Over-Prescription and Overuse of Antimicrobials in the Eastern Mediterranean Region: The Urgent Need for Antimicrobial Stewardship Programs with Access, Watch, and Reserve Adoption

Round 1

Reviewer 1 Report

This is a good paper,and suitable for publication.

Author Response

Dear Reviewer,

We would like to thank you for your valuable comments and for dedicating time to review our manuscript.

Many thanks

Reviewer 2 Report

Comments to authors

1.      Title. There may be need to amend the title to reflect the findings. It appears that antimicrobial over-prescription (which is the problem of the healthcare givers) was largely responsible for the drug over use or misuse being reported.  I suggest “Over-prescription and overuse of antimicrobials in the Eastern Mediterranean Region: The urgent need for antimicrobial stewardship to curb antimicrobial resistance”

2.      Abstract; Line 12: In the Eastern Mediterranean region (EMR), there is dearth of information…..

3.      Line 16: Constituted the sample population…

4.      Line 20: Top three classes of antimicrobials….  

5.      Line 23:”Compliance with quality indicators of antimicrobial use was limited”.  What does this entail? State exactly what was/were observed (limited).

6.      Introduction: The authors may want to provide some background information on “misuse” and “overuse” of antibiotic and The “AWaRe” programme

7.      Lines 58-58: The generic and species names of microorganisms should be italic

8.      Line 59-63: Does the use of antimicrobials actually contribute to antimicrobial resistance or is it the imprudent usage that leads to the emergence and spread of AMR organisms?  

9.      Results: Table 1: Since the caption of the first column is “antimicrobial group”. There is no need to split cephalosporin group into first, second and third generations but to have it as combine it as cephalosporin group, in line with the column caption. It’s wonderful to provide detailed breakdown (first, second , third, fourth generations)

 on the usage of each group of antimicrobial, not just for cephalosporin but fluoroquinolones, e.t.c. if the authors wish; but this should form another Table.

10.  Why group macrolides and lincosamides together in the results (Table 1, Fig. 3, e.t.c.)

11.  Discussion: From lines 86-88, it is clear that the antimicrobials used were actually prescribed. It appears that the problem is first of all over-prescription before over use. Over-prescription indicts the health care. This should be discussed

12.   Line 219-220: This statement is not evidence based, even though there is a citation. The authors did not investigate AMR and cannot make such categorical statement as if it is one of their findings. The statement should be rephrased.

13.  The authors failed to discuss the AMR and other implications of the over use of antimicrobials in the watch group (Fig 4), according to the AWaRe classification.   

14.  Materials and methods: Did the authors obtain ethical approval or clearance for this study? Both ethical approval and statement of informed consent are require and in fact pre-requisites before collecting patients’ health information.

 

Author Response

Dear Reviewer,

Kindly find our responses on the attached file. Detailed response to the comments is at the end of the attached modified manuscript.

 

 

 

Author Response File: Author Response.pdf

Reviewer 3 Report

Authors present their work entitled "Overuse of antimicrobials in the Eastern Mediterranean Region: The urgent need for antimicrobial stewardship 

programmes with Access, Watch, and Reserve adoption.

 

The survey occurred between September to December 2019 in seven countries in the Eastern Mediterranean region within 139 hospitals using a standardized point prevalence survey.

 

Of 19,611 inpatients surveyed, 11,168 patients received at least one antimicrobial with a crude prevalence: of 56.9%. 

The top three antimicrobials prescribed were third-generation cephalosporins (26.7%), beta-lactam penicillins (18.1%), and imidazole derivatives (n=1655, 9.8%).

They suggest that antimicrobial stewardship programmes in the region may help to optimize antimicrobial use and reduce antimicrobial resistance.

 

The work is well written and presented and may be published after minor editorial modifications.

 

 

 

 

In my opinion, the authors are dealing with a topic highly relevant and of scientific merit. They may help to mitigate the problem of antimicrobial resistance in the region of interest.

 

 

Author Response

Dear Reviewer,

Many thanks for your valuable comments and for taking time to review our manuscrpt.

Round 2

Reviewer 2 Report

The authors have improved the manuscript but a few issues still need to be addressed in my view.

1. Table 1: If the authors choose to retain the information of different generations of cephalosporins in it's currents form, they may have to thinker a little on the column heading. For instance, they could replace "Antimicrobial group" with "Antimicrobial group/sub-group"  

2. Lines 237-239: At least one citation is required to authenticate this claim.

3. Lines 350-351: The authors wrote "For patients receiving an antimicrobial agent, the teams collected information on the type, dose, indication for prescription, and site of infection". This don't seem to me as a retrospective data abstraction. It rather suggests an active data collection from patients, and this makes provision of statement of informed consent for this study imperative; contrary to the claims of the authors in their response.

4. Lines 422-425: Author should kindly insert the web link or reference number to the ethical approval grated for this study by the institutional review board.

Author Response

Dear Reviewer,

Thanks for taking time again to review the manuscript for the second time. Please find below our response to your valuable comments:

• Table 1: If the authors choose to retain the information of different generations of cephalosporins in it's currents form, they may have to thinker a little on the column heading. For instance, they could replace "Antimicrobial group" with "Antimicrobial group/sub-group" The heading is changed to Antimicrobial group / sub-group 
• Lines 237-239: At least one citation is required to authenticate this claim. One citation is added
• Lines 350-351: The authors wrote "For patients receiving an antimicrobial agent, the teams collected information on the type, dose, indication for prescription, and site of infection". This don't seem to me as a retrospective data abstraction. It rather suggests an active data collection from patients, and this makes provision of statement of informed consent for this study imperative, contrary to the claims of the authors in their response. It is elaborated that the data was collected from the medical records
• Lines 422-425: Author should kindly insert the web link or reference number to the ethical approval grated for this study by the institutional review board. We added the number of the ethical approval