Identifying and addressing challenges to antimicrobial use surveillance in the human health sector in low- and middle-income countries: experiences and lessons learned from Tanzania and Uganda

Prescribing patterns of antimicrobials according to the WHO AWaRe classification at a tertiary referral hospital in the southern highlands of Tanzania

Background

Antimicrobial consumption continues to rise globally and contributes to the emergence and spread of antimicrobial resistance. This study aimed to evaluate antimicrobial prescribing patterns in a selected tertiary hospital in Tanzania.

Methods

This cross-sectional study was conducted for one year (September 2021-September 2022) at Mbeya Zonal Referral Hospital, a public hospital in the southern highlands zone of Tanzania. Data on clinical diagnosis, laboratory tests, prescribed antimicrobials, and prescribers' designations were collected through a custom eMedical system, aligning antimicrobials with the WHO's 2021 AWaRe classification. Descriptive analysis was performed to assess the pattern of antimicrobial prescriptions.

Results

Of 2,293 antimicrobial prescriptions, 62.41% were ACCESS, 37.42% were WATCH, and 0.17% fell in the RESERVE categories. Metronidazole, accounting for 23.8%, was the most commonly prescribed antimicrobial. More than 50% of the ACCESS and WATCH prescriptions were justified by laboratory diagnosis and were predominantly prescribed by clinicians. A very small proportion of prescriptions (<1%) were informed by culture and sensitivity (C/S) testing. The Paediatric department had the majority of WATCH prescriptions (72.2%).

Conclusion

The prescribing patterns at the study hospital generally align with WHO AWaRe guidelines, potentially mitigating antimicrobial resistance. Nevertheless, the scarcity of culture and sensitivity testing is a concern that warrants targeted improvement.

ClpP Peptidase as a Plausible Target for the Discovery of Novel Antibiotics

Antimicrobial resistance (AMR) to currently available antibiotics/drugs is a global threat. It is desirable to develop new drugs that work through a novel target(s) to avoid drug resistance. This review discusses the potential of the caseinolytic protease P (ClpP) peptidase complex as a novel target for finding novel antibiotics, emphasising the ClpP's structure and function. ClpP contributes to the survival of bacteria via its ability to destroy misfolded or aggregated proteins. In consequence, its inhibition may lead to microbial death. Drugs inhibiting ClpP activity are currently being tested, but no drug against this target has been approved yet. It was demonstrated that Nblocked dipeptides are essential for activating ClpP's proteolytic activity. Hence, compounds mimicking these dipeptides could act as inhibitors of the formation of an active ClpP complex. Drugs, including Bortezomib, Cisplatin, Cefmetazole, and Ixazomib, inhibit ClpP activation. However, they were not approved as drugs against the target because of their high toxicity, likely due to the presence of strong electrophiles in their warheads. The modifications of these warheads could be a good strategy to reduce the toxicity of these molecules. For instance, a boronate warhead was replaced by a chloromethyl ketone, and this new molecule was shown to exhibit selectivity for prokaryotic ClpP. A better understanding of the structure and function of the ClpP complex would benefit the search for compounds mimicking N-blocked dipeptides that would inhibit ClpP complex activity and cause bacterial death.

Effective Stakeholder Engagement for Collation, Analysis and Expansion of Antimicrobial Resistance (AMR) Data: A CAPTURA Experience

BACKGROUND

An effective implementation of antimicrobial resistance (AMR) surveillance projects requires sustainable and multidisciplinary engagement with stakeholders from various backgrounds, interests and aims. The "Capturing Data on Antimicrobial resistance Patterns and Trends in Use in Regions of Asia" (CAPTURA) project, funded by the Fleming Fund, initially targeted 12 countries in South Asia (SA) and Southeast Asia (SEA) to "expand the volume of historical and current data on AMR and antimicrobial usage" and support local agencies through capacity building activities.

METHODS

In this article, we focus on early stakeholder engagement activities and present overall statistics on AMR data collated from 72 laboratories across seven countries. This included 2.3 million records of antimicrobial susceptibility testing (AST) data, which were curated, analyzed, and shared back to the facilities for informed decision making.

RESULTS

Approximately 98% of the data collated by CAPTURA originated from laboratories based in SA countries. Furthermore, country-wide data were analyzed to identify commonly reported pathogens in each country, followed by descriptions of AST practices and multidrug-resistant (MDR) pathogens. Overall, we found meager adherence to standard guidelines to perform and record AST results, and a significant number of MDR pathogens were reported.

CONCLUSIONS

We conclude that close collaboration with the existing national mechanisms for identifying AMR data sources was crucial for the project's success. Although we show a vast retrospective dataset on AMR is available for data sharing in Asia, there remain critical gaps in data generation/management practice and analysis capacity for AMR data at most facilities.

A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications

Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.

Quality of Data Recording and Antimicrobial Use in a Municipal Veterinary Clinic in Ghana

The recording of antimicrobial use data is critical for the development of interventions for the containment of antimicrobial resistance. This cross-sectional study assessed whether dissemination activities and recommendations made after an operational research (OR) study in 2021 resulted in better data recording and improved the use of antimicrobials in a rural veterinary clinic. Routinely collected data from treatment record books were compared between 2013 and 2019 (pre-OR) and from July 2021 to April 2023 (post-OR). The most common animals presenting for care in the the pre - and post OR periods were dogs (369 and 206, respectively). Overall, antimicrobial use in animals increased from 53% to 77% between the two periods. Tetracycline was the most commonly used antimicrobial (99%) during the pre-OR period, while Penicillin-Streptomycin was the most commonly used antimicrobial (65%) during the post-OR period. All animals that received care at the clinic were documented in the register during both periods. Whereas the diagnosis was documented in 269 (90%) animals in the post-OR period compared to 242 (47%) in the pre-OR period, the routes and dosages were not adequately recorded during the both periods. Therefore, the quality of data recording was still deficient despite the dissemination and the recommendations made to some key stakeholders. Recommendations are made for a standardized antimicrobial reporting tool, refresher training, and continuous supervisory visits to the clinic.

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or "golden rules," for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice.

What is the appropriate antimicrobial use surveillance tool at the health facility level for Uganda and other low- and middle-income countries?

BACKGROUND

An appropriate antimicrobial use (AMU) surveillance system provides critical data and evidence on which antimicrobial stewardship interventions are based. However, Uganda and most other low- and middle-income countries (LMICs) lack efficient systems for monitoring AMU due to unique health system challenges.

METHODS

We reviewed the key tools available for AMU surveillance in health facilities. Based on our implementation experience, we present arguments on the need for country authorities to adapt a customized and standardized tool for national uses.

RESULTS

Despite ongoing efforts to set up AMU surveillance programs in Uganda, AMU data remain sparse, with most of the available data collected through antimicrobial stewardship related continuous quality improvement efforts implemented by global AMR control programs. There is variability in the interpretation of available AMU surveillance tools and a need to identify the most appropriate AMU surveillance methodologies and tools for Uganda and other LMICs. Data fields for sex and gender are incorrectly categorized and there is no tool that records pregnancy variable. Based on the past four years of practical implementation experience since the launch of the World Health Organization's Point Prevalence Survey methodology in 2018 for inpatient settings, we believe that the tool should be modified in cognizance of existing capacity and priorities in resource-constrained settings.

CONCLUSIONS

The World Health Organization, regional experts, ministry of health authorities, and other stakeholders should urgently review available tools with a view to adopting a customized and standardized facility AMU surveillance methodology suitable for national-level rollout in LMICs.