The Resistance Patterns in E. coli Isolates among Apparently Healthy Adults and Local Drivers of Antimicrobial Resistance: A Mixed-Methods Study in a Suburban Area of Nepal
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Study Setting
2.3. Study Population and Sampling
2.4. Study Variables, Sources and Data Collection
2.5. Data Analysis
3. Results
3.1. Quantitative Findings
3.2. Qualitative Findings
3.2.1. Issues Related to Community and Individual Behavior
- Lack of awareness on antimicrobials and AMR among community members
Yes, the doctor prescribes antimicrobials. But I think we can discontinue the medicines once the symptoms subside. I don’t feel like continuing the medicine once I start feeling better. P(3)
The main problem is that the patient is not aware that the full dose of the medicine needs to be completed, when symptoms subside after having 2-3 tablets, they throw or stop taking the remaining medicine. They are not aware of the consequences. I feel public awareness is the most important thing needed. (WC_6)
- 2.
- Self-medication practices
What people usually do is, if they have symptoms similar to previously cured illness, they visit the drugstore directly and ask for the same old medicine, which increases the frequency of using the medicine even though it is not required. (FGD2-P13)
We ask if the doctor has written any prescription or have they been taking the antimicrobials regularly. Most of them practice self-medication and some of them are health care workers too. (P001)
- 3.
- Financial constraints
A culture test determines whether the antimicrobial will work for the particular disease or not, but it is very expensive. A general culture will cost you more than 1200 and the report will be ready only after 2-3 days. In such a case, it becomes difficult for an individual to afford the cost for laboratory investigations. (H001)
Some of these antimicrobials are a little expensive, they can’t afford a complete course of medicine, and they can’t take it all at once. One course can cost him up to Rs1500-2,000. He may not have the money to complete this course, so he takes one half course of antimicrobials. (P002)
- 4.
- Overuse of antimicrobials/Incomplete course of antimicrobials
People visit medical/pharmacy even if they have a simple fever and the pharmacist gives antimicrobials to them without proper check-ups and urine/fecal examinations. They are overusing antimicrobials. They think if they visit the hospital instead, it will cost a lot for all examinations. That’s why antimicrobials are being overused. I guess there is no single person in the village who has not taken antimicrobials. (WC_1)
3.2.2. Factors Related to Laws and Regulations
- Lack of guidelines to monitor the selling of antimicrobials
The medicine shops recommend them to take some strong medicine that is why people here use lots of antimicrobials......There is a system prevalent that even for a simple type of disease, people go to medicinal shops in Banepa and then take strong antimicrobials..........there is no monitoring or surveillance because they take medicine from medicine shops without tests and prescriptions, there is such a system in Nepal that is why people openly use antimicrobials. (H002)
- 2.
- Unregistered pharmacies/shops
In terms of resistance, unregistered pharmacies should be taken under control….I have seen grocery stores in Dhulikhel selling paracetamols, syrups and amoxicillin. I was surprised to see that. Such practices should not be allowed at any cost. (H003)
Yes. It is not ‘might be selling’, such unlicensed persons are selling antimicrobials and other drugs. We have found it once or twice. (WC-6)
- 3.
- Irrational sales and use of antimicrobials
If we go to the pharmacy for the common cold, they will recommend a lot of antimicrobials. It is said that patients with cold do not have to take any medicine, as they will recover in seven or ten days without medicine. Nowadays, the pharmacy will directly prescribe you strong medicine like azithromycin. When using such drugs, we should think twice. They lie that we sell drugs on prescription if we go for inspection. This is challenging because the truth is hidden. And another challenge is that consumers these days are very clever because people themselves come to buy Amoxicillin and ranitidine directly without a prescription. Grocery stores also sell antimicrobials. Because of these things we are facing a lot of challenges. (PM002)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Characteristics | Total | E. coli | Unadjusted | p Value | |||
---|---|---|---|---|---|---|---|
N | (%) ^ | n | (%) $ | PR | (95% CI) | ||
Total | 424 | (100) | 364 | (85.9) | |||
Age (in years) | |||||||
18–29 | 56 | (13.2) | 48 | (85.7) | 1.0 | (0.9–1.2) | 0.611 |
30–44 | 151 | (35.6) | 131 | (86.8) | 1.1 | (0.9–1.2) | 0.400 |
45–59 | 131 | (30.9) | 114 | (87.0) | 1.1 | (0.9–1.2) | 0.380 |
≥60 | 86 | (20.3) | 71 | (82.6) | 1 | ||
Gender | |||||||
Male | 133 | (31.4) | 112 | (84.2) | 1 | ||
Female | 291 | (68.6) | 252 | (86.6) | 1.0 | (0.9–1.1) | 0.526 |
Marital status | |||||||
Never married | 19 | (4.5) | 14 | (73.7) | 1 | ||
Currently married/cohabitating | 366 | (86.3) | 317 | (86.6) | 1.2 | (0.9–1.5) | 0.244 |
separated/divorced/widow | 36 | (8.5) | 30 | (83.3) | 1.1 | (0.8–1.5) | 0.431 |
Refused to answer | 3 | (0.7) | 3 | (100.0) | 1.4 | (1.0–1.8) | 0.026 |
Ethnicity/Caste | |||||||
Brahmin | 175 | (41.3) | 143 | (81.7) | 1 | ||
Chhetri | 53 | (12.5) | 44 | (83.0) | 1.0 | (0.9–1.2) | 0.825 |
Janajati | 176 | (41.5) | 159 | (90.3) | 1.1 | (1.0–1.2) | 0.021 |
Dalit | 20 | (4.7) | 18 | (90.0) | 1.1 | (0.9–1.3) | 0.243 |
Religion | |||||||
Hindu | 337 | (79.5) | 283 | (84.0) | 1 | ||
Buddhist | 73 | (17.2) | 68 | (93.2) | 1.1 | (1.0–1.2) | 0.009 |
Others # | 14 | (3.3) | 13 | (92.9) | 1.1 | (0.9–1.3) | 0.197 |
Education status | |||||||
No formal education | 238 | (56.1) | 205 | (86.1) | 10 | (0.9–1.2) | 0.755 |
Primary school 1 | 75 | (17.7) | 65 | (86.7) | 1.0 | (0.9–1.2) | 0.724 |
Secondary school 2 | 58 | (13.7) | 49 | (84.5) | 1 | ||
Higher secondary and above 3 | 53 | (12.5) | 45 | (85.0) | 1.0 | (0.9–1.2) | 0.951 |
Occupation status | |||||||
Agriculture/livestock | 302 | (75.5) | 263 | (87.1) | 1.2 | (0.9–1.7) | 0.141 |
Business | 45 | (10.6) | 39 | (86.7) | 1.2 | (0.9–1.7) | 0.176 |
Employed * | 20 | (4.7) | 14 | (70.0) | 1 | ||
Unemployed | 57 | (13.4) | 48 | (84.2) | 1.2 | (0.9–1.6) | 0.240 |
Ward | |||||||
Ward-2 | 309 | (72.9) | 266 | (86.9) | 1.0 | (0.9–1.1) | 0.823 |
Ward-6 | 115 | (36.6) | 98 | (85.2) | 1 | ||
Access to improved sanitation | |||||||
Yes | 422 | (99.5) | 362 | (85.8) | 1 | ||
No | 2 | (0.5) | 2 | (100.0) | 1.2 | (1.1–1.2) | <0.001 |
Presence of Livestock close to House | |||||||
Yes | 329 | (77.6) | 287 | (87.2) | 1.1 | (1.0–1.2) | 0.173 |
No | 95 | (22.4) | 77 | (81.1) | 1 | ||
Consume water from open sources | |||||||
Yes | 3 | (0.7) | 3 | (100.0) | 1.2 | (1.1–1.2) | <0.001 |
No | 421 | (99.3) | 361 | (85.7) |
Antimicrobial | Sensitive | Indeterminate | Resistant | |||
---|---|---|---|---|---|---|
N | (%) | N | (%) | N | (%) | |
Cefotaxime | 294 | (79.9) | 17 | (4.6) | 57 | (15.5) |
Ciprofloxacin | 277 | (75.3) | 52 | (14.1) | 39 | (10.6) |
Tetracycline | 289 | (78.5) | 3 | (0.8) | 76 | (20.7) |
Ampicillin | 116 | (31.5) | 106 | (28.8) | 149 | (40.5) |
Chloramphenicol | 319 | (86.7) | 36 | (9.8) | 13 | (3.5) |
Gentamicin | 366 | (99.5) | 0 | (0.0) | 2 | (0.5) |
Cotrimoxazole | 313 | (85.1) | 1 | (0.3) | 54 | (14.7) |
Characteristics | Total | MDR | Unadjusted | p Value | ||
---|---|---|---|---|---|---|
N | (%) $ | PR | (95% CI) | |||
Total | 364 | 51 | (14.0) | |||
Age (in years) | ||||||
18–29 | 48 | 7 | (14.6) | 1.5 | (0.6–4.0) | 0.435 |
30–44 | 131 | 20 | (15.3) | 1.5 | (0.7–3.5) | 0.291 |
45–59 | 114 | 17 | (14.9) | 1.5 | (0.7–3.5) | 0.328 |
≥60 | 71 | 7 | (9.9) | 1 | ||
Gender | ||||||
Male | 112 | 17 | (15.2) | 1.1 | (0.7–1.9) | 0.668 |
Female | 252 | 34 | (13.5) | 1 | ||
Marital status | ||||||
Never married | 14 | 1 | (7.1) | 1 | ||
Currently married/Cohabitating | 317 | 46 | (14.5) | 2.0 | (0.3–13.7) | 0.467 |
Separated/divorced/Widow | 30 | 4 | (13.3) | 1.9 | (0.2–15.2) | 0.560 |
Refused to answer | 3 | 0 | (0.0) | - | ||
Ethnicity | ||||||
Brahmin | 143 | 16 | (11.2) | 1 | ||
Chhetri | 44 | 7 | (15.9) | 1.4 | (0.6–3.2) | 0.402 |
Janajati | 159 | 24 | (15.1) | 1.4 | (0.7–2.4) | 0.321 |
Dalit | 18 | 4 | (22.2) | 2.0 | (0.7–5.2) | 0.170 |
Religion | ||||||
Hindu | 283 | 42 | (14.8) | 1.3 | (0.6–2.6) | 0.521 |
Buddhist | 68 | 8 | (11.8) | 1 | ||
Others # | 13 | 1 | (7.7) | 0.7 | (0.1–5.0) | 0.676 |
Education status | ||||||
No formal education | 205 | 29 | (14.1) | 1.4 | (0.6–3.4) | 0.476 |
Primary school 1 | 65 | 11 | (16.9) | 1.7 | (0.6–4.5) | 0.317 |
Secondary school 2 | 49 | 5 | (10.2) | 1 | ||
Higher secondary and above 3 | 45 | 6 | (13.3) | 1.3 | (0.4–4.0) | 0.639 |
Occupation status | ||||||
Agriculture/livestock | 263 | 34 | (12.9) | 1 | ||
Business | 39 | 6 | (15.4) | 1.2 | (0.5–2.7) | 0.670 |
Employed * | 14 | 3 | (21.4) | 1.7 | (0.6–4.7) | 0.347 |
Unemployed | 48 | 8 | (16.7) | 1.3 | (0.6–2.6) | 0.481 |
Ward | ||||||
Ward-2 | 266 | 33 | (12.4) | 1 | ||
Ward-6 | 98 | 18 | (18.4) | 1.5 | (0.9–2.5) | 0.144 |
Access to sanitary latrine | ||||||
Yes | 362 | 50 | (13.8) | 1 | ||
No | 2 | 1 | (50.0) | 3.6 | (0.9–14.9) | 0.074 |
Presence of livestock close to house | ||||||
Yes | 287 | 36 | (12.5) | 1 | ||
No | 77 | 15 | (19.5) | 1.6 | (0.9–2.7) | 1.115 |
Consume water from open sources | ||||||
Yes | 3 | 1 | (33.3) | 2.4 | (0.5–12.2) | 0.289 |
No | 361 | 50 | (13.8) | 1 |
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Shrestha, A.; Shrestha, R.; Koju, P.; Tamrakar, S.; Rai, A.; Shrestha, P.; Madhup, S.K.; Katuwal, N.; Shrestha, A.; Shrestha, A.; et al. The Resistance Patterns in E. coli Isolates among Apparently Healthy Adults and Local Drivers of Antimicrobial Resistance: A Mixed-Methods Study in a Suburban Area of Nepal. Trop. Med. Infect. Dis. 2022, 7, 133. https://doi.org/10.3390/tropicalmed7070133
Shrestha A, Shrestha R, Koju P, Tamrakar S, Rai A, Shrestha P, Madhup SK, Katuwal N, Shrestha A, Shrestha A, et al. The Resistance Patterns in E. coli Isolates among Apparently Healthy Adults and Local Drivers of Antimicrobial Resistance: A Mixed-Methods Study in a Suburban Area of Nepal. Tropical Medicine and Infectious Disease. 2022; 7(7):133. https://doi.org/10.3390/tropicalmed7070133
Chicago/Turabian StyleShrestha, Abha, Rajeev Shrestha, Pramesh Koju, Sudichhya Tamrakar, Anisha Rai, Priyanka Shrestha, Surendra Kumar Madhup, Nishan Katuwal, Archana Shrestha, Akina Shrestha, and et al. 2022. "The Resistance Patterns in E. coli Isolates among Apparently Healthy Adults and Local Drivers of Antimicrobial Resistance: A Mixed-Methods Study in a Suburban Area of Nepal" Tropical Medicine and Infectious Disease 7, no. 7: 133. https://doi.org/10.3390/tropicalmed7070133