The threat of antibiotics
resistance is growing at an alarming rate and the situation is perhaps
aggravated in Nigeria and Africa as a whole.
Here are the
four factors responsible for the increase in antibiotic resistance in Nigeria
and Africa as a whole:
Drug dispensers and drug quality
Health professionals
Patients
Non-human use of antimicrobials
DRUG DISPENSERS AND DRUG QUALITY
The lack of
appropriate regulations in the sales of antibiotics is also a driving factor in
the access and misuse of antibiotics. In Nigeria and Africa as a whole, antimicrobials
can be purchased without medical prescription and are usually dispensed on the
streets by untrained persons. These drug vendors will sell medications just to
make a sale and accommodate patients’ ability to pay. Even pharmacies operating
without a license, appear to be more accessible to the public as they have
shorter waiting time, do not charge consultation fees and above all are willing
to negotiate treatment options to adjust to the financial ability of the
patients.
Retail
pharmacies in Africa have emerged as the primary level of outpatient care
rendering unauthorized services from consultation, diagnosis, prescription and
dispensing of medication.
Many antibiotics dispensed in
Africa are of questionable pharmacological quality. Adverse climatic conditions
such as high ambient temperatures and humidity may affect the overall quality
of the antimicrobials during storage. Poor storage also increases the risk of
degradation of the drug. Degraded medicines contain less than stated dose,
implying that patients consume less than optimal dose of the drug. There is
also a problem of outright counterfeit, in which the drug may contain little or
no active substance of the antimicrobial or the wrong substance.
The influx of counterfeit and
sub-standard antimicrobials into the pharmaceutical markets in some regions is
a major problem as these preparations of reduced potency also result in
pathogens being exposed to sub-therapeutic concentrations of the drug.
A study from Cameroon revealed
that, out of 284 antimalarial obtained from 132 vendors, 32% of chloroquine,
10% quinine, and 13% sulfadoxine/pyrimethamine were likely to be fake. In
addition, some of the quinine contained chloroquine while some chloroquine
contained no active ingredient or an amount lower than the expected
concentration.
HEALTH PROFESSIONALS
Health care providers play an
essential role in the treatment and prevention of diseases, but may jeopardize
this if their practices are not evidence-based. For example, the prescription
practices of antibiotics vary among physicians in most African countries. In
some cases, the antimicrobial prescriptions are inappropriate (i.e., wrong
drug, wrong doses, or antimicrobial not necessary at all).
Due to the high patient-doctor
ratio in Nigeria and Africa as a whole, doctors are overwhelmed and there is
often inadequate time for meaningful education and communication with the
patient on drug adherence guidelines and consequences of poor or non-adherence
to these guidelines.
Due to lack of effective and
reliable surveillance systems and poor dissemination of research information,
health professionals in Africa sometimes lack up to date information on the antibiotics
resistance pattern within their populations. In tertiary hospitals with
advanced capacities, physicians rely mostly on the resistance or susceptibility
pattern of the pathogen isolated from a patient.
Health personnel in rural settings
without the capacity to do antibiotics resistance testing have difficulty to
decide on the choice of antibiotics in the absence of an antimicrobial
sensitivity test. As a result, health professionals use more and more
broad-spectrum antibiotics to treat infections caused by several bacteria
species or those for which establishing the etiology is difficult or takes a
long time.
This practice contributes to the
development of resistance as the drug applies selective pressure, not only upon
the etiological agent of the disease episode but also upon a large fraction of
the patient’s microbiota. Some health professionals issue prescriptions that
are not evidence-based and rely on a syndromic approach to both infections in
the community as well as hospitalized patients. That is treatment is based on
easily recognized signs and symptoms (syndromes) as well as to microorganism
most commonly responsible for each of these syndromes. This practice is on the
rise due to the lack of legal consequences of wrongful prescription of
antibiotics.
PATIENTS
Compliance is a major contributor
to the development of antibiotics resistance. Patients miss doses, either by
mistake or deliberate. Because patients are aware of the adverse impact of drinking
alcohol while on antibiotics, some patients may skip doses when invited for a
party in favor for the consumption of alcohol. These practices result in the exposure
of surviving microbes to sub-therapeutic concentrations of the drug and,
consequently increases the chances of developing resistance.
Because of poverty, many sick
individuals in developing countries in Africa often seek their first-line of
treatment from traditional healers who provide them with herbal mixtures of unknown
efficacy for the treatment of infections. Some combine antibiotics with their
herbal mixtures simultaneously while others take antimicrobials and supplement
them with herbal mixtures purportedly to improve efficacy. These compounds of
unknown potency may enhance pathogen fitness.
NON-HUMAN USE OF ANTIMICROBIALS
Antimicrobials are used to
prevent prophylaxis in high risk animals and treat diseases in animals, as well
as used as growth promoters in animal breeding. Additionally, they are used as
additives in plant agriculture (fruits, vegetables, and orchid, etc.),
especially in the spraying of fruit trees for disease prophylaxis and the
application of antibiotic-containing manure on farmland and in industrial
processes.
The use of antimicrobial agents
in animals and more importantly food-producing animals has important
consequences for both human and animal health as it can lead to the development
of resistant bacteria. These resistant bacteria (with resistance genes) in animals
can be transferred to humans through the consumption of food or through direct
contact with food-producing animals or through environmental spread for
instance human sewage and runoff water from agricultural sites.
The use of antimicrobial drugs in
health care, agriculture or industrial settings, exerts a selection pressure
which can favor the survival of resistant strains or genes over susceptible
ones, leading to a relative increase in resistant bacteria within microbial
communities. It is now known that increased antibiotics resistance in bacteria
affecting humans and animals is primarily influenced by an increase in the use
of antimicrobials for a variety of purposes, including therapeutic and
non-therapeutic purposes in animal production.
A strong association between
agricultural use of antimicrobials and the development of resistance has been
suggested and it has been shown that the bulk of antimicrobials used worldwide
are not consumed by humans but rather are given to animals for the purposes of
food production.
Multidrug resistant bacteria have
been detected in both meat and fresh produce and in humans in contact with livestock
in many African countries.
A study in Kenya revealed a high
level of antimicrobial drug residues in meat meant for consumption. These
findings further demonstrate that food animals are a major reservoir of drug
resistant bacteria and present a major risk for dissemination and transmission
of antimicrobial resistant bacteria in Africa. A large proportion of the
population in Africa live in close proximity with animals, thus increasing the
chances of transmission of resistant microorganisms from animals to humans through
animal handling.
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