Antimicrobial resistance in Salmonella Typhi globally, and sources, prescribing, and consumption of antimicrobial medicines in Yangon, Myanmar

Abstract

Antimicrobial resistance is a major global health concern with the worst consequences being increased disease severity, duration, morbidity, and mortality experienced by individuals in low-and middle-income countries, including Myanmar. Strains of Salmonella Typhi, the bacterium responsible of typhoid fever, which are resistant to most classes of antimicrobials are spreading in Southern Asia. However worldwide data on the emergence of antimicrobial resistance in Salmonella Typhi have scarcely been reviewed. Antimicrobial resistance has been shown to be higher in locations where inappropriate antimicrobial use is common in both community and hospital settings. Little is known about the common sources of antimicrobials in the community or antimicrobial consumption in hospital settings in Myanmar. Consequently, it is clear that more comprehensive data on the prevalence of antimicrobial resistant bacteria worldwide, and on antimicrobial consumption in both the community and hospitals settings are required to combat the challenges posed by increasing antimicrobial resistance. In this thesis I present three projects which have objectives relating to antimicrobial use and antimicrobial resistance. First, I present a systematic review of the prevalence of antimicrobial resistant Salmonella Typhi worldwide. These data will contribute evidence to country-level decisions on whether or not to introduce the typhoid conjugate vaccine. Second, I present an analysis of a healthcare utilisation survey conducted in Myanmar to investigate where individuals with fever sought healthcare, the determinants of seeking healthcare at a formal healthcare provider, the medicines that were used by individuals with fever, and which healthcare providers were the major sources of antibacterial medicines used by individuals with fever. Finally, I present a point-prevalence survey of antimicrobial consumption and resistance at Yangon Children’s Hospital, Yangon, Myanmar. This point-prevalence survey was conducted to describe current antimicrobial prescribing practices and to identify targets for a pending antimicrobial stewardship programme. The work presented in this thesis and subsequent research outputs will contribute to an updated understanding of the prevalence of antimicrobial resistant Salmonella Typhi worldwide; help policy makers to understand major community sources of antimicrobials in Yangon Region, Myanmar; and give a snapshot of antimicrobial consumption and resistance at the largest referral children’s hospital in Myanmar and provide data on which an effective antimicrobial stewardship programme can be developed.