1
|
Valia D, Ingelbeen B, Nassa GJW, Kaboré B, Kiemdé F, Rouamba T, Compaoré A, Kouanda JS, Robert A, Rodriguez-Villalobos H, Van Der Sande MAB, Tinto H. Antibiotic use by clinical presentation across all healthcare providers in rural Burkina Faso: a healthcare visit exit survey. J Antimicrob Chemother 2024; 79:2534-2542. [PMID: 39051704 PMCID: PMC11441991 DOI: 10.1093/jac/dkae252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 07/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND To guide antibiotic stewardship interventions, understanding for what indications antibiotics are used is essential. METHODS In rural Burkina Faso, we measured antibiotic dispensing across all healthcare providers. From October 2021 to February 2022, we surveyed patients in Nanoro district, Burkina Faso, following visits to health centres (3), pharmacies (2), informal medicine vendors (5) and inpatients in health centres. We estimated prevalence of antibiotic use and the proportion of Watch group antibiotics by provider type and by clinical presentation, assessing compliance with WHO's AWaRe Antibiotic Book. We estimated per capita antibiotic use by multiplying prevalence of antibiotic use, mean DDD per adult treatment course, and the rate of healthcare visits per 1000 inhabitants per day, estimated from a prior household survey. RESULTS Outpatient antibiotic use was more frequent after health centre visits (54.8%, of which 16.5% Watch, n = 1249) than after visits to pharmacies (26.2%, 16.3% Watch, n = 328) and informal medicine vendors (26.9%, 50.0% Watch, n = 349). The frequency of antibiotic use was highest for bronchitis (79.9% antibiotic use, of which 12.6% Watch), malaria (31.9%, 23.1% Watch), gastroenteritis (76.0%, 31.7% Watch), rhinopharyngitis (40.4%, 8.3% Watch) and undifferentiated fever (77.0%, 44.8% Watch). Compliance with WHO AWaRe guidance could have averted at least 68.4% of all Watch antibiotic use in outpatients at health centres. Community-wide, 2.9 DDD (95% CI 1.9-3.9) were used per 1000 adult inhabitants per day. CONCLUSIONS Most Watch antibiotic use at community level or primary care deviated from WHO guidance. Antibiotic stewardship should focus on key clinical presentations and include primary care and self-medication.
Collapse
Affiliation(s)
- Daniel Valia
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
- Department of Public Health, Institute of Tropical Medicine (ITM), Antwerp, Belgium
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Brecht Ingelbeen
- Department of Public Health, Institute of Tropical Medicine (ITM), Antwerp, Belgium
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Guétawendé Job Wilfried Nassa
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Bérenger Kaboré
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - François Kiemdé
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Adélaïde Compaoré
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Juste Stéphane Kouanda
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
| | - Annie Robert
- Epidemiology and Biostatistics Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Hector Rodriguez-Villalobos
- Microbiology unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Marianne A B Van Der Sande
- Department of Public Health, Institute of Tropical Medicine (ITM), Antwerp, Belgium
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé, Direction Régionale du Centre-Ouest/Clinical Research Unit of Nanoro, Nanoro, Burkina Faso
- Department of Public Health, Institute of Tropical Medicine (ITM), Antwerp, Belgium
| |
Collapse
|
2
|
Edessa D, Kumsa FA, Dinsa G, Oljira L. Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study. BMJ Open 2024; 14:e085352. [PMID: 39209504 PMCID: PMC11404147 DOI: 10.1136/bmjopen-2024-085352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Dumessa Edessa
- School of Pharmacy, Haramaya University, Harar, Ethiopia
- School of Public Health, Haramaya University, Harar, Ethiopia
| | - Fekede Asefa Kumsa
- School of Public Health, Haramaya University, Harar, Ethiopia
- Department of Pediatrics, College of Medicine, University of Tennessee Health Science Center-Oak Ridge National Laboratory (UTHSC-ORNL) Center for Biomedical Informatics, Memphis, Tennessee, USA
| | - Girmaye Dinsa
- School of Public Health, Haramaya University, Harar, Ethiopia
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Lemessa Oljira
- School of Public Health, Haramaya University, Harar, Ethiopia
| |
Collapse
|
3
|
Edessa D, Asefa Kumsa F, Dinsa G, Oljira L. Inappropriate antibiotic access practices at the community level in Eastern Ethiopia. Sci Rep 2024; 14:17751. [PMID: 39085272 PMCID: PMC11291666 DOI: 10.1038/s41598-024-67688-1] [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: 04/22/2024] [Accepted: 07/15/2024] [Indexed: 08/02/2024] Open
Abstract
Access to antibiotic medications is critical to achieving the Sustainable Development Goal for good health and well-being. However, non-prescribed and informal sources are implicated as the most common causes of inappropriate antibiotic access practices, resulting in untargeted therapy, which leads to antibiotic resistance. Hence, knowing antibiotic access practices at the community level is essential to target misuse sources. In this study, 2256 household representatives were surveyed between July and September 2023 to examine their antibiotic access practices. Of 1245 household members who received antibiotics, 45.6% did so inappropriately. Non-prescribed antibiotic access was more common among urban residents and individuals not enrolled in health insurance schemes. This means of antibiotic access was also more common among individuals concerned about distance, drug availability, and healthcare convenience at public facilities. In addition, women and rural individuals were more likely to get antibiotics from unauthorized sources. Unrestricted antibiotic dispensing practices in urban areas enabled their non-prescribed access, while unlicensed providers prevailed with this access practice in rural areas. In this regard, personal behaviors and healthcare-related gaps such as the lack of health insurance, inconvenience, and drug unavailability have led community members to seek antibiotics from unofficial and non-prescribed sources. Targeting the identified behavioral and institutional factors can enhance antibiotic access through prescriptions, hence reducing antibiotic resistance.
Collapse
Affiliation(s)
- Dumessa Edessa
- School of Pharmacy, College of Health and Medical Sciences, Haramaya University, P. O. Box 235, Harar, Ethiopia.
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
| | - Fekede Asefa Kumsa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Department of Pediatrics, Center for Biomedical Informatics, College of Medicine, University of Tennessee Health Science Center-Oak Ridge National Laboratory (UTHSC-ORNL), Memphis, TN, USA
| | - Girmaye Dinsa
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Fenot Project, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Addis Ababa, Ethiopia
| | - Lemessa Oljira
- School of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| |
Collapse
|
4
|
Prakashan D, Kolhe P, Gandhi S. Design and fabrication of a competitive lateral flow assay using gold nanoparticle as capture probe for the rapid and on-site detection of penicillin antibiotic in food samples. Food Chem 2024; 439:138120. [PMID: 38064831 DOI: 10.1016/j.foodchem.2023.138120] [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: 08/28/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024]
Abstract
Lateral flow assays (LFAs) are among the utmost cost-efficient, paper-based point-of-care (POC) diagnostic devices. Herein, we have reported the fabrication of a competitive LFA for on-site detection of penicillin. Various parameters such as Ab concentration for conjugation, Pen-BSA conjugate concentration, pore size of membrane, and blocking buffer were standardised for the fabrication of LFA. Different concentrations of penicillin (1 pM-1 mM) were added to the sample pad to observe the color intensity. The visual detection limit (LOD) achieved from the LFA was 10 nM for Penicillin that correlated with the LOD calculated from the 'ColorGrab' colorimeter application. Additionally, LFA showed insignificant cross reactivity with other β-lactam antibiotics and were also validated with spiked food samples such as milk, meat and egg. Hence, the fabricated LFA can be successfully utilised for the POC detection of penicillin in food samples on large scale.
Collapse
Affiliation(s)
- Drishya Prakashan
- DBT-National Institute of Animal Biotechnology (NIAB), Hyderabad 500032, Telangana, India; DBT-Regional Centre for Biotechnology (RCB), Faridabad 121001, Haryana, India
| | - Pratik Kolhe
- DBT-National Institute of Animal Biotechnology (NIAB), Hyderabad 500032, Telangana, India
| | - Sonu Gandhi
- DBT-National Institute of Animal Biotechnology (NIAB), Hyderabad 500032, Telangana, India; DBT-Regional Centre for Biotechnology (RCB), Faridabad 121001, Haryana, India.
| |
Collapse
|
5
|
Gautham M, Bhattacharyya S, Maity S, Roy MB, Balasubramaniam P, Ebata A, Bloom G. "Just as curry is needed to eat rice, antibiotics are needed to cure fever"-a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India. BMJ Open 2024; 14:e076616. [PMID: 38326259 PMCID: PMC10860043 DOI: 10.1136/bmjopen-2023-076616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVES To understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West Bengal in India. DESIGN Qualitative study using focus group discussions and in-depth interviews. SETTING Two contrasting village clusters in South 24 Parganas district, West Bengal, India. Fieldwork was conducted between November 2019 and January 2020. PARTICIPANTS 98 adult community members (42 men and 56 women) were selected purposively for 8 focus group discussions. In-depth interviews were conducted with 16 community key informants (7 teachers, 4 elected village representatives, 2 doctors and 3 social workers) and 14 community health workers. RESULTS Significant themes at the individual level included sociodemographics (age, gender, education), cognitive factors (knowledge and perceptions of modern antibiotics within non-biomedical belief systems), affective influences (emotive interpretations of appropriate medicine consumption) and economic constraints (affordability of antibiotic courses and overall costs of care). Antibiotics were viewed as essential fever remedies, akin to antipyretics, with decisions to halt mid-course influenced by non-biomedical beliefs associating prolonged use with toxicity. Themes at the community and health system levels included the health stewardship roles of village leaders and knowledge brokering by informal providers, pharmacists and public sector accredited social health activists. However, these community resources lacked sufficient knowledge to address people's doubts and concerns. Qualified doctors were physically and socially inaccessible, creating a barrier to seeking their expertise. CONCLUSIONS The interplay of sociodemographic, cognitive and affective factors, and economic constraints at the individual level, underscores the complexity of antibiotic usage. Additionally, community leaders and health workers emerge as crucial players, yet their knowledge gaps and lack of empowerment pose challenges in addressing public concerns. This comprehensive analysis highlights the need for targeted interventions that address both individual beliefs and community health dynamics to promote judicious antibiotic use.
Collapse
Affiliation(s)
- Meenakshi Gautham
- Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Priya Balasubramaniam
- Public Health Foundation of India, Gurugram, Haryana, India
- Sustainaible Health Innovations, Singapore
| | - Ayako Ebata
- Institute of Development Studies, Brighton, UK
| | | |
Collapse
|
6
|
Ardillon A, Ramblière L, Kermorvant-Duchemin E, Sok T, Zo AZ, Diouf JB, Long P, Lach S, Sarr FD, Borand L, Cheysson F, Collard JM, Herindrainy P, de Lauzanne A, Vray M, Delarocque-Astagneau E, Guillemot D, Huynh BT. Inappropriate antibiotic prescribing and its determinants among outpatient children in 3 low- and middle-income countries: A multicentric community-based cohort study. PLoS Med 2023; 20:e1004211. [PMID: 37279198 DOI: 10.1371/journal.pmed.1004211] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/03/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Antibiotic resistance is a global public health issue, particularly in low- and middle-income countries (LMICs), where antibiotics required to treat resistant infections are not affordable. LMICs also bear a disproportionately high burden of bacterial diseases, particularly among children, and resistance jeopardizes progress made in these areas. Although outpatient antibiotic use is a major driver of antibiotic resistance, data on inappropriate antibiotic prescribing in LMICs are scarce at the community level, where the majority of prescribing occurs. Here, we aimed to characterize inappropriate antibiotic prescribing among young outpatient children and to identify its determinants in 3 LMICs. METHODS AND FINDINGS We used data from a prospective, community-based mother-and-child cohort (BIRDY, 2012 to 2018) conducted across urban and rural sites in Madagascar, Senegal, and Cambodia. Children were included at birth and followed-up for 3 to 24 months. Data from all outpatient consultations and antibiotics prescriptions were recorded. We defined inappropriate prescriptions as antibiotics prescribed for a health event determined not to require antibiotic therapy (antibiotic duration, dosage, and formulation were not considered). Antibiotic appropriateness was determined a posteriori using a classification algorithm developed according to international clinical guidelines. We used mixed logistic analyses to investigate risk factors for antibiotic prescription during consultations in which children were determined not to require antibiotics. Among the 2,719 children included in this analysis, there were 11,762 outpatient consultations over the follow-up period, of which 3,448 resulted in antibiotic prescription. Overall, 76.5% of consultations resulting in antibiotic prescription were determined not to require antibiotics, ranging from 71.5% in Madagascar to 83.3% in Cambodia. Among the 10,416 consultations (88.6%) determined not to require antibiotic therapy, 25.3% (n = 2,639) nonetheless resulted in antibiotic prescription. This proportion was much lower in Madagascar (15.6%) than in Cambodia (57.0%) or Senegal (57.2%) (p < 0.001). Among the consultations determined not to require antibiotics, in both Cambodia and Madagascar the diagnoses accounting for the greatest absolute share of inappropriate prescribing were rhinopharyngitis (59.0% of associated consultations in Cambodia, 7.9% in Madagascar) and gastroenteritis without evidence of blood in the stool (61.6% and 24.6%, respectively). In Senegal, uncomplicated bronchiolitis accounted for the greatest number of inappropriate prescriptions (84.4% of associated consultations). Across all inappropriate prescriptions, the most frequently prescribed antibiotic was amoxicillin in Cambodia and Madagascar (42.1% and 29.2%, respectively) and cefixime in Senegal (31.2%). Covariates associated with an increased risk of inappropriate prescription include patient age greater than 3 months (adjusted odds ratios (aOR) with 95% confidence interval (95% CI) ranged across countries from 1.91 [1.63, 2.25] to 5.25 [3.85, 7.15], p < 0.001) and living in rural as opposed to urban settings (aOR ranged across countries from 1.83 [1.57, 2.14] to 4.40 [2.34, 8.28], p < 0.001). Diagnosis with a higher severity score was also associated with an increased risk of inappropriate prescription (aOR = 2.00 [1.75, 2.30] for moderately severe, 3.10 [2.47, 3.91] for most severe, p < 0.001), as was consultation during the rainy season (aOR = 1.32 [1.19, 1.47], p < 0.001). The main limitation of our study is the lack of bacteriological documentation, which may have resulted in some diagnosis misclassification and possible overestimation of inappropriate antibiotic prescription. CONCLUSION In this study, we observed extensive inappropriate antibiotic prescribing among pediatric outpatients in Madagascar, Senegal, and Cambodia. Despite great intercountry heterogeneity in prescribing practices, we identified common risk factors for inappropriate prescription. This underscores the importance of implementing local programs to optimize antibiotic prescribing at the community level in LMICs.
Collapse
Affiliation(s)
- Antoine Ardillon
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
- Institut Pasteur, Université Paris Cité, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France
| | - Lison Ramblière
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
- Institut Pasteur, Université Paris Cité, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France
| | - Elsa Kermorvant-Duchemin
- AP-HP, Hôpital Necker-Enfants malades, Department of Neonatal medicine, Université Paris Cité, Paris, France
| | - Touch Sok
- Ministry of Health, Phnom Penh, Cambodia
| | | | | | - Pring Long
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Siyin Lach
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Fatoumata Diene Sarr
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Laurence Borand
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | | | - Jean-Marc Collard
- Experimental Bacteriology Unit, Institut Pasteur de Madagascar, Antananarivo, Madagascar
| | | | - Agathe de Lauzanne
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Muriel Vray
- Epidemiology of Infectious Diseases Unit, Institut Pasteur de Dakar, Dakar, Sénégal
| | - Elisabeth Delarocque-Astagneau
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
- AP-HP. Paris Saclay, Public Health, Medical Information, Clinical research, Le Kremlin-Bicêtre, France
| | - Didier Guillemot
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
- Institut Pasteur, Université Paris Cité, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France
- AP-HP. Paris Saclay, Public Health, Medical Information, Clinical research, Le Kremlin-Bicêtre, France
| | - Bich-Tram Huynh
- Université Paris-Saclay, UVSQ, Inserm, CESP, Anti-infective evasion and pharmacoepidemiology team, Montigny-Le-Bretonneux, France
- Institut Pasteur, Université Paris Cité, Epidemiology and Modelling of Antibiotic Evasion (EMAE), Paris, France
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|