Improper disposal of unused antibiotics: an often overlooked driver of antimicrobial resistance

Molecularly Imprinted Titanium Dioxide: Synthesis Strategies and Applications in Photocatalytic Degradation of Antibiotics from Marine Wastewater: A Review

Antibiotic residues in the marine environment pose a serious threat to ecosystems and human health, and there is an urgent need to develop efficient and selective pollution control technologies. Molecular imprinting technology (MIT) provides a new idea for antibiotic pollution control with its specific recognition and targeted removal ability. However, traditional titanium dioxide (TiO2) photocatalysts have limited degradation efficiency and lack of selectivity for low concentrations of antibiotics. This paper reviews the preparation strategy and modification means of molecularly imprinted TiO2 (MI-TiO2) and its composites and systematically explores its application mechanism and performance advantages in marine antibiotic wastewater treatment. It was shown that MI-TiO2 significantly enhanced the selective degradation efficiency of antibiotics such as tetracyclines and sulfonamides through the enrichment of target pollutants by specifically imprinted cavities, combined with the efficient generation of photocatalytic reactive oxygen species (ROS). In addition, emerging technologies such as magnetic/electric field-assisted catalysis and photothermal synergistic effect further optimized the recoverability and stability of the catalysts. This paper provides theoretical support for the practical application of MI-TiO2 in complex marine pollution systems and looks forward to its future development in the field of environmental remediation.

Genetic basis of antibiotic resistance in bovine mastitis and its possible implications for human and ecological health

Bovine mastitis is a mammary gland inflammation that can occur due to infectious pathogens, Staphylococcus aureus and Escherichia coli, which are, respectively, the most prevalent Gram-positive and Gram-negative bacteria associated with this disease. Currently, antibiotic treatment has become more complicated due to the presence of resistant pathogens. This review, therefore, aims to identify the most common resistance genes reported for these strains in the last four years. During the review, it was noted that blaZ, blaSHV, blaTEM, and blaampC are the most reported genes for S. aureus and E. coli, associated with drug inactivation, mainly β-lactamases. They are characterized by generating bacterial resistance to β-lactam antibiotics, the most common treatment in animal and human bacterial treatments (penicillins and cephalosporins, among others). Genes associated with efflux systems were also present in the two strains and included norA, tetA, tetC, and tetK, which generate resistance to macrolide and tetracycline antibiotics. Additionally, the effects of spreading resistance between animals and humans through direct contact (such as consumption of contaminated milk) or indirect contact (through environmental contamination) has been deeply discussed, emphasizing the importance of having adequate sanitation and antibiotic control and administration protocols.

House dust microbiome differentiation and phage-mediated antibiotic resistance and virulence dissemination in the presence of endocrine-disrupting chemicals and pharmaceuticals

BACKGROUND

House dust serves as a reservoir of a diverse array of microbial life and anthropogenic chemicals, both of which can potentially influence the health of occupants, particularly those who spend significant amounts of time at home. However, the effects of anthropogenic chemicals on dust microbiomes remain poorly understood. This study investigated the presence of anthropogenic chemicals in the dust of homes occupied by elderly occupants and explored those chemicals' relationships with dust microbiomes.

RESULTS

We detected 69 out of 76 analyzed anthropogenic chemicals, including endocrine-disrupting chemicals, non-antibiotic pharmaceuticals, and antibiotics, in at least one house dust sample from 32 residential homes, with concentrations ranging from 2720 to 89,300 ng/g. Some of these detected compounds were pharmaceuticals regularly consumed by the occupants. The dust microbiomes were associated with varying levels of anthropogenic chemicals, forming two distinct clusters, each with unique diversity, taxonomy, metabolic functions, and resistome profiles. Higher concentrations and a greater variety of these chemicals were associated with an increased co-occurrence of antibiotic resistance and virulence genes, as well as an enhanced potential for their transfer through mobile genetic elements. Under these conditions, phages, especially phage-plasmids, facilitated the dissemination of antibiotic resistance and virulence among bacterial populations.

CONCLUSIONS

The findings indicate that everyday anthropogenic chemicals are important factors associated with the microbes in indoor environments. This underscores the importance of improving household chemical stewardship to reduce the health risks associated with exposure to these chemicals and their effects on indoor microbiomes. Video Abstract.

Environmental Sustainability in ICUs: A Report From the Society of Critical Care Medicine Sustainability Task Force

OBJECTIVES

The charge of the newly formed Society of Critical Care Medicine Sustainability Task Force is to describe actionable items supporting environmental stewardship for ICUs, to discuss barriers associated with sustainability initiatives and outline opportunities for future impact.

DATA SOURCES

Ovid Medline, EBSCOhost CINAHL, Elsevier Embase, and Scopus databases were searched through to March 2024 for studies reporting on environmental sustainability and critical care.

STUDY SELECTION

Systematic reviews, narrative reviews, quality improvement projects, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed.

DATA EXTRACTION

Data regarding environmental sustainability initiatives that aimed to quantify, manage, or mitigate pollution and/or carbon emissions with a focus on ICUs, barriers to change, and opportunities for development were qualitatively assessed.

DATA SYNTHESIS

ICUs are resource-intensive and as such, methods to attenuate carbon emissions and waste can play a substantial role in mitigating the sizable burden of healthcare-related pollution and greenhouse gas emissions. Several initiatives and strategies exist for clinicians and providers to engage in environmental stewardship, with specific attention to avoiding low-value care while maintaining or improving patient safety and high-quality care. Increased focus on sustainability can be met with resistance to change, including institutional, financial, and behavioral barriers. Collaboration and innovative thinking create valuable opportunities for clinicians, patients, families, and policymakers to advocate for patient and planetary health.

CONCLUSIONS

Within the healthcare system, ICUs are well positioned to lead sustainability action, policy, and practice. Critical care teams have the capability and the moral responsibility to mitigate the negative impact of critical care medicine upon our environment and become change agents promoting sustainable healthcare for the benefit of human health.

Assessment of the magnitude, economic impact, and factors associated with expired veterinary pharmaceuticals in animal health facilities in South Wollo, Ethiopia

Background

The issue of veterinary pharmaceutical expiration is a significant concern in animal health facilities globally. The existence of veterinary pharmaceutical expiration can be mainly associated with inadequate inventory control, store management, and a lack of effective pharmaceutical regulatory policies and guidelines. Hence, the study aimed to evaluate expired veterinary pharmaceuticals' scope, economic impact, and contributing factors.

Methods

A cross-sectional, explanatory sequential study design involving a mixed quantitative and qualitative approach was employed among 13 animal health facilities from March 2022 to December 2023 in and around Dessie town, South Wollo, Ethiopia. A key informant interview guide was used to retrieve the qualitative data that were analyzed through thematic content analysis. Then, the collected data were coded and analyzed using SPSS version 25. A mean score was used to determine the critical factors associated with veterinary pharmaceutical expiration.

Results

The study found that the magnitude of expired veterinary pharmaceuticals in the fourth fiscal year was 7%. This wastage rate of veterinary pharmaceuticals led to a loss of approximately 69,564.54 USD. From expired veterinary pharmaceutical unit pack perspectives, approximately 403-unit packs (66%) expired in veterinary clinics, resulting in a loss of approximately 38,229.33 USD, and 209-unit packs (34%) expired in private veterinary pharmacies, incurring a loss of approximately 31,335.22 USD. From Anatomical Therapeutic Classification (ATC), antibiotics accounted for 14.8% of the total financial loss. Additionally, approximately 53% of liquid dosage forms were expired. The quantitative study identifies the lack of an information system and necessary software, poor store management, and lack of strict accountability as critical contributors to veterinary pharmaceutical expiration. Additionally, inadequate inventory management systems and a lack of adherence to established policies and guidelines for managing veterinary pharmaceutical expiration were the most vital contributors as key informants cited.

Conclusion

The financial burden associated with expired veterinary pharmaceuticals exceeded the permissible threshold of 2%, indicating a significant concern for animal health budgets and the aquatic environment. This study underlines that the issue of veterinary pharmaceutical expiration is a critical problem that necessitates policy implications. To mitigate the expiration rate of veterinary pharmaceuticals, collaboration among multidisciplinary veterinary professionals, the Ethiopian Agricultural Authority, pharmaceutical supply chain agency, and researchers is essential.

Logistic Stewardship: Supporting Antimicrobial Stewardship Programs Based on Antibiotics Goods Flow

BACKGROUND/OBJECTIVES

Antimicrobial resistance is a global threat to safe health care, and a reduction in antibiotic consumption seems to be an appropriate preventive measure. In Germany, the reporting of hospital antibiotics consumption to an independent institution is only voluntary. Although a high level of willingness to improve can be assumed in the case of participation, the median consumptions of reporting hospitals change only slightly. This study examines the question of whether the logistical consumption figures adequately reflect real consumption, and if not, how to optimize the use of logistical data for clinical decisions.

METHODS

Four selected wards were analyzed during six months. A retrospective analysis of patient case files was performed to receive "prescribed daily doses" (PDDs). These were compared to "defined daily doses" (DDDs) from logistical data. Additional inventories were performed to calculated stored antibiotics. Antibiotics goods flows were presented via waterfall diagrams to identify logistic patterns that could explain PDD/DDD quotients. Antimicrobial stewardship (AMS) quality indicators were analyzed to give advice for optimized clinical AMS measures.

RESULTS

The total PDD/DDD quotient was 0.69. Four logistical patterns were identified. Optimized prophylaxis, AMS consultations and reevaluation of therapy seem to be the most useful measures to reduce PDDs.

CONCLUSIONS

If AMS programs rely solely on DDDs, measures cannot be optimal. A complete consideration of antibiotic goods flows supports clinical decisions, but is very costly in terms of data collection. The consideration of logistical data can help to identify areas of focus for AMS programs. Therefore, specialists of antibiotics logistics should complement clinical AMS teams.

Assessment of ecological risks posed by veterinary antibiotics in European aquatic environments: A comprehensive review and analysis

The extensive use of antibiotics in human and veterinary medicine has led to the emergence of antibiotic contaminants in the environment, posing significant risks to ecosystems and public health. This contamination arises from the persistence of antibiotics in aquatic environments, particularly in aquifer systems, where they contribute to the growing threat of antibiotic resistance. Despite increasing research, the understanding of the ecological and human health implications of these contaminants remains incomplete. Since these compounds are only partially removed by conventional wastewater treatment plants (WWTPs), they are continuously released into the environment. Antibiotics enter the environment mainly through human and animal excretions, improper drug disposal, wastewater treatment plants, and waste streams from antibiotic production. Recent research has focused on antibiotic metabolites and transformation products, which can affect aquatic ecosystems and the food chain, posing long-term risks to human health. This critical review provides a comprehensive analysis of the risk assessment of veterinary antibiotics (VAs) in European aquatic environments, where VAs concentrations ranging from micrograms to milligrams per liter. By examining toxicity data from freshwater and saltwater species, the study evaluates acute and chronic effects across different antibiotic classes. The review also assesses the sensitivity of various taxonomic groups and species to different antibiotics, providing insights into potential ecological risks. Species sensitivity distributions and hazard concentrations affecting a given percentage of species are calculated to assess the overall ecological risk. The findings reveal varying proportions of toxicity data across antibiotic classes, with Aminoglycosides, β-lactams, Fluoroquinolones, Macrolides, and Tetracyclines classes demonstrating higher toxicity levels than others towards certain cyanobacteria and chlorophyta species. Macrolides and Fluoroquinolones emerge as particularly concerning due to their high toxicological risks across various aquatic environments. The analysis underscores the urgent need for further research to fill knowledge gaps and develop effective strategies to mitigate the harmful effects of VAs on aquatic ecosystems and human health.

Efficient adsorptive removal of levofloxacin using sulfonated graphene oxide: Adsorption behavior, kinetics, and thermodynamics

Water pollution by antibiotic residues poses a potential threat to environmental and human health. Graphene-based materials are highly stable, recyclable and effective adsorbents for efficiently removing antibiotics from polluted water. In this study, the adsorption behavior of levofloxacin onto sulfonated graphene oxide (SGO) was investigated by varying the contact period, solution pH, adsorbent quantity, levofloxacin concentration, inorganic ions, and solution temperature. Spectroscopic and microscopic techniques were employed to confirm the adsorptive interaction between levofloxacin and SGO. The adsorption process was most accurately characterized by the pseudo-second-order kinetic model and the Langmuir isotherm model, as indicated by their high correlation coefficients (R 2) and low root-mean-square error (RMSE) values. The maximal quantity of levofloxacin that can be adsorbed onto SGO was determined to be 1250 μmol/g at pH 4 and 25 °C using the Langmuir model. Thermodynamic studies reveal that the process of levofloxacin adsorption onto SGO is endothermic and spontaneous in nature. Taking into consideration the results of adsorption, desorption and regeneration studies, it is proposed that SGO can be applied as an economic viable agent for the adsorptive removal of levofloxacin from the aqueous environment.

Disposal of Unused Antibiotics in Community Pharmacies in Saudi Arabia: A Mixed-Methods Study

Introduction

Improper disposal of unused antibiotics poses a significant global challenge, drawing attention from various stakeholders. This discharge of antibiotics into the environment can occur through various means such as industrial production, consumption, and excretion by humans and animals, as well as improper disposal of unused or expired antibiotics. The aim of our study is to investigate the availability of proper disposal of antibiotics in community pharmacies and to explore obstacles and opportunities from pharmacist's point of view.

Methods

This study used a mixed-methods approach that consisted of two study arms: quantitative and qualitative. The quantitative arm used a mystery-shopper method for assessing the disposal of antibiotics in community pharmacies. The qualitative study arm consisted of several in-depth semi-structured focus groups with a sample of pharmacists working in community pharmacies in Riyadh.

Results

The mystery shopper arm showed that 85% (n=88) refused to take the return of antibiotics. Interviews with pharmacists have indicated a lack of knowledge on safe disposal methods for antibiotics and medications. Additionally, pharmacists have cited several factors contributed to accumulation of the antibiotics such as nonadherence or policies mandating the sale of whole medication packs instead of the required amounts as a contributing factor to this issue. Furthermore, there is a lack of dedicated facilities for the population to safely dispose of their medications and/antibiotics.

Conclusion

By acknowledging the factors contributing to improper disposal practices, recognizing the importance of proper antibiotic disposal, and advocating for multi-faceted initiatives, we can work towards mitigating this critical issue. Through collaborative efforts involving education, policy interventions, and community engagement, we can foster a culture of responsible medication disposal, ultimately safeguarding public health and environmental well-being.

Extent and causes of unused medications among patients in rural Ethiopia: a prospective multicenter cohort study

BACKGROUND

Medication waste poses health, economic, and environmental challenges. However, the extent among patients living in rural areas is underexplored. This study assessed the proportion of prescribed medications remaining unused by patients living in rural areas of Ethiopia, and identify the causes thereof and disposal practices.

METHODS

A prospective multicenter cohort study was conducted in 5 rural health centers in Ethiopia. Patients (≥ 18 years), who received a prescription for acute or chronic medication for pick up from the outpatient pharmacy were included. After 3 months, participants received a house visit by a health employee during which a questionnaire was verbally administered to assess the quantity of unused medication, reason thereof, and disposal practices used. Data were analyzed using descriptive statistics and multivariate logistic regression to identify factors associated with presence of unused medications.

RESULTS

In total, 178 patients participated. Up to 136 out of 601 (22.6%) dispensed medications ended up unused, mainly antibiotics and analgesics, with an average economic value of $0.37. Of 178 patients, 72 (40.4%) ended up with unused medication, and 15 (8.4%) did not use 80% or more of the prescribed quantity. Early discontinuation of therapy was the main reason (61.8%) for patients' ending with unused medication. Patients reported to primarily dispose of unused medication either through the toilet (43.6%), household garbage (22.7%), burning (13.6%), or returning it to the pharmacy (2.7%). Medications dispensed to be administered with two or more-unit doses at a time were more likely to remain unused (adjusted OR 1.6 [1.0-3.4]) compared to medications dispensed to be administered one-unit dose.

CONCLUSION

A substantial amount of prescribed medications remains unused by patients in rural areas, frequently not properly disposed. Interventions are needed to ensure medications are not wasted and reduce the unwanted consequences.

Antibiotic resistance: a global crisis, problems and solutions

Healthy state is priority in today's world which can be achieved using effective medicines. But due to overuse and misuse of antibiotics, a menace of resistance has increased in pathogenic microbes. World Health Organization (WHO) has announced ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) as the top priority pathogens as these have developed resistance against certain antibiotics. To combat such a global issue, it is utmost important to identify novel therapeutic strategies/agents as an alternate to such antibiotics. To name certain antibiotic adjuvants including: inhibitors of beta-lactamase, efflux pumps and permeabilizers for outer membrane can potentially solve the antibiotic resistance problems. In this regard, inhibitors of lytic domain of lytic transglycosylases provide a novel way to not only act as an alternate to antibiotics but also capable of restoring the efficiency of previously resistant antibiotics. Further, use of bacteriophages is another promising strategy to deal with antibiotic resistant pathogens. Taking in consideration the alternatives of antibiotics, a green synthesis nanoparticle-based therapy exemplifies a good option to combat microbial resistance. As horizontal gene transfer (HGT) in bacteria facilitates the evolution of new resistance strains, therefore identifying the mechanism of resistance and development of inhibitors against it can be a novel approach to combat such problems. In our perspective, host-directed therapy (HDT) represents another promising strategy in combating antimicrobial resistance (AMR). This approach involves targeting specific factors within host cells that pathogens rely on for their survival, either through replication or persistence. As many new drugs are under clinical trials it is advisable that more clinical data and antimicrobial stewardship programs should be conducted to fully assess the clinical efficacy and safety of new therapeutic agents.

The management of unused and expired medications in Thai households: Influencing factors and prevailing practices

OBJECTIVE

Although the improper disposal of unused and expired medications represents a global environmental concern, its significance is often underestimated. This research delves into the practices and factors related to the management of unused and expired medications.

METHODS

Data was collected through a comprehensive survey of Thai households, with 400 structured questionnaires. Multiple regression was then employed to analyze the data.

RESULTS

Findings show an intriguing paradox. The participants in the survey demonstrated commendable knowledge regarding the appropriate management of unused or expired medications. Yet, this knowledge was not sufficiently put into practice. This study identifies the factors that have a positive influence on proper medication disposal practices, such as age, level of education, attitude, and perception. Surveyed participants exhibited a tendency to retain unused medications and discard expired ones with household waste. Most of them showed a low degree of medication management, pointing to the need for targeted interventions.

CONCLUSION

This research provides tangible benefits for policymakers, healthcare practitioners, and researchers addressing waste management paradigms. In terms of policy, the study highlights the need for comprehensive interventions, including medication take-back systems, infrastructure development, and educational initiatives. Policymakers are urged to bridge the gap between knowledge and behavior by promoting access to collection points for proper medication disposal to avoid perpetuating the cycle of suboptimal medication management. This research informs strategies to encourage responsible medication management practices globally, addressing the adverse environmental and health impacts associated with the improper accumulation of medications.

Antimicrobial use in laboratory rodent facilities in Australia and New Zealand- a cross-sectional survey of veterinarians and facility managers

This cross-sectional study surveyed veterinarians and facility managers to characterise the use of antimicrobials in laboratory rodent facilities within Australia and New Zealand. Most facilities (71%) reported routine administration of antimicrobials. The indications for antibiotic use reflected those described in publications and differed significantly to reasons for use in non-laboratory animals. Antimicrobials used include those of critical importance to human health, and access to these drugs is unregulated, as prescription-only classes are ordered through research catalogues, without human or veterinary physician prescriptions. The ways in which antimicrobials are used in Australian and New Zealand rodent facilities are likely contributing to antimicrobial resistance within rodent populations, particularly as they are largely administered in drinking water, risking subtherapeutic dosing. Much antimicrobial use reported is unnecessary and could be replaced with changes to husbandry and handling. The generation of resistance in both pathogenic and commensal microbes may also represent a work health and safety issue for humans working with these animals. Reported disposal of antimicrobials included discharge into wastewater, without inactivation, and some respondents reported disposal of substrate, or soiled bedding, nesting material, and disposable enrichment items, from treated animals and medicated feed into landfill, without prior inactivation. Environmental contamination with resistant microbes and antimicrobials is a significant driver of antimicrobial resistance. As such, significant opportunities exist to implement judicious and responsible use of antimicrobials within research rodent facilities in Australia and New Zealand, with a particular focus on instituting aseptic surgery, optimising dosing regimens, and inactivation of medicated water and substrate before disposal.

Review on antibiotic pollution dynamics: insights to occurrence, environmental behaviour, ecotoxicity, and management strategies

Antibiotic contamination poses a significant global concern due to its far-reaching impact on public health and the environment. This comprehensive review delves into the prevalence of various antibiotic classes in environmental pollution and their interactions with natural ecosystems. Fluoroquinolones, macrolides, tetracyclines, and sulphonamides have emerged as prevalent contaminants in environmental matrices worldwide. The concentrations of these antibiotics vary across diverse environments, influenced by production practices, consumer behaviours, and socio-economic factors. Low- and low-middle-income countries face unique challenges in managing antibiotic contamination, with dominant mechanisms like hydrolysis, sorption, and biodegradation leading to the formation of toxic byproducts. Ecotoxicity reports reveal the detrimental effects of these byproducts on aquatic and terrestrial ecosystems, further emphasizing the gravity of the issue. Notably, monitoring the antibiotic parent compound alone may be inadequate for framing effective control and management strategies for antibiotic pollution. This review underscores the imperative of a comprehensive, multi-sectoral approach to address environmental antibiotic contamination and combat antimicrobial resistance. It also advocates for the development and implementation of tailored national action plans that consider specific environmental conditions and factors. Thus, an approach is crucial for safeguarding both public health and the delicate balance of our natural ecosystems.

Emerging contaminants: A One Health perspective

Environmental pollution is escalating due to rapid global development that often prioritizes human needs over planetary health. Despite global efforts to mitigate legacy pollutants, the continuous introduction of new substances remains a major threat to both people and the planet. In response, global initiatives are focusing on risk assessment and regulation of emerging contaminants, as demonstrated by the ongoing efforts to establish the UN's Intergovernmental Science-Policy Panel on Chemicals, Waste, and Pollution Prevention. This review identifies the sources and impacts of emerging contaminants on planetary health, emphasizing the importance of adopting a One Health approach. Strategies for monitoring and addressing these pollutants are discussed, underscoring the need for robust and socially equitable environmental policies at both regional and international levels. Urgent actions are needed to transition toward sustainable pollution management practices to safeguard our planet for future generations.

The hidden dangers lurking at home: Unveiling the prevalence of leftover antibiotics and its associated factors among Lebanese households

Background

Antimicrobial Resistance (AMR) is a major global concern. Irrational use of antibiotics including self-medication (SM) with leftovers without a medical prescription can be a leading cause. This study aimed to investigate the prevalence and related factors of leftover antibiotics (LA) in Lebanese households.

Study design

A cross-sectional study of the Lebanese population was conducted between March and October 2022.

Methods

Through random proportional stratified sampling, a total of 494 families participated in this study. Data collection was carried out through phone calls using a comprehensive and reviewed questionnaire. The data was then analyzed using SPSS version 26. Logistic regression was utilized to identify the factors associated with LA, with the presence of LA in households as the dependent variable and other factors such as age, region of residence, and presence of elderly individuals at home as the independent variables.

Results

Among selected households, 118 households (23.89%) had LA. The most common type of antibiotic found was penicillin (59.84%). Most of the LA were in the form of tablets and capsules (94%) with valid expiration dates (87%). Antibiotics were mainly prescribed by doctors (61%), and the main reason for prescribing was acute respiratory tract infections (47.46%). SM was reported by 42.37% of the families with LA. A family with elderly patients (p = 0.002; OR = 2.23; 95% CI = 1.33-3.73) and those residing in Mount Lebanon (p = 0.019; OR = 2.28; 95% CI = 1.14-4.56) had significantly higher odds of having LA.

Conclusion

Leftover antibiotics were found in nearly a quarter of the addressed Lebanese families. Therefore, public educational campaigns should be launched to limit injudicious antibiotic use including SM, and to promote proper disposal of any leftovers. It is also crucial to adopt the One Health approach by developing national programs for the safe disposal of LA and implementing regulations to restrict the distribution of antibiotics in pharmacies without a prescription.

Antibiotics in semen extenders - a multiplicity of paradoxes

Addition of antibiotics to semen extenders was taken for granted for many years, from the time that commercial artificial insemination in livestock first began many decades ago. However, there is now a growing realisation that this non-therapeutic utilisation of antibacterial agents is contrary to current recommendations for prudent use that medical and veterinary professionals are advised to follow. Furthermore, antibiotics are not benign, having negative effects on sperm samples, the inseminated female, personnel and potentially the environment. The purpose of this review is three-fold: to highlight the fact that antibiotics are used in semen extenders, with the result that considerable amounts are used globally in animal breeding, to review recent studies on the negative aspects of using antibiotics for this purpose, and to look at possible alternatives. Recent changes in the legislation regarding semen extenders occurred in some, but not all, countries, leaving question marks for semen producers as to whether antibiotics should be added to semen extenders or not.

Antibiotic disposal challenges in India: investigating causes and effects

Antibiotic resistance has become a global problem and India emerges as a key battlefield in the fight against it. While inappropriate use of antibiotics is well known, the review article deliberates a less recognized yet equally perilous facet of the crisis i.e. improper antibiotic disposal. An investigation of the sources of antibiotic pollution in Indian water bodies identifies discharge of pharmaceutical effluents, hospital waste, and agricultural runoff as major contributing factors. Furthermore, it discusses the repercussions of antibiotic pollution including those relating to human health, aquatic ecosystems, and antibiotic resistance. Reviewing the causes and consequences of improper antibiotic disposal practices emphasizes the necessity of rethinking antibiotic waste management practices. The review highlights the need for stringent rules and increased awareness, while also discussing the emerging technologies and strategies to mitigate the risks of antibiotic disposal in India.

Assessment of global antimicrobial resistance campaigns conducted to improve public awareness and antimicrobial use behaviours: a rapid systematic review

INTRODUCTION

Public health campaigns with a well-defined outcome behaviour have been shown to successfully alter behaviour. However, the complex nature of antimicrobial resistance (AMR) creates challenges when evaluating campaigns aimed at raising awareness and changing behaviour.

AIMS

To determine what campaigns have been conducted and which reported being effective at improving awareness of antimicrobial resistance and changing behaviour around antimicrobial use in members of the public. It also sought to determine the outcome measures studies have used to assess campaign effectiveness.

METHODS

A systematic search of Ovid MEDLINE and Embase, was conducted in October 2022 using a predefined search strategy. Studies which were published between 2010 and September 2022 that outlined a campaign or invention aimed at the public and focusing on AMR or antibiotic usage were eligible for inclusion and studies which solely targeted healthcare professionals (HCP) were excluded.

RESULTS

Literature searches retrieved 6961 results. De-duplication and screening removed 6925 articles, five articles from grey literature and reference screening were included, giving a total of 41 studies and 30 unique interventions. There was a distribution of campaigns globally with the majority run in Europe (n = 15) with most campaigns were conducted nationally (n = 14). Campaigns tended to focus on adult members of the public (n = 14) or targeted resources towards both the public and HCPs (n = 13) and predominately assessed changes in knowledge of and/or attitudes towards AMR (n = 16). Campaigns where an improvement was seen in their primary outcome measure tended to use mass media to disseminate information, targeted messaging towards a specific infection, and including the use of HCP-patient interactions.

DISCUSSION

This review provides some evidence that campaigns can significantly improve outcome measures relating to AMR and antibiotic usage. Despite a lack of homogeneity between studies some common themes emerged between campaigns reported as being effective. However, the frequent use of observational study designs makes it difficult to establish causation between the campaign and changes seen in the studies outcome measures. It is important that clear evaluation processes are embedded as part of the design process for future campaigns; a campaign evaluation framework for use by campaign developers may facilitate this.

Antibiotic action and resistance: updated review of mechanisms, spread, influencing factors, and alternative approaches for combating resistance

Antibiotics represent a frequently employed therapeutic modality for the management of bacterial infections across diverse domains, including human health, agriculture, livestock breeding, and fish farming. The efficacy of antibiotics relies on four distinct mechanisms of action, which are discussed in detail in this review, along with accompanying diagrammatic illustrations. Despite their effectiveness, antibiotic resistance has emerged as a significant challenge to treating bacterial infections. Bacteria have developed defense mechanisms against antibiotics, rendering them ineffective. This review delves into the specific mechanisms that bacteria have developed to resist antibiotics, with the help of diagrammatic illustrations. Antibiotic resistance can spread among bacteria through various routes, resulting in previously susceptible bacteria becoming antibiotic-resistant. Multiple factors contribute to the worsening crisis of antibiotic resistance, including human misuse of antibiotics. This review also emphasizes alternative solutions proposed to mitigate the exacerbation of antibiotic resistance.

Potential Causes of Spread of Antimicrobial Resistance and Preventive Measures in One Health Perspective-A Review

Antimicrobial resistance, referring to microorganisms' capability to subsist and proliferate even when there are antimicrobials is a foremost threat to public health globally. The appearance of antimicrobial resistance can be ascribed to anthropological, animal, and environmental factors. Human-related causes include antimicrobial overuse and misuse in medicine, antibiotic-containing cosmetics and biocides utilization, and inadequate sanitation and hygiene in public settings. Prophylactic and therapeutic antimicrobial misuse and overuse, using antimicrobials as feed additives, microbes resistant to antibiotics and resistance genes in animal excreta, and antimicrobial residue found in animal-origin food and excreta are animals related contributive factors for the antibiotic resistance emergence and spread. Environmental factors including naturally existing resistance genes, improper disposal of unused antimicrobials, contamination from waste in public settings, animal farms, and pharmaceutical industries, and the use of agricultural and sanitation chemicals facilitatet its emergence and spread. Wildlife has a plausible role in the antimicrobial resistance spread. Adopting a one-health approach involving using antimicrobials properly in animals and humans, improving sanitation in public spaces and farms, and implementing coordinated governmental regulations is crucial for combating antimicrobial resistance. Collaborative and cooperative involvement of stakeholders in public, veterinary and ecological health sectors is foremost to circumvent the problem effectively.

Ecopharmacology: Knowledge, Attitude, and Medication Disposal Practice Among Pharmacy Students

Background

Ecopharmacology, as a form of drug management for the environment, focuses on the impact of drugs on the environment. Pharmacists, and by extension pharmacy students, are expected to play an important role in ecopharmacology. Therefore, this study was conducted to determine the knowledge and attitude towards ecopharmacology and the practice of disposal of leftover or expired medicines among pharmacy students.

Methods

This was a descriptive cross-sectional study among pharmacy students in Northwestern Ethiopia. The study took place from May 1 to June 15, 2023. A self-administered questionnaire was used for data collection.

Results

Four hundred and forty-five students were included in the study. Only 91 (20%) of the students were aware of the term ecopharmacology, 27% knew that excretion from the human or animal body is the major route by which pharmaceutical agents enter the environment, and 42% were aware of the risk of increased antimicrobial resistance due to antibiotic residues in the environment. In addition, only 27% of respondents reported receiving information about the disposal of pharmaceuticals. The most common method of disposing of medications was throwing them away in household trash (61.8%).

Conclusion

Our results suggest that while most pharmacy students in Ethiopia have a positive attitude toward ecopharmacology, they do not know enough about ecopharmacology and dispose of their medicines poorly. More uniform education in ecopharmacology and pharmaceutical pollution might be warranted in the pharmacy curriculum.

Knowledge, Attitude, and Practices (KAP) on Antibiotic Use and Disposal Ways in Sidama Region, Ethiopia: A Community-Based Cross-Sectional Survey

Antibiotic resistance has been among the top public health threats elsewhere. Scientific information on knowledge, attitudes, and practices (KAP) at the community level towards antibiotic use and disposal ways is a vital step for effective intervention. This study aimed at determining the levels of KAP and associated risk factors for antibiotics in and around Hawassa City, southern Ethiopia. A community-based cross-sectional study was conducted, and data were collected using a structured questionnaire. Descriptive statistics, chi-square test, and logistic regression were used to analyze and interpret the results. A total of 504 participants with a mean age of 35.32 ± 9.03 years were included in the study. Most of the participants were urban dwellers (59.5%); more than half (55.6%) of the participants were male; most of the participants (62.7%) were at least college graduates; about half were employed (52.4%); about 41.7% of the participants had a large family size (≥7) with a mean family size of 5.7 ± 2.7; the average family monthly income was ETB 7213.71 ± 3673, and over three-fourth (74.8%) of the study participants were married. In addition, about 83.13% of the study participants heard about antibiotics; almost all of them (99.8%) had ever used antibiotics at some point in their life (75% of which used antibiotics within 6 months), and all of them could name at least one common type of antibiotic. Moreover, most of the participants (86.5%) did not receive any training related to antibiotics, and 29.4% of them obtained antibiotics without a prescription. Most participants had poor knowledge (64%), negative attitudes (60.4%), and poor practices (55%) towards antibiotic use, resistance, and disposal methods. Significant and positive linear correlations between knowledge and attitude (r = 0.539, P ≤ 0.001), knowledge-practice (r = 0.532, P ≤ 0.001), and attitude-practice (r = 0.786, P < 0.001) were also observed. Most of the sociodemographic variables were significantly associated with the mean KAP scores of the study participants. Living in a rural area, having a large family size, and being female, married, illiterate, and farmer resulted in a very low level of knowledge. Similarly, living in a rural area, having a small family size, and being older and married resulted in a negative attitude. Furthermore, having a smaller family size, having a low family monthly income, and being married, illiterate, and self-employed resulted in poor practice. A very low level of KAP towards antibiotics among people living in and around Hawassa City calls for urgent and effective intervention strategies.

Advances in the screening of antimicrobial compounds using electrochemical biosensors: is there room for nanomaterials?

The abusive use of antimicrobial compounds and the associated appearance of antimicrobial resistant strains are a major threat to human health. An improved antimicrobial administration involves a faster diagnosis and detection of resistances. Antimicrobial susceptibility testing (AST) are the reference techniques for this purpose, relying mainly in the use of culture techniques. The long time required for analysis and the lack of reproducibility of these techniques have fostered the development of high-throughput AST methods, including electrochemical biosensors. In this review, recent electrochemical methods used in AST have been revised, with particular attention on those used for the evaluation of new drug candidates. The role of nanomaterials in these biosensing platforms has also been questioned, inferring that it is of minor importance compared to other applications.

Assembled mixed co-cultures for emerging pollutant removal using native microorganisms from sewage sludge

The global pharmaceutical pollution caused by drug consumption (>100,000 tonnes) and its disposal into the environment is an issue which is currently being addressed by bioremediation techniques, using single or multiple microorganisms. Nevertheless, the low efficiency and the selection of non-compatible species interfere with the success of this methodology. This paper proposes a novel way of obtaining an effective multi-domain co-culture, with the capacity to degrade multi-pharmaceutical compounds simultaneously. To this end, seven microorganisms (fungi and bacteria) previously isolated from sewage sludge were investigated to enhance their degradation performance. All seven strains were factorially mixed and used to assemble different artificial co-cultures. Consequently, 127 artificial co-cultures were established and ranked, based on their fitness performance, by using the BSocial analysis web tool. The individual strains were categorized according to their social behaviour, whose net effect over the remaining strains was defined as 'Positive', 'Negative' or 'Neutral'. To evaluate the emerging-pollutant degradation rate, the best 10 co-cultures, and those which contained the social strains were then challenged with three different Pharmaceutical Active compounds (PhACs): diclofenac, carbamazepine and ketoprofen. The co-cultures with the fungi Penicillium oxalicum XD-3.1 and Penicillium rastrickii were able to degrade PhACs. However, the highest performance (>80% degradation) was obtained by the minimal active microbial consortia consisting of both Penicillium spp., Cladosporium cladosporoides and co-existing bacteria. These consortia transformed the PhACs to derivate molecules through hydroxylation and were released to the media, resulting in a low ecotoxicity effect. High-throughput screening of co-cultures provides a quick, reliable and efficient method to narrow down suitable degradation co-cultures for emerging PhAC contaminants while avoiding toxic metabolic derivatives.

Prevalence of Antibiotic Use and Disposal at Household Level in Informal Settlements of Kisumu, Kenya

The use and abuse of antibiotics are directly related to the development of drug resistance, a global public health problem. Whereas the majority of research focus is on the use and misuse of antibiotics in drug resistance development, little is known about improper disposal, as a source of contamination in the environment that includes groundwater, especially in informal settlements. This study sought to determine antibiotic use and disposal in informal settlements in Kisumu, Kenya. A random cross-sectional sample of 447 households in selected informal settlements of Kisumu, Kenya was studied. A structured questionnaire was issued to persons heading households. The prevalence of antibiotic use was 43% (n = 193). Among these people, 74% (n = 144) had consulted a health worker in a healthcare facility for a prescription. Respondents did not always complete doses but kept the remainder for the next time they would become ill (54%). About 32% disposed of the remainder of the antibiotics in pit latrines and compost pits (10%) while 4% disposed through burning. Antibiotic use was fairly high despite a low level of awareness of the health effects of consuming water contaminated with antibiotics (35%) (n = 156); p = 0.03. Misuse and inappropriate disposal of antibiotics as identified may lead to a higher risk of antibiotic resistance, increasing the disease burden in the informal settlements.

Antibiotic resistant genes in the environment-exploring surveillance methods and sustainable remediation strategies of antibiotics and ARGs

Antibiotic Resistant Genes (ARGs) are an emerging environmental health threat due to the potential change in the human microbiome and selection for the emergence of antibiotic resistant bacteria. The rise of antibiotic resistant bacteria has caused a global health burden. The WHO (world health organization) predicts a rise in deaths due to antibiotic resistant infections. Since bacteria can acquire ARGs through horizontal transmission, it is important to assess the dissemination of antibioticresistant genes from anthropogenic sources. There are several sources of antibiotics, antibiotic resistant bacteria and genes in the environment. These include wastewater treatment plants, landfill leachate, agricultural, animal industrial sources and estuaries. The use of antibiotics is a worldwide practice that has resulted in the evolution of resistance to antibiotics. Our review provides a more comprehensive look into multiple sources of ARG's and antibiotics rather than one. Moreover, we focus on effective surveillance methods of ARGs and antibiotics and sustainable abiotic and biotic remediation strategies for removal and reduction of antibiotics and ARGs from both terrestrial and aquatic environments. Further, we consider the impact on public health as this problem cannot be addressed without a global transdisciplinary effort.

Application of antimicrobial, potential hazard and mitigation plans

The tremendous rise in the consumption of antimicrobial products had aroused global concerns, especially in the midst of pandemic COVID-19. Antimicrobial resistance has been accelerated by widespread usage of antimicrobial products in response to the COVID-19 pandemic. Furthermore, the widespread use of antimicrobial products releases biohazardous substances into the environment, endangering the ecology and ecosystem. Therefore, several strategies or measurements are needed to tackle this problem. In this review, types of antimicrobial available, emerging nanotechnology in antimicrobial production and their advanced application have been discussed. The problem of antimicrobial resistance (AMR) due to antibiotic-resistant bacteria (ARB)and antimicrobial resistance genes (AMG) had become the biggest threat to public health. To deal with this problem, an in-depth discussion of the challenges faced in antimicrobial mitigations and potential alternatives was reviewed.

Antimicrobial Resistance Monitoring of Water Environments: A Framework for Standardized Methods and Quality Control

Antimicrobial resistance (AMR) is a grand societal challenge with important dimensions in the water environment that contribute to its evolution and spread. Environmental monitoring could provide vital information for mitigating the spread of AMR; this includes assessing antibiotic resistance genes (ARGs) circulating among human populations, identifying key hotspots for evolution and dissemination of resistance, informing epidemiological and human health risk assessment models, and quantifying removal efficiencies by domestic wastewater infrastructure. However, standardized methods for monitoring AMR in the water environment will be vital to producing the comparable data sets needed to address such questions. Here we sought to establish scientific consensus on a framework for such standardization, evaluating the state of the science and practice of AMR monitoring of wastewater, recycled water, and surface water, through a literature review, survey, and workshop leveraging the expertise of academic, governmental, consulting, and water utility professionals.

Antimicrobial Resistance Monitoring of Water Environments: A Framework for Standardized Methods and Quality Control

Antimicrobial resistance (AMR) is a grand societal challenge with important dimensions in the water environment that contribute to its evolution and spread. Environmental monitoring could provide vital information for mitigating the spread of AMR; this includes assessing antibiotic resistance genes (ARGs) circulating among human populations, identifying key hotspots for evolution and dissemination of resistance, informing epidemiological and human health risk assessment models, and quantifying removal efficiencies by domestic wastewater infrastructure. However, standardized methods for monitoring AMR in the water environment will be vital to producing the comparable data sets needed to address such questions. Here we sought to establish scientific consensus on a framework for such standardization, evaluating the state of the science and practice of AMR monitoring of wastewater, recycled water, and surface water, through a literature review, survey, and workshop leveraging the expertise of academic, governmental, consulting, and water utility professionals.

Disposal practices of unused and expired pharmaceuticals among the general public in Quetta city, Pakistan

Objective

Although community practices towards disposal of expired and unused medications vary globally, the phenomenon is neglected specifically in developing countries. We, therefore, aimed to assess the disposal practices of unused and expired pharmaceuticals among the general public in Quetta city, Pakistan.

Methods

A questionnaire-based, cross-sectional survey was conducted among 830 respondents in Quetta city, Pakistan. A pre-validated, structured questionnaire was used for data collection. Data were coded and analyzed by Statistical Package for Social Science (SPSS) version 26. Both descriptive and inferential statistics were sued and p<0.05 was taken as significant.

Results

Almost 87% of the respondents had unused medicines at their homes and reusing the medications was the purpose of medicine storage (50%). Medicines were mostly kept in refrigerators (36.0%) followed by bedrooms (28.8%). Fifty percent of the respondents never checked the expiry date before using the medications. The procedure to dispose of nearly expired or expired medicines was unknown to 88% of the respondents and for those reasons, medicines were disposed either in household trash or flushed in the toilet or sink. Interestingly, medicines were kept at home even after being expired by 27% of the respondents. Income was associated with reason of storing medicines (p = 0.004; φc = 0.402) while educational status had significant associations with storage of medications (p = 0.002; φc = 0.399), reading about storage instructions (p = 0.008; φc = 0.452) and checking expiry date before purchasing and using the medicines (p = 0.007; φc = 0.114 and p = 0.001; φc = 0.100) respectively.

Conclusion

Improper storage and disposal of unused and expired medications is a common practice among study respondents and raised serious concerns. Findings of the current study call upon immediate development and implementation of the strategies to promote awareness and strengthen the pharmaceutical waste management program at the societal level.

Quantification and composition of pharmaceutical waste in New Zealand

This study aimed to quantify the amount of pharmaceutical waste produced in New Zealand, and determine the composition of pharmaceutical waste from community pharmacies in Auckland, New Zealand. Pharmaceutical waste collected in New Zealand is increasing, peaking at 542 tonne in 2019. Pharmaceutical waste collected from hospitals and pharmacies in Auckland increased by more than fourfold from 2016 to 2020. An audit of the types of pharmaceutical waste collected from community pharmacies revealed that the most common classes of drugs identified in this waste stream belonged to the nervous system, cardiovascular system and alimentary tract, and metabolism. Following examination of the contents of 12 pharmaceutical waste bins, 475 different pharmaceutical products were identified, highlighting the breadth of drugs in this waste stream. A range of dosage forms and hence materials were identified, which could present challenges for future waste treatment approaches. Hazardous drugs were identified including cytotoxic compounds, which should go into a separate waste stream for incineration. There is a need for similar data to be collected from multiple sites to fully appreciate the magnitude and composition of pharmaceutical waste. This will allow for the suitability of current practices for managing this hazardous waste stream to be evaluated.

Antibiotic resistance in the environment

Antibiotic resistance is a global health challenge, involving the transfer of bacteria and genes between humans, animals and the environment. Although multiple barriers restrict the flow of both bacteria and genes, pathogens recurrently acquire new resistance factors from other species, thereby reducing our ability to prevent and treat bacterial infections. Evolutionary events that lead to the emergence of new resistance factors in pathogens are rare and challenging to predict, but may be associated with vast ramifications. Transmission events of already widespread resistant strains are, on the other hand, common, quantifiable and more predictable, but the consequences of each event are limited. Quantifying the pathways and identifying the drivers of and bottlenecks for environmental evolution and transmission of antibiotic resistance are key components to understand and manage the resistance crisis as a whole. In this Review, we present our current understanding of the roles of the environment, including antibiotic pollution, in resistance evolution, in transmission and as a mere reflection of the regional antibiotic resistance situation in the clinic. We provide a perspective on current evidence, describe risk scenarios, discuss methods for surveillance and the assessment of potential drivers, and finally identify some actions to mitigate risks.

Antimicrobial Resistance in Equine Reproduction

Bacteria develop resistance to antibiotics following low-level "background" exposure to antimicrobial agents as well as from exposure at therapeutic levels during treatment for bacterial infections. In this review, we look specifically at antimicrobial resistance (AMR) in the equine reproductive tract and its possible origin, focusing particularly on antibiotics in semen extenders used in preparing semen doses for artificial insemination. Our review of the literature indicated that AMR in the equine uterus and vagina were reported worldwide in the last 20 years, in locations as diverse as Europe, India, and the United States. Bacteria colonizing the mucosa of the reproductive tract are transferred to semen during collection; further contamination of the semen may occur during processing, despite strict attention to hygiene at critical control points. These bacteria compete with spermatozoa for nutrients in the semen extender, producing metabolic byproducts and toxins that have a detrimental effect on sperm quality. Potential pathogens such as Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa may occasionally cause fertility issues in inseminated mares. Antibiotics are added during semen processing, according to legislation, to impede the growth of these microorganisms but may have a detrimental effect on sperm quality, depending on the antimicrobial agent and concentration used. However, this addition of antibiotics is counter to current recommendations on the prudent use of antibiotics, which recommend that antibiotics should be used only for therapeutic purposes and after establishing bacterial sensitivity. There is some evidence of resistance among bacteria found in semen samples. Potential alternatives to the addition of antibiotics are considered, especially physical removal separation of spermatozoa from bacteria. Suggestions for further research with colloid centrifugation are provided.

Factors influencing inappropriate use of antibiotics: Findings from a nationwide survey of the general public in Malaysia

Antibiotic resistance is one of the biggest threats to global public health. Misuse of antibiotics has never been investigated on a nationwide scale among the general public in Malaysia. This study aimed to identify sociodemographic and knowledge factors associated with inappropriate use of antibiotics in the Malaysian context to inform the development of interventions to mitigate inappropriate antibiotic use. We conducted computer-assisted telephone interviews (CATI) between June 2019 and December 2019. The telephone numbers were randomly generated from the electronic residential telephone directory of all 13 states and 3 Federal Territories in Malaysia. The survey consisted of questions on demographics, knowledge about antibiotics and antibiotic resistance (53 items), and practices of antibiotic use (16 questions). A total of 864 complete responses were received. Pronounced erroneous beliefs that antibiotics are effective against infections caused by viruses and that antibiotics can speed up recovery from coughs and colds were evident. The proportions that were aware of the terms ‘drug resistance’, ‘antimicrobial resistance’, and ‘superbugs’ were low. The mean and standard deviation (SD) for the antibiotic knowledge score was 23.7 (SD ±9.25; range 0 to 50) out of a possible score of 52. Regarding antibiotic practices, a considerable proportion reported non-adherence to recommended doses. The mean and SD for the antibiotic practices score was 37.9 (SD ± 6.5; range 17 to 47) out of a possible score of 48. Participants who earned an average monthly household income of MYR1001-3000 (OR 1.61, 95% CI 1.04–2.50) were more likely to report higher antibiotic practice scores than those with <MYR1000. Participants with tertiary education attainment reported higher antibiotic practice scores (OR 1.99; 95%CI 1.02–3.91) than those with primary school and below. High antibiotic knowledge scores (OR 3.94; 95% CI 2.71–5.73) were associated with higher antibiotic practice scores. Inappropriate antibiotic use is influenced by demographics and antibiotic knowledge. This study calls for education interventions focused on the lower socio-economic status population to increase awareness and to promote appropriate antibiotic use.

Access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda: a qualitative study

Background

Inappropriate use of antimicrobials in both humans and animals is a key driver of antimicrobial resistance (AMR). In addition, human behaviours such as poor disposal of antimicrobials in the environment can increase their exposure to microbes which can impact on humans and animals. However, evidence on access, use and disposal of antimicrobials for humans and animals at community level in Uganda is limited. This study therefore explored access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda.

Methods

A qualitative study was conducted that involved focus group discussions (FGDs) and key informant interviews (KIIs). Participants of the FGDs were community health workers (CHWs) and farmers involved in animal husbandry, while key informants included: officials from the Ministry of Health; Ministry of Agriculture, Animal Industry and Fisheries; human and animal health professionals; district health officials; and members of the national AMR surveillance committee. Twelve FGDs were held (8 for CHWs and 4 for farmers) while 15 KIIs were conducted. Thematic analysis in NVivo (version 12) was performed.

Results

Five main themes emerged from the study: access to antimicrobials in humans; access to antimicrobials in animals; use of antimicrobials in humans; use of antimicrobials in animals; and disposal of antimicrobials. Community members mainly accessed antimicrobials for humans from public health facilities such as government health centres, as well as private facilities, including drug shops and clinics. Antimicrobials for animals were obtained from veterinary practitioners and drug shops (both for humans and veterinary). Examples of inappropriate use of antimicrobials in both humans and animals was evident, such as sharing antibiotics among household members, and giving human-prescribed antimicrobials to food-producing animals as growth promoters. While some CHWs returned unused antimicrobials to public health facilities for proper disposal, community members mainly disposed of antimicrobials with general household waste including dumping in rubbish pits.

Conclusions

There is a need to increase awareness among the population on proper access, use and disposal of antimicrobials for both humans and animals. Development of a drug disposal system at community level would facilitate improved waste management of antimicrobials. Together, these measures would help prevent the rate of progression of AMR in communities.

Knowledge, Attitudes and Practices Regarding Antibiotic Use and Resistance among Veterinary Students in Bangladesh

The use of antibiotics in animals for both therapeutic and non-therapeutic purposes is a major driver of the emergence and spread of antimicrobial resistance (AMR). While several studies have investigated prescription and consumption patterns in humans, little attention has been paid to the veterinary sector. A cross-sectional study was conducted in 3002 veterinary students (VS) and non-medical students (NMS) from 12 universities in Bangladesh to explore their knowledge, attitudes and practices (KAP) about antibiotics and AMR using a self-administered questionnaire, and assess the influence of the veterinary curriculum. KAP regarding antibiotic use and AMR was significantly higher in veterinary than non-medical students, and in first-year than final-year students. However, gaps in knowledge and practices were highlighted, suggesting deficiencies in training. Moreover, final-year veterinary students were found to be more likely than first-year students to use antibiotics without instructions, which could indicate deficiencies in their curriculum. Although the study suggested a positive impact of the veterinary curriculum on KAP about antibiotics and AMR in Bangladesh, critical gaps remain that are likely to contribute to inadequate use in their future practice. Therefore, there is scope for improving educational programs on AMR in professional curricula.

Bacterial resistance to antibiotics: access, excess, and awareness in Bangladesh

Introduction: Antibiotic resistance is a substantial cause of mortality, morbidity burden in Bangladesh. In this perspective piece, the problem of antibiotic resistance has been analyzed by critically evaluating literature data, and based on the author's experience.Areas covered: The underlying causes of this resistance are numerous including irrational and inappropriate use of antibiotics aggravated by aggressive marketing, over-the-counter dispensing, prescribing by the unqualified providers, lack of awareness in the general population, and inadequate implementation of relevant regulations.Expert opinion: Although Bangladesh is making some progress toward containing antibiotic resistance, the pace of this progress is insufficient. Public awareness is crucial for the full implementation of the regulations. Given that it is more a social than a medical problem, the health sector is unable to tackle the problem on its own. An integrated approach is required that identifies the roles and relative importance of each sector (human, animal, and environment). A set of recommendations has been provided for the government to act.

Pharmaceutical disposal facilitates the mobilization of resistance determinants among microbiota of polluted environment

The emergence of resistance on exposure to pharmaceuticals among microorganisms has raised serious concern in the therapeutic approach against infectious diseases. Effluents discharge from hospitals, industries, and urban settlements containing pharmaceuticals and other toxic compounds into the aquatic ecosystem selects bacterial population against them; thereby promotes acquisition and dissemination of resistant traits among the inhabitant microbiota. The present study was aimed to determine the prevalence and multidrug resistance pattern of Extended Spectrum β-lactamase (ESBL) producing and non-producing bacterial isolates from the heavily polluted Delhi stretch of river Yamuna, India. Additionally, the role of abiotic factors in the dissemination of conjugative plasmids harbouring resistance genes was also studied using E. coli J53 as recipient and resistant E. coli isolates as donor strains. Of the 227 non-duplicate bacterial isolates, 60% (136) were identified as ESBL⁺ and 40% (91) as ESBL. ESBL⁺ isolates were found highly resistant to β-lactam and non-β-lactam classes of antibiotics compared with the ESBL^- isolates. 68% of ESBL⁺ and 24% of ESBL^- isolates showed an MAR index of ≥0.5. Surprisingly, multidrug resistance (MDR), extensively drug resistance (XDR), and pandrug resistance (PDR) phenotype were observed for 78.6%, 16.9%, and 0.7% of ESBL⁺ and 90%, 3%, and none for PDR among ESBL^- isolates. Conjugation under different conditions showed a higher mobilization rate at neutral pH (7-7.5) for ESBL⁺ isolates. Conjugation frequency was maximum at 40 °C for the isolate E. coli MRB6 (4.1 × 10^-5) and E. coli MRE32 (4.89 × 10^-4) and at 35 °C for E. coli MRA11 (4.89 × 10^-5). The transconjugants obtained were found tolerating different concentrations of mercuric chloride (0.0002-0.2 mg/L). Increased biofilm formation for ESBL⁺ isolates was observed on supplementing media with HgCl₂ (2 μg/mL) either singly or in combination with CTX (10 μg/mL). The present study demonstrates that anthropogenically influenced aquatic environments act as a reservoir of MDR, XDR, and even PDR strains; thereby posing a potent public health risk.