Antibiotic consumption in low-income and middle-income countries
Authors: Raph L Hamers, H Rogier van Doorn
Journal: The Lancet Global Health (2018)

Ann Versporten and colleagues (June, 2018)1Versporten A Zarb P Caniaux I et al.Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey.Lancet Glob Health. 2018; 6: e619-e629Summary Full Text Full Text PDF PubMed Scopus (272) Google Scholar report the findings from the 2015 Global Point Prevalence Survey (Global-PPS)—a simple approach to assess antimicrobial prescribing and resistance in patients in hospitals across regions and countries worldwide. However, their grouping of the data by UN regions and subregions is problematic, because some countries were seriously under-represented, especially some low-income and middle-income countries (LMICs). This under-representation potentially masked important shortcomings and differences between countries within (sub)regions. Estimates for the regions dominated by single countries (ie, western Europe by Belgium, northern Europe by UK, and east and south Asia by Japan) or represented by very few data (eastern Europa, Africa, and Oceania) should instead have been reported at the country or even hospital level. Although the authors acknowledged the misrepresentation in western and northern Europe as a study limitation, they did not comment on the biased samples for some of the other regions, especially those including LMIC. The final conclusions are thus biased for LMICs, where the concerns about rising antibiotic resistance, driven by antibiotic consumption, are most substantial.2Klein EY Van Boeckel TP Martinez EM et al.Global increase and geographic convergence in antibiotic consumption between 2000 and 2015.Proc Natl Acad Sci. 2018; 115: E3463-E3470Crossref PubMed Scopus (1355) Google Scholar, 3Mendes RE Mendoza M Banga Singh KK et al.Regional resistance surveillance program results for 12 Asia-Pacific nations (2011).Antimicrob Agents Chemother. 2013; 57: 5721-5726Crossref PubMed Scopus (68) Google Scholar Southeast Asia comprises a large geographical area with more than half the world's population and substantial variations in economic development. Prescribing practices in LMICs are reportedly poor, and robust antibiotic stewardship programmes are often non-existent. For example, a study4Thu TA Rahman M Coffin S Harun-Or-Rashid M Sakamoto J Hung NV Antibiotic use in Vietnamese hospitals: a multicenter point-prevalence study.Am J Infect Control. 2012; 40: 840-844Summary Full Text Full Text PDF PubMed Scopus (60) Google Scholar of a random sample of hospitals in Vietnam showed that 55% of indications for empirical antibiotic therapy were inappropriate. However, in the Global-PPS, the reported quality indicators for antibiotic prescriptions denoted that those in the region of east and south Asia were in the same range as those reported for western and northern Europe, probably due to the over-representation of high-income countries such as Japan, Singapore, and South Korea. This over-representation is a crucial limitation, because these favourable findings might provide false reassurance to national policy makers, risking complacency. An additional analysis in which high-income countries are contrasted against LMICs would have been useful. Nonetheless, the limited and patchy data from LMICs in the survey make it difficult to draw any firm conclusions about the quantity and quality of antimicrobial prescribing in these settings. Antibiotic consumption and resistance in LMICs are rising substantially because of rapid economic and population growth coupled with the high burden of infectious diseases.2Klein EY Van Boeckel TP Martinez EM et al.Global increase and geographic convergence in antibiotic consumption between 2000 and 2015.Proc Natl Acad Sci. 2018; 115: E3463-E3470Crossref PubMed Scopus (1355) Google Scholar We call for the further implementation of global initiatives, such as Global-PPS, endorsed by international agencies and governments, to systematically collect granular and representative data to inform policies around optimising antibiotic prescribing and minimising antibiotic resistance. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on June 29, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on June 29, 2018 We declare no competing interests. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence surveyThe Global-PPS showed that worldwide surveillance can be accomplished with voluntary participation. It provided quantifiable measures to assess and compare the quantity and quality of antibiotic prescribing and resistance in hospital patients worldwide. These data will help to improve the quality of antibiotic prescribing through education and practice changes, particularly in low-income and middle-income countries that have no tools to monitor antibiotic prescribing in hospitals. Full-Text PDF Open AccessCorrection to Lancet Glob Health 2018; 6: e732Hamers RL, van Doorn HR. Antibiotic consumption in low-income and middle-income countries. Lancet Glob Health 2018; 6: e732—In this Correspondence, the first affiliation address for the author Raph Hamers should read "Eijkman-Oxford Clinical Research Unit". This correction has been made as of June 29, 2018. Full-Text PDF Open Access