Background The decreasing effectiveness of antimicrobial agents is a growing global public health concern. Low- and middle-income countries (LMIC) are vulnerable to the loss of antimicrobial efficacy given their high burden of infectious disease and the cost of treating resistant organisms. Methods We analyzed data from the World Health Organization’s Antibacterial Resistance Global Surveillance Report. We investigated the importance of out-of-pocket spending and copayment requirements for public sector medications on the level of bacterial resistance among LMIC, adjusting for environmental factors purported to be predictors of resistance, such as sanitation, animal husbandry and poverty as well as other structural components of the health sector. Findings Out-of-pocket health expenditures were the only factor demonstrating a statistically significant relationship with antimicrobial resistance. A ten point increase in the percentage of health expenditures that were out-of-pocket was associated with a 3·2 percentage point increase in resistant isolates [95% CI, 1·17 to 5·15, p-value=0·002]. This relationship was driven by countries requiring copayments for medications in the public health sector. Among these countries, moving from the 20th to 80th percentile of out-of-pocket health expenditures was associated with an increase in resistant bacterial isolates from 17·76 [95%CI 12·54 to 22·97] to 36·27 percentage points [95% CI 31·16 to 41·38]. Interpretation Out-of-pocket health expenditures were strongly correlated with antimicrobial resistance among LMIC. This relationship was driven by countries that require copayments on medications in the public sector. Our findings suggest cost-sharing of antimicrobials in the public sector may drive demand to the private sector where supply-side incentives to overprescribe are likely heightened and quality assurance less standardized.

The decreasing effectiveness of antimicrobial agents is a global public health threat, yet risk factors for community-acquired antimicrobial resistance (CA-AMR) in low-income settings have not been clearly elucidated. Our aim was to identify risk factors for CA-AMR with extended-spectrum β-lactamase (ESBL)–producing organisms among urban-dwelling women in India. We collected microbiological and survey data in an observational study of primigravidae women in a public hospital in Hyderabad, India. We analyzed the data using multivariate logistic and linear regression and found that 7% of 1,836 women had bacteriuria; 48% of isolates were ESBL-producing organisms. Women in the bottom 50th percentile of income distribution were more likely to have bacteriuria (adjusted odds ratio 1.44, 95% CI 0.99–2.10) and significantly more likely to have bacteriuria with ESBL-producing organisms (adjusted odds ratio 2.04, 95% CI 1.17–3.54). Nonparametric analyses demonstrated a negative relationship between the prevalence of ESBL and income.

Children in the age group of six months to one year were found to be the most vulnerable. The occurrence of C. parvum, in nearly one third of cases in the present series indicates that the zoonotic transmission is of considerable significance in the epidemiology of Cryptosporidiosis in the study area.

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