Combatting antimicrobial resistance in Nepal: the need for precision surveillance programmes and multi-sectoral partnership

Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review

Background

A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal.

Methods

This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes.

Results

A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community.

Conclusion

Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors.

Systematic review registration

DOI: 10.17605/OSF.IO/FV326.

In vitro and in silico studies of enterobactin-inspired Ciprofloxacin and Fosfomycin first generation conjugates on the antibiotic resistant E. coli OQ866153

BACKGROUND

The emergence of antimicrobial resistance in bacterial pathogens is a growing concern worldwide due to its impact on the treatment of bacterial infections. The "Trojan Horse" strategy has been proposed as a potential solution to overcome drug resistance caused by permeability issues.

OBJECTIVE

The objective of our research was to investigate the bactericidal activity and mechanism of action of the "Trojan Horse" strategy using enterobactin conjugated with Ciprofloxacin and Fosfomycin against the antibiotic-resistant Escherichia coli strain OQ866153.

METHODOLOGY

Enterobactin, a mixed ligand of E. coli OQ866153, was conjugated with Ciprofloxacin and Fosfomycin individually to aid active absorption via specific enterobactin binding proteins (FepABCDG). The effectiveness of the conjugates was assessed by measuring their bactericidal activity against E. coli OQ866153, as well as their ability to inhibit DNA gyrase enzyme and biofilm formation.

RESULTS

The Fe+3-enterobactin-Ciprofloxacin conjugate effectively inhibited the DNA gyrase enzyme (Docking score = -8.597 kcal/mol) and resulted in a lower concentration (25 μg/ml) required to eliminate supercoiled DNA plasmids compared to the parent drug (35 μg/ml; Docking score = -6.264 kcal/mol). The Fe+3-Enterobactin-Fosfomycin conjugate showed a higher inhibition percentage (100%) of biofilm formation compared to Fosfomycin (21.58%) at a concentration of 2 mg/ml, with docking scores of -5.481 and -3.756 kcal/mol against UDP-N acetylglucosamine 1-carboxyvinyltransferase MurA.

CONCLUSION

The findings of this study suggest that the "Trojan Horse" strategy using enterobactin conjugated with Ciprofloxacin and Fosfomycin can effectively overcome permeability issues caused by efflux proteins and enhance the bactericidal activity of these drugs against antibiotic-resistant strains of E. coli.

Exploring community insights on antimicrobial resistance in Nepal: a formative qualitative study

BACKGROUND

Antimicrobial resistance (AMR) is the process by which microbes evolve mechanisms to survive the medicines designed to destroy them i.e. antimicrobials (AMs). Despite being a natural process, AMR is being hastened by the abuse of AMs. In context of Nepal, there is limited information on drivers of AMR and barriers in addressing it from a community perspective. This study explores the local language and terminology used around AMs in the community, commonly used AMs and reasons for their usage, how these AMs are sourced, and the perceived barriers to addressing AMR via One Health approach.

METHODS

A phenomenological study design was utilized with applied qualitative research theoretically framed as pragmatism. Twelve in-depth interviews and informal discussions with a One Health focus, were purposively conducted with wide range of stakeholders and community resident of Kapilvastu municipality of Nepal during April 2022. The acquired data was analyzed manually via a thematic framework approach. The study obtained ethical approval from ethical review board of Nepal Health Research Council and University of Leeds.

RESULTS

Nepali and Awadhi languages does not have specific words for AMs or AMR, which is understandable by the community people. Rather, community use full explanatory sentences. People use AMs but have incomplete knowledge about them and they have their own local words for these medicines. The knowledge and usage of AMs across human and animal health is impacted by socio-structural factors, limited Government regulation, inadequate supply of AMs in local government health facilities and the presence of various unregulated health providers that co-exist within the health system. Novel ideas such as the use of visual and smart technology, for instance mobile phones and social media exposure, can enable access to information about AMs and AMR.

CONCLUSION

This study shows that terminology that is understandable by the community referring to AMs and AMR in Nepali and Awadhi languages does not exist, but full explanatory sentences and colloquial names are used. Despite regular utilisation, communities have incomplete knowledge regarding AMs. Since, knowledge alone cannot improve behaviour, behavioural interventions are required to address AMR via community engagement to co-produce their own solutions.

TRIAL REGISTRATION

Not applicable.

A Qualitative Study on the Policy Process and Development of the National Action Plan on Antimicrobial Resistance in Singapore

The global public health threat of antimicrobial resistance (AMR) has been accelerated by many interrelated factors spanning across One Health-human health, animal health, and the environment. Singapore launched its own National Strategic Action Plan (NSAP) on AMR in November 2017 with the aim of tackling the growing threat of AMR in Singapore through coordinated approaches. However, little is known about the policy process and development of the NSAP in Singapore. In this study, we analysed these aspects using an AMR governance framework. In-depth interviews were conducted with 20 participants across the One Health spectrum. The interviews were transcribed verbatim and analysed thematically. Areas that were well executed included (1) good coordination across various agencies, (2) a dedicated office to coordinate the work on the NSAP, and (3) a high level of governmental support. Areas that were lacking included (1) a lack of participation from certain sectors, (2) insufficient awareness around the AMR issue, (3) constraints in information sharing, and (4) a lack of ideal indicators to track the progress in addressing AMR. Improvements in these areas will provide a more holistic One Health engagement in support of the effective planning and implementation of the NSAP.

Community engagement: The key to tackling Antimicrobial Resistance (AMR) across a One Health context?

Antimicrobial resistance (AMR) is a One Health problem underpinned by complex drivers and behaviours. This is particularly so in low - and middle-income countries (LMICs), where social and systemic factors fuel (mis)use and drive AMR. Behavioural change around antimicrobial use could safeguard both existing and future treatments. However, changing behaviour necessitates engaging with people to understand their experiences. This publication describes a knowledge-exchange cluster of six LMIC-based projects who co-designed and answered a series of research questions around the usage of Community Engagement (CE) within AMR. Findings suggest that CE can facilitate AMR behaviour change, specifically in LMICs, because it is a contextualised approach which supports communities to develop locally meaningful solutions. However, current CE interventions focus on human aspects, and demand-side drivers, of AMR. Our cluster suggests that broader attention should be paid to AMR as a One Health issue. The popularity of mixed methods approaches within existing CE for AMR interventions suggests there is interdisciplinary interest in the uptake of CE. Unfortunately, the specificity and context-dependency of CE can make it difficult to evaluate and scale. Nevertheless, we suggest that in synthesising learnings from CE, we can develop a collective understanding of its scope to tackle AMR across contexts.   .

The Role of Antimicrobial Peptides as Antimicrobial and Antibiofilm Agents in Tackling the Silent Pandemic of Antimicrobial Resistance

Just over a million people died globally in 2019 due to antibiotic resistance caused by ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species). The World Health Organization (WHO) also lists antibiotic-resistant Campylobacter and Helicobacter as bacteria that pose the greatest threat to human health. As it is becoming increasingly difficult to discover new antibiotics, new alternatives are needed to solve the crisis of antimicrobial resistance (AMR). Bacteria commonly found in complex communities enclosed within self-produced matrices called biofilms are difficult to eradicate and develop increased stress and antimicrobial tolerance. This review summarises the role of antimicrobial peptides (AMPs) in combating the silent pandemic of AMR and their application in clinical medicine, focusing on both the advantages and disadvantages of AMPs as antibiofilm agents. It is known that many AMPs display broad-spectrum antimicrobial activities, but in a variety of organisms AMPs are not stable (short half-life) or have some toxic side effects. Hence, it is also important to develop new AMP analogues for their potential use as drug candidates. The use of one health approach along with developing novel therapies using phages and breakthroughs in novel antimicrobial peptide synthesis can help us in tackling the problem of AMR.

Antimicrobial Use and Resistance in Agriculture and Food Production Systems in Africa: A Systematic Review

In Africa, there is dearth of information on antimicrobial use (AMU) in agriculture and food production systems and its consequential resistance in pathogens that affect animal, human and environmental health. Data published between 1980 and 2021 on the magnitude of AMU and AMR in agriculture and food productions systems in Africa were reviewed. Data from 13-27 countries in Africa indicate that 3558-4279 tonnes of antimicrobials were used in animals from 2015 to 2019. Tetracyclines and polypeptides contributed the largest proportion of antimicrobials used. Cattle and poultry production account for the largest consumption of antimicrobials in Africa. Although limited studies have reported AMR in crops, fish and beekeeping, AMR from a variety of farm animals has been substantially documented in Africa. Some countries in Africa have developed policies/plans to address AMU and AMR in agriculture and food production systems; however, their enforcement is challenged by weak regulations. In conclusion, although there is limited information on the quantities of antimicrobials used in agriculture and food production system, the levels of AMR are high. There is a need to strengthen regulatory authorities with a capacity to monitor AMU in agriculture and food production systems in Africa.

The Governance and Implementation of the National Action Plan on Antimicrobial Resistance in Tanzania: A Qualitative Study

Tanzania launched its first National Action Plan (NAP) on antimicrobial resistance (AMR) in 2017 to reduce the burden of AMR in the country and contribute to the global response. We aimed to analyze the implementation of the NAP on AMR in Tanzania using the governance framework. In-depth interviews were conducted with human and animal health practitioners and national-level policy actors. We adapted Chua's AMR governance framework to analyze the development and implementation of the NAP in Tanzania. Implementation of the NAP has realized several achievements, including: (i) the establishment of a functioning Multi-Sectoral Coordinating Committee for coordinating the implementation of AMR activities; (ii) existence of governance structure; (iii) establishment of human and animal surveillance sites; (iv) creation of AMR awareness in the community and (v) availability of guidelines at the health facility level to ensure AMR stewardship. However, some dimensions of the governance areas, including reporting and feedback mechanisms, accountability, transparency and sustainability of AMR plans, are not effectively implemented. Addressing these challenges should involve strengthening the collaboration of the different sectors involved at different NAP implementation levels by careful planning and coordination, and provision of adequate resources to ensure sustainability.

Policy implications for awareness gaps in antimicrobial resistance (AMR) and antimicrobial use among commercial Nepalese poultry producers

BACKGROUND

Nepal's poultry industry has increased with a growing middle class, which has translated to an increase in antimicrobial consumption and thus a rise in antimicrobial resistance (AMR). Describing and understanding antimicrobial use practices among commercial poultry producers in Nepal may help minimize the risks of AMR development in both humans and animals and determine the effectiveness of relevant policies.

METHODS

From July to August 2018, poultry farmers were randomly recruited from Nepal's Chitwan District to participate in a cross-sectional study. The lead producer in each poultry operation was administered a quantitative structured-survey via a 30-min interview. Participants were asked to provide demographics, production practices, and knowledge about their antimicrobial use practices. Descriptive data analysis was performed to obtain frequencies and compare practices.

RESULTS

In total, 150 commercial poultry producers of whom raised between 300 and 40,000 birds completed the interviews. Only 33% (n = 49) of producers reported knowing what AMR was, and among them only 50% (n = 25) consulted a veterinarian for treatment options. Antimicrobial administration for growth promotion was still employed by 13% of poultry producers. Similarly, critically important antimicrobial drugs, specifically colistin, were identified at 35% of participating operations. Producers reported low overall understanding and compliance of withdrawal periods (n = 41; 27%), which may result in both AMR development and adverse health reactions among consumers who ingest antimicrobial residues. Although Nepal has publicized antimicrobial use policies and awareness campaigns to instill healthy production practices, most producers (82%) were unaware of them.

CONCLUSION

Many Nepalese poultry producers lack overall antimicrobial use and AMR awareness, which is evidenced by low antimicrobial withdrawal period compliance, use of antimicrobials for growth promotion, and the sustained use of critically important antimicrobials. Improved outreach and educational capacities, paired with increased veterinary resources and extensive monitoring in operations and retail meat products, may increase AMR awareness and policy enforcement.

Detection and characterization of ESBL-producing Enterobacteriaceae from the gut of subsistence farmers, their livestock, and the surrounding environment in rural Nepal

The increasing trend of gut colonization by extended-spectrum β-lactamase (ESBL) producing Enterobacterales has been observed in conventional farm animals and their owners. Still, such colonization among domesticated organically fed livestock has not been well studied. This study aimed to determine the gut colonization rate of ESBL-producing Enterobacteriaceae and carbapenemase-producing Enterobacteriaceae (CPE) among rural subsistence farming communities of the Kaski district in Nepal. Rectal swabs collected by systematic random sampling from 128 households of subsistence farming communities were screened for ESBL-producing Enterobacteriaceae and CPE by phenotypic and molecular methods. A total of 357 (57%) ESBL-producing Enterobacteriaceae isolates were obtained from 626 specimens, which included 97 ESBL-producing Enterobacteriaceae (75.8%) from 128 adult humans, 101 (79.5%) from 127 of their children, 51 (47.7%) from 107 cattle, 26 (51%) from 51 goats, 30 (34.9%) from 86 poultry and 52 (42%) from 127 environmental samples. No CPE was isolated from any of the samples. blaCTX-M-15 was the most predominant gene found in animal (86.8%) and human (80.5%) isolates. Out of 308 Escherichia coli isolates, 16 human and two poultry isolates were positive for ST131 and were of clade C. Among non-cephalosporin antibiotics, the resistance rates were observed slightly higher in tetracycline and ciprofloxacin among all study subjects. This is the first one-health study in Nepal, demonstrating the high rate of CTX-M-15 type ESBL-producing Enterobacteriaceae among gut flora of subsistence-based farming communities. Gut colonization by E. coli ST131 clade C among healthy farmers and poultry birds is a consequential public health concern.