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Miller KM, Barnett TC, Cadarette D, Bloom DE, Carapetis JR, Cannon JW. Antibiotic consumption for sore throat and the potential effect of a vaccine against group A Streptococcus: a systematic review and modelling study. EBioMedicine 2023; 98:104864. [PMID: 37950997 PMCID: PMC10663680 DOI: 10.1016/j.ebiom.2023.104864] [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: 05/11/2023] [Revised: 10/15/2023] [Accepted: 10/19/2023] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Antibiotic consumption can lead to antimicrobial resistance and microbiome imbalance. We sought to estimate global antibiotic consumption for sore throat, and the potential reduction in consumption due to effective vaccination against group A Streptococcus (Strep A). METHODS We reviewed and analysed articles published between January 2000 and February 2022, identified though Clarivate Analytics' Web of Science search platform, with reference to antibiotic prescribing or consumption, sore throat, pharyngitis, or tonsillitis. We then used those analyses, combined with assumptions for the effectiveness, duration of protection, and coverage of a vaccine, to calculate the estimated reduction in antibiotic prescribing due to the introduction of Strep A vaccines. FINDINGS We identified 101 studies covering 38 countries. The mean prescribing rate for sore throat was approximately 5 courses per 100 population per year, accounting for approximately 5% of all antibiotic consumption. Based on 2020 population estimates for countries with empiric prescribing rates, antibiotic consumption for sore throat was estimated to exceed 37 million courses annually, of which half could be attributable to treatment for Strep A. A vaccine that reduces rates of Strep A infection by 80%, with 80% coverage and 10 year's duration of protection, could avert 2.8 million courses of antibiotics prescribed for sore throat treatment among 5-14 year-olds in countries with observed prescribing rates, increasing to an estimated 7.5 million averted if an effective vaccination program also reduced precautionary prescribing. INTERPRETATION A vaccine that prevents Strep A throat infections in children may reduce antibiotic prescribing for sore throat by 32-87% depending on changes to prescribing and consumption behaviours. FUNDING The Wellcome Trust, grant agreement number 215490/Z/19/Z.
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Affiliation(s)
- Kate M Miller
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; School of Population and Global Health, University of Western Australia, Nedlands, Western Australia, Australia
| | - Timothy C Barnett
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Marshall Centre for Infectious Diseases Research and Training, School of Biomedical Sciences, University of Western Australia, Nedlands, Western Australia, Australia
| | - Daniel Cadarette
- Harvard Kennedy School, Harvard University, Cambridge, MA, United States
| | - David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, United States
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Jeffrey W Cannon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia, Australia; Centre for Child Health Research, Medical School, University of Western Australia, Nedlands, Western Australia, Australia.
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Cantarero-Arevalo L, Nørgaard LS, Sporrong SK, Jacobsen R, Almarsdóttir AB, Hansen JM, Titkov D, Rachina S, Panfilova E, Merkulova V, Eseva O, Riabkova N, Kaae S. A Qualitative Analysis of the Culture of Antibiotic Use for Upper Respiratory Tract Infections Among Patients in Northwest Russia. Front Pharmacol 2022; 13:800695. [PMID: 35173616 PMCID: PMC8841995 DOI: 10.3389/fphar.2022.800695] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction: Due to the globally persistent threat of Antimicrobial Resistance (AMR), the purpose of this study was to gain an in-depth understanding of the antibiotic (AB) practices, knowledge and attitudes among patients residing in five regions in the northwest part of Russia. Given the high prevalence, this study focused on ABs for Upper Respiratory Tract Infections (URTI). Methods: The qualitative, semi-structured interviews followed a guide organized by major themes such as common symptoms, consultations with doctors and external influences in decision-making. Patient participants were recruited via convenience sampling. Fifty-five interviews were conducted among patients using ABs for URTIs purchased with or without prescription. Data was analyzed using a direct content analysis and validation rounds were conducted between interviewers and data analyzers. Results: Self-medication with ABs seemed a common practice across all five Russian regions; in some cases, patients tried to persuade pharmacists into selling them ABs without prescription. Factors, such as time spent going to the doctor, need of a sick leave or self-persuasion, influenced the decisions of whether or not to seek the doctor for symptoms of URTIs. Knowledge of ABs and AMR was generally low; however, some patients with seemingly good knowledge practiced self-medication from time to time. Family members and friends were often involved in decisions about how to handle symptoms of URTIs, especially among those patients using ABs without prescription. Few patients had noticed ABs awareness campaigns, and very few reported having learned something important from them. Conclusion: Despite enforced regulation of AB use in Russia, self-medication still exists. Knowledge is not always linked to appropriate use of AB, and the few campaigns conducted were not always noticed.
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Affiliation(s)
- Lourdes Cantarero-Arevalo
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Lotte S Nørgaard
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Sofia K Sporrong
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark.,Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Ramune Jacobsen
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Anna Birna Almarsdóttir
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Johanne M Hansen
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Dmitry Titkov
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | | | | | - Viktoria Merkulova
- Arkhangelsk Regional Centre for Public Health and Medical Prevention, Arkhangelsk, Russia
| | - Olga Eseva
- Pskov Regional Public Health Centre, Pskov, Russia
| | - Nadezhda Riabkova
- Petrozavodsk State University, Institute of Medicine, Petrozavodsk, Russia.,Republican Hospital V. A. Baranova, Petrozavodsk, Russia
| | - Susanne Kaae
- WHO Collaborating Centre for Research and Training in the Patient Perspective on Medicine Use, Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
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Merker M, Barbier M, Cox H, Rasigade JP, Feuerriegel S, Kohl TA, Diel R, Borrell S, Gagneux S, Nikolayevskyy V, Andres S, Nübel U, Supply P, Wirth T, Niemann S. Compensatory evolution drives multidrug-resistant tuberculosis in Central Asia. eLife 2018; 7:38200. [PMID: 30373719 PMCID: PMC6207422 DOI: 10.7554/elife.38200] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/02/2018] [Indexed: 12/21/2022] Open
Abstract
Bacterial factors favoring the unprecedented multidrug-resistant tuberculosis (MDR-TB) epidemic in the former Soviet Union remain unclear. We utilized whole genome sequencing and Bayesian statistics to analyze the evolutionary history, temporal emergence of resistance and transmission networks of MDR Mycobacterium tuberculosis complex isolates from Karakalpakstan, Uzbekistan (2001-2006). One clade (termed Central Asian outbreak, CAO) dating back to 1974 (95% HPD 1969-1982) subsequently acquired resistance mediating mutations to eight anti-TB drugs. Introduction of standardized WHO-endorsed directly observed treatment, short-course in Karakalpakstan in 1998 likely selected for CAO-strains, comprising 75% of sampled MDR-TB isolates in 2005/2006. CAO-isolates were also identified in a published cohort from Russia (2008-2010). Similarly, the presence of mutations supposed to compensate bacterial fitness deficits was associated with transmission success and higher drug resistance rates. The genetic make-up of these MDR-strains threatens the success of both empirical and standardized MDR-TB therapies, including the newly WHO-endorsed short MDR-TB regimen in Uzbekistan.
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Affiliation(s)
- Matthias Merker
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany.,German Center for Infection Research, Partner site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Maxime Barbier
- Laboratoire Biologie Intégrative des Populations, Evolution Moléculaire, Ecole Pratique des Hautes Etudes, PSL University, Paris, France.,Institut de Systématique, Evolution, Biodiversité, UMR-CNRS 7205, Muséum National d'Histoire Naturelle, Université Pierre et Marie Curie, Ecole Pratique des Hautes Etudes, Sorbonne Universités, Paris, France
| | - Helen Cox
- Division of Medical Microbiology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Jean-Philippe Rasigade
- Laboratoire Biologie Intégrative des Populations, Evolution Moléculaire, Ecole Pratique des Hautes Etudes, PSL University, Paris, France.,Institut de Systématique, Evolution, Biodiversité, UMR-CNRS 7205, Muséum National d'Histoire Naturelle, Université Pierre et Marie Curie, Ecole Pratique des Hautes Etudes, Sorbonne Universités, Paris, France.,CIRI INSERM U1111, University of Lyon, Lyon, France
| | - Silke Feuerriegel
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany.,German Center for Infection Research, Partner site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Thomas Andreas Kohl
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany.,German Center for Infection Research, Partner site Hamburg-Lübeck-Borstel-Riems, Germany
| | - Roland Diel
- Institute for Epidemiology, Schleswig-Holstein University Hospital, Kiel, Germany
| | - Sonia Borrell
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Sebastien Gagneux
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Vladyslav Nikolayevskyy
- Imperial College London, London, United Kingdom.,Public Health England, London, United Kingdom
| | - Sönke Andres
- Division of Mycobacteriology, National Tuberculosis Reference Laboratory, Research Center Borstel, Borstel, Germany
| | - Ulrich Nübel
- Microbial Genome Research, Leibniz-Institut DSMZ- Deutsche Sammlung von Mikroorganismen und Zellkulturen, Braunschweig, Germany.,German Center for Infection Research, Braunschweig, Germany
| | - Philip Supply
- Université de Lille, CNRS UMR 8204, Inserm U1019, CHU de Lille, Institut Pasteur de Lille, Centre d'Infection et d'Immunité de Lille, Lille, France.,Centre National de la Recherche Scientifique, Unité Mixte de Recherche, Center for Infection and Immunity of Lille, Lille, France.,Center for Infection and Immunity of Lille, Université de Lille Nord de France, Lille, France.,Center for Infection and Immunity of Lille, Institut Pasteur de Lille, Lille, France
| | - Thierry Wirth
- Laboratoire Biologie Intégrative des Populations, Evolution Moléculaire, Ecole Pratique des Hautes Etudes, PSL University, Paris, France.,Institut de Systématique, Evolution, Biodiversité, UMR-CNRS 7205, Muséum National d'Histoire Naturelle, Université Pierre et Marie Curie, Ecole Pratique des Hautes Etudes, Sorbonne Universités, Paris, France
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany.,German Center for Infection Research, Partner site Hamburg-Lübeck-Borstel-Riems, Germany
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Belkina T, Duvanova N, Karbovskaja J, Tebbens JD, Vlcek J. Antibiotic use practices of pharmacy staff: a cross-sectional study in Saint Petersburg, the Russian Federation. BMC Pharmacol Toxicol 2017; 18:11. [PMID: 28193258 PMCID: PMC5307805 DOI: 10.1186/s40360-017-0116-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/24/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-prescription access to antimicrobials is common, and self-prescribing is increasingly popular in Russian society. The aim of this study was to assess the attitudes of community pharmacists regarding antibiotic use and self-medication. METHODS We conducted a cross-sectional study from September-December 2015 of community pharmacists in the Saint-Petersburg and Leningrad region, Russia. A self-administered questionnaire was used to assess antibiotic use and self-medication practices. The data were analysed using logistic regression and Pearson chi-squared tests. RESULTS Of the 316 pharmacists (77.07%) who completed the questionnaire, 230 (72.8%) self-medicated with antibiotics. Antibiotics were mostly used to self-treat upper (53.3%) and lower respiratory tract infections (19.3%), relying on their own knowledge (81.5%), previous treatment experience (49%) and patients' prescriptions (17%). The most commonly used antibiotics were macrolides (33.2%). Characteristics such as age, education and experience were related to antibiotic use and self-medication. CONCLUSIONS The study confirmed that self-prescription of antibiotics is a common practice amongst pharmacists in Saint Petersburg and also identified personal and professional characteristics of pharmacists strongly associated with self-medication.
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Affiliation(s)
- Tatiana Belkina
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Heyrovskeho 1203, Hradec Kralove, 50005, Czech Republic.
| | - Natalia Duvanova
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Heyrovskeho 1203, Hradec Kralove, 50005, Czech Republic
| | - Julia Karbovskaja
- Department of Technology of Dosage Forms, Saint Petersburg State Chemical - Pharmaceutical Academy, Prof. Popova Str. 14, Saint Petersburg, 197376, Russian Federation
| | - Jurjen Duintjer Tebbens
- Department of Biophysics and Physical Chemistry, Faculty of Pharmacy in Hradec Kralove, Charles University, Heyrovskeho 1203, Hradec Kralove, 50005, Czech Republic
| | - Jiri Vlcek
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Heyrovskeho 1203, Hradec Kralove, 50005, Czech Republic
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Moura ML, Boszczowski I, Mortari N, Barrozo LV, Neto FC, Lobo RD, Pedroso de Lima AC, Levin AS. The Impact of Restricting Over-the-Counter Sales of Antimicrobial Drugs: Preliminary Analysis of National Data. Medicine (Baltimore) 2015; 94:e1605. [PMID: 26402824 PMCID: PMC4635764 DOI: 10.1097/md.0000000000001605] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
To describe the nationwide impact of a restrictive law on over-the-counter sales of antimicrobial drugs, implemented in Brazil in November 2010. Approximately 75% of the population receives healthcare from the public health system and receives free-of-charge medication if prescribed. Total sales in private pharmacies as compared with other channels of sales of oral antibiotics were evaluated in this observational study before and after the law (2008-2012). Defined daily dose per 1000 inhabitants per day (DDD/TID) was used as standard unit. In private pharmacies the effect of the restrictive law was statistically significant (P < 0.001) with an estimated decrease in DDD/TID of 1.87 (s.e. = 0.18). In addition, the trend of DDD/TID before the restrictive law was greater than after the intervention (P < 0.001). Before November 2010, the slope for the trend line was estimated as 0.08 (s.e. = 0.01) whereas after the law, the estimated slope was 0.03 (s.e. = 0.01). As for the nonprivate channels, no difference in sales was observed (P = 0.643). The impact in the South and Southeast (more developed) regions was higher than in the North, Northeast, and Mid-West. The state capitals had a 19% decrease, compared with 0.8% increase in the rest of the states. Before the law, the sales of antimicrobial drugs were steadily increasing. From November 2010, with the restrictive law, there was an abrupt drop in sales followed by an increase albeit at a significantly lower rate. The impact was higher in regions with better socio-economic status.
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Affiliation(s)
- Maria Luísa Moura
- From the Infection Control Department, Hospital das Clínicas (MLM, IB, NM, RDL, ASL); Department of Geography, Faculdade de Filosofia, Letras e Ciências Humanas (LVB); Department of Epidemiology, Faculdade de Saúde Pública (FCN); Department of Statistics, Institute of Mathematics and Statistics, (ACPDL); and Department of Infectious Diseases and LIM 54, Faculdade de Medicina, University of São Paulo, São Paulo, Brazil (ASL)
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Drobniewski F, Nikolayevskyy V, Maxeiner H, Balabanova Y, Casali N, Kontsevaya I, Ignatyeva O. Rapid diagnostics of tuberculosis and drug resistance in the industrialized world: clinical and public health benefits and barriers to implementation. BMC Med 2013; 11:190. [PMID: 23987891 PMCID: PMC3765611 DOI: 10.1186/1741-7015-11-190] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 08/02/2013] [Indexed: 02/06/2023] Open
Abstract
In this article, we give an overview of new technologies for the diagnosis of tuberculosis (TB) and drug resistance, consider their advantages over existing methodologies, broad issues of cost, cost-effectiveness and programmatic implementation, and their clinical as well as public health impact, focusing on the industrialized world. Molecular nucleic-acid amplification diagnostic systems have high specificity for TB diagnosis (and rifampicin resistance) but sensitivity for TB detection is more variable. Nevertheless, it is possible to diagnose TB and rifampicin resistance within a day and commercial automated systems make this possible with minimal training. Although studies are limited, these systems appear to be cost-effective. Most of these tools are of value clinically and for public health use. For example, whole genome sequencing of Mycobacterium tuberculosis offers a powerful new approach to the identification of drug resistance and to map transmission at a community and population level.
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Affiliation(s)
- Francis Drobniewski
- Public Health England National Mycobacterium Reference Laboratory, 2 Newark Street, London E1 2AT, UK.
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7
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Jaruseviciene L, Radzeviciene Jurgute R, Bjerrum L, Jurgutis A, Jarusevicius G, Lazarus JV. Enabling factors for antibiotic prescribing for upper respiratory tract infections: perspectives of Lithuanian and Russian general practitioners. Ups J Med Sci 2013; 118:98-104. [PMID: 23521359 PMCID: PMC3633337 DOI: 10.3109/03009734.2013.778925] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION General practitioners (GPs) write about 80% of all antibiotic prescriptions, the greatest number of them for patients with respiratory tract infections. However, there is a lack of research targeting the influence of external factors on antibiotic prescribing by physicians. This study aimed to explore experiences of GPs in Lithuania and the Russian Federation with regard to antibiotic prescription for upper respiratory tract infections. By such means it might be possible to reveal external enabling factors that influence antibiotic prescribing in these countries. METHOD Five focus groups were performed with 22 GPs from Lithuania and 29 GPs from the Kaliningrad Region of the Russian Federation; then, thematic analysis of data was performed. RESULTS Six thematic categories were identified that are related to external forces enabling antibiotic prescription: the necessity for political leadership to encourage clinically grounded antibiotic use; over-the-counter sale of antibiotics; designation of antibiotics as reimbursable medications; supervision by external oversight institutions; lack of guidelines for the treatment of upper respiratory tract infections; and pharmaceutical company activities. CONCLUSIONS Comprehensive efforts to reduce the burden of non-clinically grounded antibiotic prescription should go beyond addressing factors at the physician-patient level and take into account important factors in the enabling environment as well.
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Affiliation(s)
- Lina Jaruseviciene
- Department of Family Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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8
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Hughes LA, Pinchbeck G, Callaby R, Dawson S, Clegg P, Williams N. Antimicrobial prescribing practice in UK equine veterinary practice. Equine Vet J 2012; 45:141-7. [PMID: 22994559 DOI: 10.1111/j.2042-3306.2012.00602.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
REASONS FOR PERFORMING STUDY Antimicrobial use is known to select for the emergence of resistant strains of bacteria; therefore prudent use in both human and veterinary medicine is essential to preserve their efficacy. OBJECTIVES To characterise antimicrobial prescribing patterns in UK equine practice and evaluate factors associated with prescribing. METHODS A postal questionnaire including 4 clinical scenarios was sent to 740 veterinary surgeons that treat horses. Data were collected on the clinician, their practice and sources of information regarding antimicrobials and their use. Multivariable logistic regression analysis was used to ascertain factors associated with 5 outcomes; prescribing off-licence drugs; prescribing at incorrect doses; prescribing 3rd or 4th generation cephalosporins; prescribing fluoroquinolones and prescribing potentiated sulphonamides. RESULTS Questionnaires were completed by 38% of veterinary surgeons who were sent questionnaires. Less than 1% of practices had antimicrobial use guidelines. Trimethoprim-sulphonamides were most commonly prescribed in each clinical scenario. Eleven percent of prescriptions were for antimicrobial drugs not licensed for use in horses in the UK. Five percent of prescriptions for licensed antimicrobials were under the recommended dose rate and 56% over the recommended dose rate. Fluoroquinolones and 3rd and 4th generation cephalosporins accounted for 1 and 3% of prescriptions, respectively. Veterinary surgeons working at referral practices were more likely to prescribe 3rd and 4th generation cephalosporins and fluoroquinolones and off-licence antimicrobials whereas those working in first-opinion practices were more likely to prescribe potentiated sulphonamides. Sources of information regarding antimicrobials also had an effect on prescribing. CONCLUSIONS AND POTENTIAL RELEVANCE Prescription of antimicrobials at inappropriate doses was common even when provided with the weight of the animal. It is uncommon for UK equine veterinary practices to have guidelines for antimicrobial use. The introduction of such guidelines could lead to more prudent use of antimicrobials.
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Affiliation(s)
- L A Hughes
- Department of Epidemiology and Population Health Group, Institute of Infection and Global Health, School of Veterinary Science, University of Liverpool, Neston, UK
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9
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Dalhoff A. Resistance surveillance studies: a multifaceted problem--the fluoroquinolone example. Infection 2012; 40:239-62. [PMID: 22460782 DOI: 10.1007/s15010-012-0257-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 03/09/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This review summarizes data on the fluoroquinolone resistance epidemiology published in the previous 5 years. MATERIALS AND METHODS The data reviewed are stratified according to the different prescription patterns by either primary- or tertiary-care givers and by indication. Global surveillance studies demonstrate that fluoroquinolone- resistance rates increased in the past several years in almost all bacterial species except Staphylococcus pneumoniae and Haemophilus influenzae causing community-acquired respiratory tract infections (CARTIs), as well as Enterobacteriaceae causing community-acquired urinary tract infections. Geographically and quantitatively varying fluoroquinolone resistance rates were recorded among Gram-positive and Gram-negative pathogens causing healthcare-associated respiratory tract infections. One- to two-thirds of Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) were fluoroquinolone resistant too, thus, limiting the fluoroquinolone use in the treatment of community- as well as healthcare-acquired urinary tract and intra-abdominal infections. The remaining ESBL-producing or plasmid-mediated quinolone resistance mechanisms harboring Enterobacteriaceae were low-level quinolone resistant. Furthermore, 10-30 % of H. influenzae and S. pneumoniae causing CARTIs harbored first-step quinolone resistance determining region (QRDR) mutations. These mutants pass susceptibility testing unnoticed and are primed to acquire high-level fluoroquinolone resistance rapidly, thus, putting the patient at risk. The continued increase in fluoroquinolone resistance affects patient management and necessitates changes in some current guidelines for the treatment of intra-abdominal infections or even precludes the use of fluoroquinolones in certain indications like gonorrhea and pelvic inflammatory diseases in those geographic areas in which fluoroquinolone resistance rates and/or ESBL production is high. Fluoroquinolone resistance has been selected among the commensal flora colonizing the gut, nose, oropharynx, and skin, so that horizontal gene transfer between the commensal flora and the offending pathogen as well as inter- and intraspecies recombinations contribute to the emergence and spread of fluoroquinolone resistance among pathogenic streptococci. Although interspecies recombinations are not yet the major cause for the emergence of fluoroquinolone resistance, its existence indicates that a large reservoir of fluoroquinolone resistance exists. Thus, a scenario resembling that of a worldwide spread of β-lactam resistance in pneumococci is conceivable. However, many resistance surveillance studies suffer from inaccuracies like the sampling of a selected patient population, restricted geographical sampling, and undefined requirements of the user, so that the results are biased. The number of national centers is most often limited with one to two participating laboratories, so that such studies are point prevalence but not surveillance studies. Selected samples are analyzed predominantly as either hospitalized patients or patients at risk or those in whom therapy failed are sampled; however, fluoroquinolones are most frequently prescribed by the general practitioner. Selected sampling results in a significant over-estimation of fluoroquinolone resistance in outpatients. Furthermore, the requirements of the users are often not met; the prescribing physician, the microbiologist, the infection control specialist, public health and regulatory authorities, and the pharmaceutical industry have diverse interests, which, however, are not addressed by different designs of a surveillance study. Tools should be developed to provide customer-specific datasets. CONCLUSION Consequently, most surveillance studies suffer from well recognized but uncorrected biases or inaccuracies. Nevertheless, they provide important information that allows the identification of trends in pathogen incidence and antimicrobial resistance.
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Affiliation(s)
- A Dalhoff
- Institute for Infection-Medicine, Christian-Albrechts University of Kiel and University Medical Center Schleswig-Holstein, Brunswiker Str. 4, 24105, Kiel, Germany.
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10
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Hughes LA, Williams N, Clegg P, Callaby R, Nuttall T, Coyne K, Pinchbeck G, Dawson S. Cross-sectional survey of antimicrobial prescribing patterns in UK small animal veterinary practice. Prev Vet Med 2012; 104:309-16. [PMID: 22225772 DOI: 10.1016/j.prevetmed.2011.12.003] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 11/30/2011] [Accepted: 12/01/2011] [Indexed: 10/14/2022]
Abstract
The increase in the prevalence of antimicrobial resistance has resulted in both human and veterinary antimicrobial use coming under increased scrutiny. The aim of this study was to characterise antimicrobial prescribing patterns in small-animal veterinary practices in the UK. A cross-sectional survey of UK small animal veterinarians was undertaken. A postal questionnaire to evaluate antimicrobial prescribing habits was sent to 900 clinicians. Data were collected on the clinicians, their practices and their sources of information regarding antimicrobials and their use. Respondents were asked if they would prescribe antimicrobials to animals described in four clinical scenarios, and, if so, to provide details of the prescription(s). Questionnaires were completed by 51% of the veterinarians. Only 3.5% of clinicians reported that their practice had an antimicrobial use policy. Penicillins were most commonly prescribed in three clinical scenarios, and 1st generation cephalosporins were most commonly prescribed in a scenario about canine pyoderma. In one scenario, fluoroquinolones and 3rd generation cephalosporins accounted for 10% and 13% of prescriptions respectively. Five percent of all prescriptions were under the recommended dose and 20% were over the recommended dose. Overall, 2.3% of prescriptions were not licensed for use in dogs or cats in the UK. Associations between the use of various antimicrobial drugs and independent variables were analysed using multivariable logistic regression models. Off-license prescriptions and inaccurate dosing of antimicrobials by small-animal clinicians in the UK appears to occur. Antimicrobial use guidelines are rare in small animal practice. The introduction of such guidelines has been shown to lead to more appropriate use of antimicrobials and is therefore recommended.
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Affiliation(s)
- Laura A Hughes
- University of Liverpool, School of Veterinary Science, Leahurst Campus, Chester High Road, Neston, CH64 7TE, UK.
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van der Werf MJ, Langendam MW, Huitric E, Manissero D. Knowledge of tuberculosis-treatment prescription of health workers: a systematic review. Eur Respir J 2011; 39:1248-55. [PMID: 22183482 PMCID: PMC3342767 DOI: 10.1183/09031936.00125611] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Treating tuberculosis (TB) patients with inappropriate treatment regimens can lead to treatment failure and, thus, patients who have not been cured and/or to the development of (multi)-drug resistance. A systematic review was performed to assess the knowledge of appropriate TB drug regimens among all categories of healthcare workers (HCWs). In January 2011, MEDLINE, EMBASE and other databases were searched for relevant articles. Observational studies published as of the year 2000 that assessed HCW knowledge of TB treatment were selected. A treatment regimen, drug dosage or treatment duration was considered inappropriate if it was not recommended by national guidelines or by the World Health Organization (WHO). Of 1,896 studies, 31 were included from 14 different countries. No study was performed in Europe. In all studies, HCWs with inappropriate knowledge of treatment regimens (8–100%) or treatment duration (5–99%) were observed. The few studies providing detailed data showed that HCWs mainly reported giving treatment regimens with too many drugs and for too long. Knowledge of appropriate doses was also insufficient in most studies. The available studies show that there is a lack of knowledge of national or international TB treatment guidelines and recommendations. Generalisation of the findings to other settings and countries should be done with caution.
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Non-prescription antimicrobial use worldwide: a systematic review. THE LANCET. INFECTIOUS DISEASES 2011; 11:692-701. [PMID: 21659004 DOI: 10.1016/s1473-3099(11)70054-8] [Citation(s) in RCA: 534] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In much of the world antimicrobial drugs are sold without prescription or oversight by health-care professionals. The scale and effect of this practice is unknown. We systematically reviewed published works about non-prescription antimicrobials from 1970-2009, identifying 117 relevant articles. 35 community surveys from five continents showed that non-prescription use occurred worldwide and accounted for 19-100% of antimicrobial use outside of northern Europe and North America. Safety issues associated with non-prescription use included adverse drug reactions and masking of underlying infectious processes. Non-prescription use was common for non-bacterial disease, and antituberculosis drugs were available in many areas. Antimicrobial-resistant bacteria are common in communities with frequent non-prescription use. In a few settings, control efforts that included regulation decreased antimicrobial use and resistance. Non-prescription antimicrobial and antituberculosis use is common outside of North America and northern Europe and must be accounted for in public health efforts to reduce antimicrobial resistance.
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Balabanova Y, Nikolayevskyy V, Ignatyeva O, Kontsevaya I, Rutterford CM, Shakhmistova A, Malomanova N, Chinkova Y, Mironova S, Fedorin I, Drobniewski FA. Survival of civilian and prisoner drug-sensitive, multi- and extensive drug- resistant tuberculosis cohorts prospectively followed in Russia. PLoS One 2011; 6:e20531. [PMID: 21695213 PMCID: PMC3112205 DOI: 10.1371/journal.pone.0020531] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/04/2011] [Indexed: 11/18/2022] Open
Abstract
Objective and Methods A long-term observational study was conducted in Samara, Russia to assess the survival and risk factors for death of a cohort of non-multidrug resistant tuberculosis (non-MDRTB) and multidrug resistant tuberculosis (MDRTB) civilian and prison patients and a civilian extensive drug-resistant tuberculosis (XDRTB) cohort. Results MDRTB and XDRTB rates of 54.8% and 11.1% were identified in the region. Half (50%) of MDRTB patients and the majority of non-MDRTB patients (71%) were still alive at 5 years. Over half (58%) of the patients died within two years of establishing a diagnosis of XDRTB. In the multivariate analysis, retreatment (HR = 1.61, 95%CI 1.04, 2.49) and MDRTB (HR = 1.67, 95%CI 1.17, 2.39) were significantly associated with death within the non-MDR/MDRTB cohort. The effect of age on survival was relatively small (HR = 1.01, 95%CI 1.00, 1.02). No specific factor affected survival of XDRTB patients although median survival time for HIV-infected versus HIV-negative patients from this group was shorter (185 versus 496 days). The majority of MDRTB and XDRTB strains (84% and 92% respectively) strains belonged to the Beijing family. Mutations in the rpoB (codon 531 in 81/92; 88.8%), katG (mutation S315T in 91/92, 98.9%) and inhA genes accounted for most rifampin and isoniazid resistance respectively, mutations in the QRDR region of gyrA for most fluroquinolone resistance (68/92; 73.5%). Conclusions Alarmingly high rates of XDRTB exist. Previous TB treatment cycles and MDR were significant risk factors for mortality. XDRTB patients' survival is short especially for HIV-infected patients. Beijing family strains comprise the majority of drug-resistant strains.
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Affiliation(s)
- Yanina Balabanova
- Queen Mary College, Barts and the London School of Medicine, University of London, London, United Kingdom.
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Valcheva V, Mokrousov I. Drug-Resistance in Mycobacterium Tuberculosis:Molecular Basis and Genotypic Detection. BIOTECHNOL BIOTEC EQ 2011. [DOI: 10.5504/bbeq.2011.0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Chen TC, Lu PL, Lin CY, Lin WR, Chen YH. Fluoroquinolones are associated with delayed treatment and resistance in tuberculosis: a systematic review and meta-analysis. Int J Infect Dis 2010; 15:e211-6. [PMID: 21195001 DOI: 10.1016/j.ijid.2010.11.008] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 10/14/2010] [Accepted: 11/20/2010] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Current guidelines for treating community-acquired pneumonia recommend the use of fluoroquinolones for high-risk patients. Previous studies have reported controversial results as to whether fluoroquinolones are associated with delayed diagnosis and treatment of pulmonary tuberculosis (TB) and the development of fluoroquinolone-resistant Mycobacterium tuberculosis. We performed a systematic review and meta-analysis to clarify these issues. METHODS The following databases were searched through September 30, 2010: PubMed, EMBASE, CINAHL, Cochrane Library, Web of Science, BIOSIS Previews, and the ACP Journal Club. We considered studies that addressed the issues of delay in diagnosis and treatment of TB and the development of resistance. RESULTS Nine eligible studies (four for delays and five for resistance issues) were included in the meta-analysis from the 770 articles originally identified in the database search. The mean duration of delayed diagnosis and treatment of pulmonary TB in the fluoroquinolone prescription group was 19.03 days, significantly longer than that in the non-fluoroquinolone group (95% confidence interval (CI) 10.87 to 27.18, p<0.001). The pooled odds ratio of developing a fluoroquinolone-resistant M. tuberculosis strain was 2.70 (95% CI 1.30 to 5.60, p=0.008). No significant heterogeneity was found among studies in the meta-analysis. CONCLUSIONS Empirical fluoroquinolone prescriptions for pneumonia are associated with longer delays in diagnosis and treatment of pulmonary TB and a higher risk of developing fluoroquinolone-resistant M. tuberculosis.
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Affiliation(s)
- Tun-Chieh Chen
- Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
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Bishai JD, Bishai WR, Bishai DM. Heightened vulnerability to MDR-TB epidemics after controlling drug-susceptible TB. PLoS One 2010; 5:e12843. [PMID: 20877639 PMCID: PMC2943899 DOI: 10.1371/journal.pone.0012843] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 08/08/2010] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prior infection with one strain TB has been linked with diminished likelihood of re-infection by a new strain. This paper attempts to determine the role of declining prevalence of drug-susceptible TB in enabling future epidemics of MDR-TB. METHODS A computer simulation of MDR-TB epidemics was developed using an agent-based model platform programmed in NetLogo (See http://mdr.tbtools.org/). Eighty-one scenarios were created, varying levels of treatment quality, diagnostic accuracy, microbial fitness cost, and the degree of immunogenicity elicited by drug-susceptible TB. Outcome measures were the number of independent MDR-TB cases per trial and the proportion of trials resulting in MDR-TB epidemics for a 500 year period after drug therapy for TB is introduced. RESULTS MDR-TB epidemics propagated more extensively after TB prevalence had fallen. At a case detection rate of 75%, improving therapeutic compliance from 50% to 75% can reduce the probability of an epidemic from 45% to 15%. Paradoxically, improving the case-detection rate from 50% to 75% when compliance with DOT is constant at 75% increases the probability of MDR-TB epidemics from 3% to 45%. CONCLUSIONS The ability of MDR-TB to spread depends on the prevalence of drug-susceptible TB. Immunologic protection conferred by exposure to drug-susceptible TB can be a crucial factor that prevents MDR-TB epidemics when TB treatment is poor. Any single population that successfully reduces its burden of drug-susceptible TB will have reduced herd immunity to externally or internally introduced strains of MDR-TB and can experience heightened vulnerability to an epidemic. Since countries with good TB control may be more vulnerable, their self interest dictates greater promotion of case detection and DOTS implementation in countries with poor control to control their risk of MDR-TB.
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Affiliation(s)
- Jason D. Bishai
- School of Humanities and Sciences, Stanford University, Stanford, California, United States of America
| | - William R. Bishai
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - David M. Bishai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
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Rechel B, Spencer N, Blackburn C, Rechel B. Policy challenges to the quality of child health services in Bulgaria. Int J Health Plann Manage 2010; 25:350-67. [DOI: 10.1002/hpm.1030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Valcheva V, Mokrousov I, Narvskaya O, Rastogi N, Markova N. Molecular snapshot of drug-resistant and drug-susceptible Mycobacterium tuberculosis strains circulating in Bulgaria. INFECTION GENETICS AND EVOLUTION 2008; 8:657-63. [DOI: 10.1016/j.meegid.2008.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 06/26/2008] [Accepted: 06/26/2008] [Indexed: 11/26/2022]
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Danichevski K, McKee M, Balabanova D. Prescribing in maternity care in Russia: The legacy of Soviet medicine. Health Policy 2008; 85:242-51. [PMID: 17854946 DOI: 10.1016/j.healthpol.2007.08.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 08/01/2007] [Accepted: 08/02/2007] [Indexed: 11/29/2022]
Abstract
Remarkably, there has been very little detailed research on clinical practice in Russia and its neighbours in what was the USSR, even though it is known that the USSR was isolated from many international developments, in particular evidence-based medicine. In this study we examine obstetric practice, an area of practice where there is an extensive body of evidence on the appropriateness of many interventions. The study is undertaken in Tula, a region 200 km south of Moscow. Building on earlier detailed analyses of data from the facilities in the region, it reports a series of structured interviews with 52 obstetricians from all 19 facilities in the region, designed to identify patterns of prescribing, supplemented by 36 more detailed re-interviews to explore reasons for the differing practices. The study demonstrates a widespread divergence from internationally accepted practice. Maternity care is extremely medicalised but many non-evidence based medicines are used. Some are heavily marketed by large pharmaceutical companies, some were widely used during the Soviet period but never evaluated, and a few are not known to be used anywhere else in the world. For several conditions, the most widely used drugs are clearly inferior to alternative products and some are used for indications quite different from those in other countries. This study contributes to the growing evidence that much of the care provided in Russian maternity units is ineffective or potentially dangerous but also begins to offer some explanations for why this is, including a lack of access to information and a lack of awareness of the concept of evidence-based practice.
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Balabanova Y, Drobniewski F, Fedorin I, Zakharova S, Nikolayevskyy V, Atun R, Coker R. The Directly Observed Therapy Short-Course (DOTS) strategy in Samara Oblast, Russian Federation. Respir Res 2006; 7:44. [PMID: 16556324 PMCID: PMC1440858 DOI: 10.1186/1465-9921-7-44] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 03/23/2006] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The World Health Organisation (WHO) defines Russia as one of the 22 highest-burden countries for tuberculosis (TB). The WHO Directly Observed Treatment Short Course (DOTS) strategy employing a standardised treatment for 6 months produces the highest cure rates for drug sensitive TB. The Russian TB service traditionally employed individualised treatment. The purpose of this study was to implement a DOTS programme in the civilian and prison sectors of Samara Region of Russia, describe the clinical features and outcomes of recruited patients, determine the proportion of individuals in the cohorts who were infected with drug resistant TB, the degree to which resistance was attributed to the Beijing TB strain family and establish risk factors for drug resistance. METHODS Prospective study. RESULTS 2,099 patients were recruited overall. Treatment outcomes were analysed for patients recruited up to the third quarter of 2003 (n = 920). 75.3% of patients were successfully treated. Unsuccessful outcomes occurred in 7.3% of cases; 3.6% of patients died during treatment, with a significantly higher proportion of smear-positive cases dying compared to smear-negative cases. 14.0% were lost and transferred out. A high proportion of new cases (948 sequential culture-proven TB cases) had tuberculosis that was resistant to first-line drugs; (24.9% isoniazid resistant; 20.3% rifampicin resistant; 17.3% multidrug resistant tuberculosis). Molecular epidemiological analysis demonstrated that half of all isolated strains (50.7%; 375/740) belonged to the Beijing family. Drug resistance including MDR TB was strongly associated with infection with the Beijing strain (for MDR TB, 35.2% in Beijing strains versus 9.5% in non-Beijing strains, OR-5.2. Risk factors for multidrug resistant tuberculosis were: being a prisoner (OR 4.4), having a relapse of tuberculosis (OR 3.5), being infected with a Beijing family TB strain (OR 6.5) and having an unsuccessful outcome from treatment (OR 5.0). CONCLUSION The implementation of DOTS in Samara, Russia, was feasible and successful. Drug resistant tuberculosis rates in new cases were high and challenge successful outcomes from a conventional DOTS programme alone.
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Affiliation(s)
- Y Balabanova
- HPA Mycobacterium Reference Unit, Clinical TB and HIV Group, St Bartholomew and Queen Mary School of Medicine, 2 Newark street, London E1 2AT, UK
- Samara City Tuberculosis Dispensary N1, Pionerskaya street, Samara, 443001, Russia
| | - F Drobniewski
- HPA Mycobacterium Reference Unit, Clinical TB and HIV Group, St Bartholomew and Queen Mary School of Medicine, 2 Newark street, London E1 2AT, UK
| | - I Fedorin
- Samara Oblast Tuberculosis Dispensary, Samara, 154 Novo-Sadovaya Street, 443068, Russia
| | - S Zakharova
- Samara City Tuberculosis Dispensary N1, Pionerskaya street, Samara, 443001, Russia
| | - V Nikolayevskyy
- HPA Mycobacterium Reference Unit, Clinical TB and HIV Group, St Bartholomew and Queen Mary School of Medicine, 2 Newark street, London E1 2AT, UK
| | - R Atun
- Center for Health Management, Tanaka Business School, Imperial College London, South Kensington campus, London SW7 2AZ, UK
| | - R Coker
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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Pardini M, Iona E, Varaine F, Karakozian H, Arzumanian H, Brunori L, Orefici G, Fattorini L. Mycobacterium tuberculosis drug resistance, Abkhazia. Emerg Infect Dis 2005; 11:501-3. [PMID: 15789491 PMCID: PMC3298253 DOI: 10.3201/eid1103.040903] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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