Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): results from a worldwide point prevalence survey in 69 countries

Prevalence, antibiotic resistance, resistance and virulence determinants of Campylobacter jejuni in China: A systematic review and meta-analysis

Campylobacter jejuni (C. jejuni) is recognized as a serious food contaminant that extensively results in foodborne diseases. Numerous studies have been conducted on the prevalence and antibiotic resistance of C. jejuni, but there is a lack of comprehensive analysis of published data. This study provides a comprehensive overview of the epidemiology, antibiotic resistance, and virulence determinants of C. jejuni in China through a systematic review and meta-analysis. The prevalence levels of C. jejuni from low to high were the humans (5.2 %, 95 % CI: 4.2-6.4 %), foods (12.5 %, 95 % CI: 9.7-15.6 %), animals (15.4 %, 95 % CI: 13.2-17.6 %), and environment (17.8 %, 95 % CI: 9.7-27.7 %), respectively. Furthermore, C. jejuni exhibits high resistance rates to antibiotics such as cefoperazone, nalidixic acid, ciprofloxacin, cefradine, and tetracycline. The overall multi-drug resistance rate (MDR) of C. jejuni was 72.8 % (95 % CI: 62.4-82.2 %), indicating a serious problem with MDR. The resistance of C. jejuni to most antibiotics has increased in the last 20 years. Among the main resistance determinants of C. jejuni, gyrA_T86I and tet(O) had a higher pooled prevalence of 94.8 % (95 % CI: 88.7-99.0 %) and 79.0 % (95 % CI: 66.9-89.2 %), respectively. Furthermore, the high prevalence of virulence-related genes was shown in C. jejuni, such as adhesion (cadF, racR), invasion (ciaB, iamA, ceuE), and toxin (cdtB, cdtC). In summary, C. jejuni has a high prevalence with regional characteristics, and antibiotic resistance of this bacterium especially animal sources remains a serious problem in China. Comprehensive monitoring and control measures for this pathogen are urgently needed to ensure food safety and public health.

Implementation of hospital antimicrobial stewardship programmes in low- and middle-income countries: a qualitative study from a multi-professional perspective in the Global-PPS network

BACKGROUND

Hospitals in low- and middle-income countries (LMIC) face context-specific challenges in implementing antimicrobial stewardship (AMS) programmes. The Global Point Prevalence Survey (Global-PPS) project has established a network of hospitals across 90 countries, using point prevalence surveys to monitor antimicrobial use and guide AMS activities. However, little is known about AMS implementation in these hospitals. Using qualitative research, we aim to explore the implementation process in LMIC hospitals within the Global-PPS network and the factors influencing it, identify potential implementation strategies, and evaluate the role of Global-PPS in this process.

METHODS

A qualitative study was conducted using semi-structured online interviews with healthcare workers (HCWs) involved in AMS in LMIC hospitals within the Global-PPS network. Participants were selected using a combination of convenience and purposive sampling and included clinicians, microbiologists, pharmacists, and nurses. Interviews followed a topic guide based on the integrated checklist of determinants of practice (TICD Checklist). Transcripts were analysed using a combination of inductive and deductive thematic analyses.

FINDINGS

Twenty-two HCWs from 16 countries were interviewed. Hospitals were in different stages of the AMS implementation process at the time of the study, from pre-implementation to institutionalisation of AMS as part of the continuous quality improvement process. While the Global-PPS provided a valuable tool for education and implementation, contextual barriers often hindered the translation of findings into targeted interventions. Four themes influenced AMS implementation, "institutional support and resource allocation", "AMS team functioning, roles, and expertise", "adoption and integration of AMS recommendations", and "data-driven decision-making" as a cross-cutting theme. Key determinants included AMS team competencies, multidisciplinary teams, sustainable funding and leadership support, diagnostic capacity, and reliable data to inform interventions. We also identified various strategies employed by local AMS teams to enhance implementation.

CONCLUSIONS

This study examines AMS implementation in LMIC hospitals in the Global-PPS network and identifies key determinants. AMS teams address challenges through task shifting, local engagement and ownership. While empirical evidence on the effectiveness of these strategies is limited, these insights can guide future AMS interventions and studies within LMIC hospitals. Strengthening AMS requires bridging the gap between measurement and action and expanding research on behaviour change.

Increasing the use of the WHO AWaRe system in antibiotic surveillance and stewardship programmes in low- and middle-income countries

Introduction

Antimicrobial resistance (AMR) presents a major global health threat, driven in part by the inappropriate use of antibiotics including in low- and middle-income countries (LMICs). Improving the quality of antibiotic use is a key rationale for the development of the WHO's AWaRe (Access, Watch and Reserve) system. There is a need to review the uptake of the AWaRe system since its launch to guide future practice.

Methods

A literature search was conducted between 2017, the launch of AWaRe, and 2024. Inclusion criteria were studies that reported on antibiotic use in LMICs using the AWaRe system.

Results

Eighty-five studies were included in the review, of which 56.4% focused on antibiotic use trends, with 28.2% reporting on prescribing patterns; 51.7% of the studies included inpatients. Only 14.1% of studies reported meeting the 2024 United Nations General Assembly (UNGA) AMR recommended target of at least 70% of human antibiotic use being Access antibiotics, with a concerning trend of overuse of Watch antibiotics (68.2% of studies). Dispensing practices revealed significant dispensing of antibiotics without prescriptions especially in Pakistan and Bangladesh. Watch antibiotics were more available but also more expensive than Access antibiotics.

Conclusions

Encouragingly, many LMICs are now reporting antibiotic use via the AWaRe system, including in antimicrobial stewardship programmes (ASPs). Wide variation exists in the proportion of AWaRe antibiotics used across LMICs, with overuse of Watch antibiotics. There is an urgent need for targeted AWaRe-based ASPs in LMICs to meet recent UNGA recommendations. Improving the use, availability and affordability of Access antibiotics is essential to combat AMR.

Antibiotic Use Patterns at Jimma Medical Center in Southwest Ethiopia: A Call for Local Antibiogram-Guided Prescription

Background: The discovery of antibiotics revolutionized healthcare by significantly reducing morbidity and mortality. However, excessive and inappropriate use has led to a global surge in antimicrobial resistance, particularly in low- and middle-income countries. This study aimed to evaluate antibiotic use patterns among inpatients at Jimma Medical Center (JMC) in Southwest Ethiopia. Methods: A longitudinal observational study was conducted in February and March 2019 at JMC, focusing on patients admitted for over 24 h who received antibiotics. Data on patient demographics, clinical indications, and antibiotics prescribed were systematically collected. Antibiotic consumption rates were measured as days of therapy (DOTs) per 100 patient-days, and utilization was classified according to the World Health Organization (WHO) AWaRe (Access, Watch, and Reserve) framework. Results: A total of 384 inpatients were included, with a male predominance (53.9%) and a median age of 24 years (IQR: 5-37). In total, 634 antibiotic regimens were prescribed. According to the WHO AWaRe classification, 48.3% (306/634) were "Access" and 51.7% (328/634) were "Watch" antibiotics. Patients were treated with antibiotics for a median duration of 4 days (IQR: 2-7), leading to a total of 2880 days of antibiotic therapy. Ceftriaxone was the most commonly prescribed antibiotic, with a usage rate of 44.65 DOTs per 100 patient-days. Substantial variability was observed in empirical antibiotic regimens among treating physicians and across wards. Culture and antibiotic susceptibility testing (AST) were performed for only 4.2% of patients, and none of the treatments were modified based on susceptibility data. Conclusions: The study highlights critical issues in antibiotic prescribing at JMC, including over-reliance on "Watch" antibiotics, predominantly ceftriaxone, limited use of AST results, and deviations from standard treatment guidelines. Addressing these challenges requires implementing antimicrobial stewardship programs, developing evidence-based local treatment guidelines, and strengthening and encouraging the use of microbiology services to improve rational antibiotic use.

Antimicrobial Stewardship Impact on Antibiotic Use in Three Tertiary Hospitals in Zambia: A Comparative Point Prevalence Survey

Introduction: Antimicrobial stewardship (AMS) can improve the rational use of antibiotics in hospitals. This study assessed the impact of a multifaceted AMS intervention on antibiotic use and prescribing patterns at three tertiary hospitals in Zambia. Methods: Point Prevalence Surveys (PPS) were conducted in three tertiary hospitals in August 2022 and in October 2023. It was part of a 3-year AMS demonstration project that aimed to optimize the use of antibiotics in treating urinary tract infections (UTIs) and bloodstream infections (BSIs) in various health sector settings in Zambia. Up to 170 medical records in 2022 and 265 in 2023 were included in the assessment. Results: Overall, the prevalence of antibiotic use in this PPS was 75%. Eighty-one percent (81%) and 71% of patients assessed were on at least one antibiotic in 2022 and 2023, respectively, indicating a decrease of 10%. Similarly, prescribing ceftriaxone, the most prescribed antibiotic, declined from an average of 48% in 2022 to 38% in 2023. Adherence to Standard Treatment Guidelines (STGs) slightly increased from 42% in 2022 to 45% in 2023. Additionally, antibiotic prescribing was reduced from 1.38 to 1.21. Conclusions: Antimicrobial stewardship had an early positive impact on antibiotic use and adherence to Standard Treatment Guidelines.

Point Prevalence Survey of Antibiotic Use in Level 1 hospitals in Zambia: Future Prospects for Antimicrobial Stewardship Programs

Introduction

The inappropriate prescribing and use of antibiotics have contributed to the emergence and spread of antimicrobial resistance (AMR). In Zambia, there is a paucity of information on the prescribing patterns and use of antibiotics among hospitalized patients in level 1 hospitals. This study investigated antibiotic use in five level 1 hospitals in Lusaka, Zambia.

Methods

This cross-sectional study utilized the World Health Organization (WHO) Point Prevalence Survey (PPS) methodology among in-patients admitted in level 1 hospitals before 08:00 a.m. on the survey day in August 2024. Data were analysed using IBM SPSS version 23.0.

Results

The prevalence of antibiotic use among inpatients was 59.0%, with ceftriaxone being the most prescribed. Antibiotics were prescribed mainly for paediatrics and male inpatients. This study found that 53.0% of prescribed antibiotics were from the Access group while 38.2% were from the Watch group of the World Health Organization Access, Watch, and Reserve (AWaRe) classification. Adherence to national treatment guidelines was 36.0%, with most antibiotics prescribed empirically without evidence of culture and sensitivity tests.

Conclusion

This study found a high use of antibiotics and low adherence to treatment guidelines in level 1 hospitals in Lusaka, Zambia. The findings of this study demonstrate the need to establish and strengthen antimicrobial stewardship programs and strengthen laboratory capacity to aid clinicians in diagnosing, treating, and managing patients across level 1 hospitals in Zambia.

Decade-Long Trends in Antibiotic Prescriptions According to WHO AWaRe Classification Among Severe Acute Respiratory Infection Patients at Tertiary Hospitals in Bangladesh (2011-2020)

Background: To aid in the development of antimicrobial stewardship programs (ASPs), we analyzed the patterns and trends in antibiotic prescriptions for patients with severe acute respiratory infection (SARI), utilizing the WHO's AWaRe classification. Methods: We analyzed data from hospital-based influenza surveillance from January 2011 to December 2020 across nine Bangladeshi tertiary-level hospitals. Surveillance physicians collected WHO-defined SARI patient data, including demographics, clinical characteristics, and antibiotic prescriptions. Descriptive statistics and parametric and non-parametric tests were used for the analysis. Results: Of 21,566 SARI patients [median age 20 years (IQR: 1.33-45), 66% male], 91% were prescribed at least one antibiotic. A total of 25,133 antibiotics were prescribed, of which 47.0% were third-generation cephalosporins, 16.5% were macrolides, and 11.1% were beta-lactam/beta-lactamase inhibitors. According to the AWaRe classification, 28.7% were in the Access group, while 71.3% were in the Watch group, and none were from the Reserve group. A downward trend in Access group (30.4% to 25.1%; p = 0.010) and an upward trend in Watch group antibiotic prescription (69.6% to 74.9%; p = 0.010) were observed. We identified that patients aged < 5 years (aOR: 1.80; 95% CI: 1.44-2.25), who were treated in government hospitals (aOR: 1.45; 95% CI: 1.35-1.57), patients with the presence of lung diseases (aOR: 1.56; 95% CI: 1.35-1.80) had an increased likelihood of being prescribed Watch group antibiotics. Conclusions: This study reveals a concerning pattern of antibiotic overuse among SARI patients in Bangladesh, with a growing trend over the past decade towards increased Watch group antibiotic prescriptions. Only one-third of the prescribed antibiotics were from the Access group, falling short of the two-thirds threshold recommended by the WHO. Effective ASPs are crucial to optimize antibiotic prescriptions and mitigate the risk of antimicrobial resistance.

Identifying targets for antibiotic stewardship interventions in pediatric patients in Punjab, Pakistan: point prevalence surveys using AWaRe guidance

Introduction

Surveillance of antibiotic use is crucial for identifying targets for antibiotic stewardship programs (ASPs), particularly in pediatric populations within countries like Pakistan, where antimicrobial resistance (AMR) is escalating. This point prevalence survey (PPS) seeks to assess the patterns of antibiotic use in pediatric patients across Punjab, Pakistan, employing the WHO AWaRe classification to pinpoint targets for intervention and encourage rational antibiotic usage.

Methods

A PPS was conducted across 23 pediatric wards of 14 hospitals in the Punjab Province of Pakistan using the standardized Global-PPS methodology developed by the University of Antwerp. The study included all pediatric inpatients receiving antibiotics at the time of the survey, categorizing antibiotic prescriptions according to the WHO Anatomical Therapeutic Chemical classification and the AWaRe classification system.

Results

Out of 498 pediatric patients, 409 were receiving antibiotics, representing an antibiotic use prevalence of 82.1%. A substantial majority (72.1%) of the prescribed antibiotics fell under the WHO's Watch category, with 25.7% in the Access category and 2.2% in the Reserve group. The predominant diagnoses were respiratory infections, notably pneumonia (32.4%). The most commonly used antibiotics were ceftriaxone (37.2%) and Vancomycin (13.5%). Only 2% of antibiotic uses were supported by culture sensitivity reports, highlighting a reliance on empirical therapy.

Conclusion

The high prevalence of antibiotic use, particularly from the Watch category, and low adherence to culture-based prescriptions underscore the critical need for robust antibiotic stewardship programs in Pakistan. Strengthening these programs could help mitigate AMR and optimize antibiotic use, aligning with global health objectives.

Point prevalence survey of antibiotic use in Mexican secondary care hospitals

INTRODUCTION

Tackling the inertia of growing threat of antimicrobial resistance (AMR) requires changes in how antibiotics are prescribed and utilized. The monitoring of antimicrobial prescribing in hospitals is a critical component in optimizing antibiotic use. Point prevalence surveys (PPSs) enable the surveillance of antibiotic prescribing at the patient level in small hospitals that lack the resources to establish antimicrobial stewardship programs (ASP). In this study, we analyzed antibiotic use at two public secondary care hospitals in Mexico using PPSs.

METHODS

Following WHO methodology, we conducted four cross-sectional PPSs on antibiotic use in two public secondary care facilities in Mexico: two surveys in a women's specialty hospital (H1) and two in a general referral hospital (H2). We collected data from clinical records of all patients with active antibiotic prescriptions (APs) across the medical, surgical, and mixed (MIX) wards, and intensive care units (ICUs). Descriptive statistics were computed to analyze the PPSs data using Stata.

RESULTS

The PPSs collected data on 127 patients, and 283 active APs. The prevalence of antibiotic use was 60.4% (H1, n = 29/48) and 70.5% (H2, n = 98/139). Antibiotics were more frequently used among patients in the MIX wards (H1: 87.5%, n = 14/16) and ICUs (H2: 90%, n = 9/10). The most frequent patient indications for antibiotic use were medical prophylaxis (H1: 51.7%, n = 15/29), community-acquired infections (H2: 42.9%, n = 42/98), and preoperative prophylaxis (H1: 27.6%, n = 8/29; H2: 23.5%, n = 23/98). The APs were mostly empirical (H1: 97%, n = 64/66; H2: 98.2%, n = 213/217), and parenterally administered (H1: 90.9%, n = 60/66; H2: 96.8%, n = 210/217). Most clinical records lacked documented post-prescription reviews (H1: 82.8%, n = 24/29; H2: 98%, n = 96/98). Preoperative prophylaxis was predominantly administered as multiple doses for more than one day. Penicillins with extended-spectrum (24.2%, n = 16/66), aminoglycosides (22.7%, n = 15/66), and first-generation cephalosporins (16.7%, n = 11/66) were the most prescribed antibiotic classes in H1, while third-generation cephalosporins (35%, n = 76/217), fluoroquinolones (14.3%, n = 31/217), and carbapenems (13.4%, n = 29/217) were the most prescribed in H2. No hospital had formally established ASP.

CONCLUSIONS

This study shows high prevalence rates of antibiotic use and variations in commonly prescribed antibiotic classes in public Mexican secondary care hospitals, along with shared practices in broad-spectrum antibiotic prescription. PPS-based surveillance enables the identification of specific targets to optimize antibiotic use according to the healthcare needs of patients in each hospital and facilitates comparative evaluations across hospitals.

Assessing the impact of antimicrobial resistance policies on antibiotic use and antimicrobial resistance-associated mortality in children and adults in low and middle-income countries: a global analysis

Introduction

Antimicrobial resistance (AMR) poses a major threat to global health security today. In recent years, many low and middle-income countries (LMICs) have implemented policies to optimise antibiotic use in both formal and informal healthcare settings. However, there is limited evidence on the effectiveness of these national efforts in LMICs.

Methods

We investigated the empirical relationship between national policies aimed at restricting antibiotic use and actual antibiotic consumption in 138 LMICs. Data on national policies were obtained from the Tripartite AMR Country Self-Assessment Survey (TrACSS) as well as from the Global Survey of Experts on AMR (GSEAR). Seven independent variables relating to AMR policies were evaluated. Outcomes included the proportion of children receiving antibiotics for lower respiratory tract infections and diarrhoea (specific to paediatric populations), along with total antibiotic consumption and AMR-associated mortality in general populations.

Results

Our analysis of 138 LMICs found wide variation in antibiotic use between countries and regions. We observed strong evidence of negative association (mean difference MD=-0.150, 95% CI (-0.2593 to -0.0407)) between the presence of regulatory or legislative policies that ban over-the-counter sales of antibiotics and the proportion of children receiving antibiotic drugs for lower respiratory tract infection. Furthermore, stronger AMR governance was associated with reduced total antibiotic consumption at the country level (MD=-1.259, 95% CI (-2.297 to -0.2216)). No associations were found between other policy variables and antibiotic use or mortality.

Conclusion

The results presented here suggest that there is some evidence of an empirical relationship between national policies aimed at limiting over-the-counter antibiotic sales and actual antibiotic usage practices. Further policy effectiveness research will be needed to better understand the true impact of government measures. In general, a multifaceted approach will likely be needed to fight AMR and preserve antibiotics' effectiveness, including evidence-based policies, targeted education and research.

Investigating the WHO's AWaRe classification for assessing antimicrobial stewardship programs: A single-center study

BACKGROUND

AWaRe (Access, Watch, Reserve) classification proposed by the World Health Organization (WHO) holds potential for assessing antimicrobial stewardship programs (ASPs). However, increase in antibiotics for non-infectious treatment might undermine the effectiveness of using the AWaRe classification for assessing ASPs. The study aimed to evaluate the antimicrobial usage by AWaRe classification and specify issues for assessing ASPs.

METHODS

The retrospective study was conducted in a single center within an 845-bed hospital. Antimicrobial usage data for outpatients were obtained from medical records used for billing purposes. Antimicrobials for non-infectious treatment were defined by smaller dose of macrolides, tetracyclines with pemphigoid, rifaximin, and prophylactic sulfamethoxazole-trimethoprim (ST) agent.

RESULTS

The usage of antimicrobials for non-infectious treatment increased from 25.3 % to 50.1 % for the ratio of the amount to defined daily doses (DDDs) and from 46.3 % to 65.9 % for prescription days between January 2015 and March 2024. The usage of prophylactic sulfamethoxazole-trimethoprim (ST) agents increased by 2.4 times, and the usage of rifaximin increased by more than 100 times. Macrolides for non-infectious treatment was stable or fluctuated while that for infection treatment decreased to that amount for non-infectious treatment. The ratios for Access increased from 31.9 % to 58 % and 42 % to 78 % by excluding the antimicrobials for non-infectious treatment.

CONCLUSIONS

The findings suggested that the AWaRe classification might not be appropriate for assessing ASPs and comparing them among hospitals.

Impact of a hub-and-spoke approach to hospital antimicrobial stewardship programmes on antibiotic use in Zambia

Background

Antimicrobial stewardship programmes (ASPs) aim to optimize antibiotic use and prevent antimicrobial resistance.

Objective

This study assessed the impact of ASPs, initiated using a hub-and-spoke approach, on antibiotic use in Zambian public hospitals.

Methods

A pre-post study was conducted in 10 ASP-naive hospitals across Zambia using the Centers for Disease Control and Prevention (CDC)'s hospital-based ASP core elements (i.e. leadership, accountability, pharmacy expertise, stewardship actions, tracking progress, reporting and education) checklist and the global point prevalence survey methodology. The intervention involved technical staff from a national 'hub' hospital with an established ASP providing on-site orientation and mentorship to multidisciplinary teams of healthcare workers at 10 'spoke' hospitals to build capacity in antimicrobial stewardship. ASP core elements and inpatient antibiotic use prevalence (AUP) were assessed before and 12 months after ASP implementation. Data were statistically analysed.

Results

The adoption of ASP core elements improved significantly (P = 0.001, 95% CI: -17.8 to -5.42). AUP decreased from 50.1% (±5.8, n = 1477) to 44.3% (±4.6, n = 1400) after 12 months, though the reduction was not statistically significant (P = 0.442; 95% CI: -9.8 to 21.6), with 'Watch' list antibiotics remaining the most commonly prescribed across the hospitals.

Conclusions

The hub-and-spoke approach successfully catalysed ASPs in public hospitals in Zambia, demonstrating the potential for improving antibiotic use practices over time, provided structural challenges are addressed. This approach and insights can guide stakeholders in Zambia and similar settings in enhancing hospital ASPs.

Roles of the gut microbiota in human neurodevelopment and adult brain disorders

Growing evidence demonstrates the connection between gut microbiota, neurodevelopment, and adult brain function. Microbial colonization occurs before the maturation of neural systems and its association with brain development. The early microbiome interactions with the gut-brain axis evolved to stimulate cognitive activities. Gut dysbiosis can lead to impaired brain development, growth, and function. Docosahexaenoic acid (DHA) is critically required for brain structure and function, modulates gut microbiota, and impacts brain activity. This review explores how gut microbiota influences early brain development and adult functions, encompassing the modulation of neurotransmitter activity, neuroinflammation, and blood-brain barrier integrity. In addition, it highlights processes of how the gut microbiome affects fetal neurodevelopment and discusses adult brain disorders.

A longitudinal point prevalence survey of antimicrobial use and resistance in tertiary care hospitals in Kerman: results from the national Iranian multicenter point prevalence survey of antimicrobials in 2021

BACKGROUND

The Global Point Prevalence Survey (PPS) of antimicrobial consumption and resistance has been widely undertaken to combat the global threat of antimicrobial resistance (AMR). This study was conducted in alignment with the Global-PPS in three tertiary care hospitals in Kerman, Iran, to evaluate antimicrobial consumption patterns.

METHODS

The study was conducted from January 2020 to January 2021 in Afzalipour, Shafa, and Shahid Bahonar Hospitals. Data were collected using the standardized Global-PPS method at three different points throughout the year to minimize bias. Information on antimicrobial prescriptions, primary diagnosis, prophylaxis, therapy indications, and treatment type were documented. Antimicrobial prevalence was calculated using the total number of admitted patients as the denominator and those on antimicrobial regimens as the numerator.

RESULTS

The point prevalence of antimicrobial consumption in adult wards was 65.6% in Afzalipour Hospital, 42.3% in Shafa Hospital, and 78.7% in Bahonar Hospital. Non-penicillin beta-lactams, macrolides, lincosamides, and streptogramins were the most frequently prescribed antibiotic classes. Approximately 80% of prescriptions had explicit reasons documented, and targeted antibiotic therapy rates varied between 7.7% and 44.8% across hospitals.

CONCLUSIONS

Antimicrobial consumption in Kerman's tertiary care hospitals exceeded national and global levels, indicating an urgent need for interventions to promote rational antibiotic use. Infection control committees must implement rigorous monitoring measures to reduce antimicrobial resistance. Ongoing surveillance and targeted interventions are essential to curb the rising rates of antimicrobial resistance in the region.

An in-depth analysis of antimicrobial prescription quality in 10 non-university hospitals, in southwest Germany, 2021

BackgroundNon-university hospitals are the major provider of inpatient care in Germany, serving 89% of acute care hospital beds. Although surveillance data on antimicrobial use in hospitals are widely available, data on prescription quality are rare.AimWe aimed to provide an in-depth analysis of antimicrobial prescribing patterns and quality in southwest German non-university hospitals.MethodsDuring 2021, we performed three point prevalence surveys (PPS) in 10 non-university hospitals, representing ca 10% of hospital beds in the federal state of Baden-Württemberg (11 million inhabitants). Demographic and clinical information were collected. We assessed the overall performance of 14 validated process quality indicators (QI) covering infection diagnostics, antimicrobial therapy and documentation.ResultsOf 8,560 patients analysed, 2,861 (33%) received at least one antimicrobial. Most (2,789, 80%) antimicrobial prescriptions were for therapeutic indications. Most frequently prescribed agents were beta-lactam/beta-lactamase inhibitors (1,120, 40%) in therapeutic and cefuroxime (269, 37%) in prophylactic indications. According to the World Health Organization's Access, Watch, Reserve classification, the Access-to-Watch ratio was 0.73. Overall adherence to QIs was low and varied substantially (27-93%), with documentation, possible streamlining and switching to oral therapy exhibiting the lowest fulfilment rates (< 50%).ConclusionThe results indicate a need to improve antimicrobial prescribing quality in non-university hospitals. The high prevalence of antimicrobial use in our setting underlines the demand for sustainable antimicrobial stewardship programmes in this sector. Our QI-based PPS approach can be used to identify key targets for future antimicrobial stewardship interventions. The results indicate a need for further legislation on antimicrobial stewardship.

Prescription Practices and Usage of Antimicrobials in a Tertiary Teaching Hospital in Rwanda: A Call for Antimicrobial Stewardship

Background: Antimicrobial resistance (AMR) is a global problem that results in high morbidity and mortality, particularly in low- and middle-income countries. Inappropriate use of antimicrobials is a major driver of AMR. This study aimed to evaluate the rate and quality of antimicrobial prescription and use at the University Teaching Hospital of Kigali (CHUK), a tertiary-referral teaching hospital. Methodology: A point prevalence survey (PPS) of antimicrobial prescription was conducted using the Global PPS tool, including a healthcare-acquired infection (HAI) module. Results: On the day of the PPS, 39.3% (145/369) of inpatients were prescribed at least one antimicrobial. Out of the 259 prescribed antimicrobials, 232 (89.6%) were antibacterials, of which 151 (65.1%) belonged to the watch group of the WHO AWaRe classification. The top three antibiotics prescribed were cefotaxime (87; 37.5%), parenteral metronidazole (31; 13.4%), and meropenem (23; 9.9%). Stop or review dates for the prescribed antimicrobials were documented in 27/259 prescriptions (10.4%). Surgical prophylaxis (SP) was prescribed for longer than one day in 83.3% of 61 patients. Samples for culture were sent for 27.1% (63/232) of all the patients prescribed antibiotics. Conclusion: This PPS demonstrates multiple indicators of the poor use of antimicrobials, including the high prevalence usage of watch antibiotics and prolonged surgical prophylaxis and other poor-quality indicators. Thus, there is an urgent need for intervention to improve antimicrobial stewardship.

Behavioral Nudges to Encourage Appropriate Antimicrobial Use Among Health Professionals in Uganda

Background/Objectives: Antimicrobial resistance (AMR) is a global public health concern exacerbated by inappropriate antimicrobial prescribing practices, particularly in low-resource settings such as Uganda. The research aimed to develop a culturally sensitive behavioral intervention, leveraging a "nudge" strategy, to improve healthcare provider adherence to the 2016 Uganda Clinical Guidelines (UCG 2016) in five Ugandan hospitals. This intervention formed part of broader antimicrobial stewardship initiatives led by the United States Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program. Methods: This study employed a mixed-methods approach, combining formative research and behavioral intervention. Guided by the Deloitte Behavioral Insights Framework, the research team conducted key informant interviews to identify prescribing barriers and motivators and developed three suitable behavioral interventions: perceived monitoring, ward leaderboards, and educational workshops. The study evaluated the interventions' impact through point prevalence surveys (PPS), using the World Health Organization PPS methodology at three stages: pre-intervention, immediate post-intervention, and one-month post-intervention. Results: Key behavioral themes across individual, social, environmental, and organizational elements informed the intervention design and implementation. The behavioral intervention package increased antimicrobial prescription compliance with the UCG 2016 from 27% at baseline to 50% immediately post-intervention, though these effects diminished at one-month post-intervention. Conclusions: Our study addresses an existing gap in behavioral nudges-based operational research on antimicrobial prescribing in low- and middle-income countries. These results showed an immediate improvement in adherence to the UCG 2016 among healthcare providers in Ugandan hospitals, though the effect was attenuated at one-month follow-up. Despite the attenuation, behavior change presents a feasible, cost-effective, and sustainable approach to improving antimicrobial prescribing practices and addressing AMR.

Audit of antibiotic utilization patterns and practice for common eye infections at the ambulatory clinic of a teaching hospital in Ghana: Findings and implications

BACKGROUND

Antimicrobial resistance (AMR) is a serious public health issue which is exacerbated by increased inappropriate use of antibiotics for common eye infections. This cross sectional survey was to assess the appropriate use of antibiotics for eye infections in an ambulatory clinic in Ghana and possible determinants.

METHOD

The medical records of all patients who sought eye care between January 2022 to December 2022 and were prescribed antibiotics were extracted from the hospital's electronic database. Descriptive, bivariate and multivariate analyses were then conducted.

RESULTS

A total of 1925 patient medical records were extracted, whose median age was 40 years (IQR 26-69), and were mostly females (58.91%, n = 1134/1925). The eye condition commonly treated with antibiotics was bacteria conjunctivitis (33.51%, n = 645/1925). The most prescribed antibiotic was gentamycin (22.96%, n = 442/1925) followed by ciprofloxacin (16.78%, n = 321/1925). These were mostly topical dosage forms (82.13%, n = 1581/1925). Systemic antibiotics prescribed were mostly from the WHO 'Access' class (83.33%, n = 280/338). The appropriate choice of antibiotic prescribed was 42.44% (n = 817/1925) and this was positivity associated with age (p<0.001), number of antibiotics prescribed (p <0.001), the prescription of topical dosage forms (p <0.001), and WHO 'Access' antibiotic class (p <0.034).

CONCLUSION

The level of appropriateness of antibiotic prescriptions for eye infections was sub-optimal. Antimicrobial stewardship programs, including prescriber education on guidelines and prescription audit to address associated factors, must now be instigated in this hospital to improve future antibiotic use and prevent the rise of AMR.

Assessment of antibiotic consumption patterns in hospital and primary healthcare using WHO Access, Watch and Reserve classification (AWaRe) in Sichuan Western China: 2020

BACKGROUND

The Access, Watch, and Reserve (AWaRe) classification of antibiotics was a useful tool to support antibiotic stewardship. However, the AWaRe patterns of antibiotic consumption in Western China were unclear. We aimed to assess the antibiotic consumption patterns using the AWaRe Classification of public hospitals in Sichuan Province Western China.

METHODS

Antibiotic consumption data of year 2020 were obtained from the Sichuan Province Drug Use Monitoring Platform. We measured the antibiotic consumption (DDDs per 1,000 inhabitants per day, DIDs), calculated the proportion of antibiotic use, the ratio of Access to Watch antibiotics and patterns of antibiotic use by using drug utilization 90%.

RESULTS

This analysis included 4452 public health institutions. The antibiotic consumption rate was 10.39 DIDs (Median 8.50, IQR 7.71-12.96). The proportions of Access antibiotic use and Watch antibiotic use were 46.83% (Median 47.49, IQR 44.16-52.02) and 51.20% (Median 51.43, IQR 45.42-54.61), respectively. The Access-to-Watch index was 0.91 (Median 0.92, IQR 0.81-1.15). Amoxicillin (16.85%), cefuroxime (9.21%), cefixime (8.60%%), levofloxacin (8.11%) and metronidazole (6.16%) were the most consumed antibiotics.

CONCLUSIONS

The proportion of Access antibiotic consumption in Sichuan Western China has not achieved the WHO target of 60%. Overuse of antibiotic is serious in Sichuan. National and regional antibiotics management systems, stewardship programs and surveillance of antibiotic consumption based on AWaRe classification are needed to improve antibiotic consumption patterns, curb antibiotic overuse and combat antimicrobial resistance in Western China.

Antibiotic use and adherence to the WHO AWaRe guidelines across 16 hospitals in Zambia: a point prevalence survey

Background

The inappropriate use of antibiotics in hospitals contributes to the development and spread of antimicrobial resistance (AMR). This study evaluated the prevalence of antibiotic use and adherence to the World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification of antibiotics across 16 hospitals in Zambia.

Methods

A descriptive, cross-sectional study employing the WHO Point Prevalence Survey (PPS) methodology and WHO AWaRe classification of antibiotics was conducted among inpatients across 16 hospitals in December 2023, Zambia. Data analysis was performed using STATA version 17.0.

Results

Of the 1296 inpatients surveyed in the 16 hospitals, 56% were female, and 54% were aged between 16 and 50 years. The overall prevalence of antibiotic use was 70%. Additionally, 52% of the inpatients received Watch group antibiotics, with ceftriaxone being the most prescribed antibiotic. Slightly below half (48%) of the inpatients received Access group antibiotics. Compliance with the local treatment guidelines was 53%.

Conclusions

This study found a high prevalence of prescribing and use of antibiotics in hospitalized patients across the surveyed hospitals in Zambia. The high use of Watch group antibiotics was above the recommended threshold indicating non-adherence to the WHO AWaRe guidelines for antibiotic use. Hence, there is a need to establish and strengthen antimicrobial stewardship programmes that promote the rational use of antibiotics in hospitals in Zambia.

Antibiotic use in tertiary care hospitals in Bangladesh: Revealing the extent through a point prevalence survey

BACKGROUND

Prevalent use of antibiotics in hospitals results in antimicrobial resistance (AMR), rising mortality, and substantial financial burden. This study assessed the current pattern of antibiotic use among inpatients in tertiary hospitals in Bangladesh.

METHODS

Between August and November 2022, we conducted a point prevalence survey in 4 tertiary hospitals in Dhaka, Bangladesh. The World Health Organization-directed point prevalence survey methodology and tools were followed for the data collection. Descriptive and multivariate statistics were performed using Stata version 15.

RESULTS

Of 1,063 hospitalized patients, antibiotics were prescribed to 73.5% (781/1063, 95% confidence interval: 70.8-76.1) of patients. A total of 1,164 antibiotics were prescribed, and 49.1% of patients consumed multiple antibiotics. Only 31.4% of patients were prescribed antibiotics based on microbiology results. The reasons for antibiotic prescribing were mentioned only in 19.3% of patients. Infants (adjusted odds ratio: 8.52, P-value: <.001) and neonates (adjusted odds ratio: 4.32, P-value: <.001) were more likely to consume antibiotics compared to adults. Cephalosporins accounted for the majority (54.0%) of antibiotics used in hospitals. None of the hospitals had any antibiotic use guidelines.

CONCLUSIONS

Consumption of Watch group antibiotics empirically among all age groups demonstrates irrational antibiotic usage in Bangladeshi hospitals. Implementation of a tailored stewardship program, antibiotic use guidelines, and prescriber-patient awareness could improve the rational use of antibiotics.

Antibiotic usage patterns in COVID-19 patients in five tertiary hospitals from Bangladesh: A countrywide picture

Objectives

Irrational and injudicious use of antibiotics in COVID-19 patients could be detrimental in a tropical country with a weak antibiotic stewardship policy such as Bangladesh. This study aimed to focus on the antibiotic usage patterns in COVID-19 patients in Bangladesh.

Methods

This prospective observational study was performed from July 2020 to June 2021 in five tertiary hospitals in Bangladesh. Data on demographic profile, disease severity, and antibiotic usage were collected directly from the patients' hospital documents.

Results

A total of 3486 (94.4%) patients were treated with at least one antibiotic; 3261 (93.6%) patients received a single antibiotic, and 225 (6.5%) received multiple antibiotics. The most used antibiotics were ceftriaxone (37.3%), co-amoxiclav (26.3%), azithromycin (10.6%), and meropenem (10.3%). According to the World Health Organization AWaRe categorization, most (2260; 69.6%) of the antibiotics prescribed in this study belonged to the "Watch" group. Culture and sensitivity reports were available in 111 cases from one center. Only 18.9% of the patients were found to be co-infected with multi-drug-resistant bacteria (52.4% yield from sputum, 28.6% from urine, and 14.3% from blood).

Conclusions

Strict antibiotic prescribing policy and antibiotic stewardship should be implemented immediately to limit the future threat of antimicrobial resistance in countries such as Bangladesh.

Antibiotic use in public hospitals in Vietnam between 2018 and 2022: a retrospective study

OBJECTIVE

To assess the patterns of antibiotic consumption and expenditure in Vietnam.

DESIGN

This was a cross-sectional study.

SETTING

This study used data of antibiotic procurement that was publicly announced from 2018 to 2022 as a proxy for antibiotic consumption.

PARTICIPANTS

This study included winning bids from 390 procurement units in 63 provinces in Vietnam for 5 years with a total expenditure of US$ 12.8 billions that represented for approximately 20-30% of the national funds spend on medicines.

INTERVENTIONS

Antibiotics were classified by WHO AWaRe (Access, Watch and Reserve) classification.

OUTCOME MEASURES

The primary outcomes were the proportions of antibiotic consumptions in number of defined daily doses (DDD) and expenditures.

RESULTS

There was a total of 2.54 million DDDs of systemic antibiotics, which accounted for 24.7% (US $3.16 billions) of total expenditure for medicines purchased by these public health facilities. The overall proportion of Access group antibiotics ranges from 40.9% to 53.8% of the total antibiotic consumption over 5 years.

CONCLUSION

This analysis identifies an unmet target of at least 60% of the total antibiotic consumption being Access group antibiotics and an unreasonable share of expenditure for non-essential antibiotics in public hospitals in Vietnam.

Surveillance of antibiotics use in inpatients at Benjamin Mkapa Zonal Referral Hospital in Dodoma, Tanzania: a point prevalence survey

OBJECTIVE

To assess antibiotics prescribing and use patterns for inpatients at Benjamin Mkapa Zonal Referral Hospital (BMH) using the WHO-Point Prevalence Survey (WHO-PPS).

DESIGN

A cross-sectional survey.

SETTING

The Benjamin Mkapa Zonal Referral Hospital, Dodoma, Tanzania.

PARTICIPANTS

Inpatient prescriptions, regardless of whether antibiotics were prescribed (n=286) on the day of PPS.

OUTCOME MEASURES

Our study analysed the prevalence of antibiotic use at BMH for inpatients, the type of antibiotics used, the indications for use and the proportion of oral and parenteral antibiotics. We also assessed prescription-prescribed antibiotics after a positive antimicrobial susceptibility testing (AST) result.

RESULTS

A survey was conducted on 286 prescriptions, which revealed that 30.07% of them included antibiotics. On average, each prescription contained at least 1.6 antibiotics. All prescriptions that included antibiotics were written in generic names, and 77.91% (67/86) of them followed the Standard Treatment Guidelines. Of the prescriptions that included antibiotics, 58.14% (50/86) had a single antibiotic, 20.93% (18/86) had parenteral antibiotics and 79.07% (68/86) had oral antibiotics. Based on AWaRe's (Access, Watch and Reserve) categorisation of antibiotics, 50% (8/16) were in the Access group, 31.25% (5/16) were in the Watch group, 12.50% (2/16) were in the Reserve group and 6.25% (1/16) were not recommended antimicrobial combinations. Out of 86 prescriptions included antibiotics, only 4.65% showed positive culture growth. However, antibiotics were still prescribed in 29.07% of prescriptions where there was no growth of bacteria, and in 66.28% of prescriptions, antibiotics were prescribed empirically without any requesting of bacteria culture and AST.

CONCLUSION

BMH has reduced inpatient Antibiotic Use by half compared with the 2019 WHO-PPS. Adherence to National Treatment Guidelines is suboptimal. Clinicians should use AST results to guide antibiotic prescribing.

Concomitant use of lansoprazole and ceftriaxone is associated with an increased risk of ventricular arrhythmias and cardiac arrest in a large Japanese hospital database

OBJECTIVES

To determine whether concomitant use of ceftriaxone and oral or intravenous lansoprazole increases the risk of ventricular arrhythmia and cardiac arrest in the real-world setting in Japan.

METHODS

The data analyzed were obtained from the JMDC hospital-based administrative claims database for the period April 2014 to August 2022. Patients who received a proton pump inhibitor (PPI) while receiving ceftriaxone or sulbactam/ampicillin were identified. The frequency of ventricular arrhythmia and cardiac arrest was analyzed according to whether oral or intravenous PPI was concomitant with ceftriaxone or sulbactam/ampicillin. Estimates of the incidence of ventricular arrhythmia and cardiac arrest were then compared among the groups, using the Fine-Gray competing risk regression model.

RESULTS

The results showed that the risk of ventricular arrhythmia and cardiac arrest was significantly higher with concomitant ceftriaxone and oral lansoprazole (hazard ratio 2.92, 95% confidence interval 1.99-4.29, P < 0.01) or intravenous lansoprazole (hazard ratio 4.57, 95% confidence interval 1.24-16.80, P = 0.02) than with concomitant sulbactam/ampicillin and oral or intravenous lansoprazole.

CONCLUSIONS

Oral and intravenous lansoprazole may increase the risk of ventricular arrhythmia and cardiac arrest in patients who are receiving ceftriaxone.

Penicillin Allergy in China: Consequences of Inappropriate Skin Testing Practices and Policies

Penicillins are the most frequently prescribed class of medications worldwide and first-line antibiotic of choice for most bacterial infections. They are also commonly labelled as the culprit of drug 'allergy'; leading to obligatory use of second-line antibiotics, suboptimal antibiotic therapy and increased antimicrobial resistance. However, the majority of reported penicillin 'allergy' labels are found to be incorrect after allergy testing, emphasising the importance of proper drug allergy testing and evaluation. Penicillin skin testing (PST) remains an important component of drug allergy diagnosis; however, its practice and policies significantly differ across the world. Inappropriate and non-evidence-based PST practices can lead to consequences associated with allergy mislabelling. Even within different regions of China, with a population exceeding 1.4 billion, there are marked differences in the implementation, execution and interpretation of PST. This review aims to examine the differences in PST between Mainland China, Hong Kong and the rest of the world. We critically analyse the current practice of 'pre-emptive' PST in Mainland China, which has a significant false-positive rate leading to high levels of penicillin allergy mislabelling. Non-evidence-based practices further compound the high false-positive rates of indiscriminatory PST. We postulate that inappropriate PST policies and practices may exacerbate the mislabelling of penicillin allergy, leading to unnecessary overuse of inappropriate second-line antibiotics, increasing antimicrobial resistance and healthcare costs. We advocate for the importance of more collaborative research to improve the contemporary workflow of penicillin allergy diagnosis, reduce mislabelling and promote the dissemination of evidence-based methods for allergy diagnosis.

Point prevalence survey of antibiotics use among hospitalised neonates and children in Saudi Arabia: findings and implications

Background

Neonates and children are more susceptible to a variety of infections, leading to frequent antibiotic prescriptions. However, the inappropriate use of antibiotics leads to antibiotic resistance and higher mortality rates. Therefore, this study aimed to determine the prevalence of antibiotic use, and current antibiotic prescribing practices among neonates and children admitted in the selected hospitals of Saudi Arabia.

Methods

A cross-sectional study was conducted from September to November 2023 to assess the prevalence of antibiotic use, and the current antibiotic prescribing practices across six hospitals of Saudi Arabia.

Results

The study included 499 children and neonates, with 94.6% receiving antibiotic prescriptions. The most frequently prescribed antibiotic class was third-generation cephalosporin (31.5%), with ceftriaxone being the most commonly prescribed antibiotic (15%). The majority of patients were prescribed one antibiotic (81.4%), and the intravenous route (96.4%) was the primary route for administration. The majority of patients were prescribed antibiotics empirically (69.7%), and community-acquired infections (64.2%) were the most common type of infection for antibiotic prescription. Similarly, sepsis (39.2%) was the most common indication for antibiotics, and the majority of prescribed antibiotics (61.7%) belonged to the 'Watch' category as per WHO AWaRe classification.

Conclusion

Our study revealed excessive antibiotic consumption in neonates and children, therefore quality improvement programmes including antimicrobial stewardship programmes are urgently needed to address ongoing issues.

Implementation of the pharmacovigilance database in the usage of antibiotics in a tertiary care hospital: A pilot study

Background

Antimicrobial resistance (AMR) has evolved into a severe public health issue that defies all current control strategies and needs multidisciplinary, creative solutions. Antimicrobial stewardship (AMS) activities demand a set of tools and abilities that can be used by health systems. In view of the growing AMR and the difficulty for the surveillance of it in the developing country, this study was conducted to incorporate pharmacovigilance (PV) in the AMS program.

Materials and Methods

A cross-sectional pilot study was conducted to collect the PV database of antimicrobials induced adverse drug reactions (ADR) from the Adverse Drug Reactions Monitoring Center (AMC) of the institute for a period of 2 months from August 2022 to September 2022. The information from the database was analyzed to estimate the usage of antibiotics from the PV database from AMC and classified it under the Anatomical Therapeutic Chemical, to assess the rationality of the antimicrobial's usage based on "Access," "Watch," and "Reserve" (AWaRe) classification, and to assess the ADR of the antibiotics. The analysis was done by using the SPSS version 20.0 for Windows.

Results

The results showed that the prevalence of ADRs were more in adults' population with preponderance in female. The antibiotics usage was as per with World Health Organization standard and most of the antibiotics used were from the Access group of AWaRe classifications. Tetracyclines and penicillins were the most used antibiotic group of drugs. The number of patients included in the study was 70. Most of the causality assessment was "possible" (62.85%). In the study, almost 90% of the drug was withdrawn and 70% of the patients were in the recovering stage.

Conclusion

Using existing PV approaches to address usage of antibiotics and AMR issues would allow PV to progress as a field, and governments will get a stronger return on their PV investments.

Antibiotic Use Among Hospitalized Patients in Africa: A Systematic Review of Point Prevalence Studies

BACKGROUND

There is paucity of data describing the rate and quality indices of antibiotics used among hospitalized patients at continental level in Africa. This systematic review evaluated the pooled prevalence, indications, and types of antibiotics used in hospitals across Africa.

METHODS

Three electronic databases, PubMed, Scopus, and African Journals Online (AJOL), were searched using search terms. Point prevalence studies of antibiotic use in inpatient settings published in English language from January 2010 to November 2022 were considered for selection. Additional articles were identified by checking the reference list of selected articles.

RESULTS

Of the 7254 articles identified from the databases, 28 eligible articles involving 28 studies were selected. Most of the studies were from Nigeria (n = 9), Ghana (n = 6), and Kenya (n = 4). Overall, the prevalence of antibiotic use among hospitalized patients ranged from 27.6 to 83.5% with higher prevalence in West Africa (51.4-83.5%) and North Africa (79.1%) compared to East Africa (27.6-73.7%) and South Africa (33.6-49.7%). The ICU (64.4-100%; n = 9 studies) and the pediatric medical ward (10.6-94.6%; n = 13 studies) had the highest prevalence of antibiotic use. Community-acquired infections (27.7-61.0%; n = 19 studies) and surgical antibiotic prophylaxis (SAP) (14.6-45.3%; n = 17 studies) were the most common indications for antibiotic use. The duration of SAP was more than 1 day in 66.7 to 100% of the cases. The most commonly prescribed antibiotics included ceftriaxone (7.4-51.7%; n = 14 studies), metronidazole (14.6-44.8%; n = 12 studies), gentamicin (n = 8 studies; range: 6.6-22.3%), and ampicillin (n = 6 studies; range: 6.0-29.2%). The access, watch, and reserved group of antibiotics accounted for 46.3-97.9%, 1.8-53.5%, and 0.0-5.0% of antibiotic prescriptions, respectively. The documentation of the reason for antibiotic prescription and date for stop/review ranged from 37.3 to 100% and 19.6 to 100%, respectively.

CONCLUSION

The point prevalence of antibiotic use among hospitalized patients in Africa is relatively high and varied between the regions in the continent. The prevalence was higher in the ICU and pediatric medical ward compared to the other wards. Antibiotics were most commonly prescribed for community-acquired infections and for SAP with ceftriaxone, metronidazole, and gentamicin being the most common antibiotics prescribed. Antibiotic stewardship is recommended to address excessive use of SAP and to reduce high rate of antibiotic prescribing in the ICU and pediatric ward.

Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use-A Narrative Review

The spread of antimicrobial resistance (AMR) is a global challenge. Close and continuous surveillance for quick detection of AMR can be difficult, especially in remote places. This narrative review focuses on the contributions of pharmacovigilance (PV) as an auxiliary tool for identifying and monitoring the ineffectiveness, resistance, and inappropriate use of antibiotics (ABs). The terms "drug ineffective", "therapeutic failure", "drug resistance", "pathogen resistance", and "multidrug resistance" were found in PV databases and dictionaries, denoting ineffectiveness. These terms cover a range of problems that should be better investigated because they are useful in warning about possible causes of AMR. "Medication errors", especially those related to dose and indication, and "Off-label use" are highlighted in the literature, suggesting inappropriate use of ABs. Hence, the included studies show that the terms of interest related to AMR and use are not only present but frequent in PV surveillance programs. This review illustrates the feasibility of using PV as a complementary tool for antimicrobial stewardship activities, especially in scenarios where other resources are scarce.

Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

INTRODUCTION

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

METHODS

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

RESULTS

A total of 284 patients were included, most were male (66.9%), aged 30-50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the 'Watch' category (90.8%) followed by the 'Reserve' category (4.8%), similar to previous COVID-19 waves.

CONCLUSION

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

Antibiotic prescribing patterns and carriage of antibiotic-resistant Escherichia coli and Enterococcus species in healthy individuals from selected communities in Lusaka and Ndola districts, Zambia

Objectives

This study assessed antibiotic prescribing patterns in primary healthcare facilities and antimicrobial resistance (AMR) profiles of commensal Escherichia coli and enterococci isolated from pregnant women and children under 5 years of age.

Materials and methods

This cross-sectional study was conducted in Lusaka and Ndola districts of Zambia. Prescription pattern data were obtained from hospital pharmacies. Identification and antimicrobial susceptibility profiles of E. coli and enterococci were determined by conventional methods, while confirmation of both pathogens and AMR genes were determined by PCR. Data were analysed using WHONET and SPSS version 25.0.

Results

Most prescribed antibiotics at the primary healthcare facilities belonged to the Access group of the WHO Access, Watch and Reserve (AWaRe) classification. All the primary healthcare facilities adhered to the AWaRe framework of ≥60% prescribed antibiotics belonging to the Access group. However, resistance was highest in the Access group of antibiotics. E. coli resistance to ampicillin ranged from 71% to 77% and to co-trimoxazole from 74% to 80%, while enterococcal resistance to tetracycline was 59%-64%. MDR was highest in E. coli (75%) isolates, while XDR was highest in enterococcal isolates (97%). The identified AMR genes in E. coli included blaCTX-M, sul2 and qnrA, while those of enterococci included erm(B), erm(C) and erm(A).

Conclusions

Resistance was highest in the prescribed WHO Access group of antibiotics. These findings highlight the need to use local susceptibility data to formulate country-specific treatment guidelines in line with WHO AWaRe classification and enforce regulations that prohibit easy access to antibiotics.

Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana: A point prevalence survey study

INTRODUCTION

Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes.

METHODS

The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded.

RESULTS

A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). "Access" antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed "Watch" antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available.

CONCLUSIONS

There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing "Watch" antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa.

Reported antibiotic use among patients in the multicenter ANDEMIA infectious diseases surveillance study in sub-saharan Africa

BACKGROUND

Exposure to antibiotics has been shown to be one of the drivers of antimicrobial resistance (AMR) and is critical to address when planning and implementing strategies for combatting AMR. However, data on antibiotic use in sub-Saharan Africa are still limited. Using hospital-based surveillance data from the African Network for Improved Diagnostics, Epidemiology and Management of Common Infectious Agents (ANDEMIA), we assessed self-reported antibiotic use in multiple sub-Saharan African countries.

METHODS

ANDEMIA included 12 urban and rural health facilities in Côte d'Ivoire, Burkina Faso, Democratic Republic of the Congo, and Republic of South Africa. Patients with acute respiratory infection (RTI), acute gastrointestinal infection (GI) and acute febrile disease of unknown cause (AFDUC) were routinely enrolled, and clinical, demographic, socio-economic and behavioral data were collected using standardized questionnaires. An analysis of ANDEMIA data from February 2018 to May 2022 was conducted. Reported antibiotic use in the ten days prior to study enrolment were described by substance and by the WHO AWaRe classification ("Access", "Watch", "Reserve", and "Not recommended" antibiotics). Frequency of antibiotic use was stratified by location, disease syndrome and individual patient factors.

RESULTS

Among 19,700 ANDEMIA patients, 7,258 (36.8%) reported antibiotic use. A total of 9,695 antibiotics were reported, including 54.7% (n = 5,299) from the WHO Access antibiotic group and 44.7% (n = 4,330) from the WHO Watch antibiotic group. The Watch antibiotic ceftriaxone was the most commonly reported antibiotic (n = 3,071, 31.7%). Watch antibiotic use ranged from 17.4% (56/322) among RTI patients in Côte d'Ivoire urban facilities to 73.7% (630/855) among AFDUC patients in Burkina Faso urban facilities. Reported antibiotic use included WHO Not recommended antibiotics but no Reserve antibiotics.

CONCLUSIONS

Reported antibiotic use data from this multicenter study in sub-Saharan Africa revealed a high proportion of WHO Watch antibiotics. Differences in Watch antibiotic use were found by disease syndrome, country and health facility location, which calls for a more differentiated approach to antibiotic use interventions including further evaluation of accessibility and affordability of patient treatment.

Drug-Induced Anaphylaxis: National Database Analysis

(1) Background: National health system databases represent an important source of information about the epidemiology of adverse drug reactions including drug-induced allergy and anaphylaxis. Analysis of such databases may enhance the knowledge of healthcare professionals regarding the problem of drug-induced anaphylaxis. (2) Methods: A retrospective descriptive analysis was carried out of spontaneous reports (SRs) with data on drug-induced anaphylaxis (SRsAs) extracted from the Russian National Pharmacovigilance database (analyzed period 2 April 2019-21 June 2023). The percentage of SRsAs among SRs of drug-induced allergy (SRsDIAs) was calculated, as well as of pediatric, elderly, and fatal SrsAs. Drugs involved in anaphylaxis were assessed among total SRsAs, pediatric, and elderly SRsAs, and among fatal SRsAs. Demographic parameters of patients were assessed. (3) Results: SRsAs were reported in 8.3% of SRsDIAs (2304/27,727), the mean age of patients was 48.2 ± 15.8 years, and females accounted for 53.2% of cases. The main causative groups of drugs were antibacterials (ABs) for systemic use (44.6%), local anesthetics (20.0%), and cyclooxygenase (COX) inhibitors (10.1%). Fatal SRsAs were reported in 9.5% (218/2304) of cases, the mean age of patients was 48.0 ± 16.7 years, and females accounted for 56.4% of cases. Pediatric SRsAs accounted for 3.9% of pediatric SRsDIAs and 5.8% of all SRsAs, with a mean age of 11.8 ± 4.5 years, and females acccounted for 51.9% of cases. Elderly SRsAs accounted for 2% of elderly SRsDIAs and 2.8% of all SRsAs, and the mean age was 73.0 ± 5.3 years, and females accounted for 43.5% of cases. ABs caused 40% of SRsAs in the elderly, 42.9% in children, and 50% of fatal SRsAs. (4) Conclusions: Our study revealed a relatively high proportion of anaphylaxis among SRs of drug-induced allergy. ABs were the most prevalent causative agents, especially in fatal SRsAs.

The interplay between gut microbiota, short-chain fatty acids, and implications for host health and disease

Short-chain fatty acids (SCFAs) - acetate, propionate, and butyrate - are important bacterial fermentation metabolites regulating many important aspects of human physiology. Decreases in the concentrations of any or multiple SCFAs are associated with various detrimental effects to the host. Previous research has broadly focused on gut microbiome produced SCFAs as a group, with minimal distinction between acetate, propionate, and butyrate independently, each with significantly different host effects. In this review, we comprehensively delineate the roles of these SCFAs with emphasis on receptor affinity, signaling pathway involvement, and net host physiologic effects. Butyrate is highlighted due to its unique role in gastrointestinal-associated functions, especially maintaining gut barrier integrity. Butyrate functions by promoting epithelial tight junctions, serving as fuel for colonocyte ATP production, and modulating the immune system. Interaction with the immune system occurs locally in the gastrointestinal tract and systemically in the brain. Investigation into research conducted on butyrate production pathways and specific bacterial players involved highlights a unique risk associated with use of gram-positive targeted antibiotics. We review and discuss evidence showing the relationship between the butyrate-producing gram-positive genus, Roseburia, and susceptibility to commonly prescribed, widely used gram-positive antibiotics. Considering gut microbiome implications when choosing antibiotic therapy may benefit health outcomes in patients.

Antimicrobial Stewardship and Pandemic Preparedness: Harnessing Lessons Learned to Advance Our Mission

Antimicrobial stewardship programs (ASPs) demonstrated poise and resilience in assisting with COVID-19 efforts across the globe, harnessing expertise in diagnostic stewardship, therapeutics, protocol development, and use of technology to rapidly expand their scope through strategic collaborations, dissemination of content expertise, and numerous contributions to the body of knowledge on COVID-19. Lessons learned from pandemic response should be used to advance the mission of ASPs and secure a "seat at the table" as health systems continue to expand and adapt to future public health crises.

Point Prevalence Survey of Antimicrobial Use and Resistance during the COVID-19 Era among Hospitals in Saudi Arabia and the Implications

The inappropriate prescribing of antimicrobials increases antimicrobial resistance (AMR), which poses an appreciable threat to public health, increasing morbidity and mortality. Inappropriate antimicrobial prescribing includes their prescribing in patients hospitalized with COVID-19, despite limited evidence of bacterial infections or coinfections. Knowledge of current antimicrobial utilization in Saudi Arabia is currently limited. Consequently, the objective of this study was to document current antimicrobial prescribing patterns among Saudi hospitals during the COVID-19 pandemic. This study included patients with or without COVID-19 who were admitted to five hospitals in Makkah, Saudi Arabia. Data were gathered using the Global PPS methodology and analyzed using descriptive statistics. Out of 897 hospitalized patients, 518 were treated with antibiotics (57.7%), with an average of 1.9 antibiotics per patient. There were 174 culture reports collected, representing 36.5% of all cases. The most common indication for antibiotics use was community-acquired infections, accounting for 61.4% of all cases. 'Watch' antibiotics were the most commonly prescribed antibiotics, with the cephalosporins and carbapenems representing 38.7% of all antibiotics prescribed, followed by the penicillins (23.2%). Notably, Piperacillin/Tazobactam and Azithromycin were prescribed at relatively higher rates for COVID-19 patients. These findings highlight the need for continuous efforts to optimize the rational use of antibiotics through instigating appropriate antimicrobial stewardship programs in hospitals and, as a result, reduce AMR in the country.

AWaRe classification of antibiotics prescribed within 2018-2021 for hospitalised medical and surgical patients in Uyo, Nigeria

Introduction

point prevalence surveys have been used as a standardized tool to monitor antibiotic consumption to inform antimicrobial stewardship interventions in many countries. The 2021 WHO model list of Essential Medicines has classified antibiotics into three groups: access, watch and reserve. The aim of this paper is to describe the antibiotics used within a space of three years between 2018 and 2021 at the University of Uyo Teaching Hospital based on WHO AWaRe classification.

Methods

three point-prevalence surveys were conducted in the wards in our 500-bed tertiary hospital in 2018, 2019 and 2021. Each ward was surveyed on a particular day within a four-week period. The wards were grouped into medical and surgical for comparison. Antibiotics were classified as access, watch, and reserve. Validated data were analyzed with IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.).

Results

a total of 526 patients were surveyed out of which 344 were on antimicrobial therapy with a total of 687 antibiotic prescriptions. The overall prevalence of patients who received at least one antimicrobial was 65.4% (62.4 -72.8%). The Access group of antibiotics made up 48.2% of prescriptions while the watch group made up 50.5% of prescriptions. More watch Antibiotics were prescribed by surgical wards (49.7%) than by medical wards (43.7%).

Conclusion

the use of Access group antibiotics in our hospital falls below the WHO target level in both medical and surgical wards. There is a need for strengthening antibiotic stewardship activities to reduce the use of watch group antibiotics and limit antimicrobial resistance.

Antibiotic prescribing to inpatients in Limpopo, South Africa: a multicentre point-prevalence survey

BACKGROUND

Electronic continuous surveillance databases are ideal for monitoring antibiotic use (ABU) in hospitalised patients for antibiotic stewardship programmes (ASP). However, such databases are scarce in low-resource settings. Point prevalence surveys (PPS) are viable alternatives. This report describes ABU and identifies ASP implementation improvement areas in Limpopo Province, South Africa.

METHODS

This cross-sectional descriptive study extracted patient-level ABU data from patients' files using a modified global PPS tool. Data were collected between September and November 2021 at five regional hospitals in Limpopo Province, South Africa. All patients in the wards before 8 a.m. on study days with an antibiotic prescription were included. Antibiotic use was stratified by Anatomic Therapeutic Chemical and Access, Watch, Reserve classifications and presented as frequencies and proportions with 95% confidence intervals (CI). Associations between categorical variables were assessed using the chi-square test. Cramér's V was used to assess the strength of these associations.

RESULTS

Of 804 inpatients surveyed, 261 (32.5%) (95% CI 29.2-35.7) were prescribed 416 antibiotics, 137 were female (52.5%) and 198 adults (75.9%). One hundred and twenty-two (46.7%) patients received one antibiotic, 47.5% (124/261) received two, and 5.7% (15/261) received three or more antibiotics. The intensive care units had a higher ABU (68.6%, 35/51) compared to medical (31.3%, 120/384) and surgical (28.5%, 105/369) wards (p = 0.005, Cramér's V = 0.2). Lower respiratory tract infection (27.4%, 104/379), skin and soft tissue infections (SST) (23.5%, 89/379), and obstetrics and gynaecology prophylaxis (14.0%, 53/379) were the common diagnoses for antibiotic prescriptions. The three most prescribed antibiotic classes were imidazoles (21.9%, 91/416), third-generation cephalosporins (20.7%, 86/416) and combination penicillin (18.5%, 79/416). Access antibiotics accounted for 70.2% (292/416) of prescriptions and Watch antibiotics for 29.6% (123/416) (p = 0.110, Cramér's V = 0.1). Reasons for prescribing and treatment plans were documented in 64.9% (270/416) (95% CI 60.3-69.5) and 21.4% (89/416) (95% CI 17.3-25.3) of prescriptions, respectively.

CONCLUSIONS

The study serves as a baseline for ABU surveillance at the five regional hospitals in Limpopo Province. Lack of documentation indicates poor prescribing practices; ASP should address gaps by deploying evidence-based, multifaceted and stepwise interventions.

Stop antibiotic resistance - A roller coaster ride through "antibiotic stewardship," "prescription auditing" and "AWaRe" assessment tool

The emergence of superbugs and highly resistant organisms like methicillin-resistant staphylococci, vancomycin-resistant enterococci, carbapenem-resistant enterobacteriaceae demands the monitoring of antibiotic prescription and usage in various domains. The impact of antibiotic resistance is huge that it increases mortality, morbidity, and economic costs. The issue has to be addressed at various levels and that is why regulatory bodies implement antibiotic stewardship programs. These programs give a list of guidelines like infection control, tracking antibiotic use, prescription auditing, and involvement of health professionals like pharmacists, nurses, etc., A comparison of the list of guidelines given by the Centre for Disease Control and Prevention and Indian Council of Medical Research gives an idea about the measures to be taken at various levels to reduce the burden of antibiotic resistance. Prescription auditing is one of the major components of antibiotic stewardship. The auditing can be done either prospectively or retrospectively using WHO core prescribing indicators and antibiotic-specific indicators. An AWaRe assessment tool was also used to evaluate antibiotic consumption in countries and hospitals. The antibiotics are classified into access, watch and reserve categories. The aim of implementing the AWaRe tool is to increase the rational use of access antibiotic and reduce the consumption of watch and reserve antibiotics. This review focuses on the importance of prescription auditing, AWaRe tool and antibiotic stewardship in decreasing the threat of antibiotic resistance.

WHO/INRUD prescribing indicators among tertiary regional referral hospitals in Dar es Salaam, Tanzania: a call to strengthen antibiotic stewardship programmes

Background

Antibiotic prescribing should be guided by national essential medicines lists (NEMLs) and treatment guidelines; however, there are inadequate data on antibiotic utilization patterns in tertiary hospitals in Tanzania. This study aimed to determine antibiotic prescribing patterns in tertiary hospitals in Dar es Salaam, Tanzania.

Methods

A retrospective cross-sectional study was conducted in three regional referral hospitals. About 200 prescription records from 2020 to 2022 were analysed at each hospital for prescribing patterns using WHO/ International Network of Rational Use of Drugs (INRUD) indicators (1993) and the AWaRe 2021 classification. Factors associated with receiving an antibiotic prescription were assessed using a logistic regression model. Facilities were ranked on prescribing practices using the index of rational drug prescribing (IRDP).

Results

A total of 2239 drugs were prescribed, of which 920 (41.1%) were antibiotics. An average of 3.7 ± 1.5 (optimal: 1.6-1.8) total medicines and 1.53 ± 0.78 antibiotics were prescribed per patient. About 88.0% (528) of the prescriptions contained antibiotics (optimal: 20.0%-26.8%), while 78.2% (413) of all antibiotic prescriptions contained injections (optimal: 13.4%-24.1%). Furthermore, 87.5% (462) of the antibiotics were prescribed in generic names (optimal: 100%), while 98.7% (521) conformed to the NEML (optimal: 100%). Metronidazole was the most frequently prescribed antibiotic (39.2%; n = 134), followed by ceftriaxone (37.1%, n = 127) and amoxicillin/clavulanic acid (8.5%, n = 29).

Conclusions

We found substantial empirical prescribing and overuse of antibiotics exceeding WHO recommendations. Antibiotic overuse varied across the hospitals. Being male, having underlying conditions such as diabetes mellitus, and/or being treated at Temeke hospital were associated with receiving an antibiotic prescription. We recommend strengthening antibiotic stewardship programmes in the studied facilities.

Evaluation of Antibiotic Prescribing Pattern Using WHO Access, Watch and Reserve Classification in Kinshasa, Democratic Republic of Congo

BACKGROUND

The AWaRe tool was set up by the World Health Organization (WHO) to promote the rational use of antimicrobials. Indeed, this tool classifies antibiotics into four groups: access, watch, reserve and not-recommended antibiotics. In The Democratic Republic of Congo, data on antibiotic dispensing (prescribing) by health professionals according to the AWaRe classification are scarce. In this research work, we aimed to explore antibiotic dispensing pattern from health professionals according to the WHO AWaRe classification to strengthen the national antimicrobial resistance plan.

METHODS

For this purpose, a survey was conducted from July to December 2022 in the district of Tshangu in Kinshasa. From randomly selected drugstores, drug-sellers were interviewed and randomly selected customers attending those drugstores were included in the study for medical prescriptions collection. The prescribed antibiotics were classified into the access, watch, reserve and not-recommended antibiotics group and by antibiotics number by prescription among pharmacies surveyed.

RESULTS

400 medical prescriptions were collected from 80 drugstores and among which, 301 (75.25%) contained antibiotics. Out of 301 prescriptions, we noticed 164 (54.5%) containing one antibiotic, 117 (38.9%) containing two antibiotics, 15 (5%) containing three antibiotics and 5 (1.6%) containing four antibiotics. A total of 463 antibiotics were prescribed and distributed as 169 (36.5%) were from the access group, 200 (43.2%) from the watch group and 94 (20.3%) from not-recommended antibiotics group, respectively. This can explain the fact of emerging bacterial strains, as, according to the WHO recommendations, the access group should be prioritized because of its activity against a wide range of commonly encountered pathogens and its showing low resistance susceptibility compared to antibiotics from other groups. Based on the anatomical, therapeutic and chemical (ATC) classifications, we observed that third generation cephalosporins represented 34.33% of the prescribed antibiotics, followed by penicillins (17.17%), macrolides (7.63%), aminoglycosides (7.36%) and Imidazole (7.36%), thus accounting approximately for 74% of the classes of antibiotics prescribed. Additionally, among them, the most frequently prescribed antibiotics were Ceftriaxone (21.38%), Amoxicillin (11.01%), Gentamycin (5.61%), Amoxicillin-clavulanic acid (5.61%), Azithromycin (4.97%) and Metronidazole (4.75%), thus accounting for approximately 54% of all the prescribed antibiotics.

CONCLUSION

These results highlight the importance of strict implementation of the national plan to combat antimicrobial resistance and the need to train health workers in the correct application of the WHO AWaRe classification.

Practices and challenges related to antibiotic use in paediatric treatment in hospitals and health centres in Niger and Uganda: a mixed methods study

BACKGROUND

Antibiotic resistance is a significant public health problem and is responsible for high mortality in children and new-borns. Strengthening the rational use of antibiotics and improving the quality and access to existing antibiotics are important factors in the fight against antibiotic resistance. This study aims to provide knowledge on the use of antibiotics in children in resource-limited countries in order to identify problems and possible avenues for improvement of antibiotics use.

METHODS

We conducted a retrospective study in July 2020 and collected quantitative clinical and therapeutic data on antibiotic prescriptions between January and December 2019 in 4 hospitals or health centres in both Uganda and Niger, respectively from January to December 2019. Semi-structured interviews and focus groups were conducted among healthcare personnel and carers for children under 17 years of age, respectively.

RESULTS

A total of 1,622 children in Uganda and 660 children in Niger (mean age of 3.9 years (SD 4.43)) who received at least one antibiotic were included in the study. In hospital settings, 98.4 to 100% of children prescribed at least one antibiotic received at least one injectable antibiotic. Most hospitalized children received more than one antibiotic in both Uganda (52.1%) and Niger (71.1%). According to the WHO-AWaRe index, the proportion of prescriptions of antibiotics belonging to the Watch category was 21.8% (432/1982) in Uganda and 32.0% (371/1158) in Niger. No antibiotics from the Reserve category were prescribed. Health care provider's prescribing practices are rarely guided by microbiological analyses. Prescribers are faced with numerous constraints, such as lack of standard national guidelines, unavailability of essential antibiotics at the level of hospital pharmacies, the limited financial means of the families, and pressure to prescribe antibiotics from caregivers as well as from drug company representatives. The quality of some antibiotics provided by the National Medical Stores to the public and private hospitals has been questioned by some health professionals. Self-medication is a widespread practice for the antibiotic treatment of children for economic and access reasons.

CONCLUSION

The study findings indicate that an intersection of policy, institutional norms and practices including individual caregiver or health provider factors, influence antibiotic prescription, administration and dispensing practices.

Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.

Point Prevalence Survey of Antimicrobial Use in Selected Tertiary Care Hospitals of Pakistan Using WHO Methodology: Results and Inferences

Background and objectives: The inappropriate use of antibiotics in hospitals can potentially lead to the development and spread of antibiotic resistance, increased mortality, and high economic burden. The objective of the study was to assess current patterns of antibiotic use in leading hospitals of Pakistan. Moreover, the information collected can support in policy-making and hospital interventions aiming to improve antibiotic prescription and use. Methodology and materials: A point prevalence survey was carried out with data abstracted principally from patient medical records from 14 tertiary care hospitals. Data were collected through the standardized online tool KOBO application for smart phones and laptops. For data analysis, SPSS Software was used. The association of risk factors with antimicrobial use was calculated using inferential statistics. Results: Among the surveyed patients, the prevalence of antibiotic use was 75% on average in the selected hospitals. The most common classes of antibiotics prescribed were third-generation cephalosporin (38.5%). Furthermore, 59% of the patients were prescribed one while 32% of the patients were prescribed two antibiotics. Whereas the most common indication for antibiotic use was surgical prophylaxis (33%). There is no antimicrobial guideline or policy for 61.9% of antimicrobials in the respected hospitals. Conclusions: It was observed in the survey that there is an urgent need to review the excessive use of empiric antimicrobials and surgical prophylaxis. Programs should be initiated to address this issue, which includes developing antibiotic guidelines and formularies especially for empiric use as well as implementing antimicrobial stewardship activities.

Pattern of Antibiotic Use among Hospitalized Patients at a Level One Multidisciplinary Care Hospital

BACKGROUND

Antimicrobial resistance is one of the world's most serious health issues. Antibiotic resistance, excessive drug expense, and an increased risk of adverse reactions are all common outcomes of incorrect antibiotic prescribing. The goal of this study was to evaluate the prevalence of antibiotic prescriptions for inpatients to find areas for improvement.

METHODS

A retrospective study at Emergency Clinical County Hospital of Oradea, Romania was performed for five years between 2017 and 2021. Data was collected using medical records of the patients and reports from the pharmacy. Antibiotic consumption was expressed as DDD/100 BD according to the World Health Organization (WHO) by antibiotics, classes, and AWaRe classification.

RESULTS

The prevalence of antibiotic prescription was 53.8% during five years evaluated with a significant increase in 2021. A total of 13,677.42 DDD/100 BD antibiotics were prescribed, especially for surgical and medical prophylaxes. The most prescribed antibiotics were ceftriaxone, followed by metronidazole, and cefuroxime but there were some differences between years and wards. The most frequent antibiotic classes prescribed were cephalosporins (43.73%). The use of Watch Group antibiotics was high in all wards (59.69%).

CONCLUSIONS

The prevalence of antibiotic use was high with cephalosporins being the most prescribed antibiotics. As a result, interventions are required.

Ongoing Strategies to Improve Antimicrobial Utilization in Hospitals across the Middle East and North Africa (MENA): Findings and Implications

Antimicrobial resistance (AMR) is an increasing global concern, increasing costs, morbidity, and mortality. National action plans (NAPs) to minimize AMR are one of several global and national initiatives to slow down rising AMR rates. NAPs are also helping key stakeholders understand current antimicrobial utilization patterns and resistance rates. The Middle East is no exception, with high AMR rates. Antibiotic point prevalence surveys (PPS) provide a better understanding of existing antimicrobial consumption trends in hospitals and assist with the subsequent implementation of antimicrobial stewardship programs (ASPs). These are important NAP activities. We examined current hospital consumption trends across the Middle East along with documented ASPs. A narrative assessment of 24 PPS studies in the region found that, on average, more than 50% of in-patients received antibiotics, with Jordan having the highest rate of 98.1%. Published studies ranged in size from a single to 18 hospitals. The most prescribed antibiotics were ceftriaxone, metronidazole, and penicillin. In addition, significant postoperative antibiotic prescribing lasting up to five days or longer was common to avoid surgical site infections. These findings have resulted in a variety of suggested short-, medium-, and long-term actions among key stakeholders, including governments and healthcare workers, to improve and sustain future antibiotic prescribing in order to decrease AMR throughout the Middle East.

Current Antibiotic Use Among Hospitals in the sub-Saharan Africa Region; Findings and Implications

BACKGROUND

The rapid rise in antimicrobial resistance (AMR) globally, impacting on morbidity, mortality and costs with sub-Saharan African countries reporting the greatest burden is a concern. Instigation of antimicrobial stewardship programs (ASPs) can improve antibiotic use in hospitals and reduce AMR. Implementing ASPs requires knowledge of antibiotic utilization against agreed quality indicators with the data obtained from point prevalence surveys (PPS), hence the need to document antibiotic utilization patterns in sub-Saharan Africa.

METHODS

A narrative review to document current utilization patterns, challenges, indicators and ASPs across sub-Saharan Africa based on previous reviews by the authors, supplemented by the considerable knowledge and experience of the co-authors.

RESULTS

Results from multiple PPS studies showed a high prevalence of antibiotic use among hospitals, mostly over 50%. Prevalence rates ranged from as low as 37.7% in South Africa to as high as 80.1% in Nigeria. There was also considerable prescribing of broad-spectrum antibiotics which could be due to lack of facilities within hospitals, alongside concerns with co-payments to perform microbiological tests, resulting in empiric prescribing. This is a concern alongside lack of guidelines or adherence to guidelines, which was as low as 4% in one study. Another concern was the high rates of extended prophylaxis to prevent surgical site infections (SSIs), with antibiotics often prescribed for longer than 24 hours, usually multiple doses. Several quality indicators have been used to evaluate antibiotic utilization providing exemplars for the future. Among the initiatives being instigated to improve antibiotic use, ASPs have proved effective. For ASPs to be successful objectives and indicators must be agreed, and regular audits undertaken.

CONCLUSION

Antibiotic prescribing across Africa is characterised by high prevalence, usually empirical. Various prescribing and quality indicators are being employed to assess antibiotic use, and ASPs have shown to improve antibiotic prescribing providing direction to reduce AMR.