To describe the epidemiology of end stage renal disease (ESRD).
Mixed-methods systematic review.
The countries of the Gulf Cooperation Council (GCC) which consist of Saudi Arabia, the United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman.
Defined to have ESRD or patients on regular dialysis for a minimum dialysis period of at least three months. Since many outcomes were reviewed, studies that estimated the incidence and prevalence of ESRD as outcomes should not have defined the study population as ESRD population or patients on regular dialysis. Studies where the study population mainly comprised children or pregnant woman were excluded.
Main outcome measures
The trends of the incidence, prevalence, and mortality rate of ESRD; also, causes of mortality, primary causes and co-morbid conditions associated with ESRD.
44 studies included in this review show that the incidence of ESRD has increased while the prevalence and mortality rate of ESRD in the GCC has not been reported sufficiently. The leading primary causes of ESRD recorded in the countries of the GCC is diabetes with the most prevalent co-morbid conditions being Hypertension and Hepatitis C Virus infection; the most common cause of death was cardiovascular disease and sepsis.
This review highlights that the lack of national renal registries data is a critical issue in the countries of the GCC. The available data also do not provide an accurate and updated estimate for relevant outcomes. Additionally, considering the increasing burden of chronic kidney disease (CKD), these results stressed the needs and the importance of preventative strategies for leading causes of ESRD. Furthermore, more studies are needed to describe the epidemiology of ESRD and for assessing the overall quality of renal care.
There is a dearth of studies examining the relationship between research output and other socio-demographic indicators in the Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). The three interrelated aims of this study were, first, to ascertain the number of biomedical publications in the GCC from 1970 to 2010; second, to establish the rate of publication according population size during the same period and, third, to gauge the relationship between the number of publications and specific socio-economic parameters.
The Medline database was searched in October 2010 by affiliation, year and publication type from 1970 to 2010. Data obtained were normalised to the number of publications per million of the population, gross domestic product, and the number of physicians in each country.
The number of articles from the GCC region published over this 40 year period was 25,561. Saudi Arabia had the highest number followed by Kuwait, UAE, and then Oman. Kuwait had the highest profile of publication when normalised to population size, followed by Qatar. Oman is the lowest in this ranking. Overall, the six countries showed a rising trend in publication numbers with Oman having a significant increase from 1990 to 2005. There was a significant relationship between the number of physicians and the number of publications.
The research productivity from GGC has experienced complex and fluctuating growth in the past 40 years. Future prospects for increasing research productivity are discussed with particular reference to the situation in Oman.
Publications; Oman; Gulf Cooperation Council; Arabian peninsula; Biomedical research
To examine the prevalence of risk factors for diabetes and its complications in the Co-operation Council of the Arab States of the Gulf (GCC) region.
Co-operation Council of the Arab States of the Gulf (GCC) states (United Arab Emirates, Bahrain, Saudi Arabia, Oman, Qatar, Kuwait).
Residents of the GCC states participating in studies on the prevalence of overweight and obesity, hyperglycaemia, hypertension and dyslipidaemia.
Main outcome measures
Prevalences of overweight, obesity and hyperglycaemia, hypertension and hyperlipidaemia.
Forty-five studies were included in the review. Reported prevalences of overweight and obesity in adults were 25–50% and 13–50%, respectively. Prevalence appeared higher in women and to hold a non-linear association with age. Current prevalence of impaired glucose tolerance was estimated to be 10–20%. Prevalence appears to have been increasing in recent years. Estimated prevalences of hypertension and dyslipidaemia were few and used varied definitions of abnormality, making review difficult, but these also appeared to be high and increasing,
There are high prevalences of risk factors for diabetes and diabetic complications in the GCC region, indicative that their current management is suboptimal. Enhanced management will be critical if escalation of diabetes-related problems is to be averted as industrialization, urbanization and changing population demographics continue.
BACKGROUND AND OBJECTIVES:
Mortality from road traffic collisions (RTC) is a major problem in the Gulf Cooperation Council (GCC) countries. Low compliance with seatbelt usage can be a contributing factor for increased mortality. The present study aimed to ascertain the presence of a relationship between seatbelt non-compliance of vehicle occupants and mortality rates in the GCC countries versus other high-income countries.
DESIGN AND SETTING:
Observational and descriptive study using information published by the World Health Organization
Data for all GCC countries (n=6) and other high-income countries (n=37) were retrieved and compared with regard to population, gross national income, number of vehicles, seatbelt non-compliance and road traffic death rates. Univariate and multivariate analysis were used to define factors affecting the mortality rates.
The median road traffic death rates, occupant death rates, and the percentage of seatbelt non-compliance were significantly higher in the GCC countries (P<.0001, P=.02, P<.001, respectively). There was a strong correlation between occupant death rates and seatbelt non-compliance (R=.52, P=.008). Seatbelt non-compliance percentage was the only significant factor predicting mortality in the multiple linear regression model (P=.015).
Seatbelt non-compliance percentages in the GCC countries are significantly higher than in other high-income countries. This is a contributing factor in the increased road traffic collision mortality rate in these countries. Enforcement of seatbelt usage by law should be mandatory so as to reduce the toll of death of RTC in the GCC countries.
Resistance to antimicrobial agents is a major health problem that affects the whole world. Providing information on the past state of antimicrobial resistance in Libya may assist the health authorities in addressing the problem more effectively in the future. Information was obtained mainly from Highwire Press (including PubMed) search for the period 1970–2011 using the terms ‘antibiotic resistance in Libya’, ‘antimicrobial resistance in Libya’, ‘tuberculosis in Libya’, and ‘primary and acquired resistance in Libya’ in title and abstract. From 1970 to 2011 little data was available on antimicrobial resistance in Libya due to lack of surveillance and few published studies. Available data shows high resistance rates for Salmonella species in the late 1970s and has remained high to the present day. High prevalence rates (54–68%) of methicillin-resistant Staphylococcus aureus (MRSA) were reported in the last decade among S. aureus from patients with burns and surgical wound infections. No reports were found of vancomycin-resistant S. aureus (VRSA) or vancomycin-intermediate-resistant S. aureus (VISA) using standard methods from Libya up to the end of 2011. Reported rates of primary (i.e. new cases) and acquired (i.e. retreatment cases) multidrug-resistant tuberculosis (MDR-TB) from the eastern region of Libya in 1971 were 16.6 and 33.3% and in 1976 were 8.6 and 14.7%, in western regions in 1984–1986 were 11 and 21.5% and in the whole country in 2011 were estimated at 3.4 and 29%, respectively. The problem of antibiotic resistance is very serious in Libya. The health authorities in particular and society in general should address this problem urgently. Establishing monitoring systems based on the routine testing of antimicrobial sensitivity and education of healthcare workers, pharmacists, and the community on the health risks associated with the problem and benefits of prudent use of antimicrobials are some steps that can be taken to tackle the problem in the future.
antibiotic resistance; enteric bacteria; methicillin-resistant Staphylococcus aureus; multidrug-resistant tuberculosis; Libya
Antimicrobial stewardship is an emerging field currently defined by a series of strategies and interventions aimed toward improving appropriate prescription of antibiotics in humans in all healthcare settings. The ultimate goal is the preservation of current and future antibiotics against the threat of antimicrobial resistance, although improving patient safety and reducing healthcare costs are important concurrent aims. Prospective audit and feedback interventions are probably the most widely practiced of all antimicrobial stewardship strategies. Although labor-intensive, they are more easily accepted by physicians compared with formulary restriction and preauthorization strategies and have a higher potential for educational opportunities. Objective evaluation of antimicrobial stewardship is critical for determining the success of such programs. Nonetheless, there is controversy over which outcomes to measure and there is a pressing need for novel study designs that can objectively assess antimicrobial stewardship interventions despite the limitations inherent in the structure of most such programs.
antimicrobial stewardship; prospective audit and feedback; antimicrobial resistance; antibiotics; cost effectiveness; quasi-experimental study design
Stomach cancer is the most common cancer among males in Oman and the second most frequent among females from 1997 to 2007. Reports have suggested the rate is higher in Oman than in the other GCC countries. This study aims to describe the epidemiology of stomach cancer in Oman and to explore the apparent differences in the incidence of stomach cancer between Oman and the other Gulf Cooperation Council (GCC) countries.
Data were obtained from the Omani National Cancer Registry (1997 - 2007) and from Gulf Centre for Cancer Registration reports (1998 - 2004).
The annual average age-adjusted incidence rates for stomach cancer in Oman were 10.1 per 100,000 for males and 5.6 per 100,000 for females between 1997 and 2007. The age-adjusted incidence varied by region within Oman, and the incidence rate was higher in Oman than in most other GCC countries between 1998 and 2004.
Further investigation of the completeness and accuracy of cancer registration is essential for exploration of variations in stomach cancer rates in the GCC countries.
Oman; Stomach cancer; Epidemiology; Incidence; Gulf Cooperation Council
The first arrival of a sizable shipment of penicillin at the North African Theatre of Operations for USA military use in 1943 was a landmark that turned a new chapter of antibiotic use in Africa. Over the past decade the expansion of resources and the technological advances have meant that much larger quantities of drugs are available in developing countries than ever before. As a result, many more individuals are receiving necessary treatment or therapy than just ten years ago. This very welcome event is accompanied by the terrible irony that increases in drug availability and use can promote drug resistance and render the same life-saving drugs ineffective.
The study focused on bacterial pathogens. One hundred and three relevant literatures were identified from the PubMed online database. The coverage included research articles concerning antimicrobial resistance involving subjects of an African country.
Resistant bacteria are on a war path and evidently have acquired an edge over us. Our actions are evidently fuelling the resistance. The indiscriminate use of antibiotics in humans and livestock, wrong and substandard prescriptions by unqualified ‘medical personnel’ together with poor diagnosis or lack of it are all adding fuel to the already fired train of resistant microbes.
To win the war and turn tables as we did with the discovery of penicillin and other antimicrobials in the 1940s, then we must all act now. Antimicrobial stewardship programs-Education, training of laboratory personnel and investment in laboratory infrastructure development are desirable in these situations
Antibiotics; Resistance; Bacteria
The recent and ongoing worldwide expansion in prevalence of Type 2 Diabetes (T2DM) is a considerable risk to individuals, health systems and economies. The increase in prevalence has been particularly marked in the states of the Co-operation Council for the Arab States of the Gulf (GCC), and these trends are set to continue. We aimed to systematically review the current prevalence of T2DM within these states, and also within particular sub-populations.
We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched using terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, prevalence, epidemiology and Gulf States. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion and exclusion criteria, and where suitable for inclusion, data extraction and quality assessment was achieved using a specifically-designed tool. All studies where prevalence of diabetes was investigated were eligible for inclusion. The inclusion criteria required that the study population be of a GCC country, but otherwise all ages, sexes and ethnicities were included, resident and migrant populations, urban and rural, of all socioeconomic and educational backgrounds. No limitations on publication type, publication status, study design or language of publication were imposed. However, we did not include secondary reports of data, such as review articles without novel data synthesis.
The prevalence ofT2DM is an increasing problem for all GCC states. They may therefore benefit to a relatively high degree from co-ordinated implementation of broadly consistent management strategies. Further study of prevalence in children and in national versus expatriate populations would also be useful.
The Gulf cooperation council (GCC) region is considered as “Emerging market” for pharmaceutical export and bilateral trade. The understanding of the regulatory requirements of this region can be beneficial for pharmaceutical export. Some incidents of the year 2008-09, like recession or economic slowdown in highly well-off and regulated market of the EU and US, raised the demand for alternate destinations for business. The regulations of Gulf countries are encouraging the import of quality generic products, which can be good news to the Indian drug manufacturers.
Exports; Gulf cooperation council; pharmaceutical; regulatory
A disproportionate number of low-income persons are affected.
Control of fecal–orally transmitted pathogens is inadequate in many developing countries, in particular, in sub-Saharan Africa. Acquired resistance to antimicrobial drugs is becoming more prevalent among Vibrio cholerae, Salmonella enteritidis, diarrheagenic Escherichia coli, and other pathogens in this region. The poor, who experience most of the infections caused by these organisms, bear the brunt of extended illness and exacerbated proportion of deaths brought about by resistance. Improved antimicrobial drug stewardship is an often cited, but inadequately implemented, intervention for resistance control. Resistance containment also requires improvements in infectious disease control, access to and quality assurance of antimicrobial agents, as well as diagnostic facilities. Structural improvements along these lines will also enhance disease prevention and control as well as rational antimicrobial drug use. Additionally, more research is needed to identify low-cost, high-impact interventions for resistance control.
enteric pathogens; antimicrobial resistance; antibiotic resistance; sub-Saharan Africa; perspective
The need to stem the growing problem of antimicrobial resistance has prompted multiple, sometimes conflicting, calls for changes in the use of antimicrobial agents. One source of disagreement concerns the major mechanisms by which antibiotics select resistant strains. For infections like tuberculosis, in which resistance can emerge in treated hosts through mutation, prevention of antimicrobial resistance in individual hosts is a primary method of preventing the spread of resistant organisms in the community. By contrast, for many other important resistant pathogens, such as penicillin-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus faecium resistance is mediated by the acquisition of genes or gene fragments by horizontal transfer; resistance in the treated host is a relatively rare event. For these organisms, indirect, population-level mechanisms of selection account for the increase in the prevalence of resistance. These mechanisms can operate even when treatment has a modest, or even negative, effect on an individual host’s colonization with resistant organisms.
Antimicrobial resistance; population dynamics; mathematical model; infectious disease transmission; ecological study; epidemiologic methods
Antibiotics sales without medical prescriptions are increasingly recognized as sources of antimicrobial misuse that can exacerbate the global burden of antibiotic resistance. We aimed to determine the percentage of pharmacies who sell antibiotics without medical prescriptions, examining the potential associated risks of such practice in Riyadh, Saudi Arabia, by simulation of different clinical scenarios.
A cross sectional study of a quasi-random sample of pharmacies stratified by the five regions of Riyadh. Each pharmacy was visited once by two investigators who simulated having a relative with a specific clinical illness (sore throat, acute bronchitis, otitis media, acute sinusitis, diarrhea, and urinary tract infection (UTI) in childbearing aged women).
A total of 327 pharmacies were visited. Antibiotics were dispensed without a medical prescription in 244 (77.6%) of 327, of which 231 (95%) were dispensed without a patient request. Simulated cases of sore throat and diarrhea resulted in an antibiotic being dispensed in (90%) of encounters, followed by UTI (75%), acute bronchitis (73%), otitis media (51%) and acute sinusitis (40%). Metronidazole (89%) and ciprofloxacin (86%) were commonly given for diarrhea and UTI, respectively, whereas amoxicillin/clavulanate was dispensed (51%) for the other simulated cases. None of the pharmacists asked about antibiotic allergy history or provided information about drug interactions. Only 23% asked about pregnancy status when dispensing antibiotics for UTI-simulated cases.
We observed that an antibiotic could be obtained in Riyadh without a medical prescription or an evidence-based indication with associated potential clinical risks. Strict enforcement and adherence to existing regulations are warranted.
Antimicrobial stewardship has not always prevailed in a wide variety of medical institutions in Japan.
The infection control team was involved in the review of individual use of antibiotics in all inpatients (6348 and 6507 patients/year during the first and second annual interventions, respectively) receiving intravenous antibiotics, according to the published guidelines, consultation with physicians before prescription of antimicrobial agents and organisation of education programme on infection control for all medical staff. The outcomes of extensive implementation of antimicrobial stewardship were evaluated from the standpoint of antimicrobial use density, treatment duration, duration of hospital stay, occurrence of antimicrobial-resistant bacteria and medical expenses.
Prolonged use of antibiotics over 2 weeks was significantly reduced after active implementation of antimicrobial stewardship (2.9% vs. 5.2%, p < 0.001). Significant reduction in the antimicrobial consumption was observed in the second-generation cephalosporins (p = 0.03), carbapenems (p = 0.003), aminoglycosides (p < 0.001), leading to a reduction in the cost of antibiotics by 11.7%. The appearance of methicillin-resistant Staphylococcus aureus and the proportion of Serratia marcescens to Gram-negative bacteria decreased significantly from 47.6% to 39.5% (p = 0.026) and from 3.7% to 2.0% (p = 0.026), respectively. Moreover, the mean hospital stay was shortened by 2.9 days after active implementation of antimicrobial stewardship.
Extensive implementation of antimicrobial stewardship led to a decrease in the inappropriate use of antibiotics, saving in medical expenses, reduction in the development of antimicrobial resistance and shortening of hospital stay.
Antimicrobial stewardship has been promoted as a key strategy for coping with the problems of antimicrobial resistance and Clostridium difficile. Despite the current call for stewardship in community hospitals, including smaller community hospitals, practical examples of stewardship programs are scarce in the reported literature. The purpose of the current report is to describe the implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital employing a core strategy of post-prescriptive audit with intervention and feedback.
For one hour twice weekly, an infectious diseases physician and a clinical pharmacist audited medical records of inpatients receiving systemic antimicrobial therapy and made non-binding, written recommendations that were subsequently scored for implementation. Defined daily doses (DDDs; World Health Organization Center for Drug Statistics Methodology) and acquisition costs per admission and per patient-day were calculated monthly for all administered antimicrobial agents.
The antimicrobial stewardship team (AST) made one or more recommendations for 313 of 367 audits during a 16-month intervention period (September 2009 – December 2010). Physicians implemented recommendation(s) from each of 234 (75%) audits, including from 85 of 115 for which discontinuation of all antimicrobial therapy was recommended. In comparison to an 8-month baseline period (January 2009 – August 2009), there was a 22% decrease in defined daily doses per 100 admissions (P = .006) and a 16% reduction per 1000 patient-days (P = .013). There was a 32% reduction in antimicrobial acquisition cost per admission (P = .013) and a 25% acquisition cost reduction per patient-day (P = .022).
An effective antimicrobial stewardship program was implemented with limited resources on the medical-surgical service of a 100-bed community hospital.
Antimicrobial stewardship; ASP; Small community hospital
The epidemiology of headache in Arab countries was systematically reviewed through Medline identification of four papers reporting headache prevalence in the Arab nations of Qatar, Saudi Arabia (2 papers) and Oman. The prevalence of headache varied from 8 to 12% in Saudi Arabia to 72.5% in Qatar and 83.6% in Oman. Headache was commoner in females and younger people. The prevalence of tension headache was 3.1–9.5% in Saudi Arabia and the 1-year prevalence in Qatar was 11.2%. The migraine prevalence was 2.6–5% in Saudi Arabia and 7.9% in Qatar, while the 1-year migraine prevalence was 10.1% in Oman. The results show a migraine prevalence within that estimated worldwide. However, it is clear that epidemiological data from Arab countries are lacking, and there is disparity in the reported prevalence from Saudi Arabia when compared with its two neighbours, Qatar and Oman. Wider study adopting the same methodology in the six Gulf countries (Saudi Arabia, Qatar, Oman, Bahrain, United Arab Emirates and Kuwait) is needed to examine variations in headache and migraine prevalence.
Headache; Migraine; Prevalence; Epidemiology; Arab countries
Nepal is one of the largest suppliers of labour to countries where there is a demand for cheap and low skilled workers. In the recent years the Gulf countries have collectively become the main destinations for international migration. This paper aims to explore the health problems and accidents experienced by a sample of Nepalese migrant in three Gulf countries.
A cross-sectional survey was conducted among 408 Nepalese migrants who had at least one period of work experience of at least six months in any of three Gulf countries: Qatar, Saudi Arabia and United Arab Emirates (UAE). Face to face questionnaire interviews were conducted applying a convenience technique to select the study participants.
Nepalese migrants in these Gulf countries were generally young men between 26-35 years of age. Unskilled construction jobs including labourer, scaffolder, plumber and carpenter were the most common jobs. Health problems were widespread and one quarter of study participants reported experiencing injuries or accidents at work within the last 12 months. The rates of health problems and accidents reported were very similar in the three countries. Only one third of the respondents were provided with insurance for health services by their employer. Lack of leave for illness, cost and fear of losing their job were the barriers to accessing health care services. The study found that construction and agricultural workers were more likely to experience accidents at their workplace and health problems than other workers.
The findings suggest important messages for the migration policy makers in Nepal. There is a lack of adequate information for the migrants making them aware of their health risks and rights in relation to health services in the destination countries and we suggest that the government of Nepal should be responsible for providing this information. Employers should provide orientation on possible health risks and appropriate training for preventive measures and all necessary access to health care services to all their workers.
With rising reports of antimicrobial resistance in outpatient communities, surveillance of antimicrobial use is imperative for supporting stewardship programs. The primary objective of this article is to assess the levels of antimicrobial use in Canada over time.
Canadian antimicrobial use data from 1995 to 2010 were acquired and assessed by four metrics: population-adjusted prescriptions, Defined Daily Doses, spending on antimicrobials (inflation-adjusted), and average Defined Daily Doses per prescription. Linear mixed models were built to assess significant differences among years and antimicrobial groups, and to account for repeated measurements over time. Measures were also compared to published reports from European countries.
Temporal trends in antimicrobial use in Canada vary by metric and antimicrobial grouping. Overall reductions were seen for inflation-adjusted spending, population-adjusted prescription rates and Defined Daily Doses, and increases were observed for the average number of Defined Daily Doses per prescription. The population-adjusted prescription and Defined Daily Doses values for 2009 were comparable to those reported by many European countries, while the average Defined Daily Dose per prescription for Canada ranked high. A significant reduction in the use of broad spectrum penicillins occurred between 1995 and 2004, coupled with increases in macrolide and quinolone use, suggesting that replacement of antimicrobial drugs may occur as new products arrive on the market.
There have been modest decreases of antimicrobial use in Canada over the past 15 years. However, continued surveillance of antimicrobial use coupled with data detailing antimicrobial resistance within bacterial pathogens affecting human populations is critical for targeting interventions and maintaining the effectiveness of these products for future generations.
Carbapenem resistant Enterobacteriaceae is a worldwide threat, with increasing prevalence in many countries. Restricted usage of higher end antibiotics, especially carbapenem is of great importance in tackling these super bugs. Purpose of this retrospective study was to analyse the impact of antibiotic stewardship activities on the prevalence of carbapenem resistant Enterobacteriaceae in our hospital.
In the first Quarter of 2009, average usage of carbapenem group of antibiotics was 955 vials a month while in 2010, the usage dropped to 745 vials per month. Carbapenem resistant E.coli rate dropped from 3.7% in 2009 to 1.6% in 2010 and Klebsiella rate reduced from 6% in 2009 to 3.6% in 2010.
Strict antibiotic stewardship strategies in conjunction with good infection control practices are useful in restricting higher end antibiotic usage and reducing the prevalence of carbapenem resistant Enterobacteriaceae.
Carbapenem resistance; Superbug; Antibiotic usage; Antibiotic stewardship; Success story; Indian hospitals; Oncology; Infection control
Objective. To study the impact of our multimodal antibiotic stewardship program on Pseudomonas aeruginosa susceptibility and antibiotic use in the intensive care unit (ICU) setting. Methods. Our stewardship program employed the key tenants of published antimicrobial stewardship guidelines. These included prospective audits with intervention and feedback, formulary restriction with preauthorization, educational conferences, guidelines for use, antimicrobial cycling, and de-escalation of therapy. ICU antibiotic use was measured and expressed as defined daily doses (DDD) per 1,000 patient-days. Results. Certain temporal relationships between antibiotic use and ICU resistance patterns appeared to be affected by our antibiotic stewardship program. In particular, the ICU use of intravenous ciprofloxacin and ceftazidime declined from 148 and 62.5 DDD/1,000 patient-days to 40.0 and 24.5, respectively, during 2004 to 2007. An increase in the use of these agents and resistance to these agents was witnessed during 2008–2010. Despite variability in antibiotic usage from the stewardship efforts, we were overall unable to show statistical relationships with P. aeruginosa resistance rate. Conclusion. Antibiotic resistance in the ICU setting is complex. Multimodal stewardship efforts attempt to prevent resistance, but such programs clearly have their limits.
The objective of this study was to assess the impact of antimicrobial stewardship programs on the multidrug resistance patterns of bacterial isolates. The study comprised an initial retrospective analysis of multidrug resistance in bacterial isolates for one year (July 2007-June 2008) followed by prospective evaluation of the impact of Antimicrobial Stewardship programs on resistance for two years and nine months (July 2008-March 2011).
A 300-bed tertiary care private hospital in Gurgaon, Haryana (India)
• July 2007 to June 2008: Resistance patterns of bacterial isolates were studied.
• July 2008: Phase I intervention programme Implementation of an antibiotic policy in the hospital.
• July 2008 to June 2010: Assessment of the impact of the Phase I intervention programme.
• July 2010 to March 2011: Phase II intervention programme: Formation and effective functioning of the antimicrobial stewardship committee. Statistical correlation of the Defined daily dose (DDD) for prescribed drugs with the antimicrobial resistance of Gram negatives.
Phase I intervention programme (July 2008) resulted in a decrease of 4.47% in ESBLs (E.coli and Klebsiella) and a significant decrease of 40.8% in carbapenem-resistant Pseudomonas. Phase II intervention (July 2010) brought a significant reduction (24.7%) in carbapenem-resistant Pseudomonas. However, the resistance in the other Gram negatives (E.coli, Klebsiella, and Acinetobacter) rose and then stabilized. A positive correlation was observed in Pseudomonas and Acinetobacter with carbapenems and cefoperazone-sulbactam.
Piperacillin-tazobactam showed a positive correlation with Acinetobacter only. E.coli and Klebsiella showed positive correlation with cefoparazone-sulbactam and piperacillin-tazobactam.
An antimicrobial stewardship programme with sustained and multifaceted efforts is essential to promote the judicious use of antibiotics.
Carbapenem resistance; Gram negatives; Antimicrobial stewardship program; DDD and Antimicrobial resistance
Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.
GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.
A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.
A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.
Antimicrobial resistance poses a major threat in the treatment of infectious diseases. Though significant progress in the management of diarrhoeal diseases has been achieved by improved hygiene, development of new antimicrobials and vaccines, the burden remains the same, especially in children below 5 yr of age. In the case of cholera, though oral rehydration treatment is the mainstay, antimicrobial therapy is mandatory at times to reduce the volume of stool and shorten the duration of the disease. Though for many pathogens, antimicrobial resistance emerged soon after the introduction of antibiotics, Vibrio cholerae remained sensitive to most of the antibiotics for quite a long period. However, the scenario changed over the years and today, V. cholerae strains isolated world over are resistant to multiple antibiotics. A myriad number of mechanisms underlie this phenomenon. These include production of extended-spectrum beta-lactamases, enhanced multi-drug efflux pump activity, plasmid-mediated quinolone and fluoroquinolone resistance, and chromosomal mutations. Horizontal transfer of resistance determinants with mobile genetic elements like integrons and the integrating conjugative elements (ICEs), SXTs help in the dissemination of drug resistance. Though all strains isolated are not resistant to all antibiotics and we are not as yet “stranded”, expanding spectrum of drug resistance is a definite cause for concern. Pipelines of discovery of new antibiotics are drying up as major pharmaceutical companies are losing interest in investing money in this endeavour, mainly due to the short shelf-life of the antibiotics and also due to the fast emergence of drug resistance. To address this issue, attempts are now being made to discover drugs which are pathogen specific and target their “virulence mechanisms”. It is expected that development of resistance against such antibiotics would take much longer. This review briefly focuses on all these issues.
Cholera; genetic elements; multidrug resistance; resistance genes; V. cholerae
Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.
The use of antibiotic drugs triggers a complex interaction involving many biological, sociological, and psychological determinants. Resistance to antibiotics is a serious worldwide problem which is increasing and has implications for morbidity, mortality, and health care both in hospitals and in the community.
To analyze current research on the determinants of antibiotic resistance and comprehensively review the main factors in the process of resistance in order to aid our understanding and assessment of this problem.
We conducted a MedLine search using the key words “determinants”, “antibiotic”, and “antibiotic resistance” to identify publications between 1995 and 2007 on the determinants of antibiotic resistance. Publications that did not address the determinants of antibiotic resistance were excluded.
The process and determinants of antibiotic resistance are described, beginning with the development of antibiotics, resistance and the mechanisms of resistance, sociocultural determinants of resistance, the consequences of antibiotic resistance, and alternative measures proposed to combat antibiotic resistance.
Analysis of the published literature identified the main determinants of antibiotic resistance as irrational use of antibiotics in humans and animal species, insufficient patient education when antibiotics are prescribed, lack of guidelines for treatment and control of infections, lack of scientific information for physicians on the rational use of antibiotics, and lack of official government policy on the rational use of antibiotics in public and private hospitals.
antibiotic drug resistance; determinants; social-biological