Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers' Perspectives across Two States

Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study

OBJECTIVE

Antibiotic misuse includes using them to treat colds and influenza, obtaining them without a prescription, not finishing the prescribed course and sharing them with others. Although drug providers are well positioned to advise clients on proper stewardship practices, antibiotic misuse continues to rise in Ethiopia. It necessitates an understanding of why drug providers failed to limit such risky behaviours. This study aimed to explore drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia.

SETTING

The study was conducted in rural Haramaya district and Harar town, eastern Ethiopia.

DESIGN AND PARTICIPANTS

An exploratory qualitative study was undertaken between March and June 2023, among the 15 drug providers. In-depth interviews were conducted using pilot-tested, semistructured questions. The interviews were transcribed verbatim, translated into English and analysed thematically. The analyses considered the entire dataset and field notes.

RESULTS

The study identified self-medication pressures, non-prescribed dispensing motives, insufficient regulatory functions and a lack of specific antibiotic use policy as the key contributors to antibiotic misuse. We found previous usage experience, a desire to avoid extra costs and a lack of essential diagnostics and antibiotics in public institutions as the key drivers of non-prescribed antibiotic access from private drug suppliers. Non-prescribed antibiotic dispensing in pharmacies was driven by client satisfaction, financial gain, business survival and market competition from informal sellers. Antibiotic misuse in the setting has also been linked to traditional and ineffective dispensing audits, inadequate regulatory oversights and policy gaps.

CONCLUSION

This study highlights profits and oversimplified access to antibiotics as the main motivations for their misuse. It also identifies the traditional antibiotic dispensing audit as an inefficient regulatory operation. Hence, enforcing specific antibiotic usage policy guidance that entails an automated practice audit, a responsible office and insurance coverage for persons with financial limitations can help optimise antibiotic use while reducing resistance consequences.

Expanding antibiotic, vaccine, and diagnostics development and access to tackle antimicrobial resistance

The increasing number of bacterial infections globally that do not respond to any available antibiotics indicates a need to invest in-and ensure access to-new antibiotics, vaccines, and diagnostics. The traditional model of drug development, which depends on substantial revenues to motivate investment, is no longer economically viable without push and pull incentives. Moreover, drugs developed through these mechanisms are unlikely to be affordable for all patients in need, particularly in low-income and middle-income countries. New, publicly funded models based on public-private partnerships could support investment in antibiotics and novel alternatives, and lower patients' out-of-pocket costs, making drugs more accessible. Cost reductions can be achieved with public goods, such as clinical trial networks and platform-based quality assurance, manufacturing, and product development support. Preserving antibiotic effectiveness relies on accurate and timely diagnosis; however scaling up diagnostics faces technological, economic, and behavioural challenges. New technologies appeared during the COVID-19 pandemic, but there is a need for a deeper understanding of market, physician, and consumer behaviour to improve the use of diagnostics in patient management. Ensuring sustainable access to antibiotics also requires infection prevention. Vaccines offer the potential to prevent infections from drug-resistant pathogens, but funding for vaccine development has been scarce in this context. The High-Level Meeting of the UN General Assembly in 2024 offers an opportunity to rethink how research and development can be reoriented to serve disease management, prevention, patient access, and antibiotic stewardship.

Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: Findings of a multicentric study highlighting the importance of local antibiograms

Objectives

Evidence-based prescribing is essential to optimize patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. Diagnostic and Antimicrobial Stewardship (DASH) to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship program guiding centers in preparing, analyzing and disseminating local antibiograms to promote antimicrobial stewardship in community urinary tract infection. Here, we mapped the susceptibility profile of Escherichia coli from 22 Indian centers.

Methods

These centers spanned 10 Indian states and three union territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardization was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analyzed.

Results

Nationally, fosfomycin, with 94% susceptibility (inter-center range 83-97%), and nitrofurantoin, with 85% susceptibility (61-97%), retained the widest activity. The susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%), and oral cephalosporins (26%). The rates for third- and fourth-generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) extended-spectrum β-lactamase prevalence. Piperacillin-tazobactam (81%), amikacin (88%), and meropenem (88%) retained better activity; however, one center in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West, and Northeast India; centers in the heavily populated Gangetic plains, across north and northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices.

Conclusions

Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, although elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third-generation cephalosporins is discouraged, whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents.

Predicting over-the-counter antibiotic use in rural Pune, India, using machine learning methods

OBJECTIVES

Over-the-counter (OTC) antibiotic use can cause antibiotic resistance, threatening global public health gains. To counter OTC use, this study used machine learning (ML) methods to identify predictors of OTC antibiotic use in rural Pune, India.

METHODS

The features of OTC antibiotic use were selected using stepwise logistic, lasso, random forest, XGBoost, and Boruta algorithms. Regression and tree-based models with all confirmed and tentatively important features were built to predict the use of OTC antibiotics. Five-fold cross-validation was used to tune the models' hyperparameters. The final model was selected based on the highest area under the curve (AUROC) with a 95% confidence interval (CI) and the lowest log-loss.

RESULTS

In rural Pune, the prevalence of OTC antibiotic use was 35.9% (95% CI, 31.6 to 40.5). The perception that buying medicines directly from a medicine shop/pharmacy is useful, using antibiotics for eye-related complaints, more household members consuming antibiotics, and longer duration and higher doses of antibiotic consumption in rural blocks and other social groups were confirmed as important features by the Boruta algorithm. The final model was the XGBoost+Boruta model with 7 predictors (AUROC, 0.934; 95% CI, 0.891 to 0.978; log-loss, 0.279) log-loss.

CONCLUSIONS

XGBoost+Boruta, with 7 predictors, was the most accurate model for predicting OTC antibiotic use in rural Pune. Using OTC antibiotics for eye-related complaints, higher consumption of antibiotics and the perception that buying antibiotics directly from a medicine shop/pharmacy is useful were identified as key factors for planning interventions to improve awareness about proper antibiotic use.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.

Public perception and community-level impact of national action plans on antimicrobial resistance in Vietnam

Objectives

Vietnam was the first country from the WHO Western Pacific Region to adopt a national action plan (NAP) on antimicrobial resistance (AMR) in 2013. The multilayered nature of AMR requires coordination across 'One Health' sectors, dedicated financing, multistakeholder involvement, and widespread community engagement to implement the action plans. This study explores the perceived impact of NAP implementation at the community level.

Methods

Key informant interviews (KIIs) were used for data collection during 2021. An interview tool was used for the KIIs and purposive sampling was used to identify study participants from Vietnam. The study participants were those engaged with a substantial scale of antimicrobial usage, diagnosis of infections or concerned with antimicrobial content in effluents in their professional life. Twelve KIIs were conducted with participants from human health, animal health and the environmental sector. The data were entered into Microsoft Excel, and manifest and latent content analysis was done.

Results

The analysis highlighted themes such as limited public awareness of AMR, ongoing capacity building and quality assurance initiatives, implementation of guidelines and regulations for AMR containment, sustained investment in improving infrastructure, and challenges relating to accountability whilst prescribing and selling antibiotics.

Conclusions

There were many positive critical developments during the NAP implementation period in Vietnam towards AMR mitigation. For better impact, there is a need to revitalize the implementation machinery of NAPs by improving the enforcement capacity of regulations, cross-sectoral collaboration and promoting community ownership.

The dark side of drug repurposing. From clinical trial challenges to antimicrobial resistance: analysis based on three major fields

Drug repurposing is a strategic endeavor that entails the identification of novel therapeutic applications for pharmaceuticals that are already available in the market. Despite the advantageous nature of implementing this particular strategy owing to its cost-effectiveness and efficiency in reducing the time required for the drug discovery process, it is essential to bear in mind that there are various factors that must be meticulously considered and taken into account. Up to this point, there has been a noticeable absence of comprehensive analyses that shed light on the limitations of repurposing drugs. The primary aim of this review is to conduct a thorough illustration of the various challenges that arise when contemplating drug repurposing from a clinical perspective in three major fields-cardiovascular, cancer, and diabetes-and to further underscore the potential risks associated with the emergence of antimicrobial resistance (AMR) when employing repurposed antibiotics for the treatment of noninfectious and infectious diseases. The process of developing repurposed medications necessitates the application of creativity and innovation in designing the development program, as the body of evidence may differ for each specific case. In order to effectively repurpose drugs, it is crucial to consider the clinical implications and potential drawbacks that may arise during this process. By comprehensively analyzing these challenges, we can attain a deeper comprehension of the intricacies involved in drug repurposing, which will ultimately lead to the development of more efficacious and safe therapeutic approaches.

Patterns of antibiotic use for acute respiratory infections in under-three-year-old children in India: A cross-sectional study

Background

Despite its mostly viral etiology, antibiotics are frequently used to treat acute respiratory infections (ARIs) in children. India is one of the largest global consumers of antibiotics and has one of the highest rates of resistance to antimicrobial treatments. However, the epidemiology of antibiotic treatment among young children in India is poorly understood.

Methods

Using nationally representative household survey data from the Indian National Family Health Surveys (NFHS) conducted between 2015 and 2016 and 2019 and 2021, we estimated the prevalence of antibiotic use among 17 472 children under the age of three who reported ARI symptoms within two weeks before their mothers were interviewed. To assess the factors associated with antibiotic use for the treatment of ARI symptoms, we used multivariable logistic regression models that included sociodemographic, child-related, household, and health care related characteristics, with results reported on the prevalence difference (PD) scale.

Results

We estimated that 18.7% (95% CI = 17.8-19.6) of under-three-year-old (U3) children who exhibited ARI symptoms in the two weeks prior to the survey were given antibiotics as a treatment. The highest prevalence was observed in the southern and northern geographic zones of India. Furthermore, multivariable regression models indicated that children with greater access to health services were more likely to receive antibiotics for ARI treatment, regardless of the type of health care facility (public, private or pharmacy/unregulated). Additionally, the prevalence of antibiotic consumption was higher among children from families with religious affiliations other than Muslim and Hindu backgrounds (i.e. Christian, Sikh, Buddhist/neo-Buddhist, Jain, Jewish, Parsi, no religion and other) (PD = 11.7 (95% CI = 6.3-16.7)) compared to Hindu families and among mothers with a secondary or higher education (PD = 5.8 (95% CI = 1.7-9.9)) compared to mothers lacking formal education.

Conclusions

Our findings provide an important baseline for monitoring the use of antibiotics for the treatment of acute respiratory infections, and for designing interventions to mitigate potential misuse among young children in India.

Impact of Antimicrobial Stewardship on Reducing Antimicrobial Resistance

Antimicrobial resistance has become a serious global issue, posing a significant threat to public health and healthcare professionals. Since the advent of penicillin, many antibiotics have lost their effectiveness in combating microbes simply due to inappropriate, irrational, unnecessary, and unrestricted use. The ineffectiveness of an increasing number of antibiotics necessitates the utilization of more potent antimicrobial agents for combatting uncomplicated infections. In response to the escalating prevalence of multidrug-resistant pathogens and the imperative to curtail the demand for novel antibiotics, the Antimicrobial Stewardship Program was conceived and implemented. This initiative is characterized by a lead physician, ideally possessing expertise in infectious diseases, alongside a pharmacist serving as a secondary leader and a microbiologist with defined responsibilities to achieve several objectives. These objectives include reducing indiscriminate usage of antimicrobial agents, promoting selective antimicrobial utilization based on culture results, de-escalating therapy from broad-spectrum to targeted antimicrobial agents, and transitioning from parenteral to oral administration when feasible. These objectives are pursued through a combination of pre-prescription and post-prescription strategies. While the Antimicrobial Stewardship Program is widely established in developed nations, a pressing need exists for its more comprehensive implementation in less developed regions. This review aims to examine the strategies used in antimicrobial stewardship programs to evaluate their effectiveness in preventing the development of multidrug-resistant organisms (MDROs) based on existing research studies. Under the Antimicrobial Stewardship Program, education of healthcare professionals and continuous disposal of information about antimicrobial resistance have helped to restrict the emergence of multidrug-resistant organisms.

Urinary tract infections: a review of the current diagnostics landscape

Urinary tract infections are the most common bacterial infections worldwide. Infections can range from mild, recurrent (rUTI) to complicated (cUTIs), and are predominantly caused by uropathogenic Escherichia coli (UPEC). Antibiotic therapy is important to tackle infection; however, with the continued emergence of antibiotic resistance there is an urgent need to monitor the use of effective antibiotics through better stewardship measures. Currently, clinical diagnosis of UTIs relies on empiric methods supported by laboratory testing including cellular analysis (of both human and bacterial cells), dipstick analysis and phenotypic culture. Therefore, development of novel, sensitive and specific diagnostics is an important means to rationalise antibiotic therapy in patients. This review discusses the current diagnostic landscape and highlights promising novel diagnostic technologies in development that could aid in treatment and management of antibiotic-resistant UTIs.

Antibiotic-Dispensing Patterns and Awareness of Anti-microbial Resistance Among the Community Pharmacists in South-Central India

Background Anti-microbial resistance (AMR) is an ongoing epidemic contributing to extremely high healthcare costs and hospital admissions. Inappropriate dispensing of antibiotics is one of the root causes of AMR. Hence, our study aimed to assess antibiotic-dispensing patterns and AMR awareness among pharmacists from South-Central India. Methodology This cross-sectional observational study was conducted over a period of two months from June to July 2023. The pharmacies in urban and semi-urban areas of coastal and central districts of the Indian state of Andhra Pradesh were surveyed. Data were collected using a predesigned questionnaire for antibiotic-dispensing patterns and awareness of AMR, as approved by the Institutional Ethics Committee of Aster Ramesh Hospital, Vijayawada, India. The data were collected and analyzed descriptively by cross-tabulation. Results Among the 389 pharmacies that responded, 78% (n = 303) were dispensing antibiotics over the counter (OTC) and 22% (n = 86) were dispensing antibiotics only for valid prescriptions. It was found that antibiotics were dispensed OTC for common ailments such as the common cold, cough, sore throat, nasal congestion, fever, diarrhea, and urinary tract infections. As per the World Health Organization-recommended Access, Watch, and Reserve (AWaRe) criterion, antibiotics under the Watch group such as macrolides (azithromycin), fluoroquinolones (ciprofloxacin, norfloxacin, levofloxacin, and ofloxacin) and third-generation cephalosporins (cefixime and cefpodoxime) were found to be widely dispensed OTC. The most common antibiotics dispensed OTC were azithromycin (54.1%), amoxicillin (47.5%), cefixime (40%), amoxicillin + clavulanic acid (15.2%), ofloxacin (13.5%), ciprofloxacin (10%), and doxycycline (6.6%). Among the OTC dispensers, 82.5% (n = 250) were unaware of AMR and 17.5% were partially aware. However, 57% (n = 49) were unaware of AMR and its effects, in pharmacies dispensing antibiotics for valid prescriptions. Conclusion Our findings aggregate evidence on the alarming trend of inappropriate antibiotic-dispensing patterns that may further exacerbate AMR. Strict regulatory enforcement and periodical monitoring to regulate antibiotic dispensing to control unethical dispensing are inevitably necessary.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.

Factors contributing to flares of ulcerative colitis in North India- a case-control study

BACKGROUND

Ulcerative colitis is a relapsing and remitting disease that may be associated with flares. The causes of flares in the Indian setting are not well recognized.

METHODS

The present prospective case-control study was conducted at a single center in North India. Cases were defined as patients admitted for flare of ulcerative colitis, while controls were patients in remission enrolled from the outpatient department. The basis of the diagnosis of flare was a simple clinical colitis activity index (SCCAI) of ≥ 5 and endoscopic activity, while remission was based on SCCAI < 4 and a normal fecal calprotectin. A questionnaire evaluating recent infections, stress, drug intake (antibiotics, pain medication), adherence to therapy, and use of complementary and alternative therapy (CAM) was administered.

RESULTS

We included 84 patients (51 with flare and 33 in remission) with a median age of 38 years, of whom 47 (55.9%) were males. The two groups were similar for baseline parameters, including age (38, 23-50 and 38, 25.5-48.5 years), male gender (52.9% and 60.6%), extent of disease, extraintestinal manifestations (21.6% and 12.1%), use of 5-aminosalicylates (76.5% and 90.9%). The thiopurine use was lower in those having a flare (15.7% and 36.4%). Amongst the predictors of flare, the recent infections (39.2% and 30.3%), recent travel (31.4 and 27.3%), eating outside food (47.1% and 39.4%), consumption of milk products (88.2% and 75.8%), use of pain medication (43.1% and 33.3%) and recent stress (62.7% and 60.6%) were similar between cases and controls. The rates of antibiotic use (29.4% and 6.1%), lack of adherence (50.9% and 15.2%), and intake of CAM (70.6% and 33.3%) were higher in those with flare. Patients attributed a lack of adherence to the cost of therapy, presumed cure (due to lack of symptoms), and fear of adverse effects.

CONCLUSION

Lack of adherence to inflammatory bowel disease therapies and recent CAM and antibiotic intake was higher in patients with flares of UC. The study makes ground for educational intervention(s) promoting knowledge and adherence to IBD therapies.

Prevalence of vancomycin-resistant Enterococci in India between 2000 and 2022: a systematic review and meta-analysis

BACKGROUND

Vancomycin-resistant Enterococci (VRE) infections are recurrently reported in different parts of India in the last two decades. However, an up-to-date, countrywide information concerning the prevalence and the rate of VRE in India is limited and hence this study aimed to estimate the pooled prevalence of VRE in India.

METHODS

A literature search was performed using various databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed throughout. Cross-sectional studies reporting the prevalence of VRE in India from human samples whereby at least two Enterococci were isolated between 1 January 2000 and 31 December 2022 were sought for inclusion. Data were extracted and analysed using Microsoft Excel and Comprehensive Meta-analysis version 4, respectively.

RESULTS

Nineteen studies were included in the analyses. A collective total of 3683 Enterococci isolates were examined, of which 368 were VRE strains. The pooled prevalence of VRE in India was calculated at 12.4% (95% CI: 8.6-17.5; Q = 189.69; I2 = 90.51%; p = < 0.001). E. faecalis was the most frequently isolated species (1450 [39.37%]) followed by E. faecium (724 [19.66%]). Amongst the VRE strains, E. faecium was the most prevalent (214 [58.15%]) followed by E. faecalis (134 [36.41%]). An upsurge in the rate of VRE infections was observed in India over time: VRE prevalence was estimated at 4.8% between 2000 and 2010 and 14.1% between 2011 and 2020.

CONCLUSION

This study presents the most up-to-date information on the rate of VRE infections in India. Though lower than the findings for some less developed countries, VRE prevalence in India is notable and on the rise.

Social demographics determinants for resistome and microbiome variation of a multiethnic community in Southern Malaysia

The prevalence of antibiotic-resistant bacteria in Southeast Asia is a significant concern, yet there is limited research on the gut resistome and its correlation with lifestyle and environmental factors in the region. This study aimed to profile the gut resistome of 200 individuals in Malaysia using shotgun metagenomic sequencing and investigate its association with questionnaire data comprising demographic and lifestyle variables. A total of 1038 antibiotic resistance genes from 26 classes were detected with a mean carriage rate of 1.74 ± 1.18 gene copies per cell per person. Correlation analysis identified 14 environmental factors, including hygiene habits, health parameters, and intestinal colonization, that were significantly associated with the resistome (adjusted multivariate PERMANOVA, p < 0.05). Notably, individuals with positive yeast cultures exhibited a reduced copy number of 15 antibiotic resistance genes. Network analysis highlighted Escherichia coli as a major resistome network hub, with a positive correlation to 36 antibiotic-resistance genes. Our findings suggest that E. coli may play a pivotal role in shaping the resistome dynamics in Segamat, Malaysia, and its abundance is strongly associated with the community's health and lifestyle habits. Furthermore, the presence of yeast appears to be associated with the suppression of antibiotic-resistance genes.

How can lessons from the COVID-19 pandemic enhance antimicrobial resistance surveillance and stewardship?

COVID-19 demanded urgent and immediate global attention, during which other public health crises such as antimicrobial resistance (AMR) increased silently, undermining patient safety and the life-saving ability of several antimicrobials. In 2019, WHO declared AMR a top ten global public health threat facing humanity, with misuse and overuse of antimicrobials as the main drivers in the development of antimicrobial-resistant pathogens. AMR is steadily on the rise, especially in low-income and middle-income countries across south Asia, South America, and Africa. Extraordinary circumstances often demand an extraordinary response as did the COVID-19 pandemic, underscoring the fragility of health systems across the world and forcing governments and global agencies to think creatively. The key strategies that helped to contain the increasing SARS-CoV-2 infections included a focus on centralised governance with localised implementation, evidence-based risk communication and community engagement, use of technological methods for tracking and accountability, extensive expansion of access to diagnostics, and a global adult vaccination programme. The extensive and indiscriminate use of antimicrobials to treat patients, particularly in the early phase of the pandemic, have adversely affected AMR stewardship practices. However, there were important lessons learnt during the pandemic, which can be leveraged to strengthen surveillance and stewardship, and revitalise efforts to address the AMR crisis.

Sale of antibiotics without prescription in stand-alone pharmacies in Tamil Nadu

Background

Non-prescription sale of antibiotics is one of the major causes for increased consumption of antibiotics which facilitates the emergence of drug resistance. Over-the-counter sale of antibiotics in India, without prescription and often at partial doses, is quite common even though the practice is not legal.

Objectives

(1) To interview pharmacists about the sale of over-the-counter medication, and prescription drugs sold without a prescription, in particular; (2) to obtain an understanding of the reasons for such sale from the perspective of the pharmacist.

Methods

Pharmacists were interviewed with the help of a pre-validated questionnaire in 15 stand-alone pharmacies in a metropolitan city and a tier-2 city in Tamil Nadu. Major points of interest were characteristics of customers requesting antibiotics without a valid prescription, common diseases for which they were sold without prescription, whether patients asked for antibiotics by name or as treatment for their symptoms, and reasons for such requests.

Results

Pharmacists readily admitted to selling prescription drugs, including antibiotics without a valid prescription. While they know of antibiotic resistance, not a single pharmacist interviewed by us knew of the causes of antibiotic resistance.

Conclusion

The intervention listed in the National Action Plan on Antimicrobial Resistance to develop awareness campaigns targeted at dispensers regarding existing rules and appropriate use of antimicrobials and mandatory training programs on optimal antimicrobial use must be implemented immediately.

Sepsis Management in Southeast Asia: A Review and Clinical Experience

Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia.

Perspectives on the Ethics of Antibiotic Overuse and on the Implementation of (New) Antibiotics

The continuing rise in global antimicrobial resistance is seen by many governments and international organizations as a major threat to worldwide health. This means that many publications have already described the problems concerning the overuse of currently available antibiotics and potential solutions to this crisis, including the development of new alternatives to antibiotics. However, in this manuscript, the authors approach the subject of increasing global antimicrobial resistance from two perspectives not normally covered by previous publications, namely the ethical use of antibiotics and potential issues relating to the implementation of new antibiotics.

Marketing and Distribution System Foster Misuse of Antibiotics in the Community: Insights from Drugs Wholesalers in India

Antibiotic misuse is one of the major drivers of antimicrobial resistance (AMR). In India, evidence of antibiotic misuse comes largely from retailers as well as formal and informal healthcare providers (IHCPs). This paper presents the practices and perspectives of drug wholesalers, a critical link between manufacturers and last-mile dispensers. Four experienced wholesalers and an ex-State Drug Controller (ex-SDC) were interviewed in depth, using semi-structured guides in the National Capital Region of Delhi, India, between November 2020 and January 2021. Four main findings were that wholesalers (i) have limited knowledge about wholesale licensing and practice regulations, as well as a limited understanding of AMR; (ii) directly supply and sell antibiotics to IHCPs; (iii) facilitate medical representatives (MRs) of pharmaceutical companies and manufacturers in their strategies to promote antibiotics use in the community; and (iv) blame other stakeholders for unlawful sale and overuse of antibiotics. Some of the potential solutions aimed at wholesalers include having a minimum education qualification for licensing and mandatory Good Distribution Practices certification programs. Decoupling incentives by pharmaceutical companies from sales targets to improve ethical sales practices for MRs and optimize antibiotic use by IHCPs could alleviate wholesalers’ indirect actions in promoting antibiotic misuse.