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Objective: Informal healthcare providers (IHCPs) play a big role in health systems in low-and middle-income countries (LMICs) and are often the first point of contact for healthcare in rural and underserved areas where formal healthcare infrastructure is insufficient or absent. This study was performed to systematically review the literature on interventions targeting IHCPs in improving the delivery of healthcare services in LMICs., Methods: PubMed, Embase, and Cochrane CENTRAL databases were searched for studies that assessed any type of intervention among IHCPs to improve the delivery of healthcare services in any LMIC. Outcomes included changes in knowledge, attitude, and reported practice of appropriate case diagnosis and management; improved referral services; effective contraceptive use; and medication appropriateness (PROSPERO ID: CRD42024521739)., Results: A total of 7,255 studies were screened and 38 were included. Most of the studies were conducted in Africa and Asia. The IHCPs who were trained included medicine sellers, community health workers/traditional healers, and traditional birth attendants. The main intervention used was educational programs in the form of training. The other interventions were health services, policy and guidelines, and community-based interventions. Most of the interventions were multi-faceted. The disease/service areas targeted were mainly maternal and child health, sexually transmitted diseases, common infectious diseases, medicine use/dispensing practices, and contraception. The outcomes that showed improvements were knowledge, attitude, and reported practice; diagnosis and case management; improved referral services; contraceptive uses; and medication appropriateness. Around one-fourth of the studies reported negative results. The certainty of evidence generated (GRADE criteria) was very low., Conclusion: Some multifaceted interventions coupled with training showed improvements in the delivery of healthcare services by IHCPs. However, the improvements were inconsistent. Hence, it is unclear to identify any context-specific optimum intervention to improve the delivery of healthcare services by IHCPs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Das, Khare, Eriksen, Diwan, Stålsby Lundborg and Skender.)

Background: Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs., Methods: Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days., Results: Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan., Conclusions: This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings., (© 2024. The Author(s).)

Introduction: Both high- and low-income countries reported increased antibiotic consumption among COVID-19 patients during the first months of the pandemic. To date, however, no studies have examined changes in antibiotic consumption during the COVID-19 pandemic within humanitarian emergency contexts., Method: Data was collected by Médecins Sans Frontières (MSF) for the years 2018-2021 across the following humanitarian settings: Afghanistan (Lashkar Gah), Bangladesh (Kutupalong), the Democratic Republic of Congo (Mweso and Baraka), and South Sudan (Bentiu). Inpatient and outpatient antibiotic consumption was calculated as Daily Defined Dose (DDD) per 1000 inhabitants per day, as per the World Health Organisation's (WHO) Collaborating Centre for Drug Statistics Methodology. Interrupted time series (ITS) analysis, using an autoregressive integrated moving average (ARIMA) model was used to analyse retrospective monthly antibiotic consumption. The impact of COVID-19 pandemic was evaluated as total antibiotic consumption and according to WHO Access, Watch, Reserve (AWaRe) group classifications within each humanitarian setting., Results: The COVID-19 pandemic had no statistically significant impact on total antibiotic consumption in South Sudan (Bentiu) and Bangladesh (Kutupalong). Similarly, the pandemic had no impact on total antibiotic consumption in DR Congo (Baraka), despite an initial 0.27% (estimate=.274, p-value=0.006) increase in March 2020 driven by Access group antibiotics. Meanwhile, total antibiotic consumption in DR Congo (Mweso) and Afghanistan (Lashkar Gah) declined by 0.74% (estimate = -.744, p = 0.003) and 0.26% (estimate = -.26, p < 0.001), respectively with the COVID-19 pandemic., Conclusion: Further studies are required to investigate what may have contributed to these results., (© 2024 The Authors.)

Background: Inappropriate antibiotic use contributes to the global rise of antibiotic resistance, prominently in low- and middle-income countries, including India. Despite the considerable risk of surgical site infections, there is a lack of antibiotic prescribing guidelines and long-term studies about antibiotic prescribing in surgery departments in India. Therefore, this study aimed to analyse 10 years' antibiotic prescribing trends at surgery departments in two tertiary-care hospitals in Central India., Methods: Data was prospectively collected from 2008 to 2017 for surgery inpatients in the teaching (TH-15,016) and the non-teaching hospital (NTH-14,499). Antibiotics were classified based on the World Health Organization (WHO) Access Watch Reserve system and analysed against the diagnoses and adherence to the National List of Essential Medicines India (NLEMI) and the WHO Model List of Essential Medicines (WHOMLEM). Total antibiotic use was calculated by DDD/1000 patient days. Time trends of antibiotic prescribing were analysed by polynomial and linear regressions., Results: The most common indications for surgery were inguinal hernia (TH-12%) and calculus of the kidney and ureter (NTH-13%). The most prescribed antibiotics were fluoroquinolones (TH-20%) and 3 rd generation cephalosporins (NTH-41%), and as antibiotic prophylaxis, norfloxacin (TH-19%) and ceftriaxone (NTH-24%). Access antibiotics were mostly prescribed (57%) in the TH and Watch antibiotics (66%) in the NTH. Culture and susceptibility tests were seldom done (TH-2%; NTH-1%). Adherence to the NLEMI (TH-80%; NTH-69%) was higher than adherence to the WHOMLEM (TH-77%; NTH-66%). Mean DDD/1000 patient days was two times higher in the NTH than in the TH (185 vs 90). Overall antibiotic prescribing significantly increased in the TH (β 1 =13.7) until 2012, and in the NTH (β 2 =0.96) until 2014, and after that decreased (TH, β 2 = -0.01; NTH, β 3 = -0.0005). The proportion of Watch antibiotic use significantly increased in both hospitals (TH, β=0.16; NTH, β=0.96)., Conclusion: Total antibiotic use decreased in the last three (NTH) and five years (TH), whereas consumption of Watch antibiotics increased over 10 years in both hospitals. The choice of perioperative antibiotic prophylaxis was often inappropriate and antibiotic prescribing was mostly empirical. The results of this study confirmed the need for antibiotic prescribing guidelines and implementation of antimicrobial stewardship programs., (© 2024. The Author(s).)

Tuberculosis (TB) and poverty are inextricably linked. Catastrophic costs of TB illness drive TB-affected households into worsening impoverishment and hamper treatment success. The WHO's End TB Strategy recommends social protection for TB-affected households to mitigate financial shock and improve TB outcomes. This scoping review maps the landscape of social protection interventions for people with TB and their households in low- and middle-income countries with high TB burden. A systematic search of Medline, Embase, PubMed, and Web of Science for relevant articles was performed, supplemented with a gray literature search of key databases. Articles were included if they described social protection available to people with TB and TB-affected households in a low- or middle-income country. Data were synthesized in tabular form, and descriptive narrative outlined the successes and challenges of the social protection interventions identified. The search identified 33,360 articles. After abstract screening, 74 articles underwent full text screening, and 49 were included in the final analysis. Forty-three types of social protection were identified, of which 24 were TB specific (i.e., only people with TB were eligible). Varying definitions were used to describe similar social protection interventions, which limited cross-study comparison. Intervention successes included acceptability and increased financial autonomy among recipients. Challenges included delays in intervention delivery and unexpected additional bank transfer fees. A wide range of acceptable social protection interventions are available, with cash transfer schemes predominating. Use of standardized definitions of social protection interventions would facilitate consolidation of evidence and enhance design and implementation in future.

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6−38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32−5.30), previous hospitalization (OR 2.15; 95%CI 1.25−3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51−7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83−5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72−8.22), which is unconfirmed in the literature so far.

Background: Frequent antibiotic prescribing in departments with high infection risk like orthopedics prominently contributes to the global increase of antibiotic resistance. However, few studies present antibiotic prescribing patterns and trends among orthopedic inpatients., Aim: To compare and present the patterns and trends of antibiotic prescription over 10 years for orthopedic inpatients in a teaching (TH) and a non-teaching hospital (NTH) in Central India., Methods: Data from orthopedic inpatients (TH-6446; NTH-4397) were collected using a prospective cross-sectional study design. Patterns were compared based on the indications and corresponding antibiotic treatments, mean Defined Daily Doses (DDD)/1000 patient-days, adherence to the National List of Essential Medicines India (NLEMI) and the World Health Organization Model List of Essential Medicines (WHOMLEM). Antibiotic prescriptions were analyzed separately for the operated and the non-operated inpatients. Linear regression was used to analyze the time trends of antibiotic prescribing; in total through DDD/1000 patient-days and by antibiotic groups., Results: Third generation cephalosporins were the most prescribed antibiotic class (TH-39%; NTH-65%) and fractures were the most common indications (TH-48%; NTH-48%). Majority of the operated inpatients (TH-99%; NTH-97%) were prescribed pre-operative prophylactic antibiotics. The non-operated inpatients were also prescribed antibiotics (TH-40%; NTH-75%), although few of them had infectious diagnoses (TH-8%; NTH-14%). Adherence to the NLEMI was lower (TH-31%; NTH-34%) than adherence to the WHOMLEM (TH-65%; NTH-62%) in both hospitals. Mean DDD/1000 patient-days was 16 times higher in the TH (2658) compared to the NTH (162). Total antibiotic prescribing increased over 10 years (TH-β = 3.23; NTH-β = 1.02)., Conclusion: Substantial number of inpatients were prescribed antibiotics without clear infectious indications. Adherence to the NLEMI and the WHOMLEM was low in both hospitals. Antibiotic use increased in both hospitals over 10 years and was higher in the TH than in the NTH. The need for developing and implementing local antibiotic prescribing guidelines is emphasized., Competing Interests: The authors have declared that no competing interests exist.