Supply-chain factors and antimicrobial stewardship

Abstract

Efficient and secure supply chains are vital for effective health services worldwide. In low- and middle-income countries, the accessibility, affordability and availability of essential medicines, including antimicrobials, remain challenging. Ineffective supply chains often cause antimicrobial shortages, leading to inappropriate use of alternative agents and increasing the risk of antimicrobial resistance. Shortages, coupled with insecure supply chains, also encourage the infiltration of substandard and falsified medicines, leading to suboptimal treatment and further promoting antimicrobial resistance. Addressing antimicrobial supply-chain issues should be considered a key component of antimicrobial stewardship programmes. We have explored the link between medicine supply chains and antimicrobial use in seven focus countries: Kenya, Malawi, Nigeria, Sierra Leone, Uganda, United Republic of Tanzania and Zambia. We explored country medicine supply-system structures, national medicine supply-chain policy documents and global study reports. Our aim was to develop evidence-based strategies to enhance the effectiveness and efficiency of the medicine supply chains in supporting antimicrobial stewardship efforts. Better management of medical supply chains involves rational selection, quantification, forecasting, procurement, storage, distribution, use and stock management of antimicrobials. Important supply-chain considerations include pooled procurement networks to ensure consistent pricing of quality-assured antimicrobials, and improved resource utilization and information exchange among relevant stakeholders. We propose adaptable recommendations for integrating medicine supply chains as an essential part of antimicrobial stewardship programmes, with a call for action at the local, regional and national levels in low- and middle-income countries.

Global antimicrobial resistance and use surveillance system (GLASS 2022): Investigating the relationship between antimicrobial resistance and antimicrobial consumption data across the participating countries

“…The multiple comparisons of our beta regression model ( Table 3 ) showed that Iran had significantly higher (p < 0.05) AMC rates compared to any other country other than Uganda, and this confirms AMC is a major precipitator of AMR in Iran. Most Low-income, and Low and middle-income countries such as Egypt, Jordan, and Uganda, have high disease burdens and high resistance rates due to poor healthcare infrastructures, scarce economic resources, little or no legislative enforcement toward controlling antimicrobial access and use, poor education, and AMR awareness and ineffective AMR supply chain [ 23 , 27 , 71 , 88 – 91 ]. Uganda stands out amongst the 3 from our analysis as having significantly higher rates of AMC compared to any other country ( Table 3 ), which points out AMC as an important driver of AMR in Uganda.…”

“…Although, limited information exists about the actual magnitude of the antimicrobial resistance (AMR) issue in LICs and LMICs due to inadequate and unreliable AMR surveillance systems, however, consistently high AMR resistance rates have been reported in LICs and LMICs in all WHO GLASS reports over the years and several independent studies [ 20 , 28 ]. Also, the observed high consumption and high resistance could be attributed to an inefficient supply chain of antimicrobials leading to the inappropriate use of alternative drugs and escalating the risk of antimicrobial resistance [ 91 , 92 ].…”

“…These classes of antimicrobials, particularly beta-lactams-penicillins, constitute more than 60% of antimicrobials being produced, also, they are considered an empirical therapy for most bacterial infections, especially in developing countries with poor health and diagnostics facilities and a high prevalence of self-medication and non-prescription antimicrobial consumption [ 36 , 93 – 95 ]. The overall availability and accessibility of these antimicrobial classes contribute to the higher consumption rates [ 91 ]. The insufficient awareness and understanding of antimicrobial usage and indications contribute to the indiscriminate use of beta-lactams (penicillin) and cephalosporins for treating conditions like colds, flu, and other viral infections, exacerbating the inappropriate utilization of these antimicrobial classes.…”

Defining access without excess: expanding appropriate use of antibiotics targeting multidrug-resistant organisms

“…In many LMICs, access to antibiotics can be limited by inadequate health infrastructure and networks, limited budgets and high cost of medications, inadequate or fragmented supply chain, ineffective procurement schemes, and often competing health-care priorities. 22 , 25 , 26 , 27 , 28 Furthermore, these challenges can be compounded by the sometimes rigid regulatory requirements in many countries, making it harder for pharmaceutical companies and manufacturers to gain entry. 24 Countries might consider addressing these challenges of expanding access to antibiotics within the design of their national action plans on antimicrobial resistance.…”

Effect of antibiotic medicines availability on adherence to standard treatment guidelines among hospitalized adult patients in southern Malawi

“…The high burden of antibiotic resistance in low and middle-income countries (LMICs) is attributed to both high and inappropriate use of antibiotics [ 6 ]. In addition, an unstable supply of essential medicines in LMICs influences the inappropriate selection of antibiotic therapy [ 7 ].…”