Assessing antimicrobial resistance, utilization and stewardship in Yemen: An exploratory mixed-methods study

Abstract

Antimicrobial resistance (AMR), largely driven by irrational use of antimicrobials, is a global, multi-faceted problem calling for a complete understanding of all contributory factors for effective containment. In conflict settings, war-wounds and malnutrition can combine with existing social determinants to increase demand for antibiotics, compounding irrational use. In this study, we focus on Yemen, a low-income country with active conflict for the last five years, and analyze the current status of awareness and stewardship efforts regarding AMR. We performed a survey of prescribers/physicians and pharmacists to describe perceptions of AMR prevalence, antibiotic use practices and stewardship in Yemen, supported by a non-systematic scoping literature review and a key informant interview. Participants (96%, n=57) reported a perceived high AMR prevalence rate. Prescribers (74%, 20/27) reported pressure to prescribe broad-spectrum antibiotics. In the majority of cases (81%, 22/27), Antimicrobial Sensitivity Tests (AST) were not performed to inform antibiotic choice. The main barrier to AST was cost. Most pharmacists (67%, 18/27) sold antibiotics without prescriptions. Amoxicillin (including amoxicillin-clavulanate) was the most-commonly prescribed (63%, 17/27) or dispensed (82%, 22/27) antibiotic. AST was rated the least important solution to AMR in Yemen. While there was awareness of a high AMR rate, stewardship is poor in Yemen. We note that barriers to the use of AST could be addressed through the deployment of low-cost AST kits. Compulsory continuing education emphasizing the use of AST to guide prescribing and patients’ awareness programs could help avoid irrational use.

COVID-19 and Antimicrobial Resistance: Data from the Greek Electronic System for the Surveillance of Antimicrobial Resistance—WHONET-Greece (January 2018–March 2021)

“…A thorough search into the literature (January 2020–June 2021) revealed many studies trying to address the AMR issue in the pandemic era. The main issues refer to patients with COVID-19 who may receive antimicrobial therapy (a) without a microbiological confirmation of the bacterial co-infection [ 18 , 31 , 32 , 33 , 34 , 35 , 36 ] and (b) often in the absence of a microbiological confirmation of the diagnosis [ 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. Lai et al [ 24 ] recorded the consumption of antibiotics in January–June 2019 vs. January–June 2020 in The National Taiwan University Hospital.…”

A Survey Assessing Antimicrobial Prescribing at United Nations Relief and Works Agency Primary Health Care Centers in Jordan

“…The apparent low prioritization of AST by prescribers is similar to a study conducted in Yemen, although in this Jordan study, a higher proportion of prescribers rated the use of AST to guide rational prescribing as important than in Yemen, suggesting a higher level of awareness. 28 The UNRWA PHC facilities, as noted earlier, do not provide AST services, being functionally outpatient-level facilities. Although there are no institutional AST services, some patients may opt to go to the private sector for AST (the Jordan field patients can access health services from both the public and private sectors).…”

Analyzing Yemen’s health system at the governorate level amid the ongoing conflict: a case of Al Hodeida governorate

“…Supplies and management of essential medicines continue to be a major challenge for the health system in Yemen [ 4 , 22 , 40 – 43 ]. Irrational use and prescription of medicines, including antibiotics, are widely common and evident [ 15 , 44 – 46 ]. Challenges related to warehousing management and logistics of medicines and health supplies are enormous, mainly due to limited capacities in both human resources and infrastructures and weak coordination and harmonization between different health partners.…”