Addressing antimicrobial resistance by improving access and quality of care-A review of the literature from East Africa

Current access, availability and use of antibiotics in primary care among key low- and middle-income countries and the policy implications

INTRODUCTION

Antimicrobial resistance (AMR) poses a significant threat, particularly in low- and middle-income countries (LMICs), exacerbated by inappropriate antibiotic use, access to quality antibiotics and weak antimicrobial stewardship (AMS). There is a need to review current evidence on antibiotic use, access, and AMR, in primary care across key countries.

AREAS COVERED

This narrative review analyzes publications from 2018 to 2024 regarding access, availability, and use of appropriate antibiotics.

EXPERT OPINION

There were very few studies focussing on a lack of access to antibiotics in primary care. However, there was considerable evidence of high rates of inappropriate antibiotic use, including Watch antibiotics, typically for minor infections, across studied countries exacerbated by patient demand. The high costs of antibiotics in a number of LMICs impact on their use, resulting in short courses and sharing of antibiotics. This can contribute to AMR alongside the use of substandard and falsified antibiotics. Overall, limited implementation of national action plans, insufficient resources, and knowledge gaps affects sustainable development goals to provide routine access to safe, effective, and appropriate antibiotics.

CONCLUSIONS

There is a clear need to focus health policy on the optimal use of essential AWaRe antibiotics in primary care settings to reduce AMR in LMICs.

Update on antimicrobial resistance in Somalia: Current status, challenges, opportunities, and future perspectives

Antimicrobial resistance (AMR) is a critical global health challenge, and Somalia is no exception. This update examines the current status of AMR in Somalia, highlighting the prevalent patterns of resistance, contributing factors, and significant health impacts. Despite limited surveillance data, evidence suggests rising resistance to key antibiotics, exacerbated by inadequate healthcare infrastructure, overuse of antimicrobials, and lack of regulatory oversight. The review identifies key challenges, including insufficient diagnostic capabilities, poor infection control practices, and a need for robust stewardship programs. Opportunities for addressing AMR in Somalia are discussed, including strengthening surveillance systems, improving healthcare access, and fostering international collaboration. Future perspectives emphasize the importance of integrating AMR strategies into broader health policies, enhancing public awareness, and investing in research to develop new treatments and prevention methods. Addressing these issues is crucial for mitigating the impact of AMR and improving health outcomes in Somalia.

Exploring drivers of self-treatment with antibiotics in three agricultural communities of northern Tanzania

BACKGROUND

Antimicrobial resistance (AMR) poses a significant global health threat, particularly in low- and middle-income countries (LMICs). Self-treatment with antibiotics, the practice of using antibiotics without professional guidance, is often considered an important contributor to the emergence and spread of AMR.

METHOD

This study investigated the drivers of self-treatment in three common types of agricultural communities in northern Tanzania. The research employed a comprehensive array of methods, including cross-sectional surveys (n = 790), interviews (n = 30) and observations (n = 178) targeting both antibiotic (human and animal) providers and users (patients and farmers). Qualitative interview data were analysed using a coding and association matrix, while descriptive analyses were performed on survey and observation data.

RESULTS

Self-treatment with antibiotics was highly prevalent in all communities. Between 41.0% (self-reported) and 60.3% (observed) of human antibiotics were obtained without a prescription and we observed that veterinary antibiotics were regularly purchased in retail shops without referral by a professional. Structural deficiencies in the healthcare system drove this practice: limited access to healthcare facilities, medication stockouts and prolonged waiting times were identified as key factors. The absence of safety nets like insurance schemes further contributed to self-medication. Retail shops offered a convenient and cost-effective alternative when antibiotics were inaccessible or unaffordable. Notably, informal networks comprising treatment vendors, friends or neighbours, as well as personal experiences played a crucial role in guiding individuals in their self-treatment decisions by providing advice on treatment choice and modalities.

CONCLUSIONS

Addressing self-treatment requires a multi-faceted approach. Improving the availability and accessibility of antibiotics, enhancing healthcare services and involving retail vendors in antibiotic stewardship are essential. Structural issues like access to diagnostics and medicines must be tackled, alongside reducing barriers and incentivising individuals to use professional healthcare services. Training retail vendors to sell specific first-line antibiotics over the counter with guidance on appropriate usage should be considered. Such bottom-up interventions will enable sustainable promotion of responsible antibiotic use, mitigating AMR emergence and securing a healthier future for all.

Tackling antimicrobial resistance in sub-Saharan Africa: challenges and opportunities for implementing the new people-centered WHO guidelines

INTRODUCTION

Antimicrobial drugs form an essential component of medical treatment in human and animal health. Resistance associated with their use has posed a global public health threat. Multiple efforts have been made at the global level directed by the World Health Organization and associated partners to develop policies aimed at combatting antimicrobial resistance.

AREAS COVERED

Whilst the Global Action Plan on antimicrobial resistance and people-centered framework aim to guide countries in implementing successful antimicrobial resistance policies, their adoption and success depend on different implementation contexts. Therefore, this paper highlights the challenges and opportunities for implementing the World Health Organization's people-centered approach in sub-Saharan Africa, whilst recognizing antimicrobial resistance as a multifaceted problem rooted in 'complex systems.'

EXPERT OPINION

The people-centered approach provides a solid framework for combating antimicrobial resistance. Countries should build sustainable national action plans, adopt the One Health approach, limit over-the-counter antibiotic consumption, and educate communities on rational antibiotic use. They should also promote inter-country collaborations and innovative solutions, strengthen drug regulatory capacities, invest in infection control, water sanitation, hygiene, diagnostics, and surveillance tools, and promote vaccine uptake to prevent drug-resistant infections.

Evaluating the Knowledge, Practice, and Regulatory Situation of Veterinary Experts Regarding Counterfeit Veterinary Medications in the Selected Districts of Central Gondar Zone, Ethiopia

Background

The intentional and illegal misrepresentation of fake medications involves falsely indicating their source. These fraudulent medications can include products that contain either accurate or incorrect ingredients, lack proper labeling, have insufficient quantities of ingredients, and are packaged with counterfeit packaging. This unlawful activity has led to treatment failures, the development of antibiotic resistance, adverse effects, and even deaths. Hence, the objective of this study was to assess the knowledge, practice, and regulatory status of veterinary drug experts in the central Gondar zone of Ethiopia regarding counterfeit veterinary medications.

Methods

From January 2023 to July 2023, a self-administered structured questionnaire was utilized to conduct a cross-sectional study in Central Gondar Zone, Ethiopia. The analysis of the data involved the application of descriptive and chi-square tests.

Results

The study revealed that the majority of professionals possessed a work experience ranging from 5 to 9 years (23; 56.1%). Additionally, a total of 25 individuals (61.0%) who participated in the research had not undergone any kind of training. It was observed that a significant proportion of participants (82.9%) possessed knowledge about counterfeit veterinary drugs. Only about 63% and 36% of respondents had high knowledge and good practice concerning veterinary counterfeit drugs, respectively. Only 29.3% of participants have reported practices. Furthermore, a poor regulatory level of coordination was detected (85.4%). The study revealed a significant (χ2 =7.6165; p = 0.022) disparity between the respondents' practice levels and training. Respondents' regulatory levels were also significantly associated (p < 0.05) with their sex (χ2 = 13.34; p = 0.001) and work experience (χ2 = 13.64; p = 0.033). The research findings also revealed a noteworthy correlation between practice and regulatory activity (χ2 = 15.0463; p = 0.005).

Conclusion

The study outlines the necessity of awareness initiatives, with a focus on the significance of veterinary experts' knowledge, practice, and regulatory efforts in addressing the issue of counterfeit veterinary medications.

The Use of CHROMID® Colistin R for the Detection of Colistin-Resistant Gram-Negative Bacteria in Positive Blood Cultures

The aim of this study was to assess the utility of CHROMID® Colistin R for direct detection of colistin-resistant Gram-negative bacteria from positive blood cultures. A total of 390 blood cultures from hospitalised patients containing Gram-negative bacteria were included in this study. These blood cultures were referred to clinical laboratories in the United Kingdom and Türkiye. A further 16 simulated positive blood culture bottles were included that contained a range of colistin-resistant strains as well as susceptible control strains. Fluid from each positive blood culture was diluted 1/200 in saline and 10 µL aliquots cultured onto cystine-lactose-electrolyte-deficient agar and CHROMID® Colistin R. All recovered bacteria were identified, and for Gram-negative bacteria, their minimum inhibitory concentration of colistin was measured using the broth microdilution method. From a total of 443 Gram-negative isolates, 57 colistin-resistant isolates were recovered, of which 53 (93%) grew on CHROMID® Colistin R within 18 h. Of the 377 isolates determined to be colistin-susceptible, only 9 isolates were able to grow, including 6 isolates of Pseudomonas aeruginosa. For positive blood cultures that are shown to contain Gram-negative bacteria, culture on CHROMID® Colistin R is a useful diagnostic tool to detect susceptibility or resistance to colistin within 18 h.

Potential Causes of Spread of Antimicrobial Resistance and Preventive Measures in One Health Perspective-A Review

Antimicrobial resistance, referring to microorganisms' capability to subsist and proliferate even when there are antimicrobials is a foremost threat to public health globally. The appearance of antimicrobial resistance can be ascribed to anthropological, animal, and environmental factors. Human-related causes include antimicrobial overuse and misuse in medicine, antibiotic-containing cosmetics and biocides utilization, and inadequate sanitation and hygiene in public settings. Prophylactic and therapeutic antimicrobial misuse and overuse, using antimicrobials as feed additives, microbes resistant to antibiotics and resistance genes in animal excreta, and antimicrobial residue found in animal-origin food and excreta are animals related contributive factors for the antibiotic resistance emergence and spread. Environmental factors including naturally existing resistance genes, improper disposal of unused antimicrobials, contamination from waste in public settings, animal farms, and pharmaceutical industries, and the use of agricultural and sanitation chemicals facilitatet its emergence and spread. Wildlife has a plausible role in the antimicrobial resistance spread. Adopting a one-health approach involving using antimicrobials properly in animals and humans, improving sanitation in public spaces and farms, and implementing coordinated governmental regulations is crucial for combating antimicrobial resistance. Collaborative and cooperative involvement of stakeholders in public, veterinary and ecological health sectors is foremost to circumvent the problem effectively.

A brief review of online education resources on gamification in addressing antimicrobial resistance

BACKGROUND

The burden of antimicrobial resistance (AMR) is projected to be highest in Africa, with a mortality of 99 per 100 000 deaths in sub-Saharan Africa. As a result, there is an urgent need to develop education resources to raise awareness and improve understanding of AMR.

AIMS

The aim of this review was to evaluate selected games, and inform regarding their suitability, and that of gamification in general in promoting education, and inspiring action against AMR.

OBJECTIVE

This brief review of online education resources seeks to inform on the use of games in promoting education on AMR by exploring different aspects of gamification such as accessibility, usability and playability with the delivery of desired learning outcomes. The insights obtained from the game helped inform recommendations and conclusions on how to best utilize gamification to deliver AMR education to target audiences.

METHODS

The games to be reviewed were selected using search terms 'AMR Game', 'Antimicrobial Resistance Game', 'Antibiotic Resistance Game', 'ABR Game', 'Drug Resistance Game' and 'Superbugs Game' in Google Play Store and Apple App Store search engines, given their positioning as suitable application software that house game applications. After applying a selection criterion, the number of selected games was narrowed to two: Micro-Combat and Terebra.

RESULTS

The games were analysed through four key factors: accessibility, usability, playability and learning outcomes. Both games were found to apply visual, written and aural game mechanics but Terebra had an increased touch with reality, enhancing its playability, due to the emphasis on aural triggers positioning AMR as a dire health threat. On the other hand, Micro-Combat was found to be more educative, and learning-oriented but less associated with reality, which negatively influenced its playability.

CONCLUSIONS

In overall, gamification was found to be a good online resource to promote education on AMR through the review conducted on the two games, Terebra and Micro-Combat. Coupling gamification and conventional education mechanisms can go a long way in promoting the awareness and knowledge level of AMR among diverse populations The two games, Terebra and Micro-Combat, are great pilot AMR gamification projects that have set a good pace for utilization of games in AMR education. There is a need to develop AMR educational games that portray the reality in low- and middle-income countries, which was a bit lacking in the two games.

Supply-chain factors and antimicrobial stewardship

Efficient and secure supply chains are vital for effective health services worldwide. In low- and middle-income countries, the accessibility, affordability and availability of essential medicines, including antimicrobials, remain challenging. Ineffective supply chains often cause antimicrobial shortages, leading to inappropriate use of alternative agents and increasing the risk of antimicrobial resistance. Shortages, coupled with insecure supply chains, also encourage the infiltration of substandard and falsified medicines, leading to suboptimal treatment and further promoting antimicrobial resistance. Addressing antimicrobial supply-chain issues should be considered a key component of antimicrobial stewardship programmes. We have explored the link between medicine supply chains and antimicrobial use in seven focus countries: Kenya, Malawi, Nigeria, Sierra Leone, Uganda, United Republic of Tanzania and Zambia. We explored country medicine supply-system structures, national medicine supply-chain policy documents and global study reports. Our aim was to develop evidence-based strategies to enhance the effectiveness and efficiency of the medicine supply chains in supporting antimicrobial stewardship efforts. Better management of medical supply chains involves rational selection, quantification, forecasting, procurement, storage, distribution, use and stock management of antimicrobials. Important supply-chain considerations include pooled procurement networks to ensure consistent pricing of quality-assured antimicrobials, and improved resource utilization and information exchange among relevant stakeholders. We propose adaptable recommendations for integrating medicine supply chains as an essential part of antimicrobial stewardship programmes, with a call for action at the local, regional and national levels in low- and middle-income countries.

Viral etiology of lower respiratory tract infections in adults in the pre-COVID-19 pandemic era: A cross-sectional study in a single center experience from Cameroon

BACKGROUND AND AIMS

Respiratory viruses are responsible for the majority of lower respiratory tract infections (LRTIs) worldwide. However, there is a gap on the epidemiology of viral LRTIs in adults in sub-Saharan African countries. In Cameroon, like in other countries, the role of viral respiratory pathogens in the etiology of LRTIs in adults is helpful for clinical management. This study aimed to determine the viral aetiologies of LRTIs among hospitalized adults in a reference center for respiratory diseases in the town of Yaounde in Cameroon and its surroundings.

METHODS

A cross-sectional study was conducted from January 2017 to January 2018 at Jamot Hospital in Yaounde (Cameroon). Clinical and demographic information; BAL and sputa were collected from hospitalized patients meeting LRTI case definitions. The clinical samples were investigated for respiratory pathogens with a commercial Reverse Transcriptase Real-Time Polymerase Chain Reaction (RT-PCR) targeting 21 viruses, cultures for bacterial and fungal infections.

RESULTS

The 77 included adult patients with LRTIs had an appropriate clinical sample for microbial investigations. A viral agent was detected in 22.1% (17/77) samples. The main viruses detected included rhinovirus (10/77), coronavirus (hCoV-OC43 and hCoV-229E), and influenza A virus (3/77 each). A concomitant viral and bacterial co-infection occurred in 7.8% of patients (6/77) while viral co-infection occurred in one patient (1.3%). No Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) was detected in clinical samples. Most patients were under antimicrobials before getting diagnosed.

CONCLUSIONS

Respiratory viruses account for 22.1% of LRTIs in hospitalized patients in this study. Despite prior antimicrobial therapy and delay, rhinovirus, coronavirus and influenza A virus were the most detected in patients in the pre-COVID-19 pandemic era in a single center experience from Cameroon.

"If You Do Not Take the Medicine and Complete the Dose…It Could Cause You More Trouble": Bringing Awareness, Local Knowledge and Experience into Antimicrobial Stewardship in Tanzania

Antimicrobial resistance (AMR) is a global health issue disproportionately affecting low- and middle-income countries. In Tanzania, multi-drug-resistant bacteria (MDR) are highly prevalent in clinical and community settings, inhibiting effective treatment and recovery from infection. The burden of AMR can be alleviated if antimicrobial stewardship (AMS) programs are coordinated and incorporate local knowledge and systemic factors. AMS includes the education of health providers to optimise antimicrobial use to improve patient outcomes while minimising AMR risks. For programmes to succeed, it is essential to understand not just the awareness of and receptiveness to AMR education, but also the opportunities and challenges facing health professionals. We conducted in-depth interviews (n = 44) with animal and human health providers in rural northern Tanzania in order to understand their experiences around AMR. In doing so, we aimed to assess the contextual factors surrounding their practices that might enable or impede the translation of knowledge into action. Specifically, we explored their motivations, training, understanding of infections and AMR, and constraints in daily practice. While providers were motivated in supporting their communities, clear issues emerged regarding training and understanding of AMR. Community health workers and retail drug dispensers exhibited the most variation in training. Inconsistencies in understandings of AMR and its drivers were apparent. Providers cited the actions of patients and other providers as contributing to AMR, perpetuating narratives of blame. Challenges related to AMR included infrastructural constraints, such as a lack of diagnostic testing. While health and AMR-specific training would be beneficial to address awareness, equally important, if not more critical, is tackling the challenges providers face in turning knowledge into action.

Multidrug Resistance: The Growing Menace in PICU

How to cite this article: Kamath SR. Multidrug Resistance: The Growing Menace in PICU. Indian J Crit Care Med 2023;27(1):6-7.

A bottom-up view of antimicrobial resistance transmission in developing countries

Antimicrobial resistance (AMR) is tracked most closely in clinical settings and high-income countries. However, resistant organisms thrive globally and are transmitted to and from healthy humans, animals and the environment, particularly in many low- and middle-income settings. The overall public health and clinical significance of these transmission opportunities remain to be completely clarified. There is thus considerable global interest in promoting a One Health view of AMR to enable a more realistic understanding of its ecology. In reality, AMR surveillance outside hospitals remains insufficient and it has been very challenging to convincingly document transmission at the interfaces between clinical specimens and other niches. In this Review, we describe AMR and its transmission in low- and middle-income-country settings, emphasizing high-risk transmission points such as urban settings and food-animal handling. In urban and food production settings, top-down and infrastructure-dependent interventions against AMR that require strong regulatory oversight are less likely to curtail transmission when used alone and should be combined with bottom-up AMR-containment approaches. We observe that the power of genomics to expose transmission channels and hotspots is largely unharnessed, and that existing and upcoming technological innovations need to be exploited towards containing AMR in low- and middle-income settings.

Rational use of antibiotics and covariates of clinical outcomes in patients admitted to intensive care units of a tertiary hospital in Kenya

OBJECTIVES

: Rational use of antibiotics implies appropriate choice of an antibiotic administered at correct dose, frequency and duration using the most suitable route of administration. Irrational antibiotics use is associated with antimicrobial resistance, drug failure and high mortality in the critical care units (CCUs). This study sought to establish rational use of antibiotics and determinants of clinical outcomes of patients admitted in the CCUs at the Kenyatta National Hospital (KNH). The findings would guide policy formulation of antibiotics use in hospital CCUs in Kenya and the region.

METHODS

: Retrospective review of 220 admissions to the KNH CCUs over the period February 2018-February 2020 was conducted. Participants' sociodemographics, clinical characteristics, antibiotics therapy, and outcome of admission were extracted from patient files and analyzed using STATA version 23. Determinants of irrational antibiotic use and covariates of clinical outcomes were computed at 95% confidence.

RESULTS

The prevalence of rational use of antibiotics was only 18.5%. Inappropriate choice of antibiotics (51.0%) and incorrect duration (32.3%) were the most common irrational practices. Flucloxacillin (100%), cefuroxime (93.3%), cefazolin (85.7%) and ceftriaxone (83.0%) were the most irrationally used antibiotics. Irrational use of ceftriaxone was significantly associated with clinical diagnosis (p=0.012) while that of amoxiclav was associated with patient risk category (p=0.039). Mortality in the CCUs was 10%, and the odds of dying were almost six times among intubated patients compared to those who were not (AOR 5.5, 95% CI=1.1-28.1, p=0.042).

CONCLUSION

Irrational antibiotics prescribing is high in the KNH CCUs, attributable largely to incorrect choice and wrong duration of antibiotic use. Mortality was significantly associated with intubation. Intensification of management in critical care settings should be directed towards intubated patients while ensuring appropriate choice of antibiotics administered for the correct duration. Future studies should explore factors that could promote rational antibiotics use in critical care settings.