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Abejew AA, Wubetu GY, Fenta TG. Relationship between Antibiotic Consumption and Resistance: A Systematic Review. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:9958678. [PMID: 38476862 PMCID: PMC10932619 DOI: 10.1155/2024/9958678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/20/2023] [Accepted: 02/24/2024] [Indexed: 03/14/2024]
Abstract
Background Unreserved use of antibiotics exerted selective pressure on susceptible bacteria, resulting in the survival of resistant strains. Despite this, the relationship between antibiotic resistance (ABR) and antibiotic consumption (ABC) is rarely studied. This systematic review aims to review the relationship between ABC and ABR from 2016 to 2022. Methods Articles published over 7 years (2016-2022) were searched from December 23 to 31, 2022. The search strategy was developed by using keywords for ABC and ABR. From 3367 articles, 58 eligible articles were included in the final review. Results The pooled ABC was 948017.9 DPDs and 4108.6 DIDs where over 70% of antibiotics were from the Watch and Reserve category based on the WHO AWaRe classification. The average pooled prevalence of ABR was 38.4%. Enterococcus faecium (59.4%), A. baumannii (52.6%), and P. aeruginosa (48.6%) were the most common antibiotic-resistant bacteria. Cephalosporins (76.8%), penicillin (58.3%), and aminoglycosides (52%) were commonly involved antibiotics in ABR. The positive correlation between ABR and consumption accounted for 311 (81%). The correlation between ABR P. aeruginosa and ABC accounted for 87 (22.7%), followed by 78 (20.3%) and 77 (20.1%) for ABR E. coli and K. pneumoniae with ABCs, respectively. Consumption of carbapenems and fluoroquinolones was most commonly correlated with resistance rates of P. aeruginosa, K. pneumoniae, E. coli, and A. baumannii. Conclusion There is a positive correlation between ABC and the rate of ABR. The review also revealed a cross-resistance between the consumption of different antibiotics and ABR. Optimizing antibiotic therapy and reducing unnecessary ABC will prevent the emergence and spread of ABR. Thus, advocating the implementation of stewardship programs plays a pivotal role in containing ABR.
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Affiliation(s)
- Asrat Agalu Abejew
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacy, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | | | - Teferi Gedif Fenta
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Dávila-López EC, Berumen-Lechuga MG, Molina-Pérez CJ, Jimenez-Juarez RN, Leaños-Miranda A, Robles-Ordoñez N, Peña-Cano MI, Venegas-Esquivel GA. Antimicrobial Resistance and Antibiotic Consumption in a Secondary Care Hospital in Mexico. Antibiotics (Basel) 2024; 13:178. [PMID: 38391564 PMCID: PMC10886054 DOI: 10.3390/antibiotics13020178] [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: 12/21/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Antimicrobial resistance is a global health problem, due to morbidity, mortality, and healthcare costs. The misuse of antimicrobials is the main cause of antimicrobial resistance. The aim of this study was to report antimicrobial resistance and antibiotic consumption in a secondary care hospital in Mexico. METHODS Within a cross-sectional study, antimicrobial resistance data on ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) and antibiotic consumption from 2020 to 2022 were collected. Antimicrobial resistance was reported based on percentages of resistance and consumption was analyzed using the defined daily dose (DDD)/100 bed days and the AWaRe (Access, Surveillance, Reservation) antibiotic group. RESULTS Antibiotic consumption in 2020, 2021 and 2022 was 330, 175 and 175 DDD/100 beds day, respectively. The rate of ceftriaxone resistance in E. coli (n = 526) and K. pneumoniae (n = 80) was 76% and 69%, respectively, the rate of carbapenem resistance in A. baumannii (n = 168) and P. aeruginosa (n = 108) was 92% and 52%, respectively; the rate of oxacillin resistance in S. aureus (n = 208) was 27%; and the rate of vancomycin resistance in E. faecium (n = 68) was 47%. CONCLUSION The reported results are congruent with global estimates of antibiotic resistance and consumption, providing an overview that could generate actions for antimicrobial optimization at the local and regional levels.
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Affiliation(s)
- Elda Carolina Dávila-López
- Internal Medicine Departament, Hospital General Regional 251, Instituto Mexicano del Seguro Social (IMSS), Metepec 52148, Mexico
| | - María Guadalupe Berumen-Lechuga
- Medical Research Coordination, Órgano de Operación Administrativa Desconcentrada Regional Mexico Poniente, Instituto Mexicano del Seguro Social (IMSS), Toluca 50000, Mexico
| | - Carlos José Molina-Pérez
- Clinical Coordination, Hospital General de Zona 252, Instituto Mexicano del Seguro Social (IMSS), Atlacomulco 50454, Mexico
| | | | - Alfredo Leaños-Miranda
- Medical Research Unit in Reproductive Medicine, Unidad de Investigación Médica en Medicina Reproductiva, UMAE Hospital de Ginecología y Obstetricia 4 "Dr. Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Mexico City 01090, Mexico
| | - Natali Robles-Ordoñez
- Infectious Diseases Department, Hospital para el Niño, Instituto Materno Infantil del Estado de Mexico, Toluca 50170, Mexico
| | - María Isabel Peña-Cano
- Clinical Laboratory Department, Hospital de Ginecología y Obstetricia 221, Instituto Mexicano del Seguro Social (IMSS), Toluca 50150, Mexico
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Natsheh IY, Elkhader MT, Al-Bakheit AA, Alsaleh MM, El-Eswed BI, Hosein NF, Albadawi DK. Inhibition of Acinetobacter baumannii Biofilm Formation Using Different Treatments of Silica Nanoparticles. Antibiotics (Basel) 2023; 12:1365. [PMID: 37760662 PMCID: PMC10525453 DOI: 10.3390/antibiotics12091365] [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: 06/30/2023] [Revised: 08/17/2023] [Accepted: 08/19/2023] [Indexed: 09/29/2023] Open
Abstract
There exists a multitude of pathogens that pose a threat to human and public healthcare, collectively referred to as ESKAPE pathogens. These pathogens are capable of producing biofilm, which proves to be quite resistant to elimination. Strains of A. baumannii, identified by the "A" in the acronym ESKAPE, exhibit significant resistance to amoxicillin in vivo due to their ability to form biofilm. This study aims to inhibit bacterial biofilm formation, evaluate novel silica nanoparticles' effectiveness in inhibiting biofilm, and compare their effectiveness. Amoxicillin was utilized as a positive control, with a concentration exceeding twice that when combined with silica NPs. Treatments included pure silica NPs, silica NPs modified with copper oxide (CuO.SiO2), sodium hydroxide (NaOH.SiO2), and phosphoric acid (H3PO4.SiO2). The characterization of NPs was conducted using scanning electron microscopy (SEM), while safety testing against normal fibroblast cells was employed by MTT assay. The microtiter plate biofilm formation assay was utilized to construct biofilm, with evaluations conducted using three broth media types: brain heart infusion (BHI) with 2% glucose and 2% sucrose, Loria broth (LB) with and without glucose and sucrose, and Dulbecco's modified eagle medium/nutrient (DMEN/M). Concentrations ranging from 1.0 mg/mL to 0.06 µg/mL were tested using a microdilution assay. Results from SEM showed that pure silica NPs were mesoporous, but in the amorphous shape of the CuO and NaOH treatments, these pores were disrupted, while H3PO4 was composed of sheets. Silica NPs were able to target Acinetobacter biofilms without harming normal cells, with viability rates ranging from 61-73%. The best biofilm formation was achieved using a BHI medium with sugar supplementation, with an absorbance value of 0.35. Biofilms treated with 5.0 mg/mL of amoxicillin as a positive control alongside 1.0 mg/mL of each of the four silica treatments in isolation, resulting in the inhibition of absorbance values of 0.04, 0.13, 0.07, 0.09, and 0.08, for SiO2, CuO.SiO2, NaOH.SiO2 and H3PO4.SiO2, respectively. When amoxicillin was combined, inhibition increased from 0.3 to 0.04; NaOH with amoxicillin resulted in the lowest minimum biofilm inhibitory concentration (MBIC), 0.25 µg/mL, compared to all treatments and amoxicillin, whereas pure silica and composite had the highest MBIC, even when combined with amoxicillin, compared to all treatments, but performed better than that of the amoxicillin alone which gave the MBIC at 625 µg/mL. The absorbance values of MBIC of each treatment showed no significant differences in relation to amoxicillin absorbance value and relation to each other. Our study showed that smaller amoxicillin doses combined with the novel silica nanoparticles may reduce toxic side effects and inhibit biofilm formation, making them viable alternatives to high-concentration dosages. Further investigation is needed to evaluate in vivo activity.
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Affiliation(s)
- Iyad Y. Natsheh
- Department of Medical Applied Sciences, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan; (I.Y.N.); (M.T.E.); (N.F.H.); (D.K.A.)
| | - Mallak T. Elkhader
- Department of Medical Applied Sciences, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan; (I.Y.N.); (M.T.E.); (N.F.H.); (D.K.A.)
| | - Ala’a A. Al-Bakheit
- Department of Nutrition and Food Processing, Faculty of Agricultural Technology, Al-Balqa Applied University, Salt 19117, Jordan;
| | - Majd M. Alsaleh
- Department of Medical Applied Sciences, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan; (I.Y.N.); (M.T.E.); (N.F.H.); (D.K.A.)
- Department of Biology, School of Science, University of Jordan, Amman 11942, Jordan
| | - Bassam I. El-Eswed
- Department of Basic Science, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan;
| | - Nedaa F. Hosein
- Department of Medical Applied Sciences, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan; (I.Y.N.); (M.T.E.); (N.F.H.); (D.K.A.)
| | - Duaa K. Albadawi
- Department of Medical Applied Sciences, Zarqa University College, Al-Balqa Applied University, Salt 19117, Jordan; (I.Y.N.); (M.T.E.); (N.F.H.); (D.K.A.)
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Liu Y, Xu Y, Wang S, Zeng Z, Li Z, Din Y, Liu J. Antibiotic susceptibility pattern, risk factors, and prediction of carbapenem-resistant Pseudomonas aeruginosa in patients with nosocomial pneumonia. Heliyon 2023; 9:e15724. [PMID: 37159707 PMCID: PMC10163646 DOI: 10.1016/j.heliyon.2023.e15724] [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: 04/28/2022] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/11/2023] Open
Abstract
Objectives This study was aimed at describing antibiotic susceptibility patterns and developing a predictive model by assessing risk factors for carbapenem-resistant Pseudomonas aeruginosa (CRPA). Methods A retrospective case-control study was conducted at a teaching hospital in China from May 2019 to July 2021. Patients were divided into the carbapenem-susceptible P. aeruginosa (CSPA) group and the CRPA group. Medical records were reviewed to find an antibiotic susceptibility pattern. Multivariate analysis results were used to identify risk factors and build a predictive model. Results A total of 61 among 292 patients with nosocomial pneumonia were infected with CRPA. In the CSPA and CRPA groups, amikacin was identified as the most effective antibiotic, with susceptibility of 89.7%. The CRPA group showed considerably higher rates of resistance to the tested antibiotics. Based on the results of mCIM and eCIM, 28 (45.9%) of 61 isolates might be carbapenemase producers. Independent risk factors related to CRPA nosocomial pneumonia were craniocerebral injury, pulmonary fungus infection, prior use of carbapenems, prior use of cefoperazone-sulbactam, and time at risk (≥15 d). In the predictive model, a score >1 point indicated the best predictive ability. Conclusions CRPA nosocomial pneumonia could be predicted by risk factor assessment particularly based on the underlying disease, antimicrobial exposure, and time at risk, which could help prevent nosocomial pneumonia.
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Affiliation(s)
| | | | | | | | | | | | - Jinbo Liu
- Corresponding author. The Affiliated Hospital of Southwest Medical University, 25th Taiping Street, Luzhou, 646000, Sichuan, PR China.
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Pérez-Lazo G, Del Valle-Mendoza J, Sandoval-Ahumada R, Soto-Febres F, Castillo-Córdova R, Zárate-Tantaleán M, Morales-Castillo L, Páucar-Miranda CJ, Altamirano-Molina M, Pacheco-Modesto I, Ruiz de Somocurcio-Cruzado C, Arana-Jurado D, Del Villar-Alarcón C, Vargas-Castro O, Díaz-Bardales C, Guerrero-Arismendiz B, Eyzaguirre-Zapata R, Aguilar-Luis MA, Martins-Luna J, Silva-Caso W. Impact of Adding a Rapid PCR-Based Blood Culture Identification Panel to the Antimicrobial Stewardship Program of Patients with Febrile Neutropenia in a Peruvian Referral Hospital. Antibiotics (Basel) 2023; 12:antibiotics12040648. [PMID: 37107010 PMCID: PMC10135419 DOI: 10.3390/antibiotics12040648] [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: 02/28/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
The addition of Biofire® FilmArray® Blood Culture Identification panel 2 (BCID2) to the antimicrobial stewardship program (ASP) could improve outcomes in bloodstream infections (BSI) of patients with febrile neutropenia (FN). A pre- and post-quasi-experimental single-center study was conducted at a reference hospital in Peru. Three groups were considered: patients with BSI before ASP intervention (control group), patients with BSI after ASP intervention (group 1), and patients with BSI after ASP intervention plus BCID2 PCR Panel implementation (group 2). Overall, 93 patients were identified (32 control, 30 group 1, 31 group 2). The median time to effective therapy was significantly shorter in group 2 compared to group 1 and control group, respectively (3.75 vs. 10 h, p = 0.004; 3.75 vs. 19 h, p < 0.001). No significant differences in terms of relapse of bacteremia, in-hospital mortality (all cause), and 30-day-all-cause hospital readmission between the three study periods were found. The appropriateness of empirical antimicrobial use, adding or change, and the following de-escalation or discontinuation was significant when the two intervention periods were compared with the control group (p < 0.001). In addition to the lack of local studies documenting the microbiological profile of FN episodes, adding syndromic panels-based testing could allow for the consolidation of ASP strategies.
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Affiliation(s)
- Giancarlo Pérez-Lazo
- Escuela de Medicina, Universidad César Vallejo, Piura 20001, Peru
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Juana Del Valle-Mendoza
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Roxana Sandoval-Ahumada
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Fernando Soto-Febres
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Raúl Castillo-Córdova
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Melissa Zárate-Tantaleán
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Liliana Morales-Castillo
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | | | - Iván Pacheco-Modesto
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | - Denis Arana-Jurado
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carmen Del Villar-Alarcón
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Olga Vargas-Castro
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carol Díaz-Bardales
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Bruno Guerrero-Arismendiz
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Renee Eyzaguirre-Zapata
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Miguel Angel Aguilar-Luis
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Johanna Martins-Luna
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Wilmer Silva-Caso
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
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Bacterial infections epidemiology and factors associated with multidrug resistance in the northern region of Ghana. Sci Rep 2022; 12:22069. [PMID: 36543904 PMCID: PMC9772187 DOI: 10.1038/s41598-022-26547-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Bacterial infections caused by multidrug resistant organisms are a major global threat. There is still a knowledge gap on this situation in the Northern Region of Ghana. This study determined the prevalence and resistance profile of bacterial infections. It also identified factors associated with multidrug resistance in the study area. This was a retrospective cross-sectional design and it analyzed data from the samples received at the Tamale Zonal Public Health Reference Laboratory from June 2018 to May 2022. The data were analyzed using the R software version 4.2.0. Univariate and multivariable binary logistic regression analyses were used to determine the factors associated with multidrug resistance. The samples included all specimen types possible. The specimens were collected for the purpose of clinical bacteriology diagnostics. Overall a total of 1222 isolates were obtained. The three (3) main bacteria responsible for infections were: Klebsiella spp. (27%), Moraxella spp. (22%), Escherichia spp. (16%). High resistance levels were found against the tested antibiotics and about 41.60% of the bacterial strains isolated were multidrug resistant. Hospitalization was associated with multidrug resistance in univariate (COR 1.96; 95% CI 1.43-2.71; P-value < 0.001) and multivariable analyses (AOR 1.78; 95% CI 1.28-2.49; P-value < 0.001). There is the need for further research on the molecular epidemiology of antibiotic resistance genes in the study area to effectively control the spread of multidrug resistant pathogens. In addition, efforts to build the capacity of health professionals on infection prevention and control as well as diagnostic and antimicrobial stewardship needs urgent attention.
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Gwebu PC, Meyer JC, Schellack N, Matsebula-Myeni ZC, Godman B. A web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital in the Kingdom of Eswatini and the implications. Hosp Pract (1995) 2022; 50:214-221. [PMID: 35450508 DOI: 10.1080/21548331.2022.2069247] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/19/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Currently there is limited knowledge regarding antimicrobial utilization patterns among public hospitals in Eswatini. This is a concern given rising resistance rates among African countries. This study aimed to address this by determining antimicrobial utilization patterns using a point prevalence survey (PPS) methodology at Raleigh Fitkin Memorial (RFM) Hospital. The findings would be used to identify potential interventions to improve future antimicrobial utilization. METHOD A PPS was conducted using a web-based application (App). Antimicrobials were categorized according to the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) classification. Each ward in the hospital was surveyed in one day using patient files. All patients in the ward, admitted by 08h30 on the day of the survey, were included. Ethical clearance was granted by the university and at country level. RESULTS Overall, 68 patient files in 12 wards were surveyed, with 88.2% (60/68) receiving at least one antimicrobial. The most widely prescribed antimicrobials were amoxicillin (24.3%), and ceftriaxone IV (21.6%), mostly from the Access group (69.9%), and zero from the Reserve group. In the past 90 days prior to admission, most patients (60.3%; 41/68) were not receiving any antimicrobials. Of concern was that antimicrobial use was empirical for all patients (100%) with mostly parenteral administration (88.3%; 91/103). In addition, the majority of surgical prophylaxis patients (80%; 12/15) were given an extended course post surgery. There was also no documented switch or stop dates, or patient culture and drug sensitivity results. CONCLUSION Antimicrobial utilization is high at RFM hospital. Identified targets for quality improvement programs include encouraging earlier switching to oral antimicrobials, reducing extended use for surgical prophylaxis and encouraging greater sensitivity testing and documentation stop dates. The development of the App appreciably reduced data collection times and analysis, and would be recommended for use in other public hospitals.
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Affiliation(s)
- Prudence C Gwebu
- Department of Pharmacy, Raleigh Fitkin Memorial Hospital, Manzini, Eswatini
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Johanna C Meyer
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- South African Vaccination and Immunisation Centre, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Gauteng, South Africa
| | - Zinhle C Matsebula-Myeni
- Department of Pharmacy, Raleigh Fitkin Memorial Hospital, Manzini, Eswatini
- Cerium Scientific, Matsapha, Eswatini
| | - Brian Godman
- Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
- Department of Pharmacoepidemiology, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
- Centre of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
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