Cefazolin Shortages in the Developing World: The Same, But Different Too

Appropriateness of Surgical Antibiotic Prophylaxis in a Tertiary Care Teaching Hospital in Central India: A Retrospective Analysis

Surgical antibiotic prophylaxis (SAP) has been a boon in the prevention of surgical site infections (SSIs). This study was conducted to assess and evaluate the selection, timing, and duration of administration of SAP and their compliance with national and international guidelines in a tertiary care teaching hospital in India. This retrospective study included the data collected from the central records department in a tertiary care teaching hospital on major surgeries conducted between January 1, 2018, and December 31, 2018, from the departments of ENT, general surgery, orthopedic surgery, and obstetrics and gynecology. The data was analyzed for the appropriateness of their indication for SAP administration, choice, timing, and duration of antibiotics, and compliance with the American Society of Health-System Pharmacists (ASHP) and Indian Council of Medical Research (ICMR) guidelines. Results and interpretation Out of the total 394 case records included, only 2.53% (n = 10) of the cases were given an appropriate antibiotic. The duration of SAP was appropriate only in 6.53% (n = 24), and the timing of SAP administration was appropriate only in 50.76% (n = 204). The most commonly used antibiotic was ceftriaxone (pre-operative 58.12% (n = 229) and post-operative 43.14% (n = 170)). Major inappropriateness was observed in the selection of antibiotics which may be attributed to the non-availability of cefazolin in the institute. The inappropriateness of the duration of the SAP may be attributed to the extra precautions taken by the treating physicians to prevent SSIs. The overall compliance of the surgical cases with respect to the ASHP and ICMR guidelines was less than 1%. Conclusion This study identified the lacuna between the guidelines for SAP and the clinical application of the same. It also identified the areas where quality improvement was needed which can be improved by implementing antimicrobial stewardship, especially the choice and the duration of SAP administration.

Cefazolin access and use in Ethiopia: A policy implication

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.

Shortage of essential antimicrobials: a major challenge to global health security

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.

Assessment of Appropriateness of Antimicrobial Therapy in Resource-Constrained Settings: Development and Piloting of a Novel Tool-AmRAT

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.