The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate antibiotic stewardship and optimal use. In Bangladesh, data on antibiotic dispensing in pharmacies according to the AWaRe classification are scarce. We aimed to explore antibiotic dispensing pattern in pharmacies according to the WHO AWaRe classification to aid pharmacy-targeted national antibiotic stewardship program (ASP). From January to July 2021, we interviewed drug-sellers from randomly selected pharmacies and randomly selected customers attending the pharmacies. We collected data on demographics and medicines purchased. We classified the purchased antibiotics into the Access, Watch, and Reserve groups among 128 pharmacies surveyed, 98 (76.6%) were licensed; 61 (47.7%) drug-sellers had pharmacy training. Of 2686 customers interviewed; 580 (21.6%) purchased antibiotics. Among the 580 customers, 523 purchased one, 52 purchased two, and 5 purchased three courses of antibiotics (total 642 courses). Of the antibiotic courses, the Watch group accounted for the majority (344, 53.6%), followed by the Access (234, 36.4%) and Reserve (64, 10.0%) groups. Approximately half of the antibiotics (327/642, 50.9%) were purchased without a registered physician’s prescription. Dispensing of non-prescribed antibiotics was higher in the Access group (139/234, 59.4%), followed by Watch (160/344, 46.5%) and Reserve (28/64, 43.8%) groups. These findings highlight the need to implement strict policies and enforce existing laws, and pharmacy-targeted ASP focusing on proper dispensing practices to mitigate antimicrobial resistance in Bangladesh.

Background Cholera remains a substantial health burden in Asia and Africa particularly in resource poor settings. The standard procedures to identify the etiological organism V . cholerae are isolation from microbiological culture from stool as well as Polymerase Chain Reaction (PCR). Both the processes are highly lab oriented, labor extensive, time consuming, and expensive. In an effort to control for outbreaks and epidemics; an effective, convenient, quick and relatively less expensive detection method is imperative, without compromising the sensitivity and specificity that exists at present. The objective of this component of the study was to evaluate the effectiveness of a locally produced rapid diagnostic test (RDT) for cholera diagnosis. Methods In Bangladesh, nationwide cholera surveillance is ongoing in 22 hospitals covering all 8 divisions of the country since June, 2016. In the surveillance, stool samples have been collected from patients presenting to hospitals with acute watery diarrhea. Crystal VC TM (Span diagnostics, India) and Cholkit (locally produced RDT) have been used to detect V . cholerae from stool samples. Samples have also been sent to the main laboratory at icddr,b where the culture based isolation is routinely performed. All the tests were carried out for both direct and enriched stool samples. RDT sensitivity and specificity were calculated using stool culture as the gold standard. Results A total of 7720 samples were tested. Among these, 5865 samples were solely tested with Crystal VC and 1355 samples with Cholkit whereas 381 samples were tested with both the RDTs. In comparison with culture, direct testing with Crystal VC showed a sensitivity of 72% (95% CI: 50.6% to 87.9%) and specificity of 86.8% (95% CI: 82.8% to 90.1%). After enrichment the sensitivity and specificity was 68% (95% CI: 46.5% to 85.1%) and 97.5% (95% CI: 95.3% to 98.8%) respectively. The direct Cholkit test showed sensitivity of 76% (95% CI: 54.9% to 90.6%) and specificity of 90.2% (95% CI: 86.6% to 93.1%). Conclusion This evaluation has demonstrated that the sensitivity and specificity of Cholkit is similar to the commercially available test, Crystal VC when used in field settings for detecting V . cholerae from stool specimens. The findings from this study suggest that the Cholkit could be a possible alternative for cholera endemic regions where V . cholerae O1 is the major causative organism causing cholera.

Visceral leishmaniasis (VL) also known as kalaazar is a major public health problem in Bangladesh. A national VL elimination program was initiated in 2008 in Bangladesh after the signing of a memorandum of understanding between the Government of Bangladesh, India, and Nepal in 2005 for the elimination of VL from these three countries by 2015. Following the strategic plan of the VL elimination program of the three countries, the national program in Bangladesh was established in 2008. Based on information in the directorate general of health services, expert opinions in a recently held advocacy meeting in Dhaka and on available scientific literature, we report here the successes and challenges of the national VL elimination program in Bangladesh. The program prepared the national kala-azar elimination guidelines and strategic plan for VL elimination in consultation with the technical working group for VL elimination and VL experts in Bangladesh and abroad, including the World Health Organization-The Special Programme for Research and Training in Tropical Diseases (TDR). The program trained health staff from all VL endemic hospitals in proper diagnosis and treatment, stratified the country according to VL burden, and introduced the rapid diagnostic test and oral treatment with miltefosine at no cost for patients. Integrated vector control management with indoor residual spraying and the distribution of commercial, long-lasting, insecticidetreated bed-nets were also studied and then implemented. VL burden has declined, but is still far from the target of VL elimination. Thus, the program must continue to maintain these activities and also introduce new activities to involve community participation in the program. The program is facing challenges regarding the shortage of human resources and logistics because of a scarcity of resources. To maintain the success of the program, support from national and international donor agencies and policy makers will be necessary. Other options for the treatment of VL patients as well as for vector control must also be considered.

Irrational and inappropriate use of antibiotics in commercial chicken and aquaculture industries can accelerate the antibiotic resistance process in humans and animals. In Bangladesh, the growing commercial chicken and aquaculture industries are playing significantly important roles in the food value chain. It is necessary to know the antibiotic usage practices and antibiotic resistance in food animal production to design rational policies, guidelines, and interventions. We conducted a narrative review to understand the level of antibiotic usage and resistance in food animal production in Bangladesh. Information about antibiotic usage in different food animal production systems, including commercial chickens and aquaculture in Bangladesh is inadequate. Only a few small-scale studies reported that the majority (up to 100%) of the broiler and layer chicken farms used antibiotics for treating and preventing diseases. However, numerous studies reported antibiotic-resistant bacteria of public health importance in commercial chicken, fish, livestock, and animal origin food. The isolates from different pathogenic bacteria were found resistant against multiple antibiotics, including quinolones, the third or fourth generation of cephalosporins, and polymyxins. Veterinary practitioners empirically treat animals with antibiotics based on presumptive diagnosis due to inadequate microbial diagnostic facilities in Bangladesh. Intensive training is helpful to raise awareness among farmers, feed dealers, and drug sellers on good farming practices, standard biosecurity practices, personal hygiene, and the prudent use of antibiotics. Urgently, the Government of Bangladesh should develop and implement necessary guidelines to mitigate irrational use of antibiotics in food animals using a multi-sectoral One Health approach.

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15–64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.