Antibiotic Sales Research Articles

Sales of Veterinary Antibiotics in Serbia: Identification of Problem Areas Using Standardized Metrics

One Health, as a multi-disciplinary approach, considers animal, human, and environmental health. Serbia continuously records high rates of antimicrobial resistance, with a knowledge gap on practices regarding veterinary antibiotic use, as no standardized data regarding veterinary consumption of antibiotics that would allow for temporal or spatial comparison are available in Serbia. This study aimed to describe the sales of veterinary antibiotics in Serbia. Aggregated wholesale data on veterinary drug sales were retrieved from the annual reports available from the Medicines and Medical Devices Agency of the Republic of Serbia for a period between 2017 and 2020. Veterinary use was analyzed using standard European Medicines Agency proposed methodology and expressed in milligrams of active substance per population correction unit (mg/PCU). Overall, there has been a 13% increase in aggregated sales, in mg/PCU, of antibiotic veterinary medicinal products (VMPs) for food-producing animals in Serbia between 2017 and 2020. With sales of around 110 mg/PCU in 2020, Serbia would have ranked ninth in Europe. In 2020, the overall highest-selling antibiotic classes were penicillins (27.62 mg/PCU), tetracyclines (27.54 mg/PCU), and aminoglycosides (12.8 mg/PCU), accounting for 61.9% of the total sales of antibiotic VMPs for food-producing animals, in mg/PCU. An increase in the use of macrolides and lincosamides and a decrease in the use of penicillins and the group classified as “other antibacterials” was noted. The current study identified an increase in the sales of veterinary antibiotics in Serbia and pointed out several potential problem areas.

Antimicrobial stewardship in sub-Saharan African community pharmacies: a systematic review of community pharmacists’ knowledge, practice and challenges faced

Abstract Introduction The indiscriminate use of antimicrobials contributes significantly to antimicrobial resistance (AMR). The World Health Organization (WHO) recommends antimicrobial stewardship (AMS) as one of the global sustainable development interventions to tackle AMR. Implementation of AMS interventions have been documented to be successful in high-income countries 1, however, there is paucity of data regarding the implementation and effectiveness of AMS in low-income settings including sub-Sahara Africa (SSA). Community pharmacies in the SSA play a critical role in the dispensing of medicines, including antibiotics. Aim To evaluate community pharmacists' knowledge, practice, and challenges faced in relation to AMS in SSA community pharmacies. Methods The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework guided the review. We searched six electronic databases (PubMed, Web of Science, ProQuest Central, Google Scholar, African Journal Online and Wiley Online library) from January 2010 to December 2022. Reference lists of included articles were screened for additional studies. Studies published in English that described AMS interventions, antibiotic dispensing practices, community pharmacists’ knowledge and perceptions of AMS/AMR were included. Literature reviews and systematic reviews were excluded. AMS in hospital pharmacy and animal studies were also excluded. Two reviewers independently screened the abstracts and full texts according to pre-defined inclusion criteria. Disagreements were resolved through discussion. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the quality of the included studies2. Data were extracted using a standardised form in Microsoft excel and double checked for accuracy. Data were synthesised using narrative synthesis. The review protocol was registered with PROSPERO (CRD42023381320). The study did not require ethical approval because it did not involve conducting primary or secondary research involving human participants. Results The review identified 1972 articles, of which 23 studies met the inclusion criteria. Studies varied in settings, design, and data collection methods. Two broad categories were identified from the narrative synthesis. (1) Community pharmacists’ knowledge, attitude, perception, and dispensing practices (n=20). Studies reported that community pharmacists displayed an understanding of how antibiotics work. They also acknowledged threats posed by AMR. Some studies reported misconceptions on clear guidelines about the practical implementation of AMS, other studies described good adherence to antibiotic dispensing practices, including taking medication histories, assessing symptoms, advising on completion of antibiotic courses and making referrals. One study described the perception of community pharmacists of AMS as crucial for improving patient care. (2). Determinants of non-prescription antibiotic sales (n=3). The studies explored factors influencing the sale of antibiotics without prescription. Studies identified pharmacy owners’ expectations (profitability) and lack of public awareness regarding the risks of non-prescription antibiotic use as contributing factors. Limited patient access to doctors and low economic status in SSA were also cited as determinants. Conclusions Community pharmacists have knowledge of antibiotics, and they also acknowledged the importance of AMS. There were also positive dispensing practices despite existing challenges regarding implementation of AMS and sales of antibiotics without prescription. Further research should prioritize well-designed studies that evaluate the effectiveness of AMS in this setting and address the challenges identified. Heterogeneity of study methods limits the generalisability of findings.

Introducing innovative policy instrument to reduce antibiotics use. Relevant evidence from Bulgaria

Abstract Background of the public health challenge Excessive individual consumption of antibiotics (ABs) increases global antimicrobial resistance (AMR). Therefore, shaping consumers’ behaviors towards responsible ABs use is an essential strategy in the battle with the silent pandemic of AMR. The EU One Health (OH) Action Plan against AMR targets making Europe a best-practice region. Overall consumption of ABs in the EU decreased significantly, especially during the COVID-19 pandemic. Bulgaria is the only EU country that has reported an annual increase in ABs use during this period (ECDC data). A growing part of Bulgarians, believe that ‘ABs kill viruses’ and is unaware that ‘unnecessary use of ABs makes them ineffective’ (Eurobarometer 2022). This limited understanding of adequate ABs use resulted in counterproductive behaviors that demand change. Introducing innovative policy instrument as a tool for behavioral change: Undeniably, drug prescription monitoring has the potential to change consumers’ behaviors. In October 2023 mandatory electronic prescribing (e-Rx) for ABs was introduced in Bulgaria at a primary healthcare level. Consequently, there was an observed decline exceeding 30% in ABs sales (IQVIA Bulgaria data), evidencing a reduction in ABs consumption. However, there were negative reactions by the stakeholders, due to time-consuming procedures, nonoptimal IT infrastructure, etc., and that led to e-Rx-moratorium. Finally, in April 2024, the e-Rx is sustainably introduced. Conclusions Legislative measures, like e-Rx, can hinder the chaotic use of ABs. Moreover, Bulgarians need to reflect on their behaviors and values of solidarity which OH offers. Herewith, a multidisciplinary team of academic educators unite their OH efforts in raising awareness related to AMR and the rational use of ABs. Years of national endeavors toward healthcare digitalisation led to the introduction of e-Rx for ABs in Bulgaria. Research will prove its relevance for the rest of Europe. Key messages • To the European community: The introduction of the innovative policy tool (e-Rx for antibiotics) in Bulgaria is a significant national effort in making Europe a best-practice region regarding AMR. • To the Bulgarian society: Antibiotics are not bonbons! Responsible ABs use of every one of us can contribute to the EU efforts to manage AMR. In the context of AMR, every person is a stakeholder.

Monitoring community antibiotic consumption in Belgium: reimbursement versus retail data (2013-22).

In Belgium, monitoring antibiotic consumption relies on reimbursement data, which is obtained with a time delay and does not account for over-the-counter or nonreimbursed products. This study aims to bridge this gap by comparing reimbursement and retail data for primary care to understand variations and assess the accuracy of current surveillance methods. Reimbursement data were obtained from the National Institute for Health and Disability Insurance, and retail data were obtained from IQVIA for the period 2013-22. The community consumption of systemic antibiotics was expressed in defined daily doses (DDD-WHO ATC/DDD Index 2023) per inhabitants per day (DID). Relative differences in DID (RDs) based on the two data sets were computed and validated through Bland-Altman plots and correlation analysis. The sales of antibiotics declined from 22.89 DID (2013) to 20.50 (2022), with a steep drop during the COVID-19 pandemic-from 21.31 DID in 2019 to 16.55 DID in 2020-and a subsequent rebound. Reimbursement data slightly underestimated consumption compared to retail data, with RDs ranging from 2% (2013) to 9% (2022) when including quinolones and from 2% to 4% when excluding them. Bland-Altman plots showed high agreement between reimbursement and retail estimates, identifying quinolones as outliers. Our findings suggest that reimbursement data are generally reliable for monitoring antibiotic consumption, but incorporating retail data is crucial for accurate assessments. The use of retail data can facilitate timely interventions and inform public health strategies to effectively address antimicrobial resistance.

Post-pandemic consumption of outpatient antibiotics in Switzerland up to pre-pandemic levels, 2018–2023: An interrupted time series analysis

BackgroundThe COVID-19 pandemic has been a challenge for health-care systems and antibiotic stewards as uncertainty regarding treatment and bacterial coinfections raised concern. MethodsThis retrospective observational study examined the association of the pandemic on outpatient antibiotic sales and prescriptions in Switzerland using interrupted time series (ITS) analyses. Data from IQVIA™ and the Sentinella Network were used to analyze antibiotic consumption and prescription patterns over a 72-month period from January 2018 to December 2023, divided into pre-pandemic, pandemic, and post-pandemic periods. ResultsAntibiotic consumption decreased during the pandemic and returned to pre-pandemic levels in the post-pandemic period. A decrease in level was most pronounced in the French-speaking region (−2.82 defined daily doses per 1,000 inhabitants per day (DID) per month, 95 %CI [−4.34, −1.30], p < 0.001) and the Italian-speaking region (−2.80 DID per month, 95 %CI [−4.78, −0.82], p < 0.01), followed by the German-speaking region (−1.72 DID per month, 95 %CI [−2.71, −0.74], p < 0.01). Similarly, in the ITS, the relative change of model estimates in antibiotic prescriptions by GPs and pediatricians for upper respiratory tract infections, was of −36.0 % and −50.3 % resp. in the pandemic period and +10.1 % and −2.6 % in the post-pandemic period compared with the pre-pandemic period. ConclusionsA decrease of antibiotic prescriptions was observed in GPs and pediatricians during the COVID-19 pandemic, followed by a return to pre-pandemic levels. The patterns in antibiotic prescriptions aligned with the epidemiology of respiratory infections and demonstrated a pronounced association with the implementation and subsequent removal of non-pharmaceutical interventions.

Prevalence of antibiotic self-medication and knowledge of antimicrobial resistance among community members in Neno District rural Malawi: A cross-sectional study

ObjectivesDespite global efforts to address antibiotic self-medication, it is still significantly prevalent. This study aimed to investigate the prevalence of antibiotic self-medication and assess knowledge of antibiotic resistance among community members in Neno District, rural Malawi. MethodsA cross-sectional, community-based study was conducted from September to November 2023, using simple random sampling across 169 villages. Participants from two households per village were surveyed using a “drug bag” method, focusing on those who had taken antibiotics within the preceding 6 months. In addition, drug retailers were selected via snowball sampling for interviews. ResultsOf the 531 participants and 39 drug retailers, 71.1% reported antibiotic use, with 69.5% self-medicating in the past 6 months, with convenience (31.5%) and confidence (26.7%) being the reasons. Common symptoms prompting self-medication included cough (29.9%), sore throat (28.6%), and aches and pain (28.6%). Amoxicillin (61.1%) and cotrimoxazole (29.6%) were the most used antibiotics. More than half (53.1%) reused leftover antibiotics from health facilities, with employed participants significantly more likely to self-medicate. Awareness of antibiotic resistance was low (16.1%), mainly learned from hospitals. Unlawful antibiotic sales by drug retailers (46.2%) were noted. ConclusionsThe study highlights the urgent need for government-led efforts to regulate antibiotic use and increase public awareness to mitigate the impact on public health.

Coverage of policies to improve antimicrobial stewardship in human medicine in low and middle income countries: results from the Global Survey of Experts on Antimicrobial Resistance

BackgroundAntimicrobial resistance (AMR) constitutes a major threat to global health. While antimicrobial misuse or overuse is one of the main drivers for AMR, little is known about the extent to which antibiotic misuse is due to a lack of national government-led efforts to enforce rational use in low and middle-income countries (LMICs).MethodsTo assess antimicrobial stewardship and national implementation measures currently in place for optimizing antimicrobial use and for slowing the spread of AMR, we invited public health experts from 138 LMICs to participate in a Global Survey of Experts on Antimicrobial Resistance (GSEAR). Key coverage measures, as reported by experts, were compared across countries and also juxtaposed with estimates collected in the 2020-21 World Health Organization-organized Tripartite AMR Country Self-Assessment Survey (TrACSS).ResultsA total of 352 completed surveys from 118 LMICs were analysed. Experts in 67% of the surveyed countries reported a national action plan (NAP) on AMR, 64% reported legislative policies on antimicrobial use, 58% reported national training programs for health professionals, and 10% reported national monitoring systems for antimicrobials. 51% of LMICs had specific targeted policies to limit the sale and use of protected or reserve antibiotics. While 72% of LMICs had prescription requirements for accessing antibiotics, getting antibiotics without a prescription was reported to be possible in practice in 74% of LMICs. On average, country efforts reported in TrACSS were substantially higher than those seen in GSEAR.ConclusionsIn many LMICs, despite the existence of policies aimed at slowing down the spread of AMR, there are still significant gaps in their implementation and enforcement. Increased national efforts in the areas of enforcement and monitoring of antibiotic use as well as regular monitoring of national efforts are urgently needed to reduce inappropriate antibiotic use in LMICs and to slow the spread of AMR globally.

Antibacterial Resistance and Extended-Spectrum Beta-Lactamase (ESBL) Phenotypes in Enterobacteriaceae Isolated from Fecal Samples of Humans and Animals in Selected Local Government Areas of Nasarawa State, Nigeria

It is quite alarming the increasing rate of antibacterial resistance all over the world considering the public health threat and the re-emergence of multi-drug resistant Enterobacteriaceae. The aim of this study is Antibacterial resistance and phenotypic detection of Extended Spectrum Beta-Lactamase (ESBL) producing Enterobacteriaceae isolated from human and animal fecal samples in selected local government areas of Nasarawa state, Nigeria was carried out in the study. Hundred (100) samples comprising human and animal (goats, cattle, and chicken) were collected and 55 samples were multidrug resistant. A commercial biochemical kit (Eneterosystem 18R) was used for the isolation and identification of Enterobacteriaceae. Kirby Bauer Disk Diffusion Method was used for antibacterial susceptibility testing of Enterobacteriaceae isolates. The Double Disc Synergy Test (DDST) method was also used for the phenotypic confirmation test of Extended Spectrum Beta Lactamase (ESBL). The occurrence of multidrug-resistant isolates shows that Escherichia coli (100.00%) which is the highest, Proteus mirabilis (14.54%), Klebsiella pneumoniae, and Salmonella enterica (10.90%), while the occurrence of Shigella flexneri (9.09%) was the lowest. The Enterobacteriaceae isolates were more resistant to Cefuroxime, Cefexime, Amoxicillin Clavulanate, and Imipenem/Cilastatin with percentage resistance ranges from 66.6% - 100%. The occurrence of ESBL producers shows that Escherichia coli (60.00%) and Proteus mirabilis (62.5%) were high while Shigella flexneri (20.0%) had a low occurrence of ESBL. The sale and in-discriminate use of antibiotics without a prescription is an important regulatory issue in the abuse of antibiotics for both humans and animals. The Beta-Lactam and gentamycin antibiotics were not effective against the Multi-Drug Resistant (MDR) isolates and most of the isolates were ESBL producers.

Knowledge, Attitudes, and Practices towards Antibiotics, Antimicrobial Resistance, and Antibiotic Consumption in the Population of Kazakhstan.

During the COVID-19 pandemic, a ban on inspections of small businesses, including pharmacies, was imposed in Kazakhstan, which relaxed law enforcement efforts regarding the prohibition of over-the-counter antibiotic (AB) sales. This study aimed to investigate how this affected the knowledge, attitudes, and practices (KAP) related to AB and antimicrobial resistance (AMR), as well as to assess actual AB consumption at the community level. The study comprised two cross-sectional sub-studies: the first involved a KAP survey conducted in 2022 and 2024, utilizing the Special Eurobarometer questionnaire on AMR. The second sub-study analyzed AB consumption in 2021 and 2023, measured in defined daily doses per 1000 inhabitants. Results revealed an increase in the percentage of individuals reporting receipt of information about ABs and AMR in the past year (37.3% in 2022 vs. 52.9% in 2024, p < 0.001) and an increase in the percentage of individuals reporting AB use in the past year (49.0% in 2022 vs. 54.0% in 2024, p = 0.056). The most consumed ABs were from the Watch group, with azithromycin and ceftriaxone ranking highest. These findings support the hypothesis that the relaxation of law enforcement contributed to an increase in AB consumption and emphasize the need for public health policies to address this issue.

Understanding antibiotic purchasing practices in community pharmacies: A potential driver of emerging antimicrobial resistance

IntroductionAntimicrobial resistance (AMR), a transboundary health issue, critically impacting low- and middle-income countries (LMICs) where 80% of antibiotics are used in the community, with 20–50% being inappropriate. Southeast-Asia, including Bangladesh, faces heightened AMR risk due to suboptimal healthcare standard and unregulated antibiotic sales. This study aimed to audit antibiotic dispensing patterns from community pharmacies, identifying factors influencing purchasing behaviors. MethodsA cross-sectional survey of 385 antibiotic customers and structured observations of 1000 pharmacy dispensing events were conducted in four urban and rural areas in Bangladesh. Descriptive analysis defined antibiotic use, while Poisson regression examined how patients' demographics and health symptoms influenced prescription behaviors. ResultsAmong 1000 observed medicine dispensing events, 25.9% were antibiotics. Commonly purchased antibiotics included macrolides (22.8%), third-generation-cephalosporins (20.8%), and second-generation-cephalosporins (16.9%). Following WHO-AWaRe classifications, 73.5% of antibiotics were categorized as Watch, and 23.1% as Access. From the survey, 56.6% antibiotics were purchased without a prescription from drug-sellers and informal healthcare providers, primarily for “non-severe” health-symptoms such as upper-respiratory-tract infections (37.4%), fever (31.7%), uncomplicated skin infections (20%), gastrointestinal-infections (11.2%), and urinary-tract infections (7.9%). The likelihood of presenting a prescription while purchasing antibiotics was 27% lower for individuals aged 6–59 compared to those ≤5 or ≥ 60. Lower-respiratory-tract infections and enteric-fever had higher prescription rates, with adjusted prevalence ratios of 1.78 (95% CI: 1.04, 3.03) and 1.87 (95% CI: 1.07, 3.29), respectively. After adjusting for confounders, sex, urban-rural locations, income, education, and number of health-symptoms exhibited no significant influence on prescription likelihood. ConclusionThis study underscores unregulated antibiotic sales without prescriptions, urging tailored interventions considering prevailing health-seeking practices in diverse healthcare settings in LMICs. Enforcing prescription-only regulations is hindered by easy access through community pharmacies and conflicts of interest. Future strategies should consider how stewardship impacts the financial interests of pharmacy personnel in settings lacking clear authority to ensure optimal compliance.

Over-the-counter sales of antibiotics: a call to action to ensure access and prevent excess

Over-the-counter sales of antibiotics: a call to action to ensure access and prevent excess

A Systematic Review of Antibiotic Use in Humans in Nigeria and Its Potential Contribution to Rising Antimicrobial Resistance

INTRODUCTION: The value of medicines is lost when these resources are not used rationally. Out of 12 developing countries, Nigeria has the third highest percentage of antibiotic prescriptions, at 48%. Antibiotic misuse results in limited efficacy, which can lead to the emergence of antimicrobial resistance. We conducted a systematic review to synthesise the evidence on antibiotic use in humans in Nigeria. METHODS: We conducted a systematic review of medicine use behaviour by patients and prescription behaviour by health workers, which were searched for in articles published in English from 2000 to 2017. Data was entered into purpose-built templates. Key quantitative indicators were extracted and summarised as frequencies and proportions, while free-text responses were synthesised. RESULTS: The systematic review determined that the median prevalence of persons using antibiotics without prescription is 46.7%. The drivers of irrational antibiotic use included poor regulation of medicines and premises, a chaotic medicine distribution system, limited licensed medicine prescribers, over-the-counter (OTC) sales of antibiotics, patients’ demand for antibiotics, and access to health insurance. DISCUSSION: Irrational antibiotic use is widespread in humans and animals. We recommend that the government enforce regulations on antibiotic sales to humans and animals and increase awareness of irrational antibiotic use and AMR in Nigerian communities through a whole-of-society approach. The collated information was used to develop a National Action Plan on AMR in 2017.

Self-medication with antibiotics during the COVID-19 pandemic: A cross-sectional study among adults in Tema, Ghana.

Antibiotic self-medication is one of the common causes of antibiotic resistance of bacterial organisms. The COVID-19 pandemic introduced a new paradigm shift and significantly influenced healthcare behaviors, including an increase in antibiotic self-medication, which contributes to antibiotic resistance. This study was aimed at determining the prevalence of antibiotic self-medication and the possible associated factors during the peak of the COVID-19 pandemic among adult residents of Tema in Ghana from April to July 2021. Using a cross-sectional design, 400 adults were randomly selected and surveyed using a researcher-assisted questionnaire. Data were analyzed with IBM® SPSS® Statistics Version 22.0, considering associations significant at a 95% confidence interval (p < 0.05). Of the 400 respondents, (76%) 304 had practiced antibiotic self-medication within the previous 12 months during the COVID-19 pandemic. Significant factors associated with antibiotic self-medication included gender, age, marital status, education, occupation, and National Health Insurance Scheme subscription. Convenience and avoiding long hospital queues were primary non-medical reasons for antibiotic self-medication, while previous successful experience, easy access to antibiotics, treating symptoms, prophylaxis, and fear of hospital infection were the medical reasons for antibiotic self-medication. Commonly self-administered antibiotics were azithromycin (34%), amoxicillin/clavulanic acid (22%), and metronidazole (16%) for perceived respiratory tract and gastrointestinal tract infections. The high prevalence of antibiotic self-medication observed during the COVID-19 pandemic underscores the need for enhanced public education and stricter enforcement of regulations governing antibiotic sales. The non-medical and medical factors of convenience, avoiding long hospital queues, previous successful experience, easy access to antibiotics, treating symptoms, prophylaxis, and fear of hospital infection which motivated antibiotic self-medication practices require the implementation of antimicrobial stewardship interventions.

Understanding veterinary drug shop workers' knowledge and practices to identify drivers of antibiotic use in Vietnamese livestock farms.

Antimicrobial resistance (AMR) is a One Health issue and a major threat to animal and human health. Antibiotic use (ABU) drives AMR development, and several hotspots for ABU, and AMR, in livestock have been identified in Southeast Asia, including Vietnam. There are often multiple drivers of ABU at farms, and to identify all of them there is a need to look beyond farm level. The overall aim of this study was to identify routines and/or competencies, related to antibiotic sales, among veterinary drug shop workers that may be improved in order to decrease the medically non-rational use of antibiotics in livestock production. A questionnaire-based survey was conducted at 50 veterinary drug shops in northern Vietnam. Results showed high education and knowledge levels. According to the respondents, antibiotic treatment advice was almost always provided to the farmers, and the recommended treatment was most commonly based on recommendations for the specific disease. However, farmers had almost never had their animals properly diagnosed. Antibiotics were the most sold drug category, penicillins being the most common. Several broad-spectrum antibiotics were also quite frequently sold. Further, >50% of respondents recommended antibiotics for disease prevention. Even though education and knowledge levels might be high, several challenges can prevent drug shop workers from contributing to more prudent ABU at farms, for example, lack of proper diagnosis, commercial interests and individual farmer motives, often in combination with poor compliance to regulations.

Non-prescription sale and dispensing of antibiotics for prophylaxis in broiler chickens in Lusaka District, Zambia: findings and implications on one health.

The irrational use of antibiotics in humans and livestock has contributed to the emergence of antimicrobial resistance (AMR). This study investigated the commonly sold and dispensed antibiotics for prophylaxis in broiler chickens in pharmacy and agro-veterinary shop personnel in the Lusaka District of Zambia. This cross-sectional study was conducted from August 2023 to October 2023 among 200 veterinary medicine dispensers in the Lusaka District of Zambia using a simulated farmer or mystery shopper approach. Data analysis was performed using IBM Statistical Package for Social Sciences version 23.0. Out of the 200 medicine outlets investigated, 23 (11.5%) were agro-veterinary shops, while 177 (88.5%) were community pharmacies. A total of 165 community pharmacies and agro-veterinary shops provided veterinary services in the Lusaka District and sold medicines without prescription giving a 100% non-prescription sale. Of the 178 medicines dispensed for prophylaxis, 88.5% were antibiotics, while 13.5% were vitamins. The most dispensed antibiotic drug for prophylaxis in broiler chickens was oxytetracycline (30.34%), amoxicillin (17.98%) and gentamicin/doxycycline (10.67%). This study revealed a high sale and dispensing of antibiotics for prophylaxis in broiler chickens of which oxytetracycline, amoxicillin and gentamicin/doxycycline were commonly dispensed. There is a need for increased regulatory enforcement of selling antibiotics without a prescription as this may predispose poultry to the development of AMR and possible transmission of superbugs to humans and the environment. Educational interventions should be provided to community pharmacy and agro-veterinary personnel on adhering to antimicrobial stewardship practices when dispensing poultry antibiotics.

Antibiotic Resistance Mechanisms and Strategies for Combating Resistance in Germany

Purpose: The aim of the study was to explore antibiotic resistance mechanisms and strategies for combating resistance in Germany Methodology: This study adopted a desk methodology. A desk study research design is commonly known as secondary data collection. This is basically collecting data from existing resources preferably because of its low cost advantage as compared to a field research. Our current study looked into already published studies and reports as the data was easily accessed through online journals and libraries. Findings: antibiotic resistance represents a complex and evolving challenge to public health in Germany. Mechanisms such as efflux pumps, mobile genetic elements, and enzymatic degradation contribute to the resilience of bacteria against antibiotics. However, strategic interventions have been identified to combat resistance effectively. Exploration of alternative therapies like bacteriophage therapy offers promising avenues for addressing antibiotic-resistant infections, especially in light of increasing resistance rates. Unique Contribution to Theory, Practice and Policy: Evolutionary theory of antibiotic resistance &amp; Game Theory in Antibiotic Stewardship may be used to anchor future studies on antibiotic resistance mechanisms and strategies for combating resistance in Germany. Implement antimicrobial stewardship programs across healthcare settings to optimize antibiotic use. These programs should involve prescriber education, antibiotic guidelines, and regular audits to promote appropriate prescribing practices and minimize unnecessary antibiotic exposure. Prioritize infection prevention measures, including hand hygiene, environmental cleaning, and infection control protocols, to reduce the spread of resistant pathogens within healthcare facilities and communities. Enact policies to regulate the use of antibiotics in human health, veterinary medicine, and agriculture. This includes restrictions on antibiotic use in food production, bans on over-the-counter antibiotic sales, and incentives for the development of new antibiotics.

Mapping the flow of veterinary antibiotics in Kenya.

To effectively regulate and reduce antibiotic use, in the livestock sector, a thorough understanding of the flow of veterinary antibiotics will help to identify key nodes in the chain for targeted interventions. The aim of this study was to understand the flow of antibiotics from import to end-user, and identify relevant governance mechanisms. A mixed methods approach was used to collect data in three Kenyan counties (Nairobi, Kiambu, and Kajiado). Focus group discussions (n = 23), individual interviews (n = 148), and key informant interviews (n = 10) were conducted. The key actors identified include primary wholesalers, secondary wholesalers, retailers, animal health service providers (AHSPs), and farmers. Kenya imports 100% of its veterinary antibiotics: primary wholesalers legally import antibiotics as finished pharmaceutical products (90%) or active pharmaceutical ingredients (10%) after approval by the Veterinary Medicines Directorate. Secondary wholesalers play a major role in the distribution of antibiotics (60% of antibiotics) from importers to farmers, AHSPs, and retailers. Some of the illegal sources of antibiotics include unlicenced/unauthorized middlemen and online platforms that sell directly to retailers, AHSPs, and farmers. Despite the presence of various laws and regulations governing the antibiotic value chain, implementation has been a challenge due to financial and human resource constraints. This contributes to over-the-counter sale of antibiotics without prescription, unlicensed businesses selling antibiotics, illegal importation, and presence of poor-quality drugs. There is a need to review the applicability of existing policies and address policy gaps (e.g., product containing antibiotic combinations, and use of human critically important antibiotics) to ensure the prudent sale and use of antibiotics, pharmacovigilance, antimicrobial use surveillance, and developing a business model that aligns with antibiotic stewardship. Additional interventions include awareness raising and capacity building of the different stakeholders along the antibiotic distribution chain to reduce antibiotic mis- and overuse.

Epidemiology and clinical significance of carbapenemases in Australia: a narrative review.

Carbapenemase-producing gram-negative bacteria (CP-GNB) infections threaten public health with high mortality, morbidity and treatment costs. Although frequencies remain low in Australia (total number of CP-GNB infections reported was 907 in 2022), blaIMP-4 has established low levels of endemicity in many states. Imipenemase metallo-β-lactamase types alone accounted for more than half of all carbapenemases in carbapenemase-producing Enterobacterales isolates in Australia, particularly in Enterobacter cloacae complex. New Delhi metallo-β-lactamase constitutes almost 25% of all carbapenemases in Australia and was identified predominantly in Escherichia coli. The OXA-48-like carbapenemases include almost 10% of all carbapenemases and are mainly seen in Klebsiella pneumoniae and E. coli. Although K. pneumoniae carbapenemase-type carbapenemases are rare in Australia, some local outbreaks have occurred. Most carbapenem-resistant (CR) Pseudomonas aeruginosa strains in Australia do not produce carbapenemases. Finally, OXA-23-like carbapenemases are overwhelmingly positive in CR-Acinetobacter baumannii strains in Australia. Treatment of CR-GNB infections challenges physicians. Of 10 new antibiotics active against at least some CR-GNB infections that are approved by the USFood and Drug Administration, just three are approved for use in Australia. In this context, there is still an unmet need for novel antibacterials that can be used for the treatmentof CR-GNB infections in Australia, as well as a pressing requirement for new mechanisms to 'de-link' antibiotic sales from their availability. In this narrative review, we aim to overview the epidemiology and clinical significance of carbapenem resistance in Australia as it pertains to Enterobacterales, P. aeruginosa and A. baumannii.

Antibiotic use in the Northern Irish sheep flock: What lessons can be learnt from medicine records and farmer attitudes to improve stewardship of these essential medicines?

Stewardship of antibiotics used in livestock production has come under increasing scrutiny, from both the animal welfare point of view and due to concerns that antibiotic use in livestock may pose a risk to human health through selection pressure to drive development of antibiotic resistant strains of bacteria. Despite this concern, however, antibiotic consumption in the sheep sector is currently poorly described. This study determines the range and quantities of antibiotics used in the Northern Irish (NI) sheep flock as well as exploring drivers for their use. A mixed-methods approach was utilised, with an anonymous online scoping survey, analysis of the medicine records from 52 NI sheep farms and semi-structured interviews undertaken with 27 farmers. Eighteen farmers contributed both records and participated in interviews. Veterinary medicine records were derived from two sources: on-farm medicine books (seven) or veterinary practice sales data (51). As six of these farmers provided information from both sources a total of 52 unique farms participated. Overall, antibiotic use in sheep on the 52 farms sampled was low, with a median value of 11.35 mgPCU−1 (mean 13.63 mgPCU−1, sd 10.7; range 0–45.29 mgPCU−1), with all farms below 50 mgkg−1. Critically important antibiotics accounted for 0.21% of all antibiotics purchased. Lameness was the main driver of antibiotic use identified by this study. Others included a range of prophylactic treatments such as oral antibiotics to prevent watery mouth, injectable antibiotics to prevent abortion and following assisted lambing. Farmers acknowledged some of these uses had become habitual over time. The veterinary medicine sales records demonstrated significant sales of antibiotics not authorised for use in sheep, on an ongoing, rather than case-by-case, basis. Farmers were positive about their veterinarian’s ability and knowledge to improve flock welfare and productivity, but were unwilling to pay for this advice. However, veterinarians may have facilitated weak medicine stewardship through a failure to adequately challenge farmers seeking antibiotics. Farmers did not maintain accurate or up-to-date on farm medicine or production records in the majority of cases. Despite this lack of on-farm recording, veterinary sales records can be studied in consultation with farmers to provide veterinarians with a farm-specific insight into antibiotic use and related attitudes and behaviours. Farmers and veterinarians can then identify areas and behaviours to target collaboratively, improving antibiotic and wider medicine stewardship, whilst simultaneously improving flock health and productivity.

Self-medication with antibiotics in Georgian population.

Background: Self-medication with antibiotics is a global phenomenon and a potential contributor to human pathogen resistance to antibiotics. It involves obtaining medication without a prescription, taking medicines based on the advice of friends and relatives, or previous treatment experience. Self-medication is common in both developed and developing countries; however, the prevalence of self-medication is higher in developing countries. The aim of this study was to determine the characteristics of antimicrobial self-medication in Georgia and its potential to influence the overall situation regarding antimicrobial consumption in the country. Methods: We conducted a cross-sectional study using a random sampling method and developed a self-administered questionnaire to collect the data. The survey was conducted via the Internet using the Google Forms platform. Results: The overall number of respondents was 742 adults living in Georgia. The results showed that 23.8% (n = 177) of adults had consumed antibiotics without a doctor's prescription, and 12.7% (n = 94) confirmed the use of antibiotics by their own decision to treat minor family members. The total prevalence of self-medication was 32.6%. The data analysis revealed a correlation between factor F1 ("personal experience") and gender (p = 0.042, F = 2.6), and between age and factor F2 ("lack of trust in medical practitioners") (p = 0.047, F = 2.691). The correlation was stronger among young adults (aged 18-24) and senior adults (aged 60+). The correlation between the level of education and factor F2 was stronger (p = 0.00; F1 = 7.9) than with factor F1 (p = 0.04; F = 2.2). Conclusion: Self-medication is prevalent in Georgia; pharmacies are the main sources of antimicrobials. No correlation was found between factor F2, pertaining to "lack of trust in medical practitioners" and gender, between age and factor F1, linked to "personal experience." The study uncovered a lack of knowledge about self-medication with antibiotics and emphasized the importance of public awareness campaigns and implementing effective interventions to regulate the sales of antibiotics without a doctor's prescription.