Antibiotic use, resistance development and environmental factors: a qualitative study among healthcare professionals in Orissa, India

Antibiotic resistant bacteria and antibiotic resistance genes as contaminants of emerging concern: Occurrences, impacts, mitigations and future guidelines

Antibiotic resistance, driven by the proliferation of antibiotic resistance genes (ARGs) and antibiotic resistance bacteria (ARBs), has emerged as a pressing global health concern. Antimicrobial resistance is exacerbated by the widespread use of antibiotics in agriculture, aquaculture, and human medicine, leading to their accumulation in various environmental compartments such as soil, water, and sediments. The presence of ARGs in the environment, particularly in municipal water, animal husbandry, and hospital environments, poses significant risks to human health, as they can be transferred to potential human pathogens. Current remediation strategies, including the use of pyroligneous acid, coagulants, advanced oxidation, and bioelectrochemical systems, have shown promising results in reducing ARGs and ARBs from soil and water. However, these methods come with their own set of challenges, such as the need for elevated base levels in UV-activated persulfate and the long residence period required for photocatalysts. The future of combating antibiotic resistance lies in the development of standardized monitoring techniques, global collaboration, and the exploration of innovative remediation methods. Emphasis on combination therapies, advanced oxidation processes, and monitoring horizontal gene transfer can pave the way for a comprehensive approach to mitigate the spread of antibiotic resistance in the environment.

Multi-drug resistant (MDR) Gram-negative pathogenic bacteria isolated from poultry in the Noakhali region of Bangladesh

Rapidly increasing antibiotic-resistant bacterial strains in Bangladesh's food and farm animals stem from the excessive and inappropriate use of antibiotics. To assess the prevalence of multi-drug resistant (MDR) Gram-negative bacteria in poultry chicks, we sought to isolate and identify strains carrying antimicrobial resistance genes. Isolation and identification involved biochemical tests, 16S rRNA sequencing, and PCR screening of species-specific genes. MDR patterns were evaluated using CLSI guidelines with seventeen antibiotics across twelve classes. Targeted gene sequences were amplified for the detection of Extended-spectrum β-Lactamase (ESBL), carbapenem, tetracycline, sulfonamide, and colistin resistance genes. Common isolates, such as Escherichia coli, Klebsiella pneumoniae, Proteus penneri, and Enterobacter hormaechei, exhibited average Multiple Antimicrobial Resistance (MAR) indices of 0.66, 0.76, 0.8, 0.84, and 0.81, 0.76, 0.84, 0.41 for broiler and layer chicken, respectively. Providencia stuartii and Salmonella enterica, exclusive to broiler samples, had MAR indices of 0.82 and 0.84, respectively. Additional isolates Morganella morganii, Aeromonas spp., and Wohlfahrtiimonas chitiniclastica were found in layers (Average MAR indices: 0.73, 0.71, and 0.91). Notably, M. morganii, E. hormaechei and W. chitiniclastica were identified for the first time in Bangladeshi poultry chicken, although their evolution is yet to be understood. In this study, Pan-drug resistance was observed in one P. stuartii (broiler) and one Aeromonas spp. (layer) with a MAR index 1, while all isolates exhibited MAR indices >0.2, indicating MDR. Antimicrobial resistance (AMR) gene screening identified blaTEM, blaSHV, tetA, and sul1 in a majority of the MDR strains. Interestingly, E. coli (lactose positive and negative) and E. hormaechei were exclusively found to possess the tetB gene. In addition, E. coli (lactose negative), Klebsiella pneumoniae, Enterobacter hormaechei, M. morganii, and P. stuartii were observed to carry the colistin-resistant mcr-1 gene, whereas sul2 was detected in E. coli (lactose positive and negative), E. hormaechei, P. stuartii, and P. penneri. These findings emphasize the health risk of our consumers of both broiler and layer chickens as they have turned into a potent reservoir of various AMR gene carrying MDR and Pan-drug resistant bacteria.

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

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

Determinants of private-sector antibiotic consumption in India: findings from a quasi-experimental fixed-effects regression analysis using cross-sectional time-series data, 2011-2019

The consumption of antibiotics varies between and within countries. However, our understanding of the key drivers of antibiotic consumption is largely limited to observational studies. Using Indian data that showed substantial differences between states and changes over years, we conducted a quasi-experimental fixed-effects regression study to examine the determinants of private-sector antibiotic consumption. Antibiotic consumption decreased by 10.2 antibiotic doses per 1000 persons per year for every ₹1000 (US$12.9) increase in per-capita gross domestic product. Antibiotic consumption decreased by 46.4 doses per 1000 population per year for every 1% increase in girls' enrollment rate in tertiary education. The biggest determinant of private sector antibiotic use was government spending on health-antibiotic use decreased by 461.4 doses per 1000 population per year for every US$12.9 increase in per-capita government health spending. Economic progress, social progress, and increased public investment in health can reduce private-sector antibiotic use.

Extended-spectrum β-lactamases producing Enterobacteriaceae (ESBL-PE) prevalence in Nepal: A systematic review and meta-analysis

An alarming increase in the occurrence of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) has threatened the treatment and management of bacterial infections. This systematic review and meta-analysis aimed to provide a quantitative estimate of the prevalence of ESBL among the members of the Enterobacteriaceae family by analyzing the community-based and clinical studies published between 2011 and 2021 from Nepal and determine if ESBL-PE correlates with multidrug resistance (MDR). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed for systematic review and meta-analysis and the articles' quality was assessed using the Newcastle-Ottawa scale. Of the 2529 articles screened, 65 articles were systematically reviewed, data extracted, and included in in-depth meta-analysis. The overall pooled prevalence of ESBL-producers in Enterobacteriaceae was 29 % (95 % CI: 26-32 %) with high heterogeneity (I2 = 96 %, p < 0.001). Escherichia coli was the predominant ESBL-producing member of the Enterobacteriaceae family, followed by Citrobacter spp. and Klebsiella spp. The prevalence of ESBL-PE increased from 18.7 % in 2011 to 29.5 % in 2021. A strong positive correlation (r = 0.98) was observed between ESBL production and MDR in Enterobacteriaceae. ESBL-PE isolates showed high resistance to ampicillin, cephalosporins, and amoxicillin-clavulanic acid, and blaCTX-M type was the most reported gene variant among ESBL-PE. In conclusion, this study demonstrated an increased prevalence of ESBL-PE in Nepal over the last decade, and such isolates showed a high level of MDR against the β-lactams and non-β-lactam antibiotics. Tackling the rising antibiotic resistance (AR) and MDR in ESBL-PE would require concerted efforts from all stakeholders to institute effective infection control programs in the community and clinical settings.

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

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

Awareness Regarding Antimicrobial Resistance and Antibiotic Prescribing Behavior among Physicians: Results from a Nationwide Cross-Sectional Survey in India

(1) Background: Understanding the physicians' knowledge, attitudes, and antimicrobial prescribing behavior is a crucial step towards designing strategies for the optimal use of these agents. (2) Methods: A cross-sectional online survey was conducted among clinicians across India between May and July 2022 using a self-administered questionnaire in English comprising 35 questions pertaining to demographic characteristics, knowledge, attitude, and practices domains. (3) Results: A total of 544 responses were received from 710 physicians contacted. Sixty percent of participants were males, with mean age of 34.7 years. Mean ± Standard Deviation scores for knowledge, attitude, and practices domains were 8 ± 1.6, 20.2 ± 3.5, and 15.3 ± 2.1, respectively. Higher scores were associated with basic [odds ratio (95% Confidence Interval), p value: 2.95 (1.21, 7.2), 0.02], medical and allied sciences [2.71 (1.09, 6.67), 0.03], and central zone [3.75 (1.39, 10.12), 0.009]. A substantial proportion of dissatisfactory responses were found regarding hospital antibiograms, antibiotics effective against anaerobes, WHO AWaRe (access, watch, and reserve) classification of antibiotics, and the role of infection prevention and control (IPC) measures in the containment of antimicrobial resistance (AMR). (4) Conclusions: There is a need to sensitize and educate clinicians on various issues related to antimicrobial use, such as antibiograms, double anaerobic cover, IPC practices, and guideline-based recommendations, to curb the AMR pandemic.

Rationality of Prescriptions by Rational Use of Medicine Consensus Approach in Common Respiratory and Gastrointestinal Infections: An Outpatient Department Based Cross-Sectional Study from India

BACKGROUND

Drug utilisation studies are relevant for the analysis of prescription rationality and are pertinent in today's context of the increasing burden of antimicrobial resistance. Prescriptions for patients with diarrhoea or Acute Respiratory Infection (ARI) have been analysed in this study to understand the prescription pattern among various categories of prescribers in two tertiary care centers.

METHODS

This cross-sectional study was conducted from August 2019 to December 2020 in the medicine and pediatrics outpatient departments of two government teaching hospitals in West Bengal, India. A total of 630 prescriptions were evaluated against WHO standards. Prescriptions were assessed by a 'Rational Use of Medicine Consensus committee' approach.

RESULTS

The Fixed Dose Combination (FDC) was used in half of the patients (51%). Both the generic prescription (23.3%) and adherence to hospital formulary rates (36.5%) were low. The antibiotics prescription rate was high (57%), and it was higher for diarrhoea than ARI. Deviations from the standard treatment guidelines were found in 98.9% of prescriptions. Deviations were commonly found with prescriptions written by the junior doctors (99.6%).

CONCLUSION

Irrational prescribing patterns prevail in tertiary care centers and indicate the necessity of awareness generation and capacity building among prescribers regarding AMR and its unseen consequences.

Antibiotic Use among Patients Visiting Primary Hospitals in Northwest Ethiopia: A Multicenter Cross-Sectional Survey

Background

Antimicrobial medications are becoming ineffective because of the surge in antimicrobial resistance. Poor knowledge and inappropriate beliefs combined with the misuse of antibiotics may be common in the community and public health institutions. This study assessed the knowledge, belief, and antibiotic use practice among patients visiting rural hospitals in Northwest Ethiopia.

Methods

A facility-based multicenter cross-sectional survey was conducted in Northwest Ethiopian primary hospitals from August to September 2020. The data are presented as frequencies and means (±SD) of our findings. The independent samples T test and One-Way Analysis of Variance (ANOVA) were used to explore the mean knowledge differences of antibiotic use among respondents. A pvalue of <0.05 with 95% CI was considered significant.

Results

More than half of the participants (57.2%) were males, and the mean age was 34.8 ± 13.4 years. The mean (±SD) knowledge score of the respondents was 3.69 (±1.7) (range: 0 to 10), and the majority (69.7%) had poor knowledge. The mean (±SD) belief score (acceptance towards antibiotic use) of the respondents was 20.08 ± 4 (range: 7 to 35) and most (70.1%) of the respondents had moderate levels of perception regarding antibiotic use. The majority (69.5%) of respondents took antibiotics over the past year. Participants practiced inappropriate uses of antibiotics such as medication discontinuation (49.5%), keeping unused antibiotics for future use (35.5%), and sharing medications with/from others (30.1%). Diploma holder participants had significantly higher mean knowledge scores on antibiotic use than those who were unable to read and write (p=0.047). Similarly, students had higher mean knowledge scores compared with farmers (p=0.024), merchants (p=0.031), and housewives (p=0.047).

Conclusion

Our study showed a widespread misuse of antibiotics in Northwest Ethiopia. Malpractice such as dose interrupting, sharing of antibiotics for/from the others, and keeping leftover drugs for future use were common among the respondents. These findings suggest that a greater effort is required in public education related to proper and safe uses of antibiotics and that greater efforts are needed to enforce the control of antibiotic use to overcome the emergence of antibiotic resistance.

The diversity in antimicrobial resistance of MDR Enterobacteriaceae among Chinese broiler and laying farms and two mcr-1 positive plasmids revealed their resistance-transmission risk

This research aimed to investigate the microbial composition and diversity of antimicrobial resistance genes (ARGs) found in Chinese broiler and layer family poultry farms. We focused on the differences in resistance phenotypes and genotypes of multidrug-resistant Enterobacteriaceae (MDRE) isolated from the two farming environments and the existence and transmissibility of colistin resistance gene mcr-1. Metagenomic analysis showed that Firmicutes and Bacteroides were the dominant bacteria in broiler and layer farms. Many aminoglycoside and tetracycline resistance genes were accumulated in these environments, and their absolute abundance was higher in broiler than in layer farms. A total of 526 MDRE were isolated with a similar distribution in both farms. The results of the K-B test showed that the resistance rate to seven antimicrobials including polymyxin B and meropenem in broiler poultry farms was significantly higher than that in layer poultry farms (P ≤ 0.05). PCR screening results revealed that the detection rates of mcr-1, aph(3’)Ia, aadA2, bla_oxa–1, bla_CTX–M, fosB, qnrD, sul1, tetA, and catA1 in broiler source MDRE were significantly higher than those in layers (P ≤0.05). A chimeric plasmid p20432-mcr which carried the novel integron In1866 was isolated from broiler source MDRE. The high frequency of conjugation (10^–1 to 10^–3) and a wide range of hosts made p20432-mcr likely to play an essential role in the high detection rate of mcr-1, aph(3’)-Ia, and aadA2 in broiler farms. These findings will help optimize disinfection and improve antimicrobial-resistant bacteria surveillance programs in poultry farms, especially broilers.

The co-administration effects of florfenicol and lasalocid on performance, biochemical and pathological parameters of muscle, heart, liver, kidney and sciatic nerve in broiler chickens

The study aimed to examine the effect of simultaneous application of florfenicol and lasalocid on the performance and vital organ function of chickens. For this, 300 chicks were divided into four groups. Group one to three received florfenicol, lasalocid and lasalocid plus florfenicol, respectively. Group four as the control group received a basic diet without lasalocid or florfenicol. Lasalocid was used from 7 to 35 days old, continuously. Florfenicol was used at 21 days old for 5 days. The growth indices were measured at the end of each week. The chickens were euthanized at the ages of 28 and 35 days old after collecting blood samples with and without anticoagulants. The liver, heart, muscle, kidney and sciatic nerve were collected in formalin 10% for histopathological examination. The blood and serum samples were used to determine clinical pathologic and hematologic indices. The ratio of internal organs to body weight and ratio of the right ventricle to the total ventricles (RV/TV) of the heart was measured. Results showed, the use of lasalocid decreased feed conversion rate and triglyceride, and increased total protein. Simultaneous administration of lasalocid and florfenicol affected histopathology of the liver and heart and significantly increased creatine phosphokinase, uric acid and the ratio of RV/TV of heart. The eosinophil percentage in the chickens who received florfenicol plus lasalocid was significantly higher than chickens who received florfenicol alone (p < 0.05). In conclusion, it seems that simultaneous administration of the florfenicol and lasalocid induces side-effects especially on cardiac function and it is not recommended.

A systematic review of qualitative literature on antimicrobial stewardship in Sub-Saharan Africa

BACKGROUND

Antibiotic resistance is a major problem in every region of the globe and Sub-Saharan Africa (SSA) is no exception. Several systematic reviews have addressed the prevalence of resistant organisms but few have examined the underlying causes in this region. This systematic review of qualitative literature aims to highlight barriers and facilitators to antimicrobial stewardship in SSA.

METHODS

A literature search of Embase and MEDLINE(R) was carried out. Studies were included if they were in English, conducted in SSA, and reported qualitative data on the barriers and facilitators of antimicrobial stewardship or on attitudes towards resistance promoting behaviours. Studies were screened with a simple critical appraisal tool. Secondary constructs were extracted and coded into concepts, which were then reviewed and grouped into themes in light of the complete dataset.

RESULTS

The literature search yielded 169 results, of which 14 studies from 11 countries were included in the final analysis. No studies were excluded as a result of the critical appraisal. Eight concepts emerged from initial coding, which were consolidated into five major themes: ineffective regulation, health system factors, clinical governance, patient factors and lack of resources. The ineffective regulation theme highlighted the balance between tightening drugstore regulation, reducing over-the-counter sale of antibiotics, and maintaining access to medicines for rural communities. Meanwhile, health system factors explored the tension between antimicrobial stewardship and the need of pharmacy workers to maintain profitable businesses. Additionally, a lack of resources, actions by patients and the day-to-day challenges of providing healthcare were shown to directly impede antimicrobial stewardship and exacerbate other factors which promote resistance.

CONCLUSION

Antibiotic resistance in SSA is a multi-faceted issue and while limited resources contribute to the problem they should be viewed in the context of other factors. We identify several contextual factors that affect resistance and stewardship that should be considered by policy makers when planning interventions. This literature base is also incomplete, with only 11 nations accounted for and many studies being confined to regions within countries, so more research is needed. Specifically, further studies on implementing stewardship interventions, successful or not, would be beneficial to inform future efforts.

Caecal microbiota could effectively increase chicken growth performance by regulating fat metabolism

It has been established that gut microbiota influences chicken growth performance and fat metabolism. However, whether gut microbiota affects chicken growth performance by regulating fat metabolism remains unclear. Therefore, seven‐week‐old chickens with high or low body weight were used in the present study. There were significant differences in body weight, breast and leg muscle indices, and cross‐sectional area of muscle cells, suggesting different growth performance. The relative abundance of gut microbiota in the caecal contents at the genus level was compared by 16S rRNA gene sequencing. The results of LEfSe indicated that high body weight chickens contained Microbacterium and Sphingomonas more abundantly (P < 0.05). In contrast, low body weight chickens contained Slackia more abundantly (P < 0.05). The results of H & E, qPCR, IHC, WB and blood analysis suggested significantly different fat metabolism level in serum, liver, abdominal adipose, breast and leg muscles between high and low body weight chickens. Spearman correlation analysis revealed that fat metabolism positively correlated with the relative abundance of Microbacterium and Sphingomonas while negatively correlated with the abundance of Slackia. Furthermore, faecal microbiota transplantation was performed, which verified that transferring faecal microbiota from adult chickens with high body weight into one‐day‐old chickens improved growth performance and fat metabolism in liver by remodelling the gut microbiota. Overall, these results suggested that gut microbiota could affect chicken growth performance by regulating fat metabolism.

The impact of suitability of empirical antibiotics use on therapeutic outcome of respiratory tract infection patients at inpatient wards of Universitas Gadjah Mada Academic Hospital

OBJECTIVES

Currently, respiratory infection is regarded as one of the most common infectious diseases. This study aims to find out the impact of appropriate use of empirical antibiotic on therapeutic outcomes of patients with respiratory infections at inpatient wards of UGM Academic Hospital.

METHODS

This is a cross-sectional study that uses retrospective data through patient medical records. The population was all patients who received empirical antibiotic therapy for respiratory infections at inpatient ward from July 2018 to July 2019. The sample was collected using the purposive sampling method, and the total number of samples was 192. The appropriate use of empirical antibiotic including the correct type, dosage, route, duration, and frequency was evaluated according to the Antibiotic Guidelines of UGM Academic Hospital 2018, Drug Information Handbook, Frank Shann Drug Doses, Infectious Disease Society of America (IDSA)/American Thoracic Society (ATS) 2016 & 2019, Pharmacotherapy Handbook 2015, and Pharmaceutical Care for Respiratory Tract Infections 2005. The data was analyzed descriptively by using Chi-square bivariate analysis.

RESULTS

The result shows that 47.9% of 192 patients have received antibiotics properly according to the type, route, dose, frequency, and duration. The results of empirical antibiotic therapy have improved the repair of vital signs in 37.5% of patients. Meanwhile, the result of Chi-square bivariate analysis between the suitability of empirical antibiotic use and the improvement of therapeutic outcome is p=0.478 (p>0.05), which means that it is not statically significant.

CONCLUSIONS

It can be concluded that there is no correlation between the suitability of empirical antibiotics use and the improvement of the therapy outcomes. Thus, the use of empirical antibiotics based on the guidelines does not always have an impact on the improvement of the treatment outcomes of the patients with respiratory infection at inpatient wards of UGM Academic Hospital.

Environmental hotspots for antibiotic resistance genes

Bacterial resistance toward broad-spectrum antibiotics has become a major concern in recent years. The threat posed by the infectious bacteria and the pace with which resistance determinants are transmitted needs to be deciphered. Soil and water contain unique and diverse microbial communities as well as pools of naturally occurring antibiotics resistant genes. Overuse of antibiotics along with poor sanitary practices expose these indigenous microbial communities to antibiotic resistance genes from other bacteria and accelerate the process of acquisition and dissemination. Clinical settings, where most antibiotics are prescribed, are hypothesized to serve as a major hotspot. The predisposition of the surrounding environments to a pool of antibiotic-resistant bacteria facilitates rapid antibiotic resistance among the indigenous microbiota in the soil, water, and clinical environments via horizontal gene transfer. This provides favorable conditions for the development of more multidrug-resistant pathogens. Limitations in detecting gene transfer mechanisms have likely left us underestimating the role played by the surrounding environmental hotspots in the emergence of multidrug-resistant bacteria. This review aims to identify the major drivers responsible for the spread of antibiotic resistance and hotspots responsible for the acquisition of antibiotic resistance genes.

Disposal practices of expired and unused medications among households in Mwanza, Tanzania

BACKGROUND

The community practice towards disposal of expired and unused medications in spite of its adverse impact have been widely neglected in many developing countries. The available guidelines in Tanzania focus on the disposal of expired medications and cosmetics in hospitals and community pharmacies only.

AIM

The aim of this study was to assess the disposal practice of expired and unused medications at household level in Mwanza city, north-western Tanzania.

METHODOLOGY

The household based cross-sectional study was conducted among 359 randomly selected household members. Semi-structured questionnaires were used for interview during data collection and while STATA® version 13 was used for analysis.

RESULTS

Out 359 households visited, 252 (70.19%) had medications kept in their houses at the time of data collection. Among them, 10 (4.0%) households had kept medications at their houses because they were still continuing with treatment while 242 (96.0%) kept unused medications which were supposed to be discarded. The main reason for keeping unused or expired medications at home was uncompleted course of treatment (199 (82.20%) after feeling that they had recovered from illness. The main reason for discarding medications were recovering from illness (141(48.7%) and expiry (136 (46.9%). The major discarding practices for medications were disposing into domestic trashes (219 (75.5%) and pit latrines (45 (15.5%). Majority of respondents (273 (76%) were aware that improper disposal of expired medications are detrimental to human health and environment in general.

CONCLUSION

Improper disposal of unused and expired medications at household level was a common practice in the study area. Tailor-made interventions by the Food and Drugs Authority (FDA) and other national as well as local stake holders are urgently needed to address the situation.

Successful Incidences of Controlling Multidrug-Resistant, Extensively Drug-Resistant, and Nosocomial Infection Acinetobacter baumannii Using Antibiotic Stewardship, Infection Control Programs, and Environmental Cleaning at a Chinese University Hospital

Objective

We estimated the efficacy of antimicrobial stewardship (AMS), infection control programs (ICP), and environmental cleaning (ENC) for controlling the resistance of Acinetobacter baumannii (AB) and controlling the incidence of multidrug-resistant AB (MDRAB), extensively drug-resistant AB (XDRAB), and nosocomial infection AB in the ICU (NIAB-ICU) at a university hospital.

Methods

The intervention included 4-year AMS+ICP and 3-year AMS+ICP+ENC between January 2012 and December 2019.

Results

A total of 2636 AB isolates were collected totally, and 64.98% of AB isolates were MDR and 29.97% were XDR. Preintervention and postintervention incidences of MDRAB, XDRAB, and NIAB-ICU by AMS+ICP measures ranged from 84.96% to 71.98%, 41.96% to 33.13%, and 45.6% to 38%, respectively. However, all of them were not statistically changed (P=0.085, 0.072, 0.061, separately). The preintervention and postintervention incidences of MDRAB, XDRAB, and NIAB-ICU by AMS+ICP+ENC measures ranged from 71.98% to 36.55%, 33.13% to 19.88%, and 38% to 22.5%, respectively. Statistically significant declines were observed (P=0.016, 0.041, 0.032, separately). The defined daily doses (DDD) per 1000 patient-days (PD) decreased from 45±3.3 to 30.81±1.5 per 1000 PD across from 2012 to 2019, and a statistical decline was seen (P=0.01). Concurrently, the alcohol-based hand gel (ABHG) consumption per 1000 PD increased from 0.6±0.05 L to 12.5±2.3 L per 1000 PD, and a statistical increase was observed (P=0.0001). A statistically positive correlation was revealed between the DDD and incidence of MDRAB, XDRAB, and NIAB-ICU (r=0.905 and p=0.002; r=0.939 and p=0.001; r=0.956 and p=0.0002; respectively). Simultaneously, a statistically negative correlation was showed between the ABHG and incidence of MDRAB, XDRAB, and NIAB-ICU (r=-0.858 and p=0.006; r=-0.888 and p=0.003; r=-0.882 and p=0.004, separately).

Conclusion

The AMS, ICP, and ENC may be one of the most effective and best measures to address the increasing incidence of MDRAB, XDRAB, and NIAB-ICU currently.

Isolation and Comparative Genomic Analysis of Reuterin-Producing Lactobacillus reuteri From the Chicken Gastrointestinal Tract

Lactobacillus reuteri is a natural inhabitant of selected animal and human gastrointestinal tract (GIT). Certain strains have the capacity to transform glycerol to 3-hydroxypropionaldehyde (3-HPA), further excreted to form reuterin, a potent antimicrobial system. Reuterin-producing strains may be applied as a natural antimicrobial in feed to prevent pathogen colonization of animals, such as in chicken, and replace added antimicrobials. To date, only seven L. reuteri strains isolated from chicken have been characterized which limits phylogenetic studies and host-microbes interactions characterization. This study aimed to isolate L. reuteri strains from chicken GIT and to characterize their reuterin production and antimicrobial resistance (AMR) profiles using phenotypic and genetic methods. Seventy strains were isolated from faces, crops and ceca of six chicken from poultry farms and samples from slaughterhouse. Twenty-five strains were selected for further characterization. Draft genomes were generated for the new 25 isolates and integrated into a phylogenetic tree of 40 strains from different hosts. Phylogenetic analysis based on gene content as well as on core genomes showed grouping of the selected 25 L. reuteri chicken isolates within the poultry/human lineage VI. Strains harboring pdu-cob-cbi-hem genes (23/25) produced between 156 mM ± 11 and 330 mM ± 14 3-HPA, from 600 mM of glycerol, in the conditions of the test. All 25 chicken strains were sensitive to cefotaxime (MIC between 0.016 and 1 μg/mL) and penicillin (MIC between 0.02 and 4 μg/mL). Akin to the reference strains DSM20016 and SD2112, the novel isolates were resistant to penicillin, possibly associated with identified point mutations in ponA, pbpX, pbpF and pbpB. All strains resistant to erythromycin (4/27) carried the ermB gene, and it was only present in chicken strains. All strains resistant to tetracycline (5/27) harbored tetW gene. This study confirms the evolutionary history of poultry/human lineage VI and identifies pdu-cob-cbi-hem as a frequent trait but not always present in this lineage. L. reuteri chicken strains producing high 3-HPA yield may have potential to prevent enteropathogen colonization of chicken.

The Landscape of Anthrax Prevention and Control: Stakeholders' Perceptive in Odisha, India

The prevalence and outbreaks of anthrax are interlinked with the animal-environment-human context, which signifies the need for collaborative, trans-disciplinary and multi-sectoral approaches for the prevention and control of anthrax. In India, there are hardly any shreds of evidence on the role of various stakeholders' on anthrax prevention and control. Therefore, this study addressed the experiences of various stakeholders on anthrax prevention and control strategies in Odisha, India. A qualitative explorative study was carried out using 42 in-depth-interviews among the stakeholders from health, veterinary and general administrative departments from the block, district, and state level. Two major themes emerged: (1) Epidemiological investigation of anthrax in Odisha, India, and (2) Biological and social prevention strategies for anthrax in Odisha, India. The study emphasizes setting up the surveillance system as per standard guideline, and strengthening the diagnostic facility at a regional medical college laboratory to avoid delay. Moreover, it emphasizes step-up inter-sectoral co-ordination, collaboration and sensitization among health, veterinary, forestry, education, nutrition and tribal welfare departments at all levels in order to reduce the prevalence and control the outbreaks of anthrax in Odisha state. It also recommends raising community literacy, in particular on safe carcass disposal, changing behavior on dead-livestock consumption, and compliance with livestock vaccinations.

Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems

World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is fraught with several challenges. The key limiting factors include lack of clear political commitment, inadequate funding, overcrowded healthcare systems, lax legal and regulatory frameworks, non-uniform access to diagnostics, absence of electronic health record systems, limited knowledge and awareness especially with existence of multiple systems of medicines, issues with access to quality assured medicines, in-house pharmacies, and shortage of trained manpower. Since these implementation-impeding issues may differ considerably from those experienced in developed economies, intervention efforts in low- and middle-income countries (LMICs) need to address the context and focus on the root causes prevailing locally. In this article, we review the evidence highlighting the magnitude of these challenges and suggest feasible models with effective application. We also share the evidence from our center where we have contextualized the core elements to resource constrained settings. These domains include delivering prospective audit and feedback, prescriber education, development of evidence-based and implementable guidelines, and optimization of surgical antibiotic prophylaxis. However, there is a tremendous need for scaling up, extending outreach and honing these models while at the same time, addressing the existing strategic challenges that curtail the full potential of global antimicrobial stewardship.

Current trends of antimicrobials used in food animals and aquaculture

Human population has been increasing rapidly, which ultimately increases human consumption, especially, animal protein requirements. Therefore, demands of animal protein consumption are increasing worldwide at an extraordinary rate. In order to meet the protein demand, intensive animal and aquaculture farming are considered. Like livestock farming (poultry, pigs, sheep, livestock, horses, rabbits, etc.), aquaculture farming (fish, crustaceans, mollusks, etc.) is also becoming the globe's emergent protein production sector. More than 580 aquaculture species are farmed worldwide. Current food animal and aquaculture farming are coupled with standard usage of antimicrobials. The antimicrobial drugs are major solutions for the management of contagious illnesses in food animals and aquaculture. In animal husbandry, antimicrobials are widely utilized for animal therapy, prophylaxis, or as growth promoters. Imprudent usage of these antimicrobials in food animals and aquaculture is a major contributing factor in the spread of antimicrobial resistance. The widespread use of veterinary medicines is considered to signify a frightening population health threat. It not only results in the disclosure and escalation of resistant microbes but also causes other individual, animal, and ecological deterioration. The contribution of resistant microbes from various sources seems to be the major base of resistance in the environment. However, strict policies and regulations for antimicrobial usage in food animals and aquaculture must be made and applied. It is important to prevent their negative effects in humans, food animals, aquaculture, and the environment.

Survey on antimicrobial usage in local dairy cows in North-central Nigeria: Drivers for misuse and public health threats

Background

Antimicrobials are used as a measure to maintain good health and productivity of lactating cows. This study assessed pastoralists’ knowledge and practices regarding AMU in lactating cows; and risk pathways for AMR dissemination from cow milk to humans.

Methods

Interview questionnaire-based cross-sectional study was conducted in Fulani pastoral communities. Frequencies and proportions were used for descriptive statistics. Chi-square test and multivariable logistic regressions were used for analytic statistics at 95% confidence level.

Results

All recruited 384 pastoral households participated. About 11% of participants indicated antimicrobials misuse as when given at under-dose, while 58.9% had no knowledge of what antimicrobial misuse entailed. Most participants (51.6%) were unaware about effects of improper AMU. Most respondents (61.7%) reported self-prescription of antimicrobials used on cows. Also, 67.4% of respondents reported arbitrary applications of antimicrobials used in cows, while 15% used antimicrobials to increase milk yield. Frequently used antimicrobials were: tetracycline (98.7%), penicillin (96.6%), streptomycin (95.8%) and sulfonamides (95.3%). Consumption of raw milk and milk products (p = 0.010); contacts with contaminated udder (p = 0.002); and aerosols of discarded contaminated milk P = 0.001) were perceived risk pathways for spread of antimicrobial resistance from cow milk. Improper AMU (p<0.001), non-enforcement of regulating laws (p<0.001), weak financial status (p<0.001), and low education and expertise (p<0.001) influenced antimicrobials misuse in lactating cows.

Conclusions

This study highlighted low levels of knowledge, risk perceptions and practices regarding AMU and AMR among survey pastoralists. This calls for education of the vulnerable populations on promotion of prudent AMU in lactating cows through ‘One Health’ approach, to assure food safety, food security, and public and environmental health.

Prevention of antibiotic resistance - an epidemiological scoping review to identify research categories and knowledge gaps

BACKGROUND

Antibiotics have become the cornerstone for the treatment of infectious diseases and contributed significantly to the dramatic global health development during the last 70 years. Millions of people now survive what were previously life-threatening infections. But antibiotics are finite resources and misuse has led to antibiotic resistance and reduced efficacy within just a few years of introduction of each new antibiotic. The World Health Organization rates antibiotic resistance as a 'global security threat' impacting on global health, food security and development and as important as terrorism and climate change.

OBJECTIVES

This paper explores, through a scoping review of the literature published during the past 20 years, the magnitude of peer-reviewed and grey literature that addresses antibiotic resistance and specifically the extent to which "prevention" has been at the core. The ultimate aim is to identify know-do gaps and strategies to prevent ABR.

METHODS

The review covers four main data bases, Web of Science, Medline, Scopus and Ebsco searched for 2000-17. The broader research field "antibiotic OR antimicrobial resistance" gave 431,335 hits. Narrowing the search criteria to "Prevention of antibiotic OR antimicrobial resistance" resulted in 1062 remaining titles. Of these, 622 were unique titles. After screening of the 622 titles for relevance, 420 abstracts were read, and of these 282 papers were read in full. An additional 53 references were identified from these papers, and 64 published during 2018 and 2019 were also included. The final scoping review database thus consisted of 399 papers.

RESULTS

A thematic structure emerged when categorizing articles in different subject areas, serving as a proxy for interest expressed from the research community. The research area has been an evolving one with about half of the 399 papers published during the past four years of the study period. Epidemiological modelling needs strengthening and there is a need for more and better surveillance systems, especially in lower- and middle-income countries. There is a wealth of information on the local and national uses and misuses of antibiotics. Educational and stewardship programmes basically lack evidence. Several studies address knowledge of the public and prescribers. The lessons for policy are conveyed in many alarming reports from national and international organizations.

CONCLUSIONS

Descriptive rather than theoretical ambitions have characterized the literature. If we want to better understand and explain the antibiotic situation from a behavioural perspective, the required approaches are lacking. A framework for an epidemiological causal web behind ABR is suggested and may serve to identify entry points for potential interventions.

Antimicrobial dispensing practices and determinants of antimicrobial resistance: a qualitative study among community pharmacists in Pakistan

Background

There are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates.

Objective

To explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists.

Design

In this qualitative study design, a semistructured interview guide was developed based on an in-depth review of published papers. Audio-recorded interviews with transcripts were analysed by thematic content analysis.

Setting

Interviews were conducted among community pharmacists in Lahore, Pakistan.

Participants

In order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted.

Results

A total of 12 pharmacists were interviewed for the study. After analysis, four major themes emerged: (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR. Most of the pharmacists have limited knowledge about AMR, antimicrobial stewardship programmes and related guidelines. However, all the pharmacists strongly agreed that different appropriate actions should be taken in order to rationalise future antimicrobial use.

Conclusion

The results indicated that irrational antimicrobial dispensing and use is common among community pharmacists in Pakistan owing to lack of knowledge. The community pharmacists perceived that behaviour of patients and the societal environment contributed to irrational antimicrobial use and subsequent development of AMR. They suggested a need for a multidisciplinary framework in order to improve future antimicrobial use and reduce AMR in Pakistan.

"Without antibiotics, I cannot treat": A qualitative study of antibiotic use in Paschim Bardhaman district of West Bengal, India

BACKGROUND

Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal.

MATERIALS AND METHODS

We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner.

RESULTS

Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another.

CONCLUSIONS

A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts.

Knowledge, attitudes, and practices related to antibiotic use in Paschim Bardhaman District: A survey of healthcare providers in West Bengal, India

Introduction

Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature.

Objectives

This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use.

Methods

We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender.

Results

Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics.

Conclusions

Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention.

Antibiotic resistance: A cross-sectional study on knowledge, attitude, and practices among veterinarians of Haryana state in India

Aim:

The current study aimed to assess the knowledge, attitude, and practices pertaining to antibiotic usage among the field veterinarians who serve as nodal officers playing a crucial role in disseminating knowledge to the farmers regarding livestock management practices in India.

Materials and Methods:

A pilot study was conducted in which 106 of the 173 field veterinarians of Haryana, India, agreed to contribute through their valuable participation in the study. The collected data were critically analyzed by simple descriptive statistics, and the responses were ranked using Garrett’s ranking method.

Results:

Our study found that most of the clinicians were aware of the fundamental clinical aspects of antibiotic resistance (AR), i.e., the general causes and transmission of resistance, response during treatment failure, and safe disposal of hospital waste. Further, implementation of “antibiotic stewardship” (rational/responsible use of antibiotics) and interruption of AR transmission by means of cross-kingdom pathogens are two ways to restrict the spread of resistant pathogens which were not in the clinical purview of majority of the clinicians. This highlights a lack of awareness and scope of improving clinician’s knowledge pertaining to AR. Moreover, we got to know the methodology adopted by farmers for disposal of infected milk from diseased udders as well as their attitude toward diseased and unproductive animals.

Conclusion:

This study provides snippets of the current animal husbandry practices prevalent at the field level which would assist to plug in the gaps of knowledge regarding AR among the veterinarians as well as the general public and serve to reduce its deleterious impacts in Indian animal farming as well as in the world through the concept of “One World, One Health.”

Evidence of factors influencing self-medication with antibiotics in low and middle-income countries: a systematic scoping review

OBJECTIVES

Self-medication with antibiotics (SMA) is a practice of global concern with a higher incidence within the low- and middle-income countries (LMICs). Despite worldwide efforts to control and promote the rational use of antibiotics, the continuing practice of SMA systematically exposes individuals and communities to the risk of antibiotic resistance and a host of other antibiotic side-effects. This systematic scoping review maps evidence on the factors influencing SMA in these settings.

STUDY DESIGN

Systematic scoping review.

METHODS

The search strategy involved electronic databases including PubMed, Web of science, Science Direct, EBSCOhost, Google Scholar, BioMed Central, and the World Health Organization Library. PRISMA P guidelines and Arksey and O'Malley's framework were used. Thematic analysis was used to identify the factors that influence the practices of SMA in LMICs. The Mixed Method Appraisal Tool (MMAT), version 2011, was used to assess the quality of the included primary studies.

RESULTS

Fifteen studies met the inclusion criteria. Studies included participants from the following LMICs: Guatemala, India, Indonesia, Kenya, Laos, Nepal, Nigeria, Pakistan, Sri Lanka, and Yemen. The findings of the review emphasized a considerable high prevalence of SMA, ranging from 8.1% to 93%, with an association with the level of education, monthly income, and gender of participants. Accessibility, affordability, and conditions of health facilities, as well as the health-seeking behavior, are factors that influence SMA in LMICs. Health conditions such as a sore throat, common cold, cough, headache, toothache, flu-like symptoms, pain relief, fever, runny nose, toothache, upper respiratory tract infections, and urinary tract infection were the major complaints that led to the practices of SMA.

CONCLUSIONS

There is a considerable level of research evidence predominantly in some LMICs from Asia, with less evidence from African LMICs. Sociocultural determinants of health associated with the structure and conditions of health system as well as the health-seeking behavior are the main factors influencing SMA. Contextual and comprehensive studies on the factors influencing the non-prescribed use of antibiotics are needed to enable evidence-based strategies to correctly address the utilization of antibiotics and contain the problem of antimicrobial resistance, especially within the LMICs.

PROSPERO REGISTRATION

CRD42017072954.

Antimicrobial usage by pastoralists in food animals in North-central Nigeria: The associated socio-cultural drivers for antimicrobials misuse and public health implications

Antimicrobials are used to maintain good health and productivity of food animals. Misuse of antibiotics in livestock contributes to development of antimicrobial resistance, an emerging One Health issue. This study assessed pastoralists' knowledge and practices regarding antimicrobial usage, explore pathways for resistant pathogens emergence and associated social drivers for antimicrobial misuse in pastoral herds of North-central Nigeria. An interview questionnaire-based cross-sectional survey was conducted in randomly selected pastoral households. Descriptive and analytical statistical analyses were performed at 95% confidence level. All the 384 pastoralists participated in the study. Majority (58%) of respondents had no formal education. Only 8.1% of respondents knew antibiotic misuse to be when given under-dose and 70.1% of them did not know what misuse entailed. About 58.3% reported self-prescription of antimicrobials used on animals, while 67% of them reported arbitrary applications for dosage determination. Most frequently used antimicrobials were tetracycline (96.6%), tylosin (95.6%) and penicillin (94.0%). Identified pathways for antimicrobial resistant pathogens spread to humans were through contaminated animal products; contaminated animals and fomites; and environmental wastes. Improper antimicrobial usage (p < 0.001), non-enforcement of laws regulating antimicrobial usage (p < 0.001), weak financial status (p < 0.001), low education and expertise (p < 0.001), and nomadic culture (p < 0.001), influenced antimicrobials misuse in livestock. The study revealed low levels of knowledge and practices regarding antimicrobial usage in livestock. Socio-cultural activities significantly influenced antimicrobials misuse in livestock. Improve pastoralists' knowledge about effects of antimicrobials misuse and promotion of prudent usage in livestock will mitigate antimicrobial resistance menace in animals and humans.

Tracking antibiotic resistome during wastewater treatment using high throughput quantitative PCR

Wastewater treatment plants (WWTPs) contain diverse antibiotic resistance genes (ARGs), and thus are considered as a major pathway for the dissemination of these genes into the environments. However, comprehensive evaluations of ARGs dynamic during wastewater treatment process lack extensive investigations on a broad spectrum of ARGs. Here, we investigated the dynamics of ARGs and bacterial community structures in 114 samples from eleven Chinese WWTPs using high-throughput quantitative PCR and 16S rRNA-based Illumina sequencing analysis. Significant shift of ARGs profiles was observed and wastewater treatment process could significantly reduce the abundance and diversity of ARGs, with the removal of ARGs concentration by 1-2 orders of magnitude. Whereas, a considerable number of ARGs were detected and enriched in effluents compared with influents. In particular, seven ARGs mainly conferring resistance to beta-lactams and aminoglycosides and three mobile genetic elements persisted in all WWTPs samples after wastewater treatment. ARGs profiles varied with wastewater treatment processes, seasons and regions. This study tracked the footprint of ARGs during wastewater treatment process, which would support the assessment on the spread of ARGs from WWTPs and provide data for identifying management options to improve ARG mitigation in WWTPs.

Prevalence of antibiotic resistance in commensal Escherichia coli among the children in rural hill communities of Northeast India

Commensal bacteria are the representative of the reservoir of antibiotic resistance genes present in a community. The usage of antibiotics along with the demographic factors is generally associated with an increase in antibiotics resistance in pathogens. Northeast (NE) India is untapped with regard to antibiotic resistance prevalence and spread. In the current study, the prevalence of antibiotic-resistant commensal Escherichia coli in pre-school and school-going children (n = 550, 1–14 years old) from the rural areas of the state of Sikkim—an NE Indian state, with respect to associated demographic factors was investigated. A total of 550 fecal E. coli isolates were collected during July 2015 to June 2017. A structured questionnaire was used to collect data to ascertain the potential factors associated with the carriage of antibiotic resistance E. coli among the children. Statistical analysis along with a logistic regression identified potential external factors affecting the observed antibiotic resistance pattern. The data indicated a high prevalence of resistance to common antibiotics like ampicillin (92%), ceftazidime (90%), cefoxitin (88%), streptomycin (40%) and tetracycline (36%), but no resistance to chloramphenicol. The resistance to the combination of penicillin and quinolone group of antibiotics was observed in fifty-two percent of the isolates. A positive correlation between the harboring of antibiotics resistant E. coli with different demographic factors was observed such as, with children living in nuclear family (vs joint family 63.15%, OR 0.18, 95% CI:0.11–0.28, p < 0.01), below higher secondary maternal education (vs college graduates 59.27% OR 0.75, 95% CI:0.55–1.02, p < 0.02). A close association between different demographic factors and the high prevalence of antibiotic-resistant commensal E. coli in the current study suggests a concern over rising misuse of antibiotics that warrants a future threat of emergence of multidrug-resistant pathogen isolates.

Using mobile technology to optimize disease surveillance and healthcare delivery at mass gatherings: a case study from India's Kumbh Mela

Background

Planning for mass gatherings often includes temporary healthcare systems to address the needs of attendees. However, paper-based record keeping has traditionally precluded the timely application of collected clinical data for epidemic surveillance or optimization of healthcare delivery. We evaluated the feasibility of harnessing ubiquitous mobile technologies for conducting disease surveillance and monitoring resource utilization at the Allahabad Kumbh Mela in India, a 55-day festival attended by over 70 million people.

Methods

We developed an inexpensive, tablet-based customized disease surveillance system with real-time analytic capabilities, and piloted it at five field hospitals.

Results

The system captured 49 131 outpatient encounters over the 3-week study period. The most common presenting complaints were musculoskeletal pain (19%), fever (17%), cough (17%), coryza (16%) and diarrhoea (5%). The majority of patients received at least one prescription. The most common prescriptions were for antimicrobials, acetaminophen and non-steroidal anti-inflammatory drugs. There was great inter-site variability in caseload with the busiest hospital seeing 650% more patients than the least busy hospital, despite identical staffing.

Conclusions

Mobile-based health information solutions developed with a focus on user-centred design can be successfully deployed at mass gatherings in resource-scarce settings to optimize care delivery by providing real-time access to field data.

The social biography of antibiotic use in smallholder dairy farms in India

Background

Antimicrobial resistance (AMR) has been identified as one of the major threats to global health, food security and development today. While there has been considerable attention about the use and misuse of antibiotics amongst human populations in both research and policy environments, there is no definitive estimate of the extent of misuse of antibiotics in the veterinary sector and its contribution to AMR in humans. In this study, we explored the drivers ofirrational usage of verterinary antibiotics in the dairy farming sector in peri-urban India.

Methods and materials

The study was conducted in the peri-urban belts of Ludhiana, Guwahati and Bangalore. A total of 54 interviews (formal and non-formal) were carried out across these three sites. Theme guides were developed to explore different drivers of veterinary antimicrobial use. Data was audio recorded and transcribed. Analysis of the coded data set was carried out using AtlasTi. Version 7. Themes emerged inductively from the set of codes.

Results

Findings were presented based on concept of 'levels of analyses'. Emergent themes were categorised as individual, health systems, and policy level drivers. Low level of knowledge related to antibiotics among farmers, active informal service providers, direct marketing of drugs to the farmers and easily available antibiotics, dispensed without appropriate prescriptions contributed to easy access to antibiotics, and were identified to be the possible drivers contributing to the non-prescribed and self-administered use of antibiotics in the dairy farms.

Conclusions

Smallholding dairy farmers operated within very small margins of profits. The paucity of formal veterinary services at the community level, coupled with easy availability of antibiotics and the need to ensure profits and minimise losses, promoted non-prescribed antibiotic consumption. It is essential that these local drivers of irrational antibiotic use are understood in order to develop interventions and policies that seek to reduce antibiotic misuse.

Successful control of resistance in Pseudomonas aeruginosa using antibiotic stewardship and infection control programs at a Chinese university hospital: a 6-year prospective study

Objective

Pseudomonas aeruginosa is emerging as a highly multidrug-resistant (MDR) nosocomial pathogen. Data on the efficacy of infection control measures in endemic situations are lacking. We investigated the effect of antimicrobial stewardship (AMS) and infection control programs (ICPs) in controlling the resistance of P. aeruginosa at a tertiary hospital center.

Methods

Susceptibility and resistance were investigated using broth microdilution, as per the guidelines of the Clinical and Laboratory Standards Institute. Antibiotic use was restricted through AMS, which included a classification management system for antibiotic use. The ICPs included environmental cleaning and disinfection, hand hygiene, active surveillance of P. aeruginosa, and education about infection control.

Results

A total of 2,241 P. aeruginosa isolates were evaluated between 2012 and 2017. Sensitivity and resistance of the isolates to the antipseudomonal antimicrobials colistin and tigecycline were stable. The sensitivity and resistance to other antipseudomonal antimicrobials improved after 2014, after the AMS and ICPs were implemented in 2013. The use of alcohol-based hand gel significantly increased from 0.6 to 10.9 L per 1,000 patient-days (PD) during the study period (P=0.005). The incidence rates of extensively drug-resistant (XDR) and MDR P. aeruginosa showed a sustained decrease from 2013 (4.9 and 22%) to 2017 (1 and 15%), respectively. The yearly consumption of antimicrobial agents also showed a sustained and significant decrease from 45 defined daily doses (DDDs) per 1,000 PD to 38.15 DDDs per 1,000 PD (P=0.04). A significant correlation was found between the incidence rate of MDR P. aeruginosa and the consumption of antimicrobial agents (P=0.01).

Conclusion

Monitoring of P. aeruginosa, AMS, and comprehensive ICPs could be one of the best and effective methods to prevent the development of resistance in P. aeruginosa.

Antibiotic Use in Agriculture and Its Consequential Resistance in Environmental Sources: Potential Public Health Implications

Due to the increased demand of animal protein in developing countries, intensive farming is instigated, which results in antibiotic residues in animal-derived products, and eventually, antibiotic resistance. Antibiotic resistance is of great public health concern because the antibiotic-resistant bacteria associated with the animals may be pathogenic to humans, easily transmitted to humans via food chains, and widely disseminated in the environment via animal wastes. These may cause complicated, untreatable, and prolonged infections in humans, leading to higher healthcare cost and sometimes death. In the said countries, antibiotic resistance is so complex and difficult, due to irrational use of antibiotics both in the clinical and agriculture settings, low socioeconomic status, poor sanitation and hygienic status, as well as that zoonotic bacterial pathogens are not regularly cultured, and their resistance to commonly used antibiotics are scarcely investigated (poor surveillance systems). The challenges that follow are of local, national, regional, and international dimensions, as there are no geographic boundaries to impede the spread of antibiotic resistance. In addition, the information assembled in this study through a thorough review of published findings, emphasized the presence of antibiotics in animal-derived products and the phenomenon of multidrug resistance in environmental samples. This therefore calls for strengthening of regulations that direct antibiotic manufacture, distribution, dispensing, and prescription, hence fostering antibiotic stewardship. Joint collaboration across the world with international bodies is needed to assist the developing countries to implement good surveillance of antibiotic use and antibiotic resistance.

Prevailing practices in the use of antibiotics by dairy farmers in Eastern Haryana region of India

AIM

The aim of the study was to assess the antibiotic use in dairy animals and to trace its usage pattern among the small, medium, and large dairy farmers in Eastern Haryana region of India.

MATERIALS AND METHODS

Karnal and Kurukshetra districts from Eastern region of Haryana state were purposively selected, and four villages from each district were selected randomly. From each village, 21 farmers were selected using stratified random sampling by categorizing into small, medium, and large farmers constituting a total of 168 farmers as respondents. An antibiotic usage index (AUI) was developed to assess usage of antibiotics by dairy farmers.

RESULTS

Frequency of veterinary consultancy was high among large dairy farmers, and they mostly preferred veterinarians over para-veterinarians for treatment of dairy animals. Small farmers demanded low-cost antibiotics from veterinarians whereas large farmers rarely went for it. Antibiotics were used maximum for therapeutic purposes by all categories of farmers. Completion of treatment schedules and follow-up were strictly practiced by the majority of large farmers. AUI revealed that large farmers were more consistent on decision-making about prudent use of antibiotics. Routine use of antibiotics after parturition to prevent disease and sale of milk without adhering to withdrawal period was responsible for aggravating the antibiotic resistance. The extent of antibiotic use by small farmers depended on the severity of disease. The large farmers opted for the prophylactic use of antibiotics at the herd level.

CONCLUSION

Antibiotic usage practices were judicious among large dairy farmers, moderately prudent by medium dairy farmers and faulty by small farmers. The frequency of veterinary consultancy promoted better veterinary-client relationship among large farmers.

Maltese Antibiotic Stewardship Programme in the Community (MASPIC): protocol of a prospective quasiexperimental social marketing intervention

INTRODUCTION

Antibiotic misuse is a key driver of antibiotic resistance. In 2015/2016, Maltese respondents reported the highest proportions of antibiotic consumption in Europe. Since antibiotics are prescription-only medicines in Malta, research on effective strategies targeting general practitioners' (GPs) knowledge and behaviour is needed. Multifaceted behaviour change (BC) interventions are likely to be effective. Social marketing (SM) can provide the tools to promote sustained BC; however, its utilisation in Europe is limited. This paper aims to describe the design and methods of a multifaceted SM intervention aimed at changing Maltese GPs' antibiotic prescribing behaviour for patients with acute respiratory tract infections (aRTIs).

METHODS AND ANALYSIS

This 4-year quasiexperimental intervention study will be carried out in Malta and includes three phases: preintervention, intervention and postintervention. The preintervention phase intends to gain insight into the practices and attitudes of GPs, pharmacists and parents through interviews, focus group discussions and antibiotic prescribing surveillance. A 6-month intervention targeting GPs will be implemented following assessment of their prescribing intention and readiness for BC. The intervention will likely comprise: prescribing guidelines, patient educational materials, delayed antibiotic prescriptions and GP education. Outcomes will be evaluated in the postintervention phase through questionnaires based on the theory of planned behaviour and stages-of-change theory, as well as postintervention surveillance. The primary outcome will be the antibiotic prescribing rate for all patients with aRTIs. Secondary outcomes will include the proportion of diagnosis-specific antibiotic prescription and symptomatic relief medication prescribed, and the change in GPs stage-of-change and their intention to prescribe antibiotics.

ETHICS AND DISSEMINATION

The project received ethical approval from the University of Malta's Research Ethics Committee. Should this intervention successfully decrease antibiotic prescribing, it may be scaled up locally and transferred to similar settings.

TRIAL REGISTRATION NUMBER

NCT03218930; Pre-results.

A Three-Year Follow-Up Study of Antibiotic and Metal Residues, Antibiotic Resistance and Resistance Genes, Focusing on Kshipra-A River Associated with Holy Religious Mass-Bathing in India: Protocol Paper

BACKGROUND

Antibiotic resistance (ABR) is one of the major health emergencies for global society. Little is known about the ABR of environmental bacteria and therefore it is important to understand ABR reservoirs in the environment and their potential impact on health.

METHOD/DESIGN

Quantitative and qualitative data will be collected during a 3-year follow-up study of a river associated with religious mass-bathing in Central India. Surface-water and sediment samples will be collected from seven locations at regular intervals for 3 years during religious mass-bathing and in absence of it to monitor water-quality, antibiotic residues, resistant bacteria, antibiotic resistance genes and metals. Approval has been obtained from the Ethics Committee of R.D. Gardi Medical College, Ujjain, India (No. 2013/07/17-311).

RESULTS

The results will address the issue of antibiotic residues and antibiotic resistance with a focus on a river environment in India within a typical socio-behavioural context of religious mass-bathing. It will enhance our understanding about the relationship between antibiotic residue levels, water-quality, heavy metals and antibiotic resistance patterns in Escherichia coli isolated from river-water and sediment, and seasonal differences that are associated with religious mass-bathing. We will also document, identify and clarify the genetic differences/similarities relating to phenotypic antibiotic resistance in bacteria in rivers during religious mass-bathing or during periods when there is no mass-bathing.

Prescription patterns and appropriateness of antibiotics in the management of cough/cold and diarrhea in a rural tertiary care teaching hospital

BACKGROUND

Acute gastroenteritis and respiratory illnesses are the major causes of morbidity and mortality in children under 5 years of age. The objective of this study was to evaluate the prescription pattern of antibiotic utilization during the treatment of cough/cold and/or diarrhea in pediatric patients.

METHODS

A descriptive, cross-sectional study was conducted for 6 months in pediatric units of a tertiary care hospital in South India. Children under 5 years of age presenting with illness related to diarrhea and/or cough/cold were included in this study. Data were collected by reviewing patient files and then assessed for its appropriateness against the criteria developed in view of the Medication Appropriateness Index and Guidelines of the Indian Academy of Pediatrics. The results were expressed in frequencies and percentages. Chi-square test was used to analyze the data. A P < 0.05 was considered statistically significant.

RESULTS

A total of 303 patients were studied during the study period. The mean age of the patients was 3.5 ± 0.6 years. The majority of children were admitted mainly due to chief complaint of fever (63%) and cough and cold (56.4%). The appropriateness of antibiotic prescriptions was higher in bloody and watery diarrhea (83.3% and 82.6%; P < 0.05). Cephalosporins (46.2%) and penicillins (39.9%) were the most commonly prescribed antibiotics, though the generic prescriptions of these drugs were the lowest (13.5% and 10%, respectively). The seniority of prescriber was significantly associated with the appropriateness of prescriptions (P < 0.05). Antibiotics prescription was higher in cold/cough and diarrhea (93.5%) in comparison to cough/cold (85%) or diarrhea (75%) alone.

CONCLUSIONS

The study observed high rates of antibiotic utilization in Chidambaram during the treatment of cough/cold and/or diarrhea in pediatric patients. The findings highlight the need for combined interventions using education and expert counseling, targeted to the clinical conditions and classes of antibiotic for which inappropriate usage is most common.

'Struggling to be a defender of health' -a qualitative study on the pharmacists' perceptions of their role in antibiotic consumption and antibiotic resistance in Romania

BACKGROUND

Antibiotic resistance is a serious global public health problem directly correlated to high antibiotic consumption. Romania is one of the European countries with the highest rates of antibiotic consumption, non-prescription antibiotics use and resistance of several pathogens to antibiotics. Pharmacists are an important stakeholder in respect to antibiotic management and context specific research on this topic is needed. The aim of the research is to increase the understanding of how community pharmacists in Romania perceive their roles in respect to antibiotic consumption and antibiotic resistance. Semi-structured interviews with 18 pharmacists were conducted to explore the perceptions and attitudes of pharmacists towards their roles on antibiotics consumption and antibiotic resistance. Manifest and latent qualitative content analysis was used to analyse interview transcripts.

RESULTS

Three sub-themes emerged from the analysis. 'Maintaining equilibrium between ethics, law and economy' expresses how pharmacists often feel when trying to fulfil their duties considering all the dimensions of the pharmacist profession.' Antibiotic resistance problem rooted in a low social capital environment' reflects the pharmacists' perceptions of the deep causes of antibiotic resistance and the underlying problems that perpetuate the status quo and impact their role in relation to this problem. Wanting to fulfil their educational role illustrates how the pharmacists feel they could best contribute to improving the present situation. The overarching theme 'Undervalued medicines' professionals struggling with agency related and structural barriers to meet their deontological duties'- meaning the ethical responsibilities that come with the pharmacy practice, reflects that the pharmacists see their roles as being challenged by several barriers.

CONCLUSIONS

A health system and societal context perspective is helpful in order to understand the pharmacists' roles in respect to antibiotic consumption and antibiotic resistance. Health promotion interventions and policy revisions should take into account concepts of structure and agency. These could highlight barriers that pharmacists encounter in their activities related to antibiotics management.

Emergence of SCCmec Type I Obtained From Clinical Samples in Shiraz Teaching Hospitals, South-West of Iran

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a major cause of nosocomial infections. Methicillin resistance in S. aureus is caused by the acquisition of the mecA gene, located on a mobile genetic element called the staphylococcal cassette chromosome (SCC).

OBJECTIVES

The aim of this study was to evaluate the presence of the predominant SCCmec type present among clinical isolates.

MATERIALS AND METHODS

This cross-sectional study was performed on a total of 146 MRSA isolates obtained from clinical specimens between 2012 and 2013 from two major hospitals in Shiraz, Southwest of Iran. Antibiotic susceptibility profiles were determined by the disc diffusion method according to the guidelines of The Clinical and Laboratory Standards Institute. Bacterial DNA was extracted using the small-scale phenol-chloroform extraction method and was employed as polymerase chain reaction (PCR) templates for the assigned current SCCmec types.

RESULTS

The assigned SCCmec types by PCR revealed the SCCmec type I as the predominant type with 86 (58.9%) samples, followed by the SCCmec type II with 29 (19.9%), type III with 16 (11.0%), and type IV with 12 (8.2%) samples, respectively. The SCCmec type I MRSA isolates were significantly recovered from blood (80%) and sputum (67.2%). The results of antibacterial susceptibility tests for the MRSA isolates showed that all of those carrying the SCCmec type I and II had significantly greater resistance rates to Gentamicin and Rifampin than the isolates containing the SCCmec type III. Also, a significant difference was detected for susceptibility to Co-trimoxazole between the SCCmec type I and II MRSA isolates and the SCCmec type III, which was more resistant.

CONCLUSIONS

The frequency of the isolates containing type I in the current study can indicate an emergence of this SCCmec type in the studied medical centers.

Pattern of antimicrobial usage in livestock animals in south-western Nigeria: The need for alternative plans

Resistance to antibiotics has continued to increase, placing future animal and human disease management in real danger. The developing countries characterised by widespread indiscriminate antibiotic use and in which ‘third-generation’ antibiotics are not readily available or affordable are the worst affected. A 3-year (2010–2012) retrospective survey of antibiotic usage in livestock production in three selected states of south-western Nigeria was conducted. Data obtained from eight purposively selected licensed veterinary pharmaceutical sales establishments in the area, based on keeping detailed sales records for the study period, were analysed using Stata Version 12. Results showed that tetracyclines (33.6%), fluoroquinolones (26.5%) and beta-lactams/aminoglycosides (20.4%) constituted the majority of the antibiotics used over the 3 years. The differences in the quantities of antibiotic types used within each antimicrobial class were statistically significant for tetracyclines (F = 59.87; p < 0.0001) and fluoroquinolones (F = 43.97; p < 0.0001) but not for beta-lactams/aminoglycosides (F = 3.21; p = 0.148). Furthermore, antibiotic consumption increased by 40.4% between 2010 and 2012. Although statistically insignificant (F = 0.277; p = 0.762), the increasing trend across the years was at rates of 23.5% between 2010 and 2011 and 13.8% between 2011 and 2012. In addition, the findings show a significantly higher consumption rate (t = 15.21; df = 5; p < 0.0001) during the rainy (52.5%) than the dry (47.5%) seasons. The current increasing trend in antibiotic usage holds a serious danger for the future and therefore calls for alternative plans to safeguard future livestock production, food security and human health. This becomes more imperative considering emerging resistance against tetracyclines and fluoroquinolones, the foremost remedies for livestock diseases in most developing countries.

Climatic factors and community - associated methicillin-resistant Staphylococcus aureus skin and soft-tissue infections - a time-series analysis study

Skin and soft tissue infections caused by Staphylococcus aureus (SA-SSTIs) including methicillin-resistant Staphylococcus aureus (MRSA) have experienced a significant surge all over the world. Changing climatic factors are affecting the global burden of dermatological infections and there is a lack of information on the association between climatic factors and MRSA infections. Therefore, association of temperature and relative humidity (RH) with occurrence of SA-SSTIs (n = 387) and also MRSA (n = 251) was monitored for 18 months in the outpatient clinic at a tertiary care hospital located in Bhubaneswar, Odisha, India. The Kirby-Bauer disk diffusion method was used for antibiotic susceptibility testing. Time-series analysis was used to investigate the potential association of climatic factors (weekly averages of maximum temperature, minimum temperature and RH) with weekly incidence of SA-SSTIs and MRSA infections. The analysis showed that a combination of weekly average maximum temperature above 33 °C coinciding with weekly average RH ranging between 55% and 78%, is most favorable for the occurrence of SA-SSTIs and MRSA and within these parameters, each unit increase in occurrence of MRSA was associated with increase in weekly average maximum temperature of 1.7 °C (p = 0.044) and weekly average RH increase of 10% (p = 0.097).

Qualitative study of factors associated with antimicrobial usage in seven small animal veterinary practices in the UK

Responsible use of antimicrobials by veterinarians is essential to contain antimicrobial resistance in pathogens relevant to public health. Inappropriate antimicrobial use has been previously described in practice. However, there is scarce information on factors influencing antimicrobial usage in dogs and cats. We investigated intrinsic and extrinsic factors influencing decision-making of antimicrobial usage in first opinion small animal practices in the UK through the application of qualitative research methods. Semi-structured interviews were conducted with 21 veterinarians from seven veterinary first opinion practices in the UK in 2010. Topics investigated included: a) criteria used for selection of antimicrobials, b) influences by colleagues, c) influences by clients, d) pet characteristics, e) sources of knowledge, f) awareness of guidelines and g) protocols implemented in practice that may affect antimicrobial usage by veterinarians. Hypothetical scenarios selected to assess appropriateness of antimicrobial usage were: a) vomiting in a Yorkshire Terrier due to dietary indiscretion, b) deep pyoderma in a Shar-Pei, c) Feline Lower Urinary Tract disease in an 7 year-old male neutered cat and d) neutering of a 6-months dog. Interviews were recorded and transcribed by the interviewer. Thematic analysis was used to analyse content of transcribed interviews. Data management and analysis was conducted with qualitative analysis software NVivo8 (QSR International Pty Ltd). Antimicrobial usage by participants was influenced by factors other than clinical evidence and scientific knowledge. Intrinsic factors included veterinarian's preference of substances and previous experience. Extrinsic factors influencing antimicrobial selection were; perceived efficacy, ease of administration of formulations, perceived compliance, willingness and ability to treat by pet owners, and animal characteristics. Cost of therapy was only perceived as an influential factor in low, mixed socioeconomic areas. Veterinarians had limited awareness of current recommendations for responsible use in small animal practice. Social norms, particularly verbally agreed protocols influenced veterinarians. Inappropriate antimicrobial usage was identified in the therapy of non-infectious diseases and prophylaxis of routine clean surgical procedures. Discussion of clinical cases with peers and effectiveness meetings in the workplace were useful to veterinarians to share scientific knowledge. Effectiveness meetings can be a common ground for veterinarians to discuss and agree protocols for clinical conditions and surgical procedures. Protocols should be evidence-based, follow current recommendations and take into account the resources available in the workplace. Targeted training of veterinarians in the workplace with peer support should be used to promote responsible antimicrobial usage.