Current Challenges in Antibiotic Stewardship in Low- and Middle-Income Countries

Abstract

ASPs are key tools in the time where an increase in the rates of bacterial resistance and cases of Clostridium difficile disease is observed worldwide, forcing a more efficient use of antibiotic therapy. We review some examples of the actual state of bacterial resistance in low- and middle-income countries (LMIC), as well as some of the proposed strategies for the establishment of ASPs in resource-constrained environments. In LMIC, there are important challenges in antimicrobial prescription; although not all inhabitants have access to adequate antibiotic therapy, the consumption of these drugs is high, and is reflected in high rates of bacterial resistance. The implementation of the strategic tools within ASP is promising and good results have been achieved, with a decrease in antimicrobial consumption. The establishment of ASP is a worldwide need, and there are currently international initiatives for its development and implementation. LMIC deal with special challenges, as they need to guarantee the access to their population, but the use must be made in an appropriate manner. Currently, high rates of resistance are reported in hospital services, but in some countries, the implementation of ASP begins to yield results. Antibiotics are drugs that have a special place in the armamentarium of modern medicine. Since their introduction, they were one of the first drugs that changed the therapeutics, with the medical practice focused on symptom control to one of curative intent. In addition to the direct positive impact they have had on the morbidity and mortality associated with infectious diseases (ID), they have allowed the development of other areas, such as intensive care, neonatal care, complex surgery, and transplants, to the extent that we know them today. Unfortunately, these wonderful drugs are threatened by the emergence of bacterial resistance (BR). Although this phenomenon is characteristic of the nature of the infectious agents, exposure to antimicrobials favors and accelerates the natural selection of microorganisms better adapted to an environment in which these molecules are found. Hence, the use of antibiotics, whether for the treatment or prevention of ID in humans or animals, or with other industrial purposes in food production, is one of the activities that currently require the establishment of measures for a rational use. If we look at the use we have given to antibiotics in the previous decades, we must recognize that we have abused them, and it is in this context that antibiotic stewardship programs (ASPs) have been developed. We understand ASP as the set of measures that can be developed for the use of antibiotics in conditions in which they are really required (in a prophylactic or therapeutic way), aiming for the use of the molecules with the narrowest antibacterial spectrum, but with activity on the causative organisms of the infection, with a duration long enough to achieve their objective, but as short as possible to minimize selective pressure. The final goal of ASP is to reduce morbidity and mortality, and preserving antibiotic utility. Challenges for ASP in LMIC: 1. A high proportion of infections are caused by multidrug-resistant (MDR) microorganisms, not only in the hospital, but also in the community 2. Limitations on the diagnostic capacity for the detection of MDR microorganisms 3. Lax regulation on antibiotic use in both humans and animals 4. Deficient regulation in the food industry 5. Lack of clinician training and administration will in these issues However, proposals that try to bring together isolated efforts, such as the one set forth by the World Health Organization (WHO), have emerged in recent years. Some countries have reported their experience in the successful implementation of some of the components of ASPs, and can serve as a guide for its adaptation to local conditions. This is the basis for the protection of antibiotics, for present and future use.