Antibiotic use in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients during the COVID-19 pandemic has exceeded the incidence of bacterial coinfections and secondary infections, suggesting inappropriate and excessive prescribing. Even in settings with established antimicrobial stewardship (AMS) programmes, there were weaknesses exposed regarding appropriate antibiotic use in the context of the pandemic. Moreover, antimicrobial resistance (AMR) surveillance and AMS have been deprioritised with diversion of health system resources to the pandemic response. This experience highlights deficiencies in AMR containment and mitigation strategies that require urgent attention from clinical and scientific communities. These include the need to implement diagnostic stewardship to assess the global incidence of coinfections and secondary infections in COVID-19 patients, including those by multidrug-resistant pathogens, to identify patients most likely to benefit from antibiotic treatment and identify when antibiotics can be safely withheld, de-escalated or discontinued. Long-term global surveillance of clinical and societal antibiotic use and resistance trends is required to prepare for subsequent changes in AMR epidemiology, while ensuring uninterrupted supply chains and preventing drug shortages and stock outs. These interventions present implementation challenges in resource-constrained settings, making a case for implementation research on AMR. Knowledge and support for these practices will come from internationally coordinated, targeted research on AMR, supporting the preparation for future challenges from emerging AMR in the context of the current COVID-19 pandemic or future pandemics.

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Antibiotic-resistant Klebsiella pneumoniae is increasingly being implicated in invasive infections worldwide with high mortalities. forty-two multidrug resistant (MDR) K. pneumoniae isolates were collected over a 4-month period. Antimicrobial susceptibility was determined using Microscan. The evolutionary epidemiology, resistome, virulome and mobilome of the isolates were characterised using whole-genome sequencing and bioinformatics analysis. All isolates contained the bla ctX-M gene, whilst 41/42(97%) contained bla teM , 36/42(86%) contained bla oXA and 35/42(83%) harboured bla SHV genes. other resistance genes found included bla Len , aac(6′)-lb-cr, qnrA, qnrB, qnrS, oqxAB, aad, aph, dfr, sul1, sul2, fosA, and cat genes. fluoroquinolone and colistin resistance-conferring mutations in parc, gyrAB, pmrAB, phopQ and kpnEF were identified. The bla Len gene, rarely described worldwide, was identified in four isolates. The isolates comprised diverse sequence types, the most common being ST152 in 7/42(17%) isolates; clone-specific O and K capsule types were identified. Diverse virulence genes that were not clone-specific were identified in all but one isolate. IncF, IncH and IncI plasmid replicons and two novel integrons were present. the bla CTX-M-15 and bla TEM-1 genes were bracketed by Tn3 transposons, ISEc9, a resolvase and IS91 insertion sequence. There were 20 gene cassettes in 14 different cassette arrays, with the dfrA and aadA gene cassettes being the most frequent. phylogenetic analysis demonstrated that the isolates were evolutionarily associated with strains from both South Africa and abroad. These findings depict the rich resistome, mobilome and virulome repertoire in clinical K. pneumoniae strains, which are mainly transmitted by clonal, multiclonal and horizontal means in South Africa.Antibiotic resistance (ABR) is a global phenomenon widely described in the literature 1,2 , and is associated with treatment failure, as well as increased morbidity and mortality 3-5 . Dissemination of resistance in bacteria, particularly among Enterobacteriaceae, is mainly due to the exchange of ABR genes (ARGs) between and within species, mediated by mobile genetic elements (MGEs) harbouring ARGs 6-8 . MGEs include plasmids, transposons and integrons that are known to transmit ABR in both Gram-positive and Gram-negative bacteria, including cephalosporin-and carbapenem-resistant Enterobacteriaceae that have been classified as critical priority pathogens by the WHO 9 . Integrons that capture cassettes i.e., single gene fragments, usually insert into transposons, enabling their movement between bacteria. Of the eight integron classes described, class 1, 2 and 3 are associated with antimicrobial resistance although class 1 is more frequently described in the literature 6,10-12 .

Inappropriate antibiotic use in normally self-limiting acute respiratory tract infections (RTIs), such as sore throat and the common cold, is a global problem and an important factor for increasing levels of antibiotic resistance. A new group of international experts—the Global Respiratory Infection Partnership (GRIP)—is committed to addressing this issue, with the interface between primary care practitioners and their patients as their core focus. To combat the overuse of antibiotics in the community, and facilitate a change from prescribing empiric antibiotic treatment towards cautious deferment combined with symptomatic relief, there is a need to introduce and enhance evidence-based dialogue between primary care practitioners and their patients. Communication with patients should focus on the de-medicalisation of self-limiting viral infections, which can be achieved via a coherent globally endorsed framework outlining the rationale for appropriate antibiotic use in acute RTIs in the context of antibiotic stewardship and conservancy. The planned framework is intended to be adaptable at a country level to reflect local behaviours, cultures and healthcare systems, and has the potential to serve as a model for change in other therapeutic areas.

The development of antibiotic resistance is a globally recognised human health threat. Overuse of antibiotics is a major contributory factor to the development of resistance. As end users, the public play a role in antibiotic use and the development and spread of resistance. The purpose of the study was to assess the knowledge, attitudes and behaviour of the general population of Namibia accessing care in the private sector regarding antibiotic use. Methodology: A cross-sectional survey based on self-administered questionnaire was distributed to 600 patients through pharmacies in Windhoek, Namibia. The survey was conducted from March to June 2013. Results: A total of 446 completed questionnaires were collected. Eighty percent (80%) of respondents reported to have used antibiotics in the past year mainly for colds and flu symptoms. The majority of respondents obtained antibiotics through a valid doctor's prescription. A prevalence of fifteen percent (15%) of self-medication with antibiotics mainly obtained from pharmacies without a prescription was reported. Eighty percent (80%) of respondents reported completing the antibiotic course. Gaps in population understanding of antibiotics were observed. Sixty-four percent (64%) of the respondents thought that antibiotics were effective against viruses with just less than half revealing that they should take an antibiotic for a cold. Seventy-two percent (72%) of respondents understood that unnecessary use of antibiotics makes them ineffective. Conclusion: Major findings of this study include the sale of antibiotics without a prescription; over prescribing of antibiotics for self-limiting upper respiratory tract infections; and, the presence of gaps in knowledge, attitudes and behaviour of the general population towards antibiotics and their use.