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Al Masud A, Walpola RL, Sarker M, Kabir A, Asaduzzaman M, Islam MS, Mostafa AT, Akhtar Z, Barua M, Seale H. Understanding antibiotic purchasing practices in community pharmacies: A potential driver of emerging antimicrobial resistance. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2024; 15:100485. [PMID: 39318500 PMCID: PMC11419887 DOI: 10.1016/j.rcsop.2024.100485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Revised: 07/29/2024] [Accepted: 07/29/2024] [Indexed: 09/26/2024] Open
Abstract
Introduction Antimicrobial resistance (AMR), a transboundary health issue, critically impacting low- and middle-income countries (LMICs) where 80% of antibiotics are used in the community, with 20-50% being inappropriate. Southeast-Asia, including Bangladesh, faces heightened AMR risk due to suboptimal healthcare standard and unregulated antibiotic sales. This study aimed to audit antibiotic dispensing patterns from community pharmacies, identifying factors influencing purchasing behaviors. Methods A cross-sectional survey of 385 antibiotic customers and structured observations of 1000 pharmacy dispensing events were conducted in four urban and rural areas in Bangladesh. Descriptive analysis defined antibiotic use, while Poisson regression examined how patients' demographics and health symptoms influenced prescription behaviors. Results Among 1000 observed medicine dispensing events, 25.9% were antibiotics. Commonly purchased antibiotics included macrolides (22.8%), third-generation-cephalosporins (20.8%), and second-generation-cephalosporins (16.9%). Following WHO-AWaRe classifications, 73.5% of antibiotics were categorized as Watch, and 23.1% as Access. From the survey, 56.6% antibiotics were purchased without a prescription from drug-sellers and informal healthcare providers, primarily for "non-severe" health-symptoms such as upper-respiratory-tract infections (37.4%), fever (31.7%), uncomplicated skin infections (20%), gastrointestinal-infections (11.2%), and urinary-tract infections (7.9%). The likelihood of presenting a prescription while purchasing antibiotics was 27% lower for individuals aged 6-59 compared to those ≤5 or ≥ 60. Lower-respiratory-tract infections and enteric-fever had higher prescription rates, with adjusted prevalence ratios of 1.78 (95% CI: 1.04, 3.03) and 1.87 (95% CI: 1.07, 3.29), respectively. After adjusting for confounders, sex, urban-rural locations, income, education, and number of health-symptoms exhibited no significant influence on prescription likelihood. Conclusion This study underscores unregulated antibiotic sales without prescriptions, urging tailored interventions considering prevailing health-seeking practices in diverse healthcare settings in LMICs. Enforcing prescription-only regulations is hindered by easy access through community pharmacies and conflicts of interest. Future strategies should consider how stewardship impacts the financial interests of pharmacy personnel in settings lacking clear authority to ensure optimal compliance.
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Affiliation(s)
- Abdullah Al Masud
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Ramesh Lahiru Walpola
- School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Malabika Sarker
- BRAC James P. Grant School of Public Health, Bangladesh
- Heidelberg Institute of Global Health, Heidelberg University, Germany
| | - Alamgir Kabir
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Muhammad Asaduzzaman
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Md Saiful Islam
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | | | - Zubair Akhtar
- The Kirby Institute, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | | | - Holly Seale
- School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Almutairy B. Extensively and multidrug-resistant bacterial strains: case studies of antibiotics resistance. Front Microbiol 2024; 15:1381511. [PMID: 39027098 PMCID: PMC11256239 DOI: 10.3389/fmicb.2024.1381511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 06/11/2024] [Indexed: 07/20/2024] Open
Abstract
The development of antibiotic resistance compromises the effectiveness of our most effective defenses against bacterial infections, presenting a threat to global health. To date, a large number of research articles exist in the literature describing the case reports associated with extensively drug-resistant (XDR) and multidrug-resistant (MDR) bacterial strains. However, these findings are scattered, making it time-consuming for researchers to locate promising results and there remains a need for a comparative study to compile these case reports from various geographical regions including the Kingdom of Saudi Arabia. Additionally, no study has yet been published that compares the genetic variations and case reports of MDR and XDR strains identified from Saudi Arabia, the Middle East, Central Europe, and Asian countries. This study attempts to provide a comparative analysis of several MDR and XDR case reports from Saudi Arabia alongside other countries. Furthermore, the purpose of this work is to demonstrate the genetic variations in the genes underlying the resistance mechanisms seen in MDR and XDR bacterial strains that have been reported in Saudi Arabia and other countries. To cover the gap, this comprehensive review explores the complex trends in antibiotic resistance and the growing risk posed by superbugs. We provide context on the concerning spread of drug-resistant bacteria by analyzing the fundamental mechanisms of antibiotic resistance and looking into individual case reports. In this article, we compiled various cases and stories associated with XDR and MDR strains from Saudi Arabia and various other countries including China, Egypt, India, Poland, Pakistan, and Taiwan. This review will serve as basis for highlighting the growing threat of MDR, XDR bacterial strains in Saudi Arabia, and poses the urgent need for national action plans, stewardship programs, preventive measures, and novel antibiotics research in the Kingdom.
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Affiliation(s)
- Bandar Almutairy
- Department of Pharmacology, College of Pharmacy, Shaqra University, Shaqra, Saudi Arabia
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Alzahrani KO, Alshahrani SM, Alajel SM. Evaluating the effectiveness of the Ministry of Health restriction policy on seasonal antibiotic consumption trends in Saudi Arabia, 2016-2020. Front Pharmacol 2023; 14:1242087. [PMID: 38099146 PMCID: PMC10720327 DOI: 10.3389/fphar.2023.1242087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
Background: Understanding antibiotic consumption patterns over time is essential to optimize prescribing practices and minimizing antimicrobial resistance. This study aimed to determine whether the antibiotics restriction policy launched by the Saudi Ministry of Health in April 2018 has impacted antibiotic use by assessing changes and seasonal variations following policy enforcement. Methods: Quarterly sales data of J01 antibacterial for systemic use in standard units were obtained from the IQVIA-MIDAS database, spanning from the first quarter of 2016 to the last quarter of 2020. Antibiotics consumption was measured in defined daily doses per 1,000 inhabitant per day- in a quarter (DDDdq). A comparative analysis of antibiotic consumption pre- and post-policy periods introduction was conducted by computing the average consumption values for each period. Statistical comparison of the mean differences between the two periods were then made using independent samples t-test, Mann-Whitney U Test where needed. Time series analysis was employed to estimate the projected antibiotic consumption in the post-policy period if the restriction policy had not been implemented, which was then compared to actual consumption values to evaluate the effectiveness of the restriction policy. Results: During the pre-policy, there were seasonal trends of the total and oral antibiotic consumption through quarters, with higher consumption observed in the first and fourth quarters. In contrast, parenteral antibiotic consumption did not appear to follow a clear seasonal pattern. Following the restriction policy, there was a significant reduction in total and oral antibiotic use, with mean reductions of -96.9 DDDdq (p-value = 0.002) and -98 DDDdq (p-value = 0.002), respectively. Conversely, a significant increase in parenteral antibiotic consumption was observed with a mean increase of +1.4 DDDdq (p-value < 0.0001). The comparison between the forecasted and actual models showed that the actual antibiotics consumption for total, oral, and parenteral were lower than the corresponding forecasted values by 30%, 31%, and 34%, respectively. Conclusion: Overall, our analysis of antibiotics consumption from 2016 to 2020 displays great success for the policy implemented by the Saudi Ministry of Health in significantly reducing the total and oral use of antibiotics. However, future studies are needed to explore the increased consumption of the parenteral antibiotics as well as the persistent high consumption patterns during the fall and winter months even after the implementation of the restriction policy.
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Affiliation(s)
- 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, Saudi Arabia
| | - Saeed M. Alshahrani
- Department of Public Health, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
| | - Sulaiman M. Alajel
- Reference Laboratory for Microbiology, Executive Department of Reference Laboratories, Research and Laboratories Sector, Saudi Food and Drug Authority (SFDA), Riyadh, Saudi Arabia
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Hashad N, Stewart D, Perumal D, Abdulrazzaq N, Tonna AP. A theoretical exploration of perspectives of key stakeholders on the implementation of antimicrobial stewardship programmes: a qualitative study underpinned by the Consolidated Framework for Implementation Research. J Hosp Infect 2023:S0195-6701(23)00146-9. [PMID: 37211094 DOI: 10.1016/j.jhin.2023.05.003] [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: 02/27/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND While a plethora of studies report antimicrobial stewardship programme (ASP) implementation, these are limited by a lack of theoretical underpinning. This may lead to missing key factors that are likely to influence the successful or unsuccessful implementation. AIM The aim of this study was to explore key stakeholders' perspectives of ASP implementation in United Arab Emirates (UAE) hospitals, with a focus on facilitators and barriers. METHODS The study employed a qualitative approach using semi-structured interviews conducted with ASP stakeholders involved in clinical use of antimicrobials at the individual patient level and including ASP team members and non-members. An interview schedule based on published literature and grounded in the Consolidated Framework for Implementation Research (CFIR) was developed, reviewed, and piloted. Recruitment was via purposive and snowball sampling. Interviews were recorded, transcribed, and thematically analysed by two independent researchers using CFIR as a coding framework. FINDINGS Data saturation was achieved at thirty-one interviews. Multiple CFIR constructs were identified as implementation facilitators or barriers. Facilitators included external policy requirements (both national and international), leadership support, stakeholders' engagement, collaborative culture, effective communication, and forward planning. Barriers included blame culture, complexity of ASP implementation and a shortage of expert personnel. CONCLUSION Numerous facilitators and barriers to ASP implementation from a stakeholders' perspective were identified in this research. The value of early leadership engagement to support provision of required resources, a need for effective planning and establishment of multiple engagement techniques, and valuable communication with healthcare providers are the main recommendations emerging to support improvement in clinical practice.
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Affiliation(s)
- Nortan Hashad
- Pharmacy, Higher Colleges of Technology, Dubai, United Arab Emirates; School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom
| | - Derek Stewart
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Dhayaneethie Perumal
- Commission of Academic Accreditation, Ministry of Education, Abu Dhabi, United Arab Emirates
| | - Najiba Abdulrazzaq
- Al Kuwait Hospital, Emirates Health Services, Dubai, United Arab Emirates
| | - Antonella Pia Tonna
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, United Kingdom.
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Alharbi AS. Bacteriological profile of wound swab and their antibiogram pattern in a tertiary care hospital, Saudi Arabia. Saudi Med J 2022; 43:1373-1382. [PMID: 36517049 PMCID: PMC9994516 DOI: 10.15537/smj.2022.43.12.20220681] [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: 09/17/2022] [Accepted: 11/08/2022] [Indexed: 12/17/2023] Open
Abstract
OBJECTIVES To assess the microbial profile of wound infection and their antibiogram pattern. METHODS A retrospective study was carried out at King Abdulaziz University Hospital, Jeddah Saudi Arabia between December 2021 and July 2022 comprising data related to demographic, microbial profile and antibiotic sensitivity pattern of wound infection-suspected cases. RESULTS A total of 305 wound swabs were collected; of which 56.1% showed microbial growth. Among 187 microbial isolates, 62% were gram-negative bacteria, 30.5% were gram-positive bacteria and 7.5% were fungi. Staphylococcus aureus was the prevailing isolates 17.1%, followed by Klebsiella pneumoniae and Pseudomonas aeruginosa, each with 13.9% and Escherichia coli with 12.8 %. Providencia sp with 0.1% was the least isolated bacteria. Out of 173 bacterial isolates, 46.8% were sensitive to antimicrobial agents tested, while 53.2% were resistant to one and more drug tested. Of these isolates, 22% were found to be the MDR bacteria. The highest MDR percentages was noted among Acinetobacter baumannii (70%) followed by Klebsiella pneumoniae (53.9%), Escherichia coli (25%) and Pseudomonas aeruginosa (19.2%) and the least by (12.5%) by Staphylococcus aureus. CONCLUSION: The microbial isolation rates from wound infection was high, with Staphylococcus aureus being the most prevalent. Considerable antimicrobial resistance rate to the commonly used antibiotics was discovered. Thus, regular monitoring of microbial profile and their antimicrobial sensitivity pattern in the study region in attempt to contain antimicrobial resistance is highly recommended.
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Affiliation(s)
- Azzah S. Alharbi
- From the Medical Microbiology and Parasitology Department, Faculty of Medicine, King Abdulaziz University, and from Special Infectious Agent Unit, King Fahad Medical Research Center, Jeddah, Kingdom of Saudi Arabia.
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Torumkuney D, Dolgum S, van Hasselt J, Abdullah W, Keles N. Country data on AMR in Saudi Arabia in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome. J Antimicrob Chemother 2022; 77:i70-i76. [PMID: 36065727 PMCID: PMC9445845 DOI: 10.1093/jac/dkac219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. OBJECTIVES To review AMR in Saudi Arabia and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize a further rise in AMR within Saudi Arabia and improve patient outcomes. METHODS National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from a clinician in Saudi Arabia were sought to contextualize this information. CONCLUSIONS Various initiatives are underway in Saudi Arabia, including a National Action Plan for AMR, which was published in 2017. However, AMR is rising and knowledge about appropriate antibiotic use seems to be lacking among physicians and the general public. Various international guidelines are utilized by clinicians in Saudi Arabia, but a more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Saudi Arabia could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.
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Affiliation(s)
- Didem Torumkuney
- GlaxoSmithKline, 980 Great West Road, Brentford, Middlesex TW8 9GS, UK
| | - Saeed Dolgum
- Pediatric Infectious Diseases, Dr. Suliman ALhabib Hospital, Riyadh, Saudi Arabia
| | - James van Hasselt
- GlaxoSmithKline, The Campus, Flushing Meadows, 57 Sloane Street, Bryanston, Gauteng 2021, South Africa
| | - Walid Abdullah
- GlaxoSmithKline, Headquarters Business Park, Corniche Road, Jeddah 21544, Saudi Arabia
| | - Nergis Keles
- GlaxoSmithKline, Büyükdere Cad. No: 173, 1. Levent Plaza B Blok 34394 Levent, İstanbul, Türkiye
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Editorial for the Special Issue: "Current and Novel Antimicrobial Strategies for Bacterial and Fungal Infections by Resistant Organisms". Antibiotics (Basel) 2022; 11:antibiotics11040426. [PMID: 35453178 PMCID: PMC9025739 DOI: 10.3390/antibiotics11040426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/18/2022] [Indexed: 11/16/2022] Open
Abstract
The pandemic driven by the SARS-CoV-2 infection has compelled health services globally to direct all available human and economic resources toward fighting the novel coronavirus [...].
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Nassar H, Abu-Farha R, Barakat M, Alefishat E. Antimicrobial Stewardship from Health Professionals' Perspective: Awareness, Barriers, and Level of Implementation of the Program. Antibiotics (Basel) 2022; 11:99. [PMID: 35052979 PMCID: PMC8773352 DOI: 10.3390/antibiotics11010099] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/04/2023] Open
Abstract
This study aimed to evaluate health professionals' perceptions regarding the level of implementation of the Antimicrobials Stewardship (AMS) programs in Jordanian tertiary hospitals and to assess the perceived barriers to its implementation. During this cross-sectional study, a total of 157 healthcare providers agreed to participate (response rate 96.3%). Participants were asked to complete an electronic survey after meeting them at their working sites. Only 43.9% of the healthcare providers (n = 69) reported having an AMS committee in their hospital settings. The results suggested that private hospitals have significantly better AMS implementation compared to public hospitals among four areas (p ≤ 0.05). Moreover, the results showed that the most widely available strategies to implement AMS were infectious disease/microbiology advice (n = 112, 71.3%), and treatment guidelines (n = 111, 70.7%). Additionally, the study revealed that the main barrier to AMS implementation was the lack of information technology support (n = 125, 79.6%). These findings could draw managers' attention to the importance of AMS and support the health care provider's practice of AMS in Jordanian tertiary hospitals by making the right decisions and the required modifications regarding the strategies needed for the implementation of AMS programs.
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Affiliation(s)
- Haya Nassar
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan; (H.N.); (R.A.-F.); (M.B.)
| | - Rana Abu-Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan; (H.N.); (R.A.-F.); (M.B.)
| | - Muna Barakat
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman 11931, Jordan; (H.N.); (R.A.-F.); (M.B.)
| | - Eman Alefishat
- Department of Pharmacology, College of Medicine and Health Science, Khalifa University of Science and Technology, Abu Dhabi P.O. Box 127788, United Arab Emirates
- Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi P.O. Box 127788, United Arab Emirates
- Department Biopharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, The University of Jordan, Amman 11942, Jordan
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