The Impact of WHO Essential Medicines Policies on Inappropriate Use of Antibiotics

"Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

BACKGROUND

The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not.

OBJECTIVE

We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi.

METHODS

Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting.

RESULTS

Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred.

CONCLUSIONS

Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care.

Global Antimicrobial Susceptibility Patterns of Staphylococcus aureus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

Importance

Individuals with atopic dermatitis are frequently colonized and infected with Staphylococcus aureus. Empirical antibiotic therapy for individuals with atopic dermatitis is common, but data about the antimicrobial susceptibility profiles of S aureus strains isolated from these individuals are scarce for those living in particular geographic areas.

Objective

To determine the antimicrobial susceptibility of S aureus from individuals with atopic dermatitis and analyze differences according to the income level of the country of origin and the data collection period.

Data Sources

A meta-analysis of the literature was performed from the inception of the included databases (MEDLINE, Embase, Web of Science, Scopus, and Cochrane) to June 20, 2023, using predetermined Medical Subject Headings.

Study Selection

Studies were included if they reported antibiotic susceptibility profiles of 1 or more S aureus cutaneous isolates from individuals with atopic dermatitis. Articles written in English, Spanish, French, or German were included.

Data Extraction and Synthesis

Working in pairs, 6 of the authors conducted the data extraction. The guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

Main Outcomes and Measures

The outcome of interest was antimicrobial susceptibility.

Results

A total of 61 studies reported 4091 S aureus isolates from individuals with atopic dermatitis. For 4 of the 11 commonly used antibiotics (36.4%), antimicrobial susceptibility was 85% or less, including for methicillin (binomial proportion, 0.85 [95% CI, 0.76-0.91]), erythromycin (binomial proportion, 0.73 [95% CI, 0.61-0.83]), fusidic acid (binomial proportion, 0.80 [95% CI, 0.62-0.91]), and clindamycin (binomial proportion, 0.79 [95% CI, 0.65-0.89]). Most studies (46; 75.4%) were conducted in high-income countries. Antimicrobial susceptibility to erythromycin, methicillin, and trimethoprim and sulfamethoxazole was significantly lower in lower middle-income countries and upper middle-income countries. Regarding the temporal trends, 33 studies (54.1%) reported data collected from 1998 to 2010. Antimicrobial susceptibility patterns have not changed over time.

Conclusions and Relevance

In this systematic review and meta-analysis, antimicrobial susceptibility of S aureus to β-lactams, erythromycin, clindamycin, and fusidic acid may be suboptimal for empirical use in individuals with atopic dermatitis. Significant differences in antimicrobial susceptibility patterns were found in high-income countries and in lower middle-income countries and upper middle-income countries for some antibiotics.

Coverage of policies to improve antimicrobial stewardship in human medicine in low and middle income countries: results from the Global Survey of Experts on Antimicrobial Resistance

BACKGROUND

Antimicrobial resistance (AMR) constitutes a major threat to global health. While antimicrobial misuse or overuse is one of the main drivers for AMR, little is known about the extent to which antibiotic misuse is due to a lack of national government-led efforts to enforce rational use in low and middle-income countries (LMICs).

METHODS

To assess antimicrobial stewardship and national implementation measures currently in place for optimizing antimicrobial use and for slowing the spread of AMR, we invited public health experts from 138 LMICs to participate in a Global Survey of Experts on Antimicrobial Resistance (GSEAR). Key coverage measures, as reported by experts, were compared across countries and also juxtaposed with estimates collected in the 2020-21 World Health Organization-organized Tripartite AMR Country Self-Assessment Survey (TrACSS).

RESULTS

A total of 352 completed surveys from 118 LMICs were analysed. Experts in 67% of the surveyed countries reported a national action plan (NAP) on AMR, 64% reported legislative policies on antimicrobial use, 58% reported national training programs for health professionals, and 10% reported national monitoring systems for antimicrobials. 51% of LMICs had specific targeted policies to limit the sale and use of protected or reserve antibiotics. While 72% of LMICs had prescription requirements for accessing antibiotics, getting antibiotics without a prescription was reported to be possible in practice in 74% of LMICs. On average, country efforts reported in TrACSS were substantially higher than those seen in GSEAR.

CONCLUSIONS

In many LMICs, despite the existence of policies aimed at slowing down the spread of AMR, there are still significant gaps in their implementation and enforcement. Increased national efforts in the areas of enforcement and monitoring of antibiotic use as well as regular monitoring of national efforts are urgently needed to reduce inappropriate antibiotic use in LMICs and to slow the spread of AMR globally.

Understanding antibiotic knowledge, attitudes, and practices: a cross-sectional study in physicians from a Colombian region, 2023

BACKGROUND

Antibiotic resistance has been identified as a global health threat. Knowledge, attitudes, and inappropriate prescription practices of antibiotics by physicians play a crucial role in this problem. In Colombia, research addressing this issue is scarce.

METHODS

A cross-sectional study involving 258 physicians was conducted. A scale with questions on sociodemographic aspects, level of education, satisfaction with antibiotic education received, and knowledge, attitudes, and practices was administered. The scale was designed for each item to be analyzed individually or as a total score ranging from 0 to 100 (0 being the lowest and 100 the highest).

RESULTS

31.5% of physicians rated the education received on antibiotics as fair to poor. The knowledge score was 80.1 (IQR 70.5-87.5); however, 25.2% agreed to some extent that amoxicillin is useful in treating most respiratory infections, and 15% agreed that antibiotics are effective in treating upper respiratory infections. Attitudes scored 80.2 (IQR 75.0-86.5), with 99% stating that bacterial resistance is a public health problem in Colombia, but only 56.9% considering it a problem affecting their daily practice. Practices scored 75.5 (IQR 68.8-81.2), and 71.7% affirmed that if they refuse to prescribe antibiotics to a patient who does not need them, the patient can easily obtain them from another physician. General practitioners were found to have lower scores in all three indices evaluated.

CONCLUSION

The study reveals enduring misconceptions and concerning practices in antibiotic prescription, particularly among general practitioners. Enhancing knowledge necessitates the implementation of continuous medical education programs that focus on updated antibiotic guidelines, and resistance patterns. Fostering positive attitudes requires a culture of trust and collaboration among healthcare professionals. Practical enhancements can be realized through the establishment of evidence-based prescribing guidelines and the integration of regular feedback mechanisms. Moreover, advocating for the inclusion of antimicrobial stewardship principles in medical curricula is crucial, emphasizing the significance of responsible antibiotic use early in medical education.

A combined strategies intervention on the World Health Organization prescribing indicators: A quasi-randomised trial

BACKGROUND

Irrational medicine use is a global problem that may potentiate antimicrobial resistance.

AIM

This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators.

SETTING

The study was conducted in public-sector healthcare facilities in Eswatini.

METHODS

A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times.

RESULTS

At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up.

CONCLUSION

In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing.Contribution: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use.

Probing Antibacterial and Anticancer Potential of Selenicereus undatus, Pistacia vera L. and Olea europaea L. against Uropathogens, MCF-7 and A2780 Cancer Cells

Urinary tract infection is an infectious disease that requires immediate treatment. It can occur in any age group and involves both genders equally. The present study was to check the resistance of some antibiotics and to assess the antibacterial potential of three extracts of three plants against notorious bacteria involved in urinary tract infections. Along with assessing the antibacterial activity of plant extracts, we checked for the anticancer potential of these extracts against the cancer cell lines MCF-7 and A2780. Cancer is the leading cause of mortality in developed countries. Determinations of total flavonoid content, total phenolic content, total alkaloid content, total tannin content, total carotenoid content, and total steroid content were performed. The disk diffusion method was used to analyze the antibacterial activity of plant extracts. Ethanolic extract of Selenicereus undatus showed sensitivity (25-28 mm) against bacteria, whereas chloroform and hexane extracts showed resistance against all bacteria except Staphylococcus (25 mm). Ethanolic extract of Pistacia vera L. showed sensitivity (22-25 mm) against bacteria, whereas chloroform and hexane extracts showed resistance. Ethanolic extract of Olea europaea L. showed sensitivity (8-16 mm) against all bacteria except Staphylococcus, whereas chloroform and hexane extracts showed resistance. Positive controls showed variable zones of inhibition (2-60 mm), and negative control showed 0-1 mm. The antibiotic resistance was much more prominent in the case of hexane and chloroform extracts of all plants, whereas ethanolic extract showed a sensitivity of bacteria against extracts. Both cell lines, MCF-7 and A2780, displayed decreased live cells when treated with plant extracts.

Supply-chain factors and antimicrobial stewardship

Efficient and secure supply chains are vital for effective health services worldwide. In low- and middle-income countries, the accessibility, affordability and availability of essential medicines, including antimicrobials, remain challenging. Ineffective supply chains often cause antimicrobial shortages, leading to inappropriate use of alternative agents and increasing the risk of antimicrobial resistance. Shortages, coupled with insecure supply chains, also encourage the infiltration of substandard and falsified medicines, leading to suboptimal treatment and further promoting antimicrobial resistance. Addressing antimicrobial supply-chain issues should be considered a key component of antimicrobial stewardship programmes. We have explored the link between medicine supply chains and antimicrobial use in seven focus countries: Kenya, Malawi, Nigeria, Sierra Leone, Uganda, United Republic of Tanzania and Zambia. We explored country medicine supply-system structures, national medicine supply-chain policy documents and global study reports. Our aim was to develop evidence-based strategies to enhance the effectiveness and efficiency of the medicine supply chains in supporting antimicrobial stewardship efforts. Better management of medical supply chains involves rational selection, quantification, forecasting, procurement, storage, distribution, use and stock management of antimicrobials. Important supply-chain considerations include pooled procurement networks to ensure consistent pricing of quality-assured antimicrobials, and improved resource utilization and information exchange among relevant stakeholders. We propose adaptable recommendations for integrating medicine supply chains as an essential part of antimicrobial stewardship programmes, with a call for action at the local, regional and national levels in low- and middle-income countries.

Overuse of medications in low- and middle-income countries: a scoping review

Objective

To identify and summarize the evidence about the extent of overuse of medications in low- and middle-income countries, its drivers, consequences and potential solutions.

Methods

We conducted a scoping review by searching the databases PubMed®, Embase®, APA PsycINFO® and Global Index Medicus using a combination of MeSH terms and free text words around overuse of medications and overtreatment. We included studies in any language published before 25 October 2021 that reported on the extent of overuse, its drivers, consequences and solutions.

Findings

We screened 3489 unique records and included 367 studies reporting on over 5.1 million prescriptions across 80 low- and middle-income countries - with studies from 58.6% (17/29) of all low-, 62.0% (31/50) of all lower-middle- and 60.0% (33/55) of all upper-middle-income countries. Of the included studies, 307 (83.7%) reported on the extent of overuse of medications, with estimates ranging from 7.3% to 98.2% (interquartile range: 30.2-64.5). Commonly overused classes included antimicrobials, psychotropic drugs, proton pump inhibitors and antihypertensive drugs. Drivers included limited knowledge of harms of overuse, polypharmacy, poor regulation and financial influences. Consequences were patient harm and cost. Only 11.4% (42/367) of studies evaluated solutions, which included regulatory reforms, educational, deprescribing and audit-feedback initiatives.

Conclusion

Growing evidence suggests overuse of medications is widespread within low- and middle-income countries, across multiple drug classes, with few data of solutions from randomized trials. Opportunities exist to build collaborations to rigorously develop and evaluate potential solutions to reduce overuse of medications.

Antibiotic resistance pattern of microorganisms causing urinary tract infection: a 10-year comparative analysis in a tertiary care hospital of Bangladesh

BACKGROUND

Antimicrobial resistance is an emerging concern globally in recent years. Management of common infectious diseases like urinary tract infection (UTI) has become challenging. In this context, the purpose of this study is to compare the shifting trends in bacteriology and antibiotic resistance pattern among uropathogens to similar studies conducted at various times in Bangladesh.

METHODS

It was a cross-sectional study conducted at the CUMILLA MEDICAL COLLEGE HOSPITAL'S MEDICINE DEPARTMENT in three phases (2011, 2016, 2021. Patients who visited the outpatient and inpatient departments of the study center with symptoms suggestive of a urinary tract infection were undergone urine culture. Those who yielded positive growth in urne culture were finally included in the study.

RESULTS

Escherichia coli (62% in 2021, 86% in 2016 and 76% in 2011) and Klebsiella species (11% in 2021, 10% in 2016 and 11% in 2011) were the most frequently isolated bacteria. Overall, in Gram-negative organisms, resistance was almost > 50% to all the tested antibiotics. Very high frequency of resistance ranging from 66.67 to 93.75% to cotrimoxazole, ciprofloxacin, cefuroxime, cephradine, amoxicillin and nalidixic acid, moderately high resistance to ceftriaxone (64.52%) and gentamicin (53.13%) and low resistance to nitrofurantoin (25.38%) were shown by the most commonly isolated organisms. Resistance to common antibiotics has been significantly increased over time in the isolated orgnaisms, especially in carbapenem and aminoglycoside group.

CONCLUSION

Resistance of uropathogens against conventional antibiotics used to treat UTI is high and the proportion has been increased over time. The situation might be grave in upcoming years if rational consumption of antibiotics is not warranted.

Strategies for de-implementation of low-value care-a scoping review

BACKGROUND

The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al. METHOD: A scoping review was conducted according to recommendations outlined by Arksey and O'Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies.

RESULTS

The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC.

CONCLUSIONS

Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.

Noninvasive fecal metabolic profiling for the evaluation of characteristics of thermostable lactic acid bacteria, Weizmannia coagulans SANK70258, for broiler chickens

Weizmannia coagulans SANK70258 is a spore-forming thermostable lactic acid bacterium and an effective probiotic for the growth of livestock animals, but its growth-promoting mechanism remains unclear. Here, the composition of fecal metabolites in broilers continuously administered with W. coagulans SANK70258 was assessed under a regular program with antibiotics, which was transiently given for 6 days after birth. Oral administration of W. coagulans to broiler chicks tended to increase the average daily gain of body weights thereafter. The composition of fecal metabolites in the early chick stage (Day 10 after birth) was dramatically altered by the continuous exposure. The levels of short-chain fatty acids (SCFAs) propionate and butyrate markedly increased, while those of acetate, one of the SCFAs, and lactate were reduced. Simultaneously, arabitol, fructose, mannitol, and erythritol, which are carbohydrates as substrates for gut microbes to produce SCFAs, also increased along with altered correlation. Correlation network analyses classified the modularity clusters (|r| > 0.7) among carbohydrates, SCFAs, lactate, amino acids, and the other metabolites under the two conditions. The characteristic diversities by the exposure were visualized beyond the perspective associated with differences in metabolite concentrations. Further, enrichment pathway analyses showed that metabolic composition related to biosynthesis and/or metabolism for SCFAs, amino acids, and energy were activated. Thus, these observations suggest that W. coagulans SANK70258 dramatically modulates the gut metabolism of the broiler chicks, and the metabolomics profiles during the early chick stages may be associated with growth promotion.

Risk Factors for Inappropriate Antimicrobial Therapy Among Patients with Hospital-Acquired Infection at Jimma Medical Center: A Prospective Observational Study

Background

Globally, HAIs affect about 2 million people annually and result in 5% to 15% hospitalizations. In low-middle-income countries, antibiotics are improperly prescribed for 44% to 97% of hospitalized patients. A report in Ethiopia revealed that about 66.7% of HAIs are managed inappropriately.

Objective

To identify inappropriate antimicrobial therapy (AMT) and its risk factors among patients with HAIs at Jimma Medical Center (JMC).

Methods

A prospective observational study was conducted involving 300 patients with HAIs in medical, surgical, and gynecology-obstetrics wards of JMC, from October 2020 to April 2021. Data were collected using data abstraction format. Logistic regression was conducted to assess factors associated with AMT inappropriateness. A p-value <0.05 was considered to declare statistical significance.

Results

The overall mean age (± standard deviation) of the participants was 43.2 ± 19.2 years and 183 (61.0%) of them were females. About three-fourths (76.0%) of patients with HAIs were treated inappropriately. Hospital-acquired pneumonia (50.3%) was the most common type of HAI identified in this study. The frequent class of inappropriate AMT was an inappropriate choice, 102 (44.1%), followed by an inappropriate dose, 88 (38.1%), and inappropriate indication, 59 (24.2%). On multivariable logistic regression, patients having culture finding (AOR = 0.32, p = 0.016), taking metronidazole (AOR = 0.25, p = 0.001), and taking vancomycin (AOR = 2.93, p = 0.001) were significantly associated with inappropriate AMT.

Conclusion

Inappropriate AMT was identified in about three-fourths of the patients with HAIs. A decrease in the likelihood of inappropriate AMT was identified in patients having culture findings and in those taking metronidazole, whereas taking vancomycin increased the likelihood of inappropriate AMT. Therefore, the authors recommend scaling up the capacity of definitive therapy through culture and sensitivity tests. Furthermore, training of prescribers in the rational use of antimicrobials is also warranted.

Opportunities and challenges to accurate diagnosis and management of acute febrile illness in adults and adolescents: A review

Acute febrile illnesses are common reasons to seek healthcare globally. They can be caused by diverse infectious diseases which require complex diagnostics. Current clinical guidelines provide guidance on how to manage severe illness, common localizing infections like pneumonia and urinary tract infections, as well as malaria. How to manage other cases of acute febrile illness is less clear and is the focus of this review. Without an etiologic diagnosis, clinicians frequently prescribe empiric antibiotics that may be unnecessary or inadequate. We reviewed recent studies on the etiology of acute febrile illnesses in adults and adolescents that employed multiple diagnostic modalities, including rapid diagnostic tests, serologies, and polymerase chain reaction. Although studies and etiologies were heterogenous, we enumerated the causes of febrile illness in these studies. Possible improvements in clinical decision-making algorithms are discussed.

Compliance of imipenem and meropenem administration with the national antimicrobial stewardship program in a referral teaching hospital in Iran

INTRODUCTION

Considering the great significance of antimicrobial resistance, implementation of antimicrobial stewardship programs (ASPs) in healthcare facilities is of particular importance. This study aimed to evaluate the compliance of imipenem and meropenem administration with the ASP guidelines in a referral teaching hospital in Iran.

METHODS

In this retrospective cross-sectional study, the medical records of patients, who received either imipenem or meropenem at xx Hospital in Semnan, Iran, from March 21, 2017 until March 20, 2019, were reviewed using the developed ASP, according to the instructions issued by the Ministry of Health of Iran. The obtained findings were recorded in a checklist consisted of six items. If the action taken for the patient complied with the item requirement specified in the ASP, it would receive a score of one; otherwise, a score of zero. The sum of scores (range: 0-6) was reported and analyzed. Data were analyzed in SPSS version 23, using Chi-square, ANOVA, and independent t-test, and P <0.05 was considered as significant.

RESULTS

The mean duration of imipenem/meropenem administration was 9.2±8.0 days. A total of 6,032 imipenem/meropenem vials (1 g/vial) were prescribed during the study (meropenem for 210 patients and imipenem for 87 patients). In 64.2% of the patients, there was no indication, and the mean score of the subjects was 1.55±1.2. The obtained score was three in 53 (17.8%) records and four in 18 (6.1%) records. The mean score of ASP in the intensive care units was higher, while it was lower in the surgical ward as compared to the other wards (P=0.002).

DISCUSSION

Antibiotic prescription was inappropriate in our center, and compliance with the ASP guidelines was very low, especially in the surgical wards. It seems necessary to take effective steps for planning continuing education programs on rational antibiotic prescription and supervision of prescription patterns.

Bacterial uropathogens and burden of antimicrobial resistance pattern in urine specimens referred to Ethiopian Public Health Institute

BACKGROUND

Urinary tract infections (UTIs) are the leading causes of morbidity in the general population, and is the second most common infectious disease after respiratory infections. Appropriate antibiotic therapy is essential to achieving good therapeutic results. Therefore, the purpose of this study was to investigate the profile of pathogens cultured from urinary tract infections and to determine their resistance profiles to commonly prescribed antibiotics.

METHOD

A cross-sectional study was carried out at the National Referral Laboratory of the Ethiopian Institute of Public Health from January 2017 to December 2018. All positive cultures were characterized by colony morphology, Gram stain, and standard biochemical tests. The antimicrobial susceptibility test of the isolate was performed using the Kirby- Bauer disk diffusion test on Muller-Hinton agar. In addition, bacterial identification, antimicrobial susceptibility testing and phenotypic detection of MDR were performed with VITEK 2 Compact according to the manufacturer's instructions.

RESULT

Out of 1012 cultured urine specimens, 325 (32.1%) was showed significant bacteriuria. The overall prevalence of UTIs was 325(32.1%) and the highest prevalence rate was obtained from 21-30 years age group 73(22.5%). Among UTIs patients, 583(57.6%) were females and 429(42.4%) were males. The UTIs of 179 (55%) women is relatively higher than that of men 146 (45%). Among 325 isolates, Gram-negative bacteria (GNB) appeared more frequently 252 (51.7%) than Gram-positive bacteria 63 (19.4%). In GNB, E. coli 168(66.7%), Klebsiella species 32(12.7%), and Enterobacter species 13 (5.2%) were dominated isolates whereas in GPB accounted for coagulase-negative staphylococcus (CoNS) 33(52.4%), Enterococcus species 16(25.4%), and Staphylococcus aureus 10(15.9%). Major of the isolates showed high levels of antibiotic resistance to commonly prescribed antimicrobials. Imipenem, Amikacin, and Nitrofurantoin were the most sensitive antibiotics for Gram-negative isolates while Nitrofurantoin, clindamycin, and Gentamycin were effective against gram-positive uropathogens. Overall, 156/256(60.9%), 56/256(22.4%), 10/256(4%) of gram-negative isolates were MDR, XDR, and PDR respectively while among the GPB isolates, 34/63(53.1%), 10/63(15.8%), and 1/63(1.6%) were MDR, XDR, and PDR isolates respectively. Among the tested bacterial strains, 190/319 (59.5%) were MDR, 66/319 (20.7%) strains were XDR, and 11/319 (3.45%) were PDR isolated.

CONCLUSION

The prevalence of urinary tract infection was high, and Gram-negative organisms were the most common causes of UTIs in this study. It was found that the resistance to commonly used antibiotics is very high. Early detection and close monitoring of MDR, XDR, or even PDR bacterial strains must be started by all clinical microbiology laboratories to reduce the menace of antimicrobial resistance that is now a global problem.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Porphyromonas gingivalis: where do we stand in our battle against this oral pathogen?

Periodontal diseases, such as gingivitis and periodontitis, are inflammatory diseases triggered by pathogenic bacteria that lead to damage of the soft tissue and bone supporting the teeth. Amongst the identified oral periodontopathogenic bacteria, Porphyromonas gingivalis is able to enhance oral dysbiosis, which is an imbalance in the beneficial commensal and periodontal pathogenic bacteria that induces chronic inflammation. Given the critical role of oral pathogenic bacteria like P. gingivalis in the pathogenesis of periodontitis, local and/or systemic antibacterial therapy has been suggested to treat this disease, especially in its severe or refractory forms. Nevertheless, the majority of the antibacterial agents currently used for the treatment of periodontal diseases are broad-spectrum, which harms beneficial bacterial species that are critical in health, inhibit the growth of pathogenic bacteria, contribute in protecting the periodontal tissues to damage and aid in its healing. Thus, the development of more effective and specific antibacterial agents is needed to control oral pathogens in a polymicrobial environment. The strategies for the development of novel antibacterial agents include natural product isolation as well as synthetic and semi-synthetic methodologies. This review presents an overview of the periodontal diseases gingivitis and periodontitis along with current antibacterial treatment options (i.e., classes of antibacterial agents and the mechanism(s) of resistance that hinder their usage) used in periodontal diseases that specifically target oral pathogens such as P. gingivalis. In addition, to help medicinal chemists gain a better understanding of potentially promising scaffolds, this review provides an in-depth coverage of the various families of small molecules that have been investigated as potential anti-P. gingivalis agents, including novel families of compounds, repositioned drugs, as well as natural products.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of a national policy advocating rational drug use on decreases in outpatient antibiotic prescribing rates in Thailand

Objective:

This study examined the effects of a national policy advocating rational drug use (RDU), namely, the ‘RDU Service Plan’, starting in fiscal year 2017 and implemented by the Thai Ministry of Public Health (MOPH), on trends in antibiotic prescribing rates for outpatients. The policy was implemented subsequent to a voluntary campaign involving 136 hospitals, namely, the ‘RDU Hospital Project’, which was implemented during fiscal years 2014-2016.

Methods:

Hospital-level antibiotic prescribing rates in fiscal years 2014-2019 for respiratory infections, acute diarrhea, and fresh wounds were aggregated for two hospital groups using equally weighted averages: early adopters of RDU activities through the RDU Hospital Project and late adopters under the RDU Service Plan. Pre-/post-policy annual changes in the prescribing levels and trends were compared between the two groups using an interrupted time-series analysis.

Results:

In fiscal years 2014-2016, decreases in antibiotic prescribing rates for respiratory infections and acute diarrhea in both groups reflected a trend that existed before the RDU Service Plan was implemented. The immediate effect of the RDU Service Plan policy occurred in fiscal year 2017, when the prescribing level among the late adopters dropped abruptly for all three conditions with a greater magnitude than in the decrease among the early adopters, despite nonsignificant differences. The medium-term effect of the RDU Service Plan was identified through a further decreasing trend during fiscal years 2017-2019 for all conditions in both groups, except for acute diarrhea among the early adopters.

Conclusions:

The national policy on rational drug use effectively reduced antibiotic prescribing for common but questionable outpatient conditions.

What medicines do households keep in their cabinets? Understanding the possession and use of medicines at home and the role of health insurance in Nigeria

Background

Globally, the possession of medicines stored at home is increasing. However, little is known about the determinants of possessing medicines, their usage according to clinical purpose, which we term ‘correct drug match’, and the role of health insurance.

Methods

This study uses data from a 2013 survey evaluating a health insurance program in Kwara State, Nigeria, which upgraded health facilities and subsidized insurance premiums. The final dataset includes 1,090 households and 4,641 individuals. Multilevel mixed-effects logistic regressions were conducted at both the individual level and at the level of the medicines kept in respondents’ homes to understand the determinants of medicine possession and correct drug match, respectively, and to investigate the effect of health insurance on both.

Results

A total of 9,266 medicines were classified with 61.2% correct match according to self-reported use, 11.9% incorrect match and 26.9% indeterminate. Most medicines (73.0%) were obtained from patent proprietary medicine vendors (PPMVs). At 36.6%, analgesics were the most common medicine held at home, while anti-malarial use had the highest correct match at 96.1%. Antihistamines, vitamins and minerals, expectorants, and antibiotics were most likely to have an incorrect match at respectively 35.8%, 33.6%, 31.9%, and 26.6%. Medicines were less likely to have a correct match when found with the uneducated and obtained from public facilities. Enrolment in the insurance program increased correct matches for specific medicines, notably antihypertensives and antibiotics (odds ratio: 25.15 and 3.60, respectively).

Conclusion

Since PPMVs serve as both the most popular and better channel compared to the public sector to obtain medicines, we recommend that policymakers strengthen their focus on these vendors to educate communities on medicine types and their correct use. Health insurance programs that provide affordable access to improved-quality health facilities represent another important avenue for reducing the burden of incorrect drug use. This appears increasingly important in view of the global rise in antimicrobial resistance.

Biomarkers to distinguish bacterial from viral pediatric clinical pneumonia in a malaria endemic setting

Background

Differential etiologies of pediatric acute febrile respiratory illness pose challenges for all populations globally, but especially in malaria-endemic settings because the pathogens responsible overlap in clinical presentation and frequently occur together. Rapid identification of bacterial pneumonia with high-quality diagnostic tools would enable appropriate, point-of-care antibiotic treatment. Current diagnostics are insufficient, and the discovery and development of new tools is needed. We report a unique biomarker signature identified in blood samples to accomplish this.

Methods

Blood samples from 195 pediatric Mozambican patients with clinical pneumonia were analyzed with an aptamer-based, high-dynamic-range, quantitative assay (~1200 proteins). We identified new biomarkers using a training set of samples from patients with established bacterial, viral, or malarial pneumonia. Proteins with significantly variable abundance across etiologies (false discovery rate <0.01) formed the basis for predictive diagnostic models derived from machine learning techniques (Random Forest, Elastic Net). Validation on a dedicated test set of samples was performed.

Results

Significantly different abundances between bacterial and viral infections (219 proteins) and bacterial infections and mixed (viral and malaria) infections (151 proteins) were found. Predictive models achieved >90% sensitivity and >80% specificity, regardless of number of pathogen classes. Bacterial pneumonia was strongly associated with neutrophil markers—in particular, degranulation including HP, LCN2, LTF, MPO, MMP8, PGLYRP1, RETN, SERPINA1, S100A9, and SLPI.

Conclusions

Blood protein signatures highly associated with neutrophil biology reliably differentiated bacterial pneumonia from other causes. With appropriate technology, these markers could provide the basis for a rapid diagnostic for field-based triage for antibiotic treatment of pediatric pneumonia.

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Use of antibiotics to treat humans and animals in Uganda: a cross-sectional survey of households and farmers in rural, urban and peri-urban settings

Background

Use of antibiotics to treat humans and animals is increasing worldwide, but evidence from low- and middle-income countries (LMICs) is limited. We conducted cross-sectional surveys in households and farms in Uganda to assess patterns of antibiotic use among humans and animals.

Methods

Between May and December 2018, a convenience sample of 100 households in Nagongera (rural), 174 households in Namuwongo (urban) and 115 poultry and piggery farms in Wakiso (peri-urban) were selected and enrolled. Using the ‘drug bag’ method, participants identified antibiotics they used frequently and the sources of these medicines. Prevalence outcomes were compared between different sites using prevalence ratios (PRs) and chi-squared tests.

Results

Nearly all respondents in Nagongera and Namuwongo reported using antibiotics to treat household members, most within the past month (74.7% Nagongera versus 68.8% Namuwongo, P = 0.33). Use of metronidazole was significantly more common in Namuwongo than in Nagongera (73.6% versus 40.0%, PR 0.54, 95% CI: 0.42–0.70, P < 0.001), while the opposite was true for amoxicillin (33.3% versus 58.0%, PR 1.74, 95% CI: 1.33–2.28, P < 0.001).Veterinary use of antibiotics within the past month was much higher in Wakiso than in Nagongera (71.3% versus 15.0%, P < 0.001). At both sites, oxytetracycline hydrochloride was the most frequently used veterinary antibiotic, but it was used more commonly in Wakiso than in Nagongera (76.5% versus 31.0%, PR 0.41, 95% CI: 0.30–0.55, P < 0.001).

Conclusions

Antibiotics are used differently across Uganda. Further research is needed to understand why antibiotics are relied upon in different ways in different contexts. Efforts to optimize antibiotic use should be tailored to specific settings.

Tracking Antimicrobial Resistance Determinants in Diarrheal Pathogens: A Cross-Institutional Pilot Study

Infectious diarrhea affects over four billion individuals annually and causes over a million deaths each year. Though not typically prescribed for treatment of uncomplicated diarrheal disease, antimicrobials serve as a critical part of the armamentarium used to treat severe or persistent cases. Due to widespread over- and misuse of antimicrobials, there has been an alarming increase in global resistance, for which a standardized methodology for geographic surveillance would be highly beneficial. To demonstrate that a standardized methodology could be used to provide molecular surveillance of antimicrobial resistance (AMR) genes, we initiated a pilot study to test 130 diarrheal pathogens (Campylobacter spp., Escherichia coli, Salmonella, and Shigella spp.) from the USA, Peru, Egypt, Cambodia, and Kenya for the presence/absence of over 200 AMR determinants. We detected a total of 55 different determinants conferring resistance to ten different categories of antimicrobials: genes detected in ≥ 25 samples included bla_TEM, tet(A), tet(B), mac(A), mac(B), aadA1/A2, strA, strB, sul1, sul2, qacEΔ1, cmr, and dfrA1. The number of determinants per strain ranged from none (several Campylobacter spp. strains) to sixteen, with isolates from Egypt harboring a wider variety and greater number of genes per isolate than other sites. Two samples harbored carbapenemase genes, bla_OXA-48 or bla_NDM. Genes conferring resistance to azithromycin (ere(A), mph(A)/mph(K), erm(B)), a first-line therapeutic for severe diarrhea, were detected in over 10% of all Enterobacteriaceae tested: these included >25% of the Enterobacteriaceae from Egypt and Kenya. Forty-six percent of the Egyptian Enterobacteriaceae harbored genes encoding CTX-M-1 or CTX-M-9 families of extended-spectrum β-lactamases. Overall, the data provide cross-comparable resistome information to establish regional trends in support of international surveillance activities and potentially guide geospatially informed medical care.

Identifying the most effective essential medicines policies for quality use of medicines: A replicability study using three World Health Organisation data-sets

Background

Poor quality use of medicines (QUM) has adverse outcomes. Governments’ implementation of essential medicines (EM) policies is often suboptimal and there is limited information on which policies are most effective.

Methods

We analysed data on policy implementation from World Health Organisation (WHO) surveys in 2007 and 2011, and QUM data from surveys during 2006–2012 in developing and transitional countries. We compared QUM scores in countries that did or did not implement specific policies and regressed QUM composite scores on the numbers of policies implemented. We compared the ranking of policies in this and two previous studies, one from the same WHO databases (2003–2007) the other from data obtained during country visits in South-East Asia (2010–2015). The rankings of a common set of 17 policies were correlated and we identified those that were consistently highly ranked.

Findings

Fifty-three countries had data on both QUM and policy implementation. Forty policies were associated with effect sizes ranging from +13% to -5%. There was positive correlation between the composite QUM indicator and the number of policies reported implemented: (r) = 0.437 (95% CI 0.188 to 0.632). Comparison of policy rankings between the present and previous studies showed positive correlation with the WHO 2003–7 study: Spearman’s rank correlation coefficient 0.498 (95% CI 0.022 to 0.789). Across the three studies, five policies were in the top five ranked positions 11 out of a possible 15 times: drugs available free at the point of care; a government QUM unit; undergraduate training of prescribers in standard treatment guidelines, antibiotics not available without prescription and generic substitution in the public sector.

Interpretation

Certain EM policies are associated with better QUM and impact increases with co-implementation. Analysis across three datasets provides a policy short-list as a minimum investment by countries trying to improve QUM and reduce antimicrobial drug misuse.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

Healthcare-Associated Infections Due to Multidrug-Resistant Organisms: a Surveillance Study on Extra Hospital Stay and Direct Costs

BACKGROUND

The increasing antimicrobial resistance poses a challenge to surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety.

OBJECTIVE

The study aimed to estimate extra hospital stay and economic burden of infections due to alert organisms - mostly multidrug-resistant - in a teaching hospital.

METHODS

The present retrospective matched cohort study was conducted based on the analysis of hospital admissions at Sant'Andrea Teaching Hospital in Rome from April to December 2015. Extra hospital stay was the difference in the length of stay between each case and control. All the patients developing an infection due to an alert organism were considered cases, all others were eligible as controls. The costs of LOS were evaluated by multiplying the extra stay with the hospital daily cost.

RESULTS

Overall, 122 patients developed an infection due to alert organisms and were all matched with controls. The attributable extra stay was of 2,291 days (mean 18.8; median 19.0) with a significantly increased hospitalization in intensive care units (21.2 days), bloodstream infections (52.5 days), and infections due to Gram-negative bacteria (mean 29.2 days; median 32.6 days). Applying the single day hospital cost, the overall additional expenditure was 11,549 euro per patient. The average additional cost of antibiotic drugs for the treatment of infections was about 1,200 euro per patient.

CONCLUSION

The present study presents an accurate mapping of the clinical and economic impact of infections attributable to alert organisms demonstrating that infections due to multidrug-resistant organisms are associated with higher mortality, longer hospital stays, and increased costs. Article Highlights Box: The increasing antimicrobial resistance poses a challenge for surveillance systems and raises concerns about the impact of multidrug-resistant organisms on patient safety. • Healthcare-associated infections (HAIs) have historically been recognized as a significant public health problem requiring close surveillance. • Despite several and reliable findings have been achieved on clinical issues, our knowledge on the economic impact of healthcare-associated infections due to multidrug-resistant organisms needs to be widened. • Estimating the cost of infections due to multidrug-resistant organisms in terms of extra hospital stay and economic burden is complex, and the financial impact varies across different health systems. • Evaluations of social and economic implications of hospital infections play an increasingly important role in the implementation of surveillance systems. • The costs of infection prevention and control programs and dedicated personnel are relatively low and self-sustainable when efficient.

Withdrawn medicines included in the essential medicines lists of 136 countries

BACKGROUND

Essential medicines lists and related policies are intended to meet the priority health needs of populations and their implementation is associated with more appropriate use of medicines. The World Health Organization (WHO) recommends that countries carefully select the medicines to be included in their national essential medicines lists. Lists that are used to prioritize access to important treatments should not include medicines that have been withdrawn elsewhere because of an unfavourable benefit-to-harm balance; however, countries still list and use medicines that have been withdrawn worldwide. The objective of this study was to determine whether the national essential medicines lists of 137 countries include medicines that have been withdrawn in other countries.

METHODS AND FINDINGS

We performed an audit of national essential medicines lists for medicines that had been withdrawn. Medicines withdrawn from worldwide markets between 1953 and 2014 were identified using a systematic review of published literature and regulatory documents. The reviewers used sources including the WHO's database of drugs, PubMed, and the websites of regulatory agencies to obtain information regarding adverse effects associated with the medicines, the year of first withdrawal, markets of withdrawal, and the level of evidence supporting each withdrawal. We recorded the number of countries with a withdrawn medicine included in their national medicines list, the number of withdrawn medicines included in each nation's list, and the number of national essential medicines including each withdrawn medicine. 97 medicines were withdrawn in at least one country but still included in one more national essential medicines list. Of 137 countries with a national essential medicines list, 136 lists included at least one withdrawn medicine, with 54% of the lists containing 5 or fewer withdrawn medicines, and 27% including 10 or more withdrawn medicines. 11 medicines were withdrawn worldwide but still included on at least one national essential medicines list. Countries with longer essential medicines lists had more withdrawn medicines included in their lists.

CONCLUSIONS

This study found that withdrawn medicines are included in all but one national essential medicines list, representing a need for more stringent processes for selecting and removing medicines on these lists. Countries may wish to apply special scrutiny to medicines withdrawn in other nations when selecting medicines to include on their lists.

Pattern of inappropriate antibiotic use among hospitalized patients in Pakistan: a longitudinal surveillance and implications

Background

The inappropriate use of antibiotics in hospitals increases resistance, morbidity, and mortality. Little is currently known about appropriate antibiotic use among hospitals in Lahore, the capital city of Pakistan.

Methods

Longitudinal surveillance was conducted over a period of 2 months among hospitals in Lahore, Pakistan. Antibiotic treatment was considered inappropriate on the basis of a wrong dosage regimen, wrong indication, or both based on the British National Formulary.

Results

A total of 2022 antibiotics were given to 1185 patients. Out of the total prescribed, approximately two-thirds of the study population (70.3%) had at least one inappropriate antimicrobial. Overall, 27.2% of patients had respiratory tract infections, and out of these, 62.8% were considered as having inappropriate therapy. Cephalosporins were extensively prescribed among patients, and in many cases, this was inappropriate (67.2%). Penicillins were given to 283 patients, out of which 201 (71.0%) were prescribed for either the wrong indication or dosage or both. Significant variations were also observed regarding inappropriate prescribing for several antimicrobials including the carbapenems (70.9%), aminoglycosides (35.8%), fluoroquinolones (64.2%), macrolides (74.6%) and other antibacterials (73.1%).

Conclusion

Educational interventions, institutional guidelines, and antimicrobial stewardship programs need to be developed to enhance future appropriate antimicrobial use in hospitals in Pakistan. Policies by healthcare and Government officials are also needed to minimize inappropriate antibiotic use.

Clinical efficacy of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry in patients with multidrug-resistant bacteremia: a single-center study in Korea

BACKGROUND/AIMS

Matrix-assisted laser desorption/ionization time-of-f light mass spectrometry (MALDI-TOF MS) is a new diagnostic tool for microorganism identification. The clinical usefulness of this approach has not been widely examined in Korea. This retrospective pre-post-intervention quasi-experimental study examined the effect of MALDI-TOF MS on patients with multidrug-resistant (MDR) bacteremia in the intensive care unit (ICU).

METHODS

All consecutive patients with MDR bacteremia in the ICU of a tertiary care hospital between March 2011 and February 2013 and between March 2014 and February 2016 were enrolled. MALDI-TOF MS was introduced between these periods. In the pre-intervention and intervention groups, microorganisms were identified by conventional means and by MALDI-TOF MS, respectively. The groups were compared in terms of time from venipuncture to microorganism identification and antimicrobial susceptibility test results.

RESULTS

In total, 187 patients (mean age, 61.0 years; 56.7% male) were enrolled. Of these, 97 and 90 were in the pre-intervention and intervention groups, respectively. The intervention group had a significantly shorter time from venipuncture to microorganism identification and antimicrobial susceptibility test results (82.5 ± 21.6 hours vs. 92.3 ± 40.4 hours, p = 0.038). The antibiotics were adjusted in 52 patients (26 each in the pre-intervention and intervention groups) based on these results. These groups did not differ in terms of time from venipuncture to antibiotic adjustment, and multivariate regression analysis showed that MALDI-TOF MS-based microorganism identification was not associated with 28-day mortality.

CONCLUSION

Our study showed that MALDI-TOF MS accelerated microorganism identification in patients with MDR bacteremia, but did not inf luence 28-day mortality.

The right to health as the basis for universal health coverage: A cross-national analysis of national medicines policies of 71 countries

Persistent barriers to universal access to medicines are limited social protection in the event of illness, inadequate financing for essential medicines, frequent stock-outs in the public sector, and high prices in the private sector. We argue that greater coherence between human rights law, national medicines policies, and universal health coverage schemes can address these barriers. We present a cross-national content analysis of national medicines policies from 71 countries published between 1990-2016. The World Health Organization's (WHO) 2001 guidelines for developing and implementing a national medicines policy and all 71 national medicines policies were assessed on 12 principles, linking a health systems approach to essential medicines with international human rights law for medicines affordability and financing for vulnerable groups. National medicines policies most frequently contain measures for medicines selection and efficient spending/cost-effectiveness. Four principles (legal right to health; government financing; efficient spending; and financial protection of vulnerable populations) are significantly stronger in national medicines policies published after 2004 than before. Six principles have remained weak or absent: pooling user contributions, international cooperation, and four principles for good governance. Overall, South Africa (1996), Indonesia and South Sudan (2006), Philippines (2011-2016), Malaysia (2012), Somalia (2013), Afghanistan (2014), and Uganda (2015) include the most relevant texts and can be used as models for other settings. We conclude that WHO's 2001 guidelines have guided the content and language of many subsequent national medicines policies. WHO and national policy makers can use these principles and the practical examples identified in our study to further align national medicines policies with human rights law and with Target 3.8 for universal access to essential medicines in the Sustainable Development Goals.

Effect of physicians' knowledge on antibiotics rational use in China's county hospitals

BACKGROUND

Irrational prescriptions of antibiotics have received significant international attention. In China, previous studies have described the impact of physicians' knowledge on antibiotic use, however, empirical studies of the relationship between physician knowledge and antibiotic prescription behavior are limited.

OBJECTIVE

This study aimed to examine physicians' knowledge of antibiotic and explore the effects of physicians' knowledge on rational antibiotic use in county hospitals in China.

METHOD

A sample of 360 physicians from 60 county hospitals was designed. Questionnaires were used to evaluate the physicians' knowledge of antibiotic use. We assessed the rationality of antibiotic use by evaluating the physicians' prescriptions. Antibiotic prescriptions were evaluated according to percentage of encounters where an antibiotic was prescribed, percentage of encounters with combined antibiotics prescriptions and the percentage of encounters treated in accordance with a standard treatment guideline. General linear model (GLM) was performed to analyze the factors influencing rational antibiotic use.

RESULT

A total of 58,512 valid antibiotic prescriptions by 280 physicians were included in the analysis. The average score of 62.2 The average percentage of encounters with an antibiotic and combined antibiotics prescribed were 70.1% and 40.2%, respectively. 37.9% of antibiotic prescriptions were in accordance with standard treatment guidelines. GLM analysis showed that physicians with scores exceeding 80 used less antibiotics than those who score lower than 60 (P = 0.005). The percentage of combination antibiotic therapies of those who achieved scores above 80 or in the range from 60 to 80 were lower than that of physicians in low score groups (P = 0.002, P = 0.025), and higher compliance with the guidelines than those received a score below 60 (P = 0.001, P = 0.047).

CONCLUSION

Results confirmed that physicians' knowledge significantly influences rational antibiotic use. Targeted training programs to promote physicians' knowledge of antibiotic especially at county hospitals in the western regions of China are urgently needed.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Reducing inappropriate antibiotic prescribing in upper respiratory tract infection in a primary care setting in Kolkata, India

Inappropriate antibiotic use is a key factor in the emergence of antibiotic resistance. The majority of antibiotics are prescribed in primary care, where upper respiratory tract infection (URTI) is a common presentation. Inappropriate antibiotic prescribing in URTI is common globally and has increased markedly in developing and transitional countries. Antibiotic stewardship is crucial to prevent the emergence and spread of resistant microbes. This project aimed to reduce inappropriate antibiotic prescribing in URTI in a non-governmental organisation’s primary care outreach clinics in Kolkata, India, from 62.6% to 30% over 4 months. A multifaceted intervention to reduce inappropriate antibiotic use in non-specific URTI was implemented. This consisted of a repeated process of audit and feedback, interactive training sessions, one-to-one case-based discussion, antibiotic guideline development and coding updates. The primary outcome measure was antibiotic prescribing rates. A baseline audit of all patients presenting with non-specific URTI over 8 weeks in November and December 2016 (n=222) found that 62.6% were prescribed antibiotics. Postintervention audit over 4 weeks in April 2017 (n=69) showed a marked reduction in antibiotic prescribing to 7.2%. An increase in documentation of examination findings was also observed, from 52.7% to 95.6%. This multifaceted intervention was successful at reducing inappropriate antibiotic prescribing, with sustained reductions demonstrated over the 4 months of the project. This suggests that approaches previously used in Europe can successfully be applied to different settings.

Prescriber and dispenser perceptions about antibiotic use in acute uncomplicated childhood diarrhea and upper respiratory tract infection in New Delhi: Qualitative study

OBJECTIVE:

The objective of the study was to explore the prescribing practices, knowledge, and attitudes of primary care doctors and community pharmacists, regarding antibiotic use in acute upper respiratory tract infections (URTI) and diarrhea in children to better understand causes of misuse and identify provider suggestions to change such behavior.

MATERIALS AND METHODS:

Two focus group discussions (FGDs) each were conducted with primary care government doctors (GDs), private general practitioners (GPs), pediatricians, and community pharmacists in Delhi. Each FGD had 8–12 participants and lasted 2 h. Furthermore, 22 individual face-to-face semi-structured interviews were conducted with providers of varying type and experience at their workplaces. Thematic and summative qualitative content analysis was done.

RESULTS:

All groups admitted to overusing antibiotics, GPs appearing to use more antibiotics than GDs and pediatricians for URTI and diarrhea in children. Pharmacists copy the prescribing of neighborhood doctors. Antimicrobial resistance (AMR) knowledge was poor for all stakeholders except pediatricians. Causes for prescribing antibiotics were patient pressure, profit motive, lack of follow-up and in addition for GDs, workload, no diagnostic facility, and pressure to use near-expiry medicines. Knowledge was gained through self-experience, copying others, information from pharmaceutical companies, and for some, training, continuous medical education/conferences. All groups blamed other professional groups/quacks for antibiotic overuse. Interventions suggested were sensitizing and empowering prescribers through training of providers and the public about the appropriate antibiotic use and AMR and implementing stricter regulations.

CONCLUSIONS:

A package of interventions targeting providers and consumers is urgently needed for awareness and change in behavior to reduce inappropriate community antibiotic use.

Promoting quality use of medicines in South-East Asia: reports from country situational analyses

BACKGROUND

Irrational use of medicines is widespread in the South-East Asia Region (SEAR), where policy implementation to encourage quality use of medicines (QUM) is often low. The aim was to determine whether public-sector QUM is better in SEAR countries implementing essential medicines (EM) policies than in those not implementing them.

METHODS

Data on six QUM indicators and 25 EM policies were extracted from situational analysis reports of 20 country (2-week) visits made during 2010-2015. The average difference (as percent) for the QUM indicators between countries implementing versus not implementing specific policies was calculated. Policies associated with better (> 1%) QUM were included in regression of a composite QUM score versus total number of policies implemented.

RESULTS

Twenty-two policies were associated with better (> 1%) QUM. Twelve policies were associated with 3.6-9.5% significantly better use (p < 0.05), namely: standard treatment guidelines; formulary; a government unit to promote QUM; continuing health worker education on prescribing by government; limiting over-the-counter (OTC) availability of systemic antibiotics; disallowing public-sector prescriber revenue from medicines sales; not charging fees at the point of care; monitoring advertisements of OTC medicines; public education on QUM; and a good drug supply system. There was significant correlation between the number of policies implemented out of 22 and the composite QUM score (r = 0.71, r² = 0.50, p < 0.05).

CONCLUSIONS

Country situational analyses allowed rapid data collection that showed EM policies are associated with better QUM. SEAR countries should implement all such policies.

High throughput screening against pantothenate synthetase identifies amide inhibitors against Mycobacterium tuberculosis and Staphylococcus aureus

Abstract

Pantothenate is a crucial enzyme for the synthesis of coenzyme A and acyl carrier protein in Mycobacterium tuberculosis and Staphylococcus aureus. It is indispensable for the growth and survival of these bacteria. Amides analogs are designed and have been used as inhibitors of pantothenate synthetase. Molecular docking approach has been used to design and predict the drug activity of molecule to the specific disease. In this work, more than hundred amides have been screened by Discovery Studio molecular docking programme to search best suitable molecule for the treatment of Mycobacterium tuberculosis. Pharmacophore generation has been done to recognize the binding modes of inhibitors in the receptor active site. To observe the stability and flexibility of inhibitors molecular dynamics (MD) simulation has been done; Lipinski's rule of five protocols is followed to screen drug likeness and ADMET (absorption, distribution, metabolism, excretion and toxicity) filtration is also used to value toxicity. DFT computation of optimized geometry and derivation of MOs has been used to correlate the drug likeness. The small difference in energy between HOMO and LUMO may help to activate the drug in the protein environment quickly. 2-Hydroxy-5-[(E)-2-{4-[(prop-2-enamido)sulfonyl]phenyl}diazen-1-yl]benzoic acid (M1) shows best theoretical efficiency against Mycobacterium tuberculosis (MTB) pantothenate synthetase and so does 2-hydroxy-5-[(E)-2-{4-[(2-phenylacetamido)sulfonyl]phenyl}diazen-1-yl]benzoic acid (M2) against Staphylococcus aureus pantothenate synthetase. These compounds also bind to Adenine-Thymine region of tuberculosis DNA.

Graphical abstract

Current Status and Survival Impact of Infectious Disease Consultation for Multidrug-Resistant Bacteremia in Ventilated Patients: A Single-Center Experience in Korea

Background

We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia.

Methods

One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), and vancomycin-resistant Enterococcus faecium.

Results

Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden's index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P < 0.001) based on multivariate Cox regression analysis.

Conclusions

An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28-day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.

Threats to global antimicrobial resistance control: Centrally approved and unapproved antibiotic formulations sold in India

AIMS

Rising antimicrobial resistance (AMR) is a global health crisis. India has among the highest resistance rates and antibiotic consumption internationally. Extensive use of fixed-dose combination (FDC) antibiotics and of unapproved formulations are claimed contributory factors but there has been no systematic examination of formulations or volumes sold. The aim of the present study was to investigate the regulatory approval status and sales volumes of systemic antibiotics marketed in India.

METHODS

This was an ecological study using regulatory records in India, the UK and the US to determine the approval status in each country of systemic antibiotic FDCs and single-drug formulations (SDFs) sold in India. Pharmatrac® sales data were used to determine the formulations and volumes sold (2007-2012), branded-product numbers and manufacturers.

RESULTS

Of 118 systemic antibiotic FDC formulations sold in India, 43 (36%) were approved but 75 (64%) had no record of regulatory approval; four (3%) formulations were approved in the UK and/or US. Almost half of formulations (58/118; 49%) comprised dual antimicrobials, most unapproved in India (43/58; 74%), and many were pharmacologically problematic. In contrast, 80/86 (93%) SDFs were approved in India and over two-thirds in the UK and/or US. Total antibiotic sales increased by 26%, from 2056 million units (2007-08) to 2583 million units (2011-12). FDC sales rose by 38% vs. 20% for SDFs. By 2011-12, FDCs comprised one-third of sales (872 million units). Over one-third of FDCs sold (300.26 million units; 34.5%) were of unapproved formulations. Multinational companies manufactured unapproved formulations and accounted for 19% of all FDC and SDF sales annually.

CONCLUSIONS

Sales in India of antibiotic FDCs, including unapproved formulations, are rising. In the context of increasing AMR rates nationally and globally, unapproved antibiotic FDCs undermine India's national AMR strategy and should be banned from sale.

Use of mathematical modelling to assess the impact of vaccines on antibiotic resistance

Antibiotic resistance is a major global threat to the provision of safe and effective health care. To control antibiotic resistance, vaccines have been proposed as an essential intervention, complementing improvements in diagnostic testing, antibiotic stewardship, and drug pipelines. The decision to introduce or amend vaccination programmes is routinely based on mathematical modelling. However, few mathematical models address the impact of vaccination on antibiotic resistance. We reviewed the literature using PubMed to identify all studies that used an original mathematical model to quantify the impact of a vaccine on antibiotic resistance transmission within a human population. We reviewed the models from the resulting studies in the context of a new framework to elucidate the pathways through which vaccination might impact antibiotic resistance. We identified eight mathematical modelling studies; the state of the literature highlighted important gaps in our understanding. Notably, studies are limited in the range of pathways represented, their geographical scope, and the vaccine-pathogen combinations assessed. Furthermore, to translate model predictions into public health decision making, more work is needed to understand how model structure and parameterisation affects model predictions and how to embed these predictions within economic frameworks.

A current perspective on antimicrobial resistance in Southeast Asia

Southeast Asia, a vibrant region that has recently undergone unprecedented economic development, is regarded as a global hotspot for the emergence and spread of antimicrobial resistance (AMR). Understanding AMR in Southeast Asia is crucial for assessing how to control AMR on an international scale. Here we (i) describe the current AMR situation in Southeast Asia, (ii) explore the mechanisms that make Southeast Asia a focal region for the emergence of AMR, and (iii) propose ways in which Southeast Asia could contribute to a global solution.

Antibiotic use in South East Asia and policies to promote appropriate use: reports from country situational analyses

Kathleen Holloway and colleagues discuss findings from a rapid assessment of antibiotic use and policies undertaken by South East Asian countries to drive further actions to reduce inappropriate use

Reducing Uncertainty for Acute Febrile Illness in Resource-Limited Settings: The Current Diagnostic Landscape

AbstractDiagnosing the cause of acute febrile illness in resource-limited settings is important-to give the correct antimicrobials to patients who need them, to prevent unnecessary antimicrobial use, to detect emerging infectious diseases early, and to guide vaccine deployment. A variety of approaches are yielding more rapid and accurate tests that can detect more pathogens in a wider variety of settings. After decades of slow progress in diagnostics for acute febrile illness in resource-limited settings, a wave of converging advancements will enable clinicians in resource-limited settings to reduce uncertainty for the diagnosis of acute febrile illness.

Antimicrobial storage and antibiotic knowledge in the community: a cross-sectional pilot study in north-western Angola

BACKGROUND

Antimicrobials are drugs that were once lifesavers and mainly curative. Nowadays their value is increasingly under pressure because of the rapid and worldwide emergence of antimicrobial resistance, which, in low-resource settings, frequently occurs in microorganisms that are likely to be transmitted in the community.

METHODS

This was a cross-sectional pilot study including 102 households within the 10th Health and Demographic Surveillance System round in Dande, Bengo Province, Angola.

RESULTS

Of the total 102 households piloted, 79 (77.45%) were urban. Fifty-seven respondents were female (56.44%), and the mean age of the respondents was 39.70±15.35years. Overall, storage of antimicrobials was found in 55/102 households (53.92%). More than 66% of the antimicrobials stored were prescribed by a health professional and the majority of antimicrobials were bought at pharmacies or at a street market. Penicillin and its derivatives, antimalarial drugs, and metronidazole were the antimicrobials most frequently stored. Households with female respondents reported storing any drugs at home more frequently (82.50%; p=0.002) and also storing antimicrobials more frequently (64.91%; p=0.016) as compared to households with male respondents. Reported use of antimicrobials was significantly higher in urban households (60.76%, 48/79) as compared to rural households (30.43%, 7/23) (p=0.010). Overall, 74 of 101 respondents (73.26%) reported having already heard about antibiotics. The common reasons given for their use were cough and other respiratory symptoms, wounds, flu and body muscle pain, fever, bladder complaints, and diarrhoea and/or presumed typhoid fever. Nearly 40% (28/74) of the respondents thought that antibiotics should be stopped as soon as the person does not feel sick anymore.

CONCLUSIONS

Community interventions for appropriate use of antibiotics should be designed with a special focus on women. This should be done through public awareness campaigns and improving access to reliable medical services. Drug prescribers are key not only to appropriate antimicrobial prescription, but also to adequate dispensing, and are strong advocates for the possible misconceptions on antimicrobial usage by lay people.

How do hospital respiratory clinicians perceive antimicrobial stewardship (AMS)? A qualitative study highlighting barriers to AMS in respiratory medicine

BACKGROUND

Suboptimal antibiotic use in respiratory infections is widespread in hospital medicine and primary care. Antimicrobial stewardship (AMS) teams within hospitals, commonly led by infectious diseases physicians, are frequently charged with optimizing the use of respiratory antibiotics, but there is limited information on what drives antibiotic use in this area of clinical medicine, or on how AMS is perceived.

AIM

To explore the perceptions of hospital respiratory clinicians on AMS in respiratory medicine.

METHODS

In-depth interviews were conducted with 28 clinicians (13 doctors and 15 nurses) from two hospitals in Australia. Data were analysed thematically using the framework approach.

FINDINGS

Four key barriers to the integration of AMS processes within respiratory medicine, from the participants' perspectives, were identified: CONCLUSIONS: AMS processes are introduced in hospitals with established social structures and knowledge bases. This study found that AMS in respiratory medicine challenges and conflicts with many of these dynamics. If the influence of these dynamics is not considered, AMS processes may not be effective in containing antibiotic use in hospital respiratory medicine.