• Patients and the general public;
• All groups of prescribers and dispensers;
• Hospital managers and health care professionals;
• Users of antimicrobials in agriculture;
• National governments;
• Pharmaceutical, diagnostic and “surveillance” industries;
• International agencies, NGOs, professional societies.

All of these groups need to be engaged developing and implementing a resistance containment action plan.

Who contributes to misuse of antimicrobials?

Antimicrobial resistance is a natural consequence of antimicrobial use, which kills the sensitive organisms leaving the resistant ones to survive and multiply (section of resistance).overuse and misuse of antimicrobials do not help patients, they merely add to the problem of resistance and waste resources.

Prescribers 

There is a wide variation in the prescribing of antimicrobials and other drugs. In primary health care 30-60% of patients receive antibiotics perhaps twice what is clinically needed misuse is common and may take the form of incorrect dosage or inappropriate prescription. In Tanzania, 91%of antibiotics were prescribed with incorrect dosage and in India over 90% of prescriptions did not have dose specifications. Inappropriate prescription of antibiotics has been reported to occur for viral respiratory tract infections in 97% of cases in China and 81% of cases in Ghana. In propriety prescription of antibiotics for childhood diarrhoea commonly occurs, as reported in Pakistan. Here private general practitioners were found to prescribe significantly more antibiotics (41%of pediatric cases) than pediatricians (36% of pediatric cases) in the public hospitals. Hospital prescribers are often the role models for primary health care prescribers. Unfortunately, antimicrobials are misused just as much in hospitals as in primary health care. Why do providers prescribe antimicrobials too often and unnecessarily? There are many causes including:

• Lack o knowledge or information, leading to uncertainty about the diagnosis and the most appropriate drug(s), and fear of poor patient outcome
• Patient demand 
• Earning a living through selling medicines

Many prescribers in developing countries have little access to good quality information about diagnosis and drugs. Standard treatment guidelines are often unavailable and health workers are often unsupported and unsupervised. Frequently, drug company representatives are doctors’ only source of information. Such information may well be biased, particularly with regard to how effective their company’s drug is compared to rival drug of the same class. Uncertainty of the diagnosis, fear of poor patient outcome, (and in industries countries, fear of litigation), lead to over prescription for antibiotics. In many developing countries, the diagnostic process is often inadequate to arrive at a diagnosis with any certainty.

To be continued next week

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