Rational Use Of Antimicrobials Research Articles

Impact of an antimicrobial stewardship program in a medium-sized hospital

Problem consideredThe rational use of antimicrobials (ATMs) is a challenge for global health services. One strategy used to control the spread of multidrug-resistant (MDR) bacteria is antimicrobial management programs. This is a pre- and post-intervention study that assesses the impact of an antimicrobial stewardship program in a hospital through evaluating clinical and microbiological outcomes, usage measures and costs. MethodsThe sample comprised adult patients hospitalized for more than 24 h during a seven-month pre-intervention, and an eleven-month post-intervention period. Primary outcomes included length of therapy (LOT) and days of therapy (DOT) per 1000 patient-days (pd), the DOT/LOT ratio, the incidence of a number of the main multi-drug resistant bacteria, and the costs of therapy. Secondary outcomes were the use of antimicrobials and antimicrobial prescriptions by class, hospital length of stay rates, and mortality rates. Data were obtained from medical prescriptions, pre-authorization forms for restricted antibiotics, and microbiological tests. Non-critical and critical care units were compared, with a significance level of 0.05. ResultsA total of 2704 patients were evaluated and there was a significant post-intervention reduction of exposure to antimicrobials of 8.1% and of 90 days in respect of the LOT in non-critical units. There was a reduction of more than 50% in the costs of therapy and of 1.2 days in the length of hospital stay in non-critical units. There was no variation in bacterial resistance. ConclusionsAlthough the stewardship program and its interventions reduced antimicrobial consumption, costs and the length of hospital stay further studies are required to identify the components that can produce the impact on microbiological outcomes seen in other studies.

Letter to the editor: The challenge of carbapenem resistance

The global resistance of microorganisms to antimicrobials is one of the biggest public health challenges in recent decades however, among Gram-negative microorganisms, this problem has become very relevant, resulting in a shortage of medicines for the treatment of infections caused by these multi-resistant bacterial agents. Knowing the evolution of this resistance, among microorganisms in the hospital environment, is essential for: the projection of resistance in the coming decades, the rational use of antimicrobials and the adoption of measures to minimize their impact in this scenario. The most modern antimicrobial agents, which act on multi-resistant bacteria, are expensive, making their availability and use even more difficult, especially in the public health network in developing countries. However, new drugs for treating multidrug-resistant infections, due to their high cost, are often not available.

Determinants of implementing the ID ROLL OUT study's interventions: qualitative results

Abstract Issue Antimicrobial stewardship programmes (ASP) and infectious disease (ID) specialists aim to ensure the rational use of antimicrobials and to improve patient outcomes. Whilst ASPs are established to varying degrees, ID specialists are rarely available in secondary and tertiary care hospitals in Germany. Description of the problem With the ID ROLL OUT study, we implemented and evaluated an intervention, which comprises ASP with and without ID specialists’ consultation in ten hospitals (excl. university hospitals) in south-west Germany. Little has been reported on the medical and pharmaceutical staff's perspectives on the implementations. This study describes barriers, facilitators, and suggestions for improvement to successfully establish a large-scale multicentre intervention. The participants responsible for implementing the intervention were interviewed using semi-structured, guided interviews at two time-points (t1: n = 17; t2: n = 18). The recorded interviews were analysed for content, following Kuckartz. Results A high level of acceptance and a positive attitude towards the intervention are conducive to the intervention's successful implementation. The teams find extra time for the study and a close staff collaboration at a local team level to be helpful. The main barriers identified are a high workload, lack of acceptance by colleagues in key roles, and the Covid-19 pandemic. Lack of digitalisation and entrenched internal structures were identified as major barriers. To further improve implementation, more infectious disease training should be provided, along with support from superiors and extension of the intervention phase. Moreover, government-mandated ASP guidelines and quality management by the German Medical Association are desired and expected to contribute in the future. Lessons The identified determinants provide much-needed key information, which is important for the efficient, targeted and successful implementation of future similar interventions. Key messages • Acceptance, positive attitude and staff collaboration help to implement the intervention. • Heavy workloads and lack of support from key colleagues hinder the intervention’s implementation.

Effectiveness of antimicrobial interventions in animal production: systematic review & meta-analysis

Abstract In animal production, the rational use of antimicrobials has been promoted to decrease antimicrobial resistance (AMR) in microorganisms. This systematic review evaluated the effectiveness of interventions to reduce/adequate antimicrobial use and decrease AMR. Articles were identified in PubMed, Scopus, The Cochrane Library, Web of Science, and grey literature in DANS EASY, WorldCat, RCAAP. Eligible studies included original studies, assessing broiler/pig populations, antimicrobial interventions, comparator with standard/no use of antimicrobials, outcomes related to AMR, farm level and analytical observational studies. Meta-analysis was conducted for combinations including type of intervention, bacterial species, production type, population. Interventions effectiveness was estimated using odds ratio of resistance to antimicrobial substances/classes by bacteria and populations with and without intervention. A total of 46 studies were eligible. For broilers, restrictions were all non-therapeutic use (46%), complete restriction (27%), prohibition on antimicrobials used for growth promotion (23%). For pigs, restrictions included: all non-therapeutic use (37%), complete restriction (37%), group treatments (22%). For meta-analysis (21 studies), combinations indicated a protective effect for most antimicrobial classes in E. coli, Campylobacter and Enterococcus and broilers, and Escherichia coli and Campylobacter and pigs, compared to conventional production or without intervention. An increased odds of resistance were observed for cephalosporins in E. coli and broilers raised without antimicrobials, and to fluoroquinolones/quinolones in Campylobacter and pigs raised without antimicrobials, compared to conventional production. Our study revealed that organic, antimicrobial-free farms and group treatment restrictions in conventional production were mostly associated with AMR reduction, providing information on available options that may support decision-making to tackle AMR. Key messages • Organic/antimicrobial-free farms indicated a protective effect on resistance to most antimicrobials. • Fluoroquinolones resistant Campylobacter may persist in pigs raised without antimicrobials.

Klebsiella pneumoniae Metallobetalactamase in the neonatology service of the Abel Santamaría Hospital: case report

Introduction: Klebsiella pneumoniae is considered a superbacteria due to its extreme resistance to most antimicrobials and because it produces carbapenemases, enzymes that hydrolyze carbapenem antibiotics. This threat is exacerbated by the reduction in the discovery of new antibiotics. Case presentation: Preterm newborn of 32,3 weeks of gestation and birth weight of 1790 grams, born on January 3, 2023 with mild neonatal depression and early sepsis due to coagulase-negative staphylococcus. It worsens, presenting jaundice, anemia and thrombocytopenia, with blood cultures positive for Enterobacter Gergoviae and later for Enterobacter agglomerans. Antibiotic therapy was based on different antibiograms depending on the germ isolated without presenting clinical improvement. The isolation obtained from Enterobacter aglomerans showed KPC resistance phenotype, so the sample was referred to the “Pedro Kouri” Institute of Tropical Medicine, where the growth of Klebsiella pneumoniae with NDM metallobetalactamase resistance phenotype was obtained, only Sensitive to colistin and Intermediate to phosphokine. Contact precautions and treatment with colistin and phosphokine are applied. As a result, the patient resolves the infection and it is not transmitted to other neonates in the service. Conclusions: Klebsiella pneumoniae NDM infections constitute a danger due to the few therapeutic options, leaving colistin as the only alternative, due to resistance to carbapenems and due to the limitations in its identification in microbiology laboratories at the provincial level. The rational use of antimicrobials and microbiological surveillance are important for its control.

The Impact of Information Quality of Antimicrobial Susceptibility Test Report on the Rational Antimicrobial Use: A Retrospective Study.

Antimicrobial susceptibility test (AST) report was important for rational antimicrobial use. However, the reference value of AST report was sometimes limited due to poor information quality (IQ). This study aimed to measure the IQ of AST and evaluate the impact of IQ of AST report on rational antimicrobial use as a reference for antimicrobial therapy. The retrospective study included data of AST report, antimicrobials prescribed after reporting AST results and related inpatient information. The inclusion criteria of the AST report included three conditions: 1. The AST reports were from inpatients with diagnosis of infection. 2. The bacteria were extracted from a sterile-site specimen. 3. The interpretive categories (ie sensitive, intermediary or resistance) were firstly reported during one hospitalization. The IQ of AST report was measured by the total IQ and IQ of completeness, usefulness, accuracy and consistency. The rational antimicrobial use was measured by the antimicrobial adherence to the interpretive categories of AST report. Fractional logit regression model (FLRM) was chosen to evaluate the impact of IQ on the rational antimicrobial use. The median of the total IQ, completeness, usefulness, accuracy and consistency were 0.7345, 0.6082, 0.9167, 0.8966 and 1.0000, respectively. The results of FLRM showed that usefulness, accuracy and consistency had significant positive impacts on the rational antimicrobial use (β = 4.220, P < 0.001; β = 3.987, P < 0.001; β = 0.511, P = 0.001, respectively), while the total IQ and completeness had no statistically significant impacts on the rational antimicrobial use (β = -0.820, P = 0.35; β = -0.793, P = 0.20, respectively). This study confirmed that usefulness, accuracy and consistency performed well and had positive impacts on the rational antimicrobial use, which indicated that improving IQ especially usefulness, accuracy and consistency would make AST report play a greater role in promoting the rational antimicrobial use.

Clinical value of droplet digital PCR in the diagnosis and dynamic monitoring of suspected bacterial bloodstream infections

BackgroundBloodstream infections (BSIs) represent a significant public health challenge due to their high morbidity and mortality. The clinical prognosis of BSIs is closely related to the timely and accurate diagnosis and the rational use of initial antimicrobials. We aimed to evaluate the clinical value of droplet digital PCR (ddPCR) in rapid diagnosis and dynamic monitoring of BSIs. MethodsIn this prospective study, using a ddPCR-based approach which detects 18 common pathogens, we compared the detection results and clinical concordance rates of ddPCR with blood culture (BC) in 211 patients with suspected BSIs. Further, the inflammatory profile of BSIs with Gram-negative bacteria was analyzed by Olink proteomics platform. ResultsOur data showed that the positive detection rate of ddPCR was 48.82%, which was higher than that of BC (9.48%). For BC-validated BSIs, ddPCR had a sensitivity of 90.00% and a specificity of 55.50%. When considering clinically-validated BSIs, the diagnostic value of ddPCR improved with a sensitivity of 92.59% and a specificity of 78.46%.The bacterial load detected by ddPCR was correlated with traditional clinical inflammatory indicators such as interleukin-6 (IL-6) and C-reactive protein (CRP). In addition, using Olink proteomics platform, we revealed that serological osteoprotegerin (OPG), interleukin-8 (IL-8), interleukin-18 receptor 1 (IL-18R1), C–C motif chemokine 20 (CCL20) and IL-6 were substantially elevated in Gram-negative bacteria-associated BSIs, which could serve as novel auxiliary diagnostic indicators for Gram-negative bacteria BSIs. ConclusionddPCR has the potential to provide early pathogen diagnosis, dynamic monitoring, and treatment regimen optimization for patients with BSIs.

Bacteriological Profile of Surgical Site Infection Following Gastrointestinal Surgery and Their Antibiogram.

Surgical site infection is one of the common complication following abdominal surgery. It causes great morbidity and mortality, further increasing prevalence of multidrug resistant bacteria have made its management very challenging. The current study aims to identify causative agent responsible for surgical site infection and their antibiotic resistance patterns. This study was conducted among patients developing surgical site infection following gastrointestinal surgery in Tribhuvan university teaching hospital over a period of one year. The samples were collected and processed according to standard methods. The bacterial pathogens with their antimicrobial susceptibility were determined and resistant pattern like methicillin resistant Staphylococcus aureus and extended spectrum beta lactamase were further detected. A total of 832 patients had under gone gastrointestinal surgery during the study period. Among them, 162 cases (19.5%) developed surgical site infection and 125 cases showed growth in culture. A total of 160 aerobic bacteria were isolated; Escherichia coli (29.9%) was the commonest organism with 40.8% being extended spectrum beta lactamase producer and 47.4% of Staphylococcus aureus were methicillin resistant. About 75.9% (85/112) of gram negative bacteria and 60.4% (29/48) gram positive bacteria were multi drug resistant. The burden of multi drug resistant bacteria causing surgical site infection is high which needs to be addressed timely. Good surveillance of bacterial antibiogram and rational antimicrobial use is necessary to reduce emergence and spread of resistant bacteria.

Effectiveness of antimicrobial interventions directed at tackling antimicrobial resistance in animal production: A systematic review and meta-analysis.

In the last decades, a more prudent and rational use of antimicrobials has been progressively directed towards animal production to reduce antimicrobial selective pressure and antimicrobial resistance (AMR) in microorganisms and safeguard the antimicrobial efficacy of treatments in human medicine. This systematic review evaluated the effectiveness of interventions that have been applied to reduce or improve veterinary antimicrobial usage and aimed at decreasing resistant bacteria in chicken broiler and pig production contexts. Original articles were identified by searching PubMed™, Scopus™, The Cochrane Library™, and Web of Science™, and grey literature by searching DANS EASY™, WorldCat™ and RCAAP™. Inclusion criteria included: chicken broiler or pig populations (predestined for meat production), interventions intended to reduce/improve antimicrobial use, comparator with standard or no use of antimicrobials, outcomes related to prevalence of resistant bacteria, farm level studies, original data, and analytical observational studies. Data was extracted from eligible studies and meta-analysis using random or fixed effects models was conducted for combinations including type of intervention, bacterial species, production type and animal populations. Models were selected according to heterogeneity between studies. The effectiveness of interventions was assessed using pooled odds ratio of resistance to antimicrobial substances/classes by bacteria for associations between animal populations with and without intervention. A total of 46 studies were eligible for review. For chicken broilers, most interventions were identified as antimicrobial restrictions on all non-therapeutic use (46%), complete restriction (27%), and prohibition on antimicrobials used for growth promotion (23%). As for pig populations, restrictions were mainly observed on all non-therapeutic use (37%), complete restriction (37%) and group treatments (22%). For meta-analysis, 21 studies were pooled after assessment of existing combinations. These combinations demonstrated a protective effect for most antimicrobial classes in Escherichia coli, Campylobacter and Enterococcus isolates from samples of chicken broilers as well in Escherichia coli and Campylobacter spp. from samples of pigs, compared to animals raised under conventional production or without intervention. Increased odds of resistance were only observed for cephalosporins in E. coli and broilers raised without antimicrobials, and to fluoroquinolones and quinolones in Campylobacter and pigs raised without antimicrobials, compared to conventional production. Our study indicates that organic production, antimicrobial-free farms, and group treatment restrictions are recommended for AMR reduction, providing information that may support decision-making to tackle AMR and better reporting to improve comparability of results between studies.

Threat of Antimicrobial Resistance among Pilgrims with Infectious Diseases during Hajj: Lessons Learnt from COVID-19 Pandemic.

Hajj pilgrimage is a large mass gathering global event that may facilitate the spread and emergence of various infectious diseases as well as antimicrobial resistance (AMR) in a local and global scenario. Planning and preparing for these public health issues is a challenging and complex process for the Kingdom of Saudi Arabia (KSA) health authorities. Despite multiple efforts for the prevention and treatment of infectious diseases through longtime funding in education and medical care, the prevalence of infectious disease is still high among Hajj pilgrims. The commonly observed infectious diseases during Hajj include respiratory tract infections (influenza and pneumonia), urinary tract infections and skin infections that may necessitate the use of antimicrobials. Beta-lactams are used as a first-line treatment for hospital acquired infections as well as community acquired infections due to their broad-spectrum activity. However, most of the bacterial isolates such as Staphylococcus spp., Pseudomonas spp. and E. coli are resistant to beta-lactams. Irrational use of antimicrobials, lack of infection prevention practices and suboptimal healthcare access further exacerbate the risk of spreading AMR among Hajj pilgrims. Enhanced collaboration between countries, sharing of best practices and international cooperation are crucial in addressing AMR threats among pilgrims. Consequently, robust surveillance systems for early detection and monitoring of AMR, collaboration with national as well as international healthcare agencies, effective infection prevention and control measures, public awareness and rational use of antimicrobials via antimicrobial stewardship programs are required to mitigate the risk of AMR and ensure the health and well-being of pilgrims during Hajj.

Comparison between broth microdilution and agar disk diffusion methods for antimicrobial susceptibility testing of bovine mastitis pathogens

In order to counter the antibiotic resistance phenomenon, a prudent and rational use of antimicrobials should be driven by an accurate clinical diagnosis and, when possible, by the isolation of the etiological agent followed by susceptibility testing, with the aim to select the most suitable molecule for therapy. Cow mastitis is considered the main cause of antibiotic use in the cattle breeding sector. The purpose of this study was to compare the broth microdilution (BMD) method performed with Sensititre Custom Plates and the agar disk diffusion (ADD) method in determining antimicrobial susceptibility of 215 isolates from bovine mastitis, including contagious pathogens (Staphylococcus aureus, Streptococcus agalactiae) and environmental (Streptococcus uberis, Streptococcus dysgalactiae, Enterococcus spp., Escherichia coli, Serratia marcescens, Klebsiella pneumoniae). We compared results of the following antimicrobials: amoxicillin/clavulanic acid, ampicillin, cefazolin, ceftiofur, enrofloxacin, erythromycin, kanamycin, oxacillin, penicillin, pirlimycin, rifampicin and trimethoprim/sulphonamides. We applied MIC breakpoints and zone diameter breakpoints as recommended by CLSI and EUCAST. MIC and disk diffusion diameters were compared for 1839 microorganism/antimicrobial combination and discrepancies between the two methods were classified as very major discrepancy (VMD), major discrepancy (MD) and minor discrepancy (MiD). The overall agreement between the two methods was found to be 80.7% with a Cohen's kappa coefficient of 0.397, thus indicating a fair concordance. BMD method and ADD method demonstrated a satisfactory agreement (89 to 100%) for S. aureus and S. marcescens and all antimicrobial agents tested. Low agreement was observed for S. uberis and rifampicin (20%), enrofloxacin (49%), penicillin (51%) and pirlimycin (52%), E. coli and ampicillin (20%), S. dysgalactiae and enrofloxacin (44%), S. agalactiae and rifampicin (25%). A possible explanation for the discrepancies detected could be found in the breakpoints used which, sometimes, are not specific for the tissue-matrix of isolation/animal species/pathogen agent. The majority of the discrepancies found were MiD and MD, revealing a higher restrictiveness of the BMD method, while VMD represented only 0.2% of the total observations, a comforting fact since this type of error may result in treatment failure.

Development and Application of a Reference Manual for Diagnosis and Rational Use of Antimicrobial Agents for Outpatient Primary Care (Digestive System Part): A Delphi Study.

To establish a concise and easy-to-understand reference manual for outpatient primary care providers, promoting correct diagnosis of digestive system diseases and rational antimicrobial use. The establishment of the manual encompassed two processes: the development of a draft manual and the validation of the manual. The development process was based on a literature review and expert discussion. The manual comprises portions for disease diagnosis and rationality of antimicrobial use. The validation process employed a two-round Delphi technique, collecting consensus through paper-based or mail-based communications. The response of the Delphi group was assessed by the level of authority and commitment of the panelists and the degree of agreement among them. Furthermore, the manual was preliminarily applied among primary care physicians. A total of 29 panelists completed the Delphi working process. They were authoritative in their professional fields with authority coefficients of 0.813 and 0.818 for the two portions of the manual, respectively. The level of commitment of the panelists was measured by response rates, which were 100.00% and 96.67% for Round 1 and 2. After two rounds, a consensus was achieved with the consensus rates for the two portions of the manual being greater than 65% and 70%, respectively. Kendall W-tests had P-values < 0.001 in both rounds. This reference manual provides 200 diagnostic indicators for 29 common digestive diseases and recommendations for the rational use of antimicrobial agents for 13 categories of digestive diseases. The primary care physicians who used the reference manual reported high satisfaction and frequent usage. Based on a collective consensus of professionals, a reference manual has been established, to provide a concise and easy-to-understand guide specifically for physicians and pharmacists in outpatient primary care. It could facilitate rapid learning to improve the accuracy of diagnosis and treatment for digestive disorders.

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

The AWaRe tool was set up by the World Health Organization (WHO) to promote the rational use of antimicrobials. Indeed, this tool classifies antibiotics into four groups: access, watch, reserve and not-recommended antibiotics. In The Democratic Republic of Congo, data on antibiotic dispensing (prescribing) by health professionals according to the AWaRe classification are scarce. In this research work, we aimed to explore antibiotic dispensing pattern from health professionals according to the WHO AWaRe classification to strengthen the national antimicrobial resistance plan. For this purpose, a survey was conducted from July to December 2022 in the district of Tshangu in Kinshasa. From randomly selected drugstores, drug-sellers were interviewed and randomly selected customers attending those drugstores were included in the study for medical prescriptions collection. The prescribed antibiotics were classified into the access, watch, reserve and not-recommended antibiotics group and by antibiotics number by prescription among pharmacies surveyed. 400 medical prescriptions were collected from 80 drugstores and among which, 301 (75.25%) contained antibiotics. Out of 301 prescriptions, we noticed 164 (54.5%) containing one antibiotic, 117 (38.9%) containing two antibiotics, 15 (5%) containing three antibiotics and 5 (1.6%) containing four antibiotics. A total of 463 antibiotics were prescribed and distributed as 169 (36.5%) were from the access group, 200 (43.2%) from the watch group and 94 (20.3%) from not-recommended antibiotics group, respectively. This can explain the fact of emerging bacterial strains, as, according to the WHO recommendations, the access group should be prioritized because of its activity against a wide range of commonly encountered pathogens and its showing low resistance susceptibility compared to antibiotics from other groups. Based on the anatomical, therapeutic and chemical (ATC) classifications, we observed that third generation cephalosporins represented 34.33% of the prescribed antibiotics, followed by penicillins (17.17%), macrolides (7.63%), aminoglycosides (7.36%) and Imidazole (7.36%), thus accounting approximately for 74% of the classes of antibiotics prescribed. Additionally, among them, the most frequently prescribed antibiotics were Ceftriaxone (21.38%), Amoxicillin (11.01%), Gentamycin (5.61%), Amoxicillin-clavulanic acid (5.61%), Azithromycin (4.97%) and Metronidazole (4.75%), thus accounting for approximately 54% of all the prescribed antibiotics. These results highlight the importance of strict implementation of the national plan to combat antimicrobial resistance and the need to train health workers in the correct application of the WHO AWaRe classification.

Detection of antimicrobial impact on gram-negative bacterial cell envelope based on single-cell imaging by scanning electron microscopy

Rapid determination of drug efficacy against bacterial pathogens is needed to detect potentially resistant bacteria and allow for more rational use of antimicrobials. As an indicator of the antimicrobial effect for rapid detection, we found changes in image brightness in antimicrobial-affected bacteria by scanning electron microscopy (SEM). The cell envelopes of unaffected bacteria were stained with phosphotungstic acid (PTA), whereas the entire cells of affected bacteria were stained. Since tungsten density increases backscattered electron intensity, brighter bacterial images indicate lethal damage. We propose a simplified method for determining antimicrobial efficacy by detecting damage that occurs immediately after drug administration using tabletop SEM. This method enabled the visualization of microscopic deformations while distinguishing bacterial-cell-envelope damage on gram-negative bacteria due to image-brightness change. Escherichia coli, Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae, and Pseudomonas aeruginosa were exposed to imipenem and colistin, which affect the cell envelope through different mechanisms. Classification of single-cell images based on brightness was quantified for approximately 500 bacteria per sample, and the bright images predominated within 5 to 60 min of antimicrobial treatment, depending on the species. Using intracellular PTA staining and characteristic deformations as indicators, it was possible to determine the efficacy of antimicrobials in causing bacterial-cell-envelope damage.

Assessment of rational use of antimicrobials: a cross-sectional study among people of Nepal.

It was a cross-sectional survey conducted among 385 participants visiting tertiary care center from all over Nepal from February 2022 to May 2022. Modified Bloom's cut-off point was utilized to categorize the participants' overall knowledge, behavior, and practice. The chi-square (χ 2) test and odds ratio (OR) using binary logistic regression at 95% CI and Spearman's rank correlation coefficient test (r) were calculated wherever appropriate. More than three-fifths of the participants (248, 64.42%) demonstrated good behavior, whereas less than half of the participants showed good knowledge (137, 35.58%) and practice (161, 41.82%) about rational use of antimicrobials. Health professionals had higher knowledge (OR: 1.07, 95% CI: 0.70-1.62) and good behavior (OR: 0.42, 95% CI: 0.27-0.64) than other professionals (P<0.05). Those with higher income [≥50000 NRS (Nepalese rupees)] had good behavior (OR: 3.37, 95% CI: 1.65-6.87) and good practice (OR: 2.58, 95% CI: 1.47-4.50) scores than those with less monthly income (P<0.05). Similarly, higher educational degrees, viz. master's and/or above, had good behavior (OR: 4.13, 95% CI: 2.62-6.49) and good practice scores (OR: 2.55, 95% CI: 1.68-3.87). Additionally, there were significant positive correlations between knowledge (K), behavior (B), and practice (P) scores (r=0.331 for K and B, r=0.259 for K and P, and r=0.618 for B and P, respectively; P<0.05). The findings imply the demand for effective legislature, strict enforcement of the drug act, and proper implementation of plans and policies to curb antimicrobials misuse. Lack of execution of existing laws and the unawareness of the public led to the extravagant use of antimicrobials.

Clinical and Economic Impact of Antimicrobial Resistance: Role of Antimicrobial Stewardship Programs in Indian Hospitals

Abstract Antimicrobial resistance (AMR) is a threat to public health globally and is expected to worsen if not addressed. AMR has far-reaching consequences, impacting patients, public health, health-care systems, and society. It not only leads to increased morbidity and mortality but also poses significant challenges to the health-care industry, resulting in treatment failures and escalating costs associated with intensive interventions. Hospitals are also affected by AMR through prolonged hospital stays with increased costs of health care. It significantly impacts the success of cancer chemotherapy and organ transplantation and often compromises major surgeries. In this review, we have highlighted the clinical and economic consequences of AMR and the importance of antimicrobial stewardship programs (AMS programs) to combat resistance and protect patient health. As part of an organizational or system-wide health-care strategy, the AMS programs promote, evaluate, improve, and monitor the rational use of antimicrobials to safeguard their future effectiveness while promoting and protecting public health. We have also discussed the role of AMS programs in mitigating the clinical and economic impacts of AMR in Indian hospitals and provided some key suggestions for implementing AMS programs in this setting.

Prescription pattern of antimicrobial agents prescribed in outpatient department of dermatology in a tertiary care hospital in India

Background: Skin diseases contribute largely to global disease burden. Antimicrobial agents are used for treatment of various skin diseases of microbial aetiology caused by fungi, bacteria, viruses and ectoparasites. The primary objective of this study was to study the prescription pattern of antimicrobial agents in dermatology, to provide insights into the disease patterns, profile of the drugs used and their rationality. Methods: Cross-sectional observational study was conducted in dermatology outpatient department of T. N. M. C. and B. Y. L. Nair Charitable Hospital, Mumbai for period of 6 months. 372 prescriptions containing an antimicrobial agent (AMA) were analysed. Demographic data, disease pattern, associated comorbidities and prescription details were recorded after taking written informed consent. Results: Fungal infections were the most common (48%) followed by bacterial infections (31%). The most encountered condition was dermatophytosis. Average number of AMA per prescription was 2.33±0.73. Percentage of AMA prescribed by generic name was 48%. Percentage of AMA prescribed from National list of essential medicines 2015 (NLEM) was 32.60%. 87.9% of AMA were prescribed as combination therapy and 12.10% were prescribed as monotherapy. The commonest prescribed drugs were antifungals followed by antibiotics. Topical creams were the commonest prescribed dosage form. Conclusions: The most common class of antimicrobial agents prescribed was antifungal agents. Prescribing combination of oral antimicrobials with topical antimicrobials was found to be high. This study provides a framework for continuous prescription audit of antimicrobials in an outpatient setting and thus can help in rational use of antimicrobials in dermatological prescribing.

Knowledge, attitude and practice on antimicrobial use and antimicrobial resistance among competent persons in the community pharmacies in Bhutan.

Since the discovery, antimicrobials have been used to treat variety of infections both in humans and animals caused by microbes. However, with the increasing use, microbes developed resistance to the antimicrobials and many of the antimicrobials became ineffective against certain microbes. Many factors are reported to contribute to the resistance of microbes to antimicrobials. One contributing factor is the misuse and overuse of antibiotics which mainly occur due to the lack of knowledge, careless attitudes, and incorrect practices about use of antibiotics. This cross-sectional survey study was conducted among the competent persons (CP) in the community pharmacies in Bhutan, with the aim to assess their knowledge, attitude and practice (KAP) on antimicrobial use (AMU) and antimicrobial resistance (AMR). Results from the survey revealed that the competent persons had good level of knowledge about antimicrobial use and antimicrobial resistance. They also had favourable attitude towards antimicrobial resistance and rational use of antimicrobials. Their knowledge and attitude had led to good practices while dispensing antimicrobials from their pharmacies. However, almost all of them had never had any opportunity to take part in activities related to antimicrobial use and antimicrobial resistance that were organized by the public sector. Many of them did not even hear or know about the existence of the policies on use of antimicrobials or on curbing antimicrobial resistance in the country. Involvement of the community pharmacies through trainings and participations in policy making processes is seen as a vital mechanism that can eventually help achieve the goals in the national drive towards reducing antimicrobial resistance.

The action of the pharmacist in front of bacterial resistance and rational use of antimicrobials in the hospital environment

Antimicrobials are one of the best discoveries of the 20th century, which concomitant with their use came one of the biggest current problems in the world, bacterial resistance. Within this context, the present study aims to highlight the role of the pharmacist in the face of bacterial resistance and rational use of antimicrobials in the hospital environment. For the development of the study, a literature review was carried out for a reflective analysis based on studies published from 2010 to 2022 in the main databases found in Portuguese, English and Spanish. We selected 20 articles out of 6,650 found before applying the inclusion and exclusion criteria and performing the analysis. The clinical pharmacist plays a key role in combating bacterial resistance. In addition, the hospital environment is a place where there are more people in the same environment administering various antibiotics and different spectrums. The pharmaceutical professional has a direct and indirect impact on patients and medicines, being responsible for promoting the rational use of antibiotics, with standardization of medicines and possible interventions in the treatment, providing care, insurance, and health to the patient. Therefore, it is an important key in combating bacterial resistance, which is a public health issue, in addition to the possibility of promoting research and innovation in the field of microbiology and antimicrobial therapy.

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.