

The review included a total of 11 cross-sectional studies, involving 5080 participants and conducted in LMICs from Asia (India, Laos, Nepal, Pakistan, Sri Lanka and Yemen), Latin America (Guatemala), Africa (Nigeria). All studies reported existing  practices of SMA, with reported prevalence ranging from 50% to 93,8%. The pooled prevalence of SMA was 78% (95% CI: 65–89%). The main sources of NPA were; pharmacies, family and friends, old prescriptions, home cabinet and leftover antibiotics.

Conclusion

This study revealed a high prevalence of utilisation of NPA in the studied LMICs, these were found to be twice as high in women than men and those participants aged between 18 and 40 years old. The review suggests f considering broader qualitative and comprehensive contextuallized research to better understand the nuances of NPA use. These would be benefitial to uncover uncover gray areas, inform decisions, support the (re) design and implementation of multifaceted interventions towards antibiotic stewardship and conservancy in LMICs.

Non-Prescription Antibiotics Use and Associated Factors Among Drug Retail Outlets in Ambo, Ethiopia: A Cross-Sectional Study

PURPOSE

To assess the non-prescription use of antibiotics and associated factors in Ambo Town, West Shoa, Oromia, Ethiopia.

METHODS

An institutional-based cross-sectional study design supported with the qualitative study was conducted in Ambo Town from February 1 to March 1, 2020. Data were collected using a pretested semi-structured questionnaire and in-depth interview guide questions. Simple random sampling was used to select retail outlets and systematic random sampling to select study participants. The data analysis was done using SPSS and univariate and multivariate binary logistic regression analysis was performed to identify factors associated with non-prescription use of antibiotics. Thematic framework analysis was applied for the qualitative data.

RESULTS

From the 421 study sample, a total of 399 participants were interviewed with a 94.8% response rate. Among the study participants, 214 (53.6) were males, 228 (57.1%) were married, 191 (47.9%) were orthodox by religion, and 343 (86%) were Oromo by ethnicity. One hundred seventy-two (43.1%; 95% CI: 38.6, 48.1) of the participants had used non-prescribed antibiotics. Being male [AOR=2.21 95% CI: 1.276, 3.835], residing in rural area [AOR=3.659, 95% CI: 1.479, 9.054], holding diploma [AOR=0.120, 95% CI: 0.025, 0.591], and hold BSC degree [AOR=0.050, 95% CI: 0.007, 0.378], and being farmer [AOR=0.034, 95% CI: 0.004, 0.285] showed significant association with the non-prescription use of antibiotics.

CONCLUSION

This study concluded that the non-prescription use of antibiotics 172 (43.1%) was relatively high. Being male, residing in a rural area, holding a diploma, BSc degree, and being a farmer were significantly associated with non-prescription use of antibiotics. So, West Shoa Zone regulatory body should actively focus on the prevention of non-prescription use of antibiotics through health communication and public awareness on the demerits of non-prescription use of antibiotics.

Knowledge, attitudes and practices regarding antimicrobial use and resistance among communities of Ilala, Kilosa and Kibaha districts of Tanzania

BACKGROUND

Antimicrobial resistance (AMR) represents one of the biggest threats to health globally. This cross-sectional study determined knowledge, attitudes and practices (KAP) regarding antimicrobial use (AMU) and AMR among communities of Ilala, Kilosa and Kibaha in Tanzania.

METHOD

A semi-structured questionnaire was used to collect socio-demographic and KAP data through face-to-face interviews. Responses related to the triad of KAP were assigned scores that were aggregated for each participant. Linear regression analysis was conducted to determine predictors of KAP scores.

RESULTS

The study enrolled 828 participants from the three districts. A total of 816 (98.6%) were aware of antimicrobials, and 808 (99%, n = 816) reported to have used them. Antimicrobials were mainly used to treat cough (68.0%), urinary tract infections (53.4%), diarrhoea (48.5%) and wounds (45.2%). The most frequent sources of antimicrobials were health facility (65.0%, n = 820) and pharmacies/basic drug shops (53.7%). The median AMU knowledge score was 5 (IQR = 4, 7) and that of AMR was 26 (IQR=23, 29). The median AMU attitudes score was 32 (IQR: 29, 35) and that of AMR was 19 (IQR=17, 22). The median AMU practice score was 3 (IQR: 3, 3). The KAP scores were significantly influenced by increased participant's age (βadj=0.10; 95% CI: 0.05, 0.15) and level of education, being lower among those with primary education (βadj=5.32; 95% CI: 3.27, 7.37) and highest among those with college/university education (βadj=9.85; 95% CI: 6.04, 13.67).

CONCLUSION

The study documented a moderate level of KAP regarding AMU and AMR in the study districts. The participant's age and level of education were significantly associated with participant's KAP scores. The observed inadequate knowledge, inappropriate attitude, and practices of AMU and AMR should be considered as alarming problems that require immediate actions including policy formulation and planning of community-based mitigation measures.

Implications of human activities for (re)emerging infectious diseases, including COVID-19

Since 1980, the world has been threatened by different waves of emerging disease epidemics. In the twenty-first century, these diseases have become an increasing global concern because of their health and economic impacts in both developed and resource-constrained countries. It is difficult to stop the occurrence of new pathogens in the future due to the interconnection among humans, animals, and the environment. However, it is possible to face a new disease or to reduce the risk of its spread by implementing better early warning systems and effective disease control and prevention, e.g., effective global surveillance, development of technology for better diagnostics, effective treatments, and vaccines, the global political will to respond to any threats and multidisciplinary collaboration involving all sectors in charge of good health maintenance. In this review, we generally describe some factors related to human activities and show how they can play a role in the transmission and spread of infectious diseases by using some diseases as examples. Additionally, we describe and discuss major factors that are facilitating the spread of the new pandemic known as COVID-19 worldwide.

Cysteine-rich antimicrobial peptides from plants: The future of antimicrobial therapy

There has been a spurt in the spread of microbial resistance to antibiotics due to indiscriminate use of antimicrobial agents in human medicine, agriculture, and animal husbandry. It has been realized that conventional antibiotic therapy would be less effective in the coming decades and more emphasis should be given for the development of novel antiinfective therapies. Cysteine rich peptides (CRPs) are broad-spectrum antimicrobial agents that modulate the innate immune system of different life forms such as bacteria, protozoans, fungi, plants, insects, and animals. These are also expressed in several plant tissues in response to invasion by pathogens, and play a crucial role in the regulation of plant growth and development. The present work explores the importance of CRPs as potent antimicrobial agents, which can supplement and/or replace the conventional antibiotics. Different plant parts of diverse plant species showed the presence of antimicrobial peptides (AMPs), which had significant structural and functional diversity. The plant-derived AMPs exhibited potent activity toward a range of plant and animal pathogens, protozoans, insects, and even against cancer cells. The cysteine-rich AMPs have opened new avenues for the use of plants as biofactories for the production of antimicrobials and can be considered as promising antimicrobial drugs in biotherapeutics.

Evidence of the Practice of Self-Medication with Antibiotics among the Lay Public in Low- and Middle-Income Countries: A Scoping Review

The current scoping review is an attempt to explore the key reasons, determinants, patterns and prevalence related to self-medication with antibiotics (SMA) among the lay public. An online search was conducted using Google Scholar, Science Direct, ProQuest and PubMed. A two-phase mapping approach was used. In the first phase, studies were screened. In the second phase, the data were extracted from selected studies followed by the assessment of data quality. A total of 24 studies were included; 20 were cross-sectional, 3 were qualitative and one was observational. The most common indications were flu, cough, common colds, sore throat, diarrhea, toothache and fever. The most common determinants reported were past good experience and suggestions from friends or relatives. The use of SMA was observed to be more frequent in younger aged individuals belonging to low- or middle-income groups. The prevalence rate was reported to be high among the South Asian lay public and may be a major contributor to antibiotic resistance. In conclusion, this scoping review identifies a need for education campaigns and mass media campaigns to strengthen lay public awareness about the side effects and risks associated with SMA. In addition to this, there is a need to implement strict policies by government agencies to restrict over the counter availability of antibiotics.

Factors influencing the inappropriate use of antibiotics in the Rupandehi district of Nepal

INTRODUCTION

Antimicrobial resistance is a global public health crisis. A major driver of resistance is inappropriate antibiotic use, resulting from practices of prescribers, dispensers and patients. The purpose of this study was to identify the perception of service providers and policymakers about the inappropriate use of antibiotics in Nepal.

METHODS

A qualitative study was conducted to explore factors influencing antibiotic use. Participants included 17 service providers and policymakers from the Rupandehi district in Nepal, with a semi-structured interview schedule adopted. Data were analysed using thematic analysis to identify themes relating to the inappropriate use of antibiotics.

RESULTS

Inappropriate use of antibiotics was found to result from the interaction of demand and supply factors, together with a weak regulatory environment. Lack of knowledge by consumers and financial constraints resulted in practices such as self-medication and pressure being placed on providers to prescribe or dispense antibiotics. An insufficient choice of antibiotics, and health services not having investigation facilities, was also factors leading to inappropriate use of antibiotics. Additionally, in the private sector, the profit motive arising from incentives provided by pharmaceutical companies contributed to prescribing or dispensing antibiotics inappropriately.

CONCLUSION

Promoting appropriate antibiotic use is critical to reduce the growing public health threat of antibiotic resistance. A multi-faceted approach involving policymakers, providers, and the general public using both educational and regulatory measures is required to address this problem in Nepal, and potentially also in other low-income countries with a similar healthcare system.

Predicting the future distribution of antibiotic resistance using time series forecasting and geospatial modelling

Background: Increasing antibiotic resistance in a location may be mitigated by changes in treatment policy, or interventions to limit transmission of resistant bacteria. Therefore, accurate forecasting of the distribution of antibiotic resistance could be advantageous. Two previously published studies addressed this, but neither study compared alternative forecasting algorithms or considered spatial patterns of resistance spread. Methods: We analysed data describing the annual prevalence of antibiotic resistance per country in Europe from 2012 – 2016, and the quarterly prevalence of antibiotic resistance per clinical commissioning group in England from 2015 – 2018. We combined these with data on rates of possible covariates of resistance. These data were used to compare the previously published forecasting models, with other commonly used forecasting models, including one geospatial model. Covariates were incorporated into the geospatial model to assess their relationship with antibiotic resistance. Results: For the European data, which was recorded on a coarse spatiotemporal scale, a naïve forecasting model was consistently the most accurate of any of the forecasting models tested. The geospatial model did not improve on this accuracy. However, it did provide some evidence that antibiotic consumption can partially explain the distribution of resistance. The English data were aggregated at a finer scale, and expected-trend-seasonal (ETS) forecasts were the most accurate. The geospatial model did not significantly improve upon the median accuracy of the ETS model, but it appeared to be less sensitive to noise in the data, and provided evidence that rates of antibiotic prescription and bacteraemia are correlated with resistance. Conclusion: Annual, national-level surveillance data appears to be insufficient for fitting accurate antibiotic resistance forecasting models, but there is evidence that data collected at a finer spatiotemporal scale could be used to improve forecast accuracy. Additionally, incorporating antibiotic prescription or consumption data into the model could improve the predictive accuracy.

Antibiotics stewardship in Ghana: a cross-sectional study of public knowledge, attitudes, and practices among communities

BACKGROUND

Antibiotic resistance is a major contributing factor to global morbidity and mortality and is associated with inappropriate medication use. However, the level of antibiotic consumption and knowledge about antibiotic resistance in Ghana is inadequately quantified. Our study identifies strategies for improved stewardship of antibiotics to prevent the proliferation of resistant pathogens by assessing the level of antibiotic knowledge, attitudes, and consumption behaviors by region, gender, age, and education in rural and urban Ghana.

METHODS

A cross-sectional study was conducted in 12 communities in the urban Greater Accra and rural Upper West regions of Ghana. A questionnaire survey was administered to 400 individuals aged 18 years and older in selected locations during September-October 2018 to collect data on individual knowledge, attitudes, and practices concerning antibiotics and antibiotic resistance. Multivariate analysis was used to investigate the association between demographic characteristics and knowledge, attitudes, and related behaviors.

RESULTS

Over 30% (125/400) had not received a doctor's prescription during their last illness. Seventy percent (278/400) had taken at least one antibiotic in the year prior to the survey. The top five frequently used antibiotics were Amoxicillin, Amoxicillin-clavulanic acid, Ampicillin, Ciprofloxacin, and Metronidazole. Women and older adults had higher knowledge compared to their respective counterparts (p < 0.01). Furthermore, prudent antibiotic use was significantly more prevalent in women than men (p < 0.05). Although no regional differences were found in overall knowledge, compared to urban residents, individuals residing in rural settings exhibited higher knowledge about the ineffectiveness of antibiotics for viruses like the cold and HIV/AIDS (p < 0.001). Two hundred and fifty-two (63%) respondents were unaware of antibiotic resistance. There was generally a low level of self-efficacy among participants regarding their role in preserving the effectiveness of antibiotics.

CONCLUSION

Antibiotic knowledge, attitudes, and use varied significantly across demographics, suggesting a context-specific approach to developing effective community interventions.

What influences antibiotic sales in rural Bangladesh? A drug dispensers' perspective

BACKGROUND

Antibiotic resistance poses a great threat to global health, especially in low- and middle-income countries with a high infectious disease burden and limited resources. In spite of regulations, antibiotics are sold in many settings as non-prescription medicines, resulting in inappropriate use and resistance.

OBJECTIVE

This study aimed to investigate the current status of access and use of antibiotics in rural Bangladesh, by exploring the perspectives and sales practices of antibiotic drug dispensers.

METHODS

We used a mixed methods approach (qualitative and quantitative). We mapped and characterized antibiotic purchasing and dispensing sites in the Matlab Health and Demographic Surveillance System catchment area. Furthermore, we investigated the volume of provision of systemic antibiotics in 10 drug outlets. We held 16 in-depth interviews with randomly selected antibiotics dispensers. Interviews explored factors associated with antibiotic selling. Responses were transcribed, coded for themes, and summarized. We used ATLAS.ti 5.2 for conducting a thematic analysis.

RESULTS

A total of 301 antibiotic dispensers were identified, of whom 92% (n = 278) were private and 8% (n = 23) public. 52% (n = 155) operated informally (i.e. without legal authorization). In order to promote and survive in their business, dispensers sell antibiotics for a range of conditions without a qualified physician's prescription. Factors that facilitate these inappropriate sales include lack of access to healthcare in the rural community, inadequate doctor: population ratio, limited dispenser knowledge, poor pharmacovigilance concerning safety of self medication, lack of enforcement of policies, financial benefits for both customers and dispensers, and high dependency on pharmaceutical companies' information.

CONCLUSION

Dispensers in rural Bangladesh sell antibiotics inappropriately by ignoring existing national regulations. They operate the antibiotic sales without facing any legal barriers and primarily with a view to sustain their business, resulting in inappropriate sales of antibiotics to the rural community. The influence of the drug industry needs to be replaced with evidence-based, not commercially driven information. Awareness programs for antibiotic providers that promote understanding of antibiotics and antibiotic resistance through tailored interventions may be helpful in changing current antibiotic sales practices.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Impact of chemorophylaxis policy for AIDS-immunocompromised patients on emergence of bacterial resistance

Chemoprophylaxis (antibiotic prophylaxis) is a long relied-upon means of opportunistic infection management among HIV/AIDS patients, but its use represents an evolutionary tradeoff: Despite the benefits of chemoprophylaxis, widespread use of antibiotics creates a selective advantage for drug-resistant bacterial strains. Especially in the developing world, with combined resource limitations, antibiotic misuse, and often-poor infection control, the emergence of antibiotic resistance may pose a critical health risk. Extending previous work that demonstrated that this risk is heightened when a significant proportion of the population is HIV/AIDS-immunocompromised, we work to address the relationship between HIV/AIDS patients' use of antibiotic chemoprophylaxis and the emergence of resistance. We apply an SEIR compartmental model, parameterized to reflect varying percentages of chemoprophylaxis use among HIV/AIDS+ patients in a resource-limited setting, to investigate the magnitude of the risk of prophylaxis-associated emergence versus the individual-level benefits it is presumed to provide. The results from this model suggest that, while still providing tangible benefits to the individual, chemoprophylaxis is associated with negligible decreases in population-wide morbidity and mortality from bacterial infection, and may also fail to provide assumed efficacy in reduction of TB prevalence.

Widespread illegal sales of antibiotics in Chinese pharmacies - a nationwide cross-sectional study

Background

Access to antibiotics without a prescription from retail pharmacies has been described as a major contributor to anti-microbial resistance (AMR) globally. In the context of high rates of AMR, the Chinese government has recently introduced strict policies regarding hospital antibiotic use, but the existing ban on antibiotic sales without prescription in retail pharmacies has not been strongly enforced. In 2016, a goal of prescription-only antibiotics by 2020 was announced. The objective of the study was to determine progress towards the 2020 goal, through estimating the proportion of retail pharmacies selling antibiotics without prescription across the three regions of mainland China.

Methods

Using the Simulated Patient method, we conducted a cross-sectional survey across purposively-sampled retail pharmacies in urban and rural areas of 13 provinces in eastern, central and western China. Medical students presented a scenario of a mild upper respiratory tract infection, following a strict three-step protocol. They recorded the pharmacy characteristics, and details of their experience, including at which step antibiotics were offered.

Results

Complete data were obtained from 1106 pharmacies. Antibiotics were obtained in 925 (83.6, 95% CI: 81.5, 85.8%) pharmacies without a prescription, 279 (25.2%) at Stage 1 (symptoms only described), 576 (52.1%) at stage 2 (asked for antibiotics), and 70 (6.3%) at Stage 3 (asked for penicillin or cephalosporins). There were significant differences between provinces, with antibiotic access (at any stage) ranging from 57.0% (57/100) in Zhejiang (81/82) to 98.8% in Guizhou. However, there were no significant differences in access to antibiotics by level of city, county, township or village (P = 0.25), whether the pharmacy was part of a chain or independent (P = 0.23), whether a licensed pharmacist was attending (P = 0.82) or whether there was a sign saying that prescriptions were required for antibiotics (P = 0.19).

Conclusions

It is easy to obtain antibiotics without a prescription in retail pharmacies in China, despite the fact it is against the law. This must be addressed as part of the wider anti-microbial stewardship effort which could include intense enforcement of the existing law, supported by a public education campaign.

High prevalence of ESBL-producing Klebsiella pneumoniae in clinical samples from central Côte d'Ivoire

OBJECTIVES

Infections caused by multidrug-resistant Enterobacterales pose a significant challenge to clinical patient care, particularly in resource-constrained settings where epidemiological data on antimicrobial resistance are scarce. The aim of this study was to determine the prevalence of extended spectrum beta-lactamase-(ESBL)-producing Klebsiella pneumoniae among clinical samples from a teaching hospital in Bouaké, central Côte d'Ivoire.

METHODS

Clinical specimens were collected from sterile and non-sterile body sites and were subjected to microbiological diagnostics (April 2016-June 2017). The antimicrobial susceptibility patterns of K. pneumoniae were analysed using automated resistance testing and double-disk diffusion to test for ESBL production. Multiplex PCR was carried out to determine the presence of the resistance-conferring genes bla_CTX-M, bla_SHV and bla_TEM.

RESULTS

A total of 107 isolates were included, most of which were obtained from bloodstream (39%; n=42) and urinary tract infections (39%; n=42). Among all K. pneumoniae isolates, 84% (n=90) were ESBL producers, many of which were also not susceptible to sulfonamides (99%), quinolones (81%) and aminoglycosides (79%). The majority of ESBL-producing strains harboured all three investigated bla genes.

CONCLUSION

The high prevalence of ESBL-producing K. pneumoniae in clinical isolates from Côte d'Ivoire calls for revised empirical treatment regimens in critically ill patients with suspected Gram-negative infections, and the establishment of antimicrobial resistance surveillance systems.

Bacterial antibiotic resistance development and mutagenesis following exposure to subminimal inhibitory concentrations of fluoroquinolones in vitro: a systematic literature review protocol

INTRODUCTION

Antibiotic resistance (AR) is among the most pressing global health challenges. Fluoroquinolones are a clinically important group of antibiotics that have wide applicability in both humans and animals. While many drivers of AR are known, the impact of medicine quality on AR remains largely unknown. The aim of this review is to systematically evaluate the evidence of the impact of in vitro subinhibitory antibiotic exposure, a major tenet of substandard antibiotics, on the development of AR and mutagenesis, using fluoroquinolones as a case study.

METHODS AND ANALYSIS

EMBASE, Web of Science and PubMed will be systematically searched for primary experimental in vitro studies, from earliest available dates within each database (1947, 1965 and 1966, respectively) through 2018, related to subinhibitory fluoroquinolone exposure and AR. A specifically developed non-weighted tool will be used to critically assess the evidence. Subgroup analyses will be performed for different variables and outcomes.

ETHICS AND DISSEMINATION

Ethical approval is not required as no primary data are to be collected. The completed systematic review will be disseminated through conference meeting presentations and a peer-reviewed publication.

A governance framework for development and assessment of national action plans on antimicrobial resistance

Strengthening governance is an essential strategy to tackling antimicrobial resistance (AMR) at all levels: global, national, regional, and local. To date, no systematic approach to governance of national action plans on AMR exists. To address this issue, we aimed to develop the first governance framework to offer guidance for both the development and assessment of national action plans on AMR. We reviewed health system governance framework reviews to inform the basic structure of our framework, international guidance documents from WHO, the Food and Agriculture Organization, the World Organisation for Animal Health, and the European Commission, and sought the input of 25 experts from international organisations, government ministries, policy institutes, and academic institutions to develop and refine our framework. The framework consists of 18 domains with 52 indicators that are contained within three governance areas: policy design, implementation tools, and monitoring and evaluation. To consider the dynamic nature of AMR, the framework is conceptualised as a cyclical process, which is responsive to the context and allows for continuous improvement and adaptation of national action plans on AMR.

Enteric Fever in Cambodia: Community Perceptions and Practices Concerning Disease Transmission and Treatment

Enteric fever is a systemic bacterial infection in humans that is endemic in Cambodia and for which antibiotic resistance is increasingly reported. To guide public health programs, this qualitative study sought to explore community perceptions on transmission and treatment. Participant observation was carried out in hospital settings, pharmacies, and at a community level in Phnom Penh. In-depth interviews 39 and one focus group discussion were carried out with blood culture–confirmed enteric fever patients and purposively selected key informants. Informants were theoretically sampled based on initial themes identified using abductive analysis. Nvivo 11 was used for thematic coding. An urgent need to address health literacy concerning the transmission of enteric fever was identified, as lay informants did not link the disease and its symptoms to bacterial contamination of foods and drinks but rather to foods considered “bad” following humoral illness interpretations. As a result, lay informants considered recurrence of enteric fever preventable with appropriate dietary restrictions and Khmer traditional medicines. This study also reveals pluralistic health-care–seeking behavior. For initial and mild symptoms, patients preferred home treatment or traditional healing practices; limited household finances delayed treatment seeking. When symptoms persisted, patients first visited drug outlets or private practitioners, where they received a mix of nonessential medicines and one or more antibiotics often without prescription or confirmation of diagnosis. Inappropriate use of antibiotics was common and was related to diagnostic uncertainty and limited finances, factors which should be addressed during future efforts to improve the uptake of appropriate diagnostics and treatment of enteric fever.

Opportunities and Challenges for the Sustainability of Lakes and Reservoirs in Relation to the Sustainable Development Goals (SDGs)

Emerging global threats, such as biological invasions, climate change, land use intensification, and water depletion, endanger the sustainable future of lakes and reservoirs. To deal with these threats, a multidimensional view on the protection and exploitation of lakes and reservoirs is needed. The holistic approach needs to contain not just the development of economy and society but also take into account the negative impacts of this growth on the environment, from that, the balance between the three dimensions can be sustained to reach a sustainable future. As such, this paper provides a comprehensive review on future opportunities and challenges for the sustainable development of lakes and reservoirs via a critical analysis on their contribution to individual and subsets of the Sustainable Development Goals (SDGs). Currently, lakes and reservoirs are key freshwater resources. They play crucial roles in human societies for drinking water provision, food production (via fisheries, aquaculture, and the irrigation of agricultural lands), recreation, energy provision (via hydropower dams), wastewater treatment, and flood and drought control. Because of the (mostly) recent intensive exploitations, many lakes and reservoirs are severely deteriorated. In recent years, physical (habitat) degradation has become very important while eutrophication remains the main issue for many lakes and ponds worldwide. Besides constant threats from anthropogenic activities, such as urbanization, industry, aquaculture, and watercourse alterations, climate change and emerging contaminants, such as microplastics and antimicrobial resistance, can generate a global problem for the sustainability of lakes and reservoirs. In relation to the SDGs, the actions for achieving the sustainability of lakes and reservoirs have positive links with the SDGs related to environmental dimensions (Goals 6, 13, 14, and 15) as they are mutually reinforcing each other. On the other hand, these actions have direct potential conflicts with the SDGs related to social and economic dimensions (Goals 1, 2, 3 and 8). From these interlinkages, we propose 22 indicators that can be used by decision makers for monitoring and assessing the sustainable development of lakes and reservoirs.

Poverty and Community-Acquired Antimicrobial Resistance with Extended-Spectrum β-Lactamase-Producing Organisms, Hyderabad, India

The decreasing effectiveness of antimicrobial agents is a global public health threat, yet risk factors for community-acquired antimicrobial resistance (CA-AMR) in low-income settings have not been clearly elucidated. Our aim was to identify risk factors for CA-AMR with extended-spectrum β-lactamase (ESBL)–producing organisms among urban-dwelling women in India. We collected microbiological and survey data in an observational study of primigravidae women in a public hospital in Hyderabad, India. We analyzed the data using multivariate logistic and linear regression and found that 7% of 1,836 women had bacteriuria; 48% of isolates were ESBL-producing organisms. Women in the bottom 50th percentile of income distribution were more likely to have bacteriuria (adjusted odds ratio 1.44, 95% CI 0.99–2.10) and significantly more likely to have bacteriuria with ESBL-producing organisms (adjusted odds ratio 2.04, 95% CI 1.17–3.54). Nonparametric analyses demonstrated a negative relationship between the prevalence of ESBL and income.

How context can impact clinical trials: a multi-country qualitative case study comparison of diagnostic biomarker test interventions

Background

Context matters for the successful implementation of medical interventions, but its role remains surprisingly understudied. Against the backdrop of antimicrobial resistance, a global health priority, we investigated the introduction of a rapid diagnostic biomarker test (C-reactive protein, or CRP) to guide antibiotic prescriptions in outpatient settings and asked, “Which factors account for cross-country variations in the effectiveness of CRP biomarker test interventions?”

Methods

We conducted a cross-case comparison of CRP point-of-care test trials across Yangon (Myanmar), Chiang Rai (Thailand), and Hanoi (Vietnam). Cross-sectional qualitative data were originally collected as part of each clinical trial to broaden their evidence base and help explain their respective results. We synthesised these data and developed a large qualitative data set comprising 130 interview and focus group participants (healthcare workers and patients) and nearly one million words worth of transcripts and interview notes. Inductive thematic analysis was used to identify contextual factors and compare them across the three case studies. As clinical trial outcomes, we considered patients’ and healthcare workers’ adherence to the biomarker test results, and patient exclusion to gauge the potential “impact” of CRP point-of-care testing on the population level.

Results

We identified three principal domains of contextual influences on intervention effectiveness. First, perceived risks from infectious diseases influenced the adherence of the clinical users (nurses, doctors). Second, the health system context related to all three intervention outcomes (via the health policy and antibiotic policy environment, and via health system structures and the ensuing utilisation patterns). Third, the demand-side context influenced the patient adherence to CRP point-of-care tests and exclusion from the intervention through variations in local healthcare-seeking behaviours, popular conceptions of illness and medicine, and the resulting utilisation of the health system.

Conclusions

Our study underscored the importance of contextual variation for the interpretation of clinical trial findings. Further research should investigate the range and magnitude of contextual effects on trial outcomes through meta-analyses of large sets of clinical trials. For this to be possible, clinical trials should collect qualitative and quantitative contextual information for instance on their disease, health system, and demand-side environment.

Trial registration

ClinicalTrials.gov, NCT02758821 registered on 3 May 2016 and NCT01918579 registered on 7 August 2013.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3215-9) contains supplementary material, which is available to authorized users.

Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What?

Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.

Antibiotic prescribing in paediatric inpatients in Ghana: a multi-centre point prevalence survey

BACKGROUND

Excessive and inappropriate use of antibiotics in hospitalised patients contributes to the development and spread of antibiotic resistance. Implementing a stewardship programme to curb the problem requires information on antibiotic use. This study describes a multicentre point prevalence of antibiotic use among paediatric inpatients in Ghana.

METHODS

Data were extracted from a multicentre point prevalence survey of hospital acquired infections in Ghana. Data were collected between September 2016 and December 2016 from ten hospitals through inpatient folder and chart reviews using European Centre for Disease Control (ECDC) adapted data collection instrument. From each site, data were collected within a 12-h period (8 am to 8 pm) by a primary team of research investigators and a select group of health professionals from each participating hospital.

RESULTS

Among 716 paediatric inpatients, 506 (70.6%; 95% confidence interval (CI): 67.2 to 74.0%) were on antibiotics. A significant proportion of antibiotics (82.9%) was prescribed for infants compared to neonates (63.9%) and adolescents (60.0%). The majority of patients (n = 251, 49.6%) were prescribed two antibiotics at the time of the survey. The top five classes of antibiotics prescribed were third generation cephalosporins (n = 154, 18.5%) aminoglycosides (n = 149, 17.9%), second generation cephalosporins (n = 103,12.4%), beta lactam resistant penicillins (n = 83, 10.0%) and nitroimidazoles (n = 82, 9.9%). The majority of antibiotics (n = 508, 61.0%) were prescribed for community acquired infections. The top three agents for managing community acquired infections were ceftriaxone (n = 97, 19.1%), gentamicin (n = 85, 16.7%) and cefuroxime (n = 73, 14.4%).

CONCLUSION

This study points to high use of antibiotics among paediatric inpatients in Ghana. Cephalosporin use may offer an important target for reduction through antibiotic stewardship programmes.