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Participants debated just what contribution such agricultural use makes to the spread of antimicrobial resistance among human pathogens. While some participants maintained that the problem is minimal and being effectively managed by various public and private programs, others described a greater level of risk.

They expressed concern that use of antimicrobials in animals, either for. Hamilton, Antimicrobial resistance adversely affects the outcome of community-and hospital-acquired infections in developing countries. For example, mortality in recent cholera and dysentery epidemics has been significantly increased by antibiotic resistance Goma Epidemiology Group, ; Sengupta et al. Other cases in point include tuberculosis, respiratory tract infections, infectious diarrhea, sexually transmitted diseases, and malaria. These conditions account for most of the illness in the developing world.

In these countries, the infectious disease burden is typically high, whereas the options available to prescribers are few—often limited to older, cheaper, and non-patent protected drugs. Studies that have monitored resistance rates over time have documented a rising prevalence of resistance to these commonly used antimicrobials see Figure Hoge et al. Drugs that have been rendered ineffective or for which there are serious concerns include the broad-spectrum antibacterials tetracycline, ampicillin, trimethoprim-sulfamethoxazole chloramphenicol and streptomycin, anti-tuberculosis drugs as well as the antimalarial chloroquine.

Resistance to these drugs has promoted an upsurge in the use of previously second-line, more expensive agents that are, in many cases, agents of last resort.

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The fluoroquinolones and sulfadoxine-pyrimethamine are two such examples, and with both, an upward trend in the proportion of resistant strains has already been identified Okeke et al. Although there are other agents, currently in routine use in.

Antibiotic strategies in the era of multidrug resistance | Critical Care | Full Text

FIGURE Trends in the proportion of Escherichia coli from healthy subjects resistant to three or more and six or more of seven antibacterial drugs. The extent and determinants of microbial resistance vary considerably from one geographic area to another but the current globalization trend means that the consequences transcend geographical borders Okeke and Edelman, In others, regulations that would encourage appropriate antibiotic use are in place but the infrastructure or the will to enforce them is not Djimde et al.

Although there are many generalizations in this report, it must be emphasized that it is impossible to paint a picture of the current situation or draw a model for intervention that would fit every developing country. Examples are taken from different countries, but the principal focus here is on sub-Saharan Africa where the burden of infectious disease is highest and antibiotic use is commonly under-regulated Djimde et al. Studies conducted in industrialized countries have correlated antibiotic consumption with the prevalence of antibiotic resistance. Per capita expenditure on antibiotics is lower in developing countries in spite of a greater burden of infectious disease, and microbial resistance is often highly prevalent.

Some of the reasons for this are that cheaper agents are used, agricul. However, a significant reason for high selection pressure in the face of modest antimicrobial expenditure is inappropriate antibiotic use. Some of the types of antibiotic misuse in clinical practice include unjustified prescription in such conditions as diarrhea and the common cold , under-prescription for example, in urinary tract infections and sexually transmitted diseases , under-dosing, and short duration Calva, ; Nizami et al. Antimicrobial prescription in many developing countries is almost entirely empirical and based on surveillance data obtained from locations or at a time that it is unlikely to be relevant to the ensuing situation.

Broad-spectrum agents are frequently employed because susceptibility data is unavailable. In addition, the rising number of HIV-positive people increases selective pressure for resistant organisms by increasing the need for prophylactic and curative antimicrobial use.

As in industrialized countries, prescribers are subjected to pressure from patients Paredes et al. In addition, health professionals rarely have the opportunity to review cases and are often dealing with life-threatening disease. Hence, antibiotics are often prescribed when unnecessary. Advocates of appropriate antibiotic use advise the prescriber to weigh the benefits to the individual against the risk to public health. This presents a dilemma even to those health professionals that are aware of the long-term consequences of antibiotic abuse. This is because many of the benefits to the individual actually impact public health.

For example, the untreated, or improperly treated, but surviving, patient serves as a reservoir of resistant pathogens. Secondly, treatment failures in health centers will lead to lowered confidence by patients and consequent upsurge of visits to unorthodox practitioners, encouraging unsanctioned antibiotic distribution. Since health professionals frequently have only one opportunity to administer therapy, there is the inclination to use broad-spectrum therapy to increase the chances of successful treatment.

These factors serve to dissuade health professionals who are aware of the consequences of inappropriate antimicrobial use from putting their knowledge into practice Larsson et al. The dilemmas faced by prescribers are further complicated by the practices of patients in developing countries, who are more likely to fail to complete a prescribed course of antibiotics or to admit to reserving part of it for future use Calva, ; Pechere, Patients in many developing countries will often seek care for the same ailment from multiple sources, a practice that prevents follow-up and confuses case history Needham et al.

This is a function of the wide variety of sources for antimicrobial drugs and the fact that many of these sources will dispense antibiotics without prescription Chuc and Tomson, ; Wachter et al. Djimde et al. The situation is similar in many other developing countries, and pharmacy premises, although sanctioned, often serve as an outlet for unprescribed antibiotics because of the competitive pressure from unsanctioned providers Chuc and Tomson, ; Okeke et al.

Unsanctioned providers tend to have shabbier premises and a smaller range of medicines but they flourish because they are often cheaper due to lower overheads. They are more accessible to the majority of the population than doctors and nurses and will accept a non-physiologic cause of disease. Unfortunately, they may supply poor quality medicines but these are often dispensed by sanctioned providers and could serve as an outlet for illicitly sourced drugs.

As they often lack basic training on drug handling, they are often unaware or incapable of storing their wares appropriately. They have been known to ignore or are unaware of expiry dates and to mix batches, brands, and even different drugs. They also have limited if any clinical training and therefore offer diagnosis and prescription that may be incorrect Wachter et al.

Antibiotic choice is based on experience, folklore, or customer preference usually in complete disregard of the long-term consequences of antibiotic misuse.


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These providers supply antimicrobials to a varied but significant proportion of the populaces they serve. They are therefore a crucial target group for optimizing antibiotic use.


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Antibiotic policies directed at medical services alone will only affect a minority of treatments when unsanctioned persons are major providers. It is however difficult to integrate unsanctioned providers into official policies because they are often technically illegal. Another category of health providers that must be taken into account is the traditional medicine practitioners. In a Malian study 23 percent of rural antimalarial consumers preferred herbs or traditional medicines Djimde et al.

Current trends in epidemiology and antimicrobial resistance in intensive care units

Indeed, many herbal remedies have demonstrated some antimicrobial activity in vitro, and traditional medicine represents a potential alternative to antibiotic therapy, which could reduce selective pressure to orthodox antibiotics. To date, very few of these natural products have been. The majority remain unevaluated and recipes are often held as family secrets akin to a trade secret Sofowora, Traditional practitioners receive years or decades of apprenticeship in traditional medicine and herbs but have no training in Western clinical methods.

Importantly, one traditional practitioner recently admitted adulterating his concoctions with antibiotics, and the extent to which this practice occurs is not known Okeke et al. If traditional practitioners are using Western medicines, there is a need to ensure that they receive appropriate training in diagnosis, treatment, and undesirable effects, including antibiotic resistance. In many other countries, unsanctioned and traditional providers are more commonly frequented by the unwell.

We have sought to identify reasons why patients seek care from unorthodox sources. In a study designed to determine the health-seeking practices of educated Nigerians, a cohort of university undergraduates was followed for one year. The students were all entitled to free medical care provided by physicians at the University Health Center and drug supply from an attached pharmacy.

Within the year, of 43 students who had diarrhea, only 16 percent sought treatment at the health center. Twelve percent did not seek treatment at all but 72 percent resorted to self-medication, at their own expense, even though they could obtain medical care at no cost.

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Furthermore, 80 percent of the self-medicators took at least one antibacterial medicine and 45 percent took more than one antimicrobial see Table Clearly, factors other than cost and health care availability influence antibiotic misuse. Another relatively affluent population we studied were West Africans resident in Nigeria that had traveled by air to another country.


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Most of the travelers had visited Europe or North America. Of the travelers to. Only The rest preferred to take medicines they had brought with them or obtain medicines from friends Okeke et al. These findings appear to suggest that the reasons why antibiotics are abused in sub-Saharan Africa are not entirely economic.

Working in Zambia, Needham et al. Even when antibiotic prescription and use is optimal, sub-therapeutic dosing and consequent resistant selection can arise from poor quality antibiotic preparations. A recent survey of tablets claiming to contain the antimalarial Artesunate from Cambodia, Laos, Myanmar, Thailand, and Vietnam found that as many as 38 percent of the samples did not contain the drug Newton et al.

Multiple reports have described the dispensing of medicines in Nigeria that contain as little as half of their label content Okeke and Lamikanra, , ; Taylor et al. Some of the medicines are counterfeit—they were intentionally formulated with less than the stated content Chatterjee, ; Newton et al. The packaging of many pharmaceuticals may be insufficient to protect them in tropical developing countries, and in some cases it may be desirable to reformulate them for this environment or modify shelf life recommendations. One rationale for employing uniform shelf lives in temperate and tropical countries is that labels indicate that medicines are to be stored under controlled conditions.

Indeed, local regulations usually stipulate that pharmacy premises in the tropics must be air-conditioned. In reality, frequent power cuts may mean that the air is only intermittently conditioned, warehouses and unsanctioned premises are almost never air-conditioned, and imported drugs may languish for many months at ports. The warm moist climate and close proximity of non-human vectors in tropical countries increase the likelihood that pathogenic and commensal bacteria will survive in the environment and be transmitted to humans Rosas et al.

In many developing countries, these factors combine with poor sanitation and shortfalls in infection control to create havens for the amplification and dissemination of resistant strains in the community Graczyk et al. Overcrowding, a direct consequence of urban migration, increases the chance that this dissemination will occur.