Ethiopia's Antibiotic Footprint: Employing the Newly Emerging Digital Concept to Estimate Annual Consumption for the Country

Background The processes involving resistance development against antibiotics have historically been part of the Darwinian evolution. However, the increasing use of antibiotics in modern medicine has intensified the selection pressures with an acute gear-up, rather than as part of this very slow evolutionary process that selects for enhanced fitness for survival. Two major recommendations have been made in the past to tackle this challenge: (1) incentivizing the pharmaceutical industry to invest more in research and development endeavors so that they come up with new antibiotics, and (2) implementing antimicrobial stewardship programs in healthcare systems. Methodology In this study, the third and emerging approach, namely, documenting antibiotic footprint, was employed as a communication tool that targets individual consumers of antibiotics. Data obtained from the Ethiopian Pharmaceutical Supply Agency were curated to systematically compile antibiotic consumption at each of the agency's regional hubs. The exact geospatial locations of the hubs were generated and synchronized to depict the size of the antibiotic footprint infograph as proportional to the antibiotic consumption data at each hub. Moreover, the cumulative and per-capita consumption of these antibiotics at the country level (overall antibiotic footprint) were calculated by including estimated data for the livestock sector. Results A total of 698.2 tons of antibiotics were used in Ethiopia in 2018, and the per-capita consumption of antibiotics was 5.8 g per person. Extended-spectrum (J01CA) and beta-lactamase-resistant penicillins (J01CF) were the most commonly utilized classes of antibiotics which accounted for, respectively, 38.3% and 20.8% of all antibiotics used in the country's public health sector. Hubs in Addis Ababa (14%) and Hawassa (12%) topped the overall antibiotic consumption in the country. Contrarily, hubs in Gambella and Semera received relatively smaller quantities of antibiotics, with totals of 4.8 tons (0.9%) and 10.2 tons (1.9%), respectively. Conclusions This study shows that the newly emerging concept of the antibiotic footprint is a simple and suitable tool for public health policy communications targeting individual consumers of antibiotics. If implemented judicially, the concept of the antibiotic footprint has a huge potential to support global scientific efforts and collaborations in setting standards that help to reduce the overuse and misuse of antibiotics in the future.

Potential Synergistic Antibiotic Combinations against Fluoroquinolone-Resistant Pseudomonas aeruginosa

The rise in multiple-drug-resistant (MDR) phenotypes in Gram-negative pathogens is a major public health crisis. Pseudomonas aeruginosa is one of the leading causes of nosocomial infections in clinics. Treatment options for P. aeruginosa have become increasingly difficult due tdo its remarkable capacity to resist multiple antibiotics. The presence of intrinsic resistance factors and the ability to quickly adapt to antibiotic monotherapy warrant us to look for alternative strategies like combinatorial antibiotic therapy. Here, we report the frequency of P. aeruginosa multidrug-resistant and extensively drug-resistance (XDR) phenotypes in a super-specialty tertiary care hospital in north India. Approximately 60 percent of all isolated P. aeruginosa strains displayed the MDR phenotype. We found highest antibiotic resistance frequency in the emergency department (EMR), as 20 percent of isolates were resistant to 15 antipseudomonal antibiotics. Presence of plasmids with quinolone-resistance determinants were major drivers for resistance against fluoroquinolone. Additionally, we explored the possible combinatorial therapeutic options with four antipseudomonal antibiotics—colistin, ciprofloxacin, tobramycin, and meropenem. We uncovered an association between different antibiotic interactions. Our data show that the combination of colistin and ciprofloxacin could be an effective combinatorial regimen to treat infections caused by MDR and XDR P. aeruginosa.

Interprovincial variation in antibiotic use in Canada, 2019: a retrospective cross-sectional study

BACKGROUND

Geographic trends in antibiotic prescribing show regional variation in antibiotic overuse and antimicrobial resistance, posing a threat to global health care systems. This study's objective was to examine interprovincial variation in outpatient antibiotic dispensing in Canada in 2019.

METHODS

We conducted a cross-sectional study of antibiotic prescriptions dispensed in Canadian provinces in 2019, leveraging the IQVIA Geographic Prescription Monitor database. We report annual rates of overall antibiotic dispensing, broad-spectrum antibiotic dispensing and age-specific antibiotic dispensing as prescriptions per 1000 population in each province and nationally.

RESULTS

A total of 23 406 640 antibiotic prescriptions were dispensed nationally in 2019, at a rate of 627.3 prescriptions per 1000 population. Overall antibiotic dispensing rates in Newfoundland and Labrador (920.5 prescriptions per 1000 population) and Saskatchewan (713.7 prescriptions per 1000 population) significantly exceeded the national rate, whereas the rate in British Columbia (543.3 prescriptions per 1000 population) was significantly below the national rate. We observed additional variation when provincial rates of antibiotic dispensing were stratified by drug class and age group.

INTERPRETATION

We identified interprovincial variation in antibiotic use in Canadian provinces in 2019. These findings highlight the need for provincial targets for antibiotic use to reduce overuse and antimicrobial resistance.

Liposomal delivery systems and their applications against Staphylococcus aureus and Methicillin-resistant Staphylococcus aureus

Liposomal delivery systems have been widely explored for targeting superbugs such as S. aureus and MRSA, overcoming antimicrobial resistance associated with conventional dosage forms. They have the significant advantage of delivering hydrophilic and lipophilic antimicrobial agents, either singularly as monotherapy or in combination as combination therapy, due to their bilayers with action-site-specificity, resulting in improved targeting compared to conventional dosage forms. Herein, we present an extensive and critical review of the different liposomal delivery systems employed in the past two decades for the delivery of both antibiotics of different classes and non-antibiotic antibacterial agents, as monotherapy and combination therapy to eradicate infections caused by S. aureus and MRSA. The review also identifies future research and strategies potentiating the applications of liposomal delivery systems against S. aureus and MRSA. This review confirms the potential application of liposomal delivery systems for effective delivery and specific targeting of S. aureus and MRSA infections.

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications

BACKGROUND

There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

METHODS

Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

RESULTS

There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

CONCLUSION

There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.

In situ realization of asymmetric ratchet structures within microchannels by directionally guided light transmission and their directional flow behavior

An asymmetric ratchet structure within microchannels is demonstrated by directionally guided light transmission for controlled liquid flow. A direct and facile method is presented to realize programmed asymmetric structures, which control the fluid direction and speed.

The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: preventing deep infections by nosocomial organisms

BACKGROUND

Deep surgical site infections (SSI's) complicate Gustilo IIIB tibial fractures in 8-13% of cases. Antibiotic prophylaxis typically covers environmental contaminants. However, nosocomial organisms are usually implicated in deep infection. We used the microbiological profile of infected Gustilo IIIB tibial fractures to define a new, dynamic prophylactic regimen which recognises the need for prophylaxis against nosocomial organisms at the time of definitive closure.

METHODS

The microbiological profiles of Gustilo IIIB tibial fractures presenting over a 2-year period from January 2006 to December 2007 were reviewed. The environmental contaminants were compared with the organisms isolated from deep SSI's and correlated with the prophylactic antibiotic regimen used.

RESULTS

Fifty-two patients were included. Nine developed a deep tissue infection. The pathogens implicated included resistant Enterococci, Pseudomonas, Enterobacter and MRSA. Standard antibiotic prophylaxis provided cover for these combinations in only one of nine cases. This would have improved to eight of nine cases with the use of teicoplanin and gentamicin, given as a one-time dose during definitive soft-tissue closure. Specimens taken from wound debridement were neither sensitive nor specific for the subsequent development of deep infection and did not predict the organisms responsible.

CONCLUSIONS

Following high-energy open fracture, a single prophylactic antibiotic regimen directed against environmental wound contaminants does not provide cover for the organisms responsible for deepest SSI's and may have depopulated the niche, promoting nosocomial contamination prior to definitive closure. We advocate a dynamic prophylactic strategy, tailoring a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure, and at the same time avoiding the potential complications of prolonged antibiotic use.