Description
Antimicrobial resistance (AMR) has emerged as one of the leading public health threats globally, including South Africa. Overuse and poor patient adherence to medical treatment are some of the reasons why countries like South Africa continue to struggle with this public health crisis.
Recognition of this issue has resulted in the development and implementation of Antimicrobial Stewardship Programmes (ASPs) that aim to help facilitate antimicrobial use in both the public and private healthcare sector. The aim of such initiatives are to improve awareness and understanding between healthcare workers as well as the general public, thus promoting improved medical treatment and management of patients, as well as better tracking of patient outcomes.
Institution: University of Pretoria, Department of Biochemistry, Genetics, and Microbiology
Submitting authority: Dr Pamela de Waal ([email protected]), Head of Department
Email: [email protected]
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Antimicrobial resistance (AMR) represents a critical public health challenge in South Africa, significantly threatening the management of infection diseases in a country that continues to struggle with the control and management of other diseases, such as, HIV and Tuberculosis. The persistence of antibiotic resistance, particularly in gram negative bacteria, is of increased concern as increased monitoring and evaluation demands complicated and often more severe treatment protocols cross both public and private healthcare sectors.[1, 2] The World Health Organization (WHO) has identified the urgent need for improved antimicrobial stewardship to combat this crisis, underscoring that improper antibiotic use and insufficient surveillance systems exacerbate the issue.[3] As such the WHO has classified certain antibiotics as “watch” and “reserve” due to their importance in treating infections caused by drug-resistant bacteria.[3-5]
South Africa’s healthcare system faces considerable challenges in managing antibiotic use and resistance, as antibiotic prescribing patterns reveal that “access” antibiotics constitute a significant proportion (70.2%) of prescriptions, while “watch” antibiotics account for only 29.6% in surgical and medical wards. [3, 5] With the public health sector servicing approximately 71% of the population, in addition to the lack of proper antibiotics stewardship programmes (ASPs), it also faces significant challenges such as a lack of resources, underfunding, and staff shortages. [6]. Some other disparities attributed to poor responses of AMR in the healthcare sector include inappropriate prescribing practices, and systematic inadequacies such as lack of access to rapid diagnostic tests.[6, 7] Cultural attitudes towards antibiotics and limited awareness of vaccinations further complicates the public health response.[8] These challenges underline the necessity for a collaborative approach involving government, healthcare workers, and communities to effectively mitigate the effects of AMR in South Africa’s healthcare landscape.[8] Gaps in knowledge and misconceptions about antimicrobial resistance among the general public are of concern, as such, targeted education and awareness campaigns are needed to empower individuals to use antimicrobials responsibly and support broader policy efforts. Addressing these knowledge gaps through targeted educational interventions has been shown to be effective in improving awareness and understanding of AMR use and resistance.[2, 9, 10] Similar campaigns, such as, those used during the COVID-19 pandemic have proven effective in communicating health related content to the general public.
Globally, the prevalence of antimicrobial resistance poses an equally significant health concern to public health and health systems as that seen in South Africa. [11] In some parts of the western world ASPs have been introduced to assist with the education and understanding of AMR within various health settings. [6, 12]. In an effort to strengthen ASPs within South Africa healthcare facilities the National Antimicrobial Resistance Strategy Framework was developed as an initiative to combat the challenges within the healthcare sector in regard to antimicrobial resistance. [10, 13] Such programmes have been implemented as an aid that advocates for correct and optimised use of antibiotics, a reduction in selection pressure for resistant bacteria, and most importantly, improved patient outcomes.[13, 14] Despite these initiatives more work is needed to ensure that such measures continue to be implemented and compliance effectively monitored. Such control measures are necessary if antibiotic prescribing practices and infection prevention is to be improved up within the various health sectors, both human and animal. [15]
Despite initiatives such as the South African Antimicrobial Resistance National Strategy Framework, compliance has been uneven, particularly in primary care settings, where effective infection prevention and control measures are often lacking.[9, 16] Health institutes such as Mediclinic are making efforts to combat AMR by aligning with the South African Antimicrobial Resistance National Strategy Framework, Mediclinic targets reducing AMR-related deaths by 10% by 2030, in line with global initiatives.[16] This effort can be attributed to the WHO reporting in 2019 that bacterial AMR was directly responsible for 1.27 million global deaths and contributed to 4.95 million deaths.[11] Without the necessary recourse it is predicted that AMR is expected to kill 10 million people by 2050 and cost the global economy over $100 million dollars.[17]
Over time, various genetic changes through evolutionary mechanisms, such as mutation and selection, have allowed for antibiotic resistance genes to continue to survive and exist in various bacteria. For instance, various strains of Enterobacteriaceae species are tested for in intensive and high care units withing hospitals due to potential to negatively affect patient outcome due to antibiotic resistance. [13, 18] Overuse, misuse and poor patient adherence to medication course completion are some of the factors that have contributed to and accelerated the development and spread of multidrug resistant bacteria in the environment.[6, 16] The effectiveness of antimicrobials is critical not only for treating simple infections, but also for ensuring the safety of patients undergoing surgeries, chemotherapy, and transplants.
Therefore, embracing technological advancements in healthcare is just as pivotal a concern towards addressing AMR in South Africa. As such, better surveillance measures through the integration of digital health solution, such as electronic surveillance, health records and telemedicine, seek to enhance efficiency and accessibility, allowing for better tracking of antibiotic use and resistance patterns.[6, 13] Through the use of such technologies, improved communication between health providers and patients would be possible allowing for more effective monitoring of patient compliance to medical care, medication, and treatment regimes.
South African government’s commitment to social programme, such as the National Health Insurance, aims to reduce inequality and improve access to healthcare through universal health coverage,[19] which is fundamental in the fight against AMR. By promoting community-driven health initiatives and connecting them with policymakers, there is potential for significant advancements in public health responses to antimicrobial resistance.
Overall, antimicrobial resistance is a complex, multifaceted problem that requires a comprehensive, coordinated, and sustained global response. Strengthening surveillance, improving antimicrobial stewardship, enhancing public awareness, and fostering innovation are all critical components of an effective strategy to address this growing public health concern. Antimicrobial resistance has implications beyond immediate health concerns, threatening economic stability as well as food security. Therefore, addressing AMR requires an urgent commitment to fortifying healthcare infrastructure, enhancing education, and training for health professionals, and fostering global partnerships aimed at developing innovative solution to combat this growing public health threat.
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2. Engler, D., et al., Compliance with South Africa’s Antimicrobial Resistance National Strategy Framework: are we there yet? J Chemother, 2021. 33(1): p. 21-31.
3. Organization, W.H., Antimicrobial resistance and primary health care, in Technical series on primary health care, N.M. Isabel Frost, Samantha Chai and Ramanan Laxminarayan Editor. 2018.
4. Aruhomukama, D. and H. Nakabuye, Investigating the evolution and predicting the future outlook of antimicrobial resistance in sub-saharan Africa using phenotypic data for Klebsiella pneumoniae: a 12-year analysis. BMC Microbiology, 2023. 23(1): p. 214.
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11. Murray, C.J.L., et al., Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet, 2022. 399(10325): p. 629-655.
12. Singh-Moodley, A., et al., Laboratory based antimicrobial resistance surveillance for Pseudomonas aeruginosa blood isolates from South Africa. The Journal of Infection in Developing Countries, 2018. 12(08): p. 616-624.
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14. Ziv-On, E., et al., Impact of an Antibiotic Stewardship Program on the Incidence of Resistant Escherichia coli: A Quasi-Experimental Study. Antibiotics, 2021. 10(2): p. 179.
15. Ricker, N., et al., Toward Antibiotic Stewardship: Route of Antibiotic Administration Impacts the Microbiota and Resistance Gene Diversity in Swine Feces. Frontiers in Veterinary Science, 2020. 7.
16. Mediclinic. Combatting antimicrobial resistance a critical focus for SA’s healthcare sector. 2024 [cited 2024 12 December 2024]; Available from: https://www.mediclinic.co.za/en/foh-corporate/patients/combatting-antimicrobial-resistance-a-critical-focus-for-sa-s-he.html.
17. Ahmed, S., et al., Recent Approaches for Downplaying Antibiotic Resistance: Molecular Mechanisms. BioMed Research International, 2023. 2023(1): p. 5250040.
18. Almagor, J., et al., The impact of antibiotic use on transmission of resistant bacteria in hospitals: Insights from an agent-based model. PLOS ONE, 2018. 13(5): p. e0197111.19. (NDoH), N.D.o.H., National Health Insurance Act 20 of 2023. Pretoria.
