Over-Prescription and Overuse of Antimicrobials in the Eastern Mediterranean Region: The Urgent Need for Antimicrobial Stewardship Programs with Access, Watch, and Reserve Adoption

Abstract

Excessive antimicrobial use contributes to the development of antimicrobial resistance. In the Eastern Mediterranean region (EMR), there is dearth of information on the prevalence of antimicrobial use in patients hospitalized in acute healthcare settings, clinical indications, types of antimicrobials prescribed, and quality indicators for prescriptions. Between September and December 2019, seven countries in the EMR conducted a standardized point prevalence survey. All patients present in the hospital wards at 8 a.m. on the day of the survey constituted the sample population. We collected data, including patient characteristics, antimicrobials received, therapeutic indication according to predefined lists, and markers of prescribing quality. The survey included data from 139 hospitals in seven countries. Among the 19,611 inpatients surveyed, 11,168 patients received at least one antimicrobial {crude prevalence: 56.9% (95%CI: 56.2–57.6%). The top three classes of antimicrobials prescribed were third-generation cephalosporins (26.7%), beta-lactam penicillins (18.1%), and imidazole derivatives (n = 1655, 9.8%). Carbapenems were most frequently prescribed for the treatment of healthcare-associated infections. Compliance with quality indicators of antimicrobial use was limited where treatment guidelines were available for 41% of antimicrobial prescriptions and targeted antimicrobial treatment represented 21% of therapeutic indications. Overall hospital antimicrobial use was high in countries of the EMR, pointing to the need to design and implement context-specific antimicrobial stewardship programs to optimize antimicrobial use and reduce antimicrobial resistance.

Antimicrobial Resistance: Stewardship and One Health in the Eastern Mediterranean Region

“…These factors create an environment that allows antibiotic-resistant bacteria to multiply and spread rapidly, posing a significant risk to public health. In addition, these factors include a high prevalence of infectious diseases, weak health systems, and limited access to high-quality healthcare [7]. Specifically, Egypt, Iran, and Pakistan have experienced the rapid emergence of resistant pathogens due to the inappropriate use of antibiotics and inadequate regulation of antimicrobial drug sales [8][9][10].…”

Overview of Availability, Cost, and Affordability of Antibiotics for Adults in Jordan: an AWaRe Classification Perspective

“…A great proportion of the registered antibiotics in Jordan belonged to third-generation cephalosporins, fluoroquinolones, and penicillins. Third-generation cephalosporins and fluoroquinolones, in addition to penicillins with β-lactamase inhibitors as pharmacological classes were among the highest prescribed antibiotics in hospitals in Jordan and worldwide [7,17,26,27]. Route of administration, e.g.…”

“…In other words, considering AWaRe classification of antibiotics may rationalize antibiotic consumption [4,5]. The WHO had put a target that at least 60% of antibiotic consumption 2 being from agents belonging to 'Access' group [4,6], however, 70.5% of the prescribed antibiotics in Jordanian hospitals belonged to the 'Watch' category [7].…”

Pharmacovigilance Strategies to Address Resistance to Antibiotics and Inappropriate Use—A Narrative Review

“…In high-income countries, the consumption of AB decreased in the Access category between 2013 and 2018 [18]. The same was not observed in LMICs [19,20]. A recent review indicated that the general increase in the consumption of ABs in these countries, especially those in the Watch category, worsened during the COVID-19 pandemic [20].…”