Even before the COVID crisis, the overuse and misuse of life-saving antibiotics contributed to the emergence of resistant strains of disease-causing organisms. This has rendered many of the most powerful treatments in modern medicine ineffective.
It is estimated that drug-resistant infections caused more than 1.2 million deaths in 2019. That’s more than malaria and AIDS combined. The resistance contributed about 5 million additional deaths.
There is some evidence that the COVID-19 pandemic has made matters worse.
COVID-19 is caused by a virus. Viruses are not treated with antibiotics. But early treatment guidelines for COVID-19 assumed that patients admitted to hospitals would develop a bacterial infection that would require antibiotics. The sheer volume of people with respiratory infections also appears to encourage additional use of antimicrobial drugs.
Antimicrobials are drugs that treat bacterial, viral, or other microbial infections. Antimicrobial resistance, and the reduced efficacy of this broader class of drugs, was already a growing threat to global public health prior to December 2019.
Overall, Sub-Saharan Africa has the highest drug resistance-related mortality rate. But prevalence varies by country. We set out in our recent research to document the volume of antimicrobial use, a known driver of antimicrobial resistance, in selected health care facilities in Uganda.
We found high antibiotic use in all health facilities studied. Compliance with clinical guidelines in Uganda among health care workers was low. Also, men were more likely to take antibiotics than women. In addition, antibiotic use was twice as high in public health facilities than in the private sector. But this can be attributed to the higher proportion of public healthcare facilities in our study sample.
Our results highlight areas for intervention to address antimicrobial resistance. These results also provide a basis on which we can compare the impact of such interventions.
Trends in the use of antibiotics
We surveyed antibiotic use in 13 hospitals in Uganda. Our analysis included approximately 1,100 patients and was performed between December 2020 and April 2021.
Nearly three-quarters of all patients in our study were taking at least one antibiotic. This is high and could indicate overuse, some of which may be unnecessary. In addition, less than 30% of antibiotic prescriptions complied with Ugandan clinical guidelines for drug selection.
Ceftriaxone is a drug used to manage a wide variety of infections. It was among the most prescribed antimicrobials. But it is not recommended to use it in the first line. A possible explanation for this is its convenience and ease of use compared to current first-line drugs.
Initially, we looked at differences in antibiotic use between males and females as a primary indicator of gender differences in adequate antibiotic access. We found that men had 15% greater odds of using antibiotics. The reasons for this observation were not clear. But other studies have attributed it to differences in access to health care between men and women. In those studies, boys were more likely to take antimicrobials for longer periods and complete the regimen.
We also found that antibiotic use is significantly higher in public and not-for-profit hospital settings than in private hospitals. This contradicts our expectation that the profit motive usually drives the overuse of antibiotics in private hospitals and should be examined further.
We are concerned about the observed levels of antibiotic use in Uganda. Efforts to examine whether such use is appropriate or necessary are jeopardized by inadequate patient registration systems and diagnostic capacity. Adequate and complete patient records and the ability to diagnose are minimum requirements for consuming and monitoring the use of the desired antimicrobials. and to improve the quality of health care in these health care facilities.
On the positive side, Uganda is promoting antibiotic consumption, monitoring system use and diagnostic capacity of health facilities at higher levels. Efforts are being made to address policy loopholes, and to train health care workers at both the undergraduate and postgraduate levels.
Our findings should be used to accelerate implementation of ongoing strategies to reduce drug abuse, and to guide research in other sub-Saharan countries.
What we need next is sustainable investment from the government and development partners. Here are some places to start:
Invest in a new, better, and easier-to-administer single dose of antibiotics that target a narrow range of bacteria, known as narrow-spectrum antibiotics. So-called broad-spectrum antibiotics are associated with more resistance. This will enable health workers to better treat infections and comply with guidelines.
Improving laboratory and technology infrastructure. Physicians must be able to identify the microorganisms that caused the infection, so that they can choose the appropriate antimicrobials to administer them. The current ability to diagnose bacterial infection in Uganda is slim.
Strengthen the health workforce with more staff and training in infection prevention and control. Better infection control will reduce the incidence of bacterial infections, thus reducing the need for antibiotics.
Implementing and enforcing policies on the use of antibiotics, including appropriate patient records, which can act as an indirect force for improving the quality of health care. Lessons on the proper use of patient record systems can be borrowed from the health insurance industry.
Uganda is only one country that needs to improve its oversight of antimicrobial resistance. Without a coordinated global response, drug-resistant infections will cost the global economy $100 trillion in economic output by 2050, and result in more diseases and deaths than all noncommunicable diseases combined.
Freddy Eric Kituto, Senior Lecturer in Health Systems Pharmacology and Researcher, Makerere University