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Antimicrobial Resistance: Implications and Costs


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Porooshat Dadgostar Milken Institute of Public Health, George Washington University, Washington, DC, USACorrespondence: Porooshat DadgostarMilken Institute of Public Health, George Washington University, Washington, DC, USATel +1-206-696-6474Email porsh_d@gwmail.gwu.eduAbstract: Antimicrobial resistance (AMR) has developed as one of the major urgent threats to public health causing serious issues to successful prevention and treatment of persistent diseases. In spite of different actions taken in recent decades to tackle this issue, the trends of global AMR demonstrate no signs of slowing down. Misusing and overusing different antibacterial agents in the health care setting as well as in the agricultural industry are considered the major reasons behind the emergence of antimicrobial resistance. In addition, the spontaneous evolution, mutation of bacteria, and passing the resistant genes through horizontal gene transfer are significant contributors to antimicrobial resistance. Many studies have demonstrated the disastrous financial consequences of AMR including extremely high healthcare costs due to an increase in hospital admissions and drug usage. The literature review, which included articles published after the year 2012, was performed using Scopus, PubMed and Google Scholar with the utilization of keyword searches. Results indicated that the multifactorial threat of antimicrobial resistance has resulted in different complex issues affecting countries across the globe. These impacts found in the sources are categorized into three different levels: patient, healthcare, and economic. Although gaps in knowledge about AMR and areas for improvement are obvious, there is not any clearly understood progress to put an end to the persistent trends of antimicrobial resistance.Keywords: antimicrobial resistance, AMR, implications, cost
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Antimicrobial Resistance: Implications and Costs
This article was published in the following Dove Press journal:
Infection and Drug Resistance
Porooshat Dadgostar
Milken Institute of Public Health, George
Washington University, Washington,
Abstract: Antimicrobial resistance (AMR) has developed as one of the major urgent threats
to public health causing serious issues to successful prevention and treatment of persistent
diseases. In spite of different actions taken in recent decades to tackle this issue, the trends of
global AMR demonstrate no signs of slowing down. Misusing and overusing different
antibacterial agents in the health care setting as well as in the agricultural industry are
considered the major reasons behind the emergence of antimicrobial resistance. In addition,
the spontaneous evolution, mutation of bacteria, and passing the resistant genes through
horizontal gene transfer are signicant contributors to antimicrobial resistance. Many studies
have demonstrated the disastrous nancial consequences of AMR including extremely high
healthcare costs due to an increase in hospital admissions and drug usage. The literature
review, which included articles published after the year 2012, was performed using Scopus,
PubMed and Google Scholar with the utilization of keyword searches. Results indicated that
the multifactorial threat of antimicrobial resistance has resulted in different complex issues
affecting countries across the globe. These impacts found in the sources are categorized into
three different levels: patient, healthcare, and economic. Although gaps in knowledge about
AMR and areas for improvement are obvious, there is not any clearly understood progress to
put an end to the persistent trends of antimicrobial resistance.
Keywords: antimicrobial resistance, AMR, implications, cost
Antimicrobial Resistance (AMR) occurs when microorganisms including bacteria,
viruses, fungi, and parasites become able to adapt and grow in the presence of
medications that once impacted them.
AMR is considered a signicant threat to
the public health systems not just in developing countries but throughout the
The fact that infectious diseases can no longer be treated with antibiotics
depicts an unknown future in health care.
Infection with AMR leads to serious
illnesses and prolonged hospital admissions, increases in healthcare costs, higher
costs in second-line drugs, and treatment failures.
For instance, just in Europe, it
has been estimated that antimicrobial resistance has been correlated with more than
nine billion euros per year.
Furthermore, according to the Centers for Disease
Control and Prevention (CDC), antimicrobial resistance adds a 20 billion dollar
surplus in direct healthcare costs in the United States, which is exclusive of about
35 billion dollars in loss of productivity annually.
The daunting threat of antimicrobial resistance is of particular importance in the
category of antibiotic resistance in bacteria.
According to the CDC, more than
two million people in the United States become ill with antibiotic-resistant diseases
every year, resulting in a minimum of 23,000 deaths.
Antibiotic resistance com-
promises a human immune systems capacity to ght infectious diseases and also
Correspondence: Porooshat Dadgostar
Milken Institute of Public Health, George
Washington University, Washington, DC,
Tel +1-206-696-6474
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contributes to different complications in vulnerable
patients undergoing chemotherapy, dialysis, surgery, and
joint replacement.
Furthermore, people with chronic con-
ditions like diabetes, asthma, and rheumatoid arthritis will
be heavily impacted by antibiotic resistance.
Since the
effectiveness of antibiotics will be reduced due to persis-
tence in trends of AMR, physicians should use last-resort
classes of medicine such as carbapenems and polymyxins,
which are not necessarily readily available in developing
countries, have a high cost, and have many different side-
One of the most well-known cases of AMR,
Methicillin resistance in Staphylococcus aureus (MRSA),
has been associated with high mortality rates every year
across the globe.
In addition, multi-drug resistant gram-
negative bacteria (MDR-GNB) has made the treatment of
different infections like pneumonia and urinary tract infec-
tions more challenging.
Furthermore, drug resistance
to tuberculosis, gonorrhea, and typhoid fever are increas-
ing every year and substantially contribute to the high
costs of individualshealth as well as the health care
systems around the world, particularly in developing
Currently, 4.1% of new tuberculosis cases are
considered to be multi-drug resistant.
In countries like
India, the Philippines, Russia, and South Africa, which
have always had a high number of TB cases compared to
other parts of the world, multi-drug resistant TB is antici-
pated to escalate signicantly by 2040.
Factors Accelerating the Rate of AMR
Misuse and Overuse of Antibiotics
From early days of discovery of antibiotics in the 1940s,
Sir Alexander Fleming warned the public about the high
demand for antibiotics in the future which could lead to
their overuse.
Different surveys across the globe indi-
cate that many patients rmly believe antibacterial agents
would help with viral diseases like the common cold or
Furthermore, in many developing countries where
there are deciencies in proper diagnostic tools, patient
management is predominantly contingent upon the pre-
scription of medicine, particularly antibiotics.
Administering antibiotics when they are actually not
needed for the treatment is another example of common
misuse of them.
Moreover, many antibiotics are of poor
quality and sold over the counter in the developing
For instance, in India and Vietnam, where
there is insufcient enforcement of regulatory policies on
prescribing medicine, over-the-counter antibiotics are
Such availability makes it accessible for
patients to do self-treatment for diseases that do not neces-
sarily need antibiotics for treatment.
Moreover, antibacterial resistance can develop because
physicians unnecessarily prescribe lengthy courses of
Financial incentives play an important factor
in overprescribing antibiotics. For example, Chinese hos-
pitals incentivize physicians to prescribe antibiotics; as
a result, they will receive more money from pharmaceu-
tical companies.
Another factor contributing to over-
prescribing antibiotics by providers is patients
expectations from them.
Studies have implicated that
clinicians consider the perceived patient request for anti-
biotics as one of the major barriers to adhere to standard
guidelines for antibiotic prescriptions.
Providers try to
avoid the dissatisfaction of their patients by meeting their
demand for prescribing antibiotics.
Agricultural Use of Antibiotics
Agricultural use of antibiotics is another prominent con-
tributor to the antimicrobial resistance in humans.
instance, just in the United States, approximately 80% of
the antibiotics sold are applied to food that animals eat.
In 2010, 63,200 tons of antibiotics were used in livestock
production worldwide which is signicantly more than
human consumption.
In addition to the utilization of
antibiotics to treat sick animals, antibiotics are largely
added to healthy animal feed and drinking water in order
to prevent sickness (prophylaxis) among animals to a large
extent, to further grow herds at subtherapeutic levels, and
to elevate feed efciency.
For instance, one of the
widely used antibiotics in animal farming worldwide to
further promote the growth of livestock, particularly pigs,
is colistin, a critical last-line antibiotic to treat severe
infections in humans.
Increase in Income Levels
According to Klein et al, between 2000 and 2015, global
antibiotic use elevated by 65%.
This signicant rise in
global antibiotic use is predominantly because of over-
consumption of antibiotics in developing countries which
is the direct result of rising incomes.
In other words,
the rise in Growth Domestic Product (GDP) as well as
living standards in low and middle-income countries
(LMICs) have shown to be positively correlated with
antibiotic consumption.
Moreover, an increase in
income levels in developing countries has led to an
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increase in animal protein consumption which may require
more antibiotics to be added to the food animals eat.
There has been a stark change in the pattern of anti-
bacterial consumption across the globe within the past
In 2000, the highest antibiotic consumption
rate was in the United States, France, Spain, New Zealand,
and Hong Kong; however, in 2015, four of the countries
with the highest rate of antibiotic consumption were low-
middle income countries such as Turkey, Tunisia, Algeria,
and Romania.
Rate of antibiotics in LMICs is still lower
than the rate in high-income countries, due to continuous
increase in income level and living standards; however, it
is highly likely that in a few years this rate might even-
tually converge or even surpass the antibiotic consumption
rate in developed countries.
Easy Travel Routes
Studies have suggested that the modern and easy traveling
routes for people, animals, and goods have also substan-
tially contributed to the dissemination of antimicrobial
resistance across the globe.
By being exposed to resis-
tant pathogens, human travelers are highly likely to return
colonized and infected to their country.
For instance,
Ruppe et al have shown that European tourists traveling
to India who had absolutely no contact with the Indian
health care system still tested positive for carbapenemase-
producing Enterobacteriaceae (CPE) after they came back
from their trip.
Biological Factors
Antibiotic resistance may happen spontaneously through
mutation and bacterial evolution.
Furthermore, plasmids,
small circular fragments of DNA in bacteria, can obtain
a great variety of resistance genes through transposons and
insertion sequences.
These plasmids can be trans-
ferred to bacteria from other species and spread the anti-
bacterial resistance in the bacterial population.
addition, exchanging resistance genetic factors between
bacteria through horizontal gene transfer further acceler-
ates the spread of antibiotic resistance.
Gaps in Knowledge
The numerous gaps in knowledge about antibiotic resistance
contribute to the continuing trends of AMR since the statis-
tics and particulars about the use of different antibiotics in
both the health care setting and in animal production are not
systematically gathered worldwide.
For instance, cur-
rently, just 42 countries in the world systematically gather
data regarding the use of antibiotics in livestock.
quality global surveillance systems are critical for determin-
ing and providing warning bells of problems associated with
changes in antimicrobial exposure.
They also help with
observing the efcacy of the interventions implemented to
standardize the usage of antibacterial agents in order to
address the issue of AMR.
Thus, the existing gap in
knowledge about antibiotic usage worldwide highlights the
great importance of a successful approach in engaging coop-
erative efforts among different international sectors such as
human and veterinary medicine, agriculture, animal produc-
tion, and of course, informed consumers.
there is a gap in awareness of people regarding the proper
use and the potential hazard of antibiotics.
For instance,
results of national questionnaires in different developed and
developing countries, including Japan, Australia, the United
States, Sri Lanka, and Gulf Cooperation Council countries
demonstrate that most people generally have limited knowl-
edge about the correct use of antibiotics.
Search Strategy
With a thorough literature review, crucial information was
compiled, assessed, and used to understand the implications
and costs of AMR across the globe. Google, Google Scholar,
PubMed, Microsoft Academic, Scopus, Medline, Global
Health, and searches within the CDC, WHO, and compar-
able health organizations and websites were utilized to
obtain information. The review solely included published
articles written in English. Search terms including AMR
and cost,”“Antimicrobial resistance implicationsand
AMR and disease burdenwere utilized in order to gather
information. Moreover, searches within these databases con-
centrated on literature that dates back no further than 2012.
The search yielded 200 articles. The titles and abstracts
of these articles were reviewed in order to screen for
publications that addressed the drivers of AMR and dif-
ferent implications and cost of AMR. After removing the
duplicates and opinion articles, 78 articles were identied
as relevant and met the inclusion criteria for this critical
analysis project. The study ow diagram is illustrated in
Figure 1.
The literature review ndings demonstrates that the cost of
AMR can be categorized into three different levels: Patient
level, Healthcare level, and Economic level.
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Patient Perspective
Morbidity and mortality are important consequences of
AMR affecting patients.
Compared to non-resistant
forms, resistant bacteria will double the chances of devel-
oping a serious health issue and triple the chances of
Of course, these negative outcomes will be more
pronounced with elevation of the severity of the resistant
infections and the susceptibility of the host.
Table 1
shows the comparison between mortality rates due to
AMR and major causes of mortality worldwide by 2050.
Currently, across the globe, approximately 700,000 indivi-
duals lose their lives because of the drug-resistant infec-
tions each year.
Table 2 indicates the mortality rates due
to AMR by 2050 in different regions of the world. In the
United States, 2 million people are affected every year by
AMR and about 23,000 deaths occur as a result.
number is roughly the same as the European Union which
has an annual mortality rate of 25,000.
Despite the
difculty of obtaining precise mortality rates, ofcial
reports have estimated that about 10 million people will
die across the world by 2050 if strong and effective action
against AMR is not taken.
Antimicrobial resistance also sabotages decades of global
ghts against many infectious diseases like tuberculosis,
HIV, and malaria.
The number of HIV cases resistant to
medicine are on the rise, particularly in Sub-Saharan Africa
where 60% of patients with HIV have developed resistance
to HIV medicine.
Unsurprisingly, patients with resis-
tance to HIV drugs have a higher risk of dying from HIV.
According to the HIV drug resistance report in 2017, such
continuous trends in resistance to HIV medicine threaten the
global goal of putting an end to AIDS by 2030.
In addition
to tuberculosis and HIV, in the past 50 years, Plasmodium
falciparum, the causative agent of malaria, has become resis-
tant to anti-malarial medicines and this trend is predomi-
nantly seen in southeast Asia.
The increase in resistance
to malaria drugs obstructs malaria control which attempts to
decrease the average 445,000 deaths that take place annually
due to this deadly disease.
Healthcare Perspective
AMR has disastrous impacts on healthcare costs.
According to the CDC, in the United States alone, anti-
biotic resistance could add about $1,400 to the hospital bill
for treating patients with any bacterial infections.
additional cost could go up signicantly to more than
$2 billion every year.
According to different studies, it
Records identified as
eligible through
database searching
Records after duplicates removed
Conference abstracts which had
no full description
Opinion articles
Non-peer reviewed journals
78 studies
Additional records
through other sources
Records excluded
Figure 1 Aow diagram of articles included in the review.
Table 1 Mortality Rates by 2050 by Condition
Cancer 8.2 Million
Cholera 100,000120,000
Diabetes 1.5 Million
Diarrheal Disease 1.4 Million
Measles 130,000
Road Trafc Accidents 1.2 Million
Tetanus 60,000
Antimicrobial Resistance 10 Million
Notes: Adapted from Antimicrobial resistance: tackling a crisis for the health and wealth
of nations. 2014. Available from:
Review Paper - Tackling a crisis for the health and wealth of nations_1.pdf.
Accessed September 17, 2019. Creative Commons Attribution 4.0 International
Public License (
Table 2 Mortality Rates by 2050 Due to AMR in Different
Asia 4,730,000
Africa 4,150,000
Europe 390,000
Latin America 392,000
North America 317,000
Oceania 22,000
Notes: Adapted from Antimicrobial resistance: tackling a crisis for the health and wealth
of nations. 2014. Available from:
Review Paper - Tackling a crisis for the health and wealth of nations_1.pdf.
Accessed September 17, 2019. Creative Commons Attribution 4.0 International
Public License (
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is projected that AMR could cost from $300 billion to
more than $1 trillion annually by 2050 worldwide.
High costs associated with expensive and intensive treat-
ments and escalation in resource utilization are the direct
monetary effects of AMR on health care.
patients with resistant infections by using a combination
of regimens may be ineffective; as a result, compared to
other patients, they may need longer hospitalization stays
as well as more intensive care units (ICUs) and isolation
beds in order to prevent the spread of the infection.
nosocomial outbreaks with resistant pathogens may result
in the closure of a wing of a hospital and the cancellation
of elective surgeries, costing the hospital money.
In addition to direct monetary effects, AMR generates
a burden on the health care system through secondary
These effects happen when the procedures that
utilize antibiotics, which are essential to decrease the risk
of any infection after surgery, cannot be successfully car-
ried out due to the prevalence of antimicrobial
Furthermore, AMR will challenge performing
organ transplants because they expose the patients to dif-
ferent infections.
For instance, Santoro-Lopes and de
Gouvea performed a comprehensive review on different
multi-resistant infections that may occur after liver
In their work, they have discussed that
multi-drug resistant pathogens can increase the likelihood
of transplant failure and death.
Another secondary effect
of antimicrobial resistance will be on cancer treatments.
Due to AMR, chemotherapy cannot be performed on
patients with cancer.
Chemotherapy impairs the immune
system and makes patients with cancer vulnerable to dif-
ferent infections.
Thus, the prevalence of AMR prohibits
physicians from administering antibiotics to patients with
There is limited data on the exact cost of
different secondary effects of AMR which limits our
understanding regarding what we might stand to lose.
Economic Perspective
The literature review ndings indicate that the cost of
AMR across the globe is extremely high and different in
each country.
The CDC estimated that the cost of
antimicrobial resistance is $55 billion every year in the
United States, $20 billion for health care and about
$35 billion for loss of productivity.
Recent research by
the World Bank indicates that antimicrobial resistance
would elevate the rate of poverty and impact low-income
countries compared to the rest of the world.
show that annual global GDP could decrease by
approximately 1% and there would be a 57% loss in
developing countries by 2050.
This percentage ulti-
mately translates into $100-210 trillion.
resistant TB alone could cost the world $16.7 trillion by
Furthermore, due to AMR, the gap between the devel-
oping countries and the developed countries will become
more pronounced; as a result, inequity will substantially
Most of the people who are pushed into
extreme poverty as a result of AMR will be specically
from low-income countries.
This highlights the fact that
the underprivileged population of the world will even-
tually be affected the most because these countries are
more contingent on labor income which will be reduced
if there is a high prevalence of infectious diseases.
In addition to the direct impact on GDP, antimicrobial
resistance has a major inuence on labor through the loss of
productivity caused by sickness and premature death.
Deaths because of antimicrobial resistance decrease the
workforce, which in turn negatively impacts the size of the
population as well as the quality of the countrys human
Taylor et al have created a theoretical model in
order to estimate the economic impacts of AMR on the labor
force in the future. In their work, they have compared
a baseline (absence of AMR) with the current trend in
AMR as well as worse alternatives that might happen if
appropriate measures are not taken. According to their
results, if there is no change in the current pattern of AMR,
in ten years, the world working-age population will decrease
by two years. This change will be more pronounced in
Eurasia compared to the rest of the world.
In addition, in
terms of annual GDP loss, if there is no change in the trends
of AMR, the world will lose about $28 billion in ten years.
According to this model, with a $20 billion loss in GDP, the
European Union and The Organization for Economic Co-
operation and Development (OECD) countries stand to lose
more than the rest of the world.
The global trade will also be heavily affected by antimi-
crobial resistance if the continuous trends in AMR still
The World Bank report demonstrates that global
exports might decrease signicantly by 2050 due to the
effects of antimicrobial resistance on labor-intensive
Thus, it can be concluded that the undesirable
outcomes of AMR on the global economy are projected to
be even more severe than the global nancial recession due to
its long-term impacts on the economy.
Impacts of AMR on livestock output will also be
Just like humans, the effect of AMR on
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animals will be due to mortality and morbidity. The
increase in resistance to antimicrobials will make treat-
ments on animals ineffective and cause the infections to
become more severe.
Ultimately, this will lead to
decreased production and trade of livestock, resulting in
elevated prices of protein due to the decrease in protein
sources such as milk, egg, and meat.
Shortage of
protein will be a major concern, considering that the
demand for animal proteins is on the rise worldwide.
According to the World Bank, AMR will have drastic
impacts on livestock production in low-middle income
Estimates have indicated that if the persistent
trends in AMR do not slow down, there will be an 11%
loss in livestock production by 2050.
Such a substantial
loss in animal production will lead to a decline in income
generation which will exacerbate the economic situation.
Antimicrobials are the pillars of modern medicine and have
substantially contributed to the progress of health care dur-
ing the last half-century.
Thus, the persistent trends in
AMR should be stopped or it will set us back to the dark
ages of medicine.
Antibiotic resistance is a naturally
occurring mechanism that can be slowed down gradually
but not stopped completely because resistance is an inevi-
table consequence of the drug selective pressure.
combating AMR requires collective action, political
momentum, and robust multisectoral collaboration and
partnerships between all stakeholders worldwide including
governmental and non-governmental agencies, researchers,
providers, public health practitioners, pharmaceutical com-
panies, hospital administrations, policymakers, agriculture
industry leaders, and patients.
The main goal of this
partnership should be decelerating the continuous trends in
AMR so that the adverse impacts on society and the econ-
omy can be controlled. This will be achieved by establish-
ing a governance mechanism in order to bring harmony to
strategic and operational planning.
Although the cost of
abiding by the guidelines and frameworks can be high, it is
well established that the return on such investment will
unquestionably have signicant positive outcomes.
also provides hope that the adverse impacts of antimicrobial
resistance can be mitigated and may not lead to irreversible
results for society as a whole.
The author reports no conicts of interest in this work.
1. Founou RC, Founou LL, Essack SY. Clinical and economic impact of
antibiotic resistance in developing countries: a systematic review and
meta-analysis. PLoS One.2017;12:e0189621. doi:10.1371/journal.
2. Antibiotic resistance: a global threat | features | CDC. https://www. Accessed
September 15, 2019.
3. Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global
multifaceted phenomenon. Pathog Glob Health.2015;109(7):309.
4. Chokshi A, Sifri Z, Cennimo D, Horng H. Global Contributors to
Antibiotic Resistance. J Glob Infect Dis.2019;11(1):3642.
5. ECDC. Surveillance of Antimicrobial Resistance in Europe. 2017.
Available from:
/documents/EARS-Net-report-2017-update-jan-2019.pdf. Accessed
September 16, 2019.
6. Shrestha P, Cooper BS, Coast J, et al. Enumerating the economic cost
of antimicrobial resistance per antibiotic consumed to inform the
evaluation of interventions affecting their use. Antimicrob Resist
Infect Control.2018;7(1):98. doi:10.1186/s13756-018-0384-3
7. Llor C, Bjerrum L. Antimicrobial resistance: risk associated with
antibiotic overuse and initiatives to reduce the problem. Ther Adv
Drug Saf.2014;5(6):229241. doi:10.1177/2042098614554919
8. Antibiotic resistance threats in the United States; 2013.https://www.cdc.
16, 2019.
9. WHO library cataloguing-in-publication data global action plan on
antimicrobial resistance; Accessed
September 16, 2019.
10. Bassetti M, Peghin M, Vena A, Giacobbe DR. Treatment of infec-
tions due to MDR gram-negative bacteria. Front Med.2019;6:74.
11. Ramírez-Castillo FY, Moreno-Flores AC, Avelar-González FJ,
Márquez-Díaz F, Harel J, Guerrero-Barrera AL. An evaluation of
multidrug-resistant Escherichia coli isolates in urinary tract infections
from Aguascalientes, Mexico: cross-sectional study. Ann Clin Microbiol
Antimicrob.2018;17(1):34. doi:10.1186/s12941-018-0286-5
12. Annavajhala MK, Gomez-Simmonds A, Uhlemann A-C. Multidrug-
resistant enterobacter cloacae complex emerging as a global, diversi-
fying threat. Front Microbiol.2019;10:44. doi:10.3389/
13. Chatterjee S, Poonawala H, Jain Y. Drug-resistant tuberculosis: is
India ready for the challenge? Commentary. BMJ Glob Heal.
2018;3:971. doi:10.1136/bmjgh-2018-000971
14. Friedrich MJ. Drug-resistant tuberculosis predicted to increase in
high-burden countries. JAMA.2017;318(3):231. doi:10.1001/
15. Bin ZS, Hussain MA, Nye R, Mehta V, Mamun KT, Hossain N.
A review on antibiotic resistance: alarm bells are ringing. Cureus.
2017;9(6):e1403. doi:10.7759/cureus.1403
16. Langford BJ, Morris AM. Is it time to stop counselling patients to
nish the course of antibiotics?Can Pharm J (Ott).2017;150
(6):349350. doi:10.1177/1715163517735549
17. Ventola CL. The antibiotic resistance crisis: part 1: causes and
threats. PT.2015;40(4):277283.
18. Chaw PS, Höpner J, Mikolajczyk R. The knowledge, attitude and
practice of health practitioners towards antibiotic prescribing and
resistance in developing countriesA systematic review. J Clin
Pharm Ther.2018;43(5):606613. doi:10.1111/jcpt.12730
19. Van Nguyen K, Do NT T, Chandna A, et al. Antibiotic use and
resistance in emerging economies: a situation analysis for Viet
Nam. BMC Public Health.2013;13:1158. doi:10.1186/1471-2458-
Dadgostar Dovepress
submit your manuscript |
Infection and Drug Resistance 2019:12
Infection and Drug Resistance downloaded from by on 21-Dec-2019
For personal use only.
Powered by TCPDF ( 1 / 1
20. Spellberg B. The maturing antibiotic mantra: Shorter is still better.
J Hosp Med.2018;13(5):361362. doi:10.12788/jhm.2904
21. Laxminarayan R. Antibiotic effectiveness: balancing conservation
against innovation. Science.2014;345(6202):12991301. doi:10.1126/
22. Tang Q, Song P, Li J, Kong F, Sun L, Xu L. Control of antibiotic
resistance in China must not be delayed: the current state of resistance
and policy suggestions for the government, medical facilities, and
patients. Biosci Trends.2016;10(1):16. doi:10.5582/bst.2016.01034
23. Fletcher-Lartey S, Yee M, Gaarslev C, Khan R. Why do general
practitioners prescribe antibiotics for upper respiratory tract infec-
tions to meet patient expectations: a mixed methods study. BMJ
Open.2016;6(10):e012244. doi:10.1136/bmjopen-2016-012244
24. Dempsey PP, Businger AC, Whaley LE, Gagne JJ, Linder JA.
Primary care cliniciansperceptions about antibiotic prescribing for
acute bronchitis: a qualitative study. BMC Fam Pract.2014;15
(1):194. doi:10.1186/s12875-014-0194-5
25. Chang Q, Wang W, Regev-Yochay G, Lipsitch M, Hanage WP.
Antibiotics in agriculture and the risk to human health: how worried
should we be? Evol Appl.2015;8(3):240247. doi:10.1111/eva.12185
26. Animal production | antimicrobial resistance | food and agriculture orga-
nization of the United Nations.
resistance/key-sectors/animal-production/en/. Accessed September 16,
27. Bartlett JG, Gilbert DN, Spellberg B. Seven ways to preserve the
miracle of antibiotics. Clin Infect Dis.2013;56(10):14451450.
28. Drug-resistant infections a threat to our economic future; 2017.
Available from: Accessed September 16, 2019.
29. Blaser MJ. Antibiotic use and its consequences for the normal
microbiome. Science.2016;352(6285):544545. doi:10.1126/science.
30. Hao H, Cheng G, Iqbal Z, et al. Benets and risks of antimicrobial
use in food-producing animals. Front Microbiol.2014;5:288.
31. United Nations meeting on antimicrobial resistance. Bull World
Health Organ.2016;94(9):638639. doi:10.2471/BLT.16.020916
32. Lekagul A, Tangcharoensathien V, Yeung S. Patterns of antibiotic use
in global pig production: a systematic review. Vet Anim Sci.
2019;7:100058. doi:10.1016/J.VAS.2019.100058
33. Rhouma M, Beaudry F, Thériault W, Letellier A. Colistin in pig
production: chemistry, mechanism of antibacterial action, microbial
resistance emergence, and one health perspectives. Front Microbiol.
2016;7:1789. doi:10.3389/fmicb.2016.01789
34. Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and
geographic convergence in antibiotic consumption between 2000 and
2015. Proc Natl Acad Sci U S A.2018;115(15):E3463E3470.
35. Dall C. Global antibiotic use rises, fueled by economic growth |
CIDRAP. Available from:
growth. Accessed September 16, 2019..
36. Van Boeckel TP, Brower C, Gilbert M, et al. Global trends in anti-
microbial use in food animals. Proc Natl Acad Sci.2015;112
(18):56495654. doi:10.1073/pnas.1503141112
37. Robertson J, Iwamoto K, Hoxha I, et al. Antimicrobial medicines con-
sumption in Eastern Europeand Central Asia anupdated cross-national
study and assessment of quantitativemetrics for policy action. Front
Pharmacol.2019;9:1156. doi:10.3389/fphar.2018.01156
38. Castro-Sánchez E, Moore LSP, Husson F, Holmes AH. What are the
factors driving antimicrobial resistance? Perspectives from a public
event in London, England. BMC Infect Dis.2016;16(1):465.
39. Frost I, Van Boeckel TP, Pires J, Craig J, Laxminarayan R. Global
geographic trends in antimicrobial resistance: the role of international
travel. J Travel Med.2019. doi:10.1093/jtm/taz036
40. Ruppé E, Armand-Lefèvre L, Estellat C, et al. Acquisition of
carbapenemase-producing Enterobacteriaceae by healthy travellers
to India, France, February 2012 to March 2013. Eurosurveillance.
2014;19(14):20768. doi:10.2807/1560-7917.ES2014.19.14.20768
41. Read AF, Woods RJ. Antibiotic resistance management. Evol Med
Public Heal.2014;2014(1):147. doi:10.1093/emph/eou024
42. Li Q, Chang W, Zhang H, Hu D, Wang X. The role of plasmids in the
multiple antibiotic resistance transfer in ESBLs-producing escheri-
chia coli isolated from wastewater treatment plants. Front Microbiol.
2019;10:633. doi:10.3389/fmicb.2019.00633
43. Rozwandowicz M, Brouwer MSM, Fischer J, et al. Plasmids carrying
antimicrobial resistance genes in Enterobacteriaceae. J Antimicrob
Chemother.2018;73(5):11211137. doi:10.1093/jac/dkx488
44. San Millan A. Evolution of plasmid-mediated antibiotic resistance in
the clinical context. Trends Microbiol.2018;26(12):978985.
45. Sun D, Jeannot K, Xiao Y, Knapp CW. Editorial: horizontal gene
transfer mediated bacterial antibiotic resistance. Front Microbiol.
2019;10. doi:10.3389/FMICB.2019.01933
46. Paterson IK, Hoyle A, Ochoa G, Baker-Austin C, Taylor NGH.
Optimising antibiotic usage to treat bacterial infections. Sci Rep.
2016;6(1):37853. doi:10.1038/srep37853
47. Antibiotic resistance: a global threat | features | CDC. Available from:
Accessed September 16, 2019.
48. AMR in the WHO European Region. September 2019. Available
Accessed September. 16, 2019.
49. Aslam B, Wang W, Arshad MI, et al. Antibiotic resistance:
a rundown of a global crisis. Infect Drug Resist.
2018;11:16451658. doi:10.2147/IDR.S173867
50. Carter RR, Sun J, Jump RLP. A survey and analysis of the american
publics perceptions and knowledge about antibiotic resistance. Open
Forum Infect Dis.2016;3(3):ofw112. doi:10.1093/od/ofw112
51. Atif M, Asghar S, Mushtaq I, et al. What drives inappropriate use of
antibiotics? A mixed methods study from Bahawalpur, Pakistan.
Infect Drug Resist.2019;12:687699. doi:10.2147/IDR.S189114
52. Almohammed RA, Bird EL. Public knowledge and behaviours relat-
ing to antibiotic use in gulf cooperation council countries:
a systematic review. J Infect Public Health.2019;12(2):159166.
53. Kamata K, Tokuda Y, Gu Y, Ohmagari N, Yanagihara K. Public
knowledge and perception about antimicrobials and antimicrobial
resistance in Japan: a national questionnaire survey in 2017.
Angelillo IF, ed. PLoS One.2018;13(11):e0207017. doi:10.1371/
54. Cecchini M, Langer J, Slawomirski L Antimicrobial Resistance In
G7 Countries And Beyond: economic issues, policies and options for
action; 2015. Available from:
Accessed September 16, 2019..
55. Friedman ND, Temkin E, Carmeli Y. The negative impact of anti-
biotic resistance. Clin Microbiol Infect.2016;22(5):416422.
56. Tackling drug-resistant infections globally: nal report and recommen-
dations the review on antimicrobial resistance chaired by JIM ONEILL;
2016. Available from:
Final paper_with cover.pdf.AccessedSeptember16,2019.
57. Davis M, Liu T-L, Taylor Y, et al. Exploring patient awareness and
perceptions of the appropriate use of antibiotics: a mixed-methods
study. Antibiotics.2017;6(4):23. doi:10.3390/antibiotics6040023
58. WHO report on surveillance of antibiotic consumption; 2016.https://
-20181109.pdf. Accessed September 17, 2019.
Dovepress Dadgostar
Infection and Drug Resistance 2019:12 submit your manuscript |
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59. Laxminarayan R, Duse A, Wattal C, et al. Antibiotic resistancethe
need for global solutions. Lancet Infect Dis.2013;13(12):10571098.
60. Jasovský D, Littmann J, Zorzet A, Cars O. Antimicrobial resistance-a
threat to the worlds sustainable development. Ups J Med Sci.
2016;121(3):159164. doi:10.1080/03009734.2016.1195900
61. Llibre JM. Time to get serious with HIV-1 resistance in sub-Saharan
Africa. Lancet Infect Dis.2017;17(3):241243. doi:10.1016/S1473-
62. Pinoges L, Schramm B, Poulet E, et al. Risk factors and mortality
associated with resistance to rst-line antiretroviral therapy. JAIDS
J Acquir Immune Dec Syndr.2015;68(5):527535. doi:10.1097/
63. HIV drug resistance report 2017 trends quality action. Available
9789241512831-eng.pdf?sequence=1. Accessed September 17, 2019.
64. Phyo AP, Nosten F. The artemisinin resistance in Southeast Asia: an
imminent global threat to malaria elimination. 2016. doi:10.5772/
65. World malaria report 2018 ISBN 978 92 4 156565 3. Available from: Accessed September 17, 2019.
66. Antimicrobial resistance: tackling a crisis for the health and wealth of
nations. 2014. Available from:
les/AMR Review Paper - Tackling a crisis for the health and wealth
of nations_1.pdf. Accessed September 17, 2019.
67. Thorpe KE, Joski P, Johnston KJ. Antibiotic-resistant infection treat-
ment costs havedoubled since 2002, now exceeding $2 billion annually.
Health Aff.2018;37(4):662669. doi:10.1377/hlthaff.2017.1153
68. Naylor NR, Atun R, Zhu N, et al. Estimating the burden of anti-
microbial resistance: a systematic literature review. Antimicrob Resist
Infect Control.2018;7(1):58. doi:10.1186/s13756-018-0336-y
69. Li B, Webster TJ. Bacteria antibiotic resistance: new challenges and
opportunities for implant-associated orthopedic infections. J Orthop
Res.2018;36(1):2232. doi:10.1002/jor.23656
70. Santoro-Lopes G, de Gouvêa EF. Multidrug-resistant bacterial infec-
tions after liver transplantation: an ever-growing challenge. World
J Gastroenterol.2014;20(20):6201. doi:10.3748/wjg.v20.i20.6201
71. Anderson M, Clift C, Schulze K, et al. Health systems and policy
analysis - Averting the AMR crisis : what are the avenues for policy.
Eur Obs Heal Syst Policies.2019.
72. Utt E, Wells C. The global response to the threat of antimicrobial
resistance and the important role of vaccines. Pharm Policy Law.
2016;18:179197. doi:10.3233/PPL-160442
73. Drug-resistant tuberculosis: worth the investment why drug-resistant
tuberculosis? Available from:
ing/pdf/Drug-resistant-tuberculosis-Article.pdf. Accessed September
17, 2019.
74. Global pandemic | TB alliance. Available from: https://www.tballi Accessed September
17, 2019.
75. Taylor J, Hafner M, Yerushalmi E, et al. Estimating the economic
costs of antimicrobial resistance: model and Results. 2005.
76. Maddocks SE. Novel targets of antimicrobial therapies.
Microbiol Spectr.2016;4(2). doi:10.1128/microbiolspec.VMBF-
77. CDC. National action plan for combating antibiotic-resistant bacteria;
2015. Available from:
Accessed September 30, 2019.
78. Renwick MJ, Simpkin V, Mossialos E. Targeting Innovation in
Antibiotic Drug Discovery and Development. European
Observatory on Health Systems and Policies; 2016.Available
from: Accessed
September 17, 2019.
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... M ethicillin resistant staphylococci (MRS) have become a major threat to human and animal health due to the infections they cause and have become increasingly challenging to treat as these bacteria developed resistance to multiple antibiotics, predominantly due to the overuse of antibiotics in health care and agriculture settings (1)(2)(3). Many staphylococcal species are commensal to animals and humans but can act as opportunistic pathogens (4). ...
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Our findings demonstrate a possible cross-transmission of methicillin resistant staphylococci between goats and their local environments and between goats and humans. Due to ever increasing resistance to multiple antibiotics, the burden of MRS has a significant impact on livestock farming, public health, and the economy worldwide.
... Antimicrobial resistance (AMR) has evolved as a significant and growing phenomena, resulting in rising healthcare expenses around the world [1]. In recent years, bacterial resistance has been associated with high rates of disease, death, and rising expenses as a result of both prolonged medical care and hospitalization [2]. High incidence of antimicrobial resistance was recently reported in a group of nosocomial bacterial strains known as ESKAPE, which is an abbreviation for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp., and Escherichia coli pathogens [3]. ...
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The high frequency of nosocomial bacterial infections caused by multidrug-resistant pathogens contributes to significant morbidity and mortality worldwide. As a result, finding effective antibacterial agents is of critical importance. Hence, the aim of the present study was to greenly synthesize silver nanoparticles (AgNPs) utilizing Salvia officinalis aqueous leaf extract. The biogenic AgNPs were characterized utilizing different physicochemical techniques such as energy-dispersive X-ray spectroscopy (EDX), ultraviolet-visible spectrophotometry (UV-Vis), X-ray diffraction analysis (XRD), transmission electron microscopy (TEM), and Fourier transform infrared spectroscopy (FT-IR) analysis. Additionally, the synergistic antimicrobial effectiveness of the biosynthesized AgNPs with colistin antibiotic against multidrug-resistant bacterial strains was evaluated utilizing the standard disk diffusion assay. The bioformulated AgNPs revealed significant physicochemical features, such as a small particle size of 17.615 ± 1.24 nm and net zeta potential value of −16.2 mV. The elemental mapping of AgNPs revealed that silver was the main element, recording a relative mass percent of 83.16%, followed by carbon (9.51%), oxygen (5.80%), silicon (0.87%), and chloride (0.67%). The disc diffusion assay revealed that AgNPs showed antibacterial potency against different tested bacterial pathogens, recording the highest efficiency against the Escherichia coli strain with an inhibitory zone diameter of 37.86 ± 0.21 mm at an AgNPs concentration of 100 µg/disk. In addition, the antibacterial activity of AgNPs was significantly higher than that of colistin (p ≤ 0.05) against the multidrug resistant bacterial strain namely, Acinetobacter baumannii. The biosynthesized AgNPs revealed synergistic antibacterial activity with colistin antibiotic, demonstrating the highest synergistic percent against the A. baumannii strain (85.57%) followed by Enterobacter cloacae (53.63%), E. coli (35.76%), Klebsiella pneumoniae (35.19%), Salmonella typhimurium (33.06%), and Pseudomonas aeruginosa (13.75%). In conclusion, the biogenic AgNPs revealed unique physicochemical characteristics and significant antibacterial activities against different multidrug-resistant bacterial pathogens. Consequently, the potent synergistic effect of the AgNPs–colistin combination highlights the potential of utilizing this combination for fabrication of highly effective antibacterial coatings in intensive care units for successful control of the spread of nosocomial bacterial infections.
... Antibiotic resistance (AR) is rampant and is considered a global health threat of the twenty-first century [1]. Current estimates indicate without effective actions, the continued rise of AR could result to 10 million deaths and cost up to 1 trillion USD every year by 2050 [2,3]. According to the World Health Organization (WHO) definition, AR is a failure of bacteria to respond effectively to antibiotics that were originally potent for the treatment of infections caused by it [4]. ...
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Background: Misuse of antibiotics has been associated with poor knowledge, attitude and practice (KAP). Therefore, this study aimed to assess if KAP of prescribers and dispensers could drive irrational use of antibiotics among children in Tanzania. Methods: A convergent parallel mixed-methods study design that employed quantitative and qualitative approaches was conducted in 14 regional referral hospitals (RRHs). A total of 108 participants, prescribers [54] and dispensers [54] working with the pediatric population in the respective regions participated in a quantitative survey, by filling the standard questionnaire while 28 key informant interviews were conducted with in-charges of units from the pharmacy and pediatric departments. Two key informants (prescriber and dispenser) were selected from each RRH. Results: Overall, among prescribers and dispensers, there was adequate knowledge; 81.5% and 79.6%, p = 0.53, those with positive attitudes were 31.5% and 81.5%, p < 0.001 and poor practices were among 70.4% and 48% p = 0.0312 respectively. Among prescribers, 14.8% agreed and strongly agreed that prescribing antibiotics that a patient did not need does not contribute to resistance. Moreover 19% disagreed to prescribe antibiotics according to local guidelines. Among dispensers, a-quarter of the dispensers thought individual efforts to implement antibiotic stewardship would not make a difference, 17% agreed and strongly agreed that antibiotics can treat viral infection and 7% agreed and strongly agreed antibiotics can be stopped upon resolution of symptoms. From qualitative interviews, both participants displayed an adequate understanding of multi-contributors of antibiotic resistance (AR) including polypharmacy, community self-medication, among others. Regardless, both professions declared to prescribed and dispensed antibiotics according to the antibiotics available in stock at the facility. Furthermore, prescribers perceived laboratory investigation took a long time, hence wasting their time. On the other hand, Dispensers reported not to provide adequate instruction to the patients, after dispensing antibiotics. Conclusions: Both prescribers and dispensers had adequate knowledge, few prescribers had positive attitudes and the majority had poor practices. Few dispensers had poor attitude and practice. These findings highlight the need to provide adequate training on antimicrobial stewardship and enforce regulation that foster appropriate medical practice.
... A recent comprehensive study estimated that 1.27 of 4.95 million human deaths in 2019 were attributed to infection with antimicrobial-resistant bacteria (ARB) (Murray et al., 2022). In addition, infections with ARB can have longterm health effects by increasing hospital admissions, treatment failures, morbidity, mortality, and economic burden (World Health Organization [WHO], , 2021Dadgostar, 2019). Since antimicrobial use (AMU) is a driver for the emergence of AMR, local, national, and global public health stakeholders have expressed concerns about the extent of AMU in humans and food animals (Aidara-Kane et al., 2018;Agunos et al., 2020;Ceccarelli et al., 2020;World Health Organization [WHO], 2021). ...
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Antimicrobial resistance (AMR) in enteric bacteria continues to be detected in turkey flocks and retail products worldwide, including in Canada. However, studies assessing linkages between on-farm antimicrobial use (AMU) and the development of AMR are lacking. This study aims to identify AMU characteristics that impact the development of AMR in the indicator bacteria Escherichia coli in turkey flocks, building on the Canadian Integrated Program for Antimicrobial Resistance Surveillance methodology for farm-level AMU and AMR data integration. Two analytic approaches were used: (1) multivariable mixed-effects logistic regression models examined associations between AMU (any route, route-specific, and route-disease-specific indication) summarized as the number of defined daily doses in animals using Canadian standards ([nDDDvetCA]/1,000 kg-animal-days at risk) and AMR and (2) multivariable mixed-effects Poisson regression models studied the linkages between AMU and the number of classes to which an E. coli isolate was resistant (nCR E. coli). A total of 1,317 E. coli isolates from a network of 16 veterinarians and 334 turkey producers across the five major turkey-producing provinces in Canada between 2016 and 2019 were used. Analysis indicated that AMR emerged with the use of related antimicrobials (e.g., tetracycline use-tetracycline resistance), however, the use of unrelated antimicrobial classes was also impacting AMR (e.g., aminoglycosides/streptogramins use-tetracycline resistance). As for studying AMU-nCR E. coli linkages, the most robust association was between the parenteral aminoglycosides use and nCR E. coli , though in-feed uses of four unrelated classes (bacitracin, folate pathway inhibitors, streptogramins, and tetracyclines) appear to be important, indicating that ongoing uses of these classes may slow down the succession from multidrug-resistant to a more susceptible E. coli populations. The analysis of AMU (route and disease-specific)-AMR linkages complemented the above findings, suggesting that treatment of certain diseases (enteric, late-stage septicemic conditions, and colibacillosis) are influential in the development of resistance to certain antimicrobial classes. The highest variances were at the flock level indicating that stewardship actions should focus on flock-level infection prevention practices. This study added new insights to our understanding of AMU-AMR linkages in turkeys and is useful in informing AMU stewardship in the turkey sector. Enhanced surveillance using sequencing technologies are warranted to explain molecular-level determinants of AMR.
... Simeoni et al. BMC Primary Care (2022) 23:188 Background Deemed a "crisis" almost three decades ago, antimicrobial resistance continues to be a major challenge to modern medicine globally [1], leading to higher levels of mortality and severity of infection, and lost productivity [2]. One driver of antimicrobial resistance is the misuse and overuse of antibiotics in healthcare. ...
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Background Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms. Methods Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20 th percentile versus “medium” defined as 40 th to 60 th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved. Results Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician ( Knowledge, Skills, Social/Professional Role, and Belief about Capabilities ) and external to the physician ( Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation ). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician–patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty. Conclusions Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices.
... Antimicrobial resistance (AMR) has been declared by the World Health Organization (WHO) as one of the top ten global public health threats facing humanity. 1 Currently, AMR is causing 700,000 deaths worldwide each year and this number is expected to be approximately 10 million people by 2050. The majority of deaths are anticipated to be in low-to middle-income countries (LMICs), where devastating infectious diseases are well-established. ...
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Background: Dispensing antibiotics without prescription (DAwP) is a widespread practice, especially in developing countries, contributing to antibiotic resistance. Community pharmacists play a significant role in promoting rational use of antibiotics by refraining from DAwP, and providing drug information to patients. This study aimed to evaluate community pharmacists' knowledge, attitude and practice, and to assess the factors behind DAwP. Methods: A cross-sectional study was conducted in 2020 among random sample of community pharmacists in Sudan. Online semi-structured questionnaire was used for data collection. The association between dependent and independent variables was assessed using Chi-square test; a P-value less than 0.05 was considered significant. Results: Of the 1217 pharmacists who participated, the majority were female (n = 645, 53%). Most pharmacists have a B. Pharm degree (n = 1026, 84%) and less than 5 years' experience (n = 718, 59%). Notably, the majority of community pharmacists have good knowledge (n = 735, 61.7%), which is significantly associated with years of experience (P < 0.00). More than half (n = 623, 52.2%) of the pharmacists have above average score of practice. Nearly all the pharmacists who participated have a positive attitude in relation to DAwP (n = 1204, 98.9%). More than half of the pharmacists were DAwP for tonsillitis (n = 817, 67%), wound infection (n = 766, 62.9%), and urinary tract infection (n = 664, 54%). The leading factor behind DAwP was the low socioeconomic status of the patients (n = 624, 51%). Additionally, 47% of the pharmacists (n = 572) thought that they were knowledgeable enough to DAwP. Conclusion: Despite their positive attitude and average level of knowledge regarding DAwP, Sudanese community pharmacists frequently are DAwP for tonsillitis. Low patients' socioeconomic status was the leading factor behind DAwP. Accordingly, extensive work from health authorities to improve the accessibility and affordability of the health system as well as the development of an antibiotic stewardship program are required to diminish DAwP.
Antibiotic-resistance genes (ARGs) and resistant bacteria (ARB) are abundant in stormwater that could cause serious infections, posing a potential threat to public health. However, there is no inference about how stormwater contributes to ARG profiles as well as the dynamic interplay between ARGs and bacteria via vertical gene transfer (VGT) or horizontal gene transfer (HGT) in urban water ecosystems. In this study, the distribution of ARGs, their host communities, and the source and community assembly process of ARGs were investigated in Yundang Lagoon (China) via high-throughput quantitative PCR, 16S rRNA gene amplicon sequencing, and application of SourceTracker before, after and recovering from an extreme precipitation event (132.1 mm). The abundance of ARGs and mobile genetic elements (MGEs) was the highest one day after precipitation and then decreased 2 days after precipitation and so on. Based on SourceTracker and NMDS analysis, the ARG and bacterial communities in lagoon surface water from one day after precipitation were mainly contributed by the wastewater treatment plant (WWTP) influent and effluent. However, the contribution of WWTP to ARG communities was minor 11 days after the precipitation, suggesting that the storm promoted the ARG levels by introducing the input of ARGs, MGEs, and ARB from point and non-point sources, such as sewer overflow and land-applied manure. Based on a novel microbial network analysis framework, the contribution of positive biological interactions between ARGs and MGEs or bacteria was the highest one day after precipitation, indicating a promoted VGT and HGT for ARG dissemination. The microbial networks deconstructed 11 days after precipitation, suggesting the stormwater practices (e.g., tide gate opening, diversion channels, and pumping) alleviated the spread of ARGs. These results advanced our understanding of the distribution and transport of ARGs associated with their source in urban stormwater runoff.
The rise of multidrug-resistant (MDR) pathogens has become a global health threat and an economic burden in providing adequate and effective treatment for many infections. This large-scale concern has emerged mainly due to mishandling of antibiotics (ABs) and has resulted in the rapid expansion of antimicrobial resistance (AMR). Nowadays, there is an urgent need for more potent, non-toxic and effective antimicrobial agents against MDR strains. In this regard, clinicians, pharmacists, microbiologists and the entire scientific community are encouraged to find alternative solutions in treating infectious diseases cause by these strains. In its "10 global issues to track in 2021", the World Health Organization (WHO) has made fighting drug resistance a priority. It has also issued a list of bacteria that are in urgent need for new ABs. Despite all available resources, researchers are unable to keep the pace of finding novel ABs in the face of emerging MDR strains. Traditional methods are increasingly becoming ineffective, so new approaches need to be considered. In this regard, the general tendency of turning towards natural alternatives has reinforced the interest in essential oils (EOs) as potent antimicrobial agents. Our present article aims to first review the main pathogens classified by WHO as critical in terms of current AMR. The next objective is to summarize the most important and up-to-date aspects of resistance mechanisms to classical antibiotic therapy and to compare them with the latest findings regarding the efficacy of alternative essential oil therapy.
Antibiotics are identified as an emerging contaminant due to their persistence in the environment. Antibiotics, due to their accumulation in freshwater sources and wastewater have become a pollutant of concern. Every year million tons of these emerging contaminants are discharged into the water bodies. Through, the feces and urine of humans and animals, the antibiotics and their metabolites enter the environment. Aquatic ecosystems are exposed to persistent pollutants as they escape the wastewater treatment process. Excessive usage of antibiotics has resulted in the generation of antibiotic-resistant genes and bacteria in the environment. To maintain the vitality of the environment, it becomes imperative to mitigate antibiotics and their toxic metabolites. To avoid the adverse consequences on the non-target organisms, their removal from the environment is vital. Various remediation methods such as conventional methods including ion exchange, and precipitation are used for antibiotics degradation, however, the efficacy of the traditional methods is limited due to the production of toxic sludge and the high cost of maintenance. Biological methods such as bioremediation and phytoremediation are sustainable strategies to eradicate antibiotics, hence used widely. There are many reviews on antibiotic bioremediation using microbes and phytoremediation of antibiotics. But not all antibiotics can be remediated using microorganisms, so there is a need for more sustainable removal methods and recent remediation strategies. In the present review, a web-based search for literature published between 2010 to 2022 is carried out. Previous studies reported that living organisms like bacteria, fungi, algae, and plants could be utilized for the degradation of antibiotics. But not all antibiotics could be degraded using bacteria, as bioremediation may get affected by many factors such as inoculum size, microbial strain, and the culture conditions. Therefore, recent remediation techniques such as the use of microbial fuel cells, biochar, and sawdust are used for the possible removal of antibiotics from the environment. For the sustainable elimination of recalcitrant antibiotics, combined processes seem to be a more efficient and permanent solution for bypassing the toxicity of antibiotics
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Purpose: This study investigates the knowledge, attitudes and practices of the general public regarding the use of antibiotics in community pharmacy, in Pakistan. Methods: This is a mixed method study where data were collected through a validated questionnaire and semi-structured interviews. Convenience sampling techniques were used to recruit participants from the general public of Bahawalpur, Pakistan who visited pharmacies to purchase antibiotics between 1 June 2018 and 31 July 2018. Descriptive statistics and regression analyses were used to tabulate the results of quantitative data while inductive thematic analysis was used to identify themes and draw conclusions from the qualitative data. Results: Over 60% of the 400 survey participants (n=246; 61.5%) had a moderate level of antibiotic knowledge; however, attitudes regarding antibiotics use were poor in half the sample (n=201; 50.3%). More than half (n=226; 56.6%) of the respondents stated that antibiotics could cure all types of infections. Just under one third (n=129; 32.3%) of respondents obtained the appropriate dosage regimen while the majority did not complete the course (n=369; 92.3%); stopping when they felt better. Inductive thematic analysis yielded four themes, 10 subthemes and 27 categories. Two subthemes were related to knowledge, one to attitude, three to practices and four subthemes were related to suggestions to improve the healthcare system. Inappropriate antibiotic practices included: lack of consultation with healthcare professionals, purchase of antibiotics without prescription or refilling of previous prescription, use of home supply of antibiotics, sharing of antibiotics with others, improper dosage regimens and early cessation of antibiotic therapy. Conclusion: Level of education, low health literacy, high consultation fees of private practitioners, inadequate health facilities in government hospitals and patient overload, busy schedules of people, poor healthcare infrastructure in rural areas and unrestricted supply of antibiotics were key factors associated with inappropriate use of antibiotics in Pakistan.
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The treatment of multidrug-resistant Gram-negative bacteria (MDR-GNB) infections in critically ill patients presents many challenges. Since an effective treatment should be administered as soon as possible, resistance to many antimicrobial classes almost invariably reduces the probability of adequate empirical coverage, with possible unfavorable consequences. In this light, readily available patient's medical history and updated information about the local microbiological epidemiology remain critical for defining the baseline risk of MDR-GNB infections and firmly guiding empirical treatment choices, with the aim of avoiding both undertreatment and overtreatment. Rapid diagnostics and efficient laboratory workflows are also of paramount importance both for anticipating diagnosis and for rapidly narrowing the antimicrobial spectrum, with de-escalation purposes and in line with antimicrobial stewardship principles. Carbapenem-resistant Enterobacteriaceae, Pseudomonas aeruginosa, and Acinetobacter baumannii are being reported with increasing frequencies worldwide, although with important variability across regions, hospitals and even single wards. In the past few years, new treatment options, such as ceftazidime/avibactam, meropenem/vaborbactam, ceftolozane/tazobactam, plazomicin, and eravacycline have become available, and others will become soon, which have provided some much-awaited resources for effectively counteracting severe infections due to these organisms. However, their optimal use should be guaranteed in the long term, for delaying as much as possible the emergence and diffusion of resistance to novel agents. Despite important progresses, pharmacokinetic/pharmacodynamic optimization of dosages and treatment duration in critically ill patients has still some areas of uncertainty requiring further study, that should take into account also resistance selection as a major endpoint. Treatment of severe MDR-GNB infections in critically ill patients in the near future will require an expert and complex clinical reasoning, of course taking into account the peculiar characteristics of the target population, but also the need for adequate empirical coverage and the more and more specific enzyme-level activity of novel antimicrobials with respect to the different resistance mechanisms of MDR-GNB.
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This review assesses the evidence for patterns of antibiotic use in pig on the basis of papers published in peer-reviewed journals in English between 2000 and 2017. Thirty-six articles were identified and reviewed, of which more than 85% of studies were conducted in Europe and North America. Penicillins and Tetracyclines groups were the most commonly used antibiotics in many countries. Oral medication in suckling and post-weaning periods were the most common applications of antibiotic administration in pig production. Antibiotic use is driven by age-specific diseases and the common pathogens causing these conditions where epidemiological profiles varied greatly across countries. In addition, the type and size of farm were associated with antibiotic use with finisher and larger farms using more antibiotics than farrow-to-finish and smaller farms. There is variation in the use of the highest priority critically important antimicrobials in humans across studies. However, this review indicates that they are still commonly used in pig production, for treatment and prevention of infection. This evidence calls for global efforts on the prudent use of antibiotics in response to the emergence of antimicrobial resistance (AMR) in the agricultural sector.
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We compared the diversity of extended-spectrum β-lactamases (ESBLs) producing Escherichia coli (E. coli) in wastewater of a municipal wastewater treatment plant. This was done by analyzing multiple antibiotic resistant phenotypes and genotypes. Also, we investigated the antibiotic resistance transfer mechanism of the plasmid by comparing the antibiotic resistance gene linked transfer using a conjugative test, and by analyzing the full-length DNA sequence of one plasmid. The results showed that 50 ESBLs-producing E. coli isolates were isolated from 80 wastewater samples at the rate of 62.5% (50/80), out of which 35 transconjugants were obtained with the multiple antibiotic resistant transfer rate as high as 70.0% (35/50). Multiple antibiotic resistance was shown in all transconjugants and donor bacteria, which were capable of resistance to 11 out of 15 kinds of antibiotics. Both transconjugants and donors were capable of resistance to the Ampicillin and Cefalotin at a rate of 100.00% (35/35), while the total antibiotic resistant spectrum of transconjugants narrowed at the rate of 94.29% (33/35) and broadened at the rate of 5.71% (2/35) after conjugate to the donor bacteria. PCR showed that the resistant genotypes decreased or remained unchanged when compared to donor bacteria with transconjugants while the blaTEM and blaCTX-M genes were transferred and linked at a rate of 100.00% (35/35) and the blaSHV gene was at the rate as high as 94.29% (33/35). However, the qnrS gene was transferred at a low rate of 4.17% (1/24). In addition, the major resistance gene subtypes were blaTEM-1, blaSHV -11, and blaCTX-M-15 according to sequencing and Blast comparison. Plasmid wwA8 is a closed-loop DNA molecule with 83157 bp, and contains 45 predicted genes, including three antibiotic resistant resistance genes, blaCTX-M-15, blaTEM-1 and qnrS1, which can be transferred with E. coli in vitro. This study shows that E. coli isolated from wastewater was capable of transferring resistance genes and producing antibiotic resistant phenotypes. The plasmids containing different resistance genes in E. coli play an important role in the multiple antibiotic resistant transfer. Most importantly, antibiotic resistant resistance genes have different transfer efficiencies, the blaTEM and blaCTX-M genes transferred at a rate of 100.00% and linked transfer in all 35 transconjugants.
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Introduction: Surveillance of antimicrobial medicines consumption is central to improving their use and reducing resistance rates. There are few published data on antibiotic consumption in Eastern Europe and Central Asia. To address this, 18 non-European Union (EU) countries and territories contribute to the WHO Regional Office for Europe (WHO Europe) Antimicrobial Medicines Consumption (AMC) Network. Objectives: (i) Analyze 2015 consumption of J01 class antibacterials for systemic use from 16 AMC Network members; (ii) compare results with 2011 data and 2015 ESAC-Net estimates; (iii) assess consumption against suggested indicators; (iv) evaluate the impact of planned changes to defined daily doses (DDDs) in 2019 for some commonly used antibiotics; and (v) consider the utility of quantitative metrics of consumption for policy action. Methods: Analysis methods are similar to ESAC-Net for EU countries. The Anatomical Therapeutic Chemical (ATC) classification and DDD methodology were used to calculate total consumption (DDD/1000 inhabitants/day [DID]), relative use measures (percentages), extent of use of WHO Watch and Reserve group antibiotics and impact of DDD changes. Findings: Total J01 consumption in 2015 ranged 8.0–41.5 DID (mean 21.2 DID), generally lower than in 2011 (6.4–42.3 DID, mean 23.6 DID). Beta-lactam penicillins, cephalosporins, and quinolones represented 16.2–56.6, 9.4–28.8, and 7.5–24.6% of total J01 consumption, respectively. Third-generation cephalosporins comprised up to 90% of total cephalosporin consumption in some countries. Consumption of WHO Reserve antibiotics was very low; Watch antibiotics comprised 17.3–49.5% of total consumption (mean 30.9%). Variability was similar to 2015 ESAC-Net data (11.7–38.3 DID; mean 22.6 DID). DDD changes in 2019 impact both total and relative consumption estimates: total DIDs reduced on average by 12.0% (7.3–35.5 DID), mostly due to reduced total DDDs for commonly used penicillins; impact on rankings and relative use estimates were modest. Discussion: Quantitative metrics of antibiotic consumption have value. Improvements over time reflect national activities, however, changes in total volumes may conceal shifts to less desirable choices. Relative use measures targeting antibiotics of concern may be more informative. Some, including WHO Watch and Reserve classifications, lend themselves to prescribing targets supported by guidelines and treatment protocols.
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The Enterobacter cloacae complex (ECC) includes common nosocomial pathogens capable of producing a wide variety of infections. Broad-spectrum antibiotic resistance, including the recent emergence of resistance to last-resort carbapenems, has led to increased interest in this group of organisms and carbapenem-resistant E. cloacae complex (CREC) in particular. Molecular typing methods based on heat-shock protein sequence, pulsed-field gel electrophoresis, comparative genomic hybridization, and, most recently, multilocus sequence typing have led to the identification of over 1069 ECC sequence types in 18 phylogenetic clusters across the globe. Whole-genome sequencing and comparative genomics, moreover, have facilitated global analyses of clonal composition of ECC and specifically of CREC. Epidemiological and genomic studies have revealed diverse multidrug-resistant ECC clones including several potential epidemic lineages. Together with intrinsic β-lactam resistance, members of the ECC exhibit a unique ability to acquire genes encoding resistance to multiple classes of antibiotics, including a variety of carbapenemase genes. In this review, we address recent advances in the molecular epidemiology of multidrug-resistant E. cloacae complex, focusing on the global expansion of CREC.
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Background Antimicrobial resistance (AMR) is a threat to global health. To increase public awareness about AMR and encourage the prudent use of antimicrobials is one of the goals of the National Action Plan in Japan. Methods A nationwide online cross-sectional survey was conducted to evaluate the existing knowledge and perception of AMR in Japan, based on the Antimicrobial Resistance Eurobarometer Survey. Participants included Japanese adults aged 20–69 years, who were not medical professionals. Results Among a total of 3,390 participants, about half had taken antibiotics over the past 12 months, and majority of them obtained the antimicrobials from healthcare institutions for the common cold. While 11.7% of the participants kept leftover antibiotics, 23.6% of them have adjusted doses by themselves. About 10% of the participants have requested antibiotics from their doctors, and nearly 30% of them preferred doctors who prescribed antibiotics when had a cold. The common informational sources were TV news and newspapers, and more than 40% of the participants reported receiving some information over the past year. However, approximately 80% of the participants did not know that antibiotics do not kill viruses and that antibiotics are ineffective against cold and flu. Conclusion Not many Japanese have adequate information about antimicrobials and AMR, and many have taken antimicrobials inappropriately. Greater educational interventions are, therefore, necessary to increase public awareness and develop effective countermeasures against AMR in Japan.
Rationale: Rising antimicrobial resistance (AMR) is a threat to modern medicine and increasing international mobility facilitates the spread of AMR. Infections with resistant organisms have higher morbidity and mortality, are costlier to treat, result in longer hospital stays, and place a greater burden on health systems than infections caused by susceptible organisms. Here we review the role of travel in the international dissemination of antimicrobial resistance and consider actions at the levels of travelers, travel medicine practitioners, and policymakers that would mitigate this threat. Findings: Resistant pathogens do not recognize international borders; travelers to areas with high AMR prevalence are likely to be exposed to resistant bacteria and return to their home countries colonized. Medical tourists go between health facilities with drastically different rates of AMR, potentially transmitting highly resistant strains.Drug-resistant bacteria have been found in every continent, however, differences between countries in the prevalence of AMR depend on multiple factors. These include levels of antibiotic consumption (including inappropriate use), access to clean water, adequate sanitation, vaccination coverage, the availability of quality healthcare, and access to high quality medical products. Conclusions: Travelers to areas with high levels of AMR should have vaccines up to date, be aware of ways of treating and preventing travelers' diarrhea (other than antibiotic use) and be informed on safe sexual practices. The healthcare systems of low- and middle-income countries require investment to reduce the transmission of resistant strains by improving access to clean water, sanitation facilities and vaccines. Efforts are needed to curb inappropriate antibiotic use worldwide. In addition, more surveillance is needed to understand the role of the movement of humans, livestock and food products in resistance transmission. The travel medicine community has a key role to play in advocating for the recognition of AMR as a priority on the international health agenda. Key policy recommendations: Antimicrobial resistance is a threat to modern medicine and international travel plays a key role in the spread of highly resistant strains. It is essential that this is addressed at multiple levels: Individual travelers can reduce antibiotic consumption and the likelihood of infection. Travelers should have up to date vaccines and be informed on methods of preventing and treating travelers' diarrhea, other than use of antibiotics, and on safe sexual practices, such as condom use. Healthcare facilities need to be aware of the travel history of patients to provide appropriate treatment to those who are at high risk of exposure and to prevent further spread. Internationally, in countries without reliable and universal access to clean water, sanitation and hygiene, investment is needed to reduce the emergence and spread of resistance and ensure the antimicrobials available are of assured quality. High-income countries must ensure their use of antimicrobials is appropriate to reduce selection for AMR. Surveillance across all countries is needed to monitor and respond to this emerging threat.
Introduction Antibiotic-resistant infections have become increasingly prevalent nowadays. As a result, it is essential to examine the key socioeconomic and political factors which contribute to the rise in the prevalence of antibiotic resistance in developing and developed nations. This study aims to identify the various contributors to the development of antibiotic resistance in each type of nation. Methods PUBMED was used to identify primary research, systematic reviews, and narrative reviews published before Jan 2017. Search terms included antibiotic resistance, antimicrobial resistance, superbugs, multidrug-resistant organisms, developing countries, developed countries. Publications from different countries were included to ensure generalizability. Publications were excluded if they didn't mention factors causing resistance, focused on the molecular basis of resistance, or if they were case reports. Publicly available reports from national and international health agencies were used. Results In developing countries, key contributors identified included: (1) Lack of surveillance of resistance development, (2) poor quality of available antibiotics, (3) clinical misuse, and (4) ease of availability of antibiotics. In developed countries, poor hospital-level regulation and excessive antibiotic use in food-producing animals play a major role in leading to antibiotic resistance. Finally, research on novel antibiotics is slow ing down due to the lack of economic incentives for antibiotic research. Conclusion Overall, multiple factors, which are distinct for developing and developed countries, contribute to the increase in the prevalence of antibiotic resistance globally. The results highlight the need to improve the regulatory framework for antibiotic use and research globally.