Stewardship / Resistance Scan for Sep 06, 2019

Resistance rates and income
Assessing national stewardship programs

Study links resistance rates with national income status

A study of antibiotic resistance surveillance systems and gross national income (GNI) in 67 countries suggests that low-income status is linked to higher rates of invasive infections caused by antibiotic-resistant pathogens, German and Italian researchers reported today in The Journal of Antimicrobial Chemotherapy.

Of the 67 countries with available surveillance data from 2012 onward, 38 (57%) were high income, 16 (24%) were upper-middle income, 11 (16%) were lower-middle income, and 2 (3%) were low income, based on GNI per capita. For the purposes of the study, the researchers focused on the top-ranked antibiotic-resistant bacteria from the World Health Organization's 2017 priority pathogens list: carbapenem-resistant (CR) Acinetobacter spp, CR Klebsiella spp, CR Pseudomonas aeruginosa, third-generation cephalosporin–resistant (3GCR) Escherichia coli, 3GCR Klebsiella spp, vancomycin-resistant Enterococcus faecium, and methicillin-resistant Staphylococcus aureus (MRSA). The association between antibiotic resistance prevalence data and GNI per capita was investigated individually for each bacterium through linear regression analysis.

The analysis showed a significant inverse association (P < 0.0001) between the prevalence of infections caused by the selected pathogens and GNI per capita. The highest rate of increase per unit decrease in log GNI per capita was observed in 3GCR Klebsiella  (22.5%; 95% confidence interval [CI], 18.2% to 26.7%; P < 0.0001), followed by CR Acinetobacter  (19.2%; 95% CI, 11.3% to 27.1%; P < 0.0001) and 3GCR E coli (15.3%; 95% CI, 11.6% to 19.1%; P < 0.0001). The rate of increase per unit decrease in log GNI per capita was slightly lower in gram-positive bacteria (MRSA 9.5%, 95% CI 5.2% to 13.7%, P < 0.0001; VR E faecium 1%; 95% CI, −6.3% to 8.3%, P = 0.78).

The authors of the study suggest that several factors could explain the relationship between increased antibiotic resistance and lower income status, including suboptimal hygiene conditions, inadequate sanitation, lack of access to clean water, climate, and unregulated access to antibiotics.

They conclude, "Public health interventions designed to limit the burden of antimicrobial resistance should also consider determinants of poverty and inequality, especially in lower middle-income and low income countries."
Sep 6 J Antimicrob Chemother study


Impact of national stewardship interventions hard to assess, analysis finds

In another study today in the Journal of Antimicrobial Chemotherapy, researchers conducting a systematic review of national initiatives to reduce the overuse and misuse of antibiotics report that more evidence is needed to assess their long-term impact.

The researchers identified 34 articles detailing interventions in 21 high- and upper-middle-income countries. The differences in study designs, populations, analytical strategies, and effect measures made it impossible to conduct a meta-analysis. But the researchers said the overall evidence suggested that interventions addressing inappropriate antibiotic access, including antibiotic committees, clinical guidelines, and prescribing restrictions, were effective at reducing antibiotic use and prescribing. The evidence for other interventions, such as education campaigns aimed at healthcare professional and the general public, was mixed, with several studies showing no impact on overall antibiotic consumption.

The researchers also found that only five of the studies established a direct link between antibiotic consumptions and resistance rates, and that these studies reported mixed results. "Establishing an association between antibiotic consumption and resistance rates could help to determine the extent to which reducing antibiotic consumption is an effective intervention, as well as to assess how this compares with other types of interventions, such as improving vaccination coverage and reducing animal antibiotic use," they write.

The researchers conclude, "Based on the available evidence from primarily high-income countries, our systematic review highlights that strategies to reduce inappropriate demand and access to antibiotics appear to have a quantifiable impact primarily on antibiotic consumption, but more evidence is needed on the long-term impacts of these interventions, such as increases in the consumption of antibiotic subtypes, impacts on prevalence of antibiotic-resistant organisms, as well as the health and economic burden of these infections."
Sep 6 J Antimicrob Chemother study

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