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Poomchaichote T, Kiatying-Angsulee N, Boonthaworn K, Naemiratch B, Ruangkajorn S, Prapharsavat R, Thirapantu C, Sukrung K, Limmathurotsakul D, Osterrieder A, Cheah PY. Embedding community and public voices in co-created solutions to mitigate antimicrobial resistance (AMR) in Thailand using the 'Responsive Dialogues' public engagement framework. Antimicrob Resist Infect Control 2024; 13:71. [PMID: 38965593 PMCID: PMC11225371 DOI: 10.1186/s13756-024-01416-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 05/29/2024] [Indexed: 07/06/2024] Open
Abstract
The use of antimicrobials in Thailand has been reported as one of the highest in the world in human and animal sectors. Our engagement project aimed to improve our understanding of the issue of antimicrobial use and antimicrobial resistance (AMR) among adult Thai communities, and co-create locally relevant solutions to AMR, especially those focusing on raising awareness to improve related policies in Thailand.We conducted a series of online and in-person 'conversations' according to Wellcome's 'Responsive Dialogues' engagement approach, designed to bring together different voices to understand complex AMR problems and find potential solutions. This approach enabled key AMR stakeholders and policy makers to hear directly from communities and members of the public, and vice versa. Conversations events took place between 25 November 2020 and 8 July 2022, and we engaged 179 AMR key stakeholders and members of the public across Thailand.The issues found were: there were quite a lot of misunderstandings around antimicrobials and AMR; participants felt that communications and engagement around antimicrobial resistance had limited reach and impact; asking for and taking antibiotics for self-limiting ailments is a social norm in Thailand; and there appeared to be a wide availability of cheap antimicrobials. To mitigate the spread of AMR, participants suggested that the messages around AMR should be tailored to the target audience, there should be more initiatives to increase general health literacy, there should be increased availability of AMR related information at the local level and there should be increased local leadership of AMR mitigation efforts.Trial registration Thaiclinicaltrials.org registration: TCTR20210528003 (28/05/2021).
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Affiliation(s)
- Tassawan Poomchaichote
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Niyada Kiatying-Angsulee
- Drug System Monitoring and Development Centre, Social Research Institute, Chulalongkorn University, Bangkok, Thailand
| | - Kanpong Boonthaworn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Bhensri Naemiratch
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Supanat Ruangkajorn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ravikanya Prapharsavat
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Direk Limmathurotsakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Anne Osterrieder
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Phaik Yeong Cheah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Gerede A, Nikolettos K, Vavoulidis E, Margioula-Siarkou C, Petousis S, Giourga M, Fotinopoulos P, Salagianni M, Stavros S, Dinas K, Nikolettos N, Domali E. Vaginal Microbiome and Pregnancy Complications: A Review. J Clin Med 2024; 13:3875. [PMID: 38999442 DOI: 10.3390/jcm13133875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/12/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: There are indications that the microbial composition of the maternal mucosal surfaces is associated with adverse events during pregnancy. The aim of this review is to investigate the link between vaginal microbiome alterations and gestational complication risk. Methods: This comprehensive literature review was performed using Medline and Scopus databases. The following search algorithm was used, "Pregnancy Complications" [Mesh] AND (Vagin*), and after the literature screening, 44 studies were included in the final review. Results: The studies that were included investigated the association between vaginal microbial composition and preterm birth, miscarriage, preeclampsia, ectopic pregnancy, gestational diabetes mellitus, chorioamnionitis, and preterm premature rupture of membranes. In most of the studies, it was well established that increased microbial diversity is associated with these conditions. Also, the depletion of Lactobacillus species is linked to most of the gestational complications, while the increased relative abundance and especially Lactobacillus crispatus may exert a protective effect in favor of the pregnant woman. Several pathogenic taxa including Gardnerella, Prevotella, Sneathia, Bacterial Vaginosis-Associated Bacteria-2, Atopobium, and Megasphera seem to be correlated to higher maternal morbidity. Conclusions: Vaginal microbiome aberrations seem to have an association with pregnancy-related adverse events, but more high-quality homogenous studies are necessary to reliably verify this link.
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Affiliation(s)
- Angeliki Gerede
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Konstantinos Nikolettos
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Eleftherios Vavoulidis
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Chrysoula Margioula-Siarkou
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Stamatios Petousis
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Maria Giourga
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Panagiotis Fotinopoulos
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Maria Salagianni
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Sofoklis Stavros
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
| | - Konstantinos Dinas
- Second Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54640 Thessaloniki, Greece
| | - Nikolaos Nikolettos
- Unit of Maternal-Fetal-Medicine, Department of Obstetrics and Gynecology, Medical School, Democritus University of Thrake, GR-68100 Alexandroupolis, Greece
| | - Ekaterini Domali
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, GR-11528 Athens, Greece
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Dayapera LZA, Sy JCY, Valenzuela S, Eala SJL, Del Rosario CMIP, Buensuceso KNC, Dy AS, Morales DA, Gibson AG, Apostol GLC. One health in the Philippines: A review and situational analysis. One Health 2024; 18:100758. [PMID: 38846705 PMCID: PMC11153869 DOI: 10.1016/j.onehlt.2024.100758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/14/2024] [Indexed: 06/09/2024] Open
Abstract
The Philippines faces a complex and interconnected web of human, animal, and environmental health issues, including zoonotic and reverse zoonotic diseases, antimicrobial resistance, food insecurity and contamination, and threats from environmental degradation. This paper examines these issues, existing interventions, and their implementation challenges. The overall framework used to analyze the level of operationalization of the One Health approach is the Multi-sectoral One Health Coordination Framework developed by the World Health Organization, Food and Agriculture Organization, and the World Organization for Animal Health. A two-step process was conducted: literature review, followed by consultations with government and non-government stakeholders across national, subnational, and local levels. There has been significant progress in laying the foundation for collaboration between the human, animal, and environmental sectors. These are demonstrated by the presence of structures and systems, including inter-agency task forces, emergency response plans and mechanisms, and a network for health human resources. However, these are eclipsed by challenges, including the limited governance mechanisms within inter-agency committees, fragmented risk assessment and surveillance, untapped opportunities for joint investigation and response, insufficient resources for capacity-building, and absence of comprehensive risk communication and community engagement initiatives. These challenges highlight the importance of promoting multi-sectoral governance and ensuring resource allocation and sharing. Joint activities across risk assessment, surveillance, investigation, and response are critical in ensuring a proactive and holistic approach to addressing threats. A well-capacitated interdisciplinary workforce, not only capable of managing these hazards but also empowering communities to protect themselves, is necessary in ensuring innovation and collaboration on health risks at the human-animal-environment interface. In light of the multifaceted challenges faced by the Philippines, the One Health approach emerges as a vital strategy. By addressing governance issues, enhancing coordination, and bolstering resource allocation, the country can better protect the health and well-being of its people, animals, and ecosystems.
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Affiliation(s)
- Lystra Zyrill A. Dayapera
- SciLore LLC, Unit 10 Paz Madrigal Plaza, Madrigal Business Park, Ayala Alabang, Muntinlupa 1781, Metro Manila, Philippines
| | - Jenica Clarisse Y. Sy
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
- Department of Biology, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Metro Manila, Philippines
| | - Sary Valenzuela
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
| | - Samantha Julia L. Eala
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
| | - Ciara Maria Ines P. Del Rosario
- Department of Biology, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Metro Manila, Philippines
| | - Karen Nicole C. Buensuceso
- Department of Biology, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Metro Manila, Philippines
| | - Adrian S. Dy
- Department of Biology, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Metro Manila, Philippines
| | - Danielle A. Morales
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
| | - Anna Giselle Gibson
- SciLore LLC, Unit 10 Paz Madrigal Plaza, Madrigal Business Park, Ayala Alabang, Muntinlupa 1781, Metro Manila, Philippines
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
| | - Geminn Louis C. Apostol
- Ateneo de Manila University School of Medicine and Public Health, Don Eugenio Lopez Sr. Medical Complex, Ortigas Ave, Pasig, Metro Manila 1604, Indonesia
- Murdoch University, 90 South St, Murdoch, WA 6150, Australia
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Mathew P, Chandy SJ, Ranjalkar J. Community engagement to mitigate antimicrobial resistance in low-and middle-income countries - an essential strategy for implementation of national action plans on AMR. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 24:100379. [PMID: 38510334 PMCID: PMC10951515 DOI: 10.1016/j.lansea.2024.100379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Affiliation(s)
| | - Sujith J. Chandy
- ReAct Asia Pacific, India
- Department of Pharmacology and Clinical Pharmacology, Chrisitan Medical College, Vellore, Tamil Nadu, India
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Parajuli A, Mitchell J, King N, Arjyal A, Latham S, King R, Baral S. Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review. Front Public Health 2024; 12:1384779. [PMID: 38706550 PMCID: PMC11066241 DOI: 10.3389/fpubh.2024.1384779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/01/2024] [Indexed: 05/07/2024] Open
Abstract
Background A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal. Methods This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes. Results A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community. Conclusion Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors. Systematic review registration DOI: 10.17605/OSF.IO/FV326.
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Affiliation(s)
| | - Jessica Mitchell
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Natalie King
- Academic Unit of Health Economics, University of Leeds, Leeds, United Kingdom
| | | | - Sophia Latham
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Rebecca King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
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Thomas SA, Mathew P, Ranjalkar J, Nguyen TBV, Giao VTQ, Chandy SJ. Public perception and community-level impact of national action plans on antimicrobial resistance in Vietnam. JAC Antimicrob Resist 2024; 6:dlad146. [PMID: 38161968 PMCID: PMC10753920 DOI: 10.1093/jacamr/dlad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives Vietnam was the first country from the WHO Western Pacific Region to adopt a national action plan (NAP) on antimicrobial resistance (AMR) in 2013. The multilayered nature of AMR requires coordination across 'One Health' sectors, dedicated financing, multistakeholder involvement, and widespread community engagement to implement the action plans. This study explores the perceived impact of NAP implementation at the community level. Methods Key informant interviews (KIIs) were used for data collection during 2021. An interview tool was used for the KIIs and purposive sampling was used to identify study participants from Vietnam. The study participants were those engaged with a substantial scale of antimicrobial usage, diagnosis of infections or concerned with antimicrobial content in effluents in their professional life. Twelve KIIs were conducted with participants from human health, animal health and the environmental sector. The data were entered into Microsoft Excel, and manifest and latent content analysis was done. Results The analysis highlighted themes such as limited public awareness of AMR, ongoing capacity building and quality assurance initiatives, implementation of guidelines and regulations for AMR containment, sustained investment in improving infrastructure, and challenges relating to accountability whilst prescribing and selling antibiotics. Conclusions There were many positive critical developments during the NAP implementation period in Vietnam towards AMR mitigation. For better impact, there is a need to revitalize the implementation machinery of NAPs by improving the enforcement capacity of regulations, cross-sectoral collaboration and promoting community ownership.
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Affiliation(s)
| | - Philip Mathew
- ReAct Asia Pacific, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jaya Ranjalkar
- ReAct Asia Pacific, Christian Medical College, Vellore, Tamil Nadu, India
| | | | | | - Sujith J Chandy
- Department of Pharmacology & Clinical Pharmacology, Christian Medical College, Vellore, Tamil Nadu, India
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Mathew P, Chandy SJ, Sivaraman S, Ranjalkar J, Ali HM, Thomas SA. Formulating a Community-Centric Indicator Framework to Quantify One Health Drivers of Antibiotic Resistance: A Preliminary Step towards Fostering 'Antibiotic-Smart Communities'. Antibiotics (Basel) 2024; 13:63. [PMID: 38247622 PMCID: PMC10812418 DOI: 10.3390/antibiotics13010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Antibiotic resistance (ABR) is increasing the mortality and morbidity associated with infectious diseases, besides increasing the cost of healthcare, saturating health system capacity, and adversely affecting food security. Framing an appropriate narrative and engaging local communities through the 'One Health' approach is essential to complement top-down measures. However, the absence of objective criteria to measure the performance of ABR interventions in community settings makes it difficult to mobilize interest and investment for such interventions. An exercise was therefore carried out to develop an indicator framework for this purpose. A comprehensive list of indicators was developed from experiences gathered through community engagement work in a local panchayat (small administrative area) in Kerala, India and a consultative process with health, veterinary, environment, and development experts. A prioritization exercise was carried out by global experts on ABR, looking at appropriateness, feasibility, and validity. A 15-point indicator framework was designed based on the prioritization process. The final set of indicators covers human health, animal health, environment management, and Water Sanitation and Hygiene (WASH) domains. The indicator framework was piloted in the panchayat (located in Kerala), which attained a score of 34 (maximum 45). The score increased when interventions were implemented to mitigate the ABR drives, indicating that the framework is sensitive to change. The indicator framework was tested in four sites from three other Indian states with different socioeconomic and health profiles, yielding different scores. Those collecting the field data were able to use the framework with minimal training. It is hoped that, this indicator framework can help policymakers broadly understand the factors contributing to ABR and measure the performance of interventions they choose to implement in the community as part of National Action Plan on AMR.
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Affiliation(s)
- Philip Mathew
- ReAct Asia Pacific, Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India; (P.M.); (S.S.); (H.M.A.); (S.A.T.)
| | - Sujith J. Chandy
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India;
| | - Satya Sivaraman
- ReAct Asia Pacific, Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India; (P.M.); (S.S.); (H.M.A.); (S.A.T.)
| | - Jaya Ranjalkar
- ReAct Asia Pacific, Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India; (P.M.); (S.S.); (H.M.A.); (S.A.T.)
| | - Hyfa Mohammed Ali
- ReAct Asia Pacific, Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India; (P.M.); (S.S.); (H.M.A.); (S.A.T.)
| | - Shruthi Anna Thomas
- ReAct Asia Pacific, Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore 632002, Tamil Nadu, India; (P.M.); (S.S.); (H.M.A.); (S.A.T.)
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Moriel DG, Piccioli D, Raso MM, Pizza M. The overlooked bacterial pandemic. Semin Immunopathol 2024; 45:481-491. [PMID: 38078911 PMCID: PMC11136754 DOI: 10.1007/s00281-023-00997-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/28/2023] [Indexed: 05/30/2024]
Abstract
The COVID-19 pandemic had a significant economic and health impact worldwide. It also reinforced the misperception that only viruses can pose a threat to human existence, overlooking that bacteria (e.g., plague and cholera) have severely haunted and shaped the course of human civilization. While the world is preparing for the next viral pandemic, it is again overlooking a silent one: antimicrobial resistance (AMR). This review proposes to show the impact of bacterial infections on civilization to remind the pandemic potential. The work will also discuss a few examples of how bacteria can mutate risking global spread and devastating outcomes, the effect on the global burden, and the prophylactic and therapeutic measures. Indeed, AMR is dramatically increasing and if the trend is not reversed, it has the potential to quickly turn into the most important health problem worldwide.
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Affiliation(s)
- Danilo Gomes Moriel
- GSK Vaccines Institute for Global Health, Via Fiorentina 1, 53100, Siena, Italy
| | - Diego Piccioli
- GSK Vaccines Institute for Global Health, Via Fiorentina 1, 53100, Siena, Italy
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Mitchell J, Hawkings H, Latham S, Fieroze F, Arjyal A, Barrington DJ, Baral S, Saify MB, Cooke P, Hamade P, Huque R, Parajuli A, Siddiki AZ, King R. Addressing antimicrobial resistance through community engagement: a framework for developing contextually relevant and impactful behaviour change interventions. JAC Antimicrob Resist 2023; 5:dlad124. [PMID: 38021035 PMCID: PMC10673675 DOI: 10.1093/jacamr/dlad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background Community engagement (CE) interventions often explore and promote behaviour change around a specific challenge. Suggestions for behaviour change should be co-produced in partnership with the community. To facilitate this, it is essential that the intervention includes key content that unpacks the challenge of interest via multiple sources of knowledge. However, where community lived experience and academic evidence appear misaligned, tensions can appear within the co-production dynamic of CE. This is specifically so within the context of antimicrobial resistance (AMR) where ideal behaviours are often superseded by what is practical or possible in a particular community context. Methods Here we describe a framework for the equitable development of contextually appropriate, clearly evidenced behavioural objectives for CE interventions. This framework explores different sources of knowledge on AMR, including the potentially competing views of different stakeholders. Findings The framework allows key content on AMR to be selected based upon academic evidence, contextual appropriateness and fit to the chosen CE approach. A case study of the framework in action exemplifies how the framework is applicable to a range of contexts, CE approaches and One Health topics beyond just AMR. Conclusions Within CE interventions, academic evidence is crucial to develop well-informed key content. However, this formative work should also involve community members, ensuring that their contextual knowledge is valued. The type of CE approach also needs careful consideration because methodological constraints may limit the breadth and depth of information that can be delivered within an intervention, and thus the scope of key content.
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Affiliation(s)
- Jessica Mitchell
- Nuffield Centre for International Health and Development, Leeds Institute for Health Sciences, Faculty of Medicine and Health, University of Leeds, Woodhouse, Leeds LS2 9JT, UK
| | - Helen Hawkings
- Malaria Consortium, The Green House 244-254 Cambridge Heath Rd, London EC2 9DA, UK
| | - Sophia Latham
- Department of Livestock and One Health, Institute of Veterinary and Ecological Sciences, University of Liverpool, Leahurst Campus, Chester High Road, Neston CH64 7TE, UK
| | - Fariza Fieroze
- ARK Foundation, Suite C3 & C4, House 06, Road 109, Gulshan-2, Dhaka 1212, Bangladesh
| | | | - Dani Jennifer Barrington
- School of Population and Global Health, The University of Western Australia, 35 Stirling Highway, Crawley 6009, Western Australia
| | | | - Md Badruddin Saify
- ARK Foundation, Suite C3 & C4, House 06, Road 109, Gulshan-2, Dhaka 1212, Bangladesh
| | - Paul Cooke
- Faculty of Arts and Humanities, Centre for World Cinemas and Digital Cultures, University of Leeds, Woodhouse, Leeds LS2 9JT, UK
| | - Prudence Hamade
- Malaria Consortium, The Green House 244-254 Cambridge Heath Rd, London EC2 9DA, UK
| | - Rumana Huque
- ARK Foundation, Suite C3 & C4, House 06, Road 109, Gulshan-2, Dhaka 1212, Bangladesh
| | | | - Amam Zonaed Siddiki
- Faculty of Veterinary Medicine, Chattogram Veterinary and Animal Sciences University, Chattogram 4225, Bangladesh
| | - Rebecca King
- Nuffield Centre for International Health and Development, Leeds Institute for Health Sciences, Faculty of Medicine and Health, University of Leeds, Woodhouse, Leeds LS2 9JT, UK
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Rickard H, Watkin S, Baldwin N, De Souza A, Ciric L, Cloutman-Green E. Antimicrobial resistance as a super wicked problem: how do we engage the public to be part of the solution. Infect Prev Pract 2023; 5:100314. [PMID: 38107239 PMCID: PMC10724478 DOI: 10.1016/j.infpip.2023.100314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/13/2023] [Indexed: 12/19/2023] Open
Abstract
Antimicrobial resistance (AMR) is now regarded as one of the greatest global challenges of the 21st century. The complexity, urgent timeframe, and lack of clear solution to AMR have contributed to its classification as a 'super wicked problem'. Yet knowledge surveys of the general public have found that they still harbour numerous misconceptions linked to both the sources and impact of AMR. This confusion is compounded by AMR being a One Health issue, and therefore a factor in not just human health but in other industries, such as farming. This can further inhibit understanding and knowledge transfer around AMR for those without a prior knowledge base. In order to address the escalating risk that AMR presents, however, it is essential to address this knowledge gap and engage with the public to support wide scale changes in behaviour and consumer choice. The WHO now requires national action plans tackling AMR to include patient and public involvement/engagement (PPI/E) to support changing the trajectory of AMR. Despite this, little detail is available as part of strategic plans on how PPI/E should be undertaken in order to aid implementation. This paper discusses a number of approaches to support the design and delivery of PPI/E in relation to AMR, including the different social behaviour models underlying successful PPI/E strategies, and key considerations linked to specific activity types. The framework produced includes features for steps from initial planning and design through to evaluation. The aim is to help improve the ability of scientists and healthcare professionals to produce high quality AMR PPI/E.
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Affiliation(s)
- Helen Rickard
- Healthy Infrastructure Research Group, University College London, Department of Civil Environmental and Geomatic Engineering, Chadwick Building, London, UK
| | - Sam Watkin
- Healthy Infrastructure Research Group, University College London, Department of Civil Environmental and Geomatic Engineering, Chadwick Building, London, UK
- Nosocomial Project, London, UK
| | | | - Anthony De Souza
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
| | - Lena Ciric
- Healthy Infrastructure Research Group, University College London, Department of Civil Environmental and Geomatic Engineering, Chadwick Building, London, UK
| | - Elaine Cloutman-Green
- Healthy Infrastructure Research Group, University College London, Department of Civil Environmental and Geomatic Engineering, Chadwick Building, London, UK
- Nosocomial Project, London, UK
- Great Ormond Street Hospital NHS Foundation Trust, Camelia Botnar Laboratories, Department of Microbiology, London, UK
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11
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Kolokithas A, Merkel B, Hunnicutt D, Fenzl L, Petersen M. Community involvement in addressing the antibiotic crisis. JOURNAL OF MICROBIOLOGY & BIOLOGY EDUCATION 2023; 24:e00136-23. [PMID: 38108001 PMCID: PMC10720476 DOI: 10.1128/jmbe.00136-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
Increasing student interest and success in STEM education is a top priority for many postsecondary educational institutions. One well-documented approach to both priorities is to have students participate in a Course Undergraduate Research Experience (CURE). Faculty from several technical colleges and universities in Wisconsin teamed up with the Tiny Earth organization to offer a CURE to address the search for new antibiotics. Students enrolled in undergraduate microbiology courses engaged in research and participated in community outreach. To involve the community, faculty from various institutions joined an NFL team, the Green Bay Packers, and created the Tiny Earth in Titletown symposium. Here, students presented their work via scientific posters, to community and industry members, and networked with other scientists from around the region. The Tiny Earth in Titletown symposium started in 2018, was held again in 2019, and returned in 2022 following a 2-year hiatus due to the COVID-19 pandemic. Record attendance in 2022 suggests that community outreach and education may be helping restore trust in science that was lost during the pandemic.
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Affiliation(s)
| | - Brian Merkel
- University of Wisconsin, Green Bay, Green Bay, Wisconsin, USA
| | | | - Lucy Fenzl
- College of Menominee Nation, Keshena, Wisconsin, USA
| | - Matthew Petersen
- Northeast Wisconsin Technical College, Green Bay, Wisconsin, USA
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12
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Waswa JP, Kiggundu R, Joshi MP, Mpagi J, Kasujja H, Murungi M, Kajumbula H, Were E, Schwarz D, Lwere K, Konduri N. Addressing gaps in AMR awareness in the public: an evidence-based policy brief to guide school curriculum review in Uganda. Front Public Health 2023; 11:1287523. [PMID: 38074735 PMCID: PMC10707988 DOI: 10.3389/fpubh.2023.1287523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
The government of Uganda, through its Ministry of Health, previously adopted curriculum review as a mechanism to respond to public health threats such as HIV/AIDS and include content in primary and secondary schools. This approach contributes to raising public awareness, a key strategy recommended by the World Health Organization to support the global response to the threat of antimicrobial resistance (AMR). This policy brief, developed for policymakers related to school curricula, aims to advocate for and support integration of AMR content in Uganda's primary and secondary level school curricula. The policy brief supports efforts by the multisectoral National AMR Subcommittee to create awareness on this issue as part of its role in facilitating the operationalization of Uganda's National Action Plan on AMR.
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Affiliation(s)
- JP Waswa
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Kampala, Uganda
| | - Reuben Kiggundu
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Kampala, Uganda
| | - Mohan P. Joshi
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Arlington, VA, United States
| | - Joseph Mpagi
- Faculty of Health Sciences, Busitema University, Mbale, Uganda
| | - Hassan Kasujja
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Kampala, Uganda
| | - Marion Murungi
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Kampala, Uganda
| | - Henry Kajumbula
- Department of Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Were
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Arlington, VA, United States
| | - Dan Schwarz
- Global Health Systems Innovation, Management Sciences for Health, Medford, MA, United States
| | - Kamada Lwere
- Faculty of Health Sciences, Soroti University, Soroti, Uganda
- Faculty of Health Sciences, Islamic University in Uganda, Mbale, Uganda
| | - Niranjan Konduri
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Arlington, VA, United States
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13
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Musoke D, Lubega GB, Gbadesire MS, Boateng S, Twesigye B, Gheer J, Nakachwa B, Brown MO, Brandish C, Winter J, Ng BY, Russell-Hobbs K, Gibson L. Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study. J Pharm Policy Pract 2023; 16:147. [PMID: 37978569 PMCID: PMC10655315 DOI: 10.1186/s40545-023-00659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda. METHODS This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis. RESULTS Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS. CONCLUSION There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Grace Biyinzika Lubega
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Mimi Salome Gbadesire
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Stephanie Boateng
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Belinda Twesigye
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Jagdeep Gheer
- Medicines Optimisation Team, Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Trust Offices, Amersham Hospital, Amersham, HP7 0JD, UK
| | - Betty Nakachwa
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Michael Obeng Brown
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Claire Brandish
- Pharmacy Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, HP21 8AL, UK
| | - Jody Winter
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, UK
| | - Bee Yean Ng
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Kate Russell-Hobbs
- Pharmacy Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, HP21 8AL, UK
| | - Linda Gibson
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
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14
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Dhungel B, Thapa Shrestha U, Adhikari S, Adhikari N, Bhattarai A, Pokharel S, Karkey A, Limmathurotsakul D, Ghimire P, Rijal KR, Cheah PY, Pell C, Adhikari B. Use of antimicrobials during the COVID-19 pandemic: A qualitative study among stakeholders in Nepal. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002166. [PMID: 37963156 PMCID: PMC10645294 DOI: 10.1371/journal.pgph.0002166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/05/2023] [Indexed: 11/16/2023]
Abstract
The COVID-19 pandemic was a major public health threat and the pressure to find curative therapies was tremendous. Particularly in the early critical phase of the pandemic, a lot of empirical treatments, including antimicrobials, were recommended. Drawing on interviews with patients, clinicians and drug dispensers, this article explores the use of antimicrobials for the management of COVID-19 in Nepal. A total of 30 stakeholders (10 clinicians, 10 dispensers and 10 COVID-19 patients) were identified purposively and were approached for an interview. Clinicians and dispensers in three tertiary hospitals in Kathmandu assisted in the recruitment of COVID-19 patients who were undergoing follow-up at an out-patient department. Interviews were audio recorded, translated and transcribed into English, and were analyzed thematically. The respondents report that over-the-counter (OTC) use of antibiotics was widespread during the COVID-19 pandemic in Nepal. This was mostly rooted in patients' attempts to mitigate the potential severity of respiratory illnesses, and the fear of the stigmatization and social isolation linked to being identified as a COVID-19 patient. Patients who visited drug shops and physicians reportedly requested specific medicines including antibiotics. Clinicians reported uncertainty when treating COVID-19 cases that added pressure to prescribe antimicrobials. Respondents from all stakeholder groups recognized the dangers of excessive use of antimicrobials, with some referring to the development of resistance. The COVID-19 pandemic added pressure to prescribe, dispense and overuse antimicrobials, accentuating the pre-existing OTC use of antimicrobials. Infectious disease outbreaks and epidemics warrant special caution regarding the use of antimicrobials and specific policy response.
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Affiliation(s)
- Binod Dhungel
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
| | | | - Sanjib Adhikari
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
| | - Nabaraj Adhikari
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
| | - Alisha Bhattarai
- Manmohan Cardiothoracic Vascular and Transplant Center, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Sunil Pokharel
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Abhilasha Karkey
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Direk Limmathurotsakul
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medical Research Unit, Faculty of tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Prakash Ghimire
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
| | - Komal Raj Rijal
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal
| | - Phaik Yeong Cheah
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medical Research Unit, Faculty of tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Christopher Pell
- Amsterdam Institute for Social Science Research, University of Amsterdam, Amsterdam, The Netherlands
| | - Bipin Adhikari
- Center for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medical Research Unit, Faculty of tropical Medicine, Mahidol University, Bangkok, Thailand
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15
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Fuller W, Kapona O, Aboderin AO, Adeyemo AT, Olatunbosun OI, Gahimbare L, Ahmed YA. Education and Awareness on Antimicrobial Resistance in the WHO African Region: A Systematic Review. Antibiotics (Basel) 2023; 12:1613. [PMID: 37998815 PMCID: PMC10669252 DOI: 10.3390/antibiotics12111613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/07/2023] [Accepted: 10/11/2023] [Indexed: 11/25/2023] Open
Abstract
This review documents the status of AMR education and awareness in the WHO African region, as well as specific initiatives by its member states in implementing education and awareness interventions, as a strategic objective of the Global Action Plan on AMR, i.e., improve knowledge and understanding on AMR through effective communication, education, and training. A systematic search was conducted in Google Scholar, PubMed, and African Journals Online Library according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, for articles published in English. Retrieval and screening of articles was performed using a structured search protocol following a pre-set inclusion/exclusion criterion. Eighty-five published articles reporting 92 different studies from 19 Member States met inclusion criteria and were included in the final qualitative synthesis. Nigeria (21) and Ethiopia (16) had most of the studies, while the rest were distributed across the remaining 17 Member States. The majority of the articles were on knowledge, attitude, and practices with regard to AMR and antimicrobial use and most of them documented a general lack and suboptimal knowledge, poor attitude and practices, and widespread self-medication. This review shows low levels of knowledge of AMR coupled with extensive misuse of antimicrobial medicines by different target audiences. These findings underscore the urgent need for enhanced and context-specific educational and positive behavioural change interventions.
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Affiliation(s)
- Walter Fuller
- World Health Organization Regional Office for Africa, Brazzaville P.O. Box 06, Congo; (L.G.); (Y.A.A.)
| | - Otridah Kapona
- Zambia National Public Health Institute, Lusaka 10101, Zambia;
| | - Aaron Oladipo Aboderin
- Department of Medical Microbiology & Parasitology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife 220005, Nigeria; (A.O.A.); (A.T.A.); (O.I.O.)
| | - Adeyemi Temitayo Adeyemo
- Department of Medical Microbiology & Parasitology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife 220005, Nigeria; (A.O.A.); (A.T.A.); (O.I.O.)
| | - Oluwadamilare Isaiah Olatunbosun
- Department of Medical Microbiology & Parasitology, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife 220005, Nigeria; (A.O.A.); (A.T.A.); (O.I.O.)
| | - Laetitia Gahimbare
- World Health Organization Regional Office for Africa, Brazzaville P.O. Box 06, Congo; (L.G.); (Y.A.A.)
| | - Yahaya Ali Ahmed
- World Health Organization Regional Office for Africa, Brazzaville P.O. Box 06, Congo; (L.G.); (Y.A.A.)
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16
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Truppa C, Alonso B, Clezy K, Deglise C, Dromer C, Garelli S, Jimenez C, Kanapathipillai R, Khalife M, Repetto E. Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now. Antimicrob Resist Infect Control 2023; 12:89. [PMID: 37667372 PMCID: PMC10476422 DOI: 10.1186/s13756-023-01301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 08/30/2023] [Indexed: 09/06/2023] Open
Abstract
Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.
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Affiliation(s)
- Claudia Truppa
- International Committee of the Red Cross, Geneva, Switzerland.
- CRIMEDIM Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, University of Eastern Piedmont, Novara, Italy.
| | | | - Kate Clezy
- Médecins Sans Frontières, Amsterdam, The Netherlands
| | | | - Carole Dromer
- International Committee of the Red Cross, Geneva, Switzerland
| | - Silvia Garelli
- International Committee of the Red Cross, Geneva, Switzerland
| | | | | | | | - Ernestina Repetto
- Médecins Sans Frontières, Geneva, Switzerland
- Service des Maladies Infectieuses, Clinique Hospitalière Universitaire Saint Pierre, Bruxelles, Belgium
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17
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Salam MA, Al-Amin MY, Salam MT, Pawar JS, Akhter N, Rabaan AA, Alqumber MAA. Antimicrobial Resistance: A Growing Serious Threat for Global Public Health. Healthcare (Basel) 2023; 11:1946. [PMID: 37444780 DOI: 10.3390/healthcare11131946] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
Antibiotics are among the most important discoveries of the 20th century, having saved millions of lives from infectious diseases. Microbes have developed acquired antimicrobial resistance (AMR) to many drugs due to high selection pressure from increasing use and misuse of antibiotics over the years. The transmission and acquisition of AMR occur primarily via a human-human interface both within and outside of healthcare facilities. A huge number of interdependent factors related to healthcare and agriculture govern the development of AMR through various drug-resistance mechanisms. The emergence and spread of AMR from the unrestricted use of antimicrobials in livestock feed has been a major contributing factor. The prevalence of antimicrobial-resistant bacteria has attained an incongruous level worldwide and threatens global public health as a silent pandemic, necessitating urgent intervention. Therapeutic options of infections caused by antimicrobial-resistant bacteria are limited, resulting in significant morbidity and mortality with high financial impact. The paucity in discovery and supply of new novel antimicrobials to treat life-threatening infections by resistant pathogens stands in sharp contrast to demand. Immediate interventions to contain AMR include surveillance and monitoring, minimizing over-the-counter antibiotics and antibiotics in food animals, access to quality and affordable medicines, vaccines and diagnostics, and enforcement of legislation. An orchestrated collaborative action within and between multiple national and international organizations is required urgently, otherwise, a postantibiotic era can be a more real possibility than an apocalyptic fantasy for the 21st century. This narrative review highlights on this basis, mechanisms and factors in microbial resistance, and key strategies to combat antimicrobial resistance.
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Affiliation(s)
- Md Abdus Salam
- Department of Basic Medical Sciences, Kulliyyah of Medicine, International Islamic University Malaysia, Kuantan 25200, Malaysia
| | - Md Yusuf Al-Amin
- Purdue University Interdisciplinary Life Sciences Graduate Program, Purdue University, West Lafayette, IN 47907, USA
- Department of Chemistry, Purdue University, West Lafayette, IN 47907, USA
| | | | - Jogendra Singh Pawar
- Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN 47907, USA
- The Ohio State University Comprehensive Cancer Center, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH 43210, USA
| | - Naseem Akhter
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA
| | - Ali A Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Mohammed A A Alqumber
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Albaha University, Al Baha 65431, Saudi Arabia
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18
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Tull F, Bamert RS, Smith L, Goodwin D, Lambert K. Identifying and Prioritising Behaviours to Slow Antimicrobial Resistance. Antibiotics (Basel) 2023; 12:949. [PMID: 37370268 DOI: 10.3390/antibiotics12060949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/29/2023] Open
Abstract
As a nation with relatively low levels of AMR, due to both community and agricultural stewardship, as well as geographical isolation, Australia is somewhat unique. As this advantage is being eroded, this project aimed to investigate the spectrum of human behaviours that could be modified in order to slow the spread of AMR, building upon the argument that doable actions are the best-targeted and least complex to change. We conducted a workshop with a panel of diverse interdisciplinary AMR experts (from sociology, microbiology, agriculture, veterinary medicine, health and government) and identified twelve behaviours that, if undertaken by the public, would slow the spread of AMR. These were then assessed by a representative sample of the public (285 Australians) for current participation, likelihood of future participation (likelihood) and perceived benefits that could occur if undertaken (perceived impact). An impact-likelihood matrix was used to identify four priority behaviours: do not pressure your doctor for antibiotics; contact council to find out where you can safely dispose of cleaning products with antimicrobial marketing; lobby supermarkets to only sell antibiotic free meat products; and return unused antibiotics to a pharmacy. Among a multitude of behavioural options, this study also highlights the importance of tailoring doable actions to local conditions, increasing community education, and emphasizing the lack of a one-size fits all approach to tackling this global threat.
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Affiliation(s)
- Fraser Tull
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne 3170, Australia
| | - Rebecca S Bamert
- Centre to Impact AMR, Monash University, Melbourne 3170, Australia
| | - Liam Smith
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne 3170, Australia
| | - Denise Goodwin
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne 3170, Australia
| | - Karen Lambert
- Faculty of Education, Monash University, Melbourne 3170, Australia
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19
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Coque TM, Cantón R, Pérez-Cobas AE, Fernández-de-Bobadilla MD, Baquero F. Antimicrobial Resistance in the Global Health Network: Known Unknowns and Challenges for Efficient Responses in the 21st Century. Microorganisms 2023; 11:1050. [PMID: 37110473 PMCID: PMC10144039 DOI: 10.3390/microorganisms11041050] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
Antimicrobial resistance (AMR) is one of the Global Health challenges of the 21st century. The inclusion of AMR on the global map parallels the scientific, technological, and organizational progress of the healthcare system and the socioeconomic changes of the last 100 years. Available knowledge about AMR has mostly come from large healthcare institutions in high-income countries and is scattered in studies across various fields, focused on patient safety (infectious diseases), transmission pathways and pathogen reservoirs (molecular epidemiology), the extent of the problem at a population level (public health), their management and cost (health economics), cultural issues (community psychology), and events associated with historical periods (history of science). However, there is little dialogue between the aspects that facilitate the development, spread, and evolution of AMR and various stakeholders (patients, clinicians, public health professionals, scientists, economic sectors, and funding agencies). This study consists of four complementary sections. The first reviews the socioeconomic factors that have contributed to building the current Global Healthcare system, the scientific framework in which AMR has traditionally been approached in such a system, and the novel scientific and organizational challenges of approaching AMR in the fourth globalization scenario. The second discusses the need to reframe AMR in the current public health and global health contexts. Given that the implementation of policies and guidelines are greatly influenced by AMR information from surveillance systems, in the third section, we review the unit of analysis ("the what" and "the who") and the indicators (the "operational units of surveillance") used in AMR and discuss the factors that affect the validity, reliability, and comparability of the information to be applied in various healthcare (primary, secondary, and tertiary), demographic, and economic contexts (local, regional, global, and inter-sectorial levels). Finally, we discuss the disparities and similarities between distinct stakeholders' objectives and the gaps and challenges of combatting AMR at various levels. In summary, this is a comprehensive but not exhaustive revision of the known unknowns about how to analyze the heterogeneities of hosts, microbes, and hospital patches, the role of surrounding ecosystems, and the challenges they represent for surveillance, antimicrobial stewardship, and infection control programs, which are the traditional cornerstones for controlling AMR in human health.
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Affiliation(s)
- Teresa M. Coque
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Rafael Cantón
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Ana Elena Pérez-Cobas
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- CIBER en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Miguel D. Fernández-de-Bobadilla
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Fernando Baquero
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP), Instituto de Salud Carlos III, 28029 Madrid, Spain
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20
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Werkneh AA, Islam MA. Post-treatment disinfection technologies for sustainable removal of antibiotic residues and antimicrobial resistance bacteria from hospital wastewater. Heliyon 2023; 9:e15360. [PMID: 37123966 PMCID: PMC10130869 DOI: 10.1016/j.heliyon.2023.e15360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Abstract
The World Health Organization (WHO) has identified antimicrobial resistance bacteria and its spread as one of the most serious threats to public health and the environment in the twenty-first century. Different treatment scenarios are found in several countries, each with their own regulations and selection criteria for the effluent quality and management practices of hospital wastewater. To prevent the spread of disease outbreaks and other environmental threats, the development of sustainable treatment techniques that remove all antibiotics and antimicrobial resistant bacteria and genes should be required. Although few research based articles published focusing this issues, explaining the drawbacks and effectiveness of post-treatment disinfection strategies for eliminating antibiotic residues and antimicrobial resistance from hospital wastewater is the reason of this review. The application of conventional activated sludge (CAS) in large scale hospital wastewater treatments poses high energy supply needs for aeration, capital and operational costs. Membrane bioreactors (MBR) have also progressively replaced the CAS treatment systems and achieved better treatment potential, but membrane fouling, energy cost for aeration, and membrane permeability loss restrict their performance at large scale operations. In addition, the membrane process alone doesn't completely remove/degrade these micropollutants; as a substitute, the pollutants are being concentrated in a smaller volume, which requires further post-treatment. Therefore, these drawbacks should be solved by developing advanced techniques to be integrated into any of these or other secondary wastewater treatment systems, aiming for the effective removal of these micropollutants. The purpose of this paper is to review the performances of post-treatment disinfection technologies in the removal of antibiotics, antimicrobial resistant bacteria and their gens from hospital wastewater. The performance of advanced disinfection technologies (such as granular and powered activated carbon adsorption, ozonation, UV, disinfections, phytoremediation), and other integrated post-treatment techniques are primarily reviewed. Besides, the ecotoxicology and public health risks of hospital wastewater, and the development, spreading and mechanisms of antimicrobial resistant and the protection of one health are also highlighted.
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Affiliation(s)
- Adhena Ayaliew Werkneh
- Department of Environmental Health, School of Public Health, College of Health Sciences, Mekelle University, P.O. Box 1871, Mekelle, Ethiopia
- Corresponding author. ;
| | - Md Aminul Islam
- COVID-19 Diagnostic Lab, Department of Microbiology, Noakhali Science and Technology University, Noakhali-3814, Bangladesh
- Advanced Molecular Lab, Department of Microbiology, President Abdul Hamid Medical College, Karimganj, Kishoreganj, Bangladesh
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Perestrelo S, Amaro A, Brouwer MSM, Clemente L, Ribeiro Duarte AS, Kaesbohrer A, Karpíšková R, Lopez-Chavarrias V, Morris D, Prendergast D, Pista A, Silveira L, Skarżyńska M, Slowey R, Veldman KT, Zając M, Burgess C, Alvarez J. Building an International One Health Strain Level Database to Characterise the Epidemiology of AMR Threats: ESBL—AmpC Producing E. coli as An Example—Challenges and Perspectives. Antibiotics (Basel) 2023; 12:antibiotics12030552. [PMID: 36978419 PMCID: PMC10044432 DOI: 10.3390/antibiotics12030552] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/12/2023] Open
Abstract
Antimicrobial resistance (AMR) is one of the top public health threats nowadays. Among the most important AMR pathogens, Escherichia coli resistant to extended spectrum cephalosporins (ESC-EC) is a perfect example of the One Health problem due to its global distribution in animal, human, and environmental sources and its resistant phenotype, derived from the carriage of plasmid-borne extended-spectrum and AmpC β-lactamases, which limits the choice of effective antimicrobial therapies. The epidemiology of ESC-EC infection is complex as a result of the multiple possible sources involved in its transmission, and its study would require databases ideally comprising information from animal (livestock, companion, wildlife), human, and environmental sources. Here, we present the steps taken to assemble a database with phenotypic and genetic information on 10,763 ESC-EC isolates retrieved from multiple sources provided by 13 partners located in eight European countries, in the frame of the DiSCoVeR Joint Research project funded by the One Health European Joint Programme (OH-EJP), along with its strengths and limitations. This database represents a first step to help in the assessment of different geographical and temporal trends and transmission dynamics in animals and humans. The work performed highlights aspects that should be considered in future international efforts, such as the one presented here.
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Affiliation(s)
- Sara Perestrelo
- Department of Biological Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany
| | - Ana Amaro
- Laboratory of Bacteriology and Micology, National Institute of Agrarian and Veterinary Research, National Reference for Animal Health, 2780-157 Oeiras, Portugal
| | - Michael S. M. Brouwer
- Department of Bacteriology, Host Pathogen Interaction & Diagnostics, Wageningen Bioveterinary Research, Part of Wageningen University & Research, 8221 Lelystad, The Netherlands
| | - Lurdes Clemente
- Laboratory of Bacteriology and Micology, National Institute of Agrarian and Veterinary Research, National Reference for Animal Health, 2780-157 Oeiras, Portugal
| | | | - Annemarie Kaesbohrer
- Department of Biological Safety, German Federal Institute for Risk Assessment, 10589 Berlin, Germany
- Veterinary Public Health and Epidemiology, University of Veterinary Medicine, 1210 Vienna, Austria
| | - Renata Karpíšková
- Department of Public Health, Medical Faculty, Masaryk University, 625 000 Brno, Czech Republic
| | | | - Dearbháile Morris
- Antimicrobial Resistance and Microbial Ecology Group, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Deirdre Prendergast
- Backweston Laboratory Campus, Department of Agriculture, Food and the Marine, W23 X3PH Celbridge, Ireland
| | - Angela Pista
- National Reference Laboratory for Gastrointestinal Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge, Avenida Padre Cruz, 1649-016 Lisbon, Portugal
| | - Leonor Silveira
- National Reference Laboratory for Gastrointestinal Infections, Department of Infectious Diseases, National Institute of Health Doutor Ricardo Jorge, Avenida Padre Cruz, 1649-016 Lisbon, Portugal
| | - Magdalena Skarżyńska
- Department of Microbiology, National Veterinary Research Institute, 24-100 Pulawy, Poland
| | - Rosemarie Slowey
- Backweston Laboratory Campus, Department of Agriculture, Food and the Marine, W23 X3PH Celbridge, Ireland
| | - Kees T. Veldman
- Department of Bacteriology, Host Pathogen Interaction & Diagnostics, Wageningen Bioveterinary Research, Part of Wageningen University & Research, 8221 Lelystad, The Netherlands
| | - Magdalena Zając
- Department of Microbiology, National Veterinary Research Institute, 24-100 Pulawy, Poland
| | - Catherine Burgess
- Food Safety Department, Teagasc Food Research Centre Ashtown, D15 DY05 Dublin, Ireland
| | - Julio Alvarez
- VISAVET Health Surveillance Centre, Universidad Complutense, 28040 Madrid, Spain
- Department of Animal Health, Faculty of Veterinary Medicine, Universidad Complutense, Avda. Puerta de Hierro S/N, 28040 Madrid, Spain
- Correspondence:
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Zago LF, Correa JS, da Silva‐Brandão RR, Fracolli LA, Padoveze MC, de Oliveira SM, Corboda Currea GC. Experiences of antibiotic use among Brazilian healthcare users: An exploratory study. Health Expect 2022; 26:343-354. [PMID: 36420763 PMCID: PMC9854310 DOI: 10.1111/hex.13664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION This article analyzes experiences of antibiotic use and bacterial infections among Primary Health Care users of the Brazilian Unified Health System (SUS) and the possible implications for antimicrobial resistance (AMR). The aim is to map aspects that shape users' lay knowledge regarding antibiotics use and AMR. METHODS This is an exploratory study, which consists primarily of individual in-depth interviews with 19 respondents. Recurrent interview topics were coded and analysed according to thematic content analysis. RESULTS Our findings show users' lived experiences constitute three dimensions related to users' previous antibiotic use: (1) lay knowledge about medicines; (2) previous bacterial infections and (3) communication during the consultation. Lay knowledge encompasses the users' understanding of how antibiotics work in comparison to other drugs and experimentations they make with medication. Users' narratives about bacterial infections are divided into situations of urinary tract infections and antibiotic treatments for other conditions. Communication during the consultation is mainly characterized by a lack of shared knowledge and trust in the doctor-patient relationship. DISCUSSION Users bring together knowledge learned from their own experiences to create the rationale, which shapes how they understand antibiotic use, bacterial infections and medical advice. These experiences are interwoven with information received from healthcare professionals (HPs) on these topics, creating a scenario that goes beyond professional information about antibiotic use. Users have knowledge about medication, antibiotics use and bacterial infection but do not have room to share it with HP, allowing lived experiences to take precedence over professional information. CONCLUSION Users ascribe symbolic meanings to antibiotics creating a lay knowledge frame, even if this knowledge is not scientifically correct. The personal experiences of bacterial infections and their treatment are also an important source of knowledge about antibiotic use and AMR among users. Users demand from their HPs both trust and willingness to listen to their health narratives and experiences. By considering lay knowledge as part of the assessment of a user's health condition, rather than dismissing it as erroneous and therefore unworthy of attention, HPs may enhance the compliance of users. PATIENT OR PUBLIC CONTRIBUTION Patients or community members did not participate in the design stage of the study. Primary Care patients were invited to participate as respondents of in-depth interviews, which were carried out by the first author at a Primary Care Unit (PCU) in the suburb of Campo Limpo, Southern region of São Paulo, Brazil. Patients were interviewed after reading and signing a Free and Informed Consent Form, holding with them a copy of the Form. Among the final activities of the project, a feedback session at the same PCU is planned to report on the results of the study. All respondents will have the opportunity to contribute further information regarding their antibiotic use and exchange knowledge and experiences on antimicrobial resistance.
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Affiliation(s)
- Luiz F. Zago
- Department of Nursing in Collective Health, School of NursingUniversity of São PauloSão PauloBrazil
| | - Juliana S. Correa
- Department of Nursing in Collective Health, School of NursingUniversity of São PauloSão PauloBrazil
| | | | - Lislaine A. Fracolli
- Department of Nursing in Collective Health, School of NursingUniversity of São PauloSão PauloBrazil
| | - Maria Clara Padoveze
- Department of Nursing in Collective Health, School of NursingUniversity of São PauloSão PauloBrazil
| | - Sandi Michele de Oliveira
- Section of General Practice, Institute of Public Health, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Gloria C. Corboda Currea
- Section of General Practice, Institute of Public Health, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark,Antimicrobial Research Unit, School of Health SciencesUniversity of Kwazulu‐NatalDurbanSouth Africa
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Meagher KM, Watson S, Suh GA, Virk A. The New Precision Stewards? J Pers Med 2022; 12:jpm12081308. [PMID: 36013256 PMCID: PMC9409858 DOI: 10.3390/jpm12081308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
Abstract
The precision health era is likely to reduce and respond to antimicrobial resistance (AMR). Our stewardship and precision efforts share terminology, seeking to deliver the “right drug, at the right dose, at the right time.” Already, rapid diagnostic testing, phylogenetic surveillance, and real-time outbreak response provide just a few examples of molecular advances we dub “precision stewardship.” However, the AMR causal factors range from the molecular to that of global health policy. Mirroring the cross-sectoral nature of AMR science, the research addressing the ethical, legal and social implications (ELSI) of AMR ranges across academic scholarship. As the rise of AMR is accompanied by an escalating sense of its moral and social significance, what is needed is a parallel field of study. In this paper, we offer a gap analysis of this terrain, or an agenda for “the ELSI of precision stewardship.” In the first section, we discuss the accomplishments of a multi-decade U.S. national investment in ELSI research attending to the advances in human genetics. In the next section, we provide an overview of distinct ELSI topics pertinent to AMR. The distinctiveness of an ELSI agenda for precision stewardship suggests new opportunities for collaboration to build the stewardship teams of the future.
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Affiliation(s)
- Karen M. Meagher
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: ; Tel.: +1-507-293-9528
| | - Sara Watson
- Biomedical Ethics Research Program, Mayo Clinic, Rochester, MN 55905, USA
| | - Gina A. Suh
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Abinash Virk
- Division of Public Health, Infectious Disease, and Occupational Medicine, Mayo Clinic, Rochester, MN 55905, USA
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