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Cipriano P, Chau J, Jashi M, Kickbusch I, Koonin J, Mofokeng T, Phumaphi J, Robalo M, Shiozaki A. Leveraging universal health coverage to leave no one behind in tackling AMR. Lancet Glob Health 2024; 12:e1389-e1390. [PMID: 39002549 DOI: 10.1016/s2214-109x(24)00309-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024]
Affiliation(s)
| | - James Chau
- UHC Movement Political Panel, UHC2030, Geneva, Switzerland
| | - Mariam Jashi
- UHC Movement Political Panel, UHC2030, Geneva, Switzerland
| | | | - Justin Koonin
- UHC Movement Political Panel, UHC2030, Geneva, Switzerland
| | | | - Joy Phumaphi
- UHC Movement Political Panel, UHC2030, Geneva, Switzerland
| | - Magda Robalo
- UHC Movement Political Panel, UHC2030, Geneva, Switzerland
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Edessa D, Kumsa FA, Dinsa G, Oljira L. Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study. BMJ Open 2024; 14:e085352. [PMID: 39209504 PMCID: PMC11404147 DOI: 10.1136/bmjopen-2024-085352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVE Antibiotic misuse includes using them to treat colds and influenza, obtaining them without a prescription, not finishing the prescribed course and sharing them with others. Although drug providers are well positioned to advise clients on proper stewardship practices, antibiotic misuse continues to rise in Ethiopia. It necessitates an understanding of why drug providers failed to limit such risky behaviours. This study aimed to explore drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia. SETTING The study was conducted in rural Haramaya district and Harar town, eastern Ethiopia. DESIGN AND PARTICIPANTS An exploratory qualitative study was undertaken between March and June 2023, among the 15 drug providers. In-depth interviews were conducted using pilot-tested, semistructured questions. The interviews were transcribed verbatim, translated into English and analysed thematically. The analyses considered the entire dataset and field notes. RESULTS The study identified self-medication pressures, non-prescribed dispensing motives, insufficient regulatory functions and a lack of specific antibiotic use policy as the key contributors to antibiotic misuse. We found previous usage experience, a desire to avoid extra costs and a lack of essential diagnostics and antibiotics in public institutions as the key drivers of non-prescribed antibiotic access from private drug suppliers. Non-prescribed antibiotic dispensing in pharmacies was driven by client satisfaction, financial gain, business survival and market competition from informal sellers. Antibiotic misuse in the setting has also been linked to traditional and ineffective dispensing audits, inadequate regulatory oversights and policy gaps. CONCLUSION This study highlights profits and oversimplified access to antibiotics as the main motivations for their misuse. It also identifies the traditional antibiotic dispensing audit as an inefficient regulatory operation. Hence, enforcing specific antibiotic usage policy guidance that entails an automated practice audit, a responsible office and insurance coverage for persons with financial limitations can help optimise antibiotic use while reducing resistance consequences.
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Affiliation(s)
- Dumessa Edessa
- School of Pharmacy, Haramaya University, Harar, Ethiopia
- School of Public Health, Haramaya University, Harar, Ethiopia
| | - Fekede Asefa Kumsa
- School of Public Health, Haramaya University, Harar, Ethiopia
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center-Oak Ridge National Laboratory (UTHSC-ORNL) Center for Biomedical Informatics, Memphis, Tennessee, USA
| | - Girmaye Dinsa
- School of Public Health, Haramaya University, Harar, Ethiopia
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Lemessa Oljira
- School of Public Health, Haramaya University, Harar, Ethiopia
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Raju R, Srinivas SC, Siddalingegowda SM, Vaidya R, Gharat M, Kumar TMP. Community pharmacists as antimicrobial resistance stewards: a narrative review on their contributions and challenges in low- and middle-income countries. JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES : A PUBLICATION OF THE CANADIAN SOCIETY FOR PHARMACEUTICAL SCIENCES, SOCIETE CANADIENNE DES SCIENCES PHARMACEUTIQUES 2024; 27:12721. [PMID: 38939359 PMCID: PMC11208321 DOI: 10.3389/jpps.2024.12721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024]
Abstract
Antimicrobial resistance (AMR) is a global public health crisis that impedes the therapeutic effectiveness of available antimicrobial agents. Due to the high burden of infectious diseases and limited resources, especially trained healthcare professionals, low- and middle-income countries (LMICs) are particularly susceptible to the detrimental effects of AMR. Sometimes, as the first and last point of contact for patients seeking treatment for infections, community pharmacists can play a pivotal role in the stewardship required for AMR. This review aims to highlight the contributions made by community pharmacists in LMICs as AMR stewards. The review considers the challenges from the perspectives of limited resources, inadequate training, a lack of policies and regulations, and issues related to patient behavior. Community pharmacists in LMICs could optimize their advocacy contributions by focusing on One Health AMR stewardship. Transformational and actionable patient and population-centric antimicrobial stewardship (AMS) is feasible with the synergy of policymakers and other healthcare providers in the implementation of AMS policies and programs that support community pharmacists in their efforts to promote rational antimicrobial use.
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Affiliation(s)
- Rosy Raju
- JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysore, India
| | | | | | | | | | - T. M. Pramod Kumar
- JSS College of Pharmacy, JSS Academy of Higher Education and Research, Mysore, India
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Chiumia FK, Chithope-Mwale C, Abikoloni F, Matchaya V, Gaviyawo T, Khuluza F. Availability, pricing, and affordability of essential medicines for pediatric population in Malawi. Front Pharmacol 2024; 15:1379250. [PMID: 38666031 PMCID: PMC11043549 DOI: 10.3389/fphar.2024.1379250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Objective Lack of access to essential medicines negatively impacts on the quality of healthcare delivery and increases morbidity and mortality, especially to the vulnerable pediatric population. We assessed the availability, pricing, and affordability of pediatric formulations in Malawi. Methodology The study was conducted in 76 health facilities (public, faith-based and private pharmacies, and clinics) from the northern and southern regions of Malawi from March to May 2023. We adapted the WHO/HAI method for the assessment of both availability and pricing of medicines. Data on availability were collected from stock card records using a WHO/HAI template and medicine prices were provided by the pharmacy personnel who were managing the facilities. Availability of medicines was calculated as the percentage of facilities which had a stock of the respective medicine at the time of data collection while medicine prices was assessed by calculating the median prices of each medicine. To assess the affordability of the medicines, we calculated the number of days it takes for a person who is receiving the government-set minimum wage to work to pay for a treatment course of common indications. The study was approved by the KUHES ethics committee under the numbers U.12/22/3900 and U.12/22/3903. Results and conclusion The overall availability of pediatric medicines was 38.1% for public health facilities, 53.7% for private retail pharmacies and drug stores, 49.5% for private clinics and 48.3% for Christian Health Association of Malawi (CHAM) facilities. We found the illegal availability of prescription-only medicines of up to 54% in medicine stores. Medicine median prices were higher in the private clinics followed by retail pharmacies and drugs stores. CHAM had the lowest median prices for medicines of all the sectors. More than 50% of medicines were found to be affordable as less than a day's wage was required to purchase the treatment. We found poor availability of pediatric formulation among public, CHAM, and private sectors in Malawi. This may affect the quality of care among pediatric patients and therefore contribute to morbidity and mortality in Malawi. The supply of medicines and health commodities needs to consider needs of special populations such as children to achieve universal health coverage.
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Affiliation(s)
| | | | | | | | | | - Felix Khuluza
- Department of Pharmacy, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi
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Hamill MM, Onzia A, Parkes-Ratanshi RM, Kyambadde P, Mande E, Nakate V, Melendez JH, Gough E, Manabe YC. Antibiotic overuse, poor antimicrobial stewardship, and low specificity of syndromic case management in a cross section of men with urethral discharge syndrome in Kampala, Uganda. PLoS One 2024; 19:e0290574. [PMID: 38489281 PMCID: PMC10942085 DOI: 10.1371/journal.pone.0290574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/11/2023] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVE High prevalence of sexually transmitted infections (STIs) combined with poor antimicrobial stewardship are drivers of STI antimicrobial resistance (AMR) especially in resource-limited settings where syndromic case management (SCM) is the norm. We characterized patterns of antibiotic use prior to clinic attendance and study enrollment in Ugandan men with urethral discharge syndrome (UDS), evaluated in-clinic prescribing, and the performance characteristics of SCM. METHODS Participants were recruited from government clinics participating in an existing gonococcal surveillance program in Kampala, Uganda. Questionnaires including antimicrobial use prior to attendance, prior episodes of UDS, penile swabs, and blood samples were collected. Bivariable and multivariable logistic regression models were used to estimate odds ratios (OR) for preselected factors likely to be associated with antibiotic use. In-clinic antibiotic treatment data were extracted from clinical notes, and the performance of SCM against laboratory-based STI diagnoses was evaluated. FINDINGS Between October 2019 and November 2020, 100(40%) of 250 men with UDS reported taking antibiotics in the 14days prior to attending the clinic. Of these 210(84%) had at least one curable STI and 20% had a reactive point-of-care HIV test. Multivariable analysis demonstrated significant associations between recent antimicrobial use and duration of UDS symptoms <6 days (OR 2.98(95%CI 1.07,8.36), p = 0.038), and sex with women only (OR 0.08(95%CI 0.01,0.82),p = 0.038). The sensitivity of SCM ranged from 80.0% to 94.4%; specificity was low between 5.6% and 33.1%. The positive predictive value of SCM ranged from 2.4(95%CI 0.7,6.0) for trichomoniasis to 63.4(95%CI 56.5,69.9) for gonorrhea. CONCLUSION Pre-enrollment antibiotic use was common in this population at high risk of STI and HIV. Combined with the poor specificity of SCM for male UDS, extensive antibiotic use is a likely driver of STI-AMR in Ugandan men. Interventions to improve antimicrobial stewardship and deliver affordable diagnostics to augment SCM and decrease overtreatment of STI syndromes are required.
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Affiliation(s)
- Matthew M. Hamill
- Division of infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Annet Onzia
- Infectious Disease Institute, Kampala, Uganda
| | | | - Peter Kyambadde
- Ministry of Health, National Sexually Transmitted Infections Control Program, Kampala, Uganda
| | | | | | - Johan H. Melendez
- Division of infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Ethan Gough
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Yukari C. Manabe
- Division of infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
- Infectious Disease Institute, Kampala, Uganda
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Nguyen-Thanh L, Wernli D, Målqvist M, Graells T, Jørgensen PS. Characterising proximal and distal drivers of antimicrobial resistance: An umbrella review. J Glob Antimicrob Resist 2024; 36:50-58. [PMID: 38128730 DOI: 10.1016/j.jgar.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/29/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a multifactorial challenge driven by a complex interplay of proximal drivers, such as the overuse and misuse of antimicrobials and the high burden of infectious diseases, and distal factors, encompassing broader societal conditions such as poverty, inadequate sanitation, and healthcare system deficiencies. However, distinguishing between proximal and distal drivers remains a conceptual challenge. OBJECTIVES We conducted an umbrella review, aiming to systematically map current evidence about proximal and distal drivers of AMR and to investigate their relationships. METHODS Forty-seven reviews were analysed, and unique causal links were retained to construct a causality network of AMR. To distinguish between proximal and distal drivers, we calculated a 'driver distalness index (Di)', defined as an average relative position of a driver in its causal pathways to AMR. RESULTS The primary emphasis of the literature remained on proximal drivers, with fragmented existing evidence about distal drivers. The network analysis showed that proximal drivers of AMR are associated with risks of resistance transmission (Di = 0.49, SD = 0.14) and antibiotic use (Di = 0.58, SD = 0.2), which are worsened by intermediate drivers linked with challenges of antibiotic discovery (Di = 0.62, SD = 0.07), infection prevention (Di = 0.67, SD = 0.14) and surveillance (Di = 0.69, SD = 0.16). Distal drivers, such as living conditions, access to sanitation infrastructure, population growth and urbanisation, and gaps in policy implementation were development and governance challenges, acting as deep leverage points in the system in addressing AMR. CONCLUSIONS Comprehensive AMR strategies aiming to address multiple chronic AMR challenges must take advantage of opportunities for upstream interventions that specifically address distal drivers.
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Affiliation(s)
- Luong Nguyen-Thanh
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Uppsala Antibiotic Centre (UAC), Uppsala University, Uppsala, Sweden; Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden.
| | - Didier Wernli
- Global Studies Institute and Faculty of Science, University of Geneva, Geneva, Switzerland
| | - Mats Målqvist
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tiscar Graells
- Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden
| | - Peter Søgaard Jørgensen
- SWEDESD - Sustainability Learning and Research Center, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Global Economic Dynamics and the Biosphere, Royal Swedish Academy of Sciences, Stockholm, Sweden; Stockholm Resilience Centre, Stockholm University, Stockholm, Sweden.
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Boccabella L, Palma EG, Abenavoli L, Scarlata GGM, Boni M, Ianiro G, Santori P, Tack JF, Scarpellini E. Post-Coronavirus Disease 2019 Pandemic Antimicrobial Resistance. Antibiotics (Basel) 2024; 13:233. [PMID: 38534668 DOI: 10.3390/antibiotics13030233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/04/2024] [Accepted: 02/28/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND AIM Antimicrobial resistance (AMR) is a chronic issue of our Westernized society, mainly because of the uncontrolled and improper use of antimicrobials. The coronavirus disease 2019 (COVID-19) pandemic has triggered and expanded AMR diffusion all over the world, and its clinical and therapeutic features have changed. Thus, we aimed to review evidence from the literature on the definition and causative agents of AMR in the frame of the COVID-19 post-pandemic era. METHODS We conducted a search on PubMed and Medline for original articles, reviews, meta-analyses, and case series using the following keywords, their acronyms, and their associations: antibiotics, antimicrobial resistance, severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), COVID-19 pandemic, personal protective equipment. RESULTS AMR had a significant rise in incidence both in in-hospital and outpatient populations (ranging from 5 up to 50%) worldwide, but with a variegated profile according to the germ and microorganism considered. Not only bacteria but also fungi have developed more frequent and diffuse AMR. These findings are explained by the increased use and misuse of antibiotics and preventive measures during the first waves of the SARS-CoV2 pandemic, especially in hospitalized patients. Subsequently, the reduction in and end of the lockdown and the use of personal protective equipment have allowed for the indiscriminate circulation of resistant microorganisms from low-income countries to the rest of the world with the emergence of new multi- and polyresistant organisms. However, there is not a clear association between COVID-19 and AMR changes in the post-pandemic period. CONCLUSIONS AMR in some microorganisms has significantly increased and changed its characteristics during and after the end of the pandemic phase of COVID-19. An integrated supranational monitoring approach to this challenge is warranted in the years to come. In detail, a rational, personalized, and regulated use of antibiotics and antimicrobials is needed.
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Affiliation(s)
- Lucia Boccabella
- Internal Medicine Unit, Madonna del Soccorso General Hospital, Via Luciano Manara 7, 63074 San Benedetto del Tronto, Italy
| | - Elena Gialluca Palma
- Internal Medicine Clinics, Riuniti University Hospital, Polytechnics University of Marche, 60121 Ancona, Italy
| | - Ludovico Abenavoli
- Department of Health Sciences, University "Magna Graecia", 88100 Catanzaro, Italy
| | | | - Mariavirginia Boni
- Vascular Medicine Unit, "C. and G. Mazzoni" General Hospital, 63076 Ascoli Piceno, Italy
| | - Gianluca Ianiro
- Gastroenterology Unit, Fondazione Policlinico Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Pierangelo Santori
- Internal Medicine Unit, Madonna del Soccorso General Hospital, Via Luciano Manara 7, 63074 San Benedetto del Tronto, Italy
| | - Jan F Tack
- Translational Research in GastroIntestinal Disorders (T.A.R.G.I.D.), Gasthuisberg University Hospital, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Emidio Scarpellini
- Internal Medicine Unit, Madonna del Soccorso General Hospital, Via Luciano Manara 7, 63074 San Benedetto del Tronto, Italy
- Translational Research in GastroIntestinal Disorders (T.A.R.G.I.D.), Gasthuisberg University Hospital, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
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Rojop N, Moreno P, Grajeda L, Romero J, Reynoso L, Muñoz E, Palmer GH, Cordón-Rosales C, Call DR, Ramay BM. Informal sale of antibiotics in Guatemalan convenience stores before and after implementation of federal antibiotic dispensing legislation. BMC Pharmacol Toxicol 2024; 25:11. [PMID: 38273410 PMCID: PMC10809560 DOI: 10.1186/s40360-023-00720-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/05/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Convenience stores in Guatemala provide essential consumer goods in communities, but many dispense antibiotics illegally. Federal legislation, passed in August of 2019, requires prescriptions for antibiotic purchase at pharmacies but it is unclear if this legislation is enforced or if it has any impact on unlawful sales of antibiotics. METHODS To determine if antibiotic availability changed in convenience stores, we carried out a repeated measures study collecting antibiotic availability data before and after implementation of the dispensing regulation. RESULTS There was no statistical difference in the proportion of convenience stores that sold antibiotics before and after antibiotic regulations [66.6% (295/443) and 66.7% (323/484), respectively, P>0.96], nor in the number of stores selling amoxicillin [55.5% (246/443) and 52.3% (253/484), respectively, P>0.96], but fewer stores (20%) sold tetracycline capsules after regulation was passed (P<0.05). For stores visited both before and after passage of legislation (n=157), 15% stopped selling antibiotics while 25% started selling antibiotics. Antibiotics from convenience stores were reportedly sold for use in people and animals. CONCLUSIONS Antibiotics remain widely available in convenience stores consistent with no significant change in the informal sector after implementation of prescription requirements for pharmacies. Importantly, effects from regulatory change could have been masked by potential changes in antibiotic use during the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic.
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Affiliation(s)
- N Rojop
- Department of Epidemiology, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - P Moreno
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Department of Pharmaceutical Chemistry, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - L Grajeda
- Department of Epidemiology, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - J Romero
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - L Reynoso
- Department of Pharmaceutical Chemistry, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - E Muñoz
- Department of Pharmaceutical Chemistry, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala
| | - G H Palmer
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States of America
| | - C Cordón-Rosales
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States of America
| | - D R Call
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States of America
| | - B M Ramay
- Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
- Department of Pharmaceutical Chemistry, School of Sciences and Humanities, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, United States of America.
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Mzumara GW, Mambiya M, Iroh Tam PY. Protocols, policies and practices for antimicrobial stewardship in hospitalized patients in least-developed and low-income countries: a systematic review. Antimicrob Resist Infect Control 2023; 12:131. [PMID: 37993964 PMCID: PMC10666353 DOI: 10.1186/s13756-023-01335-8] [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: 09/15/2023] [Accepted: 11/14/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND We aimed to identify interventions used to implement antimicrobial stewardship practices among hospitalized patients in least-developed countries. METHODS The research team searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for studies of AMS interventions in the least developed and low-income countries, published between 2000 and 2023. Included studies had a population of hospitalized patients of all age groups in least-developed countries, implemented an AMS intervention, and reported its impact on prescription practices, clinical outcomes, or microbiological results. The risk of bias was assessed using the integrated quality criteria for review of multiple study designs. A total of 443 articles were identified, 386 articles were screened, 16 full-text papers were reviewed, and 10 studies were included in the analysis. RESULTS The ten studies included three controlled before and after, two qualitative, one controlled interrupted time series, two non-controlled interrupted time series, one quasi-experimental study, and one randomized controlled trial. Three studies implemented either enabling, persuasive, or structural interventions respectively. The rest used bundled strategies, including a combination of persuasive, enabling, structural, and restrictive interventions. Bundled interventions using enabling and persuasive strategies were the most common. These involved creating a prescription guideline, training prescribers on updated methods, and subsequent review and feedback of patient files by members of an AMS team. Improved microbiological surveillance was important to most studies but, sustained improvement in appropriate prescriptions was dependent on enabling or persuasive efforts. Studies noted significant improvements in appropriate prescriptions and savings on the costs of antibiotics. None evaluated the impact of AMS on AMR. CONCLUSION AMS practices generally involve multiple strategies to improve prescription practices. In the setting of least-developed countries, enabling and persuasive interventions are popular AMS measures. However, measured outcomes are heterogeneous, and we suggest that further studies assessing the impact of AMS should report changes in AMR patterns (microbiological outcomes), patient length of stay and mortality (patient outcomes), and changes in prescription practices (prescription outcomes). Reporting on these as outcomes of AMS interventions could make it easier for policymakers to compare which interventions have desirable outcomes that can be generalized to similar settings.
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Affiliation(s)
- Grace Wezi Mzumara
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
- Kamuzu University of Health Sciences, P/Bag 320, Blantyre, Malawi.
| | - Michael Mambiya
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Pui-Ying Iroh Tam
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Kamuzu University of Health Sciences, P/Bag 320, Blantyre, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
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Musoke D, Lubega GB, Gbadesire MS, Boateng S, Twesigye B, Gheer J, Nakachwa B, Brown MO, Brandish C, Winter J, Ng BY, Russell-Hobbs K, Gibson L. Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study. J Pharm Policy Pract 2023; 16:147. [PMID: 37978569 PMCID: PMC10655315 DOI: 10.1186/s40545-023-00659-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda. METHODS This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis. RESULTS Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS. CONCLUSION There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.
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Affiliation(s)
- David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Grace Biyinzika Lubega
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Mimi Salome Gbadesire
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Stephanie Boateng
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Belinda Twesigye
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Jagdeep Gheer
- Medicines Optimisation Team, Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board Trust Offices, Amersham Hospital, Amersham, HP7 0JD, UK
| | - Betty Nakachwa
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Michael Obeng Brown
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
| | - Claire Brandish
- Pharmacy Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, HP21 8AL, UK
| | - Jody Winter
- Department of Biosciences, School of Science and Technology, Nottingham Trent University, Nottingham, NG11 8NS, UK
| | - Bee Yean Ng
- Department of Pharmacy, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Kate Russell-Hobbs
- Pharmacy Department, Buckinghamshire Healthcare NHS Trust, Aylesbury, HP21 8AL, UK
| | - Linda Gibson
- Institute of Health and Allied Professions, School of Social Sciences, Nottingham Trent University, Nottingham, NG1 4FQ, UK
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11
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Kanan M, Ramadan M, Haif H, Abdullah B, Mubarak J, Ahmad W, Mari S, Hassan S, Eid R, Hasan M, Qahl M, Assiri A, Sultan M, Alrumaih F, Alenzi A. Empowering Low- and Middle-Income Countries to Combat AMR by Minimal Use of Antibiotics: A Way Forward. Antibiotics (Basel) 2023; 12:1504. [PMID: 37887205 PMCID: PMC10604829 DOI: 10.3390/antibiotics12101504] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Antibiotic overuse poses a critical global health concern, especially in low- and middle-income countries (LMICs) where access to quality healthcare and effective regulatory frameworks often fall short. This issue necessitates a thorough examination of the factors contributing to antibiotic overuse in LMICs, including weak healthcare infrastructure, limited access to quality services, and deficiencies in diagnostic capabilities. To address these challenges, regulatory frameworks should be implemented to restrict non-prescription sales, and accessible point-of-care diagnostic tools must be emphasized. Furthermore, the establishment of effective stewardship programs, the expanded use of vaccines, and the promotion of health systems, hygiene, and sanitation are all crucial components in combating antibiotic overuse. A comprehensive approach that involves collaboration among healthcare professionals, policymakers, researchers, and educators is essential for success. Improving healthcare infrastructure, enhancing access to quality services, and strengthening diagnostic capabilities are paramount. Equally important are education and awareness initiatives to promote responsible antibiotic use, the implementation of regulatory measures, the wider utilization of vaccines, and international cooperation to tackle the challenges of antibiotic overuse in LMICs.
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Affiliation(s)
- Mohammed Kanan
- Department of Clinical Pharmacy, King Fahad Medical City, Riyadh 12211, Saudi Arabia
| | - Maali Ramadan
- Department of Pharmacy, Maternity and Children Hospital in Rafha, Rafha 76312, Saudi Arabia; (M.R.); (H.H.); (B.A.); (J.M.)
| | - Hanan Haif
- Department of Pharmacy, Maternity and Children Hospital in Rafha, Rafha 76312, Saudi Arabia; (M.R.); (H.H.); (B.A.); (J.M.)
| | - Bashayr Abdullah
- Department of Pharmacy, Maternity and Children Hospital in Rafha, Rafha 76312, Saudi Arabia; (M.R.); (H.H.); (B.A.); (J.M.)
| | - Jawaher Mubarak
- Department of Pharmacy, Maternity and Children Hospital in Rafha, Rafha 76312, Saudi Arabia; (M.R.); (H.H.); (B.A.); (J.M.)
| | - Waad Ahmad
- Department of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia; (W.A.); (S.M.)
| | - Shahad Mari
- Department of Pharmacy, King Khalid University, Abha 61421, Saudi Arabia; (W.A.); (S.M.)
| | - Samaher Hassan
- Department of Clinical Pharmacy, Jazan College of Pharmacy, Jazan 82726, Saudi Arabia;
| | - Rawan Eid
- Department of Pharmacy, Nahdi Company, Tabuk 47311, Saudi Arabia;
| | - Mohammed Hasan
- Department of Pharmacy, Armed Forces Hospital Southern Region, Mushait 62562, Saudi Arabia; (M.H.); (A.A.)
| | - Mohammed Qahl
- Department of Pharmacy, Najran Armed Forces Hospital, Najran 66256, Saudi Arabia;
| | - Atheer Assiri
- Department of Pharmacy, Armed Forces Hospital Southern Region, Mushait 62562, Saudi Arabia; (M.H.); (A.A.)
| | | | - Faisal Alrumaih
- Department of Pharmacy, Northern Border University, Rafha 76313, Saudi Arabia;
| | - Areej Alenzi
- Department of Infection Control and Public Health, Regional Laboratory in Northern Border Region, Arar 73211, Saudi Arabia;
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12
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Li J, Zhou P, Wang J, Li H, Xu H, Meng Y, Ye F, Tan Y, Gong Y, Yin X. Worldwide dispensing of non-prescription antibiotics in community pharmacies and associated factors: a mixed-methods systematic review. THE LANCET. INFECTIOUS DISEASES 2023; 23:e361-e370. [PMID: 37105212 DOI: 10.1016/s1473-3099(23)00130-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/06/2023] [Accepted: 02/22/2023] [Indexed: 04/29/2023]
Abstract
This mixed-method systemic review estimated the pooled prevalence of non-prescription antibiotic dispensing in community pharmacies worldwide and identified associated factors influencing the practice. 162 studies covering 52 countries were included. The pooled prevalence of community pharmacy non-prescription antibiotic dispensing was 63·4% (95% CI 59·6-67·1). The prevalence was significantly higher in low-income countries than in high-income countries. Additionally, the situation of dispensing antibiotics without prescriptions has not improved over time in the past two decades. Quantitative studies showed that pharmacies located in poorer economic areas, pharmacy staff who were also the pharmacy owners, and private pharmacies were more likely to dispense non-prescription antibiotics. Qualitative findings suggested four major factors driving antibiotics being dispensed without a prescription. First, strong customer demand for non-prescription antibiotics and a lack of relevant knowledge; second, pharmacy staff motivated by financial or personal viewpoints; third, alternative health-care services being expensive or inconvenient, or having irregular prescribing practices; and finally, weak social, industry, and legal regulation. The current antibiotic stewardship needs to be strengthened.
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Affiliation(s)
- Jinxi Li
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Pengfei Zhou
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Wang
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Li
- School of Health Services Management, Anhui Medical University, Hefei, China
| | - Hongbin Xu
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuan Meng
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Ye
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuqian Tan
- Department of Health Toxicology, Key Laboratory for Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhong Gong
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxv Yin
- Department of Social Medicine and Health Management, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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13
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Ndaki PM, Mwanga JR, Mushi MF, Konje ET, Fredricks KJ, Kesby M, Sandeman A, Mugassa S, Manyiri MW, Loza O, Keenan K, Mwita SM, Holden MTG, Mshana SE. Practices and motives behind antibiotics provision in drug outlets in Tanzania: A qualitative study. PLoS One 2023; 18:e0290638. [PMID: 37651424 PMCID: PMC10470936 DOI: 10.1371/journal.pone.0290638] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
Dispensing antibiotics without prescription is among the major factors leading to antimicrobial resistance. Dispensing of antibiotics without prescription has negative impact at the individual and societal level leading to poor patient outcomes, and increased risks of resistant bacteria facilitated by inappropriate choice of antibiotics doses/courses. Antimicrobial resistance is a global public health threat which is projected to cause 10 million deaths by 2050 if no significant actions are taken to address this problem This study explored the practices and motives behind dispensing of antibiotics without prescription among community drug outlets in Tanzania. Finding of this study provides more strategies to antibiotics stewardship intervention. In-depth interviews with 28 drug dispensers were conducted for three months consecutively between November 2019 and January 2020 in 12 community pharmacies and 16 Accredited Drug Dispensing Outlets (ADDOs) in the Mwanza, Kilimanjaro and Mbeya regions of Tanzania. Transcripts were coded and analyzed thematically using NVivo12 software. Majority of dispensers admitted to providing antibiotics without prescriptions, selling incomplete courses of antibiotics and not giving detailed instructions to customers on how to use the drugs. These practices were motivated by several factors including customers' pressure/customers' demands, business orientation-financial gain of drug dispensers, and low purchasing power of patients/customers. It is important to address the motives behind the unauthorized dispensing antibiotics. On top of the existing regulation and enforcement, we recommend the government to empower customers with education and purchasing power of drugs which can enhance the dispensers adherence to the dispensing regulations. Furthermore, we recommend ethnographic research to inform antibiotic stewardship interventions going beyond awareness raising, education and advocacy campaigns. This will address structural drivers of AMR such as poverty and inadequate government health services, and the disconnect between public messaging and/or policy and the public itself.
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Affiliation(s)
- Pendo M. Ndaki
- Department of Biostatistics, Epidemiology and Behavioral Sciences, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Joseph R. Mwanga
- Department of Biostatistics, Epidemiology and Behavioral Sciences, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Martha F. Mushi
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Eveline T. Konje
- Department of Biostatistics, Epidemiology and Behavioral Sciences, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Kathryn Jean Fredricks
- Department of Geography and Sustainable Development, University of St Andrews, St Andrews, United Kingdom
| | - Mike Kesby
- Department of Geography and Sustainable Development, University of St Andrews, St Andrews, United Kingdom
| | - Alison Sandeman
- Department of Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Stella Mugassa
- Department of Biostatistics, Epidemiology and Behavioral Sciences, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Msilikale W. Manyiri
- Department of Biostatistics, Epidemiology and Behavioral Sciences, School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Olga Loza
- Department of Geography and Sustainable Development, University of St Andrews, St Andrews, United Kingdom
| | - Katherine Keenan
- Department of Geography and Sustainable Development, University of St Andrews, St Andrews, United Kingdom
| | - Stanley M. Mwita
- School of Pharmacy, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Matthew T. G. Holden
- School of Pharmacy, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Stephen E. Mshana
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
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14
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Belachew SA, Hall L, Selvey LA. "Handing out non-prescribed antibiotics is storing up trouble for the next generation!" Unpacking multistakeholder views of drivers and potential solutions in Ethiopia. BMC Health Serv Res 2023; 23:830. [PMID: 37550647 PMCID: PMC10405379 DOI: 10.1186/s12913-023-09819-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 07/16/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a global health crisis, with inappropriate antibiotic use often being linked to non-prescribed antibiotic dispensing practices. This study aimed to examine the perspectives of multiple stakeholders on the drivers and potential solutions for non-prescribed antibiotic dispensing in Ethiopian community drug retail outlets (CDROs). Despite the prescription only use policies, the practice remains prevalent in Ethiopia. Many factors are thought to contribute to this issue, although little research is available for non-urban settings. METHODS A phenomenological qualitative study was conducted. Pharmacy professionals (owners or employees) working in non-urban towns CDROs were selected through a simulated client study, which identified CDROs that had dispensed antibiotics without a prescription. Some high-level decision makers in the Ethiopian health system were also purposively selected. Interviews were conducted in-person and over the phone or via Zoom. The interview data were transcribed verbatim, translated to English, and thematically analysed. NVivo 12 software was used to assist with coding. RESULTS CDRO pharmacy professionals (n = 18) and five decision makers were interviewed. Most professionals (61%) were pharmacists working in drug stores, with one to 11 years of work experience. Several contributing factors were identified at the level of patients, CDRO staff, and the healthcare system. These included economic interests, inadequate knowledge and inappropriate attitudes about antibiotic use or supply, and issues within the healthcare system included inaccessibility and insufficient capacity, absence of or a weak enforcement of prescription-only regulations or service supervision. Additionally, patient-related factors included a lack of knowledge and inappropriate attitudes about antibiotics use and their supply, previous successful treatment experience and a culture of seeking out antibiotics. CONCLUSIONS A complex set of modifiable factors related to patients, CDRO staff and healthcare system were identified that contribute to the non-prescribed supply of antibiotics. Due to this complexity, a single solution will not resolve the issues. Therefore, a range of multifaceted solutions have been suggested, including stricter regulation, increasing availability and accessibility of healthcare services, collaboration, and local consensus-building among CDROs, regular training for CDRO staff, and using community social events to educate the public about responsible use of antibiotics.
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Affiliation(s)
- Sewunet Admasu Belachew
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld, 4006, Australia.
- School of Pharmacy, Faculty of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Lisa Hall
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld, 4006, Australia
| | - Linda A Selvey
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld, 4006, Australia
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15
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Wildbret S, Stuck L, Luchen CC, Simuyandi M, Chisenga C, Schultsz C, Harris VC. Drivers of informal sector and non-prescription medication use in pediatric populations in a low- and middle-income setting: A prospective cohort study in Zambia. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002072. [PMID: 37410740 DOI: 10.1371/journal.pgph.0002072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/29/2023] [Indexed: 07/08/2023]
Abstract
Obtaining medication from the informal sector is common in low- and middle- income countries. Informal sector use increases the risk for inappropriate medication use, including inappropriate antibiotic usage. Infants are at the highest risk of complications from inappropriate medication use, yet there is insufficient knowledge about the risk factors driving caregivers to obtain medication from the informal sector for young children. We aimed to define infant and illness characteristics associated with use of medication purchased in the informal sector for infants up to fifteen months of age in Zambia. We used data from, a prospective cohort study (ROTA-biotic) conducted among 6 weeks to 15 months old children in Zambia, which is nested within an ongoing phase III rotavirus vaccine trial (Clinicaltrial.gov NCT04010448). Weekly in-person surveys collected information about illness episodes and medication usage for the trial population and for a community control cohort. The primary outcome for this study was whether medication was purchased in the formal sector (hospital or clinic) or informal sector (pharmacy, street vendor, friend/relative/neighbor, or chemical shop) per illness episode. Descriptive analyses were used to describe the study population, and the independent and medication use variables stratified by the outcome. A mixed-effects logistic regression model with a participant-level random intercept was used to identify independent variables associated with the outcome. The analysis included 439 participants accounting for 1927 illness episodes over fourteen months in time. Medication was purchased in the informal sector for 386 (20.0%) illness episodes, and in the formal sector for 1541 (80.0%) illness episodes. Antibiotic usage was less common in the informal sector than in the formal sector (29.3% vs 56.2%, p < 0.001, chi-square). Most medications purchased in the informal sector were orally administered (93.4%), and non-prescribed (78.8%). Increased distance from the closest study site (OR: 1.09; 95% CI: 1.01, 1.17), being included in the community cohort site (OR: 3.18; 95% CI: 1.86, 5.46), illnesses with general malaise fever, or headache (OR: 2.62; 95% CI: 1.75, 3.93), and wound/skin disease (OR: 0.36; 95% CI: 0.18, 0.73) were associated with use of medication from the informal sector. Sex, socioeconomic status, and gastrointestinal disease were not associated with use of medication from the informal sector. Informal sector medication use is common and, in this study, risk factors for obtaining medications in the informal sector included a long distance to a formal clinic, type of illness, and not being enrolled in a clinical trial. Continued research on medication use from the informal sector is crucial and should include generalizable study populations, information on severity of disease, emphasis on qualitative research, and a move towards testing interventions that aim to improve access to formal health care settings. Our findings suggest that improved access to formal health care services may decrease reliance on medication from the informal sector for infants.
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Affiliation(s)
- Sanne Wildbret
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Logan Stuck
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Chaluma C Luchen
- Department of Global Health, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | | | | | - Constance Schultsz
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Medical Microbiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious Diseases, Amsterdam, The Netherlands
| | - Vanessa C Harris
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Global Health, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity, Infectious Diseases, Amsterdam, The Netherlands
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
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16
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Sono TM, Yeika E, Cook A, Kalungia A, Opanga SA, Acolatse JEE, Sefah IA, Jelić AG, Campbell S, Lorenzetti G, Ul Mustafa Z, Marković-Peković V, Kurdi A, Anand Paramadhas BD, Rwegerera GM, Amu AA, Alabi ME, Wesangula E, Oluka M, Khuluza F, Chikowe I, Fadare JO, Ogunleye OO, Kibuule D, Hango E, Schellack N, Ramdas N, Massele A, Mudenda S, Hoxha I, Moore CE, Godman B, Meyer JC. Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance. Expert Rev Anti Infect Ther 2023; 21:1025-1055. [PMID: 37740561 DOI: 10.1080/14787210.2023.2259106] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/07/2023] [Indexed: 09/24/2023]
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription. AREAS COVERED A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients. EXPERT OPINION ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists' activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.
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Affiliation(s)
- Tiyani Milta Sono
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
- Saselamani Pharmacy, Saselamani, South Africa
| | - Eugene Yeika
- Programs coordinator/Technical supervisor for HIV/Malaria, Delegation of Public Health, Cameroon
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, Institute of Infection and Immunity, St. George's University of London, London, UK
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Aubrey Kalungia
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Sylvia A Opanga
- Department of Pharmacology, Clinical Pharmacy and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | | | - Israel Abebrese Sefah
- Pharmacy Practice Department, School of Pharmacy, University of Health and Allied Sciences, Volta Region, Ho, Ghana
| | - Ana Golić Jelić
- Department of Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia & Herzegovina
| | - Stephen Campbell
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
- Centre for Epidemiology and Public Health, School of Health Sciences, University of Manchester, Manchester, UK
| | - Giulia Lorenzetti
- Centre for Neonatal and Paediatric Infection, Institute of Infection and Immunity, St. George's University of London, London, UK
| | - Zia Ul Mustafa
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor, Penang, Malaysia
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan, Pakistan
| | - Vanda Marković-Peković
- Department of Pharmacy, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia & Herzegovina
| | - Amanj Kurdi
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
- College of Pharmacy, Al-Kitab University, Kirkuk, Iraq
| | - Bene D Anand Paramadhas
- Department of Health Services Management, Central Medical Stores, Ministry of Health, Gaborone, Botswana
| | - Godfrey Mutashambara Rwegerera
- Faculty of Medicine, Department of Internal Medicine, University of Botswana, Gaborone, Botswana
- DestinyMedical and Research Solutions Proprietary Limited, Gaborone, Botswana
| | - Adefolarin A Amu
- Pharmacy Department, Eswatini Medical Christian University, Mbabane, Kingdom of Eswatini
| | - Mobolaji Eniola Alabi
- School of Pharmaceutical Sciences, College of Health Sciences,University of Kwazulu-natal (UKZN), Durban, South Africa
| | - Evelyn Wesangula
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Margaret Oluka
- Department of Pharmacology, Clinical Pharmacy and Pharmacy Practice, School of Pharmacy, University of Nairobi, Nairobi, Kenya
| | - Felix Khuluza
- Pharmacy Department, Kamuzu University of Health Sciences (KUHeS) (formerly College of Medicine), Blantyre, Malawi
| | - Ibrahim Chikowe
- Pharmacy Department, Kamuzu University of Health Sciences (KUHeS) (formerly College of Medicine), Blantyre, Malawi
| | - Joseph O Fadare
- Department of Pharmacology and Therapeutics, Ekiti State University, Ado-Ekiti, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Olayinka O Ogunleye
- Department of Pharmacology, Therapeutics and Toxicology, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria
- Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Uganda
| | - Dan Kibuule
- Department of Pharmacology & Therapeutics, Busitema University, Mbale, Uganda
| | - Ester Hango
- Department of Pharmacy Practice and Policy, School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, SouthAfrica
| | - Nishana Ramdas
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
| | - Amos Massele
- Department of Clinical Pharmacology and Therapeutics, Hurbert Kairuki Memorial University, Dar Es Salaam, Tanzania
| | - Steward Mudenda
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
- Africa Center of Excellence for Infectious Diseases of Humans and Animals, School of Veterinary Meicine, University of Zambia, Lusaka, Zambia
| | - Iris Hoxha
- Department of Pharmacy, Faculty of Medicine, University of Medicine Tirana, Tirana, Albania
| | - Catrin E Moore
- Centre for Neonatal and Paediatric Infection, Institute of Infection and Immunity, St. George's University of London, London, UK
| | - Brian Godman
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Johanna C Meyer
- Department of Public Health Pharmacy and Management, Schoolof Pharmacy, Sefako Makgatho Health Sciences University, Garankuwa, Pretoria, South Africa
- South African Vaccination and Immunisation Centre, Sefako Makgatho HealthSciences University, Garankuwa, Pretoria, South Africa
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17
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Ngyedu EK, Acolatse J, Akafity G, Incoom R, Rauf A, Seaton RA, Sneddon J, Cameron E, Watson M, Wanat M, Godman B, Kurdi A. Selling antibiotics without prescriptions among community pharmacies and drug outlets: a simulated client study from Ghana. Expert Rev Anti Infect Ther 2023; 21:1373-1382. [PMID: 37975725 DOI: 10.1080/14787210.2023.2283037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Selling antibiotics without prescriptions is mostly illegal worldwide, including in Ghana, and promotes antimicrobial resistance. We evaluated the prevalence and practice of selling antibiotics without prescriptions among community pharmacies (CPs) and drug outlets, for the first time, in Ghana to quantify and characterize this issue to inform future interventions. RESEARCH DESIGN AND METHODS Two scenarios utilizing the Simulated Client Methodology were enacted: an upper respiratory tract infection of viral origin (scenario one); and pediatric diarrhea (scenario two). CPs/Outlets were selected by stratified proportional random sampling from four metropolitan cities (~14% of the total Ghanaian population). Selling of antibiotics was assessed at three demand levels and its overall prevalence was estimated, then stratified by the study variables. RESULTS Out of the 265 sampled CPs/outlets, the prevalence of selling antibiotic without prescription was 88.3% (n = 234/265), with variations not only across the four regions [92.5% (n = 123/133) in Kumasi, 87.5% (n = 14/16) in Cape Coast, 84.1% (n = 69/82) in Accra, and 82.4% (n = 28/34) in Tamale] but also across CPs [90% (n = 121/134)] and drug outlets [86% (n = 113/131)]. CONCLUSIONS A very high prevalence/sub-optimal practice of selling antibiotics without prescriptions was found. This highlights the need to increase compliance with antibiotic dispensing legislation through evidence-based interventions including education of key stakeholders.
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Affiliation(s)
- Eric Kofi Ngyedu
- Oral and Maxillofacial Surgery, Research Unit, Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana
| | - Joseph Acolatse
- Oral and Maxillofacial Surgery, Research Unit, Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana
| | - George Akafity
- Oral and Maxillofacial Surgery, Research Unit, Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana
| | - Robert Incoom
- Oral and Maxillofacial Surgery, Research Unit, Cape Coast Teaching Hospital (CCTH), Cape Coast, Ghana
| | | | - R Andrew Seaton
- Department is Infectious Unit, Queen Elizabeth University Hospital, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | - Elaine Cameron
- School of Psychology, University of Stirling, Stirling, UK
| | - Margaret Watson
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Oxford, UK
| | - Brian Godman
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
- Department of Clinical Pharmacy, College of Pharmacy, Hawler Medical University, Erbil, Iraq
- Centre of Medical and Bio allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Amanj Kurdi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
- Centre of Medical and Bio allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- College of Pharmacy, Al-Kitab University, Kirkuk, Iraq
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18
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Sulis G, Sayood S, Gandra S. How can we tackle the overuse of antibiotics in low- and middle-income countries? Expert Rev Anti Infect Ther 2023; 21:1189-1201. [PMID: 37746828 DOI: 10.1080/14787210.2023.2263643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/22/2023] [Indexed: 09/26/2023]
Abstract
INTRODUCTION Antibiotic overuse is a pressing global health concern, particularly in low- and middle-income countries (LMICs) where there is limited access to quality healthcare and insufficient regulation of antibiotic dispensation. This perspective piece highlights the challenges of antibiotic overuse in LMICs and provides insights into potential solutions to address this issue. AREAS COVERED This perspective explores key factors contributing to antibiotic overuse in LMICs, encompassing weak healthcare infrastructure, limited access to quality services, and deficiencies in diagnostic capabilities. It discusses regulatory frameworks to curb non-prescription sales, the role of accessible point-of-care diagnostic tools, challenges in implementing effective stewardship programs, the expanded use of vaccines, and the importance of health systems, hygiene, and sanitation. EXPERT OPINION In this article, we emphasize the need for a comprehensive approach involving collaboration among healthcare professionals, policymakers, researchers, and educators. We underscore the importance of improving healthcare infrastructure, enhancing access to quality services, and strengthening diagnostic capabilities. The article also highlights the significance of education and awareness in promoting responsible antibiotic use, the role of regulatory measures, the expanded utilization of vaccines, and the need for international collaboration to address the challenges of antibiotic overuse in LMICs.
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Affiliation(s)
- Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sena Sayood
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Sumanth Gandra
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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19
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Gul B, Sana M, Saleem A, Mustafa ZU, Salman M, Khan YH, Mallhi TH, Sono TM, Meyer JC, Godman BB. Antimicrobial Dispensing Practices during COVID-19 and the Implications for Pakistan. Antibiotics (Basel) 2023; 12:1018. [PMID: 37370337 PMCID: PMC10294926 DOI: 10.3390/antibiotics12061018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/18/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
Antibiotics are one of the most frequently dispensed classes of medicines. However, excessive misuse and abuse enhances antimicrobial resistance (AMR). Previous studies in Pakistan have documented extensive dispensing of 'Watch' and 'Reserve' antibiotics, which is a concern. In view of this, there is a need to assess current dispensing patterns following COVID-19 in Pakistan. A cross-sectional study was undertaken, collecting dispensing data from 39 pharmacies and 53 drug stores from November 2022 to February 2023. Outlets were principally in urban areas (60.9%), with pharmacists/pharmacy technicians present in 32.6% of outlets. In total, 11,092 prescriptions were analyzed; 67.1% of patients were supplied at least one antimicrobial, 74.3% antibiotics, 10.2% antifungals and 7.9% anthelmintics. A total of 33.2% of antimicrobials were supplied without a prescription. Common indications for dispensed antibiotics were respiratory (34.3%) and gastrointestinal (16.8%) infections, which can be self-limiting. In addition, 12% of antibiotics were dispensed for the prevention or treatment of COVID-19. The most frequent antibiotics dispensed were ceftriaxone (18.4%) and amoxicillin (15.4%). Overall, 59.2% antibiotics were 'Watch' antibiotics, followed by 'Access' (40.3%) and 'Reserve' (0.5%) antibiotics. Of the total antibiotics dispensed for treating COVID-19, 68.3% were 'Watch' and 31.7% 'Access'. Overall, there appeared to be an appreciable number of antibiotics dispensed during the recent pandemic, including for patients with COVID-19, alongside generally extensive dispensing of 'Watch' antibiotics. This needs to be urgently addressed with appropriate programs among pharmacists/pharmacy technicians to reduce AMR.
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Affiliation(s)
- Bushra Gul
- Department of Medicines, Tehsil Head Quarter (THQ) Hospital, District Bhakkar, Darya Khan 3000, Punjab, Pakistan;
| | - Maria Sana
- Department of Medicine, Faisalabad Medical University, Faisalabad 38000, Punjab, Pakistan; (M.S.); (A.S.)
| | - Aneela Saleem
- Department of Medicine, Faisalabad Medical University, Faisalabad 38000, Punjab, Pakistan; (M.S.); (A.S.)
| | - Zia Ul Mustafa
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Gelugor 11800, Penang, Malaysia
- Department of Pharmacy Services, District Headquarter (DHQ) Hospital, Pakpattan 57400, Punja, Pakistan
| | - Muhammad Salman
- Institute of Pharmacy, Faculty of Pharmaceutical and Allied Health Sciences, Lahore College for Women University, Lahore 54000, Punja, Pakistan;
| | - Yusra Habib Khan
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka 72388, Saudi Arabia; (Y.H.K.); (T.H.M.)
| | - Tauqeer Hussain Mallhi
- Department of Clinical Pharmacy, College of Pharmacy, Jouf University, Sakaka 72388, Saudi Arabia; (Y.H.K.); (T.H.M.)
| | - Tiyani Milta Sono
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, Gauteng, South Africa; (T.M.S.); (J.C.M.)
- Saselamani Pharmacy, Saselamani 0928, Limpopo, South Africa
| | - Johanna C. Meyer
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, Gauteng, South Africa; (T.M.S.); (J.C.M.)
- South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, Gauteng, South Africa
| | - Brian B. Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa 0208, Gauteng, South Africa; (T.M.S.); (J.C.M.)
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Science (SIPBS), University of Strathclyde, Glasgow G4 0RE, UK
- Centre of Medical and Bio-Allied Health Sciences Research, Ajman University, Ajman P.O. Box 346, United Arab Emirates
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20
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Valia D, Kouanda JS, Ingelbeen B, Derra K, Kaboré B, Kiemdé F, Rouamba T, Rouamba E, Hien FS, Campbell L, Meudec M, Robert A, Tinto H, van der Sande MAB, Villalobos HR. Healthcare seeking outside healthcare facilities and antibiotic dispensing patterns in rural Burkina Faso: A mixed methods study. Trop Med Int Health 2023; 28:391-400. [PMID: 36871194 DOI: 10.1111/tmi.13868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
OBJECTIVE Optimising antibiotic use is important to limit increasing antibiotic resistance. In rural Burkina Faso, over-the-counter dispensing of antibiotics in community pharmacies and non-licensed medicine retail outlets facilitates self-medication. We investigated its extent, reasons and dispensing patterns. METHODS In an exploratory mixed-method design conducted between October 2020 and December 2021, this study first explored illness perceptions, the range of healthcare providers in communities, antibiotics knowledge and reasons for seeking healthcare outside healthcare facilities. Second, frequencies of illness and healthcare utilisation in the last 3 months were quantitatively measured. RESULTS Participants distinguished between natural and magico-religious illnesses, according to origins. For illnesses considered to be 'natural', healthcare was mainly sought at healthcare facilities, private pharmacies and informal drug outlets. For illnesses considered as magico-religious, traditional healers were mainly visited. Antibiotics were perceived in the community as medicines similar to painkillers. Healthcare-seeking outside healthcare facilities was reported by 660/1973 (33.5%) participants reporting symptoms, including 315 (47.7%) to informal vendors. Healthcare seeking outside facilities was less common for 0-4-year-olds (58/534, 10.9% vs. 379/850, 44.1% for ≥5-year-olds) and decreased with improving socio-economic status (108/237, 45.6% in the lowest quintile; 96/418, 23.0% in the highest). Reported reasons included financial limitation, and also proximity to informal drug vendors, long waiting times at healthcare facilities, and health professionals' non-empathetic attitudes towards their patients. CONCLUSION This study highlights the need to facilitate and promote access to healthcare facilities through universal health insurance and patient-centred care including reducing patients' waiting time. Furthermore, community-level antibiotic stewardship programmes should include community pharmacies and informal vendors.
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Affiliation(s)
- Daniel Valia
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Epidemiology and Biostatistics Unit, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Brussels, Belgium
| | - Juste Stéphane Kouanda
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Brecht Ingelbeen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karim Derra
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Bérenger Kaboré
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - François Kiemdé
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Eli Rouamba
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Franck Sovi Hien
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Linda Campbell
- Centre for Population, Family and Health, University of Antwerp, Antwerp, Belgium.,Department for Public Health and Primary Care, University of Ghent, Ghent, Belgium
| | - Marie Meudec
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Annie Robert
- Epidemiology and Biostatistics Unit, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Brussels, Belgium
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marianne A B van der Sande
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hector Rodriguez Villalobos
- Microbiology Unit, Institut de recherche expérimentale et clinique, Université catholique de Louvain, Brussels, Belgium
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21
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Hutchinson E, Hansen KS, Sanyu J, Amonya LP, Mundua S, Balabanova D, Clarke SE, Kitutu FE. Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda. BMJ Glob Health 2023; 8:bmjgh-2022-011097. [PMID: 36822666 PMCID: PMC9950907 DOI: 10.1136/bmjgh-2022-011097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/05/2023] [Indexed: 02/25/2023] Open
Abstract
The medicines retail sector is an essential element of many health systems in Africa and Asia, but it is also well known for poor practice. In the literature, it is recognised that improvements in the sector can only be made if more effective forms of governance and regulation can be identified. Recent debate suggests that interventions responsive to structural constraints that shape and underpin poor practice is a useful way forward. This paper presents data from a mixed-methods study conducted to explore regulation and the professional, economic and social constraints that shape rule breaking among drug shops in one district in Uganda. Our findings show that regulatory systems are undermined by frequent informal payments, and that although drug shops are often run by qualified staff, many are unlicensed and sell medicines beyond their legal permits. Most shops have either a small profit or a loss and rely on family and friends for additional resources as they compete in a highly saturated market. We argue that in the current context, drug shop vendors are survivalist entrepreneurs operating in a market in which it is extremely difficult to abide by policy, remain profitable and provide a service to the community. Structural changes in the medicines market, including removing unqualified sellers and making adjustments to policy are likely prerequisite if drug shops are to become places where individuals can earn a living, abide by the rules and facilitate access to medicines for people living in some of the world's poorest countries.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Jacquellyn Sanyu
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Lydia Peace Amonya
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda
| | - Sunday Mundua
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian E Clarke
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Freddy Eric Kitutu
- Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
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22
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Belachew SA, Hall L, Selvey LA. Magnitude of non-prescribed antibiotic dispensing in Ethiopia: a multicentre simulated client study with a focus on non-urban towns. J Antimicrob Chemother 2022; 77:3462-3465. [PMID: 36210768 DOI: 10.1093/jac/dkac341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/16/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Non-prescription dispensing of antibiotics significantly contributes to widespread antibiotic misuse, which in turn hastens the occurrence of antibiotic resistance. It is believed to be common in Ethiopia despite prescription-only regulations. We aimed to quantify non-prescription dispensing of antibiotics in community drug retail outlets (CDROs) with a focus on non-urban towns in the Amhara region of Ethiopia. METHODS A multicentre simulated client (SC) study was conducted to measure the non-prescription provision of antibiotics in 225 consenting CDROs. Each CDRO was visited twice by two trained SCs, one to present pre-prepared clinical case scenarios and the other to directly request specific antibiotics. Descriptive statistical analysis was performed to report the findings. RESULTS The study had 450 interactions across the two visits. Non-prescribed antibiotics were obtained in 198 (88%) of the 225 clinical case scenarios-based visits and in 205 (91%) of the 225 direct antibiotic request visits. Most of the supply was at the first level of demand: 84% of the 198 clinical case scenario visits and 95% of the 205 direct antibiotic request visits. CDRO staff requested further information about the patient or the case in 40% of the clinical case scenarios-based visits and 30% of the direct antibiotic request visits. CONCLUSIONS It was possible to obtain antibiotics without prescription from a high proportion of CDROs, both in clinical scenario-based and direct antibiotic request interactions. Multifaceted interventions including stringent regulatory enforcement, frequent CDRO practice surveillance, CDRO staff training and community health education are needed with greater emphasis on rural areas.
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Affiliation(s)
- Sewunet Admasu Belachew
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld 4006, Australia.,Clinical Pharmacy, School of Pharmacy, Faculty of Medicine and Health Sciences, University of Gondar, Gondar PO Box 196, Ethiopia
| | - Lisa Hall
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld 4006, Australia
| | - Linda A Selvey
- School of Public Health, The University of Queensland, 288 Herston Rd, Herston, Qld 4006, Australia
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23
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de Souza EV, Vieira LJSC, dos Santos SNP, Cerqueira-Santos S, Rocha KSS, de Lyra DP. Antimicrobial dispensing process in community pharmacies: a scoping review. Antimicrob Resist Infect Control 2022; 11:116. [PMID: 36116000 PMCID: PMC9482305 DOI: 10.1186/s13756-022-01157-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 08/25/2022] [Indexed: 11/20/2022] Open
Abstract
Background Antimicrobial resistance remains a major global public health concern, and antimicrobial dispensing in community pharmacies is an important factor in preventing this damage. However, the current literature focuses on the technical and attitudinal aspects related to antimicrobial dispensing, with little emphasis on the interventions provided in this service. Thus, this study aimed to determine the antimicrobial dispensing process in community pharmacies. Methods A scoping review was performed in September 2020 using the PubMed, EMBASE, LILACS, Web of Science, and Cochrane databases. The search terms included words related to dispensing, antibacterial agents, and pharmacies in various combinations. Two reviewers screened the titles, abstracts, and full-text articles according to the eligibility criteria, and extracted the data. The findings were presented in a descriptive form. Results Of the 7713 studies screened, 35 were included, of which 22 (63%) were published in Asia. Most studies followed a cross-sectional design (n = 27), and the simulated patient was the most often used method to assess the antimicrobial dispensing process (n = 22). Moreover, 31 (89%) studies investigated antimicrobial dispensing without prescription, and only four (11%) studies evaluated antimicrobial dispensing with prescription. In the 35 studies, the most frequently asked questions were about drug allergies (n = 19) and patient symptoms (n = 18), and counseling mainly focused on the side effects (n = 14), precautions (n = 14), how to take the medication (n = 12), and duration of medication use (n = 11). Another common intervention was referral (n = 15). Among clinical cases, counseling on medication use occurred often in cases of urinary tract infection (51%) and otitis media (50%). Conclusions Antimicrobial dispensing processes have been primarily investigated in low- and middle-income countries, with a focus on dispensing antimicrobials without prescriptions. During the dispensing process, pharmacists mostly posed minimal questions and counseling, highlighting the deficiencies that persist in this practice. Our results indicate the need for multifaceted strategies, such as implementing educational, regulatory or administrative strategies and changes in cultural background, especially in low- and middle-income countries, that aim to reduce indiscriminate use of antimicrobials. Therefore, qualifying the antimicrobial dispensing process is a fundamental factor for improving the rational use of antimicrobials and reducing microbial resistance. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01157-0.
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24
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Nguyen TTP, Do TX, Nguyen HA, Nguyen CTT, Meyer JC, Godman B, Skosana P, Nguyen BT. A National Survey of Dispensing Practice and Customer Knowledge on Antibiotic Use in Vietnam and the Implications. Antibiotics (Basel) 2022; 11:antibiotics11081091. [PMID: 36009960 PMCID: PMC9405246 DOI: 10.3390/antibiotics11081091] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 07/26/2022] [Accepted: 08/04/2022] [Indexed: 11/28/2022] Open
Abstract
Misconceptions and pressures have increased the sales of antibiotics without a prescription across countries. There are concerns with such practices in Vietnam given rising antimicrobial resistance rates. A national survey was conducted among 360 private drugstores located in nine provinces in Vietnam. Anonymous interviews were conducted with participants selected by convenience sampling. Subsequently, multivariable logistic regression analyses were undertaken evaluating the relationship between customer characteristics and antibiotic purchases. A total of 480 out of 1626 surveyed participants purchased antibiotics, 81.7% of which did not have a prescription, involving 29 different antibiotics. In 86.4% of these, participants were prescribed antibiotics by drug sellers. Most antibiotics were sold to treat respiratory tract infections (61.4%), with the ‘Access’ antibiotics (amoxicillin and cephalexin) being the most frequently sold. Only one-fifth of participants understood that they were breaking the law by purchasing antibiotics without a prescription. Participants purchasing antibiotics without a prescription had lower awareness concerning antibiotic laws and treatment duration (p < 0.05). Under 50% agreed to having a doctors’ prescription in the future when purchasing antibiotics. Freelancer occupation (OR = 0.52, 95% CI = 0.83−0.96) and a lower educational level (OR = 0.49, 95% CI = 0.25−0.96) were factors related to purchasing antibiotics without a prescription. Overall, we recommend increasing fines and monitoring of drugs stores, greater promotion of the family doctor system as well as increasing media and educational campaigns to limit self-purchasing of antibiotics in Vietnam and reduce resistance.
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Affiliation(s)
- Thuy Thi Phuong Nguyen
- Department of Pharmaceutical Management and Economics, Hanoi University of Pharmacy, Hanoi City 10000, Vietnam
| | - Thang Xuan Do
- Department of Pharmaceutical Management and Economics, Hanoi University of Pharmacy, Hanoi City 10000, Vietnam
| | - Hoang Anh Nguyen
- The National Center of Drug Information & Adverse Drug Reaction Monitoring, Hanoi University of Pharmacy, Hanoi City, 10000, Vietnam
- Bach Mai Hospital, Hanoi City 10000, Vietnam
| | - Cuc Thi Thu Nguyen
- Department of Pharmaceutical Management and Economics, Hanoi University of Pharmacy, Hanoi City 10000, Vietnam
- Correspondence: (C.T.T.N.); (B.G.)
| | - Johanna Catharina Meyer
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Brian Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
- Centre of Medical and Bio allied Health Sciences Research, Ajman University, Ajman P.O. Box 346, United Arab Emirates
- Correspondence: (C.T.T.N.); (B.G.)
| | - Phumzile Skosana
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Pretoria 0204, South Africa
| | - Binh Thanh Nguyen
- Department of Pharmaceutical Management and Economics, Hanoi University of Pharmacy, Hanoi City 10000, Vietnam
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25
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Belachew SA, Hall L, Selvey LA. Community drug retail outlet staff's knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns. Antimicrob Resist Infect Control 2022; 11:64. [PMID: 35488321 PMCID: PMC9052473 DOI: 10.1186/s13756-022-01102-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Some evidence suggests that knowledge and attitudes towards rational antibiotic use influences dispensing practice in community drug retail outlets. However, there is limited evidence in resource limited countries, including Ethiopia. We aimed to assess the knowledge and attitudes surrounding antibiotic use or supply and antibiotic resistance, and the non-prescribed antibiotic dispensing practices in community drug retail outlets in non-urban Ethiopia. METHODS We conducted a cross-sectional survey of community drug retail outlet staff in the Amhara region, Ethiopia with a focus on non-urban towns. An expert validated self-administered questionnaire was used. Following exploratory factor analysis and best items selection, we summarised our findings and assessed factors associated with non-prescribed antibiotic dispensing. The data were analysed using Stata Statistical Software version 17. P-values < 0.05 were considered significant. RESULTS A total of 276 participants from 270 drug outlets completed the questionnaire. The participants median age was 30 (Interquartile range (IQR) = 25-35) years and 79.7% were pharmacy assistants. The majority demonstrated good levels of knowledge about antibiotic use or supply and antibiotic resistance (77.9% and 76% of the participants responded correctly to more than half of the items, respectively). We identified four attitude domains: the role of antibiotics in recovering from diseases regardless of their cause (median score = 2 (IQR = 2-4), beliefs inconsistent with good practice); professional competency to supply non-prescribed antibiotics, and the non-prescribed antibiotics supply (median score for each domain = 4 (IQR = 4-5), attitudes consistent with good practice); and positive attitudes towards actions to prevent antibiotic resistance and promote appropriate antibiotic use (median score = 4 (IQR = 4-5). Fifty eight percent of the participants reported that they had dispensed antibiotics without a prescription. Participants who did not perceive that they were competent to supply non-prescribed antibiotics (adjusted odds ratio = 0.86, 95% confidence interval = 0.78-0.93) were less likely to report non-prescribed antibiotics dispensing. CONCLUSION While most of the participants had appropriate knowledge about and attitudes to antibiotic use and antibiotic resistance, basic knowledge and attitude gaps remain. Despite Ethiopia's regulatory restrictions, the non-prescribed antibiotic provision continues to be a common practice. Our study highlights the need for multifaceted interventions that may include a strict regulatory system, staff training and public education.
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Affiliation(s)
- Sewunet Admasu Belachew
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia. .,School of Pharmacy, Faculty of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Lisa Hall
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia
| | - Linda A Selvey
- School of Public Health, The University of Queensland, 288 Herston Road, Herston, QLD, 4006, Australia
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It is complicated: Potential short- and long-term impact of coronavirus disease 2019 (COVID-19) on antimicrobial resistance—An expert review. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2022; 2:e27. [PMID: 36310817 PMCID: PMC9614949 DOI: 10.1017/ash.2022.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 12/24/2022]
Abstract
As of December 2021, the coronavirus disease 2019 (COVID-19) pandemic has claimed millions of deaths and caused disruptions in health systems around the world. The short- and long-term effects of COVID-19 on antimicrobial resistance (AMR), which was already a global threat before the pandemic, are manifold and complex. In this expert review, we summarize how COVID-19 might be affecting AMR in the short term (by influencing the key determinants antibiotic use, infection control practices and international/local mobility) and which additional factors might play a role in the long term. Whereas reduced outpatient antibiotic use in high-income countries, increased awareness for hand hygiene, and reduced mobility have likely mitigated the emergence and spread of AMR in the short term, factors such as overuse of antibiotics in COVID-19 patients, shortage of personal protective equipment, lack of qualified healthcare staff, and patient overcrowding have presumably facilitated its propagation. Unsurprisingly, international and national AMR surveillance data for 2020 show ambiguous trends. Although disruptions in antibiotic stewardship programs, AMR surveillance and research might promote the spread of AMR, other developments could prove beneficial to the cause in the long term. These factors include the increased public awareness for infectious diseases and infection control issues, the strengthening of the One Health perspective as outlined by the Centers for Disease Control and Prevention, and the unprecedented number of international research collaborations and platforms. These factors could even serve as leverage and provide opportunities to better combat AMR in the future.
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Mokwele RN, Schellack N, Bronkhorst E, Brink AJ, Schweickerdt L, Godman B. OUP accepted manuscript. JAC Antimicrob Resist 2022; 4:dlab196. [PMID: 35146427 PMCID: PMC8826632 DOI: 10.1093/jacamr/dlab196] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background Objectives Patients and methods Results Conclusions
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Affiliation(s)
- R. Nelly Mokwele
- School of Pharmacy, Division of Clinical Pharmacy, Sefako Makgatho Health Sciences University, South Africa
| | - Natalie Schellack
- School of Pharmacy, Division of Clinical Pharmacy, Sefako Makgatho Health Sciences University, South Africa
- Department of Pharmacology, University of Pretoria, South Africa
| | - Elmien Bronkhorst
- School of Pharmacy, Division of Clinical Pharmacy, Sefako Makgatho Health Sciences University, South Africa
| | - Adrian J. Brink
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Louise Schweickerdt
- Skills Centre, Sefako Makgatho Health Sciences University, Ga-Rankuwa,Gauteng, South Africa
| | - Brian Godman
- School of Pharmacy, Division of Clinical Pharmacy, Sefako Makgatho Health Sciences University, South Africa
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow G4 0RE, UK
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates
- Corresponding author. E-mail:
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Community Use of Antibiotics in Turkey: The Role of Knowledge, Beliefs, Attitudes, and Health Anxiety. Antibiotics (Basel) 2021; 10:antibiotics10101171. [PMID: 34680752 PMCID: PMC8532753 DOI: 10.3390/antibiotics10101171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 12/29/2022] Open
Abstract
Turkey has been among the leading countries in antibiotic consumption. As a result of the 4-year National Action Plan for Rational Drug Use, antibiotic prescriptions had declined from 34.9% in 2011 to 24.6% in 2018. However, self-medication with antibiotics without prescription is common, which is not reflected in official statistics. The present study aims at investigating antibiotic use in the community and the factors related to it. A web-based survey was conducted among 945 Turkish-speaking respondents (61.3% female). The questionnaire included questions about antibiotic use for different illnesses, ways to obtain and handle leftover antibiotics, knowledge, beliefs of the antibiotic effectiveness, attitudes, health anxiety, and background factors. According to the results, 34.2% of the sample had self-medicated themselves with antibiotics without a valid prescription. The most common way to self-medicate was to use leftover antibiotics. While 80.4% knew that antibiotics are used to treat bacterial infections, 51.4% thought that antibiotics are effective for viral diseases. The most important predictor of antibiotic use frequency was the belief in their efficiency for various illnesses and symptoms, followed by negative attitudes to antibiotics, health anxiety, knowledge level, positive attitudes, and health status. The results underline the importance of targeting misbeliefs about antibiotics in future campaigns.
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