A tale of antibiotic use in a sub-Saharan African setting: A focus on Ethiopia

A blog by Jabir Abdulahi, Student Liaison Officer for the AMR Centre.
A patient-doctor consultation.

Inappropriate antibiotic use as a driving factor for resistance  

The misuse or overuse of antibiotics speeds up the process of resistance by creating selective pressure that favours the growth of resistant bacteria. Although low-resource countries have lower per capita antibiotic consumption than high-income countries, differences in dispensing regulations and prescription audits may lead to different patterns of consumption. Implementing such regulations in resource-constrained areas can be challenging.

Patients' misconception & over-prescription by health care workers

The information reported in this blog post is based on my observations as a healthcare professional in Ethiopia. During my tenure as a medical doctor at a hospital in eastern Ethiopia, I witnessed an alarming misuse of antibiotics. I noticed a relaxed approach toward the use of antibiotics, particularly in remote areas. Even though the hospital was in an urban area, many patients came from the surrounding rural areas. Patients visiting the hospital were routinely administered an injection of a broad-spectrum antibiotic “ceftriaxone”. This practice is widely prevalent in Ethiopia that locals had coined their own term for it - "the warm injection" - roughly translated from the local language. Patients believed that this injection was the cure-all they were seeking, however carbapenem resistance is presenting a major challenge to treat serious bacterial infections in Africa.

Surprisingly, antibiotic misuse among outpatient clinics was not that different. During my time there, a 40-year-old patient whom I supervised, complained of musculoskeletal pain with no signs or symptoms of infection. After a thorough history and physical examination, I prescribed an analgesic and advised him to return if his condition did not improve. However, the patient insisted on receiving the "warm injection" and was dissatisfied with my response. 

Overprivileged patients in Ethiopia can also receive meropenem treatment in private hospitals, simply because they could afford the expensive drug. Similarly, in intensive care units, the choice of antibiotic is affected by your sociodemographic status. Where critically ill patients receive ceftriaxone because they cannot afford drugs such as carbapenems or other second line treatment.

The need for comprehensive action for the fight against AMR to be successful

There is policy-implementation gap on who can prescribe antibiotics in Ethiopia. Even non-medical healthcare professionals have the freedom to prescribe antibiotics as they see fit. It is not surprising that ceftriaxone is one of the most prescribed antibiotics, often used indiscriminately. In some cases, individuals will bypass medical consultation and go directly to pharmacies, where they are able to obtain antibiotics without a prescription. 

Despite the stringent rules in the capital for prescription-leaflets to obtain antibiotics in pharmacies, this regulatory scheme gradually becomes less stringent as one travels further away from cities into rural areas. The consequences of these practices are significant, contributing directly to the emergence of highly resistant pathogens. it is crucial to strengthen health systems in low-resource settings so that proper diagnoses through culture and sensitivity testing, is conducted to guide etiological-based treatment. 

One way to addresses the issue of antibiotic misuse is to build hospital capacity by training healthcare professionals on the rational use of antibiotics and develop antimicrobial stewardship programmes. Complemented by robust surveillance of antibiotic resistance.

We must work to preserve our antibiotic arsenal so that they may continue to serve as life-saving tools.

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