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Abebe RB, Ayal BM, Alemu MA, Zeleke TK. Antibiotic appropriateness at outpatient settings in Ethiopia: the need for an antibiotic stewardship programme. Drugs Context 2024; 13:2023-12-2. [PMID: 38742144 PMCID: PMC11090269 DOI: 10.7573/dic.2023-12-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/04/2024] [Indexed: 05/16/2024] Open
Abstract
Background Antibiotics are drugs of natural or synthetic origin used to treat various infections. The practice of excessive and inappropriate antibiotics use is the main global cause of bacterial resistance, which is one of the most serious global public health threats. It is estimated that about 50% of global antibiotic prescriptions are inappropriate. This study assesses the prevalence and pattern of inappropriate prescriptions of antibiotics amongst ambulatory care visits in Ethiopia. Methods A facility-based, cross-sectional study with a quantitative approach was conducted amongst randomly selected prescriptions issued for outpatients from May to June 2022 at Debre Markos Specialized Comprehensive Hospital, Northwest Ethiopia. Descriptive statistics, such as frequencies and percentages, were computed. For group comparisons, χ2 and independent sample t-tests were computed. The statistical significance of the association was considered at p<0.05. Results A total of 2640 antibiotics were prescribed for patients in the outpatient setting with various bacterial infections via 911 prescriptions, of which 49.5% were non-compliant with the national treatment guideline. Guideline non-compliant prescriptions increased remarkably amongst patients in the outpatient setting diagnosed with community-acquired pneumonia (38.8% versus 30.1%; p=0.006) and peptic ulcer disease (14.9% versus 9%; p=0.006). Moreover, inappropriate prescription was significantly higher amongst patients taking amoxicillin/clavulanic acid (33.2% versus 48.2%; p<0.001) and cephalexin (17.8% versus 24.3%; p=0.016). Conclusion Large proportions of antibiotic prescriptions for outpatients were non-compliant with the national treatment guideline, suggesting that prescribers need to give special attention to outpatients whilst ordering antibiotics such as amoxicillin/clavulanic acid and cephalexin. Antibiotic stewardship efforts to optimize outpatient antibiotic prescriptions and reduce the use of potentially inappropriate antibiotics are needed in Ethiopia.
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Affiliation(s)
- Rahel Belete Abebe
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Bezawit Mulat Ayal
- Department of Physiology, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Muluken Adela Alemu
- Department of Pharmacy, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tirsit Ketsela Zeleke
- Department of Pharmacy, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
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Aguilar AG, Canals PC, Tian M, Miller KA, Piper BJ. Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid. PHARMACY 2024; 12:46. [PMID: 38525726 PMCID: PMC10961814 DOI: 10.3390/pharmacy12020046] [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: 12/22/2023] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/26/2024] Open
Abstract
Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.
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Affiliation(s)
- Alexia G. Aguilar
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Priscilla C. Canals
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Maria Tian
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Kimberly A. Miller
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
| | - Brian J. Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA 17822, USA; (A.G.A.); (P.C.C.); (M.T.); (K.A.M.)
- Center for Pharmacy Innovation and Outcomes, Danville, PA 17822, USA
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Alajel SM, Alzahrani KO, Almohisen AA, Alrasheed MM, Almomen SM. Antimicrobial Sales Comparison before and after the Implementation of Nationwide Restriction Policy in Saudi Arabia. Antibiotics (Basel) 2023; 13:15. [PMID: 38275325 PMCID: PMC10812388 DOI: 10.3390/antibiotics13010015] [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: 10/05/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 01/27/2024] Open
Abstract
Antimicrobial dispensing without a prescription has been identified as a significant contributor to the burgeoning crisis of antimicrobial resistance. To combat this, the Saudi Ministry of Health introduced a stringent antimicrobial restriction policy in mid-2018, mandating prescriptions for all antimicrobial drug dispensations at pharmacies. Therefore, this study aimed to assess the immediate impact of this policy on retail antimicrobial sales. To do so, we analyzed annual sales data from 2017 to 2019 sourced from the IQVIA-MIDAS® database, which included a range of antimicrobials, such as antibiotics, antifungals, and other related agents. The analysis revealed a notable reduction in overall antimicrobial sales by 23.2%, decreasing from 818.9 million SAR in 2017 to 648.4 million SAR in 2019. While the Wilcoxon signed-rank test indicated a statistically significant median reduction in total antimicrobial sales post-policy implementation (p = 0.0397), it is important to acknowledge that the long-term effects and adherence to the policy require further investigation. Notably, sales of amoxicillin dropped by 70% in 2019 compared to 2017, contributing largely to the decline. Conversely, a continuous increase in sales of some antimicrobial drugs following the restriction policy was observed, led by amoxicillin/clavulanic acid. Our data support the implementation of antimicrobial restriction measures as an effective means of controlling excessive antimicrobial sales and dispensing without prescriptions.
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Affiliation(s)
- Sulaiman M. Alajel
- Reference Laboratory for Microbiology, Executive Department of Reference Laboratories, Research and Laboratories Sector, Saudi Food and Drug Authority (SFDA), Riyadh 11561, Saudi Arabia
| | - Khaloud O. Alzahrani
- Molecular Biology Division, Reference Laboratory for Microbiology, Executive Department of Reference Laboratories, Research and Laboratories Sector, Saudi Food and Drug Authority (SFDA), Riyadh 11561, Saudi Arabia;
| | - Amal A. Almohisen
- Statistics Department, King Saud University, Riyadh 11451, Saudi Arabia
| | - Meshael M. Alrasheed
- Drug Safety and Risk Management, Drug Sector, Saudi Food and Drug Authority (SFDA), Riyadh 13513, Saudi Arabia
| | - Salwa M. Almomen
- Research and Studies Department, Research and Laboratory Sector, Saudi Food and Drug Authority (SFDA), Riyadh 13513, Saudi Arabia
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Ndip RA, Hanna JN, Mbah JA, Ghogomu SM, Ngemenya MN. In Vitro Synergistic Activity of Combinations of Tetrahydroisoquinolines and Treatment Antibiotics against Multidrug-Resistant Salmonella. Adv Pharmacol Pharm Sci 2023; 2023:6142810. [PMID: 38130400 PMCID: PMC10733592 DOI: 10.1155/2023/6142810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/31/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023] Open
Abstract
The global burden of Salmonella infections remains high due to the emergence of multidrug resistance to all recommended treatment antibiotics. Tetrahydroisoquinolines (THIQs) have demonstrated promising activity against multidrug-resistant (MDR) Salmonella Typhi. Hence, their interaction with treatment antibiotics was investigated for possible synergy. Twenty combinations of five THIQs (1, 2, 3, 4, and 5) and four antibiotics were tested against each of 7 Salmonella isolates by the checkerboard method giving a total of 140 assays performed. Fractional inhibitory concentration indices (FICIs) were calculated, and isobolograms were plotted. In terms of FICI, synergism ranged from 0.078 to 0.5 and the highest magnitude (0.078) was recorded for chloramphenicol-THIQ 1 combination. In a total of 140 antibiotics-THIQs combination assays, 27 were synergistic (17%), 42 were additive (30%), 11 were antagonistic (7.8%), and 60 were indifferent (42%). The synergistic activity recorded for each antibiotic class in combination based on the total of 7 bacterial isolates tested ranged from 14.29% to 71.43%; the highest percentage was recorded for two combinations (chloramphenicol or sulphamethoxazole with THIQ 1). Ciprofloxacin-THIQ 1 combination showed additivity on all bacteria isolates tested (100%). Overall, THIQ 1 was the most synergistic and most additive in combination with three antibiotics (ampicillin, chloramphenicol, or sulphamethoxazole-trimethoprim). Some combinations of the THIQs and treatment antibiotics have shown high synergism which could potentially be efficacious against multidrug-resistant S. Typhi, hence this interaction should be further studied in vivo.
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Affiliation(s)
- Rita Ayuk Ndip
- Department of Biochemistry and Molecular Biology, University of Buea, P.O. Box 63, Buea, Cameroon
| | - Joelle Ngo Hanna
- Department of Chemistry, Faculty of Science, University of Douala, P.O. Box 24157, Douala, Cameroon
| | - James Ajeck Mbah
- Department of Chemistry, Faculty of Science, University of Buea, P.O. Box 63, Buea, Cameroon
| | - Stephen Mbigha Ghogomu
- Department of Biochemistry and Molecular Biology, University of Buea, P.O. Box 63, Buea, Cameroon
| | - Moses Njutain Ngemenya
- Department of Biochemistry and Molecular Biology, University of Buea, P.O. Box 63, Buea, Cameroon
- Department of Medical Laboratory Sciences, University of Buea, P.O. Box 63, Buea, Cameroon
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5
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Brhlikova P, Mehta A, McGettigan P, Pollock AM, Roderick P, Farooqui HH. Regulatory enforcement of the marketing of fixed-dose combinations in India: a case study of systemic antibiotics. J Pharm Policy Pract 2023; 16:139. [PMID: 37950272 PMCID: PMC10636890 DOI: 10.1186/s40545-023-00644-y] [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: 07/12/2023] [Accepted: 10/21/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND In India, states have licensed the manufacture of large numbers of fixed-dose combination (FDC) drugs without the required prior approval of the central regulator. This paper describes two major regulatory initiatives to address the problem, which began in 2007 and 2013, and examines whether they have been sufficient to remove centrally unapproved systemic antibiotic FDCs from the market. METHODS Information was extracted from documents published by the central regulator and the ministry of health, including the National List of Essential Medicines (NLEM), and court judgments, and analysed alongside sales volume data for 2008-2020 using PharmaTrac market dataset. RESULTS The regulatory initiatives permitted 68 formulations to be given de facto approvals ('No Objection Certificates') outside the statutory regime, banned 46 FDCs and restricted one FDC. Market data show that FDCs as a proportion of total antibiotic sales increased from 32.9 in 2008 to 37.3% in 2020. The total number of antibiotic FDC formulations on the market fell from 574 (2008) to 395 (2020). Formulations with a record of prior central approval increased from 86 (2008) to 94 (2020) and their share of the antibiotic FDC sales increased from 32.0 to 55.3%. In 2020, an additional 23 formulations had been permitted de facto approval, accounting for 10.6% of the antibiotic FDC sales. Even in 2020, most marketed formulations (70.4%, 278/395) were unapproved or banned, and comprised a 15.9% share of the antibiotic FDC sales. The share of NLEM-listed antibiotic FDC sales increased from 21.2 (2008) to 26.7% (2020). CONCLUSION The initiatives had limited impact. Regulatory enforcement has been slow and weak, with many unapproved, and even banned, FDCs remaining on the market.
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Affiliation(s)
- Petra Brhlikova
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle Upon Tyne, NE2 4AX, UK.
| | - Aashna Mehta
- Public Health Foundation of India, Gurugram, India
| | - Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Allyson M Pollock
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle Upon Tyne, NE2 4AX, UK
| | - Peter Roderick
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle Upon Tyne, NE2 4AX, UK
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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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Mazzolini R, Rodríguez-Arce I, Fernández-Barat L, Piñero-Lambea C, Garrido V, Rebollada-Merino A, Motos A, Torres A, Grilló MJ, Serrano L, Lluch-Senar M. Engineered live bacteria suppress Pseudomonas aeruginosa infection in mouse lung and dissolve endotracheal-tube biofilms. Nat Biotechnol 2023; 41:1089-1098. [PMID: 36658340 PMCID: PMC10421741 DOI: 10.1038/s41587-022-01584-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 10/21/2022] [Indexed: 01/21/2023]
Abstract
Engineered live bacteria could provide a new modality for treating lung infections, a major cause of mortality worldwide. In the present study, we engineered a genome-reduced human lung bacterium, Mycoplasma pneumoniae, to treat ventilator-associated pneumonia, a disease with high hospital mortality when associated with Pseudomonas aeruginosa biofilms. After validating the biosafety of an attenuated M. pneumoniae chassis in mice, we introduced four transgenes into the chromosome by transposition to implement bactericidal and biofilm degradation activities. We show that this engineered strain has high efficacy against an acute P. aeruginosa lung infection in a mouse model. In addition, we demonstrated that the engineered strain could dissolve biofilms formed in endotracheal tubes of patients with ventilator-associated pneumonia and be combined with antibiotics targeting the peptidoglycan layer to increase efficacy against Gram-positive and Gram-negative bacteria. We expect our M. pneumoniae-engineered strain to be able to treat biofilm-associated infections in the respiratory tract.
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Affiliation(s)
- Rocco Mazzolini
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
- Pulmobiotics Ltd, Barcelona, Spain
| | - Irene Rodríguez-Arce
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
- Institute of Agrobiotechnology, CSIC-Navarra Government, Navarra, Spain
| | - Laia Fernández-Barat
- Cellex Laboratory, CibeRes, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
- Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona, SpainICREA, Barcelona, Spain
| | - Carlos Piñero-Lambea
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
- Pulmobiotics Ltd, Barcelona, Spain
| | - Victoria Garrido
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
- Institute of Agrobiotechnology, CSIC-Navarra Government, Navarra, Spain
| | - Agustín Rebollada-Merino
- VISAVET Health Surveillance Centre, Complutense University of Madrid, Madrid, Spain
- Department of Internal Medicine and Animal Surgery, Faculty of Veterinary Medicine, Complutense University of Madrid, Madrid, Spain
| | - Anna Motos
- Cellex Laboratory, CibeRes, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
- Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona, SpainICREA, Barcelona, Spain
| | - Antoni Torres
- Cellex Laboratory, CibeRes, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
- Department of Pneumology, Thorax Institute, Hospital Clinic of Barcelona, SpainICREA, Barcelona, Spain
| | | | - Luis Serrano
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain.
- Universitat Pompeu Fabra, Barcelona, Spain.
- ICREA, Barcelona, Spain.
| | - Maria Lluch-Senar
- Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain.
- Pulmobiotics Ltd, Barcelona, Spain.
- Basic Sciences Department, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain.
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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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Russell NJ, Stöhr W, Plakkal N, Cook A, Berkley JA, Adhisivam B, Agarwal R, Ahmed NU, Balasegaram M, Ballot D, Bekker A, Berezin EN, Bilardi D, Boonkasidecha S, Carvalheiro CG, Chami N, Chaurasia S, Chiurchiu S, Colas VRF, Cousens S, Cressey TR, de Assis ACD, Dien TM, Ding Y, Dung NT, Dong H, Dramowski A, DS M, Dudeja A, Feng J, Glupczynski Y, Goel S, Goossens H, Hao DTH, Khan MI, Huertas TM, Islam MS, Jarovsky D, Khavessian N, Khorana M, Kontou A, Kostyanev T, Laoyookhon P, Lochindarat S, Larsson M, Luca MD, Malhotra-Kumar S, Mondal N, Mundhra N, Musoke P, Mussi-Pinhata MM, Nanavati R, Nakwa F, Nangia S, Nankunda J, Nardone A, Nyaoke B, Obiero CW, Owor M, Ping W, Preedisripipat K, Qazi S, Qi L, Ramdin T, Riddell A, Romani L, Roysuwan P, Saggers R, Roilides E, Saha SK, Sarafidis K, Tusubira V, Thomas R, Velaphi S, Vilken T, Wang X, Wang Y, Yang Y, Zunjie L, Ellis S, Bielicki JA, Walker AS, Heath PT, Sharland M. Patterns of antibiotic use, pathogens, and prediction of mortality in hospitalized neonates and young infants with sepsis: A global neonatal sepsis observational cohort study (NeoOBS). PLoS Med 2023; 20:e1004179. [PMID: 37289666 PMCID: PMC10249878 DOI: 10.1371/journal.pmed.1004179] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 01/19/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND There is limited data on antibiotic treatment in hospitalized neonates in low- and middle-income countries (LMICs). We aimed to describe patterns of antibiotic use, pathogens, and clinical outcomes, and to develop a severity score predicting mortality in neonatal sepsis to inform future clinical trial design. METHODS AND FINDINGS Hospitalized infants <60 days with clinical sepsis were enrolled during 2018 to 2020 by 19 sites in 11 countries (mainly Asia and Africa). Prospective daily observational data was collected on clinical signs, supportive care, antibiotic treatment, microbiology, and 28-day mortality. Two prediction models were developed for (1) 28-day mortality from baseline variables (baseline NeoSep Severity Score); and (2) daily risk of death on IV antibiotics from daily updated assessments (NeoSep Recovery Score). Multivariable Cox regression models included a randomly selected 85% of infants, with 15% for validation. A total of 3,204 infants were enrolled, with median birth weight of 2,500 g (IQR 1,400 to 3,000) and postnatal age of 5 days (IQR 1 to 15). 206 different empiric antibiotic combinations were started in 3,141 infants, which were structured into 5 groups based on the World Health Organization (WHO) AWaRe classification. Approximately 25.9% (n = 814) of infants started WHO first line regimens (Group 1-Access) and 13.8% (n = 432) started WHO second-line cephalosporins (cefotaxime/ceftriaxone) (Group 2-"Low" Watch). The largest group (34.0%, n = 1,068) started a regimen providing partial extended-spectrum beta-lactamase (ESBL)/pseudomonal coverage (piperacillin-tazobactam, ceftazidime, or fluoroquinolone-based) (Group 3-"Medium" Watch), 18.0% (n = 566) started a carbapenem (Group 4-"High" Watch), and 1.8% (n = 57) a Reserve antibiotic (Group 5, largely colistin-based), and 728/2,880 (25.3%) of initial regimens in Groups 1 to 4 were escalated, mainly to carbapenems, usually for clinical deterioration (n = 480; 65.9%). A total of 564/3,195 infants (17.7%) were blood culture pathogen positive, of whom 62.9% (n = 355) had a gram-negative organism, predominantly Klebsiella pneumoniae (n = 132) or Acinetobacter spp. (n = 72). Both were commonly resistant to WHO-recommended regimens and to carbapenems in 43 (32.6%) and 50 (71.4%) of cases, respectively. MRSA accounted for 33 (61.1%) of 54 Staphylococcus aureus isolates. Overall, 350/3,204 infants died (11.3%; 95% CI 10.2% to 12.5%), 17.7% if blood cultures were positive for pathogens (95% CI 14.7% to 21.1%, n = 99/564). A baseline NeoSep Severity Score had a C-index of 0.76 (0.69 to 0.82) in the validation sample, with mortality of 1.6% (3/189; 95% CI: 0.5% to 4.6%), 11.0% (27/245; 7.7% to 15.6%), and 27.3% (12/44; 16.3% to 41.8%) in low (score 0 to 4), medium (5 to 8), and high (9 to 16) risk groups, respectively, with similar performance across subgroups. A related NeoSep Recovery Score had an area under the receiver operating curve for predicting death the next day between 0.8 and 0.9 over the first week. There was significant variation in outcomes between sites and external validation would strengthen score applicability. CONCLUSION Antibiotic regimens used in neonatal sepsis commonly diverge from WHO guidelines, and trials of novel empiric regimens are urgently needed in the context of increasing antimicrobial resistance (AMR). The baseline NeoSep Severity Score identifies high mortality risk criteria for trial entry, while the NeoSep Recovery Score can help guide decisions on regimen change. NeoOBS data informed the NeoSep1 antibiotic trial (ISRCTN48721236), which aims to identify novel first- and second-line empiric antibiotic regimens for neonatal sepsis. TRIAL REGISTRATION ClinicalTrials.gov, (NCT03721302).
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Affiliation(s)
- Neal J. Russell
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Wolfgang Stöhr
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Aislinn Cook
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - James A. Berkley
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Ramesh Agarwal
- Newborn Division and WHO-CC, All India Institute of Medical Sciences, New Delhi, India
| | - Nawshad Uddin Ahmed
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Manica Balasegaram
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Daynia Ballot
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | | | | | | | - Cristina G. Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Neema Chami
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Suman Chaurasia
- All India Institute of Medical Sciences, Department of Paediatrics, New Delhi, India
| | - Sara Chiurchiu
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | | | - Simon Cousens
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tim R. Cressey
- PHPT/IRD-MIVEGEC, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - Tran Minh Dien
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Yijun Ding
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Nguyen Trong Dung
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Han Dong
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Madhusudhan DS
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Ajay Dudeja
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Jinxing Feng
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Youri Glupczynski
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Srishti Goel
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Doan Thi Huong Hao
- Vietnam National Children’s Hospital, Hanoi, Vietnam and Surgical Intensive Care Unit, Vietnam National Children’s Hospital, Hanoi, Vietnam
| | - Mahmudul Islam Khan
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Tatiana Munera Huertas
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | | | - Daniel Jarovsky
- Pediatric Infectious Diseases Unit, Santa Casa de São Paulo, São Paulo, Brazil
| | - Nathalie Khavessian
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Meera Khorana
- Neonatal Unit, Department of Pediatrics, Queen Sirikit National Institute of Child Health, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Angeliki Kontou
- Neonatology Dept, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | | | | | - Mattias Larsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maia De Luca
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | | | - Nivedita Mondal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Nitu Mundhra
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Philippa Musoke
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University and MUJHU Care, Kampala, Uganda
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ruchi Nanavati
- Neonatology Department, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Firdose Nakwa
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi, India
| | - Jolly Nankunda
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Borna Nyaoke
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Christina W. Obiero
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Department of Global Health, Amsterdam, the Netherlands
| | - Maxensia Owor
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Wang Ping
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | | | - Shamim Qazi
- World Health Organization, Maternal, Newborn, Child and Adolescent Health Department, Geneva, Switzerland
| | - Lifeng Qi
- Department of Infectious Diseases, Shenzhen Children’s Hospital, Shenzhen, China
| | - Tanusha Ramdin
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Amy Riddell
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Lorenza Romani
- Academic Hospital Paediatric Department, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Praewpan Roysuwan
- PHPT/IRD-MIVEGEC, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Robin Saggers
- Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Dept Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Samir K. Saha
- Child Health Research Foundation (CHRF), Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Kosmas Sarafidis
- Neonatology Dept, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Valerie Tusubira
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University and MUJHU Care, Kampala, Uganda
| | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Tuba Vilken
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Xiaojiao Wang
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Centre for Children’s Health, Beijing, China
| | - Yajuan Wang
- Department of Neonatology, Children’s Hospital, Capital Institute of Pediatrics, Yabao Road, Chaoyang District, Beijing, China
| | - Yonghong Yang
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Liu Zunjie
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Julia A. Bielicki
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - A. Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, London, United Kingdom
| | - Paul T. Heath
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Mike Sharland
- Center for Neonatal and Paediatric Infection (CNPI), Institute of Infection & Immunity, St George’s University of London, London, United Kingdom
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Vliegenthart-Jongbloed K, Jacobs J. Not recommended fixed-dose antibiotic combinations in low- and middle-income countries - the example of Tanzania. Antimicrob Resist Infect Control 2023; 12:37. [PMID: 37076936 PMCID: PMC10116708 DOI: 10.1186/s13756-023-01238-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Fixed-dose combinations (FDC) are medicine formulations that combine two or more ingredients in fixed ratios in a single dose form. Although advantageous in tuberculosis and malaria (efficacy, adherence, protection against resistance), only a few antibiotic FDC (FDC-AB) have been developed along full microbiological, pharmacological and clinical validation and safety studies. The World Health Organization (WHO) database of Access, Watch and Reserve (AWaRe) antibiotics contains, since 2021, a list of "Not Recommended" FDC-AB (n = 103) which are rejected for use in clinical practice. BODY: The share of non-recommended FDC-AB in global antimicrobial use (2000-2015) was < 3% but substantially higher in middle income countries. The share increases over time, but recent data particular concerning sub-Saharan Africa are rare. Along three non-recommended FDC-AB listed in the Tanzanian National Essential Medicine List (ampicillin-cloxacillin, flucloxacillin-amoxicillin and ceftriaxone-sulbactam) we discuss the concerns and reasons behind use of these products. Non-recommended FDC-AB have poor rationale (ratios of both ingredients), lack evidence of efficacy (pharmacological, microbiological and clinical), have difficulties in dosing (underdosing of the single ingredients, absence of pediatric dosing) and risks of safety (additive toxicity). They are expected to fuel antimicrobial resistance (unnecessary broad spectrum coverage) and are incompatible with antimicrobial stewardship. The specific context of low- and middle-income countries contributes to their increased use: at the side of prescriber and supplier are the lack of diagnostics, poor training in antibiotic prescribing, patients' preferences, role-model of senior prescribers and pharmaceutical promotion. International market mechanisms include economic motivation for development, branding and promotion, poor access to the single antibiotic forms and weak national regulatory capacity. CONCLUSION AND IMPLICATIONS There is an urgent need for monitoring consumption of non-recommended FDC-AB in low- and middle-income countries, particular in Sub-Saharan Africa. A multinational and multisectoral antimicrobial stewardship strategy is needed in order to abolish the use of non-recommended FDC-AB.
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Affiliation(s)
- Klaske Vliegenthart-Jongbloed
- Haydom Lutheran Hospital, Haydom, United Republic of Tanzania.
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands.
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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11
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Bittner B. Drug delivery improvements to enable a flexible care setting for monoclonal antibody medications in oncology - Analogue-based decision framework. Expert Opin Drug Deliv 2023; 20:457-470. [PMID: 36855292 DOI: 10.1080/17425247.2023.2184343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The substantial acceleration in healthcare spending together with the expenditures to manage the COVID19 pandemic demand drug delivery solutions that enable a flexible care setting for high-dose monoclonal antibodies (mAbs) in oncology. AREAS COVERED This expert opinion introduces an analogue-based framework applied to guide decision-making for associated product improvements for mAb medications that are either already authorized or in late-stage clinical development. The four pillars of this framework comprise (1) the drug delivery profile of current and emerging treatments in the market, (2) the needs and preferences of people treated with mAbs, (3) existing healthcare infrastructures, and (4) country-dependent reimbursement and procurement models. The following product optimization examples for mAb-based treatments are evaluated based on original research and review articles in the field: subcutaneous formulations, an established drug delivery modality to reduce parenteral dosing complexity, fixed-dose combinations, an emerging concept to complement combination therapy, and (connected) on-body delivery systems, an identified future opportunity to support dosing outside of a controlled healthcare institutional environment. EXPERT OPINION Leveraging existing synergies and learnings from other disease areas is a measure to reduce associated development and commercialization costs and thus to provide sustainable product offerings already at the initial launch of a medication.
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Affiliation(s)
- Beate Bittner
- Global Product Strategy - Product Optimization, F. Hoffmann-La Roche Ltd, Basel, Switzerland
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12
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Mehta A, Brhlikova P, McGettigan P, Pollock AM, Roderick P, Farooqui HH. Systemic antibiotic sales and WHO recommendations, India. Bull World Health Organ 2022; 100:610-619. [PMID: 36188020 PMCID: PMC9511665 DOI: 10.2471/blt.22.287908] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 11/27/2022] Open
Abstract
Objective To analyse sales of fixed-dose combination and single antibiotics in India in relation to World Health Organization (WHO) recommendations and national regulatory efforts to control antibiotic sales. Methods We extracted data on sales volumes of systemic antibiotics in India from a market research company sales database. We compared the market share of antibiotic sales in 2020 by WHO AWaRe (Access, Watch and Reserve) category and for those under additional national regulatory controls. We also analysed sales of fixed-dose combinations that were: formally approved for marketing or had a no-objection certificate; on the national essential medicines list; and on the WHO list of not-recommended antibiotics. Findings There were 78 single and 112 fixed-dose combination antibiotics marketed in India, accounting for 7.6 and 4.5 billion standard units of total sales, respectively. Access, Watch and Reserve antibiotics comprised 5.8, 5.6 and 0.1 billion standard units of total market sales, respectively. All additionally controlled antibiotics were Watch and Reserve antibiotics (23.6%; 2.9 billion standard units of total sales). Fixed-dose combinations on the WHO not-recommended list were marketed in 229 formulations, with 114 formulations (49.8%) having no record of formal approval or no-objection certificate. While there were no not-recommended fixed-dose combinations on the national list of essential medicines, 13 of the top-20 selling antibiotic fixed-dose combinations were WHO not-recommended. Conclusion The sale of Watch group drugs, and antibiotics banned or not approved, needs active investigation and enforcement in India. The evidence base underpinning formal approvals and no-objection certificates for not-recommended fixed-dose combinations should be audited.
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Affiliation(s)
- Aashna Mehta
- Public Health Foundation of India, Gurugram, India
| | - Petra Brhlikova
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, NE2 4AX, England
| | - Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, London, England
| | - Allyson M Pollock
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, NE2 4AX, England
| | - Peter Roderick
- Population Health Sciences Institute, Newcastle University, Baddiley-Clark Building, Newcastle upon Tyne, NE2 4AX, England
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13
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Koya SF, Ganesh S, Selvaraj S, Wirtz VJ, Galea S, Rockers PC. Consumption of systemic antibiotics in India in 2019. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 4:100025. [PMID: 37383993 PMCID: PMC10305917 DOI: 10.1016/j.lansea.2022.100025] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Inappropriate use of antibiotics is a significant driver of antibiotic resistance in India. Largely unrestricted over-the-counter sales of most antibiotics, manufacturing and marketing of many fixed-dose combinations (FDC) and overlap in regulatory powers between national and state-level agencies complicate antibiotics availability, sales, and consumption in the country. METHODS We analyzed cross-sectional data from PharmaTrac, a nationally representative private-sector drug sales dataset gathered from a panel of 9000 stockists across India. We used the AWaRe (Access, Watch, Reserve) classification and the defined daily dose (DDD) metrics to calculate the per capita private-sector consumption of systemic antibiotics across different categories: FDCs vs single formulations; approved vs unapproved; and listed vs not listed in the national list of essential medicines (NLEM). FINDINGS The total DDDs consumed in 2019 was 5071 million (10.4 DDD/1000/day). Watch contributed 54.9% (2783 million) DDDs, while Access contributed 27.0% (1370 million). Formulations listed in the NLEM contributed 49.0% (2486 million DDDs); FDCs contributed 34.0% (1722 million), and unapproved formulations contributed 47.1% (2408 million DDDs). Watch antibiotics constituted 72.7% (1750 million DDDs) of unapproved products and combinations discouraged by the WHO constituted 48.7% (836 million DDDs) of FDCs. INTERPRETATION Although the per-capita private-sector consumption rate of antibiotics in India is relatively low compared to many countries, India consumes a large volume of broad-spectrum antibiotics that should ideally be used sparingly. This, together with significant share of FDCs from formulations outside NLEM and a large volume of antibiotics not approved by the central drug regulators, call for significant policy and regulatory reform. FUNDING Not applicable.
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Affiliation(s)
| | - Senthil Ganesh
- Public Health Foundation of India, New Delhi, Delhi, India
| | | | | | - Sandro Galea
- Boston University School of Public Health, Boston, MA, USA
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Ben Hassen C, Tahir R, Singh-Manoux A, Milic D, Paquet C, Sabia S, Dumurgier J. Ten-Year Trends in Sales of Alzheimer Disease Drugs in France Compared With Sales in Germany, Spain, and the UK. JAMA HEALTH FORUM 2022; 3:e222253. [PMID: 36003418 PMCID: PMC9356313 DOI: 10.1001/jamahealthforum.2022.2253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022] Open
Abstract
This cross-sectional study analyzes 10-year trends in sales of Alzheimer disease drugs in France compared with trends in the UK, Spain, and Germany.
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Affiliation(s)
- Céline Ben Hassen
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Rameen Tahir
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Archana Singh-Manoux
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | | | - Claire Paquet
- Université Paris Cité, Cognitive Neurology Center, Lariboisiere-Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Séverine Sabia
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France
| | - Julien Dumurgier
- Université Paris Cité, Inserm U1153, Epidemiology of Ageing and Neurodegenerative Diseases, Paris, France.,Université Paris Cité, Cognitive Neurology Center, Lariboisiere-Fernand Widal Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Bassitta R, Kronfeld H, Bauer J, Schwaiger K, Hölzel C. Tracking Antimicrobial Resistant E. coli from Pigs on Farm to Pork at Slaughter. Microorganisms 2022; 10:1485. [PMID: 35893543 PMCID: PMC9394271 DOI: 10.3390/microorganisms10081485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 12/02/2022] Open
Abstract
Antimicrobial-resistant bacteria might be transferred via the foodchain. However, that risk is rarely tracked along different production steps, e.g., from pigs at farm to meat. To close that gap, we performed a prospective study in four conventional and two organic farms from the moment pigs entered the farm until meat sampling at slaughter. Antimicrobial use was recorded (0 to 11 agents). Antimicrobial susceptibility (AMS) against 26 antibiotics, including critically important substances, was tested by microdilution, and tetA-tetB-sulI-sulII-strA-strB-bla-CTXM-qacEΔ1 were included in PCR-genotyping. From 244 meat samples of 122 pigs, 54 samples (22.1%) from 45 animals were positive for E. coli (n = 198). MICs above the breakpoint/ECOFF occurred for all antibiotics except meropenem. One isolate from organic farming was markedly resistant against beta-lactams including fourth-generation cefalosporines. AMS patterns differed remarkably between isolates from one piece of meat, varying from monoresistance to 16-fold multiresistance. Amplicon-typing revealed high similarity between isolates at slaughter and on farm. Prior pig lots andeven the farmer might serve as reservoirs for E. coli isolated from meat at slaughter. However, AMS phenotyping and genotyping indicate that antimicrobial resistance in E. coli is highly dynamic, impairing reliable prediction of health risks from findings along the production chain.
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Affiliation(s)
- Rupert Bassitta
- Former Department of Animal Hygiene, Technical University of Munich, Weihenstephaner Berg 3, 85354 Freising, Germany;
| | - Hanna Kronfeld
- Department for Animal Hygiene, Animal Health and Food Safety, Institute of Animal Breeding and Husbandry, Christian-Albrechts-University, Olshausenstr. 40, 24098 Kiel, Germany;
| | - Johann Bauer
- Former Department of Animal Hygiene, Technical University of Munich, Weihenstephaner Berg 3, 85354 Freising, Germany;
| | - Karin Schwaiger
- Unit of Food Hygiene and Technology, Institute of Food Safety, Food Technology and Veterinary Public Health, University of Veterinary Medicine, Veterinärplatz 1, 1210 Vienna, Austria;
| | - Christina Hölzel
- Department for Animal Hygiene, Animal Health and Food Safety, Institute of Animal Breeding and Husbandry, Christian-Albrechts-University, Olshausenstr. 40, 24098 Kiel, Germany;
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Trends of Fixed-Dose Combination Antibiotic Consumption in Hospitals in China: Analysis of Data from the Center for Antibacterial Surveillance, 2013-2019. Antibiotics (Basel) 2022; 11:antibiotics11070957. [PMID: 35884211 PMCID: PMC9312249 DOI: 10.3390/antibiotics11070957] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Fixed-dose combination (FDC) antibiotics can be clinically inappropriate and are concerning with regards to antimicrobial resistance, with little usage data available in low- and middle-income countries. Methods: Based on retrospective data from the Center for Antibacterial Surveillance, we investigated the consumption of FDC antibiotics in hospital inpatient settings in China from 1 January 2013 to 31 December 2019. The metric for assessing antibiotic consumption was the number of daily defined doses per 100 bed days (DDD/100BDs). FDC antibiotics were classified according to their composition and the Access, Watch, Reserve (AWaRe) classification of the World Health Organization. Results: A total of 24 FDC antibiotics were identified, the consumption of which increased sharply from 8.5 DDD/100BDs in 2013 to 10.2 DDD/100BDs in 2019 (p < 0.05) despite the reduction in the total antibiotic consumption in these hospitals. The increase was mainly driven by FDC antibiotics in the Not Recommended group of the AWaRe classification, whose consumption accounted for 63.0% (6.4 DDD/100BDs) of the overall FDC antibiotic consumption in 2019, while the consumption of FDC antibiotics in the Access group only accounted for 13.5% (1.4 DDD/100BDs). Conclusion: FDC antibiotic consumption significantly increased during the study period and accounted for a substantial proportion of all systemic antibiotic usage in hospitals in China. FDC antibiotics in the Not Recommended group were most frequently consumed, which raises concerns about the appropriateness of FDC antibiotic use.
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17
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Hernandez-Jaimes OA, Cazares-Olvera DV, Line J, Moreno-Eutimio MA, Gómez-Castro CZ, Naisbitt DJ, Castrejón-Flores JL. Advances in Our Understanding of the Interaction of Drugs with T-cells: Implications for the Discovery of Biomarkers in Severe Cutaneous Drug Reactions. Chem Res Toxicol 2022; 35:1162-1183. [PMID: 35704769 DOI: 10.1021/acs.chemrestox.1c00434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Drugs can activate different cells of the immune system and initiate an immune response that can lead to life-threatening diseases collectively known as severe cutaneous adverse reactions (SCARs). Antibiotics, anticonvulsants, and antiretrovirals are involved in the development of SCARs by the activation of αβ naïve T-cells. However, other subsets of lymphocytes known as nonconventional T-cells with a limited T-cell receptor repertoire and innate and adaptative functions also recognize drugs and drug-like molecules, but their role in the pathogenesis of SCARs has only just begun to be explored. Despite 30 years of advances in our understanding of the mechanisms in which drugs interact with T-cells and the pathways for tissue injury seen during T-cell activation, at present, the development of useful clinical biomarkers for SCARs or predictive preclinical in vitro assays that could identify immunogenic moieties during drug discovery is an unmet goal. Therefore, the present review focuses on (i) advances in the understanding of the pathogenesis of SCARs reactions, (ii) a description of the interaction of drugs with conventional and nonconventional T-cells, and (iii) the current state of soluble blood circulating biomarker candidates for SCARs.
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Affiliation(s)
| | - Diana Valeria Cazares-Olvera
- Instituto Politécnico Nacional, Unidad Profesional Interdisciplinaria de Biotecnología, México City 07340, México
| | - James Line
- MRC Centre for Drug Safety Science, Department of Pharmacology, University of Liverpool, Liverpool L69 3GE, United Kingdom
| | | | | | - Dean J Naisbitt
- MRC Centre for Drug Safety Science, Department of Pharmacology, University of Liverpool, Liverpool L69 3GE, United Kingdom
| | - José Luis Castrejón-Flores
- Instituto Politécnico Nacional, Unidad Profesional Interdisciplinaria de Biotecnología, México City 07340, México
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18
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Sulis G, Pradhan R, Kotwani A, Gandra S. India's ban on antimicrobial fixed-dose combinations: winning the battle, losing the war? J Pharm Policy Pract 2022; 15:33. [PMID: 35484606 PMCID: PMC9047325 DOI: 10.1186/s40545-022-00428-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022] Open
Abstract
Background and objectives India, the country with the largest market availability of antimicrobial fixed-dose combinations (FDCs), banned certain antimicrobial FDCs in September 2018. Our objective was to examine the impact of Government ban on the sales of antimicrobial FDCs. Methods The sales patterns of 14 of the 26 banned antimicrobial FDCs were analyzed using monthly private sector drug sales data from IQVIA (a comprehensive and nationally representative drug sales database) between January 2018 and December 2019. We carried out descriptive analyses to evaluate the trend in sales over time for banned and non-banned antimicrobial FDCs using cumulative sales volumes. Results Overall, the cumulative sales volume of banned antimicrobial FDCs declined by 75% between January and September 2018 and the same months of 2019, although some banned FDCs continued to be available in significant volumes. The effectiveness of the ban was offset by several pathways. First, the sales of combinations containing moieties belonging to the same drug-classes as the antimicrobials in the banned FDCs increased after the ban. Second, while certain formulations of particular combinations were banned, the sales of other non-banned formulation of these combinations increased. Third, in some cases, products containing new non-antimicrobial components added to the banned combinations remained available. Interpretation and conclusions While sales of the banned antimicrobial FDCs decreased in 2019, we identified several mechanisms that counterbalanced the ban, including implementation failure, rising sales of congeners, and products with additional non-antimicrobial components. Supplementary Information The online version contains supplementary material available at 10.1186/s40545-022-00428-w.
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Affiliation(s)
- Giorgia Sulis
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Richeek Pradhan
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Anita Kotwani
- Department of Pharmacology, V. P. Chest Institute, University of Delhi, Delhi, India
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine in Saint Louis, Saint Louis, MO, USA.
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19
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Holloway B, Chandrasekar H, Purohit M, Sharma A, Mathur A, KC A, Fernandez-Carballo L, Dittrich S, Hildenwall H, Bergström A. Antibiotic Use before, during, and after Seeking Care for Acute Febrile Illness at a Hospital Outpatient Department: A Cross-Sectional Study from Rural India. Antibiotics (Basel) 2022; 11:antibiotics11050574. [PMID: 35625218 PMCID: PMC9138085 DOI: 10.3390/antibiotics11050574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 12/26/2022] Open
Abstract
Antibiotic resistance is a naturally occurring phenomenon, but the misuse and overuse of antibiotics is accelerating the process. This study aimed to quantify and compare antibiotic use before, during, and after seeking outpatient care for acute febrile illness in Ujjain, India. Data were collected through interviews with patients/patient attendants. The prevalence and choice of antibiotics is described by the WHO AWaRe categories and Anatomical Therapeutic Chemical classes, comparing between age groups. Units of measurement include courses, encounters, and Defined Daily Doses (DDDs). The antibiotic prescription during the outpatient visit was also described in relation to the patients’ presumptive diagnosis. Of 1000 included patients, 31.1% (n = 311) received one antibiotic course, 8.1% (n = 81) two, 1.3% (n = 13) three, 0.4% (n = 4) four, 0.1% (n = 1) five, and the remaining 59.0% (n = 590) received no antibiotics. The leading contributors to the total antibiotic volume in the DDDs were macrolides (30.3%), combinations of penicillins, including β-lactamase inhibitors (18.8%), tetracyclines (14.8%), fluoroquinolones (14.6%), and third-generation cephalosporins (13.7%). ‘Watch’ antibiotics accounted for 72.3%, 52.7%, and 64.0% of encounters before, during, and after the outpatient visit, respectively. Acute viral illness accounted for almost half of the total DDDs at the outpatient visit (642.1/1425.3, 45.1%), for which the macrolide antibiotic azithromycin was the most frequently prescribed antibiotic (261.3/642.1, 40.7%).
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Affiliation(s)
- Bronwen Holloway
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (H.C.); (A.K.); (A.B.)
- Correspondence:
| | - Harshitha Chandrasekar
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (H.C.); (A.K.); (A.B.)
| | - Manju Purohit
- Department of Pathology, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, India;
- Department of Global Public Health, Health Systems and Policy, Karolinska Institute, 171 77 Stockholm, Sweden;
| | - Ashish Sharma
- Department of Medicine, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, India;
| | - Aditya Mathur
- Department of Paediatrics, Ruxmaniben Deepchand Gardi Medical College, Ujjain 456006, India;
| | - Ashish KC
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (H.C.); (A.K.); (A.B.)
| | | | - Sabine Dittrich
- Foundation for Innovative New Diagnostics, 1202 Geneva, Switzerland; (L.F.-C.); (S.D.)
| | - Helena Hildenwall
- Department of Global Public Health, Health Systems and Policy, Karolinska Institute, 171 77 Stockholm, Sweden;
- Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 171 64 Solna, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, 141 52 Huddinge, Sweden
| | - Anna Bergström
- Department of Women’s and Children’s Health, Uppsala University, 751 85 Uppsala, Sweden; (H.C.); (A.K.); (A.B.)
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20
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Pivk Lukančič P, Drčar T, Bruccoleri R, Črnugelj M, Mrak P. Teleocidin-producing genotype of Streptomyces clavuligerus ATCC 27064. Appl Microbiol Biotechnol 2022; 106:1521-1530. [PMID: 35138454 PMCID: PMC8882083 DOI: 10.1007/s00253-022-11805-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/28/2022]
Abstract
Abstract
Streptomyces clavuligerus is an industrially important producer of clavulanic acid (CA), a β-lactamase inhibitor which is used together with amoxicillin in one of the most widely prescribed antibacterial medicines, the co-amoxiclav. In a mid-eighties ATCC vial of S. clavuligerus ATCC 27064 culture, we have found a new genotype, which was apparently lost from the subsequent ATCC collection stocks, and has remained obscure to the scientific community. Most importantly, this genotype harbors teleocidin (lyngbyatoxin) biosynthetic genes, which are located on an enigmatic 138 kb chromosomal region and support accumulation of significant amounts of these highly toxic, tumor-promoting secondary metabolites in cultures of S. clavuligerus. While this genomic region is completely absent from all published sequences for S. clavuligerus ATCC strain, at least one of the industrial strains for commercial production of CA, originating from ATCC 27064, retained the genetic potential for production of teleocidins. The origin of teleocidin biosynthetic cluster can now be traced back to early S. clavuligerus stocks at the ATCC. Our work provides a genome sequence and a deposited monoisolate of this genotype. Given the scale of industrial use of S. clavuligerus world-wide and toxicity of teleocidins, we also discuss the environmental and safety implications and provide a method of abolishing teleocidin production without affecting productivity of CA. Key points • Early stocks of S. clavuligerus ATCC 27064 produce toxic teleocidins • Teleocidin biosynthetic genes were found within a distinct S. clavuligerus genotype • The genotype has been passed on to some industrial clavulanic acid producer strains Supplementary Information The online version contains supplementary material available at 10.1007/s00253-022-11805-5.
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Affiliation(s)
| | - Tjaša Drčar
- Novartis Technical Operations, MS&T Antiinfectives, Mengeš, Slovenia
| | | | - Martin Črnugelj
- Sandoz Development Center Slovenia, Physical Analytics Department, Ljubljana, Slovenia
| | - Peter Mrak
- Novartis Technical Operations, MS&T Antiinfectives, Mengeš, Slovenia.
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21
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Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda. Antibiotics (Basel) 2022; 11:antibiotics11020199. [PMID: 35203802 PMCID: PMC8868487 DOI: 10.3390/antibiotics11020199] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.
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22
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The Overlooked Issue of Outpatient Combination Antibiotic Prescribing in Low- and Middle-Income Countries: An Example from Syria. Antibiotics (Basel) 2022; 11:antibiotics11010074. [PMID: 35052951 PMCID: PMC8772973 DOI: 10.3390/antibiotics11010074] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/02/2022] [Accepted: 01/05/2022] [Indexed: 02/06/2023] Open
Abstract
This study aimed to determine and describe the prevalence of combination antibiotics dispensed in outpatients with health insurance in Syria. Data on all dispensed medicines between June 2018 and May 2019 for 81,314 adults were obtained, and medicines belonging to the J01 group of the World Health Organization (WHO) anatomical therapeutic classification (ATC) were included in the analysis. Prescriptions were stratified according to the number of antibiotics, age, and sex. Antibiotic utilization was expressed as the number of prescriptions per 1000 persons per year. Out of 59,404 prescriptions for antibiotics, 14.98% contained antibiotic combinations, distributed to 22.49% of the patients. The prevalence of dispensing antibiotic combinations was higher in female patients (23.00%), and the youngest (18–30 years, 26.19%) and oldest age groups (>70 years, 25.19%). The antibiotics most commonly combined were co-amoxiclav, second- and third-generation cephalosporins, and macrolides. Over 60% of the combinations contained ceftriaxone alone or in combination with sulbactam. The present study shows an alarmingly widespread prescription of antibiotic combinations, posing a risk to global health by promoting resistance development.
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23
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Anand P, Kaur N, Verma V, Shafiq N, Malhotra S. Assessment of rationality of available fixed dose combinations of antibiotics in India. Expert Rev Anti Infect Ther 2021; 20:797-808. [PMID: 34865581 DOI: 10.1080/14787210.2022.2015324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE India is among the largest consumers of antibiotics. Easy availability and growing sales of Fixed Dose Combinations (FDCs) of antibiotics can worsen Antimicrobial Resistance (AMR). There is lack of comprehensive data on available antibiotic FDC formulations, their dose strengths and adequacy of scientific evidence regarding their efficacy, safety and suitability for human use. In the present work, we aimed at addressing this knowledge gap. METHODS Availability of FDCs was ascertained from the Current Index of Medical Specialties (CIMS) [Issue Jan-April 2020]. Customized data abstraction form was used to capture pertinent information for these FDCs. Assessment of rationality was done based on standard parameters. RESULTS More than 90% of the existing FDCs were found to be irrational; with two third of them being unapproved and or banned from use in the country. CONCLUSIONS Although the regulatory agency has already taken cognizance of the seriousness of the matter; there is an urgent need to revisit these FDCs to promote prudent antibiotic use. EXPERT OPINION High antibiotic use is associated with antimicrobial resistance; it is imperative that all factors which lead to high antibiotic use are adequately addressed. Easy availability of fixed dose combinations (FDCs) has begun to catch the attention of regulators in developing economies like India leading to a ban of 330 FDCs of which 19% were antibiotic combinations. The continuing presence and increasing sales of these irrational FDCs is a concern for effective antimicrobial stewardship.
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Affiliation(s)
- Pooja Anand
- Department of Pharmacology, Vardhman Mahavir Medical College (VMMC) & Safdarjung Hospital, New Delhi, India
| | - Navjot Kaur
- Department of Pharmacology, Vardhman Mahavir Medical College (VMMC) & Safdarjung Hospital, New Delhi, India
| | - Veena Verma
- Department of Pharmacology, Vardhman Mahavir Medical College (VMMC) & Safdarjung Hospital, New Delhi, India
| | - Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Nguyen TD, Itayama T, Ramaraj R, Iwami N, Shimizu K, Dao TS, Pham TL, Maseda H. Chronic ecotoxicology and statistical investigation of ciprofloxacin and ofloxacin to Daphnia magna under extendedly long-term exposure. ENVIRONMENTAL POLLUTION (BARKING, ESSEX : 1987) 2021; 291:118095. [PMID: 34537598 DOI: 10.1016/j.envpol.2021.118095] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/09/2021] [Accepted: 08/31/2021] [Indexed: 05/22/2023]
Abstract
Ciprofloxacin (CFX) and ofloxacin (OFX) are two of the most often used fluoroquinolone antibiotics, and their residues are found in large amounts in various aquatic settings. However, the toxicity tests of CFX using eukaryotic organisms such as Daphnia magna are inadequate, and the test result of OFX is currently unknown. Therefore, the chronic toxicity test for D. magna was performed during 42 days under exposure to CFX and OFX concentrations of 50, 500, and 5000 μg L-1. All exposure conditions did not cause mortality for D. magna. CFX exposure at 500 μg L-1 resulted in an earlier oogenesis date and increased brood size in the second birth. The Poisson-based generalized linear mixed-effects model revealed that the reduction of fertility was statistically significant for the CFX and OFX exposures at 5000 μg L-1. On the other hand, the production of dead eggs as offspring degradation was also found significantly as maternal D. magna exposed to antibiotics at 5000 μg L-1. In addition, following long-term exposure to antibiotics, maternal adaptation to antibiotics was established for offspring deterioration and fertility. However, the OFX exposure showed that the fertility-suppressed effects continued for a longer period than the CFX exposure. Although no rational explanation has yet been given for the more substantial effect of OFX on reducing fertility than CFX, molecular cell biology and symbiotic microbial flora derived from previous studies could explain our ecotoxicological results. This study is the first report for the OFX chronic toxicities on D. magna by comparing it to the toxicity of CFX. Our study contributes to guiding the future impact assessment of fluoroquinolone antibiotic pollution on ecosystems, including the need for new statistical methods in ecotoxicological studies.
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Affiliation(s)
- Tan-Duc Nguyen
- Graduate School of Engineering, Nagasaki University, 1-14 Bunkyo-machi, Nagasaki-shi, Japan
| | - Tomoaki Itayama
- Graduate School of Engineering, Nagasaki University, 1-14 Bunkyo-machi, Nagasaki-shi, Japan.
| | - Rameshprabu Ramaraj
- School of Renewable Energy, Maejo University, Sansai, Chiang Mai, 50290, Thailand
| | - Norio Iwami
- School of Science and Engineering, Meise University, 2-1-1 Hodokubo, Hino-shi, Tokyo, 191-8506, Japan
| | - Kazuya Shimizu
- Graduate School of Science and Technology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba-shi, Ibaraki, Japan
| | - Thanh-Son Dao
- Faculty of Environment and Natural Resources, Ho Chi Minh City University of Technology (HCMUT), 268 Ly Thuong Kiet Street, District 10, Ho Chi Minh City, Viet Nam; Vietnam National University Ho Chi Minh City, Linh Trung Ward, Thu Duc District, Ho Chi Minh City, Viet Nam
| | - Thanh-Luu Pham
- Graduate University of Science and Technology, Vietnam Academy of Science and Technology (VAST), 18 Hoang Quoc Viet Street, Cau Giay District, Hanoi, 100000, Viet Nam; Institute of Tropical Biology, Vietnam Academy of Science and Technology (VAST), 85 Tran Quoc Toan Street, District 3, Ho Chi Minh City, 700000, Viet Nam
| | - Hideaki Maseda
- Biomedical Research Institute, National Institute of Advanced Industrial Science and Technology, 1-8-31 Midorigaoka, Ikeda, Osaka, 563-8577, Japan
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Abstract
Currently, thanks to the development of sensitive analytical techniques, the presence of different emerging pollutants in aquatic ecosystems has been evidenced; however, most of them have not been submitted to any regulation so far. Among emerging contaminants, antimicrobials have received particular attention in recent decades, mainly due to the concerning development of antibiotic resistance observed in bacteria, but little is known about the toxicological and ecological impact that antimicrobials can have on aquatic ecosystems. Their high consumption in human and veterinary medicine, food-producing animals and aquaculture, as well as persistence and poor absorption have caused antimicrobials to be discharged into receiving waters, with or without prior treatment, where they have been detected at ng-mg L−1 levels with the potential to cause effects on the various organisms living within aquatic systems. This review presents the current knowledge on the occurrence of antimicrobials in aquatic ecosystems, emphasizing their occurrence in different environmental matrixes and the effects on aquatic organisms (cyanobacteria, microalgae, invertebrates and vertebrates).
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