E-DRUG: Antimicrobial therapy: Cambodia, inappropriate use, increased AMR
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The World Health Organization (WHO) has released a report that the world is still failing to develop desperately needed antibacterial treatments, despite growing awareness of the urgent threat of antibiotic resistance which has been known for years to be high in Cambodia.
WHO revealed that none of the 43 antibiotics that are currently in clinical development sufficiently address the problem of drug resistance to the world's most dangerous bacteria.
Dr Hanan Balkhy, WHO assistant director-general said: "The persistent failure to develop, manufacture, and distribute effective new antibiotics is further fueling the impact of antimicrobial resistance (AMR) and threatens our ability to successfully treat bacterial infections."
The report added that almost all the new antibiotics that have been brought to market in recent decades are variations of antibiotic drug classes that had been discovered no later than the 1980s.
"The impact of AMR is most severe in resource-constrained settings and among vulnerable groups such as newborns and young children. Bacterial pneumonia and bloodstream infections are among the major causes of childhood mortality under the age of 5," said the WHO report.
It also revealed that 30 percent of neonates with sepsis die due to bacterial infections resistant to multiple 1st-line antibiotics.
A study published by Oxford University last year [2020], titled "Frequent unregulated use of antibiotics in rural Cambodian infants," [see reference below] shows that antibiotics have been used widely among infants and that amoxicillin was the most commonly used antibiotic.
The study concluded that misuse of antibiotics was widespread, driven by a determined antibiotic-seeking behaviour facilitated by trained and untrained healthcare providers who supplied and enabled the community's antibiotic use.
"Data on the prevalence of AMR in Cambodia is still limited but suggests a potentially high prevalence in common pathogenic organisms to important antibiotics, including ampicillin, 3rd-generation cephalosporins, and fluoroquinolones," the study said.
The study area was conducted in 12 small villages along the Mekong River in Kampong Cham province's Stung Trang district.
Dr Mengly Quach, an educationist and medical doctor said that drug resistance is a major problem in Cambodia. "In most developing or under-developed countries, people mostly do self-medication and they don't go to a doctor because they can't afford it. They would rather go to their neighbours, friends, or relatives and ask for advice from them. Then they go to pharmacies and tell them what their problem is and order a specific antibiotic," he said.
However, Dr Quach said that not all pharmacists in Cambodia are real pharmacists. Most of them are just relatives of the owners or just individuals without any knowledge about drugs and prescriptions. As a result, most people develop a tolerance to antibiotics. They do not only overuse them but also underuse or in short -- misuse them because the dosage is not right and most of the time it is not even the right medication. The immune system is unable to fight the antigens because the dosage is not right," he added.
[Byline: Rhea Mae Soco]
[The author of the article above seeks to increase awareness of the urgent threat of antibiotic resistance in Cambodia, where misuse of antibiotics is a known phenomenon. However, there are limited data on AMR.
The reference and abstract of the article mentioned above follow:
Miyazaki A, Tung R, Taing B, et al. Frequent unregulated use of antibiotics in rural Cambodian infants. Trans R Soc Trop Med Hyg. 2020; 114(6): 401-407. doi: 10.1093/trstmh/traa020. PMID: 32307551; PMCID: PMC7266683;
https://academic.oup.com/trstmh/article/114/6/401/5822555
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Abstract
Background
Despite a high prevalence of antibiotic resistance in Cambodia, few studies have assessed health-seeking behaviour and the use of antibiotics by caregivers of young children in Cambodia.
Methods
We conducted a cross-sectional survey of infants Of 149 infants (ages 1-11 months, 54.4% male) enrolled in the cross-sectional study, 76 (51.4%) reported symptoms of diarrhoea, fever, or cough in the previous 14 d, with associated use of antibiotics reported in 22 (14.8%) infants. In 47 infants enrolled in the longitudinal surveillance, there were 141 reported episodes of illness in 44 (94%) infants with 21 infants (45%) reported to have received antibiotics in 32/141 (22.7%) episodes. Amoxicillin was the most commonly reported antibiotic in both surveys (68% [40/59 episodes reporting the use of antibiotics]).
Conclusions
Antibiotic usage is high in this population and appears to be occurring largely outside of the formal healthcare system."
"The practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improving antibiotic prescribing is unlikely to occur unless education programs are provided to improve the diagnostic capacity and the usefulness of microbiology services. In the meantime, antibiotic therapeutic guidelines should be developed from the limited microbiology services that are currently available. In parallel, hygiene and infection control in hospital must be improved, and access to antibiotics in the community must be restricted."
(12 months of age and their caregivers, assessing the frequency of reported illness, common symptoms, and associated health-seeking behaviour through structured questionnaires administered by trained fieldworkers at a home visit. In a subset of these participants, ages 4-8 months with no acute malnutrition, we conducted a 3-month surveillance with fortnightly home visits.)
Results
Of 149 infants (ages 1-11 months, 54.4% male) enrolled in the cross-sectional study, 76 (51.4%) reported symptoms of diarrhea, fever, or cough in the previous 14 d, with associated use of antibiotics reported in 22 (14.8%) infants. In 47 infants enrolled in the longitudinal surveillance, there were 141 reported episodes of illness in 44 (94%) infants with 21 infants (45%) reported to have received antibiotics in 32/141 (22.7%) episodes. Amoxicillin was the most commonly reported antibiotic in both surveys (68% [40/59 episodes reporting the use of antibiotics]).
Conclusions
Antibiotic usage is high in this population and appears to be occurring largely outside of the formal healthcare system."
"The practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improving antibiotic prescribing is unlikely to occur unless education programs are provided to improve the diagnostic capacity and the usefulness of microbiology services. In the meantime, antibiotic therapeutic guidelines should be developed from the limited microbiology services that are currently available. In parallel, hygiene and infection control in hospital must be improved, and access to antibiotics in the community must be restricted."
"Availability of AMR data for Cambodia is limited but improving. From the data published to date, the AMR rates for GLASS [Global Antimicrobial Resistance Surveillance System] organisms appear to be similar to those of other countries in the region. High resistance rates are seen to many 1st line antibiotics, especially among [Enterobacterales]. The recently commenced national AMR surveillance systems in humans and food animals will bring together data from across the country, in a uniform manner, to improve the clarity of the AMR situation in Cambodia." https://www.ijidonline.com/article/S1201-9712(19)30244-9/fulltext
The Royal Government of Cambodia (RGC) launched on 23 Dec 2019 the Multi-Sectoral Action Plan (MSAP) 2019-2023 encompassing 7 key strategic areas that will guide collaborative interventions to address the threat of antimicrobial resistance (AMR). http://www.fao.org/cambodia/news/rss/detail-events/en/c/1256929/
- Mod.TTM
HealthMap/ProMED map:
Cambodia: http://healthmap.org/promed/p/145\]
[See Also: Surveillance (33): LMIC, gaps in surveillance http://promedmail.org/post/20210403.8286680
Antimicrobial therapy (02): inappropriate use, rise in AMR, ongoing saga
http://promedmail.org/post/20210331.8280040
Surveillance (26): Cambodia, M. tuberculosis, 2nd-line drug resistance
http://promedmail.org/post/20210319.8257021
Surveillance (24): LMIC, community-based, AMR tailored solutions
http://promedmail.org/post/20210313.8245717
Research & innovation (06):
AMR may spread even more easily than expected
http://promedmail.org/post/20210124.8129566 2020
WHO (02): AMR fact sheet, threats to global health
http://promedmail.org/post/20200802.7637035\]
Carinne Bruneton
E-MED@healthnet.org
<carinne.bruneton@gmail.com>