Expanding horizons

Antibiotic resistance challenges from around the world

Resistance snapshot – USA

The USA has many activities and initiatives currently in action to raise awareness of AMR, the main being the national ‘Get Smart’ campaign, which has a multi-faceted approach of creating guidelines and educational materials aimed at HCPs and patients, as well as campaigns that run on TV and radio.

However, despite these successes, the USA still has much to do. Worryingly, some have argued that an improvement in healthcare will only occur if there is a resulting increase in revenue or cost saving. Although doctors receive remuneration for avoiding antibiotic use, they actually receive more from writing a prescription. This may be why antibiotics are often prescribed as they are inexpensive and there is no unease associated with prescribing them. Perhaps further contributing to unnecessary prescribing is the referral to ‘patients’ as ‘consumers’, leading to many HCPs assuming they must give patients what they want rather than what is right.

Moving towards prescriptions for symptomatic relief so that doctors are still benefitting from the associated revenue, is one method to avoid inappropriate antibiotic prescriptions suggests Dr Burgoyne.

Targeting employers may also prove to be a successful reach for the campaign as many larger companies often vaccinate their staff against the flu, and can provide an opportunity for many people to speak to HCPs about cold and flu, as well as educate them on antibiotic use. Future campaigns targeting Minute Clinics may also be planned as 65% of URTI diagnoses are made there. Focusing on communication efforts to HCPs and pharmacists on symptomatic relief and alternatives to antibiotics, as well as collaborating with private employers and state programs such as Medicaid, will most certainly provide results in the USA’s fight against AMR.

Resistance snapshot – Saudi Arabia

There are many factors contributing to antibiotic resistance in Saudi Arabia; one main problem being that it seems to be relatively simple to access antibiotics. As well as through prescriptions and pharmacy, antibiotics can be sourced from leftovers, relatives and neighbours, and samples and donations. The need to provide education to patients, doctors and HCPs in Saudi Arabia is even more evident when taking into account the influences on antibiotic use within the country. Many patients still hold misbeliefs regarding the use of antibiotics, and can often be demanding. A lack of knowledge within physicians and in policies and regulations of antibiotic use, coupled with the financial benefit for pharmacies prescribing antibiotics, can all lead to incorrect antibiotic use.

A study by Bin Abdulhak et al., published in 2011 in BMC Public Health, investigated the non-prescription sale of antibiotics in one region of Saudi Arabia. Results showed that 77.6% of the pharmacies included in the study dispensed antibiotics without prescription, and 95% of these sales were made without patient request.

It was also noted that ciprofloxacin is the most common antibiotic given for a URTI (in 86% of cases), even though it may not be the most appropriate. Another study by Abdallah et al. in 2011 in the Research Journal of Medical Science assessed the attitudes of 50 patients with antibiotic-resistant Staphylococcus:

24% of doctors or pharmacists said they felt ignored by the patient; 64% of patients exaggerated symptoms to get an antibiotic; 64% of patients purchased antibiotics based on quality; and 44% of patients had <50% compliance to treatment.

Saudi Arabia recognises their need to implement and enforce guidelines and regulations, as well as educate doctors, pharmacists and the general public in an effort to raise awareness and effect change in antibiotic use.

Resistance snapshot – Turkey

A study by Versporten et al. published in 2014 comparing antibiotic use within ESAC-Net countries showed that Turkey has the highest consumption of antibiotics in Eastern Europe. There are several factors contributing to the inappropriate and widespread use of antibiotics in Turkey, which include the attitudes and behaviours of family physicians, over-the-counter selling by pharmacists, high rates of self-medication, patient or family requests, and poor infection prevention and control practices. One particular trend increase was noted after implementation of the Social Security Reform, which allowed the prescription and consumption of drugs much easier. The issue of compliance also seems to be a major factor, with many not finishing their course or using leftover antibiotics.

Before responsible antibiotic use can occur in Turkey, there are many barriers to overcome said Dr Topcu. Insufficient national guidelines and surveillance systems for antibiotic resistance and consumption of drugs need to be addressed, as well as poor enforcement of regulation.

Investigating the lack of laboratory facilities that contribute to the diagnosis in primary care and the widespread practice of selling antibiotics over the counter are also major focal points. However, Turkey has already begun to tackle a few of these issues with many initiatives currently taking place. These include a policy released in 2003 that restricts the prescription of antimicrobials so that some prescriptions can only be made by infectious disease specialists, and an action plan that contains quantitative targets to reduce antibiotic use by 2017. Furthermore, the Turkish Ministry of Health established an educational programme for Rational Antibiotic Use in 2014. With the actions of medical associations such as the Turkish Clinical Microbiology and Infectious Diseases Society at several related conferences and their involvement in creating and preparing guidelines, Turkey looks set to place a concerted and coordinated effort in tackling the spread of AMR.

Resistance snapshot – India

A total of 15.7% of the drug market in India is attributable to antibiotics and antibiotic consumption in India is currently estimated to be the largest worldwide, with statistics indicating that there was a 36% increase in antibiotic consumption between 2000 and 2010.

Consumption of antibiotics peaks in September and seems to correlate with the increase in dengue fever in the post monsoon season. A study by Boeckel in 2014 showed that 51–69% of patients hospitalised due to dengue fever were prescribed antibiotics, with most receiving third-generation cephalosporins or fluoroquinolones.

There are many reasons why antibiotics are misused in India comments Dr Mahashur, who explains that the top determinants of irrational antibiotic prescribing are a lack of knowledge about appropriate use and an inability to access reliable laboratory results. On the other hand, antibiotic dispensing occurs as a desire to meet consumer demand and because of economic incentives. Stressing the importance of educating people about antibiotics, Dr Mahashur highlights that with bacterial infections increasing, 400,000 people die of pneumonia each year; however, due to misuse, antibiotics are often not available when they are truly needed.

There is also an issue with the copying of prescriptions and a lack of regulation into the production of antibiotics – patients are more likely to choose the cheap, poor quality medicines.

Although government controls regarding AMR have been lax, Dr Mahashur reports that they have significantly improved since a new controller has been appointed. Now, prescriptions must be noted down and dated; as a result, many pharmacies have closed down. With the government’s support and cooperation from associations targeted to tackling AMR, India’s main objectives to reduce inappropriate use of antibiotics in the near future will be to monitor antibiotic use and resistance patterns, reduce disease incidence and prevent spread of bacteria, improve diagnostics and appropriate usage of antibiotics, and improve the management of non-medical usage. Having these goals in mind will surely aid India into running a successful campaign against AMR.