Current Trends of Antibiotic Use in Bangladesh and Its Possible Outcomes

Running head: ANTIBIOTIC USE IN BANGLADESH 1

Current Trends of Antibiotic Use in Bangladesh and Its possible Outcomes

Arafat Siddiqui

East-West University

Author Note

Arafat Siddiqui, Department of Pharmacy, East- West University.

This assignment was instructed by Farjana Khatun, Lecturer, and Dept. of Pharmacy,

Course: PHRM 306, East-West University.

Correspondence concerning this assignment should be addressed to Arafat Siddiqui, ID:

2009-1-70-014, Department of Pharmacy, East-West University, Mohakhali, Dhaka. E-mail:

[email protected]

mailto:[email protected]


Abstract

This assignment is based on the use of antibiotic in Bangladesh. It was found that irrational

prescribing is common in Bangladesh. Hence, bacterial resistances are observed in our country

like outside world. Here current type of antibiotic prescribing practice, its scopes, advantages and

disadvantages, causes, role of pharmacists and doctors, public consciousness and possible

outcomes are briefly described. Some data are of outside world are mentioned here for better

understanding. Some lists of locally popular antibiotics with its manufacturer and brand names

are also included.

Key words: antibiotic, multi-drug resistance, infection


Current Trends of Antibiotic Use in Bangladesh and Its Possible Outcomes

Before 1900s thousands of people died of bacterial infections and other diseases which

are caused by microbes. At the battle field hundreds of soldiers died due to bacterial infections

on major injuries and cut. Mercury was used to treat syphilis as early as 1495. In 1798 Edward

Jenner discovered vaccination for smallpox using cowpox vaccine. Louis Pasteur worked on

rabies. In 1910 an arsenical compound having antimicrobial property known as Salvarsan was

synthesized by Paul Ehrlich. But during 1929, there was a breakthrough. It was Alexander

Fleming who discovered the first antibiotic Known as Penicillin, a metabolic product of

Penicillium notatum (Pelczar, Chan, & Krieg, 2005). It was just the beginning of a new era.

Since then development of newer antibiotics has been a major interest for scientists all over the

world. Thousands of lives are saved. Within in few decades antibiotics became one of the most

common names in medical prescriptions. Unfortunately due to widely use of antibiotics and lack

of rational practice of it, new headache has came for scientists. Like environment pollution,

natural disaster, insufficient sources of energy, a new problem for future generation of mankind

has been created. It is bacterial resistance against antibiotics. Day by day choices of antibiotics

are reducing. Scientists are working hard to find new source and developing newer antibiotics.

International communities are working to create consciousness among public.

Our country is not safe from this disaster. It is necessary to get an overview of present

situation of antibiotic prescribing practice in our country so that we can predict the fortune of our

next generation and take preventive measures as early as possible. In the past few years lots of

survey was done. National public health organizations and others are working on it. Here we

have gathered available information to get an overview.

Survey and Case Studies


Bacterial Resistence

Increasing spectrum in antimicrobial resistance of Shigella isolates in Bangladesh:

resistance to azithromycin and ceftriaxone and decreased susceptibility to ciprofloxacin.

Antimicrobial resistance of Shigella was isolated in Bangladesh, during 2001-2002, was

studied and compared with that of 1991-1992 to identify the changes in resistance patterns and

trends. A significant increase in resistance to trimethoprim-sulphamethoxazole (from 52% to

72%, p < 0.01) and nalidixic acid (from 19% to 51%, p < 0.01) was detected. High, but

unchanged, resistance to tetracycline, ampicillin, and chloramphenicol, low resistance to

mecillinam (resistance 3%, intermediate 3%), and to emergence of resistance to azithromycin

(resistance 16%, intermediate 62%) and ceftriaxone/cefixime (2%) were detected in 2001-2002.

Of 266 recent isolates, 63% were resistant to > or =3 anti-Shigella drugs (multidrug-resistant

[MDR]) compared to 52% of 369 strains (p < 0.007) in 1991-1992. Of 154 isolates tested by E-

test in 2001-2002, 71% were nalidixic acid-resistant (minimum inhibitory concentration [MIC] >

or =32 microg/mL) and had 10-fold higher MIC90 (0.25 microg/mL) to ciprofloxacin than that

of nalidixic acid-susceptible strains exhibiting decreased ciprofloxacin susceptibility, which were

detected as ciprofloxacin-susceptible and nalidixic acid-resistant by the disc-diffusion method.

These strains were frequently associated with MDR traits. High modal MICs were observed to

azithromycin (MIC 6 microg/mL) and nalidixic acid (MIC 128 micdrog/mL) and low to

ceftriaxone (MIC 0.023 microg/mL). Conjugative R-plasmids-encoded extended-spectrum beta-

lactamase was responsible for resistance to ceftriaxone/cefixime. The growing antimicrobial

resistance of Shigella is worrying and mandates monitoring of resistance. Pivmecillinam or

ciprofloxacin might be considered for treating shigellosis with caution (Rahman et al., 2003).


Of 266 of Shigella isolates tested for antimicrobial susceptibilities by the disc-diffusion

method in 2001-2002, S. flexneri (51%) was the predominant species, followed by S. boydii, S.

sonnei, and S. dysenteriae. Overall, Shigellaisolates had high rates of resistance to tetracycline

(79%), trimethoprim-sulphamethoxazole (72%), ampicillin (56%), nalidixic acid (51%), and

chloramphenicol (42%). Moderate-to-low rate of resistance to azithromycin (16%), gentamicin

(4%), mecillinam (3%), and third-generation cephalosporins (TGC), such as cefixime (2%) and

ceftriaxone (2%) was observed. Many isolates were intermediate to azithromycin (62%),

amoxicillin-clavulanate (26%), ciprofloxacin (12%), and mecillinam (3%). No resistance to

levofloxacin and moxifloxacin was detected. Resistance to azithromycin and third-generation

cephalosporins was detected for the first time among recent (2001–2002) isolates in our study.

None of the Shigella isolates had complete resistance to ciprofloxacin (Rahman et al., 2003).

Overall, MDR strains defined as simultaneously resistant to ≥3 of eight useful

antimicrobial agents (ampicillin, trimethoprim-sulphamethoxazole, nalidixic acid, ciprofloxacin,

mecillinam, tetracycline, azithromycin, and ceftriaxone/cefixime) were detected in 63% of the

isolates. It was significantly high (94%, p<0.01) in S. dysenteriae, followed by S. sonnei (60%)

and S. flexneri (58%) and was low in S. boydii (27%, p<0.01). Resistance to ampicillin,

trimethoprim-sulphamethoxazole, nalidixic acid, and tetracycline was most frequent (48%),

followed by resistance to ampicillin, trimethoprim-sulphamethoxazole, and tetracycline (R-type

ApSXTTe) (18%), nalidixic acid, trimethoprim-sulphamethoxazole, and tetracycline (R-type

NalSXTTe) (14%). Resistance to one and two drug(s) was 8% and 19% respectively. Only 26

(10%) isolates were susceptible to all eight drugs tested (Rahman et al., 2003).

Resistance frequencies of Shigella isolates of 2001-2002 was compared with those

isolated during 1991-1992, which constituted part of our previous report. Resistance increased


during the 2000s. Of note, the resistance to trimethoprim-sulphamethoxazole increased from

52% to 72% (p<0.01), resistance to nalidixic acid from 19% to 51% (p<0.01), and mecillinam

from 0.5% to 3% (p<0.01). Resistance to ampicillin, tetracycline, and chloramphenicol was high

(range 49-79%) in 1991-1992 and remained almost unchanged in 2001-2002. Strains with MDR

phenotype increased to 63% in 2001-2002 from 52% (p<0.007) in 1991-1992 (Rahman et al.,

2003).

The MIC results of 154 available isolates (2001-2002) to nalidixic acid, ciprofloxacin,

levofloxacin, azithromycin, and ceftriaxone are shown in the. High modal MICs and MIC90 of

nalidixic acid (modal MIC 128 μg/mL and MIC90 256 μg/mL) and azithromycin (modal MIC of

6 μg/mL and MIC90 8 μg/mL) and very low modal MIC (0.047 μg/mL) and MIC90 (0.023

μg/mL) of ceftriaxone were observed(Rahman et al., 2003).

Of four Shigella isolates that were resistant to third-generation cephalosporins (TGC),

two isolates of S. sonnei were highly resistant to ceftriaxone (MIC >256 μg/mL), and S. flexneri

and S. boydii were intermediate to it (MIC 24 μg/mL). However, all but one ceftriaxone-resistant

strain was susceptible to mecillinam (Rahman et al., 2003).

MIC of ciprofloxacin-differentiated isolates having high MICs (0.064-0.38 μg/mL) and

MIC90 (0.25 μg/mL) exhibiting decreased susceptibility to ciprofloxacin and nalidixic acid

resistance (MIC ≥32 μg/mL) from nalidixic acid-susceptible (MIC <32 μg/mL) and

ciprofloxacin-susceptible isolates having 10-fold lower MIC90 (MIC 0.023 μg/mL) and low

MIC (range 0.012-0.047 μg/mL, Levofloxacin showed similar results as ciprofloxacin. Of

154 Shigella isolates, decreased susceptibility to ciprofloxacin and resistance to nalidixic acid

were detected among 110 (71%) strains. All isolates having decreased susceptibility to

ciprofloxacin by MIC were susceptible to ciprofloxacin by the disc-diffusion method and


resistant to nalidixic acid by the MIC and disc-diffusion method. Of 105 MDR strains tested,

91% exhibited decreased susceptibility to ciprofloxacin compared to 29% of 49 non-MDR

strains (relative risk=3.20, p<0.00001) (Rahman et al., 2003).

Three (two S. sonnei and one S. boydii) of four TGC-resistant strains were susceptible to

amoxicillin-clavulanate and positive in DDST, indicating production of a class A ESBL, as

described earlier. We were able to transfer ß-lactam resistance and ESBL production of these

TGC-resistant strains to E. coli andShigella by conjugation, which was encoded by a 50-MDa

autotrasferable R-plasmid. The fourth isolate (S. flexneri) was resistant to amoxicillin-

clavulanate but negative in DDST, thus exhibiting a class C (Amp C) ß-lactamase phenotype

mediated by a 94-MDa autotrasferable R-plasmid (Rahman et al., 2003).

Shigella causes invasive infection of the intestine that presents the most pressing

challenge for providing effective antimicrobial therapy. Due to the emergence of resistance,

antimicrobial agents, such as sulphonamides, tetracycline, ampicillin, trimethoprim-

sulphamethoxazole, nalidixic acid, and mecillinam have all in succession been used as first-line

drugs in Bangladesh and many countries of the world. During the past several decades, the

organisms have progressively become resistant to most useful and inexpensive antimicrobial

agents. Our study demonstrates an increasing incidence and spectrum of antimicrobial resistance

of Shigella isolates in Bangladesh in 2001-2002. Rates of resistance to ampicillin, trimethoprim-

sulphamethoxazole, and nalidixic acid increased to more than 50%. The resistance to tetracycline

and chloramphenicol, which are not used currently for treating shigellosis, remained high and

unchanged during the last decade. It is likely that the resistance rates observed in our hospital-

based microbiology laboratory reflect the prevalence of resistance that exists in the community

since nearly all cases of shigellosis were community-acquired, and the cultures were obtained on


the day of admission. By analyzing the trends in the resistance patterns of various Shigella spp.,

we found that S. dysenteriae was at present significantly more resistant, followed by S. flexneri

and other Shigella spp., in Bangladesh, especially to commonly-used antimicrobial agents. This

finding is of special importance because S. flexneri is at present the predominant species in

Bangladesh, like many other developing countries (Rahman et al., 2003).

At present, pivmecillinam (oral form of mecillinam), fluoroquinolones, azithromycin, and

third-generation cephalosporins (cefixime) are used in many countries for treating shigellosis

caused by Shigella resistant to all first-line drugs. Pivmecillinam is currently used as an

empirical antimicrobial therapy for shigellosis in Bangladesh with caution since resistance to it is

emerging. The rate of mecillinam resistance, observed in the present study, is significantly lower

than that observed in our earlier study in Bangladesh. This was due to lack of precise guidelines

for determining susceptibility to mecillinam in the past that inherently overestimated the

resistance rate. We used the CLSI (formerly NCCLS) methodology for the determination of

mecillinam susceptibility that reflects the true resistance rate in the present study. Azithromycin

was found to be effective in treating shigellosis both in children and adults, including multidrug-

resistant Shigella-associated infections. High modal MICs (6 μg/mL) and MIC90 (8 μg/mL) of

azithromycin for Shigella isolates were observed in our study, and we detected in-vitro resistance

to azithromycin in Shigellafor the first time in Bangladesh. It is not clear why Shigella exhibits

high modal MIC values to azithromycin. It is surprising that a significant proportion of isolates

are resistant to this drug, although the drug is not commonly used for treating shigellosis in

Bangladesh. However, the frequent use of macrolides for other infections and high carriage rate

of Shigella in the gut of apparently healthy humans in Bangladesh might contribute to the

emergence and spread of azithromycin-resistant Shigella strains. The significance of in-vitro


resistance of Shigella to azithromycin is still unknown since intracellular concentration of

azithromycin achieved in colonic cells and leucocytes exceeds serum concentration by 100-fold

or more that could be fatal for intracellular bacteria. It should be mentioned that the two zones of

inhibition produced by azithromycin by the disc-diffusion method and E-test sometimes caused

difficulty in interpretation of results (Rahman et al., 2003).

Quinolones are a good choice for the treatment of shigellosis in adults. Nalidixic acid was

effective and approved for use in the treatment of shigellosis in children aged less than three

months. However, >50% of our Shigella isolates were resistant to nalidixic acid like many other

developing countries. Fluoroquinolones (ciprofloxacin and norfloxacin) are also effective in

treating nalidixic acid-resistant shigellosis, but paediatric use is limited by concerns about

arthopathy and chondrotoxicity. However, reported data suggest that they are generally safe for

the treatment of shigellosis in children. In 1994, S. dysenteriae type 1, resistant to nalidixic acid

having decreased susceptibility to ciprofloxacin (MIC >0.125 μg/mL), was reported for the first

time in Bangladesh by our group. The isolation rate of such strains of Shigella remarkably

increased to 71% in 2001-2002 involving all species. The importance of strains having decreased

susceptibility to fluoroquinolones was revealed recently by an outbreak of S. dysenteriae type 1

in 2002 in eastern India that affected 1,728 persons (attack rate of 25.6%), resulting in 16 deaths.

Suboptimal clinical responses, therapeutic and microbiologic (positive culture after therapy)

failures were associated with decreased ciprofloxacin susceptibilities of clinical isolates of

Salmonella spp. and other bacteria in many countries, including India, the UK, Denmark, and the

USA. To reduce such risks for humans, a recommendation has recently been made to lower

breakpoint to 0.125 μg/mL for fluoroquinolones for Salmonella. With the increasing prevalence

of Shigella strains having decreased susceptibility to fluoroquinolones such as ciprofloxacin,


there is a need for careful observation of the outcome of ciprofloxacin therapy for shigellosis to

detect suboptimal clinical response or therapeutic failures, if any. However, the problem is that

the strains having decreased susceptibility to ciprofloxacin are not reported as these appear

susceptible when subjected to ciprofloxacin-susceptibility testing (disc-diffusion method or by

current MIC breakpoints) by the CLSI guidelines. As suggested by our study, resistance to

nalidixic acid appears to be a useful screening marker for decreased ciprofloxacin susceptibility.

Hence, future studies should evaluate the clinical outcome of the treatment of shigellosis caused

by strains having susceptibility to ciprofloxacin but resistance to nalidixic acid. Further, in our

earlier study, we detected a single-point mutation at codon Ser83 (TGC) to Tyr83 (TTC) in the

quinolone resistance-determining region of gyrA gene of S. dysenteriae type 1, resulting in

resistance to nalidixic acid with decreased susceptibility to ciprofloxacin. Additional mutations

in the same gene (codon 87) and/or parC (codons 80 and 84) are known to result in complete

resistance to ciprofloxacin. Thus, the use of fluoroquinolones is likely to result in complete

resistance in Shigella strains harbouring resistance to nalidixic acid by additional mutations that

we have witnessed recently in Bangladesh and India. Interesting is the fact that the recent isolates

of ciprofloxacin-resistant S. dysenteriae type 1 in Bangladesh and India appeared to originate by

such mechanisms: a mutation in codon 87 of the gyrA and additional mutation in codon 80 of

parC genes. Although R-plasmid-mediated quinolone resistance may occur on rare occasion, it is

not unlikely that we will see more and more ciprofloxacin-resistant Shigella-associated

infections in the near future (Rahman et al., 2003).

Cefixime and ceftriaxone were active against 98% of our isolates in vitro, but there is

some dispute regarding the clinical efficacy of cefixime in treating shigellosis. Recently,

cefixime was found to be clinically effective in 78% of children with shigellosis, predominantly


caused by S. flexneri. However, it is an re-assuring finding that no increase in the MIC of

ceftriaxone was observed in susceptibleShigella strains, unlike for ciprofloxacin or azithromycin.

On the contrary, ESBL-mediated TGC resistance in Shigella strains was detected for the first

time in Bangladesh. Detection of R-plasmid-mediated ESBL in Shigella isolates, transferable to

E. coli K 12 and Shigella by conjugation, suggests that ESBL could spread resistance to third-

generation cephalosporins among Shigella spp. and other pathogens in the community (Rahman

et al., 2003).

The limitation of our study is that we could not test all strains for antimicrobial

susceptibility to detect exact rates of resistance to conventional and new useful antimicrobial

agents. The isolates were from patients who came to the hospital for treatment or submitted

faecal samples on the advice of physicians. Thus, strains might be associated with severe form of

illnesses or from cases not responding to therapy reflecting high rates of resistance compared to

those existing in the community. However, high rates of resistance among Shigella isolates have

been reported in the community of Bangladesh (Rahman et al., 2003).

Our study showed that Shigella strains developed resistance to many useful antimicrobial

agents, including mecillinam, azithromycin, ceftriaxone, and cefixime in Bangladesh. Options

for antimicrobial therapy for such MDR Shigella-associated infections are very limited leaving

fluo-roquinoloes as the only option. Detection of decreased susceptibility to fluoroquinoloes in a

high proportion of Shigella strains and complete fluoroquinolones-resistant S. dysenteriae type 1

clearly demands careful and judicial use of these drugs to avoid rapid emergence and spread of

resistance (Rahman et al., 2003).

In conclusion, physicians should be aware of the high rates of antimicrobial resistance

and increasing spectrum of resistance of Shigella spp. in Bangladesh. Continuous monitoring of


the resistance patterns is essential, and antimicrobial susceptibility testing should be carried out

on clinical isolates, and empirical antimicrobial therapy need to change accordingly. In addition,

reduced susceptibility of Shigella strains to useful drugs should be identified by determination of

MICs of antimicrobial agents for the early detection of the emergence of resistance. When

indicated, pivmecillinam or ciprofoxacin might be considered for treating shigellosis with

caution in Bangladesh (Rahman et al., 2003).

Antibiotic resistance and genetic diversity of Shigella sonnei isolated from patients

with diarrhoea between 1999 and 2003 in Bangladesh. Talukdar et al. (2004) found that

Shigella sonnei is a significant cause of diarrhoeal infection in both developing and

industrialized countries. From 1999 to 2003, 445 strains of Shigella sonnei were isolated from

patients admitted to the diarrhoea treatment centre of the International Center for Diarrhoeal

Disease Research, Bangladesh. More than 60% of the isolates were resistant to nalidixic acid,

89% to sulfamethoxazole-trimethoprim and 9.5% to ampicillin. In addition, 4% of strains were

resistant to multiple antibiotics (AmpR TetR SxtR StrR) and 4.2% of strains were sensitive to all

antibiotics tested.

Improved outcome in shigellosis associated with butyrate induction of an

endogenous peptide antibiotic. In 2006 Rubhana et al. study on this topic showed that

Shigella is a major cause of morbidity, mortality, and growth retardation for children in

developing countries. Emergence of antibiotic resistance among Shigellae demands the

development of effective medicines. Previous studies found that the endogenous antimicrobial

peptide LL-37 is down-regulated in the rectal epithelium of patients during shigellosis and that

butyrate up-regulates the expression of LL-37 in colonic epithelial cells in vitro and decreases

severity of inflammation in experimental shigellosis. In this study, Shigella-infected dysenteric


rabbits were treated with butyrate (0.14 mmol/kg of body weight) twice daily for 3 days, and the

expression levels of the rabbit homologue to LL-37, CAP-18, were monitored in the colon.

Butyrate treatment resulted in (i) reduced clinical illness, severity of inflammation in the colon,

and bacterial load in the stool, (ii) significant up-regulation of CAP-18 in the surface epithelium,

and (iii) disappearance of CAP-18-positive cells in lamina propria. The active CAP-18 peptide

was released in stool from its proform by butyrate treatment. In healthy controls, CAP-18

expression was localized predominantly to the epithelial surface of the colon. In infected rabbits,

CAP-18 expression was localized to immune and inflammatory cells in the colon, whereas the

ulcerated epithelium was devoid of CAP-18 expression. The combination of CAP-18 and

butyrate was more efficient in killing Shigella in vitro than CAP-18 alone. Our findings indicate

that oral butyrate treatment in shigellosis may be of clinical value because of induction of the

endogenous cathelicidin CAP-18 in the colonic epithelium, stimulation of the release of the

active peptide CAP-18, and promoting elimination of Shigella.

Multiple drug-resistant Shigella dysenteriae type 1 in Rajbari district, Bangladesh.

In 1997 Jahan, Hossain obtained twenty-one Shigellae isolates from bloody faecal

specimens of diarrhoeal patients at Rajbari District Hospital from January 1994 to June 1995,

and serogrouped. Fourteen (67%) isolates belonged to the Shigella dysenteriae serogroup and 7

(33%) to Shigella flexneri serogroup. Shigella dysenteriae strains were further serotyped; all

were Shigella dysenteriae 1. Each strain was tested for resistance to 6 common antimicrobial

agents. The two strains had different antibiotic susceptibility patterns. The 7 S. flexneri showed 6

different resistant patterns and the 14 S. dysenteriae 1 isolates had 4 resistance patterns. One of

the S. dysenteriae 1 isolates was resistant to all 6 antimicrobial agents; 10 to 5, and twice to a

different combination of 4 antimicrobials. The 14 (100%) S. dysenteriae 1 strains were resistant

to 3 major antimicrobial agents: ampicillin, tetracycline, and chloramphenicol; 13 (93%) were


resistant to 5 agents: ampicillin, tetracycline, chloramphenicol, trimethoprim-sulphamethoxazole,

and nalidixic acid. Ciprofloxacin was the only drug active against all 7 S. flexneri and 13 of the

14 (93%) S. dysenteriae 1 strains.

Antibiotic usage at a primary health care unit in Bangladesh. Fahad, Matin, Asish

(2010) found that one of the most costly, frequently and commonly used categories of

medications is antibiotics. Not only do these drugs have the potential for adverse effects but

inappropriate use may also lead to resistant infections. For the past two decades antibiotic

resistance has become a major problem in the public health as the prevalence of multi-drug

resistant bacteria is growing and the availability of new antibacterial agents is limited. Bacterial

resistance is one of the major causes of failure in the treatment of infectious diseases and results

in increased morbidity, mortality, and costs. The literature suggests that this global phenomenon

needs to monitored and tackled. Studies conducted in Bangladesh suggested that Pseudomonas

aeruginosa responsible for wound, urine, ear, throat and other infections were more than 50%

resistant to commonly used antibiotics used in Bangladesh(8) including ciprofloxacin,

gentamicin, ceftriaxone, cefixime and azithromycin. Azithromycin was 100% ineffective in

wound and urine infections, while ceftriaxone and cefixime was 100% ineffective in tracheal

infections. Another study in Bangladesh also reports that E.Coli was resistant in 40% of cases to

commonly used ceftriaxone, levofloxacin, ciprofloxacin, amoxicillin and ampicillin and 95%

resistant to azithromycin. Klebsiella pneumoniae also showed similar patterns inappropriate

prescribing and use of antimicrobial agents continues to be global problems; reasons include the

demand for antibiotic treatment even when not indicated. Lack of understanding about the

ineffectiveness of antibiotics against viral illness and the worldwide and uncontrolled availability

of antibiotics are contributing factors. Moreover the clinician’s desire to satisfy the patient, and


pressure to address the wants of the individual rather than to consider the overall population. The

problem of antibiotic resistance has also been linked with overuse of antibiotics in Bangladesh

due to iself-prescribing and over-the-counter availability. But adequate data has not presented to

provide robust evidence. Although some hospitals in Bangladesh have maintained records of

their antibiotic usage this data is rarely reported in literature and there have been no studies to

assess and examine the usage pattern of antibiotics in primary care units of Bangladesh. This

pilot study aims to explore the prescribing patterns of antibiotics at one primary healthcare unit.

Retrospective treatment and medication record data of 150 patients who were admitted

as in-patients at a primary health Complex were collected from January 2009 to June 2009 with

an average of 25 patient records per month. The first 150 cases were selected based upon

availability of complete patient records with adequate documentation. However incomplete

patient records were excluded. Records were maintained by the superintendent Nurse in charge.

All diagnoses and treatment decisions were made by the Resident Medical Officer (RMO) or

authorized physicians or surgeons at the hospital. The treatment record sheets included age, sex,

diagnosis and medication prescribed. The number of antibiotics and their percentages prescribed

in all patients were analyzed by age group and by gender. Also the cost of antibiotics, the types

and number of antibiotics used, and details of antibiotics when used in combination were also

noted. Finally the top 7 diagnoses where the antibiotic usage was the highest were identified and

Comparing antibiotic usage pattern at various age groups. Table 1 and Figure 1 compares

the amount of antibiotics prescribed at various age groups. It shows that antibiotics were most

commonly prescribed in patients older than 65 years of age and also in young children between

the ages of 5 to 11 years. Antibiotic prescriptions were relatively uncommon for people aged 35

to 49 and 50 to 65.


Table 1

Antibiotic Usage in Different Age Groups

Figure 1:Antibiotic usage in different age groups.

Comparing antibiotic usage pattern by gender. Table 2 shows the variations of the

amount of antibiotics in females vs. males. The male group received 20% higher percentage of

antibiotics.


Table 2

Antibiotic Usage by Gender

Comparing antibiotic usage pattern of various antibiotics. Table 3 and Figure 2 show

the extent of usage of various antibiotics that are available in Bangladesh. Ceftriaxone, a third

generation cephalosporin is by far the most used antibiotic (30.2%, 95%CI: 22.2 -39.5%).

Following it is cefixime, another third generation cephalosporin and it was used 18.9% of the

time (95%CI: 12.5-27.4%). Amoxycillin, ciprofloxacin, metronidazole and cefuroxime follows

the list. The least used antibiotics were Cefepime and Erythromycin.

Figure 2: Usage pattern of different antibiotics.


Table 3

Anntibiotics Usage of Different Types of Antibiotics

Comparing antibiotic usage pattern in the top 7 Diagnoses (based on highest

antibiotic usage). Physical assault, general weakness, acute watery diarrhea, acute trauma,

gastrointestinal distress (GID), respiratory diseases and post partum cases in descending order

were the top seven classes of diagnoses which resulted in most frequent antibiotic prescriptions.

Ceftriaxone, Cefixime and other cephalosporins were most frequently used in physical assaults,

while in general weakness and acute traumas Amoxycillin usage was very prominent too in

addition the previously mentioned antibiotics. Both Ciprofloxacin and Metronidazole were used

in 50% (95%CI: 23.7to 76.3%) of all acute watery diarrhea cases while Ceftriaxone was used in

20% (95%CI: 4.6 to 52.1%) of the cases. In 28.6% (95%CI: 11.3 to 55.0%) of GID cases

Ceftriaxone was used. Amoxycillin seemed to be the most commonly used antibiotic (57.4%,

95%CI: 25.0 to 84.2%) in respiratory diseases Australasian Medical Journal AMJ 2010, 3, 7,


414-421 416 followed by Ceftriaxone (14.3%, 95% CI: 0.5 to 53.4%) and other cephalosporins

(14.3%, 95%CI: 0.5 to 53.4%). Ampicillin was prescribed in all post partum cases (95%CI: 29 to

100%) while Amoxycillin, ciprofloxacin and metronidazole were prescribed in 50% (95%CI: 9.5

to 90.6%) of all cases. Analysis of amount of antibiotic used and detailed Analysis of

combination antibiotic therapy usage. Table 4 shows the frequency of combination

antibiotictherapy in various diagnoses. Antibiotic usage was highest in March 2009. This

probably occurred because of the high prevalence of diarrhea in March (35). A combination of

two antibiotics were prescribed for 12.7% of the total population of patients (95%CI: 8 – 19%)

while 3 antibiotic combination were received by 0.01% (95%CI: 0.06 to 5%). These

combinations were mostly generated in January and March 2009. Combination therapies were

most common in patients diagnosed with physical assault with 22.7% (95%CI: 9.7 to 43%) of all

combination therapies being prescribed in this class. Other cases where combination therapies

were mostly used were acute watery diarrhea (95%CI: 6.7 to 39.1%), GID (95%CI: 3.9to 34.2%)

followed by those with General Weakness and Partum cases. Analysis of Cost profile of

antibiotic usage. Figure 3 shows the contribution of the cost of antibiotics on the total

prescription costs at various time periods. On an average, antibiotics accounted for Tk.136.3,

while the total cost for the total prescription were Tk.238.5. The prescription costs averaged

around Tk.102 where antibiotics had not been prescribed. The cost of total prescription for the

group of patients who were receiving antibiotics was compared with those who were not

receiving antibiotics. Paired t-test analysis revealed that the difference in the two groups were

Tk.105.9 (p value of 0.049) with the antibiotic group incurring a cost of Tk.241.9 (where

antibiotic itself accounted for Tk.134.9) while the average prescription costs for the non

antibiotic group were Tk.148.2 which is almost half of the antibiotic group.


Table 4

Combination Antibiotic Therapy

Figure 3: Antibiotic’s cost.


Drug resistance of Mycobacterium tuberculosis in selected urban and rural areas in

Bangladesh. In 2005 Zaman et al. studied the drug resistance patterns of Mycobacterium

tuberculosis in an urban and a rural area of Bangladesh. A tuberculosis (TB) surveillance system

has been set up in a population of 106,000 in rural Matlab and in a TB clinic in urban Dhaka.

Trained field workers interviewed all persons > or =15 y at Matlab to detect suspected cases of

tuberculosis (cough >21 d) and sputum samples were examined for acid-fast bacilli (AFB). The

first 3 AFB positive patients daily from the urban clinic were included. AFB positive cases

diagnosed between June 2001 and June 2003 from both settings were cultured and drug

susceptibility tests were performed. Of 657 isolates, resistance to 1 or more drugs was observed

in 48.4% of isolates. Resistance to streptomycin, isoniazid, ethambutol and rifampicin was

observed in 45.2%, 14.2%, 7.9% and 6.4% of isolates, respectively. Multidrug resistance was

observed in 5.5% of isolates. It was significantly higher among persons who previously had

received tuberculosis treatment of > or =1 month (15.4% vs 3.0%, adjusted OR: 6.12, 95% CI:

3.03-12.34). The magnitude of anti-tuberculosis drug resistance in Bangladesh is high. Further

evaluation is needed to explain the high proportion of streptomycin resistant M. tuberculosis.

Appropriate measures to control and prevent drug resistant tuberculosis in Bangladesh to reduce

mortality and transmission are warranted.

Emergence of high-level fluoroquinolone-resistantEscherichia coli in Bangladesh.

Saha et al. isolated fifteen fluoroquinolone-resistant strains of Escherichia coli from

different clinical specimens of paediatric patients, 2 years after introduction of the drugs into

Bangladesh. However, none of these patients had any definite history of treatment with

fluoroquinolones. MICs of these strains to different antibiotics were determined by the broth

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Zaman%20K%22%5BAuthor%5D


microdilution method recommended by the Working Party of BSAC. Strains were highly

resistant to all drugs except ceftriaxone. Study indicates a high frequency of fluoroquinolone-

resistant E. colistrains among the clinical isolates which is possibly related to fluoroquinolone

introduction.

Antibiotic Prescribing Practice

Socioeconomic and Behavioral Factors Leading to Acquired Bacterial Resistance to

Antibiotics in Developing Countries. Okeke (1996) found that in developing countries,

acquired bacterial resistance to antimicrobial agents is common in isolates from healthy persons

and from persons with community-acquired infections. Complex socioeconomic and behavioral

factors associated with antibiotic resistance, particularly regarding diarrheal and respiratory

pathogens, in developing tropical countries, include misuse of antibiotics by health professionals,

unskilled practitioners, and laypersons; poor drug quality; unhygienic conditions accounting for

spread of resistant bacteria; and inadequate surveillance.

Risk factors of persistent diarrhea in children below five years of age. Karim (2001)

found that most of the children (82%) were aged below 2 years. Among the risk factors, Grade

III malnutrition (p<0.008), irrational antibiotic use during acute diarrheal episode

(p<0.0000005), use of unsafe drinking water (p<0.004) and lack of exclusive breast-feeding up

to the first four months of life (p<0.004) were significantly associated with persistent diarrhea.

Logistic analysis showed irrational antibiotic use (p<0.0001) during an episode of acute diarrhea

and lack of exclusive breast-feeding (p<0.05) during the first four months of life as independent

risk factors associated with persistent diarrhea. Improvement of nutritional status, encouraging

exclusive breast-feeding during the first four months of life, discouraging the irrational use of

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Karim%20AS%22%5BAuthor%5D


antibiotic for the treatment of acute diarrhea, and provision of safe drinking water may be

important for the prevention of persistent diarrhea as these have been identified as risk factors in

Bangladeshi children below five years of age.

Current practices for treatment of dysentery in rural Bangladesh. Ronsmans et al.

(1991) found that a rural area of Bangladesh with a population of 191,000 had 643 health care

providers, of whom 324 (50%) practiced allopathic (Western) medicine, 152 (24%) were

spiritualists, 109 (17%) were herbalists, and 58 (9%) were homeopaths. Two hundred eight

(64%) of the allopaths had no formal training, and only 18 (6%) were graduates of medical

school. In a community-based study of 480 children with bloody diarrhea and 480 children with

nonbloody diarrhea, allopathic treatment was the most common care provided. Furazolidone and

metronidazole were the two most commonly prescribed drugs, given to 26% and 23% of

children, respectively, who were seen by a practitioner. Only 25% of children had received oral

rehydration therapy. We conclude that in this region of Bangladesh care of acute diarrhea is

provided mostly by private medical practitioners who have little or no training; that such care

currently is largely irrational; and that the provision of rational care will require the development

of simple algorithms that these practitioners can implement for treatment of this disease.

Prescribing pattern in acute diarrhoea in three districts in Bangladesh. Since the

irrational administration of drugs in diarrhea cases is a serious problem, a prescribing survey was

made among 10 government health facilities (GHF) and private dispensaries (PD) in the Dhaka,

Tangail, and Serajgong districts of Bangladesh. Using standard indicators on prescribing, patient

care, and drug supply developed by the International Network for the Rational Use of Drugs, 12

prescriptions written for children under 5 years old with acute diarrhea were studied from each

center (total = 120). It was found that the average number of drugs administered per encounter

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ronsmans%20C%22%5BAuthor%5D


was 1.82 and 2.30 in the GHFs and PDs, respectively. Almost every prescription (0.79 and 0.96

in the GHFs and PDs, respectively) had an antimicrobial component, with metronidazole used in

most cases despite the fact that it is not indicated in acute diarrhea and treatment guidelines

advise against its use in children under age 5 years in Bangladesh. Oral rehydration salt solution

was used in each facility in about 80% of cases (vs. 11% of cases in the community). Because of

the inclusion of the antimicrobial, standard treatment guidelines were followed in only 17 and

23% of cases in the GHFs and PDs, respectively. Patient care indicators revealed that 1.8% of

patients were examined in the GHFs vs. 65% in the PDs. 50% of patients in both facilities could

report the correct dosing schedule for the drugs they were given. The GHFs do not label

prescriptions, but all the drugs administered by the PDs remain in manufacturer-labeled

containers. The existence of an essential drugs list and the distribution of standard treatment

guidelines have not ensured good prescribing habits among health professionals for this common

disease. Additional efforts are required to improve this situation (Chowdhury, 1993).

Antibiotic use in a rural community in Bangladesh. In 1982 Hossain studied on

antibiotic use by 175 000 people in the Matlab rural surveillance area (MSA) of the International

Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) to identify practices which

might affect microbial drug resistance. We surveyed a 3% sample of drug purchases from

pharmacies in the MSA over a four-week period in August and September 1980. Fifty-seven drug

purchases were made per thousand Matlab residents per week; 9% of these were of tetracycline

and 26% were antibiotics. Forty-eight per cent of the antibiotic tablets or capsules for persons

aged 15 years or more were purchased in quantities which represented less than a single day's

dose and rarely was a full course of therapy purchased at one time. The rate of tetracycline

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Hossain%20MM%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Chowdhury%20AK%22%5BAuthor%5D


purchase for young children--in whom it is usually contraindicated--equalled the rate for older

children and young adults. These practices have probably not led to improvements in health and

may have promoted the emergence and persistence of drug-resistant micro-organisms. To

optimize antibiotic use, control measures at government, producer, prescriber and consumer

levels need to be pursued.

Gender difference in treatment seeking behaviors of tuberculosis cases in rural

communities of Bangladesh. In 2004 this descriptive cross-sectional study was conducted by

Ahsan to investigate gender differences in the epidemiological factors associated with the

treatment seeking behaviors of TB cases in the rural communities of Bangladesh. The study

reveals that there is significant gender difference in treatment seeking behaviors of rural TB

cases and the majority of them (52%) have taken prior treatment from various traditional healers,

70% of them are females who attended health centers (UZHCs) as the other choice (adjusted OR:

4.2, 95% CI: 2.0-8.4). It was found that the mean patient delay was 63 days (range 14-210 days)

where half of the females delayed more than 60 days while they were spreading their disease.

The study findings reveal gender differences in treatment seeking behaviors associated with

socio-cultural barriers, particularly among females in their access to TB care. Fifty-five percent

of cases wanted the diagnosis of TB remain confidential to avoid being labeled as TB patients,

where 82.7% were female, 85.6% of female TB patients had problems in their relationships with

their spouse (61%) and family members (58%) after being diagnosed with TB. The results of the

TB service factors found that 39% of females were not satisfied with their provider's behaviors,

which was significantly associated with treatment seeking behavior (adjusted OR: 2.6, 95% CI:

1.0-6.6). The study findings strongly suggest that there was a significant gender difference in

treatment seeking behavior in rural Bangladesh. Based on the study findings, we recommend

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ahsan%20G%22%5BAuthor%5D


developing an appropriate gender strategy for developing a TB control program, comprised of

operational, socio-cultural and community awareness interventions aimed at treating

undiscovered reservoirs of female TB cases in rural Bangladesh.

Adherence to cotrimoxazole treatment for acute lower respiratory tract infections in

rural Bangladeshi children. In 1998 De Francisco studied to evaluate compliance with taking

oral cotrimoxazole in an ALRI control programme in rural Bangladesh. Health workers

administered the first dose to children with moderate disease and entrusted relatives to give the

remaining doses. A team of medical assistants visited the families of cases 3 to 5 days after

initiating treatment and counted the remaining tablets. Medical assistants undertook 367 visits to

families of children under treatment at a mean (SD) of 4.4 (0.99) days after treatment began. All

children appeared to have been given the antibiotic, but one-quarter were being under-dosed on

the day of the visit. Under-dosing did not correlate with any of the socio-demographic variables

studied, and seemed to be homogeneously distributed in the community. Under-dosed children

did not seem to have a higher risk of subsequent ALRI episodes during the study period. There

was no indication of progression to severe disease or death in home-managed cases of moderate

pneumonia in this study. These findings raise a question about the need for 5 days of oral

antibiotic in the management of moderate pneumonia. Careful studies of the effect on subsequent

morbidity, mortality and antibiotic resistance of providing briefer treatment for moderate

episodes of ALRI are required. If a briefer course proves effective, this would have important

implications for funding programmes of control of ALRI in the community.

Antibiotic Resistant Bacteria in Hospitals: A Time for Action. Every few years there

are reports of antibiotic resistant microbes that prompt a series of predictions about “the end of

http://thehealthcareblog.com/blog/2010/11/17/antibiotic-resistant-bacteria-in-hospitals-a-time-for-action/

http://www.ncbi.nlm.nih.gov/pubmed?term=%22de%20Francisco%20A%22%5BAuthor%5D


antibiotics.” Srinivasan (2011) found that it happened in the 90s with multi-drug resistant

tuberculosis and then again earlier this decade with methicillin-resistantStaphylococcus aureus or

MRSA. It’s happening again with carbapenem-resistant Enterobacteriaceaeor CRE. Predictably,

over time these bacteria have become resistant to more and more antibiotics. Almost just as

predictably, they could be treated by a category of powerful antibiotics known as carbapenems –

until now.

Today, 35 states have reported cases of CRE infection to the Centers for Disease Control

and Prevention in Atlanta. And they are dangerous. In a recent study of almost 100 cases, more

than a third of the patients died from the infection. The concern over these bacteria is

compounded by the fact that there are no new antibiotics to treat them coming anytime soon.

Most experts agree that even in the most optimistic scenario it will likely be about 10 years

before effective new drugs are developed. A variety of efforts are being debated to speed the

development of new antibiotics, but these discussions often overlook one critically important

issue. One of the reasons our current antibiotics are losing their effectiveness is because we

don’t use them properly. Studies have shown, repeatedly, that up to 50% of antibiotic

prescriptions are either unnecessary or inappropriate – a statistic that is disappointingly

consistent across both in-patient hospitals and out-patient clinics. Not only does this overuse

reduce the effectiveness of our current antibiotics, it threatens the utility of any new antibiotics

that come along in the future.

While we work on new antibiotics for the future, there is much that must be done right

now to both preserve the lifespan of the antibiotics we currently have and to pave the way to

ensure prolonged usefulness of new antibiotics that are developed. The most important

immediate need is to reducing the overuse of these drugs. Reducing antibiotic over-use is good


for society as a whole but it is also good for individual patients. A recent study showed that

exposure to a carbapenem antibiotic was the single greatest risk factor for getting an infection

with CRE, increasing the risk by 15-fold.

This week, the CDC and its partners have launched the “Get Smart for

Healthcare”program to complement the existing “Get Smart: Know When Antibiotics

Work” program. This is an expansion of CDC’s existing Get Smart programs targeting outpatient

clinics and pediatricians offices to include hospitals and nursing homes. Promoting appropriate

antibiotic use, as basic as it seems, can carry our drugs a great deal further.

It can be helpful to view antibiotics much like we view natural resources that benefit

from concerted, coordinated conservation efforts. Conservation requires collaboration and

recognition that individual actions have an impact on the common good. Reducing overuse

means engaging everyone in the effort—for example, by urging the passage of innovative

policies aimed at hospitals, other healthcare facilities, and even pharmaceutical companies, to

encourage stewardship. By aligning incentives for hospitals and healthcare facilities to focus on

infection control and prevention, we can reduce the prevalence of resistant infections that jump

from healthcare facilities into the community. By motivating pharmaceutical companies to care

about drug resistance, we can encourage them to stop overselling their drugs. Consumers also

need to stop demanding antibiotics when they suffer from a viral infection.

We do need new antibiotics–urgently. But, in the meantime, we must focus on using the

ones we already have in a sustainable fashion. Not only will this extend the utility of the drugs

we have on the market today, but it will also ensure that drugs approved in the future will stay

effective for longer periods.

http://www.cdc.gov/getsmart

http://www.cdc.gov/getsmart

http://www.cdc.gov/getsmart/healthcare/

http://www.cdc.gov/getsmart/healthcare/


It is easy to make frightening predictions about the end of antibiotics. It is harder but no

less possible, to take definitive steps to ensure that such a day never comes. It is time for action.

Rational use of antibiotics is a serious issue in the context of Bangladesh. Bacteria are so

well armoured that frequently they develop an array of biochemical mechanisms by which they

can resist the antibiotic. Thus, the greater an antibiotic is in use the faster will be the

development of resistance. With its 130 million people and a very heavy infectious disease load,

in Bangladesh huge quantities of antibiotics are used annually. But a very large portion of this is

used unfortunately under conditions of inadequate or no medical supervision and in most cases

without prior tests on identification of the disease-causing organism and determination of its

sensitivity to the antibiotic prescribed. The sale of antibiotics without proper medical

prescription or on a quack 'prescription' or simply on verbal demand of the buyer is common

both in cities and rural areas. Even in those cases where a qualified doctor prescribes an

antibiotic, patient compliance regarding using the full course of the drug is not always

satisfactory largely due to ignorance. All of these contribute to rapid emergence of resistant types

of bacteria soon after a new antibiotic is introduced. This is happening even with the newer types

of antibiotics against which laboratory studies indicate that there should not be rapid

development of resistance (Rahman, 2000).

Patients' Knowledge and Awareness towards Use of Antibiotics in Bangladesh: A

Cross-sectional Study Conducted in Three Tertiary Healthcare Centers in Bangladesh.

This study is aimed to estimate general knowledge and awareness of patients regarding

use of antibiotics to find out possible reasons of irrational use of antibiotics in Bangladesh. It was

a questionnaire based crosssectional health survey conducted on 350 subjects aged 18 or over

who came to get service at three tertiary healthcare centers named Dhaka Medical College


(DMC) Hospital, Sir Salimullah Medical College (SSMC) Mitford Hospital and Bangabandhu

Sheikh Mujib Medical University (BSMMU) Hospital of Dhaka, Bangladesh. Saha found from

the study that the general knowledge of the patients about the indication of antibiotics was very

poor. Majority of the patients did not know the appropriate use of antibiotics. Only 26%

respondents answered correctly that antibiotics are indicated for bacterial infections. In addition,

38.97% of them also did not know that an antibiotic is a prescription drug and should not be used

without doctor’s prescription. The awareness about the patients towards use of antibiotics was

also poor. A very high percentage of the patients (51.71%) answered that they do not complete

the full course of therapy. Surprisingly, 39.14% of the patients replied that they stop antibiotics

when the symptoms disappear and remarkably 14.29% just make the dose double if they forget

to take due dose. On the other hand, 28.86% of the patients said that they do not maintain dosing

schedule during the course of therapy. Moreover, prevalence of self-medication with antibiotics

in cold and fever was also extremely high (60.86%). This study indicates that there is an urgent

need of health education for the community to increase knowledge and awareness about use of

antibiotics to decrease the self-medication and inappropriate use of antibiotics.

News Coverage

Bangladesh News line (BDNL) (2011) found that many antibiotics are losing

effectiveness on patients because of their misuse, utterly ignoring the long term side effects.

Different studies and surveys show people, irrespective of their social and financial

status, seldom get doctors’ advice before taking antibiotics for treating common illness like flue,

cold and food poisoning.


A survey finds misuse of antibiotics is higher in the rural areas where people are less

aware about proper use of drugs and urban people are also reluctant to follow prescription all the

time.

Another study reveals the misuse is increasing rapidly, ringing an alarm bell to the

authorities who are surprisingly showing their indifference to the serious health threat.

A bdnl.net query, however, finds severe manpower shortages in the drug administration

to monitor the practices of doctors and drug sales procedures country-wide.

Bangladesh Health Watch – a non-government organization working in the field of health

and nutrition- in a report said the misuse of antibiotics doubled in 15 years when it increased to

50 percent in 2009 from 25 percent in 1994.

The increasing trend was comparatively higher in the rural areas as salesmen at medicine

shops there often suggest patient antibiotic for flu or cold, the report said.

According to the report, retail drug sellers in rural areas mostly advise people antibiotics,

which is 60 percent of the total medicine they prescribe. The rate is 45 percent at urban clinics

and 43 percent at upazilla health centers.

The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B)

conducted a survey in Mirpur area in the capital city in 2009 where it found that most patients

first go to local pharmacies for medicine and take antihistamine and antibiotics for the disease

like influenza.

Some specialists even gave a dreadful scenario saying a large number of doctors

prescribed antibiotics to bring quick relief to the patient without considering the consequence of

the wrong prescription.


They said the wrong uses of antibiotic have become very common in our society due

mainly to noncompliance with doctors’ advice, self-diagnosis and self-medication.

Associate Professor of Medicine Department at Bangabandhu Sheikh Mujib Medical

University Dr Md Abul Kalam said people mostly misused antibiotics in cases of flu and cold

related illness. But, he said fever is not a disease; rather it is only the symptom of a disease.

Similarly, hepatitis-B, jaundice and dengue are virus-borne diseases, which cannot be

treated with antibiotics though people take such medicine from a common perception that

antibiotics cure everything, he said.

“Such misuse helps grow resistance to the respective antibiotic inside the patent body and

as a result the same drug does not work in future for real cause,” Kalam said.

He said patients should be diagnosed properly before prescribing any antibiotic.

Officer-in-charge of Upazilla Health Complex at Raipur in Norsingdi district Dr Sadiq

Khan said he observed people in the rural area take antibiotics for virus-related sickness like

common cold and flu without consulting doctors.

He said antibiotics are usually prescribed for bacteria related diseases like tuberculosis,

severe cold and pneumonia.

On the other hand, virus-related sickness like common cold and flu require antiviral

intake. These illnesses cannot be treated by antibiotics.

Khan said some people are not aware that antibiotics take one to two weeks to work. So

they switch to another antibiotic, which may cause serious side affect.

Besides, he said some people stop taking the drug without completing the full course as

per the doctor’s prescription, which also helps develop resistance like misuse of it.


There are certain regulations, which prohibit selling prescription medicine without

doctors’ written advice. But medicine shops hardly follow the regulation only to make more

profit by selling as much medicine as they can.

The drug administration does not have enough manpower to implement the regulation.

Official sources said the regulator only has 25 staff for overseeing thousands of medicine shops

across the country.

Bangladesh gets tough with antibiotic use. Bangladesh is set to pass a new rule on the

use of antibiotics such as nitrofurans and chloramphenicol in animal feeds after the EU detected

the two drugs in freshwater prawn imported from the country. Bangladesh’s livestock and

fisheries departments have drafted the Fish and Animal Feed Law to regulate antibiotics use in

animal feeds and prevent them from entering the food chain.

Rafiqul Islam, Director General of the Department of Fisheries, said the Parliament’s

standing committee on fisheries has reviewed the draft and it is expected to be passed as a law

soon. The detection prompted the EU to impose a ban on shrimp exports from Bangladesh. After

tracing back the cause of contamination, authorities found that the drugs came from the feed and

chicken manure in the water. (www. Zootechnicainternational.com, 2010)

Prevention and Containment of Antimicrobial Resistance

In 2010 a meeting by regional office for south east asia of WHO found that consequences

of resistances are:


Systematic studies to understand the status of antimicrobial resistance and its trends, and

consumption of antimicrobial agents have been undertaken in the SEA Region. However, the

data available from published reports from Member States of the Region provide an insight into

the magnitude of the problem of resistance. The information available for selected

diseases/organisms is briefly described below:

Tuberculosis

Resistance to first-line anti-TB drugs has become a concern for national TB control

programmes. The population weighted mean of MDR-TB1 in the Region is 2.08% (1.9%-3.6%)

among new cases and 18.8% (13.3%-24.3%) among previously treated cases. It is estimated that

around 150 000 cases of MDR-TB reside in this Region with more than 80% of these being in

Bangladesh, India, Indonesia, Myanmar and Thailand. 1 MDR-TB = Resistance in mycobacteria

to isoniazid and rifamipicin. The level of multidrug-resistant TB however remains low (below

3%) reflecting the good quality of TB programmes. The need for preserving the efficacy of first-

line antituberculous drugs has been widely felt since drugs used in the management of MDR-TB


cases are not only expensive but also toxic. Extensively drug-resistant TB (XDR-TB) has been

detected in mycobacteria isolated in Bangladesh, India, Indonesia and Thailand giving another

serious dimension to managing resistance in TB.

HIV and sexually-transmitted infections

Emerging diseases continue to challenge public health as never before. An estimated 3.5

million people are currently living with HIV/AIDS; the Region’s HIV/AIDS burden is next only

to sub-Saharan Africa. The generic antiretroviral (ART) drugs produced by the pharmaceutical

industry in the Region are contributing greatly to improve the survival rate of patients worldwide

and in rendering HIV as a chronic but manageable condition. Although the response to ART

drugs is excellent when they are delivered at health facilities, the emergence of resistance in HIV

can destroy the hopes of survival for millions of people living with HIV. There has been a

substantial change in the antimicrobial susceptibility of Neisseria gonorrhoeae. Thirty years ago,

gonorrhoea used to respond effectively to penicillin. Now, the resistance to penicillin and

fluoroquinolones is widespread across the Region.

Malaria

Resistant malaria has become a major issue for a population of 400 million living in areas

that expose them to a high risk of contracting it. Artemisininbased combination therapies (ACT)

have recently been introduced in virtually all countries in which malaria is endemic, thereby

making such drugs the most essential class of antimalarial agents. However, recent data indicate

that artemisinin resistance has emerged along the border between Cambodia and Thailand.

Surveillance data from the Thai Ministry of Public Health indicate that clinical failures of

artemisinin-based therapies exist in the Thai–Cambodian 2 XDR-TB = MDR-TB + resistance to

fluoroquinolones and at least one of the three injectable second-line drugs (capreomycin,


kanamycin and amikacin). Sutrisna A, Soebjakto O, Wignall FS, Kaul S, LimniosEA, Ray S et

al. Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from

East Java and Papua, Indonesia, in 2004-implications for treatment. Int J STD AIDS 2006,

17:810-12. border, whereas efficacy with artesunate–mefloquine along the western borders of

Thailand remains high. A “global disaster” could happen if malaria parasites worldwide

developed resistance against the new artemisinin-based combination therapies (ACTs) that have

become the gold standard. Large parts of the world would have no drugs to fall back on, and

malaria cases and deaths could soar, erasing the hope that the world might be close to a huge

reduction in the disease. Yet, resistance against ACTs is precisely what now seems to be

developing in western Cambodia, along the Thai border.

Kala-azar

Kala-azar is a public health problem in Bangladesh, India and Nepal and is being targeted

for elimination using miltefosine. Pentavalent antimonials have been successfully used for

treatment of kalaazar since the last six decades. Since the 1970s, however, their conventional

dosages have failed to achieve the desired results with 60% unresponsiveness being reported

with the WHO regimen in Bihar (India). Pentamidine initially used as a second-line drug,

acquired resistance (25%) even with prolonged dosage. The newer oral drug, miltefosine is a

potent antileishmanial drug with a longer half-life, a property likely to delay resistance. The

evolution of resistance to this drug will cause havoc to the regional efforts to combat this disease.

Diarrhoeal diseases

Cholera germs have acquired resistance to a number of antimicrobials. The resistance

spectrum varies in different locales. In areas around New Delhi (India) extensive resistance to

furazolidone, cotrimoxazole and nalidixic acid has been noted while tetracycline has remained


effective. On the other hand, in Bangladesh, tetracycline resistance has also been found to be

frequent. 4 Vijaykadga S, Rojanawatsirivej C, Cholpol S, et al. In vivo sensitivity monitoring of

mefloquine monotherapy and artesunate-mefloquine combinations for the treatment of

uncomplicated P. falciparum malaria in Thailand in 2003. Tropical Medicine and International

Health 2006;11:211-219. 5 Enserink M. . Malaria: signs of drug resistance rattle experts, Trigger

bold plan. Science; 2008:322:1776. 6 Jha T.K. Drug unresponsiveness and combination therapy

for kala-azar . Indian Journal of Medical Research 123,2006, 389-398. 7 Sharma NC et al.

Changing profile of Vibrio cholerae O1, O139 in Delhi and periphery. Indian Journal of Medical

Research 2007;125:633.

Respiratory infections

Streptococcus pneumoniae is the most common causative agent of pneumonias in

children and adults in Asia8. Till the 1980s, almost all isolates of this organism used to be

susceptible to penicillin. In 2006, in a hospital in Thailand, almost 69% isolates of this bacterium

were found to be penicillin-resistant.

Typhoid and paratyphoid fever

Typhoid and paratyphoid fever continue to be important causes of illness and death,

particularly among children and adolescents in the SEA Region where this disease is associated

with poor sanitation and unsafe food and water. Published reports indicate that multidrug-

resistant Salmonella typhi are prevalent widely in India and Indonesia. Shortly after the

emergence of multidrug-resistant Salmonella typhi in this Region, case fatality rates approaching

10% (close to 12.8% recorded in pre-antibiotic era) were reported.

Wound sepsis due to Staphylococcus aureus


More than 50% isolates of Staphylococcus aureus in hospital settings are now

methicillin-resistant. In a study undertaken in a 1000-bedded hospital in Thailand, 48% patients

with bacteraemia due to resistant Staphylococcus aureus died. Methicillin-resistant Staph. aureus

(MRSA) is a major problem in hospital-associated infections in almost all countries in the SEA

Region.

Nosocomial infections

Multiresistant klebsiellae, pseudomonas and Acinetobacter species have given new

dimensions to the problem of hospital-associated infections. Acinetobacter baumannii has

become an important pathogen in intensive care units. It 8 Song J.H. et al. Epidemiology and

clinical outcomes of community acquired pneumonia in adult patients in Asian countries: a

prospective study by the Asian network for surveillance of resistant pathogens. International

Journal of Antimicrobial Agents 2008, 31:107-114. 9 Srifuengfung S et al. Antimicrobial

susceptibility of Streptococcus pneumoniae isolated from patients with respiratory tract

infections in Thailand. Southeast Asian Journal of Tropical Medicine and Public Health

2008;39:461. 10 Gupta A. Multidrug-resistant typhoid fever in children: epidemiology and

therapeutic approach. Pediatr Infect Dis J 1994;13: 134–40. 11 Tyagi A, Kapil A, Singh P.

Incidence of methicillin resistant Staphylococcus aureus (MRSA) in pus samples at a tertiary

care hospital. JIACM 2008, 9:33-35. produces a wide range of beta lactamases and has a

formidable spectrum of intrinsic resistance mechanisms that can mean that some strains are

resistant to almost all known antimicrobial agents. In a study done in Thailand, mortality in

admitted patients due to imipenem-resistant Acinetobacter baumannii was 52% as compared to

19% in those who were infected with the sensitive variant.

Country reports


Bangladesh

Antimicrobial resistance (AMR) is considered a national priority though there is no

national alliance or regulations governing the use of antimicrobials and no national coordination

mechanism on AMR. The Director-General of Drugs Administration is the proposed focal point

for AMR in Bangladesh. Antimicrobials are also used extensively in the veterinary sector. There

is no national surveillance and network of laboratories on AMR at present but it is being

planned. Many medical colleges and NGOs have published several scientific papers in different

technical journals highlighting the problem of AMR in Bangladesh.

Many infectious diseases do not respond to conventional antimicrobial agents. While

standard treatment guidelines are available at various levels of health care delivery and medical

professionals are oriented on the rational use of antimicrobials, community awareness

programmes are weak. Most of the antimicrobials are available over the counter all over he

country and usually prescribed even by unqualified or unauthorized personnel. For surveillance

of antimicrobial resistance, national authorities are planning to establish a national network of

laboratories to be coordinated by a National Reference Laboratory.

India

Antimicrobial resistance in important disease pathogens has become a matterof great

public health concern globally including India. The factors responsible for this are widespread

use and availability of practically all the antimicrobials across the counter meant for human as

well as animal consumption. Though there are definite policies/guidelines for appropriate use of

antimicrobials at national level in specific national health programmes being run in the country,

the same are not available for other pathogens of public health importance like enteric fever,

diarrhoeal disease, respiratory infections etc. However, during the recent H1N1 pandemic,


national guidelines were framed and implemented regarding restricted sale/use of oseltamivir in

the country. Similarly, there is no national data base on antimicrobial resistance in different

pathogens except for those where there is a specific national health programme. Though a large

number of laboratories in the country (both in the private and public sector) are carrying out drug

susceptibility testing of micro organisms, the data is either not analysed on a regular basis or not

being disseminated for use of clinicians/public health experts/programme managers. There are

also issues of quality control and data sharing with these laboratories. There are a few examples

of successful networking of laboratories carrying out antimicrobial sensitivity testing of

gonococcus in the country with the Regional STD laboratory Prevention and Containment of

Antimicrobial Resistance 15 at S.J. Hospital, New Delhi being the referral laboratory.

There is networking of such laboratories also in the Revised National TB Control

Programme of the country generating some useful data on drug resistance in TB and recently a

laboratory network has also been established for antimicrobial testing of HIV under National

AIDS Control Organization. Meta analyses of the drug susceptibility results of various

laboratories across the country reveal an increasing trend of development of resistance to

commonly used antimicrobials in pathogens like salmonellae, shigellae, V.cholerae, Staph

aureus, gonococcus, meningococcus, klebsiellae, Mycobacterium tuberculosis, HIV, malarial

parasite and others. Though there is no national database on surveillance of use of antimicrobials

in the community, there are a few studies in the country in this regard. Studies carried out in

Delhi and Vellore, with support from WHO during 2003-2005 suggested a very high use of

flouroquinolones in the community as compared to other antimicrobials. At present there are a

large number of challenges that need to be addressed for effective containment of this problem.

Available data suggest increasing drug resistance trends in the country. There is no national


programme for the purpose, there is inadequacy of quality assured laboratories, insufficient data

analysis and dissemination, absence of national guidelines on antimicrobial usage, no control on

sale of these drugs for public consumption etc. In the last decade or so a large number of new

initiatives have been launched by various agencies to contain this problem.

These include IndiaClen (Indian Clinical Epidemiology Network) which has generated

some quality data on AMR in pathogens like pneumococcus, H.influenzae across the country;

IIMAR (Indian Initiative for Management of Antibiotic Resistance) launched in March 2008,

with WHO support, by a consortium of NGOs to promote prudent use of antimicrobials, INSAR

(Indian Network for Surveillance of Antimicrobial Resistance) a network of 20 laboratories in

the private as well as public sectoracross the country to generate quality data on AMR,

organization by the ICMR of an expert group meeting in December 2009 and an Indo-Swedish

workshop held at New Delhi on 2 February 2010 to discuss a joint strategy for containment of

AMR, recommendations of which are under consideration by the Ministry of Health & Family

Welfare. Proceedings of the meeting

Maldives

Antimicrobial resistance is considered as a national priority as the resistance of

antimicrobials is increasing over the years. There is no national policy or a guideline on AMR.

There are no national programmes or alliances on use of antimicrobials with any country or

nation. Since there are no animals in the country, there is no veterinary sector and hence

antibiotics are not used in these areas. There is no national focal point, no national surveillance

mechanism and no network of labs on AMR. Data collection has not been done nationwide.

However, data is available with the Indira Gandhi Memorial Hospital (IGMH) Lab

information system. The data that is available on AMR is taken from IGMH Lab information


system from 2007 to 2009. Three organisms that are commonly isolated are selected along with

the antibiotics tested for them. The three organisms are:

Escherichia coli, Staphylococcus aureus and Klebsiella species. When the data are

analyzed, it is seen that all the three organisms are showing more than 70% resistance to

ampicillin and amoxacillin. Amikacin shows less than 3% resistance to E.coli and Klebsiella.

Also, it is seen that the resistance of Klebsiella to all antibiotics is much more compared to that

of E.coli. Based on the data, it is seen that the resistance has been increasing over the years to the

antibiotics that we are using. This can be very useful information for the clinicians regarding

AMR. There is some training for doctors and pharmacists about the rational use of drugs, but for

nurses and dental professionals training is not being conducted regarding AMR. The mechanism

for monitoring of rational use of drugs is under development and it is hoped to be completed in

the near future.

Most of the antimicrobials are not available over the counter and it can be taken only by a

prescription from a qualified professional. There are no NGOs working on rational use of drugs.

Community awareness programmes are coordinated through the media but no research has been

done to analyze the impact of these programmes. Major issues with regard to prevention and

containment of AMR are absence of a national guideline on AMR, availability/accessibility of

data/ information nationally and also lack of resources to carry out sustainable assessments like

not having enough microbiologists and also no funds for research.

A plan of action is being proposed to the government on AMR advising on consideration

for policy formulation, formation of guidelines and also action plans.

Myanmar


Myanmar needs to formulate a national policy on use of antimicrobials and national

regulations related to the use of antimicrobials. A national policy on use of antimicrobials and a

national co-ordination mechanism on AMR do not exist but are being developed. Although

restrictions on the use of specific antimicrobials in therapeutic purposes (veterinary sector) is

present, it needs to be implemented. It is the same for non-therapeutic purposes. A national

network of laboratories on AMR needs to be developed for initiating quality national

surveillance. There is a strong need to formulate standard treatment guidelines at the national

level. CME is required for physicians, nurses, dental professionals and pharmacists. Community

awareness programmes also need to improve. Major issues with regard to prevention and

containment of AMR and future national plans are the following:

• Establish national alliance against AMR.

• Establish national policy on AMR.

• Promote public awareness on rational use of drugs.

• Improve national surveillance system on AMR.

• Improve infection control programme in health care practice.

Nepal

Public sector health institutions in Nepal are categorized in three levels: primary level

constitutes the health post and sub-health post, where paramedical staff are available, the

secondary level constitutes primary healthcare centre and district hospitals. There are zonal, sub-

regional, regional, central and specialized hospitals at the tertiary level. In the non-governmental

sector, there are 18 Proceedings of the meeting teaching, I/NGO, community and private sector

hospitals. Antibacterial drugs are prescribed both by physicians and paramedical personnel. The

National Drug Policy, 1995 addresses the issues regarding rational use of antimicrobials in


human and animals. However, implementation status is far from satisfactory. The Drug Act has

categorised antibiotics as a prescriptive drug, which cannot be sold without prescription, though

there may be a gap between the legal provision and practice. Standard treatment protocol is

available for some national programmes like tuberculosis, leprosy, HIV/AIDS and also for

health posts and sub-health posts to treat common infections.

For the surveillance of AMR, 11 laboratories are participating, coordinated by the

National Public Health Laboratory. Data dissemination is done every year although there is no

formal publication. Various journals and bulletins published by academic institutions and

professional organizations include results of AMR surveillance. The organisms regularly

monitored are: Neisseria gonorrhoae, Salmonella typhi, Shigella, Vibrio cholerae, Streptococcus

pneumoniae, Haemophilus influenza and E. coli. Training on the rational use of drugs is

normally conducted by NGOs, though recently the Ministry of Health has also started such

training. The government has initiated the process for developing treatment protocols for various

levels of health institutions. Antibiotics used for curative purposes are not allowed to be used in

feed supplement or as growth promoters. Though policy guidelines and a legal framework is in

place, there are lapses in practice due to inadequate monitoring and supervision. This results in

over-the-counter sale of antibiotics, which may enhance the development of resistance. The

laboratory findings suggest that the above-mentioned micro organisms have developed resistance

of various degrees towards many antibacterials in use.

Sri Lanka

Monitoring of AMR is considered a national priority. Though presently there is no

national programme, there is an on-going activity by the Sri Lanka College of Microbiologists

that commenced in 2009 and involves seven surveillance centres to monitor AMR in gram


negative organisms. It is proposed to expand this programme to three additional laboratories in

2010. AMR surveillance for gram positive organisms shall also commence in a few centres in

August 2010. Data r elated to AMR in different settings are published in the Bulletin of the Sri

Lanka College of Microbiologists and released annually. The Ministry of Health has constituted

a Task Force on Microbiology that has recognized the need for an antimicrobial policy and it will

be formulated on data generated by the aforesaid surveillance programme. There is no national

policy for use of antimicrobials. There are no direct regulations on antimicrobial use, but

indirect controls are exerted at the time of drug registration and in selecting prescribers. Legal

restrictions on nontherapeutic use of antimicrobials in veterinary practice exist but the status of

implementation remains unknown. Standard treatment guidelines are available nationally and in

major hospitals but compliance is inadequate which is compounded by frequent shortages of

antimicrobials. Monitoring of drugs at the community level is done through authorized officials

belonging to the National Regulatory Authority. Professional bodies are working on rational use

of antimicrobials and some of them are the Sri Lanka College of Microbiologists and the Sri

Lanka Medical Association. There have been training programmes on rational use of drugs to

different categories of healthcare providers but coverage remains inadequate. Availability of

antimicrobials over the counter and their prescription by unauthorized personnel takes place in

spite of laws against such practices.

Thailand

Antimicrobial resistance (AMR) is considered a national priority although not so

prominently. This reflects that there is no national policy with only a draft policy for more than

10 years without adoption or action. There are two major national programmes regarding AMR,

one on human health (Ministry of Public Health) and another covering animal health (Ministry of


Agriculture and Cooperatives). National antimicrobial resistance surveillance in Thailand was set

up by the National Institute of Health, Department of Medical Sciences, Ministry of Public

Health in 1997. It started with 28 hospitals as members and increased to 60 hospitals in 2005.

Data from routine laboratory isolation of bacterial pathogens 20 Proceedings of the meeting was

collected, analyzed, and the information of resistance was disseminated annually through

websites (http://narst.dmsc.moph.go.th), brochures and reports to all hospitals and relevant

institutions. There are standard treatment guidelines for a few selected diseases both at the

national level and at major hospitals but the updating system is not very clear. Implementation is

unlikely to be followed in all settings.

Training imparted on rational use of drugs both in the undergraduate curriculum and as

continuing education are provided to all health professionals (physicians, nurses, dentists, and

pharmacists). There are at least three official programmes that always have sessions on

promoting the rational use of antibiotics. These are: the National Congress in Infection Control;

secondly, the short training in infection control; and thirdly, the Annual Academic Meeting of

the Infectious Disease Association of Thailand. All these activities are held annually aimed at

physicians, pharmacists, nurses, and laboratory personnel. There is no national regulation related

to the use of antimicrobials.

Only some scattered activities in different organizations such as requirement for DUE

(drug use evaluation) for some schedule IV and V of Essential Drug List (EDL). Mechanism for

monitoring of rational use of drugs is not set as routinely but is covered by occasional

observation or by research and by indirect approach such as Pay for Performance Programme.

Antimicrobials are unfortunately available over the counter, allowed by law to be dispensed

without prescription from pharmacies by pharmacists and illegally distributed via grocery by


unqualified professionals. There are some academic programmes on rational use of drugs

specifically with antimicrobials. The first is the ‘Antibiotic Smart Use’ programme coordinated

by the Thai FDA and IHPP. The second is DMD (Drug System Monitor and Development

Programme) by Chulalongkorn University that works broadly on the drug system and supports

the movement for AMR policy as one direction. Monitoring of drug use at the community level

is observed but not systematically.

Awareness of the community regarding AMR is low as observed by the high tendency of

using antimicrobials in the community and poor understanding on antimicrobial use. Ten major

issues for prevention and containment of AMR and future national plans are as follows:

(1) National Policy on AMR.

(2) National Monitor System on antibiotic use pattern and rationality at all levels of

health facilities and the community.

(3) Alert or signal system on AMR to stakeholders.

(4) Linkage from monitoring data to policy implementation.

(5) Regulatory strengthening of antibiotics registration.

(6) Antimicrobial in vet and farm/fishery.

(7) Pharmacy and therapeutic committee (PTC) strengthening on rational use of drugs

(RUD) especially antimicrobials

(8) Consumer knowledge and awareness on antimicrobial use and resistance.

(9) Curriculum and continuing education in RUD of antimicrobial use and resistance.

(10) Collaboration among countries in the Region for further AMR prevention and

containment.

Timor-Leste


This important issue has not been discussed in any formal forum in Timor- Leste since

there are many other priorities. This workshop on prevention and containment of AMR has

highlighted the real problem being faced now globally including Timor-Leste. Limited data are

available from the national laboratory.

Available test results show high level (62%) of the isolates being resistant against

cloxacillin among isolates of Staphylococcus aureus from patients in the national hospital Guido

Valadares in Dili. At the same time, 13% resistance is recorded against amoxicillin plus

clavulanic acid. The data as interpreted is likely to reflect that the difference between cloxacillin

and amoxiclav resistance reflect Staph aureus carrying betalactamases, while the remaining

proportion may be true mec gene dependent, so called MRSA resistance, e.g. resistance against

all betalactam antibiotics. If this is the case, the available test data suggest that some 13 % of the

Staphylococcal infections would need treatment with vancomycin. This issue needs to be

addressed with the help of molecular biology, to assess the true mec gene positive Staph aureus

rate. The rate of quinolone resistance in clinical isolates of Staph aureus is also considered to be

surprisingly high. Likewise the Gentamicin resistance rate of 22% presents a cause for concern,

which needs to be considered further also in the recommendations provided for treatment of

pneumonia, in cases where Staph spp infection is suspected. Proceedings of the meeting Major

issues for prevention and containment of AMR and future Timor- Leste national plans include:

(1) Strategy plan for prevention and containment of AMR.

(2) A national drug policy drafted.

(3) A new Pharmacy Law with stronger prescribing rules drafted.

(4) Standard Treatment Guideline for PHC and hospital care has been developed, to be

launched and implemented as a tool for guiding patient treatment throughout Timor-Leste


(5) Inspection of private pharmacies, including prescription handling and drug OTC sale

practices.

(6) Establish regulation and legislation for antibiotic use.

Table 5

Penicillin Group of Drugs.

Generic Brand Name Manufacturer

Penicillin G PEN- G

PRONAPEN

Opsonin

Renata

Penicillin V OPEN

ORACYN- K

PENVIK

Opsonin

Aventis

Square

Benzathine Penicillin BENZAPEN

DIAMINE PENICILLIN

BPEN

Square

Renata

Opsonin

Cloxacillin CLOXICAP

CLOXIN

FICLOX

Renata

Opsonin

Aventis

Dicloxacillin DICLOX Novartis

Flucoxacillin FLUBEX

FLUCLOXIX

Beximco

SK+ F


FLUX

FLUXON

PHYLOPEN

Opsonin

Aventis

Square

Ampicillin AMPEXIN

AMPICIN

FICILLIN

Opsonin

Square

Aventis

Amoxycillin AMOXI

AMOXIL

AVLOMOX

BITOXIL

FIMOXYL

MOXACIL

MOXAPEN

MOXILIN

MOXIN

SERVIMOX

SK- MOX

TYCIL

Renata

Glaxo-Smithkline

ACI

Aventis/ Unihealth

Aventis

Square

Nipa

Acme

Opsonin

Novartis

SK+ F

Beximco

CO-Amoxiclav FIMOXYCLAV

MOXACLAV

Aventis

Square

Carbenkillin PYOPEN Beecham

(Shahidi. 2004)


Table 6

Cephalosporins.


Cefadroxil ADORA

AROCEF

CEDRIL

Incepta

SK+F

ACI

Cephalexin ACELEX

ALEXIN

CEPHALEN

CEPOREX

CEPORIN

KEFLIN

NEOREX

SELEX

Acme

Renata

Beximco

GlaxoSmithkline

Square

Opsonin

SK+F

Orion

Cephradine AVLOSEF

CEPHRAN

ACI

Opsonin


INTRACEF

KEFDRIN

LEBAC

POLYCEF

PROCEF

SEFIN

SEFRAD

Beximco

GlaxoSmithkline

Square

Renata

Incepta

Orion

Aventis

Cefaclor BIOCEF

CEFLON

LORACEF

Novartis

SK+F

Square

Cefuroxime AXET

CEFOTIL

CEROX-A

FUROCEF

KILBAC

ZINNAT

Orion

Square

ACI

Renata

Incepta

GlaxoSmithKline

Cefetamet GLOBOCEF Roche

Cefixime CEF-3

CEFIM-3

CEFTID

ROXIM

Square

ACI

Opsonin

SK+F


TRIOCIM Beximco

Cefotaxime MAXCEF

TAXIM

Square

Acme

Cefpodoxime STERIN

TAXETIL

XIMEPROX

SK+F

Aristopharma

Incepta

Ceftazidime CEFTAZIM

FORTUM

TAZID

Aristopharma

GlaxoSmithKline

Square

Ceftibuten CEDAX Janata Health Care

Ceftriaxone ACIPHIN

ARIXON

CEFTIZON

CEFTRON

ENOCEF

MEGION

ORICEF

TRAXON

ACI

Beximco

Renata

Square

Aventis

Novartis

Roche

Opsonin

(Shahidi. 2004)


Table 7

Tetracycline Group of Drugs.


Tetracycline DECACYCLINE

TETRACYCLINE

TETRACYN

TETRAX

Beximco

Opsonin

Renata

Square

Oxytetracycline OXYCIN

RENAMYCIN

Nipa

Renata

Doxycycline DOXACIL

DOXICAP

IMPEDOX

MEGADOX

SERVIDOSYNE

Square

Renata

ACI

Beximco

Novartis

(Shahidi. 2004)


Table 8

Aminoglycosides.


Amikacin KACIN ACI

Gentamicin GENACYN

GENTIN

INVIGEN

Square

Opsonin

Beximco

Kanamycin KANTREX Bristol/ Myers

(Shahidi. 2004)


Table 9

Macrolides.


Erythomycin EROMYCIN

ERYTHIN

ERYTHROX

ETROCIN

FIRMAC

MACROCIN

SERVITROCIN

Square

ACI

Renata

Beximco

Incepta

Aventis

Novartis

Azithromycin AZICIN

AZYTH

ODAZYTH

ZIMAX

ZITHRIN

ZITHROX

Opsonin

Novartis

ACI

Square

Renata

SK+F

Claithromycin BINOCLAR Novartis


REMAC

ROLACIN

Square

Beximco

Roxithromycin PEDILID Incepta

Sipramycin ROVAMYCINE Aventis

(Shahidi. 2004)

Table 10

Miscellaneous Antibiotics.


Chloramphenicol CHLORPHEN

OPSOMYCETIN

Nipa

Opsonin

Vancomycin VANCOMYCIN DBL/ Globex

(Shahidi. 2004)


Table 11

Sulphonamides and Trimethoprin.


Sulphasalazine SALAZINE Opsonin

Co- trimoxaxzole AVLOTRIN

BACTIPRONT

BITRIM

COSAT

COTRIM

COTS

FISAT

MEGATRIM

OCTRIM

SUPTRIM

ACI

Renata

Aventis

SK+ F

Square

Opsonin

Aventis

Beximco

Orion

Incepta

(Shahidi. 2004)


Table 12

Quinolone Groups


Ciprofloxacin CIPROCIN

CIPROX

FIPROX

FLONTIN

FLOXABID

MAPROCIN

NEOFLOXIN

QUINOX

SERVIFLOX

Square

Opsonin

Aventis

Renata

ACI

Orion

Beximco

SK+ F

Novartis

Levofloxacin LEFLOX

LEVOX

LEVOXIN

TREVOX

ACI

Opsonin

Incepta

Square


XENOXIN SK+ F

Lomefloxaci MEXLO Square

Moxifloxacin MAXIMOX Orion

Ofloxacin RUTIX Square

Pefloxacine PEFLACINE

PIPROX

Aventis

Opsonin

Sparfloxacin ACIFLOX

PARLOX

SAGA

SPACIN

SPARLIN

ACI

SK+ F

Square

Novartis

Beximco

(Shahidi. 2004)


Table 13

Anti tubercular Antibiotics.


Streptomycin STREPTOMYCIN Opsonin

Rifampicin FIRIFAM

REFANIN

RIMACTANE

Aventis

Opsonin

Novartis

Isoniazid INH

SERVIZID

Aventis

Novartis

Ethambutol FLAMBUTOL

SERVAMBUTOL

Aventis

Novartis

Pyrazinamide FIRAZIN

TUBRANIN

Aventis

Opsonin


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