Potential strategies to reduce inappropriate prescribing and dispensing of antimicrobials in Bangladesh building on the experiences in other developing countries

TLDR: The objective was to establish an experimental procedure and show direct results that can be used as a guide for clinical practice in the treatment of central giant cell granuloma and its complications.

Abstract: In our previous editorial, we discussed that antimicrobial resistance (AMR) is a growing problem world-wide increasing morbidity, mortality and costs1-3. This needs to be urgently addressed with the World Bank recently documenting that the costs associated with AMR could exceed US$1 trillion annually after 2030, and potentially up to US$3.4 trillion annually, unless activities are instigated across countries to improve the prescribing and dispensing of antibiotics4. This is equivalent to 3.8% of annual Gross Domestic Product (GDP)4, with the costs associated with AMR typically greatly exceeding the costs of any antibiotic prescribed or dispensed5. We are aware that mortality rates from AMR are likely to be greatest among low- and middle-income countries (LMICs), including Asian countries such as Bangladesh by 2050, which is a concern going forward6,7. This builds on considerable resistance already to commonly prescribed antibiotics among LMICs including Bangladesh, with AMR rates continuing to rise2,8-15 enhanced by appreciable usage in animal and food production alongside humans16-18. In their recent study, Ara et al. (2021) found high rates of resistance to colistin as well as amoxicillin/clavulanic acid and the cephalosporins in isolates of women attending out-patient clinics for urinary tract infections9. This needs to be urgently addressed.

Figures

Figure 1 : Overview of activities to improve antibiotic utilisation in ambulatory care and the rationale

Full text

700
Bangladesh Journal of Medical Science Vol. 20 No. 04 October’21
Invited Editorial
Potential strategies to reduce inappropriate prescribing and dispensing of antimicrobials in Bangladesh
building on the experiences in other developing countries
Mainul Haque
1
, Brian Godman
2,3,4*
Keywords:Acuterespiratorytractinfections,Antimicrobialresistance,Bangladesh,Community
pharmacies,COVID-19,Prescribing,self-purchasingantibiotics
Correspondence to: Brian Godman, Strathclyde Institute of Pharmacy and Biomedical Sciences,
UniversityofStrathclyde,GlasgowG40RE,UnitedKingdom.Email:Brian.Godman@strath.ac.uk.
Telephone:+44(0141)5483825.Fax:+44(0141)5522562
1. UnitofPharmacology,FacultyofMedicineandDefenceHealth,UniversitiPertahananNasionalMalaysia
(NationalDefenceUniversityofMalaysia),KemPerdanaSungaiBesi,57000KualaLumpur,Malaysia.
2. StrathclydeInstituteofPharmacyandBiomedicalSciences,UniversityofStrathclyde,GlasgowG40RE,
United Kingdom.
3. DivisionofPublicHealthPharmacyandManagement,SchoolofPharmacy,SefakoMakgathoHealth
Sciences University, Pretoria, South Africa
4. School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
Bangladesh Journal of Medical Science Vol. 20 No. 04 October’21. Page : 700-706
DOI: https://doi.org/10.3329/bjms.v20i4.54123
In our previous editorial, we discussed that
antimicrobial resistance (AMR) is a growing
problemworld-wideincreasingmorbidity,mortality
and costs
1-3
.Thisneedstobeurgentlyaddressedwith
theWorldBankrecentlydocumentingthatthecosts
associated with AMR could exceed US$1 trillion
annually after 2030, and potentially up to US$3.4
trillion annually, unless activities are instigated across
countriestoimprovetheprescribinganddispensing
of antibiotics
4
.Thisisequivalentto3.8%ofannual
Gross Domestic Product (GDP)
4
, with the costs
associated with AMR typically greatly exceeding
thecostsofanyantibioticprescribedordispensed
5
.
We are aware that mortality rates from AMR are
likelytobegreatestamonglow-andmiddle-income
countries (LMICs), includingAsian countries such
as Bangladesh by 2050, which is a concern going
forward
6,7
. This builds on considerable resistance
already to commonly prescribedantibiotics among
LMICs including Bangladesh, with AMR rates
continuing to rise
2,8-15
enhancedbyappreciableusage
inanimalandfoodproductionalongsidehumans
16-18
.
In their recent study, Ara et al. (2021) found high
ratesofresistancetocolistinaswellasamoxicillin/
clavulanicacidandthecephalosporinsinisolatesof
womenattendingout-patientclinicsforurinarytract
infections
9
.Thisneedstobeurgentlyaddressed.
Rising AMR rates in Bangladesh and other LMICs have
beenenhancedbyconsiderableover-prescribingand
dispensingofantibioticsforessentiallyviralinfections
suchasacuterespiratorytractinfections(ARIs)
12,19-21
.
Thisisimportantwithupto80%ormoreofpatientsin
LMICs receiving antibiotics unnecessarily for ARIs
21-
23
.Thisover-useofantibioticshasbeenexacerbatedby
theCOVID-19pandemic
24-26
,withstudiessuggesting
high rates of antibiotic utilisation, including broad
spectrum antibiotics, even without proven bacterial
infections
27-29
. Overall, less than 10% of COVID
19 patients appear to have concomitant fungal or
bacterial infections necessitating antimicrobials
30
,
whichcouldbeaslowas3.2%insome studies
31,32
.
Despitethis,anappreciablenumberofpatientswith
actual or suspected COVID-19 are prescribed or
dispensedantibiotics,increasingshortages,costsand
AMR
31,33-35
.
High levels of inappropriate use of antibiotics in
ambulatory care in Bangladesh and other LMICs
mirrorsconcernswiththeirprescribinginhospitals
including inappropriate timing of the rst dose of
antibioticstopreventsurgicalsiteinfectionsaswell
as extended use
1,36
.

701
PotentialstrategiestoreduceinappropriateprescribinganddispensingofantimicrobialsinBangladeshbuildingontheexperiencesinotherdevelopingcountries
Theconcernswithinappropriateuseofantimicrobials
andtheimpactonAMRhasresultedinmanycountries
including Bangladesh launching their National
Action Plans (NAPs) following guidance from the
WorldHealthOrganisation
1,14,37,38
.Typically,therst
stepsinhospitalstoreduceinappropriateprescribing
of antibiotics include undertaking point prevalence
studies to document current utilisation patterns
and their rationale coupled with the instigation of
antimicrobialstewardshipgroups
1,39-42
.Ourprevious
editorial discusses such activities in more detail
1
.
However, in this editorial we will just focus on
ambulatorycareespeciallyamongLMICsincluding
Bangladesh.
Key stakeholders involved with improving
antimicrobial usage in Bangladesh in ambulatory
care include physicians, pharmacists/ drug store
owners and patients
14,19,43
. Community pharmacies
anddrugstoresareparticularlyimportantincountries
suchasBangladeshwithhighpatientco-payments,
patients having diculties with purchasing both
medicines as well as paying for physician fees,
storesopenforlongerhoursthanphysicianoces,
and antimicrobials freely available over-the-counter
despitelegislation,similartootherLMICsincluding
Pakistan
14,44-47
.
We have seen among LMICs including Kenya,
Namibia,theRepublicofSrpskaandSriLanka(Figure
1)thattrainedpharmacists,coupled with guideline
availability, can appreciably reduce inappropriate
dispensingofantibioticsespeciallyforARIsincluding
patients with COVID 19
48-53
. This has important
ramicationsforcountriessuchasBangladesh,andit
isencouragingtoseethatcommunitypharmacistsin
Bangladesh,especiallyinruralareas,areapreferred
and trusted source of information and medicines for
managing infections
45
.Thismirrorsthesituationin
other countries with the growing involvement of
pharmaciesinthemanagementofdiseasesincluding
infectious diseases
54-56
. The development of the
ModelPharmacyProgrammeshouldhelpalongside
greater education regarding antibiotics and infectious
diseases among pharmacy students in Bangladesh
during their training given current concerns,
althoughwehaveseengreaterknowledgeregarding
antimicrobials among biological versus non-
biological students in Bangladesh
43,44,57
. Concerns
with pharmacists’ knowledge regarding antibiotics
and AMR in Bangladesh mirror those in other LMICs,
necessitating greater input during undergraduate
trainingaswellaspostqualication
44,53,58-60
.
A key way forward could also be to restrict the
range of antibiotics that can be dispensed within
Figure1:Overviewofactivitiestoimproveantibioticutilisationinambulatorycareandtherationale

702
MainulHaque,BrianGodman
community pharmacies and drug stores based on
the WHO AWaRe list of antibiotics, especially
with concerns with rising resistance rates to
critical antibiotics such as colistin
9,18,61,62
, alongside
improving pharmacists’ knowledge. We have seen
regulations in other LMICs restricting antimicrobials
thatcanbedispensedbygradeofpharmacy,which
provide guidance to the authorities in Bangladesh
63
.Thismaybepreferrabletoningpharmacistsfor
dispensing antimicrobials without a prescription,
whichcouldbecounter-productiveespeciallyinrural
settingsandslumareaswherepatientshavelimited
incomesandcannotaordtotaketimeoworkto
visit a physician
19,64,65
. This could be accompanied
bytheuseofmobileandothertechnologiestotrack
antimicrobialdispensinginpharmacies
65
,especially
if there are concerns with the extent of antibiotics
being dispensed for essentially viral infections
exacerbatedbycommercialpressures,whichinclude
thosefrompharmaceuticalcompanies
44,66
.
Concomitant with this, instigating targeted
educational programmes among patients building
ontheexperienceswithCOVID-19,whichincludes
improvinghygieneandthewatersupplyaswellas
addressingtheimplicationsofmisinformation
14,34,67
.
We have also seen a number of activities among
physicians in LMICs to reduce inappropriate
prescribingofantibioticsespeciallyforpatientswith
ARIs(Figure1).Boonyasiriet al.(2014)inThailand
ascertainedthattheinstigationofmultipleeducational
initiativeslimitedtheprescribingofantibioticstojust
13%ofpatientswithARIs
68
, and Wei et al. (2019)
in China also found that multiple interventions,
especiallysurroundingeducation,resultedina49%
reductionintheprescribingofantibioticsforARIs
after6months,withthisreductionpersisting
69
. More
recently,Tayet al.(2019)inMalaysiaalsofoundthat
multipleinterventionsincludingtoolkitsappreciably
reducedantibioticprescribing forARIs downfrom
29.1% of patients to 13.7%
70
.This follows similar
activitiesandndingsinhigher-incomecountries
19
,
with such activities helping to reduce adverse
inuencesfrompharmaceuticalcompanies
71
.
In conclusion in Bangladesh, the rst steps have
been taken by the authorities to improve future
antimicrobial use through the development and
publication of their NAP as well as the Global
AntibioticResistancePartnership(GARP)initiative.
The next steps involve co-ordinated activities
especially in ambulatory care to improve future
prescribing and dispensing of antimicrobials along
with similar activities in animal management and
food production. Co-ordinated activities among
physicians, pharmacists and patients have worked
well in other countries to improve utilisation
comparedwithcountrieswithlimitedmeasures
72-75
.
Asaresult,providingdirectionandguidancetokey
groupsinBangladesh.Wewillcontinuetomonitor
such developments and the need for additional
activities given concerns with risingAMR rates in
Bangladesh.
Conicts of interest
Theauthorshavenoconictsofinteresttodeclare.
Authors Orcid ID
MainulHaque https://orcid.org/0000-0002-6124-7993
Brain Godman https://orcid.org/0000-0001-6539-6972

703
PotentialstrategiestoreduceinappropriateprescribinganddispensingofantimicrobialsinBangladeshbuildingontheexperiencesinotherdevelopingcountries
References:
1. Haque M,Godman B. PotentialStrategiesto Improve
Antimicrobial Utilisation in Hospitals in Bangladesh
BuildingonExperiencesAcrossDevelopingCountries.
Bangladesh Journal of Medical Science. 2021; 19 (3):
469-77.DOI:https://doi.org/10.3329/bjms.v20i3.52787.
2. Haque M. Antimicrobial Use, Prescribing, And
Resistance in Selected Ten Selected Developing
Countries:ABriefOverview.Asian J Pharm Clin Res.
2017;10(8):37-45.
 DOI:http://dx.doi.org/10.22159/ajpcr.2017.v10i8.19468
3. Hofer U. The cost of antimicrobial resistance. Nature
reviews Microbiology. 2019;17(1):3. doi: 10.1038/
s41579-018-0125-x.
4. The World Bank. Final Report - DRUG-RESISTANT
INFECTIONS.AThreattoOurEconomicFutureMarch
2017.AvailableatURL:http://documents1.worldbank.
org/curated/en/323311493396993758/pdf/nal-report.
pdf.
5. Shrestha P, Cooper BS, Coast J, Oppong R, Do Thi
Thuy N, Phodha T, et al. Enumerating the economic
costofantimicrobialresistanceperantibioticconsumed
toinformtheevaluationofinterventionsaectingtheir
use. Antimicrobial Resistance & Infection Control.
2018;7(1):98.doi:10.1186/s13756-018-0384-3
6. O’Neill. TACKLING DRUG-RESISTANT
INFECTIONS GLOBALLY: FINAL REPORT AND
RECOMMENDATIONS. 2016. Available at URL:
https://amr-review.org/sites/default/files/160518_
Final%20paper_with%20cover.pdf.
7. DadgostarP.AntimicrobialResistance:Implicationsand
Costs. Infection and drug resistance.2019;12:3903-10.
doi:10.2147/IDR.S234610
8. Urmi UL, Nahar S, Rana M, Sultana F, Jahan N,
Hossain B, et al. Genotypic to Phenotypic Resistance
Discrepancies Identied Involving β-Lactamase
Genes, blaKPC, blaIMP, blaNDM-1, and blaVIM in
Uropathogenic Klebsiella pneumoniae. Infection and
drug resistance. 2020;13:2863-75. doi: 10.2147/IDR.
S262493
9. Ara B, Urmi UL, Haque TA, Nahar S, Rumnaz A,
Ali T, et al. Detection of mobile colistin-resistance
gene variants (mcr-1 and mcr-2) in urinary tract
pathogens in Bangladesh: the last resort of infectious
disease management colistin ecacy is under threat.
Expert review of clinical pharmacology. 2021. doi:
10.1080/17512433.2021.1901577
10. Ahmed I, Rabbi Md. B, Sultana S. Antibiotic resistance
in Bangladesh: A systematic review. International
Journal of Infectious Diseases. 2019; 80: 54–61. doi:
10.1016/j.ijid.2018.12.017
11. MannanA,ShohelM,RajiaS,MahmudNU,KabirS,
HasanI.Acrosssectionalstudyonantibioticresistance
pattern of Salmonella typhi clinical isolates from
Bangladesh. Asian Pac J Trop Biomed. 2014;4(4):306-
11. doi:10.12980/APJTB.4.2014C770
12. The GARP-Bangladesh National Working Group.
Antibiotic Use and Resistance in Bangladesh: Situation
Analysis and Recommendations. 2018. Available at
URL: https://cddep.org/wp-content/uploads/2018/08/
antibiotic-use-and-resistance-in-bangladesh.pdf.
13. HameedF,KhanMA,BilalH,MuhammadH,TayyabUr
R.DetectionofMCR-1GeneinMultipleDrugResistant
EscherichiacoliandKlebsiellapneumoniaeinHuman
ClinicalSamplesfromPeshawar,Pakistan.Comb Chem
High Throughput Screen. 2020. doi:10.2174/13862073
23666200914100119
14. HoqueR,Ahmed SM,NaherN, IslamMA, Rousham
EK, IslamBZ, et al.Tacklingantimicrobial resistance
in Bangladesh: A scoping review of policy and
practice in human, animal and environment sectors.
PloS one. 2020;15(1):e0227947. doi: 10.1371/journal.
pone.0227947
15. Islam A, Rahman Z, Monira S, Rahman MA, Camilli
A, George CM, et al. Colistin resistant Escherichia
coli carrying mcr-1 in urban sludge samples: Dhaka,
Bangladesh. Gut Pathog. 2017;9:77. doi: 10.1186/
s13099-017-0227-4
16. VanBoeckelTP,PiresJ, SilvesterR,ZhaoC,SongJ,
Criscuolo NG, et al. Global trends in antimicrobial
resistance in animals in low- and middle-income
countries. Science. 2019;365(6459). doi: 10.1126/
science.aaw1944
17. WangY,HuY,CaoJ,BiY,LvN,LiuF,etal.Antibiotic
resistance gene reservoir in live poultry markets. The
Journal of infection.2019;78(6):445-53. doi:10.1016/j.
jinf.2019.03.012
18. IslamS,UrmiUL,RanaM,SultanaF,JahanN,Hossain
B,etal.Highabundanceofthecolistinresistancegene
mcr-1inchicken gut-bacteriain Bangladesh.Sci Rep.
2020;10(1):17292.doi:10.1038/s41598-020-74402-4
19. Godman B, Haque M, McKimm J, Abu Bakar M,
SneddonJ,WaleJ,etal.Ongoingstrategiestoimprove
the management of upper respiratory tract infections
and reduce inappropriate antibiotic use particularly
among lower and middle-income countries: ndings
and implications for the future. Current medical
research and opinion. 2020;36(2):301-27. doi:
10.1080/03007995.2019.1700947
20. Shaikhan F, Rawaf S, Majeed A, Hassounah S.
Knowledge, attitude, perception and practice
regarding antimicrobial use in upper respiratory
tract infections in Qatar: a systematic review.
JRSM open. 2018;9(9):2054270418774971. doi:
10.1177/2054270418774971

704
MainulHaque,BrianGodman
21. Sulis G, Adam P, Nafade V, Gore G, Daniels B, Daftary A,
etal.Antibioticprescriptionpracticesinprimarycarein
low-andmiddle-incomecountries:Asystematicreview
and meta-analysis. PLoS Med. 2020;17(6):e1003139.
doi:10.1371/journal.pmed.1003139
22. Al-Amin S, Hassan MZ, Saif-Ur-Rahman KM,
Chowdhury MAB, Morrison SD, Donevant SB, et al.
Patternofantibioticuseforacuterespiratoryinfections
amongout-patientsinSouthAsianRegion:Protocolfor
a systematic review. Medicine. 2021;100(4):e22398.
doi:10.1097/MD.0000000000022398
23. Zhang Z, Hu Y, Zou G, Lin M, Zeng J, Deng S,
et al. Antibiotic prescribing for upper respiratory
infections among children in rural China: a
cross-sectional study of outpatient prescriptions.
Glob Health Action. 2017;10(1):1287334. doi:
10.1080/16549716.2017.1287334
24. Majumder MAA, Rahman S, Cohall D, Bharatha A,
Singh K, Haque M, et al.Antimicrobial Stewardship:
Fighting Antimicrobial Resistance and Protecting
Global Public Health. Infection and drug resistance.
2020;13:4713-38.doi:10.2147/IDR.S290835
25. UNA-SUS. FIOCRUZ IN THE AIR: Covid-19 and
antibiotic self-medication: a dangerous combination.
2020. Available at URL: https://www.unasus.gov.br/
noticia/ocruz-no-ar-covid-19-e-a-automedicacao-de-
antibioticos-uma-combinacao-perigosa.
26. SchuelerP.AntibioticresistanceandCOVID-19.2020.
Available at URL: https://www.bio.ocruz.br/index.php/
br/noticias/1823-modernidade-e-sustentabilidade-no-
centro-tecnologico-de-plataformas-vegetais.
27. Strathdee SA, Davies SC, Marcelin JR. Confronting
antimicrobial resistance beyond the COVID-19
pandemic and the 2020 US election. Lancet.
2020;396(10257):1050-3. doi: 10.1016/S0140-
6736(20)32063-8
28. Rawson TM, Moore LSP, Zhu N, Ranganathan
N, Skolimowska K, Gilchrist M, et al. Bacterial
and Fungal Coinfection in Individuals With
Coronavirus:A Rapid Review To Support COVID-19
Antimicrobial Prescribing. Clinical infectious diseases.
2020;71(9):2459-68.doi:10.1093/cid/ciaa530
29. Rodríguez-ÁlvarezM,López-VidalY,Soto-Hernández
JL, Miranda-Novales MG, Flores-Moreno K, Ponce
de León-Rosales S. COVID-19: Clouds Over the
Antimicrobial Resistance Landscape. Archives of
medical research. 2021;52(1):123-6. doi: 10.1016/j.
arcmed.2020.10.010
30. Hsu J. How covid-19 is accelerating the threat of
antimicrobial resistance. BMJ. 2020;369:m1983. doi:
10.1136/bmj.m1983
31. Sriram A, Kalanxhi E, Kapoor G, Craig J,
Balasubramanian R,BrarSet al. State of the world’s
antibiotics 2021: A global analysis of antimicrobial
resistance and its drivers. Center for Disease Dynamics,
Economics & Policy, Washington DC. 2021. Available
at URL: https://cddep.org/wp-content/uploads/2021/02/
The-State-of-the-Worlds-Antibiotics-in-2021.pdf.
32. NoriP,CowmanK,ChenV,BartashR,SzymczakW,
Madaline T, et al. Bacterial and fungal coinfections
in COVID-19 patients hospitalized during the New
York City pandemic surge. Infection control and
hospital epidemiology. 2021;42(1):84-8. doi: 10.1017/
ice.2020.368
33. Langford BJ, So M, Raybardhan S, Leung V, Soucy JR,
WestwoodD,etal.Antibioticprescribinginpatientswith
COVID-19: rapid review and meta-analysis. Clinical
microbiology and infection. 2021; 27(4):520-531. doi:
10.1016/j.cmi.2020.12.018
34. GodmanB,HaqueM,IslamS,IqbalS,UrmiUL,Kamal
ZM, et al. Rapid Assessment of Price Instability and
Paucity of Medicines and Protection for COVID-19
AcrossAsia: Findings and Public Health Implications
for the Future. Frontiers in Public Health. 2020;8(744).
doi:10.3389/fpubh.2020.585832
35. HaqueM,IslamS,IqbalS,UrmiUL,KamalZM,Shuvo
SA et al. Availability and price changes of potential
medicines and equipment for the prevention and
treatmentofCOVID-19amongpharmacyanddrugstores
in Bangladesh; ndings and implications. Bangladesh
Journal of Medical Science2020; 19Special Issueon
Covid19: S36-S50. DOI:https://doi.org/10.3329/bjms.
v19i0.48106
36. Mwita JC, Ogunleye OO, Olalekan A, Kalungia AC,
Kurdi A, Saleem Z, et al. Key Issues Surrounding
AppropriateAntibiotic Use for Prevention of Surgical
SiteInfectionsinLow-andMiddle-IncomeCountries:A
NarrativeReviewandtheImplications.Int J Gen Med.
2021;14:515-30. doi:10.2147/IJGM.S253216
37. IACG.NOTIMETOWAIT:SECURINGTHEFUTURE
FROM DRUG-RESISTANT INFECTIONS. REPORT
TOTHESECRETARY-GENERALOFTHEUNITED
NATIONS. April 2019. Available at URL: https://
www.who.int/antimicrobial-resistance/interagency-
coordination-group/IACG_nal_report_EN.pdf.
38. Ministry of Health and Family Welfare (MoHFW),
Government of Bangladesh. National Action
Plan: Antimicrobial Resistance Containment in
Bangladesh 2017-’22. 2017. Available from URL:
https://www.flemingfund.org/wp-content/uploads/
d3379eafad36f597500cb07c21771ae3.pdf.
39. Saleem Z, Godman B, Hassali MA, Hashmi FK,
Azhar F, Rehman IU. Point prevalence surveys of
health-care-associated infections: a systematic review.
Pathogens and global health.2019;113(4):191-205.doi:
10.1080/20477724.2019.1632070
40. Saleem Z, Hassali MA, Godman B, Versporten A,

Frequently asked questions

Q1. What are the contributions mentioned in the paper "Potential strategies to reduce inappropriate prescribing and dispensing of antimicrobials in bangladesh building on the experiences in other developing countries" ?

Godman et al. this paper presented a study on the use of pharmacology at the University of Strathclyde in Malaysia. 

Q2. How many patients with COVID 19 have concomitant infections necessit?

less than 10% of COVID 19 patients appear to have concomitant fungal or bacterial infections necessitating antimicrobials30, which could be as low as 3.2% in some studies31,32. 

Q3. What is the last resort of colistin efficacy in Bangladesh?

Detection of mobile colistin-resistance gene variants (mcr-1 and mcr-2) in urinary tract pathogens in Bangladesh: the last resort of infectious disease management colistin efficacy is under threat. 

Q4. Who are the key stakeholders involved in improving antibiotic use in Bangladesh?

Key stakeholders involved with improving antimicrobial usage in Bangladesh in ambulatory care include physicians, pharmacists/ drug store owners and patients14,19,43. 

Q5. What is the impact of antibiotics on AMR?

The concerns with inappropriate use of antimicrobials and the impact on AMR has resulted in many countries including Bangladesh launching their National Action Plans (NAPs) following guidance from the World Health Organisation1,14,37,38. 

Q6. What are the main reasons for the need for antibiotics in Bangladesh?

Community pharmacies and drug stores are particularly important in countries such as Bangladesh with high patient co-payments, patients having difficulties with purchasing both medicines as well as paying for physician fees, stores open for longer hours than physician offices, and antimicrobials freely available over-the-counter despite legislation, similar to other LMICs including Pakistan 14,44-47. 

Q7. What are the steps to reduce inappropriate prescribing of antibiotics in Bangladesh?

the first steps in hospitals to reduce inappropriate prescribing of antibiotics include undertaking point prevalence studies to document current utilisation patterns and their rationale coupled with the instigation of antimicrobial stewardship groups1,39-42. 

Q8. What is the role of antibiotics in the treatment of COVID-19?

This over-use of antibiotics has been exacerbated by the COVID-19 pandemic24-26, with studies suggesting high rates of antibiotic utilisation, including broad spectrum antibiotics, even without proven bacterial infections27-29. 

Q9. What is the importance of antibiotics in ambulatory care in Bangladesh?

High levels of inappropriate use of antibiotics in ambulatory care in Bangladesh and other LMICs mirrors concerns with their prescribing in hospitals including inappropriate timing of the first dose of antibiotics to prevent surgical site infections as well as extended use1,36. 

Q10. What could be done to reduce antibiotic prescribing in Bangladesh?

This could be accompanied by the use of mobile and other technologies to track antimicrobial dispensing in pharmacies 65, especially if there are concerns with the extent of antibiotics being dispensed for essentially viral infections exacerbated by commercial pressures, which include those from pharmaceutical companies44,66.