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      Knowledge, attitudes and behaviors on antimicrobial resistance among general public across 14 member states in the WHO European region: results from a cross-sectional survey

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          Abstract

          Background

          Antimicrobial resistance (AMR) is a major global public health threat requiring urgent action. Pan-European data on knowledge, attitudes and behaviors among the general public regarding antibiotic use and AMR is limited.

          Methods

          A multicentric, cross-sectional survey of the general public was conducted in the capital cities of 14 Member States of the WHO European Region. A validated questionnaire from the AMR Eurobarometer survey was used to collect data on antibiotic use and knowledge, access to antibiotics, and understanding of policy responses through face-to-face exit interviews.

          Results

          Out of 8,221 respondents from 14 Member States, 50% took antibiotics in the past 12 months and the majority (53%) obtained their most recent course from a medical practitioner. The most reported reasons for taking antibiotics orally in the past 12 months were cold (24%), sore throat (21%), cough (18%), and flu (16%). Overall, 84% of participants showed a lack of knowledge about appropriate antibiotic use. However, only 37% of respondents reported receiving any information in the past year about the importance of avoiding unnecessary antibiotic use. Doctors were the most cited (50%) and most trusted (80%) source of information. Among respondents who experienced COVID-19, 28% took antibiotics with a prescription, while 8% took antibiotics without a prescription.

          Conclusion

          This study highlights the urgent need for targeted awareness campaigns and educational initiatives to address knowledge gaps and promote responsible antibiotic use. The findings emphasize the role of the general population in combating AMR. The data serve as baseline information for future evaluations and interventions in the Region.

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          Most cited references27

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          Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis

          (2022)
          Summary Background Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen–drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen–drug combinations in 204 countries and territories in 2019. We obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years. We used predictive statistical modelling to produce estimates of AMR burden for all locations, including for locations with no data. Our approach can be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drug-resistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. We present final estimates aggregated to the global and regional level. Findings On the basis of our predictive statistical models, there were an estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9–35·3), and lowest in Australasia, at 6·5 deaths (4·3–9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000–1 270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019. One pathogen–drug combination, meticillin-resistant S aureus, caused more than 100 000 deaths attributable to AMR in 2019, while six more each caused 50 000–100 000 deaths: multidrug-resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporin-resistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae, and third-generation cephalosporin-resistant K pneumoniae. Interpretation To our knowledge, this study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.
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            The antibiotic resistance crisis: part 1: causes and threats.

            Decades after the first patients were treated with antibiotics, bacterial infections have again become a threat because of the rapid emergence of resistant bacteria-a crisis attributed to abuse of these medications and a lack of new drug development.
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              Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis

              Summary Background Infections due to antibiotic-resistant bacteria are threatening modern health care. However, estimating their incidence, complications, and attributable mortality is challenging. We aimed to estimate the burden of infections caused by antibiotic-resistant bacteria of public health concern in countries of the EU and European Economic Area (EEA) in 2015, measured in number of cases, attributable deaths, and disability-adjusted life-years (DALYs). Methods We estimated the incidence of infections with 16 antibiotic resistance–bacterium combinations from European Antimicrobial Resistance Surveillance Network (EARS-Net) 2015 data that was country-corrected for population coverage. We multiplied the number of bloodstream infections (BSIs) by a conversion factor derived from the European Centre for Disease Prevention and Control point prevalence survey of health-care-associated infections in European acute care hospitals in 2011–12 to estimate the number of non-BSIs. We developed disease outcome models for five types of infection on the basis of systematic reviews of the literature. Findings From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 (95% uncertainty interval [UI] 583 148–763 966) infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. These infections accounted for an estimated 33 110 (28 480–38 430) attributable deaths and 874 541 (768 837–989 068) DALYs. The burden for the EU and EEA was highest in infants (aged <1 year) and people aged 65 years or older, had increased since 2007, and was highest in Italy and Greece. Interpretation Our results present the health burden of five types of infection with antibiotic-resistant bacteria expressed, for the first time, in DALYs. The estimated burden of infections with antibiotic-resistant bacteria in the EU and EEA is substantial compared with that of other infectious diseases, and has increased since 2007. Our burden estimates provide useful information for public health decision-makers prioritising interventions for infectious diseases. Funding European Centre for Disease Prevention and Control.
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                Author and article information

                Contributors
                Role: Role: Role: Role: Role: Role: Role: Role: Role: Role:
                URI : http://loop.frontiersin.org/people/2531914/overviewRole: Role: Role: Role:
                Role: Role: Role: Role: Role:
                URI : http://loop.frontiersin.org/people/1164534/overviewRole: Role: Role: Role: Role: Role: Role:
                URI : http://loop.frontiersin.org/people/2403547/overviewRole: Role: Role: Role: Role: Role: Role: Role:
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                23 November 2023
                2023
                : 11
                : 1274818
                Affiliations
                [1] 1Infectious Diseases Data Observatory (IDDO), University of Oxford , Oxford, United Kingdom
                [2] 2WHO Regional Office for Europe , Copenhagen, Denmark
                Author notes

                Edited by: Vera Manageiro, Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA), Portugal

                Reviewed by: Diane Ashiru-Oredope, UK Health Security Agency (UKHSA), United Kingdom; Karine Blouin, Laval University, Canada; Brittany Lauren Morgan Bustamante, University of California, Berkeley, United States

                *Correspondence: Ketevan Kandelaki kandelakik@ 123456who.int

                †These authors share first authorship

                Article
                10.3389/fpubh.2023.1274818
                10704021
                38074764
                0c3d77d9-fcee-4f55-b6f9-f99a794ff20b
                Copyright © World Health Organization 2023. Licensee Frontiers Media SA.

                This is an open access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, adaptation (including derivative works), distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction or adaptation of this article there should not be any suggestion that WHO or this article endorse any specific organisation or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

                History
                : 08 August 2023
                : 10 October 2023
                Page count
                Figures: 13, Tables: 1, Equations: 0, References: 33, Pages: 19, Words: 8172
                Funding
                Funded by: World Health Organization, doi 10.13039/100004423;
                The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This study was funded by grants provided by the Ministries of Health of Germany and the Kingdom of the Netherlands, which had no role in data collection, analysis, or interpretation of data. The WHO Control of Antimicrobial Resistance Programme, under the Division of Country Health Programmes, was the recipient of these grants and coordinated the development of this survey. This study was supported by the WHO Regional Office for Europe.
                Categories
                Public Health
                Original Research
                Custom metadata
                Public Health Education and Promotion

                antimicrobial resistance (amr),antibiotics,kab survey,who european region,behavior,antibiotic resistance

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