The antimicrobial stewardship program in Gulf Cooperation Council (GCC) states: insights from a regional survey

The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq

Background

This study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy.

Methods

A cross-sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey.

Results

The majority of the participants (85.6%) strongly agreed/agreed that "antimicrobial stewardship programs reduce the problems of antibiotic resistance"; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection-control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6-10 years (p < 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3-5 years, and medical complex pharmacy (p < 0.001).

Conclusion

Community pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.

Origin of Antibiotics and Antibiotic Resistance, and Their Impacts on Drug Development: A Narrative Review

Antibiotics have revolutionized medicine, saving countless lives since their discovery in the early 20th century. However, the origin of antibiotics is now overshadowed by the alarming rise in antibiotic resistance. This global crisis stems from the relentless adaptability of microorganisms, driven by misuse and overuse of antibiotics. This article explores the origin of antibiotics and the subsequent emergence of antibiotic resistance. It delves into the mechanisms employed by bacteria to develop resistance, highlighting the dire consequences of drug resistance, including compromised patient care, increased mortality rates, and escalating healthcare costs. The article elucidates the latest strategies against drug-resistant microorganisms, encompassing innovative approaches such as phage therapy, CRISPR-Cas9 technology, and the exploration of natural compounds. Moreover, it examines the profound impact of antibiotic resistance on drug development, rendering the pursuit of new antibiotics economically challenging. The limitations and challenges in developing novel antibiotics are discussed, along with hurdles in the regulatory process that hinder progress in this critical field. Proposals for modifying the regulatory process to facilitate antibiotic development are presented. The withdrawal of major pharmaceutical firms from antibiotic research is examined, along with potential strategies to re-engage their interest. The article also outlines initiatives to overcome economic challenges and incentivize antibiotic development, emphasizing international collaborations and partnerships. Finally, the article sheds light on government-led initiatives against antibiotic resistance, with a specific focus on the Middle East. It discusses the proactive measures taken by governments in the region, such as Saudi Arabia and the United Arab Emirates, to combat this global threat. In the face of antibiotic resistance, a multifaceted approach is imperative. This article provides valuable insights into the complex landscape of antibiotic development, regulatory challenges, and collaborative efforts required to ensure a future where antibiotics remain effective tools in safeguarding public health.

Assessment of drug utilization pattern of antimicrobial agents in hospitalized patients with Infectious Diseases: A cross-sectional study in the United Arab Emirates

Efficacious use of antimicrobial agents (AMAs) is paramount to combat a wide range of infections, ensure patient safety, and reduce antimicrobial resistance. To assess the drug utilization patterns of AMAs in hospitalized patients with infectious diseases in a secondary care hospital. A prospective observational study was conducted for 6 months in the internal medicine department. Data were collected, antimicrobial prescription patterns were screened, and drug utilization was assessed using the anatomical therapeutic chemical/defined daily dose methodology. Furthermore, predictors of the prescription of multiple AMAs were also analyzed. A total of 146 patient case records were reviewed and 285 AMAs were prescribed during the study period with a mean patient age of 54.2 ± 24.4 years. The average number of antimicrobials administered per patient was 1.94 ± 0.94. Respiratory tract infection and urinary tract infection were the common indications, and penicillins were the most prescribed class of AMAs. Multivariate analysis showed that the presence of comorbidities (P < 0.05) and longer hospital stays (P < 0.0001) increased the likelihood of prescribing multiple AMAs. The study provides insight into the pattern of prescribing of AMAs which help to improve the quality of care. Prescribing AMAs by generics and from the hospital formulary list according to the recommendations of the World Health Organization is a good sign of clinical practice. The study signifies the need to continuously monitor AMAs to optimize drug therapy and enhance the quality of drug use in clinical practice.

Evaluation of inappropriate antibiotic prescribing and management through pharmacist-led antimicrobial stewardship programmes: a meta-analysis of evidence

Purpose

This meta-analysis aims to evaluate inappropriate antibiotic prescribing in the Gulf region and determine the effect of pharmacist-led antimicrobial stewardship (AMS) programmes on reducing inappropriateness.

Method

Articles were searched, analysed, and quality assessed through the risk of bias (ROB) quality assessment tool to select articles with a low level of bias. In step 1, 515 articles were searched, in step 2, 2360 articles were searched, and ultimately 32 articles were included by critical analysis. Statistical analysis used to determine risk ratio and standard mean differences were calculated using Review manager 5.4; 95% confidence intervals were calculated using the fixed-effect model. The I² statistic assessed heterogeneity. In statistical heterogeneity, subgroup and sensitivity analyses, a random effect model was performed. The α threshold was 0.05. The primary outcome was inappropriateness in antibiotic prescribing in the Gulf region and reduction of inappropriateness through AMS.

Result

Detailed review and analysis of 18 studies of inappropriate antibiotic prescribing in the Gulf region showed the risk of inappropriateness was 43 669/100 846=43.3% (pooled RR 1.31, 95% CI 1.30 to 1.32). Test with overall effect was 58.87; in the second step 28 AMS programmes led by pharmacists showed reduced inappropriateness in AMS with pharmacist versus pre-AMS without pharmacist (RR 0.36, 95% CI 0.32 to 0.39).

Conclusion

Inappropriate antibiotic prescribing in the Gulf region is alarming and needs to be addressed through pharmacist-led AMS programmes.

Promoting cross-regional collaboration in antimicrobial stewardship: Findings of an infectious diseases working group survey in Arab countries of the Middle East

BACKGROUND

Antimicrobial resistance is a significant global issue that presents an increasing threat to patients' wellbeing. Although a global concern, the emergence of multi-drug resistant organisms is of particular significance in the Middle East. In recent years, this region has seen an alarming increase in antimicrobial resistance presenting a major challenge to physicians managing various infectious diseases.

METHODS

A Working Group comprising experts in infectious diseases from Arab countries of Middle East assembled to review similarities and differences in antimicrobial practices and management of multi-drug resistant organisms across the region and assess the barriers to achieving cross-regional collaboration. The Working Group conducted an anonymous online survey to evaluate current practice and understanding of management of multi-drug resistant organisms across the region.

RESULTS

A total of 122 physicians from Arab countries of the Middle East responded to the survey. Their responses demonstrated heterogeneity between countries in awareness of local epidemiology, management of multi-drug resistant organisms and antimicrobial stewardship practices. The Working Group recognized similarities and differences in the management of multi-drug resistant organisms across the region, and these were validated by the data collected in the survey. Overall, the similarities across the region reflect several key issues that can have an impact on the management of multi-drug resistant organisms and the prevention of antimicrobial resistance.

CONCLUSIONS

This paper highlights the urgency of addressing antimicrobial resistance in Arab countries of the Middle East. The Working Group identified key barriers to effective management which may guide the development of future coherent strategies to promote effective antimicrobial stewardship in the region. Here, we outline a call to action for the region, with a need to focus on training and education, capacity building, infrastructure, regional research, and regional surveillance.

Molecular detection of carbapenem resistance genes in rectal swabs from patients in Gulf Cooperation Council hospitals

BACKGROUND

Gram-negative organisms harbouring carbapenem resistance genes (CRGs) are spreading globally, including in Gulf Cooperation Council (GCC) countries. However, relatively few data are available about carriage of CRGs in hospitalized patients in this region.

AIM

To determine prevalence of CRG carriage and risk factors for colonization among patients in GCC hospitals.

METHODS

Rectal swabs were obtained from ∼50 intensive care unit (ICU) patients from each of 11 hospitals in five GCC countries between March and November 2019. The swabs were tested for the presence of bla_KPC, bla_NDM, bla_VIM, bla_IMP, and bla_OXA-48 CRG using a commercial polymerase chain reaction test. Data on risk factors for colonization were collected and analysed.

FINDINGS

Of 529 specimens screened, 138 (26.1%) were positive for one or more CRGs. The positivity rates among the hospitals ranged from 8.0% to 67.3%; ∼20% of the positive specimens harboured ≥2 CRGs. The most common CRG detected was bla_OXA-48, which was present in 82 specimens (15.5%). Additional CRGs included bla_NDM, bla_VIM, bla_KPC, and bla_IMP either alone or in combination. Overall, 31.1% of patients on antibiotics on admission to the ICU were positive for CRGs compared to 16.5% not on antibiotic therapy (P < 0.001). CRG detection was also more common among patients aged >65 years (P = 0.027) and increased with hospital length of stay (P = 0.025).

CONCLUSION

The rate of CRGs detected in hospitalized patients in GCC countries varied considerably. Prior antibiotic exposure, increasing age, and prolonged length of stay were associated with CRG detection.

A systematic review of Antimicrobial Stewardship Program implementation in Middle Eastern countries

BACKGROUND

Antimicrobial resistance is a serious threat to global health. Antimicrobial Stewardship Programs (ASPs) are adopted by healthcare systems worldwide. This review aimed to evaluate the published practices of ASPs in Middle Eastern countries.

METHODS

Searches were carried out in PubMed/MEDLINE, Embase, EBSCO, Cochrane Library, Google, and Google Scholar electronic databases for studies published from January 2005 to December 2020 that assessed ASP practices in Middle Eastern countries, following PRISMA guidelines.

RESULTS

Of the 422 titles identified, 20 studies met the inclusion criteria. Eight studies were conducted in the Kingdom of Saudi Arabia, five in Qatar, two each in Lebanon and Jordan, and one each in Palestine and UAE; there was also one multinational study. Different ASP practices, including prospective auditing and feedback, pre-authorization, tracking, antibiotic restriction, education, de-escalation, and intravenous-to-oral switch, were reported. ASP practices correlated with improved susceptibility rates and decreases in antimicrobial use.

CONCLUSION

The outcomes of this review reveal the scarcity of data on ASP practices. The introduction of ASPs in hospitals in Middle Eastern countries has led to favorable clinical effects. Policymakers and stakeholders should promote and invest in implementing these programs as an essential component of their healthcare systems.

Antimicrobial Stewardship Programmes in Saudi Hospitals: Evidence from a National Survey

Saudi hospitals and healthcare facilities are facing increasing rates of antimicrobial resistance and the emergence of new multi-drug resistant strains. This is placing an unprecedented threat to successful treatments and outcomes of patients accessing those facilities. The inappropriate use of antimicrobials is fueling this crisis, warranting urgent implementation of interventions to preserve antimicrobials and reduce resistance rates. Antimicrobial stewardship programmes (ASPs) can improve antimicrobial use, treatment success rates and reduce the levels of antimicrobial resistance. The Saudi Ministry of Health (MOH) devised a national antimicrobial stewardship plan to implement ASPs in hospitals, but little is known about the progress of implementation and the factors affecting it. This study aims to assess the level and the factors affecting the adoption and implementation of ASPs in Saudi hospitals at a national level. A nationwide cross-sectional survey was conducted in 2017 using an online questionnaire sent to all MOH hospitals. Overall, 147 out 247 MOH hospitals responded to the survey (54%). Only 26% of the hospitals reported the implementation of ASPs. Hospitals lack the knowledge, technological and staff resources to adopt and implement ASPs. Alternative models of ASP adoption could be explored to improve the rates of implementation of ASPs.

Assessment of antimicrobial stewardship programs within governmental hospitals in Qatar: a SWOC analysis

OBJECTIVES

Antimicrobial resistance is a worldwide public health issue that requires emergent action. Antimicrobial stewardship programs (ASPs) have been proposed as a strategy to minimise resistance. Although ASPs were implemented in governmental hospitals in Qatar since 2015, a formal evaluation of these programs has not been conducted. We aimed to assess the status of ASPs in Qatar and to identify strengths, weaknesses, opportunities and challenges (SWOC) to further enhance ASPs within Hamad Medical Corporation (HMC).

METHODS

Lead stakeholders of ASPs in HMC filled a questionnaire adapted from the 2019 Centers for Disease Control Prevention checklist for ASPs. Notes were taken by research team to assist in formulating a SWOC analysis.

KEY FINDINGS

All hospitals (12/12) had an infectious diseases physician and pharmacist designated as an ASP leader (major strength identified). Almost all hospitals lack a financial statement and information technology resources to support ASPs (major weaknesses identified). Nine hospitals had an antibiotic pre-authorisation policy and adopted a prospective audit with feedback strategy. Among hospitals surveyed, 11 hospitals tracked antibiotic use by measuring the defined daily dose, and only four hospitals tracked rates of Clostridioides difficile infection. Qatar's rich economy supports the allocation of financial resources and budgeting to improve ASPs despite the increased emergence of resistant organisms and the limited resources currently available to expand ASPs across the country's healthcare settings.

CONCLUSIONS

Although ASPs were implemented in all governmental hospitals in Qatar, national efforts and more resources are needed to further develop and improve these programs.

Evaluation of Antimicrobial Stewardship Programs (ASPs) and their perceived level of success at Makkah region hospitals, Kingdom of Saudi Arabia

Antimicrobial stewardship programs (ASPs) are collaborative efforts to optimize antimicrobial use in healthcare institutions through evidence-based quality improvement strategies. The general administration of pharmaceutical care in the Saudi ministry of health (MOH) is putting outstanding efforts in implementing antimicrobial stewardship in Saudi health care settings. Several surveys have been conducted globally and reported many types of antimicrobial stewardship strategies in health institutions and their effectiveness. This study aims to identify ASPs in Makkah region hospitals and their perceived level of success. We administered a regional survey to explore current progress and issues related to the implementation of ASPs in Makkah region hospitals at the pharmacy level (n = 25). Among responding hospitals, 19 (76%) hospitals, the most commonly reported ASP were as following: formulary restrictions (90%) for broad-spectrum antimicrobials and use of prospective feedback on antimicrobial prescribing (68%), use of clinical guidelines and pathways (100%), and use of automatic stop orders (68%) to limit inappropriate antimicrobial therapy. The study outcomes will also be of pivotal importance to devise policies and strategies for antimicrobial stewardship implementation in other non-MOH settings in the Makkah region. Based on our results, all reported institutions have at least one antimicrobial stewardship program in a process with a high success rate. A multidisciplinary ASP approach, active involvement of drug & therapeutic committee, formulary restrictions, and availability of education & training of pharmacists and physicians on ASP are the primary elements for perceived successful antimicrobial stewardship programs in the Makkah region hospitals.

Ten-year resistance trends in pathogens causing healthcare-associated infections; reflection of infection control interventions at a multi-hospital healthcare system in Saudi Arabia, 2007-2016

Background

Studying temporal changes in resistant pathogens causing healthcare-associated infections (HAIs) is crucial in improving local antimicrobial and infection control practices. The objective was to describe ten-year trends of resistance in pathogens causing HAIs in a tertiary care setting in Saudi Arabia and to compare such trends with those of US National Health Surveillance Network (NHSN).

Methods

Pooled analysis of surveillance data that were prospectively collected between 2007 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Definitions and methodology of HAIs and antimicrobial resistance were based on NHSN. Consecutive NHSN reports were used for comparisons.

Results

A total 1544 pathogens causing 1531 HAI events were included. Gram negative pathogens (GNP) were responsible for 63% of HAIs, with a significant increasing trend in Klebsiella spp. and a decreasing trend in Acinetobacter. Methicillin-resistant Staphylococcus aureus (27.0%) was consistently less frequent than NHSN. Vancomycin-resistant Enterococci (VRE, 20.3%) were more than doubled during the study, closing the gap with NHSN. Carbapenem resistance was highest with Acinetobacter (68.3%) and Pseudomonas (36.8%). Increasing trends of carbapenem resistance were highest in Pseudomonas and Enterobacteriaceae, closing initial gaps with NHSN. With the exception of Klebsiella and Enterobacter, multidrug-resistant (MDR) GNPs were generally decreasing, mainly due to the decreasing resistance towards cephalosporins, fluoroquinolones, and aminoglycosides.

Conclusion

The findings showed increasing trends of carbapenem resistance and VRE, which may reflect heavy use of carbapenems and vancomycin. These findings may highlight the need for effective antimicrobial stewardship programs, including monitoring and feedback on antimicrobial use and resistance.

Health care providers' perceptions regarding antimicrobial stewardship programs (AMS) implementation-facilitators and challenges: a cross-sectional study in the Eastern province of Saudi Arabia

BACKGROUND

Infections result from invasions of an organism into body tissues leading to diseases and complications that might eventually lead to death. Inappropriate use of antimicrobials has led to development of antimicrobial resistance (AMR) which has been associated with increased mortality, morbidity and health costs. Antimicrobial stewardship (AMS) programs are designed to ensure appropriate selections of an effective antimicrobial drugs and optimizing antibiotic use to minimize antibiotic resistance by implementing certain policies, strategies and guidelines. The aim of this study was to investigate practitioners' perceptions regarding AMS implementation and to identify challenges and facilitators of these programs execution.

METHODS

Cross-sectional study among health care providers in Eastern province of Saudi Arabia Hospitals. The data was collected using a survey including questions about demographic data and information about clinicians' (physicians, pharmacists and nurses) previous experience with AMS and prescribing of antibiotics, the level of knowledge and attitudes regarding AMS programs' implementation.

RESULTS

More than 50% of clinicians (N = 184) reported lack of awareness of AMS programs and their components, whereas 71.2% do not have previous AMS experience. The majority of clinicians (72.3%) noticed increasing number of AMR infections over the past 5 years and (69.6%) were involved in care of patients with an antibiotic-resistant infection. Around 77.2% of respondents reported that formulary management can be helpful for AMS practice and majority of respondents (79.9%) reported that the availability of pathogens and antimicrobial susceptibility testing can be helpful for AMS. Major barriers to AMS implementation identified were lack of internal policy/guidelines and specialized AMS information resources. Lack of administrative awareness about AMS programs; lack of personnel, time limitation, limited training opportunities, lack of confidence, financial issue or limited funding and lack of specialized AMS information resources were also reported 65.8%, 62.5%, 60.9%, 73.9%, 50%, 54.3 and 74.5%, respectively.

CONCLUSION

Our study identified comprehensive education and training needs for health care providers about AMS programs. Furthermore, it appears that internal policy and guidelines need revision to ensure that the health care providers work consistently with AMS. Future research must focus on the benefit of implementing AMS as many hospitals are not implementing AMS as revealed by the clinicians. We recommend policy makers and concerned health authorities to consider the study findings into account to optimize AMS implementation.

Barriers to implementing antimicrobial stewardship programmes in three Saudi hospitals: Evidence from a qualitative study

•

Adoption of ASPs in Saudi hospitals remains low despite a national implementation strategy.

•

Lack of enforcement of policies and guidelines is a main contributor to inappropriate antimicrobial prescribing.

•

Barriers to ASP adoption in Saudi hospitals are mainly organisational.

•

Physicians’ fears and concerns inhibit their adoption of antimicrobial stewardship practices.

Objectives

This study explored antimicrobial stewardship programme (ASP) team members’ perspectives regarding factors influencing the adoption and implementation of these programmes in Saudi hospitals.

Methods

This was a qualitative study based on face-to-face semistructured interviews with healthcare professionals involved in ASPs and activities across three Ministry of Health (MoH) hospitals in Saudi Arabia (n = 18). Interviews were also conducted with two representatives of a General Directorate of Health Affairs in a Saudi region and two representatives of the Saudi MoH (n = 4) between January–February 2017.

Results

Despite the existence of a national strategy to implement ASPs in Saudi MoH hospitals, their adoption and implementation remains low. Hospitals have their own antimicrobial stewardship policies, but adherence to these is poor. ASP team members highlight that lack of enforcement of policies and guidelines from the MoH and hospital administration is a significant barrier to ASP adoption and implementation. Other barriers include disintegration of teams, poor communication, lack of recruitment/shortage of ASP team members, lack of education and training, and lack of health information technology (IT). Physicians’ fears and concerns in relation to liability are also a barrier to their adoption of ASPs.

Conclusion

This is the first qualitative study exploring barriers to ASP adoption and implementation in Saudi hospitals from the perspective of ASP team members. Formal endorsement of ASPs from the MoH as well as hospital enforcement of policies and provision of human and health IT resources would improve the adoption and implementation of ASPs in Saudi hospitals.

Antimicrobial resistance in the Gulf Cooperation Council region: A proposed framework to assess threats, impacts and mitigation measures associated with AMR in the marine and aquatic environment

It is becoming increasingly clear that the genetic diversity and abundance of antimicrobial resistance (AMR) in non-clinical settings has been underestimated and that the environment plays an integral role in enabling the development of AMR. Due to specific demographic and environmental factors the Gulf Cooperation Council (GCC) region may be particularly susceptible to the threat of AMR, with the marine and aquatic environment potentially playing a specific role in its development and propagation. The demographic factors include rapid population growth, significant international population movements, heavy antibiotic use and insufficient antibiotic stewardship. Environmental factors leading to susceptibility include notable inputs of untreated sewage effluent, high ambient water temperatures, elevated concentrations of heavy metals, and poorly regulated use of antimicrobials in veterinary settings. However, to date there is only a limited understanding of the role that this environment plays in enabling the emergence and propagation AMR in this region. This article provides an overview of the risk associated with AMR in the marine and aquatic environment in the GCC region and proposes a framework for understanding how such environments interact with the wider development and propagation of resistance. It identifies priority actions aligned with the World Health Organisation AMR Global Action Plan and associated national action plans to evaluate the role of marine and aquatic systems relative to the wider factors driving AMR emergence and propagation. The proposed framework and actions to evaluate the role of marine and aquatic environments in driving propagation and emergence of AMR are equally applicable at the regional and national level beyond the GCC.