Antibiotic use and resistance in South Africa: The need for better data
Over the past decade, the overuse of antibiotics has increased drastically worldwide. This has happened despite advanced diagnostics tools, policies and guidelines for the treatment of most bacterial infections. Human behaviour is at the heart of the problem. New research shows that South Africa needs better data to combat the rise of antibiotic resistance, write Neusa Torres and Buyisile Chibi.
By 2050, 10 million people could die per year from drug-resistant infections, according to the World Health Organization (WHO) – a mortality rate that outstrips that of cancer today. Drug-resistant bacteria are eroding attainments in health care such as those pertaining to pneumonia, surgeries, organ transplantation, treatment of preterm babies, treatment of tuberculosis, and other bacterial infections. A “post-antibiotic era”, in which antibiotics become useless, can be avoided. However, this will require comprehensive data on antibiotic use across the world, as well as surveillance systems to track the emergence and spread of drug-resistant diseases.
The HSRC’s recent systematic scoping review study of non-prescribed antibiotic use revealed critical gaps in such data in low- and middle-income countries. The study reported on the accessibility, affordability and the conditions of health facilities, and on the actions of individuals that influence the unappropriated use of antibiotics.
• Resistance emerges when the use of antibiotics increases selection pressure on bacteria populations. This causes the most vulnerable bacteria to die first and an increased percentage of resistant bacteria to continue growing into a drug-resistant population.
• Not finishing a recommended course of antibiotics treatment makes it more likely that the ‘strongest’ bacteria will survive and develop into a drug-resistant population.
• The overuse and unnecessary use of antibiotics - when people self-medicate, share antibiotics or as a result of poor prescribing and dispensing practices - also drive resistance.
• The high volume of antibiotics in agricultural animals also contributes to the development of drug-resistant bacteria that can be transmitted from animals to humans via direct contact or through the food chain, and the environment.
People living with HIV
In South Africa, keeping tabs on drug-resistant diseases is particularly important because of the vulnerability of people living with HIV. It has been reported that about 50% of new TB cases, for example, are of HIV co-infected people. In an ongoing study, one of us (Buyisile Chibi) is exploring factors that contribute to prescription drug diversion, misuse and abuse among people living with HIV in the eThekwini District, KwaZulu-Natal.
Preliminary results show that antibiotics are among the prescription drugs diverted and misused by people living with HIV. Using qualitative and quantitative methods, the study reports widespread self-medicating, sharing antibiotics and not finishing the recommended course of antibiotic intake – practices that are paving the way for the development of antibiotic resistance in South Africa.
In some sub-Saharan African countries, such as Mozambique, Malawi and Tanzania, antibiotics are commercially available over the counter. While this is not the case in South Africa, the misuse of antibiotics, such as self-medication, sharing, and not following the recommended course, is still common. A nationwide 2005 HSRC study by Professor Karl Peltzer and colleagues, showed that only 30% of patients who participated in the study adhered to their medication. A further 29% had taken medication not prescribed by a health-care provider.
Wrongly or overprescribed
Another problem is that patients are often prescribed antibiotics for viral infections, against which they are ineffectual. A 2017 study by a team of researchers from the University of the Western Cape, found that 53% of 166 821 patients with bronchitis were given antibiotics. Bronchitis is mostly caused by viral infections, with less than 5% caused by bacteria. In instances like this, antibiotics can lead to drug resistance developing in the gut bacteria of the patient. This resistance can also be passed on to other bacteria, in a process called horizontal gene transfer.
In a 2015 study that determined the general prescribing trends of pharmacy-dispensed drugs, Prof Ilse Truter from the Nelson Mandela University found that a total of 660 500 patients in South Africa received 1 576 593 antibiotics during 2010, translating to over two courses of antibiotics per person. In 2018, Truter and her colleagues found that 80% of pharmacists in Nelson Mandela Bay believed that antibiotics are overprescribed.
Rise of resistance
A 2013 publication, led by Ramanan Laxminarayan, the director of the Center for Disease Dynamics, Economics and Policy, an international public-health research organisation, painted a picture of antibiotic resistance globally. The study found that in high-income countries, high rates of antibiotic use in hospitals, in the community, and in agriculture have contributed to selection pressure that has sustained resistant strains, forcing a shift to more expensive and more broad-spectrum antibiotics.
Resistance is also on the rise in low- and middle-income countries, with rising incomes, high rates of hospitalisation, and a high prevalence of hospital infections. Overcrowded conditions and poor sanitation also contribute to the spread of drug-resistant diseases.
Obstacles to improving the appropriate use of antibiotics include poor surveillance systems to monitor their availability, no geographic boundaries to impede the spread of resistance, and limited studies to inform interventions. In addition, infectious diseases that can be transmitted between animals and humans are under-studied.
Within the health-care sector, there is a critical lack of implementation of antimicrobial stewardship programmes to educate and guide health-care workers.
Efforts to promote the appropriate use of antibiotics and contain the resistance to them have been targeted at the formal health-care service platform. These efforts started in the 1970s when the WHO introduced an essential drug list, today adopted by over 100 countries, including South Africa. Experts hoped that a limited number of drugs would lead to better supply, better prescriptions, lower cost of health care and better control of resistance. However, the consumption of medicines in general, and antibiotics in particular, is still increasing worldwide.
In 2013, with input from the HSRC and other organisations, the South African government implemented the National Drug Master Plan 2013 – 2017, and the National Drug Policy, with the aim of addressing the challenges of drug diversion, misuse and abuse.
However, recent HSRC research suggests that strategies to raise awareness and promote the appropriate use of antibiotics within the country should be more intensive.
Physicians, pharmacists and patients play a central role in antibiotic usage. Therefore, further studies to better understand prescription, dispensing and patient behaviour, are critical to designing effective interventions. This is particularly important in relation to HIV/Aids and TB.
Education has been widely recognised as a successful strategy for appropriate antibiotic prescription, despite some studies reporting no improvements after educational interventions. Additionally, health systems should establish coordinated national and international actions, especially at the political level.
Authors: Neusa Torres, a researcher at the Higher Institute for Health Sciences in Maputo, Mozambique, and the School of Nursing and Public Health of University of KwaZulu-Natal; and Buyisile Chibi, a PhD research intern at the HSRC’s Social Aspects of Public Health research programme