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Alemkere G, Teshome A, Temesgen G, Abebe G, Degefaw Y, Tilahun H, Getahun W, Girma E, Amogne W. Cefazolin access and use in Ethiopia: A policy implication. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001421. [PMID: 36962932 PMCID: PMC10021613 DOI: 10.1371/journal.pgph.0001421] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 12/17/2022] [Indexed: 01/19/2023]
Abstract
Healthcare systems in resource-limited nations have been challenged by the shortage of essential medicines. This study explores cefazolin access and uses history in the Ethiopian healthcare delivery system, for possible policy implications. An exploratory qualitative study was conducted from July to August 2021. Semi-structured questions and observation guides were used to extract necessary data from people, documents, and field visits to hospitals, government supply agencies, and pharmaceutical business firms. The data were transcribed, coded, organized into themes, and presented. Cefazoline is the recommended first-line surgical antibiotic prophylaxis (SAP) in the Ethiopian Standard Treatment Guideline (STG) and is included in the national Essential Medicine List (EML). However, it was not available for use in the Ethiopian pharmaceutical markets for years. While the shortage might stem from supply-demand mismatches, multiple unknown issues exist in the background of the shortage. This is evidenced by the removal of cefazolin from the recent government procurement list regardless of the recommendation set in the national EML and STG. This study found a historic shortage of cefazolin in Ethiopian healthcare settings. This implies that the antibiotic availability in the pull market may not reflect required usage at facilities for several reasons including the misalignment of national guidelines and national procurement processes, and miscommunication between pharmacies and clinicians at sites on drug availability. Changing the essential medicines list and/or procurement requests without active review of the supply chain system and prescribing practices at facilities can lead to the elimination of necessary antimicrobial agents from the national public health sector supply.
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Affiliation(s)
- Getachew Alemkere
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Asres Teshome
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gobezie Temesgen
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getnet Abebe
- Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yidnekachew Degefaw
- Antimicrobial Resistance Prevention and Control Case Team, Pharmaceuticals and Medical Equipment Directorate, Ministry of Health, Addis Ababa, Ethiopia
| | - Hiwot Tilahun
- Department of Surgery, Gimjabet Primary Hospital, Gimjabet, Amhara, Ethiopia
| | - Workineh Getahun
- Antimicrobial Resistance and Global Partnership, USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Addis Ababa, Ethiopia
| | - Eshetu Girma
- Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Infectious Diseases, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Shafiq N, Pandey AK, Malhotra S, Holmes A, Mendelson M, Malpani R, Balasegaram M, Charani E. Shortage of essential antimicrobials: a major challenge to global health security. BMJ Glob Health 2021; 6:bmjgh-2021-006961. [PMID: 34728479 PMCID: PMC8565534 DOI: 10.1136/bmjgh-2021-006961] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/20/2021] [Indexed: 11/06/2022] Open
Abstract
The lack of access to safe and effective antimicrobials for human populations is a threat to global health security and a contributor to the emergence and spread of antimicrobial resistance (AMR). The increasingly common shortages of antimicrobials are an additional threat to the emergence of AMR. While the threat of such drug shortages is most acutely experienced in low-income and middle-income settings, their consequences impact the quality and effectiveness of antimicrobials worldwide. Furthermore, there is a need for robustly conducted studies examining the impact of these increasingly prevalent shortages on patient outcomes and on the emergence and spread of AMR. In this review, we have mapped common drivers for antimicrobial shortages and propose strategies for rethinking the regulation, supply and pricing of antimicrobials to secure their sustainable access across diverse healthcare systems and to help minimise the unintended consequences of weak and ineffective supply chains. Greater government involvement in antimicrobial manufacture and supply is essential to ensure no one is left behind. Dedicated demand systems need to be developed for antimicrobials which take into consideration evolving AMR patterns, burden of diseases, pandemic events and supply and demand issues and facilitate implementation of strategies to address them. Interventions, ranging from advocacy and forecasting to public–private collaborations, new economic models and international consortia working across countries and supply chains, will help assure access to safe and effective antimicrobials to all populations around the globe and ensure that shortages no longer contribute to AMR.
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Affiliation(s)
- Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Avaneesh Kumar Pandey
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alison Holmes
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK
| | - Marc Mendelson
- Department of Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Rohit Malpani
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Manica Balasegaram
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | - Esmita Charani
- Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Department of Medicine, Imperial College London, London, UK .,Department of Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
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Koizumi R, Kusama Y, Asai Y, Yoshiaki G, Muraki Y, Ohmagari N. Effects of the cefazolin shortage on the sales, cost, and appropriate use of other antimicrobials. BMC Health Serv Res 2021; 21:1118. [PMID: 34663315 PMCID: PMC8523201 DOI: 10.1186/s12913-021-07139-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/05/2021] [Indexed: 01/01/2023] Open
Abstract
Background Shortages of antimicrobials lead to treatment failures, increase medical costs, and accelerate the development of antimicrobial resistance. We evaluated the effects of the serious cefazolin shortage in 2019 in Japan on the sales, costs, and appropriate use of other antimicrobials. Methods We evaluated monthly defined daily doses/1000 inhabitants/day (DID) values of antimicrobial sales from January 2016 to December 2019 using wholesaler’s sales databases. Using 2016–2018 sales data, we generated a prediction model of DID in 2019 under the assumption that the cefazolin shortage did not occur. We then compared the predicted DID and actual DID. Cefazolin, government-recommended alternatives, and government-not-recommended broad-spectrum alternatives were assessed. Antimicrobial groups according to the AWaRe classification were also assessed to evaluate the effect on appropriate antimicrobial use. In addition, we evaluated changes in costs between 9 months before and after the cefazolin shortage. Results DID values of total antimicrobials increased sharply 1 month before the decrease in cefazolin. Actual DIDs were higher than predicted DIDs for ceftriaxone, flomoxef, clindamycin, cefotiam, piperacillin/tazobactam, and meropenem. Actual DID values were higher than the predicted DID values in the Watch group. The costs of antimicrobials between pre- and post- cefazolin shortage were unchanged. Conclusion The cefazolin shortage brought confusion to the antimicrobial market and led to a setback in the appropriate use of antimicrobials. Early recognition and structures for prompt reactions to antimicrobial shortages are needed. Moreover, development of a system to secure the supply of essential antimicrobials is required. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07139-z.
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Affiliation(s)
- Ryuji Koizumi
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshiki Kusama
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan. .,Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.
| | - Yusuke Asai
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Gu Yoshiaki
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuichi Muraki
- Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, Kyoto, Japan
| | - Norio Ohmagari
- AMR Clinical Reference Center, Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan.,Collaborative Chairs Emerging and Reemerging Infectious Diseases, National Center for Global Health and Medicine, Graduate School of Medicine, Tohoku University, Sendai, Miyagi, Japan.,Department of Clinical Pharmacoepidemiology, Kyoto Pharmaceutical University, Kyoto, Japan
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Kakkar AK, Shafiq N, Malhotra S. Cefazolin Shortages in the Developing World: The Same, But Different Too. Clin Infect Dis 2021; 72:1293-1295. [PMID: 32579180 DOI: 10.1093/cid/ciaa847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nusrat Shafiq
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kakkar AK, Shafiq N, Sahni N, Mohindra R, Kaur N, Gamad N, Panditrao A, Kondal D, Malhotra S, Kumar M P, Rohilla R, Bhattacharjee S, Kumar A, Bhandari RK, Pandey AK, Rather I, Mothsara C, Harish C, Belavagi D, Vishwas G. Assessment of Appropriateness of Antimicrobial Therapy in Resource-Constrained Settings: Development and Piloting of a Novel Tool-AmRAT. Antibiotics (Basel) 2021; 10:200. [PMID: 33669509 PMCID: PMC7923130 DOI: 10.3390/antibiotics10020200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 12/04/2022] Open
Abstract
Inappropriate antimicrobial prescribing is considered to be the leading cause of high burden of antimicrobial resistance (AMR) in resource-constrained lower- and middle-income countries. Under its global action plan, the World Health Organization has envisaged tackling the AMR threat through promotion of rational antibiotic use among prescribers. Given the lack of consensus definitions and other associated challenges, we sought to devise and validate an Antimicrobial Rationality Assessment Tool-AmRAT-for standardizing the assessment of appropriateness of antimicrobial prescribing. A consensus algorithm was developed by a multidisciplinary team consisting of intensivists, internal medicine practitioners, clinical pharmacologists, and infectious disease experts. The tool was piloted by 10 raters belonging to three groups of antimicrobial stewardship (AMS) personnel: Master of Pharmacology (M.Sc.) (n = 3, group A), Doctor of Medicine (MD) residents (n = 3, group B), and DM residents in clinical pharmacology (n = 4, group C) using retrospective patient data from 30 audit and feedback forms collected as part of an existing AMS program. Percentage agreement and the kappa (κ) coefficients were used to measure inter-rater agreements amongst themselves and with expert opinion. Sensitivity and specificity estimates were analyzed comparing their assessments against the gold standard. For the overall assessment of rationality, the mean percent agreement with experts was 76.7% for group A, 68.9% for group B, and 77.5% for group C. The kappa values indicated moderate agreement for all raters in group A (κ 0.47-0.57), and fair to moderate in group B (κ 0.22-0.46) as well as group C (κ 0.37-0.60). Sensitivity and specificity for the same were 80% and 68.6%, respectively. Though evaluated by raters with diverse educational background and variable AMS experience in this pilot study, our tool demonstrated high percent agreement and good sensitivity and specificity, assuring confidence in its utility for assessing appropriateness of antimicrobial prescriptions in resource-constrained healthcare environments.
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Affiliation(s)
- Ashish Kumar Kakkar
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Nusrat Shafiq
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Neeru Sahni
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ritin Mohindra
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Navjot Kaur
- Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi 110029, India;
| | - Nanda Gamad
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Aditi Panditrao
- Adesh Institute of Medical Sciences and Research, Bathinda 151101, India;
| | - Dimple Kondal
- Public Health Foundation of India, Gurugram 122002, India;
| | - Samir Malhotra
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Praveen Kumar M
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Rachna Rohilla
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Samiksha Bhattacharjee
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ankit Kumar
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Ritika Kondel Bhandari
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Avaneesh Kumar Pandey
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Imraan Rather
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Chakrant Mothsara
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Cvn Harish
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Devaraj Belavagi
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
| | - Gopal Vishwas
- Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India; (A.K.K.); (N.S.); (R.M.); (N.G.); (S.M.); (P.K.M); (R.R.); (S.B.); (A.K.); (R.K.B.); (A.K.P.); (I.R.); (C.M.); (C.H.); (D.B.); (G.V.)
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Kakkar AK. Pharmaceutical price regulation and its impact on drug innovation: mitigating the trade-offs. Expert Opin Ther Pat 2021; 31:189-192. [PMID: 33435784 DOI: 10.1080/13543776.2021.1876029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Khanijo S, Kakkar AK, Kumar R, Patil AN, Bhusal G, Vishwas G, Arora G. Impact of pharmaceutical price controls on the cost of cardiovascular drugs: does essentiality matter? Expert Rev Clin Pharmacol 2020; 13:797-806. [DOI: 10.1080/17512433.2020.1783248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Simran Khanijo
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Kumar Kakkar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amol Narayan Patil
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gomata Bhusal
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gopal Vishwas
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Geetika Arora
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Rickard J. Bacterial Resistance in Surgical Infections in Low-Resource Settings. Surg Infect (Larchmt) 2020; 21:509-515. [PMID: 32380936 DOI: 10.1089/sur.2020.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: There is an alarming increase in antimicrobial resistance (AMR) globally, complicating management of surgical infections, especially in low-resource settings. Of particular concern for surgeons are third generation cephalosporin-resistant and carbapenem-resistant Enterobacteriaceae. Methods: The published literature was searched to identify the scope and causative factors of emerging bacterial resistance in low- and middle-income countries (LMICs). Results: Antimicrobial resistance impacts economics, human development, health equity, health security, and food production. Factors that contribute to AMR include use of antibiotic agents in livestock, antibiotic agents in wastewater and sewage, poor sanitation, and overprescribing or unregulated use of antibiotic agents. Because the factors influencing AMR globally are multi-factorial, solutions must be addressed at multiple levels. In LMICs, these can occur through national initiatives, at the facility level, or at the community level with coordination engaging government agencies, the private sector, civil service, and professional groups. Conclusions: There is a growing recognition of the need for national AMR prevention programs. Meanwhile, infection prevention and control programs and antimicrobial stewardship remain cornerstones of management at the facility level.
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Affiliation(s)
- Jennifer Rickard
- Department of Surgery, University of Minnesota Minneapolis, Minnesota, USA
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Kakkar AK, Shafiq N, Singh G, Ray P, Gautam V, Agarwal R, Muralidharan J, Arora P. Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems. Front Public Health 2020; 8:140. [PMID: 32411647 PMCID: PMC7198767 DOI: 10.3389/fpubh.2020.00140] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 04/03/2020] [Indexed: 12/12/2022] Open
Abstract
World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is fraught with several challenges. The key limiting factors include lack of clear political commitment, inadequate funding, overcrowded healthcare systems, lax legal and regulatory frameworks, non-uniform access to diagnostics, absence of electronic health record systems, limited knowledge and awareness especially with existence of multiple systems of medicines, issues with access to quality assured medicines, in-house pharmacies, and shortage of trained manpower. Since these implementation-impeding issues may differ considerably from those experienced in developed economies, intervention efforts in low- and middle-income countries (LMICs) need to address the context and focus on the root causes prevailing locally. In this article, we review the evidence highlighting the magnitude of these challenges and suggest feasible models with effective application. We also share the evidence from our center where we have contextualized the core elements to resource constrained settings. These domains include delivering prospective audit and feedback, prescriber education, development of evidence-based and implementable guidelines, and optimization of surgical antibiotic prophylaxis. However, there is a tremendous need for scaling up, extending outreach and honing these models while at the same time, addressing the existing strategic challenges that curtail the full potential of global antimicrobial stewardship.
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Affiliation(s)
- Ashish Kumar Kakkar
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallab Ray
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jayashree Muralidharan
- Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pankaj Arora
- Department of Hospital Administration, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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