Abused and Resistant: Antibiotics in Rural and Urban Nigeria.

Author(s) Hamidu Oluyedun1.
Affiliation(s) 1Pharmaceutical Servicea, State Hospitlas Management Board, Ibadan, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary The development of effective and safe drugs to deal with bacterial infections has reduced morbidity and mortality from microbial disease. This study aimed at identifying specific cultural, demographic and institutional factors in rural and urban settings in Ibadan, Nigeria. The research showed that the rise of drug-resistant bacteria “superbugs” is mainly a consequence of the overuse, inappropriate use and misuse of antibiotics which occurs across geographical, economic and social boundaries in the two communities. Pharmaceutical care interventions are needed in the communities to safeguard the health of the populace against bacteria resistance.
Background The development of effective and safe drugs to deal with bacterial infections has reduced morbidity and mortality from microbial disease. Nevertheless, the emergence of drug-resistant organisms as a result of environmental flexibility and genetic adaptability has imposes serious constraints on the options available for the medical treatment of many bacterial infections. Bacteria can spread resistance in bacterial populations from person to person.
This is a world-wide problem, which is particularly serious in low-income countries where many of the affordable antibiotics have become powerless due to resistance, and also where the newer, broad-spectrum antibiotics are a financial burden for the poor who cannot afford good medical care and expensive new antibiotics. High numbers of patients, lack of time, small resources and lack of diagnostic laboratory test are all confounding factors in abuse of antibiotics. Disease-causing microbes that have become resistant to antibiotic drug therapy are an increasing public health problem. Bacteria and other microbes that cause infections are remarkably resilient and have developed several ways to resist antibiotics and other antimicrobial drugs
Objectives This study attempted to identify specific cultural, demographic and institutional factors in rural and urban setting in Ibadan, Nigeria that favor resistance to antibacterial drugs. This will help the public health workers and policy makers to safeguarding public health by putting in place strategic interventions.
Methodology In Ibadan, Oyo Nigeria the study was carried out in two communities settings, one rural the other urban. The two settings were selected through stratified sampling method.  Through the multistage sampling method ten households were picked for six weeks recall on the use of antibiotics. A hospital was chosen within each setting.
The study was non-experimental and employed descriptive research design to describe data. Also, context and ethnographic analysis was used to analyze the data. The survey employed 10 in-depth interviews with policy makers, medical practitioners and community based pharmacists. Ten key-informant interviews were conducted for Patent Proprietary Vendor License holders (PPMVL holder), Head of Household and Hospitals staff. Four focus group discussion (FGDs) were held with 2 groups of nurses and two groups of PPMVL holders and ante-natal women. Ten Household recalls were undertaken in both the communities for six weeks.
The key informant interviews and in-depth interviews were analyzed through context analysis and ethnographic summary. This involved verbatim quoting of respondents to buttress certain arguments that arose during the course of the study. Content analysis involved critical evaluation of the respondents’ position on any issue.
Results The household recall revealed that remnants of antibiotics were found in 80% of the respondents. The adherence to antibiotics usage was extremely low: 30% in the rural setting and 70% in the urban setting. Incomplete prescription filling accounted for 70% of abused use of antibiotics in rural setting, whereas, it accounted for 20% in the urban area. In both settings the male abuse was a ratio of 2: 1, and this is likely connected with male dominance within the community. In the rural community 60% of the respondents had been treated with antibiotics 6 weeks preceding the study, and within the hospital 90% of those surveyed were already on antibiotics prior to consultation. In the urban setting 80% used antibiotics prior to the study and 40% that visited the hospital were on antibiotics prior to consultation. The most commonly used antibiotics were beta-lactams ampicillin, amoxicillin, ciprofloxacin and co-trimoxazole. The urban setting respondents are now gradually moving towards third generation cephalosporin due to the failure of common antibiotics. It was discovered that most of the antibiotics were purchased from small private shops with unqualified personnel. The ability to correctly diagnose and treat was worse in the rural setting. Various case mismanagements were found in the rural setting. The majority of the respondents in both rural and urban settings consulted and purchased antibiotics from mega source. The health–seeking behaviour of the respondents is based upon personal decisions of what to buy, which is in turn influenced by the out-of-pockets payment, health literacy and previous experience. There is high rate of antibiotics used and over 50% of this use represented self–medication. The result revealed that health literacy had positive effect on self-care. The educated in both communities to non-educated was ratio 1:4 when it comes to antibiotics self medication. Also, financial power plays significant roles in the ability to fill prescriptions and buy the recommended dose of antibiotics. Non-adherence is 80% in the rural setting compare to 20% in urban. The community cannot be blamed for this because the entire local government of Oluyole, with over 100,000 residents, has only 23 health personnel in the state owned Health facilities compared to 557 in Ibadan North West,  an urban setting with four State owned Health facilities (MOH, 2009). The result revealed that pressure to use cheaper, proven drugs, led health care providers to over-prescribe antibiotics.
Conclusion The rise in drug-resistant bacteria “super-bugs” is mainly a consequence of the overuse, inappropriate, and misuse of antibiotics which occurs across geographical, economic and social boundaries in the two communities. The two communities are already reporting ineffectiveness and lack of confidence in the common antibiotics found in the communities. Pharmaceutical care interventions are needed in the communities to safeguard the health of the populace against bacteria resistance. The study revealed that there are discrepancies between knowledge and practice among healthcare providers and health literacy is poor in the two communities. In addition, there are no antibiotic prescription policies to guide prescribers and there is easy access in the community to antibiotics. The drug providers/vendors require regular training, monitoring and proper surveillance.

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