Antibiotic Use in Sub-Saharan Africa: Key Insights from the ANDEMIA Study on Infection Patterns and Antimicrobial Resistance

A recent study by Wieters, et al. (2024) titled “Reported antibiotic use among patients in the multicenter ANDEMIA infectious diseases surveillance study in sub-Saharan Africa” published in Antimicrobial Resistance & Infection Control by Springer Nature shows that the use of antibiotics varied significantly by disease syndrome, country, and health facility location.

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Antibiotic use in sub-Saharan Africa varies significantly by disease type, country, and facility location, impacting AMR.

– Wieters, et al. 2024

The article explores a comprehensive analysis of antibiotic usage patterns across multiple health facilities in sub-Saharan Africa. The study, which ran from February 2018 to May 2022, focused on understanding the prevalence and nature of antibiotic use in both urban and rural healthcare settings within Côte d’Ivoire, Burkina Faso, the Democratic Republic of the Congo, and South Africa. By examining antibiotic usage in these diverse settings, the study addresses a critical data gap on antibiotic consumption in sub-Saharan Africa, which is vital for developing effective strategies to combat antimicrobial resistance (AMR) in the region. The authors targeted patients presenting with specific types of infections: acute respiratory infections (RTI), acute gastrointestinal infections (GI), and acute febrile diseases of unknown cause (AFDUC). The study enrolled a total of 19,700 patients, gathering extensive data on clinical, demographic, socio-economic, and behavioral factors through standardized questionnaires. This multifaceted data collection allowed for a nuanced analysis of how these factors influenced antibiotic use among the patient population. The study revealed marked variations in antibiotic use based on the type of infection, country, and health facility location. For instance, antibiotic use was influenced not only by the disease syndrome (whether RTI, GI, or AFDUC) but also by socio-economic and behavioral factors that varied widely across countries and between urban and rural settings. These findings underscore the need for a differentiated approach to managing antibiotic use across different healthcare contexts in sub-Saharan Africa. The high prevalence of WHO Watch antibiotics used in these settings highlights the urgent need for targeted interventions that consider local patterns of antibiotic access and affordability. Such interventions could support more rational antibiotic use, help reduce inappropriate prescribing, and ultimately contribute to reducing the spread of antimicrobial resistance. The study advocates for further research and policy evaluation focused on improving access to appropriate antibiotics and ensuring affordable treatment options for patients, particularly in low-resource settings where overuse and misuse of antibiotics are prevalent.

How the Study was Conducted

The study is a descriptive analysis of data from the ANDEMIA (African Network for Improved Diagnostics, Epidemiology and Management of Common Infectious Agents) infectious disease surveillance network. Data were collected from 12 urban and rural health facilities in Côte d’Ivoire, Burkina Faso, Democratic Republic of the Congo, and Republic of South Africa between February 2018 and May 2022. Patients with acute respiratory infection (RTI), acute gastrointestinal infection (GI), and acute febrile disease of unknown cause (AFDUC) were enrolled. Clinical, demographic, socio-economic, and behavioral data were collected using standardized questionnaires. The data included information on patient demographics, current symptoms, medical history, past and current hospitalization, medication, and socio-economic factors. The authors recorded antibiotic use in the ten days prior to study enrollment. This included self-medication, prescribed antibiotics, and antibiotics administered at the health facility before study enrollment. The antibiotics were categorized according to the WHO AWaRe classification (Access, Watch, Reserve, and Not recommended). The authors analyzed data using Stata software. Antibiotic use was defined as the self-reported use of one or more antibiotics in the ten days prior to study enrollment. The antibiotics were analyzed by total reported antibiotics and by patients who received one or more antibiotics. The analysis also included stratification by location, disease syndrome, and individual patient factors. Furthermore, the study adhered to national legislation and ethical standards, including the Declaration of Helsinki. Institutional ethics approval was obtained in all participating countries. Patient data were pseudonymized and only accessible to selected trained study staff.

What the Authors Found

A notable finding from the study was that 36.8% of patients reported using antibiotics within the ten days prior to enrollment. The most commonly reported antibiotic was ceftriaxone, a WHO Watch antibiotic, accounting for 31.7% of the reported antibiotics. Other frequently used antibiotics included amoxicillin and amoxicillin/clavulanic acid. The study also found that the use of antibiotics varied significantly by disease syndrome, country, and health facility location. For example, Watch antibiotic use ranged from 17.4% among RTI patients in urban facilities in Côte d’Ivoire to 73.7% among AFDUC patients in urban facilities in Burkina Faso. In addition, the study observed an increase in the use of Watch antibiotics during the COVID-19 pandemic. Before the pandemic, 40.7% of reported antibiotics were from the Watch group, which increased to 50.6% during the pandemic.

Why is this important?

Combatting Antimicrobial Resistance (AMR): Antibiotic misuse and overuse are major drivers of AMR, which poses a significant global health threat. Understanding antibiotic use patterns helps in planning and implementing strategies to combat AMR effectively.

Data Scarcity: There is limited data on antibiotic use in sub-Saharan Africa. This study provides valuable insights into the region’s antibiotic use, which is essential for developing targeted interventions.

Health Policy and Interventions: The findings highlight the need for differentiated approaches to antibiotic use interventions. This includes evaluating the accessibility and affordability of treatments, which can inform health policies and improve patient outcomes.

Public Health Impact: High rates of antibiotic use, especially of WHO Watch antibiotics like ceftriaxone, indicate potential misuse. Addressing this can reduce the risk of developing resistant infections, improving overall public health.

COVID-19 Influence: The study also shows an increase in Watch antibiotic use during the COVID-19 pandemic, underscoring the need to monitor and manage antibiotic use during health crises.

What the Authors Recommended

• The authors emphasize the need for a more differentiated approach to antibiotic use interventions. This includes evaluating the accessibility and affordability of patient treatment in various settings.
• The study highlights the importance of targeted strategies to manage antibiotic use, considering the significant differences in antibiotic use by disease syndrome, country, and health facility location.
• The authors call for further evaluation of the factors influencing antibiotic use, such as socio-economic and behavioral factors, to develop more effective interventions.
• The study recommends ongoing monitoring of antibiotic use and the implementation of antimicrobial stewardship programs to ensure appropriate use of antibiotics and combat antimicrobial resistance (AMR).

In conclusion, the ANDEMIA study provides crucial insights into antibiotic use patterns across diverse healthcare settings in sub-Saharan Africa, underscoring the urgent need for targeted interventions to combat antimicrobial resistance (AMR) in the region. By revealing significant variations in antibiotic use influenced by disease type, country, and health facility location, the study highlights the complexity of AMR challenges in low-resource settings. These findings call for differentiated approaches to managing antibiotic access and affordability, along with improved stewardship programs to guide appropriate antibiotic usage. Addressing these factors through policy and research efforts is essential to safeguard public health, particularly as the COVID-19 pandemic has exacerbated antibiotic misuse risks. As AMR continues to threaten global health, this study serves as a critical foundation for more effective, localized strategies in antibiotic stewardship and public health planning.

AR Managing Editor (2024). Antibiotic Use in Sub-Saharan Africa: Key Insights from the ANDEMIA Study on Infection Patterns and Antimicrobial Resistance. Retrieved from https://www.africanresearchers.org/antibiotic-use-in-sub-saharan-africa-key-insights-from-the-andemia-study-on-infection-patterns-and-antimicrobial-resistance/