Encouraging AWaRe-ness and discouraging inappropriate antibiotic use—the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool

Sharland, Mike; Gandra, Sumanth; Huttner, Benedikt; Moja, Lorenzo; Pulcini, Céline; Zeng, Mei; Mendelson, Marc; Cappello, Bernadette; Cooke, Graham; Magrini, Nicola; Aziz, Zeba; Cavalli, Franco; Vries, Elisabeth G.E. de; Genazzani, Armando A.; Imi, Monica; Kearns, Gregory L.; Kokwaro, Gilbert; Prutsky, Gabriela; Sarrafzadegan, Nizal; Ranganathan, Shalini Sri; Suleman, Fátima; Yoongthong, Worasuda; Harbarth, Stéphan Juergen; Loeb, Mark; Mertz, Dominik; Tacconelli, Evelina; Villegas, María Virginia

doi:10.1016/s1473-3099(19)30532-8

Cited by 114 publications

(100 citation statements)

References 7 publications

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“…Depending on the type of data available from individual studies, we calculated either the proportion of patients evaluated in a given health facility or by a certain provider who received antibiotics or the proportion of all drug prescriptions containing any antibiotics, along with their Clopper-Pearson (or exact) 95% confidence intervals (CIs) [20]. The 2019 WHO Access, Watch, and Reserve (AWaRe) framework was used to classify antibiotics according to their potential for selecting resistance [21]. Access-group antibiotics are first-line and narrowspectrum agents such as penicillin, amoxicillin, and trimethoprim-sulfamethoxazole.…”

Section: Discussionmentioning

confidence: 99%

“…The classification underlines that, where appropriate, narrow-spectrum antibiotics included in the Access group should be preferred over broad-spectrum antibiotics from Watch and Reserve groups in order to limit the selection and spread of antibiotic resistance. Accordingly, WHO recommends that Access-group antibiotics should constitute at least 60% of overall antibiotic use [21]. Only 16 of the 48 studies identified through our systematic review reported detailed information on individual antibiotic drugs, and all but 3 had at least 60% of antibiotics being from the Access group [21].…”

Section: Plos Medicinementioning

confidence: 98%

“…To promote the optimal use of antibiotics and assist antibiotic stewardship efforts, WHO introduced the AWaRe classification in 2017 [21]. The classification underlines that, where appropriate, narrow-spectrum antibiotics included in the Access group should be preferred over broad-spectrum antibiotics from Watch and Reserve groups in order to limit the selection and spread of antibiotic resistance.…”

Section: Plos Medicinementioning

confidence: 99%

“…Accordingly, WHO recommends that Access-group antibiotics should constitute at least 60% of overall antibiotic use [21]. Only 16 of the 48 studies identified through our systematic review reported detailed information on individual antibiotic drugs, and all but 3 had at least 60% of antibiotics being from the Access group [21]. Three studies with a high proportion of Watch-group antibiotics were from Mexico, China, and Pakistan; however, we cannot generalize these estimates to overall antibiotic consumption in these countries based on only 1 study in each country.…”

Section: Plos Medicinementioning

confidence: 99%

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Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

et al. 2020

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Background The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low-and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate. Methods and findings We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled PLOS MEDICINE

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Section: Discussionmentioning

confidence: 99%

Section: Plos Medicinementioning

confidence: 98%

Section: Plos Medicinementioning

confidence: 99%

Section: Plos Medicinementioning

confidence: 99%

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Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

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“…Antibacterial agents were further classified using both the ATC (Anatomical–Therapeutic–Chemical) Index and the WHO Access–Watch–Reserve (AWaRe) framework. 16 17 Fixed-dose combinations (FDCs) of antibiotics (eg, ciprofloxacin/ornidazole) were classified as ‘discouraged’ antibiotics as per WHO recommendations.…”

Section: Methodsmentioning

confidence: 99%

Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya

et al. 2020

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IntroductionDetermining whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions. In low-income and middle-income countries (LMICs), where misdiagnoses are frequent, this is challenging. Additionally, such details are often unavailable for prescription audits. Recent studies using standardised patients (SPs) offer a unique opportunity to generate unbiased prevalence estimates of antibiotic overuse, as the research design involves patients with predefined conditions.MethodsSecondary analyses of data from nine SP studies were performed to estimate the proportion of SP–provider interactions resulting in inappropriate antibiotic prescribing across primary care settings in three LMICs (China, India and Kenya). In all studies, SPs portrayed conditions for which antibiotics are unnecessary (watery diarrhoea, presumptive tuberculosis (TB), angina and asthma). We conducted descriptive analyses reporting overall prevalence of antibiotic overprescribing by healthcare sector, location, provider qualification and case. The WHO Access–Watch–Reserve framework was used to categorise antibiotics based on their potential for selecting resistance. As richer data were available from India, we examined factors associated with antibiotic overuse in that country through hierarchical Poisson models.ResultsAcross health facilities, antibiotics were given inappropriately in 2392/4798 (49.9%, 95% CI 40.8% to 54.5%) interactions in India, 83/166 (50.0%, 95% CI 42.2% to 57.8%) in Kenya and 259/899 (28.8%, 95% CI 17.8% to 50.8%) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (adjusted prevalence ratio (aPR) 0.70, 95% CI 0.52 to 0.96) and higher for qualified versus non-qualified providers (aPR 1.55, 95% CI 1.42 to 1.70), and for presumptive TB cases versus other conditions (aPR 1.19, 95% CI 1.07 to 1.33). Access antibiotics were predominantly used in Kenya (85%), but Watch antibiotics (mainly quinolones and cephalosporins) were highly prescribed in India (47.6%) and China (32.9%).ConclusionGood-quality SP data indicate alarmingly high levels of antibiotic overprescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.

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Association of Exposure to High-risk Antibiotics in Acute Care Hospitals With Multidrug-Resistant Organism Burden in Nursing Homes

et al. 2022

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IMPORTANCELittle is known about the contribution of hospital antibiotic prescribing to multidrugresistant organism (MDRO) burden in nursing homes (NHs). OBJECTIVESTo characterize antibiotic exposures across the NH patient's health care continuum (preceding health care exposure and NH stay) and to investigate whether recent antibiotic exposure is associated with MDRO colonization and room environment contamination at NH study enrollment. DESIGN, SETTING, AND PARTICIPANTS This is a secondary analysis of a prospective cohort study (conducted from 2013-2016) that enrolled NH patients and followed them up for as long as 6 months. The study was conducted in 6 NHs in Michigan among NH patients who were enrolled within 14 days of admission. Clinical metadata abstraction, multi-anatomical site screening, and room environment surveillance for MDROs were conducted at each study visit. Data were analyzed between May 2019 and November 2021. EXPOSURES Antibiotic data were abstracted from NH electronic medical records by trained research staff and characterized by class, route, indication, location of therapy initiation, risk for Clostridioides difficile infection (C diffogenic agents), and 2019 World Health Organization Access, Watch, and Reserve (AWARE) antibiotic stewardship framework categories. MAIN OUTCOMES AND MEASURESThe primary outcomes were MDRO colonization and MDRO room environment contamination at NH study enrollment, measured using standard microbiology methods. Multivariable logistic regression was used to identify whether antibiotic exposure within 60 days was associated with MDRO burden at NH study enrollment. Additionally, antibiotic exposure data were characterized using descriptive statistics. RESULTSA total of 642 patients were included (mean [SD] age, 74.7 [12.2] years; 369 [57.5%] women; 402 [62.6%] White; median [IQR] NH days to enrollment, 6.0 [3.0-7.0]). Of these, 422 (65.7%) received 1191 antibiotic exposures: 368 (57.3%) received 971 hospital-associated prescriptions, and 119 (18.5%) received 198 NH-associated prescriptions. Overall, 283 patients (44.1%) received at least 1 C diffogenic agent, and 322 (50.2%) received at least 1 high-risk WHO AWARE antibiotic (watch or reserve agent). More than half of NH patients (364 [56.7%]) and room environments (437 [68.1%]) had MDRO-positive results at enrollment. In multivariable analysis, recent antibiotic exposure was positively associated with baseline MDRO colonization (odds ratio [

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Encouraging AWaRe-ness and discouraging inappropriate antibiotic use—the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool

Cited by 114 publications

References 7 publications

Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

Antibiotic overuse in the primary health care setting: a secondary data analysis of standardised patient studies from India, China and Kenya

Association of Exposure to High-risk Antibiotics in Acute Care Hospitals With Multidrug-Resistant Organism Burden in Nursing Homes

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