'You never know when you will need an antibiotic': A qualitative study of structural barriers and cultural assumptions in antibiotic misuse among immigrants in the United States.

OBJECTIVES: The use of nonprescribed antibiotics increases the risk of antibiotic resistance, which is a primary public health concern of the 21st century. This study explores structural and cultural determinants of antibiotic misuse among immigrants living in the United States who arrived from home countries with easier access to antibiotics. METHODS: Adopting a qualitative approach, we interviewed 34 immigrants living in the United States and who had traveled back to their home countries within 1 year of the interview. We followed the steps of constructive grounded theory to analyze the data. RESULTS: We found two primary influences of immigrants' use of nonprescribed antibiotics. The first was structural barriers to health care access in the host country, including insurance coverage, cost of an emergency department visit, cost of missing a paid day of work, complexity of the healthcare system, and communication issues with health care providers. The second was participants' cultural assumptions, including their experiences of antibiotics use, beliefs about antibiotics, a habit of self-medication, and uncertainty about future medical needs. CONCLUSIONS: This study informs policymakers concerned with combating antibiotic resistance. Promoting antibiotic stewardship among immigrants from countries with lax antibiotic-prescribing practices and improving access to appropriate channels for preventative and same-day care may reduce the inappropriate use of antibiotics.

The Challenge of Antimicrobial Resistance in the Indian Healthcare System.

The emergence and rapid spread of antimicrobial resistance (AMR) pose a grave threat to public health globally, and particularly so in India. With its unique combination of a dense population, a significant disease burden, and diverse healthcare practices, India stands at a critical juncture in the global battle against AMR. The implications of this escalating crisis are far-reaching, threatening decades of medical progress, undermining healthcare delivery, and posing potential roadblocks to the realization of several Sustainable Development Goals. AMR is a crisis within the Indian healthcare system as it severely hampers the effective treatment of infectious diseases, leading to higher mortality rates, longer hospital stays, and increased healthcare costs. Its rise could mark the return of the pre-antibiotic era, where common infections and minor surgeries could once again become life-threatening. Addressing the challenge of AMR in India requires a comprehensive, multifaceted, and well-coordinated response. From creating strong regulatory frameworks for antibiotic usage and improving diagnostic capabilities to fostering greater public awareness and promoting research into new antimicrobials, the strategies need to be as diverse and interconnected as the problem itself. This editorial will delve into the specificities of the AMR challenge within the Indian healthcare system, discuss potential strategies for mitigating the crisis, and evaluate the broader implications for public health and national policy. It will also highlight why India's response to this global health threat is crucial not only for the country but for the world at large.

Development of multidrug-resistant Escherichia coli in some Egyptian veterinary farms.

Background and Aim: Food of animal origin is considered a major source of foodborne diseases. In this context, multidrug-resistant (MDR) Escherichia coli pose a serious hazard to public health due to the consumption of food contaminated with antibiotics that are used for the treatment of various bacterial infections in farm animals. Therefore, this study aimed to determine the effect of the excessive use of antibiotics on the development of MDR E. coli strains in Egyptian poultry, dairy, and meat farms. Materials and Methods: A total of 1225 samples were randomly collected from poultry, dairy, and meat products intended for human consumption in different governorates. E. coli were isolated from the collected samples and subjected to biochemical identification and antibiotic sensitivity tests with antibiotics commonly used in human and veterinary medicine. Then, amoxicillin (AML)- and oxytetracycline (OT)-resistant E. coli isolates were subjected to a polymerase chain reaction test to detect the bla TEM and tetA genes, respectively. Results: E. coli were isolated from 132 out of 350, 148 out of 350, 177 out of 350, and 35 out of 175 poultry, milk, meat, and human samples, respectively. Most of the isolates expressed multidrug resistance, and resistance genes (bla TEM and tetA) were detected in all the tested AML- and OT-resistant E. coli isolates. Conclusion: Foods of animal origin may represent a source of MDR E. coli, which can be a major threat to public health.

The Impact of Antibiotic Usage Guidelines, Developed and Disseminated through Internet, on the Knowledge, Attitude and Prescribing Habits of Orthokeratology Contact Lens Practitioners in China.

It has been previously reported that the improper prescribing of antibiotic eye drops is common among orthokeratology (ortho-k) practitioners. Guidelines have since been developed and disseminated to improve their understanding and implementation of antibiotic prescriptions. This study aimed to investigate the influence of these guidelines on the knowledge, attitude, and prescribing habits of ortho-k practitioners by means of a questionnaire, which was administered nationwide via an official online account to eye care practitioners (ECPs) involved in ortho-k lens fitting, 548 of whom completed the survey. Differences in characteristics before and after the dissemination of the guidelines and between the groups were explored using χ2 tests. The relationship between prescribing habits and demographics was analyzed using stepwise logistic regression models. The implementation of the guidelines significantly improved the overall prescribing habits of ECPs (p < 0.001), especially for prophylactic antibiotic use before and after ortho-k lens wear (p < 0.001). Most ECPs who prescribed antibiotics properly displayed significantly better knowledge of correct antibiotic use, which in turn affected the compliance in their ortho-k patients (p < 0.001). The ECPs' occupations (professionals other than ophthalmologists and optometrists, including nurses and opticians), clinical setting (distributor fitting centers), and age (younger than 25 years) were risk factors for the misuse of antibiotics. Although the implementation of the antibiotic guidelines significantly improved overall prescribing habits, some practitioners' prescribing behavior still needs improvement. A limitation of this study was that all questions were mandatory, requiring ECPs to recall information, and therefore was subjected to selection and recall bias.

Antibiotic Prescribing and Antimicrobial Resistance from an Australian Perspective.

In Australia, the overuse or inappropriate prescribing of antimicrobials in health (human and animal) and agriculture is a concern that has increased over the years. This has given bacteria, fungi, parasites, and some viruses through exposure more opportunity to develop resistance. A process of artificial and natural selection, which favors microorganisms in developing the strongest natural defenses increasing prevalence of antimicrobial resistance (AMR). Appropriate use of antimicrobials can be lifesaving to humans and animals, but inappropriate use needs to be closely monitored and acted on to promote improved safety and quality of care. Inappropriate use includes prescribing antimicrobials when they are not necessary, prescribing the wrong type of antimicrobial and prescribing them for the incorrect duration. This short report reviews and summarizes some of the efforts used in Australia to control AMR and antibiotic prescribing.

Polyvalent human immunoglobulin for infectious diseases: Potential to circumvent antimicrobial resistance.

Antimicrobial resistance (AMR) is a global health problem that causes more than 1.27 million deaths annually; therefore, it is urgent to focus efforts on solving or reducing this problem. The major causes of AMR are the misuse of antibiotics and antimicrobials in agriculture, veterinary medicine, and human medicine, which favors the selection of drug-resistant microbes. One of the strategies proposed to overcome the problem of AMR is to use polyvalent human immunoglobulin or IVIG. The main advantage of this classic form of passive immunization is its capacity to enhance natural immunity mechanisms to eliminate bacteria, viruses, or fungi safely and physiologically. Experimental data suggest that, for some infections, local administration of IVIG may produce better results with a lower dose than intravenous application. This review presents evidence supporting the use of polyvalent human immunoglobulin in AMR, and the potential and challenges associated with its proposed usage.

Antibiotic resistant Cutibacterium acnes among acne patients in Jordan: a cross sectional study.

BACKGROUND: Antibiotics have been used for decades against Cutibacterium acnes (previously known as Propionibacterium acnes; C. acnes). Alarmingly, antibiotic resistance to this bacterium has become a worldwide problem in recent years. No studies are available on the antibiotic susceptibility patterns of C. acnes among Jordanian acne patients and how that is influenced by antibiotic use. This study aims to assess antibiotic resistance patterns of C. acnes clinical isolates and neighboring Gram-positive normal flora of the skin obtained from acne patients attending dermatology clinics in Amman -Jordan appraising the role of antibiotic consumption. METHODS: This is a cross-sectional study of acne patients presenting to selected dermatology outpatient clinics over a 6-month study period. Swabs obtained from inflamed lesions were cultured aerobically and anaerobically. Isolates were identified and screened for antibiotic susceptibility. In addition, all patients were asked to fill in a questionnaire that included questions about the history of antibiotic treatment. RESULTS: C. acnes was isolated from lesions of 100 patients out of 115 participants included in this study. 73% of the isolates were resistant to erythromycin and 59% to clindamycin 37% to doxycycline, 36% to tetracycline, 31% to trimethoprim / sulfamethoxazole, 15% to levofloxacin, and 3% to minocycline. Multi drug resistance (MDR) in C. acnes isolates as well as Staphylococcus aureus (S. aureus) and Staphylococcus epidermidis (S. epidermidis) with a similar pattern of resistance were detected from the same patient in most cases. A pattern of higher resistance towards variable antibiotic was observed in patients previously treated with antibiotics for acne management. CONCLUSIONS: The findings of this study demonstrate the distribution of antibiotic resistance of C. acnes towards used antibiotics and emphasizes the influence of antibiotic consumption on development of antibiotic resistance. The similar pattern of resistance between skin bacteria tested in this study highlights the genetic transfer of resistance between skin commensals including S. aureus and S. epidermidis hence promoting its circulation in the community.

Knowledge, attitude and perception survey of doctors regarding antibiotic use and resistance in Karachi, Pakistan.

OBJECTIVE: To establish a better understanding of physicians' knowledge and beliefs, and to compare distinctions in knowledge, attitude and perception of junior and senior doctors regarding rational use of antibiotics. METHODS: The cross-sectional study was conducted at a tertiary care hospital in Karachi, from June 1 to July 31, 2016, and comprised senior and junior doctors. A 26-item questionnaire divided in three sections was used to test knowledge, attitude and perception of the subjects regarding rational use of antibiotics. Data was analysed using SPSS 23. RESULTS: Of the 200 subjects, 132(66%) were senior doctors; 68(34%) were junior; 116(58%) were females; 84(42%) were males; and the highest number of respondents were from General Medicine 65(32.5%). While 182(91%) doctors realised that antibiotic resistance was a pressing issue, only 131(65.5%) felt confident about their prescriptions and 94(47%) admitted that they over-prescribed antibiotics. Among young physicians, 13(19.1%) believed that antibiotics did not cause side effects even when prescribed unnecesarily. Also, 47(69.1%) junior doctors felt that patients' demands influenced their prescriptions compared to 66(50%) senior doctors (p=0.01). CONCLUSIONS: Although physicians were found to be knowledgeable about rational use of antibiotics, there were gaps in knowledge and perception.

Análisis crítico de un antimicrobiano sub-óptimo, de frecuente sobre-utilización e inadecuada dosificación: vancomicina / Critical review of a suboptimal antibiotic, frequently overused and inappropriately dosed: vancomycin

Resumen Introducción: Vancomicina, terapia estándar para enterococos y estafilococos resistentes a β-lactámicos tradicionales (Staphylococcus aureus [SARM] y Staphylococcus coagulasa negativa), tiene extenso uso empírico en infecciones nosocomiales. Farmacológicamente débil, de estrecho margen terapéutico y farmacocinética poco predecible, es un fármaco sub-estándar según criterios contemporáneos. Tiene excesivo uso, por sobrediagnóstico de infecciones bacterianas y, en infecciones genuinas, por sobre-estimación etiológica de patógenos β-lactámico-resistentes. Últimamente han surgido nuevas amenazas a su efectividad: peores desenlaces en infecciones por SARM con CIM en rango alto de sensibilidad y resistencia de enterococos. Hay frecuente administración inadecuada en: dosis e intervalos, ausencia de dosis de carga inicial, falta de monitoreo con concentraciones plasmáticas, inadecuada dosificación en presencia de insuficiencia renal o diálisis e, importantemente, mantención de uso en ausencia de clara documentación de su necesidad. Nuevos fármacos anti-estafilocócicos no han permitido un reemplazo generalizado de vancomicina por lo que ésta mantiene un importante rol en la medicina contemporánea. Conclusiones: Una comprensión de las fortalezas y debilidades del fármaco, así como de la cambiante epidemiología y propiedades microbiológicas de los patógenos relevantes, al igual que un uso prudente y selectivo, permitirán optimizar su uso y mantener su rol terapéutico en la medicina actual y futura.

Background: Vancomycin, standard parenteral therapy for Gram positive cocci resistant to traditional beta-lactam antibiotics (Staphylococcus aureus and coagulase negative staphylococci [CNS]) and Enterococcus spp, frequent agents of nosocomial infections, is extensively used empirically in that setting. However, its pharmacological weakness, narrow therapeutic margin and poorly predictable pharmacokinetics, make it a suboptimal drug according to contemporary criteria. Vancomycin is over utilized due to both, overestimation of bacterial infections and, in genuine cases, overestimation of the etiological role of these resistant cocci, either nosocomially or community acquired. New threats narrow further its therapeutic role: poorer outcomes in infections with higher vancomycin MIC and resistance by enterococci. It is frequently given at inappropriate dosage and intervals, failing to: give loading dose when recommended, measure blood levels, adjust dosing to changing renal function and continued use when not necessary. Newer anti staphylococcal drugs haven't replaced completely the role of vancomycin, which maintains its usefulness in contemporary medicine. Conclusion: Understanding the strengths and weaknesses of vancomycin, current epidemiology and microbiology of infections for which it may be indicated, as well as the proper administration and monitoring, together with a prudent and selective indication will allow to preserve its present and future utility in the changing medical scenario.

Clinical, economic and societal impact of antibiotic resistance.

The concern over antibiotic resistance has been voiced since the discovery of modern antibiotics > 75 years ago. The concerns have only increased with time, with efforts to control resistance caused by widespread overuse of antibiotics in human medicine and far more than appreciated use in the feeding of animals for human consumption to promote growth. The problem is worldwide, but certain regions and selected health care institutions report far more resistance, including strains of Gram-negative bacteria that are susceptible only to the once discarded drugs polymyxin B or colistin, and pan-resistant strains are on the rise. One of the central efforts to control resistance, apart from antimicrobial stewardship, is the development of new antimicrobial agents. This has lagged significantly over the past 10 - 15 years, for a variety of reasons; but promising new agents are being developed, unfortunately none thus far addressing all potentially resistant strains. There is the unlikely, but not unreal, possibility that we could return to a pre-antibiotic era, where morbidity and mortality rates have risen dramatically and routine surgical procedures are not performed for fear of post-operative infections. The onus of control of resistance is a moral imperative that falls on the shoulders of all.