PHAM THANH PHUONGINTERVENTIONS TO IMPROVE ANTIMICROBIAL RESISTANCE KNOWLEDGE, ATTITUDES, AND PRACTICES OF HEALTH WORKERS IN LOW AND MIDDLE INCOME COUNTRIES: A SCOPING REVIEW MASTER OF
LITERATURE REVIEW
Causes of antimicrobial resistance
The establishment and spread of antimicrobial resistance (AMR) are driven by several key factors Firstly, the rising prevalence of AMR phenotypes among microorganisms is largely attributed to their evolving drug resistance mechanisms Secondly, the global population explosion and increased globalization have made diseases more contagious on a worldwide scale Lastly, the inappropriate use of antibiotics by humans significantly exacerbates the AMR crisis.
The development of antimicrobial resistance (AMR) is a natural process where bacteria can evolve resistance mechanisms through their DNA These microorganisms can carry genes that confer various types of resistance and can also share these antimicrobial-resistant genes with other bacteria that have not been exposed to antibiotics.
The behavior of both humans and animals significantly contributes to the rapid rise of antimicrobial resistance (AMR) Research highlights issues such as inappropriate prescriptions by doctors, the sale of antibiotics in private pharmacies, and personal choices made by patients and caregivers regarding antibiotic use, all of which exacerbate the AMR crisis Additionally, factors like poor hygiene and sanitation, restricted access to healthcare, and insufficient regulations are key drivers of AMR in low- and middle-income countries (LMICs), facilitating its spread.
The rampant use of antibiotics in agriculture, particularly in animal feed production, significantly contributes to the rise of antibiotic resistance in animals and poses a heightened risk of antimicrobial resistance (AMR) in humans In Africa, a staggering 77.6% to 100% of farms utilize antimicrobials for livestock Alarmingly, certain human antibiotics are administered to livestock without any prescription In the United States, the approval of seven human medicine compounds—including bacitracin, chlortetracycline, erythromycin, lincomycin, novobiocin, oxytetracycline, and penicillin—for use in poultry feeds without veterinary oversight raises serious concerns about public health.
Antimicrobial resistance (AMR) has primarily focused on human health and agriculture, but emerging evidence highlights the significant role of environmental factors in its development and spread Research indicates that AMR organisms are present in various exposure-relevant environments, including recreational areas, drinking water, ambient air, shellfish, fresh produce, wildlife, and soil, posing potential risks for human exposure Despite this, there is currently no direct evidence linking AMR transmission to humans through environmental sources Key environmental contributors to AMR include runoff from agricultural practices, wastewater pollution from hospitals and communities, pharmaceutical manufacturing effluents, and other waste discharges.
In summary, the human-animal-environment relationship is evident in the proliferation and transmission of AMR so a complex approach is required to tackle this problem.
Antimicrobial resistance (AMR) poses significant health and economic challenges, impacting patient care, healthcare systems, and economies worldwide It complicates the treatment and prevention of infectious diseases such as tuberculosis, HIV, and malaria, leading to increased morbidity and mortality rates Patients facing AMR infections often require more intensive treatments, resulting in severe side effects and extended recovery times The strain on healthcare systems is substantial, as AMR escalates treatment costs and necessitates greater hospital resources, while also compromising the success of critical medical procedures like organ transplants and cancer therapies The global financial burden of AMR varies by country, highlighting the urgent need for new antimicrobial development, which remains underfunded Furthermore, AMR adversely affects global trade, diminishes GDP through decreased labor productivity, and disrupts livestock production and trade.
J 1.4 AMR prevalent and related factors ill the world and LMICs
Antimicrobial resistance (AMR) poses a significant global public health threat, particularly in low- and middle-income countries (LMICs) The World Health Organization's Global Antimicrobial Resistance and Use Surveillance System (GLASS) report indicates that over 50% of common bacteria exhibit high resistance levels Notably, 60% of Neisseria gonorrhoeae isolates show resistance to ciprofloxacin, the most commonly used oral antibiotic Additionally, more than 20% of E coli isolates resist first-line treatments like ampicillin and co-trimoxazole, as well as second-line fluoroquinolones In the European Region alone, AMR is responsible for approximately 670,000 illnesses and 33,000 deaths each year, highlighting urgent public health challenges.
According to GLASS reports, antimicrobial resistance (AMR) rates in low- and middle-income countries (LMICs) are significantly higher than in developed nations, primarily due to a limited number of referral hospitals reported to the World Health Organization (WHO) This disparity is exacerbated by insufficient testing coverage and weak laboratory capacity, making it difficult to accurately interpret AMR rates in these regions.
Numerous studies have examined the prevalence of antimicrobial resistance (AMR) and its substantial impact on low- and middle-income countries (LMICs) A comprehensive analysis across 204 countries and territories revealed that in 2019, approximately 4.95 million deaths were linked to bacterial AMR, with 1.27 million of those deaths directly attributable to this growing threat.
In 2019, Western sub-Saharan Africa experienced the highest all-age mortality rate associated with antibiotic resistance, while Australasia reported the lowest incidence Lower respiratory infections accounted for over 15 million deaths linked to resistance that year A genetic analysis conducted across 33 low- and middle-income countries revealed that all strains of K pneumoniae were multi-drug resistant, with 13.6% classified as hypervirulent.
12 LMICs have reported the emergence of convergent strains, with Asia being the central hotspot’’.
Despite the establishment of policies to combat antimicrobial resistance (AMR), their effectiveness in low- and middle-income countries (LMICs) remains limited The behavior of healthcare staff, community members, and service providers plays a crucial role in antimicrobial stewardship (AMS) efforts Importantly, enhancing the knowledge, attitudes, and practices (KAP) of health workers can lead to improvements in the AMR landscape However, there exists a significant gap in KAP regarding drug use among healthcare providers (HCPs).
Antimicrobial resistance (AMR) poses a significant global threat, particularly to low- and middle-income countries (LIMCs), with potentially severe consequences The complex mechanisms behind the emergence and dissemination of AMR highlight the interconnectedness of human, animal, and environmental health, known as the One Health approach To effectively combat AMR, it is essential to foster collaborative efforts among microbiologists, ecologists, healthcare professionals, educators, policymakers, legislators, and stakeholders from the agricultural and pharmaceutical sectors, alongside public engagement.
1.2 Barriers and facilitators of prudent antimicrobial prescribing
1.2.1 Antimicrobial prescribing in the world
Antimicrobials are widely prescribed worldwide, and inappropriate AMU is common In the Center for Disease Control and Prevention (CDC) report, total outpatient oral antibiotic prescriptions were 211.1 million ill
2021 or 636 for every 1000 people in the United States^5.
The use of antibiotics in treating viral diseases, particularly in the context of COVID-19, has become a significant topic of discussion Antibiotics are effective only against bacterial infections and do not impact viruses; nonetheless, studies show a high rate of inappropriate prescribing For instance, a study in Spain found that nearly 80% of COVID-19 patients were prescribed antibiotics, with 34% receiving them unnecessarily Similarly, in France, 59% of antibiotic prescriptions for upper respiratory tract infections were deemed unnecessary, with a substantial portion being overly broad-spectrum Hospitalized patients with viral respiratory tract infections often receive antibiotics due to concerns about potential bacterial co-infections However, evidence indicates that such prophylactic use does not improve treatment outcomes and increases the risk of side effects and antibiotic resistance in patients with viral infections.
1.2.2 Harriers and facilitators of prudent antimicrobial prescribing
As mentioned above, inappropriate antimicrobial prescribing happens frequently and becomes a key driver of antimicrobial resistance Numerous individual, interpersonal, organizational, community, and public policy factors influence antimicrobial prescribing.
Personal factors, including knowledge, awareness, experience, and misconceptions among physicians, significantly impact their prescribing practices A study conducted on healthcare professionals in six tertiary hospitals in Saudi Arabia revealed that inadequate skills and knowledge led to inappropriate antimicrobial prescribing Consequently, the research emphasized the urgent need for comprehensive education and training for healthcare workers regarding antimicrobial resistance (AMR).
Interpersonal factors, such as patient demands and pressures from pharmaceutical representatives, significantly influence general practitioners' decisions Additionally, the limited access to relevant guidelines and up-to-date community data on antimicrobial resistance poses a major challenge at both organizational and public policy levels In low- and middle-income countries (LMICs), diagnostic testing remains underutilized, and physicians often hold conflicting views regarding the use of rapid point-of-care tests (POCTs) to guide antibiotic prescribing decisions.
1.3 Interventions to improve KAP in Antimicrobial Resistance of health workers