Assessing Antimicrobial Resistance, Utilization, and Stewardship in Yemen: An Exploratory Mixed-Methods Study

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  • 1 Institute for Health System Innovation & Policy, Boston University, Boston, Massachusetts;
  • | 2 Department of Biomedical Engineering, College of Engineering, Boston University, Boston, Massachusetts;
  • | 3 Public Health Network, Aden, Yemen;
  • | 4 Yemeni Pharmacovigilance Center, Aden, Yemen;
  • | 5 Faculty of Medicine and Health Sciences, University of Aden, Yemen

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 = 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 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.

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Author Notes

Address correspondence to E. Sam F. Orubu, Institute for Health System Innovation & Policy, Boston University, 44 Cummington Mall, Boston, MA 02215. E-mail: sforubu@bu.edu

Financial support: We confirm no financial support was received for this project.

Disclosure: Ethical clearance (REC-81-2020) was obtained from the Research Ethics Committee of the University of Aden – in line with similar studies – before questionnaires were distributed.24

Authors’ addresses: E. Sam F. Orubu, Institute for Health System Innovation & Policy, Boston University, Boston, MA, E-mail: sforubu@bu.edu. Najwa Al-Dheeb and Rashad Sheikh Public Health Network, Aden, Yemen, E-mails: nyaldheeb@gmail.com and rashadinwork@gmail.com. Carly Ching, Department of Biomedical Engineering, College of Engineering, Boston University, Boston, MA, E-mail: chingc@bu.edu. Sima Bu Jawdeh, Jessica Anderson, and Muhammad H. Zaman, Department of Biomedical Engineering, College of Engineering, Boston University, Boston, MA, E-mails: simabujawdeh@gmail.com, andersoj@bu.edu, and zaman@bu.edu. Fadhel Hariri, Yemeni Pharmacovigilance Center, Aden, Yemen, E-mail: ypvcsbd59@gmail.com. Huda Basaleem, Faculty of Medicine and Health Sciences, University of Aden, Yemen, E-mail: hudabasaleem92@yahoo.com.

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