Antimicrobial Resistance in Developing Countries (eBook)
XXIII, 554 Seiten
Springer New York (Verlag)
978-0-387-89370-9 (ISBN)
Avoiding infection has always been expensive. Some human populations escaped tropical infections by migrating into cold climates but then had to procure fuel, warm clothing, durable housing, and crops from a short growing season. Waterborne infections were averted by owning your own well or supporting a community reservoir. Everyone got vaccines in rich countries, while people in others got them later if at all. Antimicrobial agents seemed at first to be an exception. They did not need to be delivered through a cold chain and to everyone, as vaccines did. They had to be given only to infected patients and often then as relatively cheap injectables or pills off a shelf for only a few days to get astonishing cures. Antimicrobials not only were better than most other innovations but also reached more of the world's people sooner. The problem appeared later. After each new antimicrobial became widely used, genes expressing resistance to it began to emerge and spread through bacterial populations. Patients infected with bacteria expressing such resistance genes then failed treatment and remained infected or died. Growing resistance to antimicrobial agents began to take away more and more of the cures that the agents had brought.
Foreword 5
Introduction 8
Preface 10
Acknowledgment 12
Contents 13
Contributors 17
Part 1: General Issues in Antimicrobial Resistance 22
1 Global Perspectives of Antibiotic Resistance 23
1.1 Introduction 23
1.2 The Biological Side of Resistance 24
1.3 The Pharmacological Side of Resistance 26
1.4 The Educational Side of Resistance 27
1.5 The Regulatory Side of Resistance 28
1.6 The Financial Side of Resistance 29
1.7 The Biological Consequences of Resistance 30
1.8 The Clinical Consequences of Resistance 31
1.9 Final Considerations 31
References 32
2 Mechanisms of Antimicrobial Resistance 34
2.1 Introduction 34
2.2 Mechanisms of Action of Antimicrobial Agents 36
2.3 Mechanisms of Antimicrobial Resistance 37
2.3.1 Resistance to beta-Lactam Antibiotics 38
2.3.2 Tetracycline Resistance 39
2.3.3 Chloramphenicol Resistance 40
2.3.4 Aminoglycoside Resistance 41
2.3.5 Quinolone Resistance 41
2.3.6 Macrolide, Lincosamide, and Streptogramin (MLS) Resistance 42
2.3.7 Glycopeptide Resistance 42
2.3.8 Sulfonamides and Trimethoprim Resistance 43
2.3.9 Multidrug Resistance 43
References 44
3 Poverty and Root Causes of Resistance in Developing Countries 46
3.1 Susceptibility to Infection 48
3.2 Access to Appropriate Care and Antimicrobials 49
3.3 The Challenge of Antimicrobial Quality Assurance in Low-Income Countries 50
3.4 Resistance Containment 51
References 52
4 What the Future Holds for Resistance in Developing Countries 55
4.1 Introduction 56
4.2 Improving the Knowledge Base 57
4.2.1 Improving the Knowledge Base in the Care of Individual Patients 57
4.2.2 Improving the Public Health Knowledge Base 58
4.3 Improving Information Flow 59
4.3.1 Improving Information Flow to Health Providers 59
4.3.2 Improving Information Flow to Consumers 60
4.4 Regulatory Environment 61
4.4.1 Regulating the Private Sector 61
4.4.2 Regulating the Public Sector 63
4.5 Management Capacity and Systems 64
4.6 Reducing Infectious Disease Burden 66
4.7 Improving Social and Economic Conditions 66
4.8 Alternatives to Standard Antimicrobial Therapy 67
4.9 Summary 67
References 73
5 The Introduction of Antimicrobial Agents in Resource-Constrained Countries: Impact on the Emergence of Resistance 76
5.1 Antimicrobial Resistance in Resource-Constrained Settings 77
5.2 Risk Factors for the Development of Antimicrobial Resistance After the Introduction of Antimicrobial Agents into Resource-Constrained Settings 77
5.2.1 Social Determinants 78
5.2.2 Health-Care Provider Factors 79
5.2.3 Patient-Related Determinants 80
5.2.4 Health-Care Institutional Factors 80
5.2.5 Governmental and Regulatory Issues 81
5.3 Antimicrobial Resistance After the Introduction of Antiretroviral Therapy into Developing Countries 82
5.4 Antimicrobial Resistance After the Introduction of Quinolones into Developing Countries 84
5.5 The Way Forward 85
References 86
Part 2: The Human Impact of Resistance 89
6 Human Immunodeficiency Virus: Resistance to Antiretroviral Drugs in Developing Countries 90
6.1 Introduction 90
6.1.1 Emergence and Transmission of Resistant HIV 92
6.1.2 Antiretroviral Therapy in Developing Countries 93
6.2 Emergence and Transmission of Resistant HIV 94
6.2.1 Adherence and Emergence of Resistance 94
6.2.2 Treatment Interruption and Emergence of Resistance 95
6.2.3 Measurement of Primary Resistance 96
6.2.4 Transmissibility of Resistant Viral Strains 97
6.3 ART Delivery Systems in Developing Countries: Implications for Resistance 97
6.4 Insights from Mathematical Modeling 99
6.4.1 Operational Questions 99
6.4.2 Emergence and Evolution of Resistance within Individuals 100
6.4.3 Transmission of Drug Resistance 100
6.5 Empirical Data on HIV Primary Resistance in Developing Countries 101
6.5.1 Asia 101
6.5.2 Africa 102
6.5.3 Latin America 103
6.5.4 Russia and Eastern Europe 103
6.6 Implications and Policy Recommendations 104
References 105
7 Drug Resistance in Malaria in Developing Countries 110
7.1 Introduction 110
7.2 History of Malarial Treatment and the Emergence of Resistance 112
7.3 Current Status of Drug-Resistant Malaria 115
7.4 Determinants of Drug Resistance 116
7.4.1 Confounding Factors Responsible for Treatment Failure 116
7.4.2 Definitions of Antimalarial Drug Resistance 117
7.4.3 Mechanisms of Antimalarial Resistance: The Host 118
7.4.4 Mechanisms of Antimalarial Resistance: The Parasite, the Vector and the Environment 119
7.4.5 Mechanisms of Antimalarial Resistance: The Drugs 119
7.5 Molecular Markers of Antimalarial Resistance 120
7.5.1 Chloroquine 121
7.5.2 Sulfadoxine-Pyrimethamine (SP) and Antifolates 121
7.5.3 Mefloquine, Quinine and Atovaquone 122
7.5.4 Artemisinin 123
7.6 Detection of Drug Resistance 123
7.6.1 In Vitro Tests 123
7.6.2 In Vivo Tests 124
7.6.3 Molecular Markers 125
7.7 Future Prospects 126
7.8 Conclusions 128
References 128
8 Drug Resistance in Mycobacterium tuberculosis 132
8.1 Introduction and Epidemiology 132
8.2 Terminology - Definitions are based on Aziz MA et al. 2003 134
8.2.1 New Case of TB 134
8.2.2 Previously Treated TB Patient 134
8.2.3 Primary Drug Resistance 134
8.2.4 Acquired Drug Resistance 134
8.2.4.1 Treatment Failure 135
8.2.4.2 Relapse 135
8.2.4.3 Return After Default 135
8.2.4.4 Chronic Case 135
8.2.5 Mono Resistance 135
8.2.6 Multidrug-Resistant Tuberculosis 136
8.2.7 Extensively Drug-Resistant Tuberculosis 136
8.3 Drugs for Tuberculosis 136
8.4 Development of Drug Resistance in M. tuberculosis 136
8.5 Mechanism of Resistance to Anti-tuberculosis Drugs 139
8.6 Drug Susceptibility Testing of M. tuberculosis 140
8.6.1 Conventional Susceptibility Methods 141
8.6.1.1 Proportion Method 141
8.6.1.2 The Absolute Concentration Method 143
8.6.1.3 The Resistance Ratio Method 143
8.6.2 New Phenotypic Methods 143
8.6.2.1 The Mycobacterial Growth Indicator Tube 143
8.6.2.2 Microscopic Observation Drug Susceptibility Assay 144
8.6.2.3 Colorimetric Methods 144
8.6.2.4 Other New Phenotypic Tests 144
8.6.3 New Genotypic Methods 145
8.6.3.1 Solid-Phase Hybridization Techniques 145
8.6.3.2 DNA Sequencing 145
8.6.3.3 Other Molecular Tests 146
8.6.4 Direct Detection of Drug Resistance 146
8.6.5 Implementation Issues in Drug Susceptibility Testing 146
8.7 Treatment of Drug-Resistant Tuberculosis 147
8.8 Control of Drug-Resistant Tuberculosis 148
8.9 Surveillance for Drug-Resistant Tuberculosis 148
References 148
9 Antifungal Drug Resistance in Developing Countries 151
9.1 Introduction 151
9.2 Antifungal Options 153
9.3 Mechanisms of Resistance 153
9.3.1 Azoles 154
9.3.2 Polyenes 155
9.3.3 Echinocandins 156
9.3.4 Flucytosine 156
9.3.5 Sulfamethoxazole 156
9.4 Antifungal Resistance 157
9.4.1 Candidemia 158
9.4.2 Cryptococcosis 160
9.4.3 Pneumocystis Pneumonia 161
9.4.4 Invasive Mold Infections 162
9.5 Conclusion 163
References 163
10 Drug Resistance in African Trypanosomiasis 171
10.1 The African Trypanosomiases 171
10.2 Human African Trypanosomiasis Is a Zoonosis 172
10.3 Chemotherapy Is the Mainstay in the Control of Trypanosomiasis 173
10.4 Mechanisms of Drug Action 178
10.5 Mechanisms of Drug Resistance 180
10.6 Facing the Challenge 183
References 185
11 Antimicrobial Resistance in Enteric Pathogens in Developing Countries 191
11.1 Common Enteric Bacteria for Which Multidrug Resistance Is Documented 191
11.1.1 Multidrug-Resistant E. coli from Clinical and Environmental Sources 192
11.1.2 Cefotaxime-Hydrolysing and Multidrug-Resistant Klebsiella spp. 195
11.1.3 Multidrug-Resistant Non-Typhoidal Salmonella Infections 196
11.1.4 Emergence of Multidrug-Resistant S. enterica Serovar Typhi 199
11.1.5 Emergence of Antibiotic-Resistant V. cholerae Outbreaks 200
11.1.6 Outbreaks of Multidrug-Resistant Shigellosis in Africa and Other Developing Countries 202
11.1.7 Campylobacter Species 204
11.1.8 Helicobacter Species and Gastritis 204
11.2 Conclusion 205
References 206
12 Bacterial-Resistant Infections in Resource-Limited Countries 212
12.1 Introduction 212
12.2 Micro-organisms 214
12.2.1 Streptococcus pneumoniae 214
12.2.2 Staphylococcus aureus 219
12.2.3 Salmonella enterica serotype Typhi and Paratyphi 220
12.2.4 Shigella spp. 222
12.2.5 Vibrio cholerae 224
12.2.6 Campylobacter jejuni 226
12.2.7 Neisseria gonorrhoeae 228
12.3 Surveillance 230
12.3.1 Role of Surveillance Through Commensal Bacteria 231
12.4 Antibiotic Use and Bacterial Resistance 231
12.5 Knowledge Gaps 233
12.6 Conclusion 233
References 234
13 Prevalence of Resistant Enterococci in Developing Countries 245
13.1 Epidemiology in Developing Countries 245
13.1.1 East Asia and Pacific 245
13.1.2 Europe and Central Asia 246
13.1.3 Latin America and the Caribbean 248
13.1.4 Middle East and North Africa 251
13.1.5 South Africa 252
13.2 Conclusion 252
References 253
14 Antimicrobial Resistance in Gram-Negative Bacteria from Developing Countries 260
14.1 Salmonella spp. and Shigella spp. 260
14.2 Enterobacteriaceae 264
14.3 Pseudomonas aeruginosa and Acinetobacter spp. 267
14.4 Neisseria gonorrhoeae 271
14.5 Neisseria meningitidis 272
References 273
15 Resistance in Reservoirs and Human Commensals 278
15.1 Introduction 278
15.2 Defining Commensals 279
15.3 Commensals as Reservoirs of Antibiotic Resistance: A Conceptual Overview 280
15.4 Survey of Resistance in Commensals 281
15.4.1 Resistance in African Commensals 281
15.4.2 Resistance in Asian and Middle Eastern Commensals 282
15.4.3 Resistance in Latin American Commensals 283
15.4.4 Summary of Resistance Patterns in Developing Regions 284
15.5 Molecular Approaches 285
15.5.1 DNA Sequencing 285
15.5.2 Pulsed Field Gel Electrophoresis 286
15.5.3 PCR Methods 286
15.6 Future Directions 287
References 288
Part 3: Antimicrobial Use and Misuse 291
16 Determinants of Antimicrobial Use: Poorly Understood-Poorly Researched 292
16.1 Introduction 292
16.2 Who Decides on Antimicrobial Use? 293
16.2.1 Lay Networks 294
16.2.2 Pharmacies 294
16.2.3 Physicians 295
16.2.4 Traditional Medical Practitioners 295
16.3 Determinants of Antimicrobial Prescribing, Dispensing and Consumption 296
16.3.1 Antimicrobial Use by Consumers 296
16.3.1.1 Popularity Antimicrobial Folk Culture 296
16.3.1.2 Powerful Medicine 297
16.3.1.3 Antimicrobials as Preventive Agents 297
16.3.2 Antimicrobial Dispensing and Sales 297
16.3.2.1 Knowledge of Correct Dispensing 298
16.3.2.2 Client Demand 298
16.3.2.3 Lack of Regulation and Enforcement 298
16.3.3 Antimicrobial Prescription by Qualified Prescribers 299
16.3.3.1 Knowledge of Correct Prescribing 299
16.3.3.2 Fear of Bad Outcomes 299
16.3.3.3 Perceived Patient Demand 300
16.3.3.4 Peer Norms and Local Medical Cultures 300
16.3.3.5 Availability of Laboratory Services 301
16.3.3.6 Unstable Antimicrobial Supply 301
16.3.3.7 Pressure of Pharmaceutical Promotion 301
16.3.4 Economic Determinants 302
16.3.5 Pharmaceutical Industry Influence 303
16.4 Discussion 303
16.4.1 Consumers 304
16.4.2 Dispensers 304
16.4.3 Prescribers 304
16.5 Conclusion 305
References 306
17 Antimicrobial Use and Resistance in Africa 310
17.1 Scale and Status of the Antimicrobial Resistance in Africa 310
17.1.1 Malaria 311
17.1.2 Cholera in the Time of Resistance 312
17.1.3 Multidrug-Resistant Salmonella 313
17.1.4 Neisseria gonorrhoeae 314
17.1.5 Resistance Concerns in Other Pathogens 315
17.2 Antimicrobial Use and Potential Contributions to Resistance 315
17.2.1 Curative Antimicrobial Use by Health Professionals 315
17.2.2 Prophylactic Use and the Expansion of Indications for Antimicrobials Threatened by Resistance 316
17.2.3 Unregulated Antimicrobial Use 317
17.2.4 Poor-Quality Antimicrobials 317
17.3 Conclusion: Prospects for Controlling Antimicrobial Resistance by Improving Drug Use 318
References 319
18 Antimicrobial Drug Resistance in Asia 324
18.1 Drug Resistance in Bacterial Infection 324
18.1.1 Community-Acquired Infections 324
18.1.1.1 Respiratory Tract Infections 324
18.1.1.2 Diarrheal Diseases and Bacteremia 326
18.1.1.3 Community-Acquired Methicillin-Resistant Staphylococcus aureus (CAMRSA) 328
18.1.1.4 Sexually Transmitted Diseases 328
18.1.2 Nosocomial Infections 329
18.1.2.1 Gram-Negative Pathogens 329
18.1.2.2 Gram-Positive Pathogens 331
18.2 Drug Resistance of Mycobacterium tuberculosis (TB) 332
18.3 Drug Resistance in Fungi 333
References 333
19 Antimicrobial Drug Resistance in Latin America and the Caribbean 339
19.1 Introduction 339
19.2 Surveillance of Antimicrobial Resistance, Infection Control in Latin America and the Caribbean 340
19.2.1 Antibiotic Resistance Among Gram-Positive Bacteria 340
19.2.1.1 Penicillin and beta-Lactam-Resistant Pneumococcus 340
19.2.1.2 Methicillin-Resistant Staphylococcus aureus (MRSA) 342
19.2.1.3 Healthcare-Associated MRSA 342
19.2.1.4 Community-Associated MRSA (CA-MRSA) 343
19.2.1.5 Enterococcus 344
19.2.2 Antibiotic Resistance Among Gram-Negatives Bacteria 344
19.2.2.1 Extended-Spectrum beta-Lactamase (ESBL)-Producing Bacteria 346
19.2.2.2 Fluoroquinolone Resistance 348
19.2.2.3 Carbapenem Resistance 348
19.2.2.4 Enterobacter 348
19.2.2.5 Acinetobacter 349
19.2.2.6 Pseudomonas 349
19.3 Development and Use of New Antimicrobial Drugs in the Region 350
19.4 Summary 350
References 350
20 Hospital Infections by Antimicrobial-Resistant Organisms in Developing Countries 354
20.1 Introduction 354
20.2 Common Antimicrobial-Resistant Pathogens in Developing Countries 355
20.3 Implications of Antimicrobial Resistance in Developing World Hospitals 357
20.4 Antimicrobial-Resistant Infection Rates in Developing Country Hospitals 358
20.5 Antimicrobial-Resistant Neonatal Infections in Developing Countries 359
20.6 Economic Implications of Antimicrobial Resistance 362
20.7 Antimicrobial Resistance Containment Strategies 362
References 365
Part 4: Cost, Policy, and Regulation of Antimicrobials 370
21 The Economic Burden of Antimicrobial Resistance in the Developing World 371
21.1 Introduction 372
21.2 What is Meant by ‘‘Costs’’? 372
21.3 The Drug Supply System: Identifying Opportunities to Intervene 375
21.4 The Economics of Switching Therapy 378
21.5 The Important Role for Diagnostics: A Case Study of Meningitis 380
21.6 Wider and Unintended Consequences of Antimicrobial Use 384
21.7 Counterfeit of Antimicrobial Drugs 385
21.8 Environmental Cost of Antimicrobial Production and Use 385
21.9 Malaria: Who Pays for the Cost of Resistance? 385
21.10 Conclusion 388
References 388
22 Strengthening Health Systems to Improve Access to Antimicrobials and the Containment of Resistance 391
22.1 Introduction 391
22.2 Medicines from the Health Systems Perspective 392
22.2.1 Pharmaceutical Management 393
22.2.2 Human Resources Management 394
22.2.3 Information Systems Management 395
22.2.4 Finance 396
22.2.5 Stewardship and Governance 397
22.3 Measuring Access 398
22.3.1 Access Framework 398
22.4 Case Study - Improving Access to and Use of Medicines in Tanzania 400
22.5 Conclusion 404
References 405
23 The Role of Unregulated Sale and Dispensing of Antimicrobial Agents on the Development of Antimicrobial Resistance in Developing Countries 408
23.1 Introduction 409
23.2 Classes of Antimicrobial Agents 409
23.3 Regulation of Antimicrobial Agents 409
23.3.1 Factors Contributing to Unregulated Sale and Dispensing 410
23.4 Prescription Patterns and Effect on Development of Resistance 411
23.5 Some Selected Antibiotics and Impact on Bacterial Resistance Development 412
23.5.1 Penicillins 412
23.5.2 Tetracycline 412
23.5.3 Newer Agents 413
23.5.4 Fluoroquinolone 413
23.6 Control of Antimicrobial Agents: Interventions 413
23.6.1 Public Education 414
23.6.2 Pharmacy Education 414
23.6.3 Establishment of Legislative Framework and Law Enforcement 415
23.6.4 Regular Surveillance and Monitoring 415
References 415
24 Counterfeit and Substandard Anti-infectives in Developing Countries 417
24.1 Introduction 417
24.2 The Prevalence of Poor-Quality Anti-Infectives 419
24.3 Strategies for the Laboratory Chemical Analysis of Counterfeit and Substandard Drugs in Developing Countries 427
24.4 How to Identify Poor-Quality Medicines Rapidly and Inexpensively 433
24.5 The Consequences of Counterfeit and Substandard Anti-Infectives for Individual Patients 435
24.6 For the Community 436
24.7 Counterfeit Drugs and Policy 439
24.7.1 Conflict of Interest Statement 440
References 440
Part 5: Strategies to Contain Antimicrobial Resistance 448
25 Containment of Antimicrobial Resistance in Developing Countries and Lessons Learned 449
25.1 Introduction 450
25.2 The World Health Organization Global Strategy for Containment of Antimicrobial Resistance 450
25.3 Root Causes of AMR 451
25.4 Detection and Surveillance of Antimicrobial Resistance 451
25.5 Impact on Morbidity and Mortality of Antimicrobial Resistance in Developing Countries 452
25.6 Regional Approaches to Contain AMR: Africa, Asia, and Latin America and the Caribbean 453
25.6.1 Africa 453
25.6.2 Asia 454
25.6.3 Latin American and the Caribbean 455
25.7 The Problem: What Do We Know? 455
25.8 What Have We Learned? 456
25.9 What Has Worked? 457
25.10 What Has Not Worked? 458
25.11 The Solution 459
25.12 Conclusion 460
References 460
26Surveillance of Antibiotic Resistance in Developing Countries: Needs, Constraints and Realities 464
26.1 Introduction 464
26.2 The Microbiological Gap 465
26.2.1 Definitions of Surveillance 466
26.2.2 Basic Needs for Improving Surveillance Capability 466
26.2.3 WHONET 466
26.3 Problems in Organizing Surveillance 467
26.3.1 Planning and Development 467
26.3.2 Impact of Funding 467
26.3.3 Manpower and Human Resources 468
26.4 Available Data 468
26.4.1 Asia 468
26.4.2 Africa 469
26.5 Resistance Data on Key Pathogens 470
26.5.1 S. aureus 470
26.5.2 S. pneumoniae 471
26.5.3 Enteric Pathogens 471
26.5.3.1 Salmonella, Shigella and Vibrio spp. 471
26.5.4 E. coli and Other Enterobacteriaceae 472
26.6 Conclusion 473
References 474
27 Vaccines: A Cost-Effective Strategy to Contain Antimicrobial Resistance 477
27.1 Introduction 478
27.2 Vaccines and Infectious Disease 479
27.2.1 Vaccines Against Viral Infections and Their Cost-Effectiveness 479
27.2.2 Vaccines Against Bacterial Infections and Their Cost-Effectiveness 480
27.3 Vaccine for the Expanded Programme of Immunization 482
27.4 Newer Vaccines 483
27.5 Vaccine for the Future 483
27.6 Why Choose Vaccines? 485
27.7 Vaccines: The Cost 486
27.8 Vaccines - A Renewed Hope 487
27.9 Conclusion 487
References 488
28 Teaching Appropriate Antibiotic Use in Developing Countries 491
28.1 Introduction 491
28.2 Inappropriate Antibiotic Use 492
28.3 Intervention Studies 494
28.4 Medical Students and Residents 495
28.5 Community Interventions 498
28.6 Conclusion 501
References 502
29 Containing Global Antibiotic Resistance: Ethical Drug Promotion in the Developing World 505
29.1 Introduction 506
29.2 Resistance to Antimicrobials: Biology and Inappropriate Drug Use 507
29.3 Drug Promotion and Inappropriate Drug Use in Developing Countries: Ethical Considerations 508
29.3.1 Building Ethical Frameworks Based on Resource Availability 508
29.3.2 Moving Beyond the Resource Availability Criteria in Defining Ethical Thresholds 510
29.4 Mapping the ‘Control Points’ in Drug Promotion Practices in Health Care: The ‘Drug Representative’ as a Key Mediator 512
29.5 Antimicrobial Use in the Food Industry and Adverse Effects on Human Health 514
29.6 Overcoming the Link Between Promotion of Antimicrobial Agents and Emergence of Antimicrobial Resistance in Pathogens 516
29.7 Essential Medicines Library: An Empirical Resource to Evaluate the Accuracy of Drug Promotional Material in Developing Countries 518
29.8 Conclusions and ‘Points to Consider’ 519
References 521
30 News Media Reporting of Antimicrobial Resistance in Latin America and India 525
30.1 Analysis of the Mass Media in Latin America 525
30.1.1 Radio and Television 525
30.1.2 The Internet 526
30.1.3 Newspapers 527
30.2 Analysis of News Reporting of AMR 527
30.3 Recommendations and Priorities for Improved News Reporting of AMR in Latin America 530
30.3.1 Key Recommendations 531
30.4 Analysis of the Mass Media in India 531
30.4.1 Newspapers 532
30.4.2 Television 533
30.4.3 The Internet 534
30.4.4 Scientific Reporting 534
30.5 Problems and Issues in Reporting 534
30.6 Misuse or Simplification of Data for Lay Audiences 535
30.7 Indian Media Reporting on Antibiotic and Antimicrobial Resistance 536
30.8 Trends and Future Directions 537
Index 538
| Erscheint lt. Verlag | 8.10.2009 |
|---|---|
| Zusatzinfo | XXIII, 554 p. |
| Verlagsort | New York |
| Sprache | englisch |
| Themenwelt | Medizin / Pharmazie ► Allgemeines / Lexika |
| Medizin / Pharmazie ► Medizinische Fachgebiete | |
| Studium ► 1. Studienabschnitt (Vorklinik) ► Biochemie / Molekularbiologie | |
| Studium ► Querschnittsbereiche ► Infektiologie / Immunologie | |
| Naturwissenschaften ► Biologie ► Mikrobiologie / Immunologie | |
| Technik | |
| Schlagworte | Antibiotics • Antimicrobial • Antimicrobial Resistance • Bacteria • HIV • Infection • Infections • Infectious Diseases • Malaria |
| ISBN-10 | 0-387-89370-9 / 0387893709 |
| ISBN-13 | 978-0-387-89370-9 / 9780387893709 |
| Haben Sie eine Frage zum Produkt? |
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