Tackling Antibiotic Misuse: the View from Sudan
Co-authors: Jaskaran Singh Multani, HBMSc, MMASc (c); Francisco Mendina HBSc, MMASc (c); Asaad Ali Hassan Mohammed MBBS (MD), MBA-HCM, MMASc (c); Rahil Prajapati HBMSc, MMASc (c)
MMASc Global Health Systems, Western University
No matter where you live in the world, almost everyone has taken an antibiotic. However, not everyone’s experience with antibiotics has been the same. These drugs are used to treat bacterial infections, and if misused, they can lead to antibiotic resistance. When antibiotics are no longer be effective, this degrades advances made in medicine and science significantly and increases risks of severe illness, hospitalization, and even death (Laxminarayan et al., 2013).
For countries with fragile health systems, the issue of antibiotic resistance poses even greater risks to health. This is the case in Sudan. The World Health Organization (WHO, 2020) has acknowledged the antibiotic resistance issue in Sudan and is linked to several factors. Sudan has 41 million people, and the healthcare system is heavily reliant on private spending (Republic of Sudan, 2020). Due to many civil wars, the country has experienced numerous waves of displacement, destruction, and insecurity. While impacting health outcomes directly, these factors have also discouraged medical professionals from working in the country. It is against this backdrop that antibiotic resistance in Sudan poses an important challenge to the health and well-being of the Sudanese population. But how does antibiotic resistance develop in the first place? As trainees in Global Health with a particular interest in Sudan, we sought to understand the emergence of antibiotic resistance in this country. What we learnt in a review of the literature on antibiotic resistance in Sudan seems worth sharing, given the multi-layered behavioural practices at play in this context. Sudan’s antibiotics crisis exemplifies the pathways through which antibiotic resistance develops and key routes to tackling this urgent global health issue.
Patient behaviour plays a crucial role in the development of antibiotic resistance. Antibiotic use and misuse in Sudan is driven by low adherence to physician instructions regarding antibiotic use and the self-administration of antibiotics. Some studies suggest that, despite physicians’ efforts to prescribe proper antibiotic treatments and accurate doses for an appropriate duration, patients do not adhere to these guidelines (Ahmed et al., 2019; Eibs et al., 2020; Otim et al., 2021). Patients may, for example, stop their course early once their symptoms subside, save antibiotics for future use, or share their medications with family members who have similar symptoms (Eibs et al., 2020). Additionally, self-administration of antibiotics obtained from local pharmacies without prescriptions exacerbates the issue of antibiotic misuse and contributes to antibiotic resistance (Ahmed et al., 2018; Awad et al., 2007; Eibs et al., 2020; Otim et al., 2021). This self-administration results from structural conditions: geographical and financial access limitations and limited health knowledge leave many opting for self-administration rather than trying to reach and secure resources to visit a physician (Eibs et al., 2020).
Healthcare practitioners also play a role in the case of Sudan: overprescribing and misprescribing antibiotics and deviating in some instances from guidelines and usage policies (Otim et al., 2021). Research has indicated that doctors prescribe antibiotics without performing diagnostic tests (Otim et al., 2021; Saad et al., 2020). This could be because of a lack of knowledge, training policies and guidelines, unavailability of testing devices in some health facilities, or the high cost of testing. Sudan suffers from a shortage of qualified doctors and medical practitioners. Due to the harsh economic conditions in the country and low income, many of them migrate abroad to work in the neighbouring wealthy countries such as Saudi Arabia, UAE, Qatar, Kuwait or Europe, North America, and Australia, especially with the increased demand in those countries for medical professionals. Civil unrest, wars, and insecurity also limit health practitioners’ presence in some areas with many health workers preferring to work in urban, conflict-free regions. This has led to a kind of chaos in the health system. Additionally, lack of supervision, is also a factor researchers suggest contributes to health workers’ overprescription and incorrect prescription of antibiotics (Eibs et al., 2020; Otim et al., 2021; Ahmed et al., 2000).
Antibiotic resistance can affect anyone anywhere and is called one of the biggest global threats today (WHO, 2020). Infection with antibiotic-resistant bacteria results in a higher likelihood of hospitalization, longer hospital stays slower recovery, disability, and even death (Elbadawi et al., 2019; Otim et al., 2021). It also leads to other health issues caused by the possibility of taking the wrong medication (Ibrahim et al., 2012). In Sudan, the current misuse of antibiotics leads to increased resistance which causes added stress to an already burdened healthcare system. What can be done?
Tackling the antibiotic resistance issue in Sudan will not be easy. Alongside the social determinants and health system issues mentioned above, there is also incomplete and limited data on antimicrobial use and antibiotic resistance. Pair this with the inadequate lab support in the country’s rural areas; this makes it difficult, if not impossible, to monitor and generate current surveillance data (Ahmed et al., 2000; Elbadawi et al., 2019; Otim et al., 2021).
Policies need to be developed to prevent the misuse of antibiotics without prescriptions. There appears to be a need for training programs to increase awareness of antibiotic use, abuse and resistance for undergraduates, graduate students, and healthcare practitioners in Sudan. An influx of funding to upgrade Sudan’s testing and data-generating capacities would ameliorate its antibiotic misuse issues and create a solid foundation for the country to improve its health system.
Ultimately, to address the mounting concerns outlined in this publication, all levels of government, the private sector, and international organizations must work in unison to advance health research on antibiotic resistance, strengthen national policy and surveillance on antibiotic use, and perform larger-scale research studies on antibiotic use and misuse in Sudan.
Some practitioners believe that having guidelines is unimportant and state that they would not adhere to them if developed (Ahmed et al., 2019). This may indicate a lack of knowledge and training as guidelines were developed with a lack of consultation with practitioners (Ramadan et al., 2019). Therefore, there needs to be a participatory approach to guideline development along with extensive training programs to increase awareness of antibiotic use, abuse and resistance for students and practitioners.
From a health system perspective, targeting any microbial disease requires healthcare professionals to be aware of current trends in antibiotic resistance to optimize their treatment. However, as mentioned before, there is minimal data for healthcare professionals to examine. Thus, they have a little foundational basis for adjusting their pharmacological treatment options and often tend to continue their current prescription patterns. Furthermore, the Sudanese public has been given little information regarding antibiotic misuse and the potential resistance which can develop (Ahmed et al., 2000).
As a matter of health equity, we believe that there is an ethical responsibility on both the national government and the international community to address many of the social determinants of health contributing to antibiotic misuse in Sudan. Given the rising concern of antibiotic resistance, not only in Sudan but across sub-Saharan Africa, there needs to be a concerted effort to address the misuse of antibiotics. Some factors that need to be addressed include ending wars, improving security, improving the economy and supporting medical education and healthcare training programs to incentivize healthcare practitioners to continue working within the country. Furthermore, to address the issue of self-administration, patient adherence to proper antibiotic usage guidelines needs to be improved. This can be facilitated by health education on the drawbacks of self-administration and the lack of affordable and accessible options to visit a physician. Finally, from a health system perspective, a nationwide educational campaign to inform practitioners and the public of Sudan’s antibiotic misuse problem, and the threat of future antibiotic resistance, would constitute a step forward in the right direction.
References:
Ahmed, A. A., Osman, H., Mansour, A. M., Musa, H. A., Ahmed, A. B., Karrar, Z., & Hassan, H. S. (2000). Antimicrobial agent resistance in bacterial isolates from patients with diarrhea and urinary tract infection in the Sudan. The American journal of tropical medicine and hygiene, 63(5-6), 259–263.
Ahmed, A. M., Nasr, S., Ahmed, A. M., & Elkhidir, O. (2019). Knowledge, attitude and practice of surgical staff towards preoperative surgical antibiotic prophylaxis at an academic tertiary hospital in Sudan. Patient safety in surgery, 13, 42. https://doi.org/10.1186/s13037-019-0224-2
Ahmed, S., Abdelrahman, S. S., Saad, D. M., Osman, I. S., Osman, M. G., & Khalil, E. (2018). Etiological Trends and Patterns of Antimicrobial Resistance in Respiratory Infections. The open microbiology journal, 12, 34–40. https://doi.org/10.2174/1874285801812010034
Awad, A. I., & Eltayeb, I. B. (2007). Self-medication practices with antibiotics and antimalarials among Sudanese undergraduate university students. The Annals of pharmacotherapy, 41(7), 1249–1255. https://doi.org/10.1345/aph.1K068
Eibs, T., Koscalova, A., Nair, M., Grohma, P., Kohler, G., Bakhit, R. G., Thurashvili, M., Lasry, E., Bauer, S. W., & Jimenez, C. (2020). Qualitative study of antibiotic prescription patterns and associated drivers in Sudan, Guinea-Bissau, Central African Republic and Democratic Republic of Congo. BMJ open, 10(9), e036530. https://doi.org/10.1136/bmjopen-2019-036530
Elbadawi, H.S., Elhag, K.M., Mahgoub, E., et al. (2019). Antimicrobial resistance surveillance among gram-negative bacterial isolates from patients in hospitals in Khartoum State, Sudan. F1000Research, 8, 156. https://doi.org/10.12688/f1000research.17744.1
Ibrahim, M. E., Bilal, N. E., & Hamid, M. E. (2012). Increased multi-drug resistant Escherichia coli from hospitals in Khartoum state, Sudan. African health sciences, 12(3), 368–375. https://doi.org/10.4314/ahs.v12i3.19
Laxminarayan, R., Duse, A., Wattal, C., Zaidi, A. K., Wertheim, H. F., Sumpradit, N., Vlieghe, E., Hara, G. L., Gould, I. M., Goossens, H., Greko, C., So, A. D., Bigdeli, M., Tomson, G., Woodhouse, W., Ombaka, E., Peralta, A. Q., Qamar, F. N., Mir, F., Kariuki, S., … Cars, O. (2013). Antibiotic resistance-the need for global solutions. The Lancet. Infectious diseases, 13(12), 1057–1098. https://doi.org/10.1016/S1473-3099(13)70318-9
Otim, M. E., Demaya, D. K., Al Marzouqi, A., & Mukasa, J. (2021). Are Antibiotics Prescribed to Inpatients According to Recommended Standard Guidelines in South Sudan? A Retrospective Cross-Sectional Study in Juba Teaching Hospital. Journal of multidisciplinary healthcare, 14, 2871–2879. https://doi.org/10.2147/JMDH.S321990
Ramadan, A.M., Al Rikaby, O.A., Abu-Hammad, O.A., & Dar-Odeh, N.S. (2019). Knowledge and attitudes towards antibiotic prescribing among dentists in Sudan. Pesquisa Brasileira em Odontopediatria e Clinica Integrada, 19(1), e4430. https://doi.org/10.4034/PBOCI.2019.191.17
Republic of Sudan: Ministry of Finance and Economic Planning. (2020). Approved Budget for 2021. Retrieved December 17, 2021, from http://mof.gov.sd/en/images/Budget/Sudan-2021-MOF-FinalBudgetEnglish_-February22021.pdf
Saad, D., Gameel, S., Ahmed, S., et al. (2020). Etiological agents of urinary tract infection and 7 years trend of antibiotic resistance of bacterial uropathogens in sudan. Open Microbiology Journal, 14(1), 310-320. https://doi.org/10.2174/1874434602014010312
World Health Organization. (2020). Antibiotic resistance. Retrieved December 17, 2021, from https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance
Photo by Pawel Czerwinski on Unsplash
