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, multifaceted 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 5 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 nonsystematic scoping literature review and a key informant interview. Participants (96%, N = 54) 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 (81%, 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 reliable, affordable, quality rapid diagnostics, and AST kits. Compulsory continuing education emphasizing the use of AST to guide prescribing and patients' awareness programs could help avoid irrational use.

Figure 1.

Summary of select results from a survey assessing antimicrobial resistance, use, and stewardship in healthcare workers (HCW) and pharmacists in Yemen. (A, B, and C) Antimicrobial resistance (AMR): The majority of respondents (96%) thought AMR to be a problem in Yemen (A) but were more split in terms of if IDPs had the greater risk (B). Among solution options to tackling AMR, both respondents ranked the use of increased antimicrobial sensitivity testing the lowest and ranked increased training of pharmacists and physicians (HCW) the highest. (D, E, and F) Antimicrobial use: There were several overlapping reasons for choice of empirical treatment or empirical antibiotic selection both in prescribing physicians and dispensing pharmacists with cost (price patient can afford), signs and symptoms (including “identification of bacterial infection”) of patient and availability with a preference for broad-spectrum antibiotics. In terms of antibacterial agents, amoxicillin (including amoxicillin/clavulanic acid) was the most commonly prescribed or dispensed followed by ciprofloxacin. (G and H) Antimicrobial stewardship: Among select criteria, physicians reported to be under pressure to prescribe broad-spectrum antibiotics, and even where there was the possibility to perform antimicrobial sensitivity tests, these were not used to guide prescribing in the majority of cases. The reason for this was largely cost (H).

Figure 1.

Summary of select results from a survey assessing antimicrobial resistance, use, and stewardship in healthcare workers (HCW) and pharmacists in Yemen. (A, B, and C) Antimicrobial resistance (AMR): The majority of respondents (96%) thought AMR to be a problem in Yemen (A) but were more split in terms of if IDPs had the greater risk (B). Among solution options to tackling AMR, both respondents ranked the use of increased antimicrobial sensitivity testing the lowest and ranked increased training of pharmacists and physicians (HCW) the highest. (D, E, and F) Antimicrobial use: There were several overlapping reasons for choice of empirical treatment or empirical antibiotic selection both in prescribing physicians and dispensing pharmacists with cost (price patient can afford), signs and symptoms (including “identification of bacterial infection”) of patient and availability with a preference for broad-spectrum antibiotics. In terms of antibacterial agents, amoxicillin (including amoxicillin/clavulanic acid) was the most commonly prescribed or dispensed followed by ciprofloxacin. (G and H) Antimicrobial stewardship: Among select criteria, physicians reported to be under pressure to prescribe broad-spectrum antibiotics, and even where there was the possibility to perform antimicrobial sensitivity tests, these were not used to guide prescribing in the majority of cases. The reason for this was largely cost (H).