AMR driven by erratic use and lack of access to effective and affordable medicines- MAAP 2016-2018 Study reveals

By Samwel Doe Ouma

The antibiotic consumption data in Kenya conducted between 2016-2018 show that only five drugs comprised more than half (58 percent) of all the antibiotics used in healthcare settings during the study period.

According to the study titled ‘National Situation of Antimicrobial Resistance and Consumption Analysis from 2016-2018’ led by The African Society for Laboratory Medicine (ASLM) conducted by Mapping Antimicrobial resistance and antimicrobial use Partnership (MAAP) consortium, the top five most consumed antimicrobials in Kenya are amoxicillin, sulfamethoxazole/trimethoprim, ampicillin/cloxacillin, erythromycin and doxycycline.

“Consumption of these drugs together accounted for over 58 percent of the total consumption share, suggesting a lack of variation revealing that the consumption trend could potentially increase AMR scourge in the country,” the study says.

The study reveals that combined lack of access and erratic use of antimicrobials magnifies the Antimicrobial resistance (AMR) crisis in Kenya with stronger medicines to treat more resistant infections (such as severe pneumonia, sepsis, and complicated intraabdominal infections) not available, suggesting limited access to some groups of antibiotics.

The study further reveals that Antimicrobial consumption patterns recorded overuse/misuse of antimicrobials from the ‘Access’ classification list which stood at 70.4percent, while ‘Watch’ list antimicrobials consumption was at 29.6percent, and ‘Reserve’ below 0.1 percent. The data shows that the Access category further exceeded the World Health organization (WHO) minimum recommended consumption threshold which limit at least 60 percent of global antibiotic consumption to the “Access” group of antibiotics.

On the other hand, the consumption data on Reserve category, show how drastically underutilized they are—a critical problem given the levels of resistant infections that have been found with just limited data.

According to the WHO, antibiotics are classified into AWaRe which divides the antibiotics into three categories; Access (first-choice antibiotics that are typically narrow-spectrum and have less potential for resistance, Watch (broader-spectrum antibiotics and second-and third-generation cephalosporins), and Reserve (last-resort option antibiotics classes such as linezolid, imipenem, meropenem, aztreonam, and colistin.

The number one goal of the AWaRe classification of antibiotics is to have all countries report antibiotic use by 2023. The second goal is to limit at least 60percent of global antibiotic consumption to the “Access” group of antibiotics. The tool also emphasizes limited use of Watch and Reserve antibiotics.

The study also further reveals a lurking danger with erratic consumption of fixed combinations of antibiotics, (FDCs) having found out that Nine combinations of two or more broad-spectrum fixed-dose combinations of antimicrobials were identified that were not recommended for clinical utility but were nevertheless consumed in Kenya. Of these FDCs, ampicillin/cloxacillin was most commonly consumed.

“Kenya’s Drug Resistance Index estimate is moderately high at 56.2 percent, implying low antibiotic effectiveness that threatens the effective management of infectious disease in the country therefore calling for urgent policy intervention.”

Drug resistance index (DRI) is a simple metric based on aggregate rates of resistance measured on a scale of 0-100, where 0 indicates fully susceptible while 100 indicates fully resistant.

The study also found out that most laboratories across Kenya are not ready for Antimicrobial resistant (AMR) testing.

During the study period approximately 1 037 laboratories in the national laboratory network were mapped out, of all the laboratories only 64 reported capacities for bacteriology testing which also revealed dearth of bacteriology/microbiology laboratory infrastructure.

“Clinics and laboratories don’t speak to each other which leads to failure to consistently test for all priority resistant pathogens thus translating to substandard care, where antimicrobials are used to treat infections without first determining whether they will be effective.”

Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat.

According to the study high levels of resistance were noted for third-generation cephalosporins in the Enterobacterales 67-73 percent carbapenem in Pseudomonas aeruginosa 36-51 percent and methicillin in Staphylococcus aureus 40-52percent.

Antimicrobial-resistant infections were found to be more common in males and the elderly.

Antimicrobial consumption (AMC) is measured as the number of antimicrobials sold or dispensed, whereas Antimicrobial Use (AMU) reviews whether antimicrobials are used appropriately based on additional data such as clinical indicators.

During the study only antimicrobial consumption data (AMC) were retrieved, however antimicrobial use data (AMU) were not obtained due to the lack of a unique patient identifier and tracking systems across hospital departments.

“A clear link has been shown between the misuse of antimicrobials and the emergence of AMR. However, owing to the limited capacity of health systems and technological hurdles, comprehensive and robust AMR, antimicrobial use (AMU), and antimicrobial consumption (AMC) data is lacking in many low- and middle- income countries (LMICs), and there remains significant uncertainty as to the burden of drug resistance.”

The average national total AMC consumption levels in Kenya between 2016-2018 were 8.8 defined daily doses (DDD) per 1 000 inhabitants per day (DID), ranging from 11 in 2016, 7.4 in 2017 and 8.1 in 2018.

Antimicrobial utilisation by the World Health Organisation (WHO) Anatomical Therapeutic Chemical (ATC) classification was highest for penicillins with extended-spectrum range 21.2percent to 29.9percent, followed by combinations of penicillins and beta-lactamase inhibitors range 9.7percent to 16.2percent and by combinations of sulfonamides and trimethoprim, including derivatives range 7.7percent to 16.4percent.

Identified pathogens

Staphylococcus species 27.1 percent, Escherichia species 23.6percent), and Klebsiella species 17.6percent and Enterococcus species at five percent.

Resistance profiles of the most and least consumed antimicrobial classes

The most consumed antimicrobial classes across the study years were aminopenicillins, macrolides, folate pathway inhibitors, and beta-lactam combinations.

According to the study in 2016, resistance rates were more than 75 percent for folate inhibitor resistant Escherichia species, Klebsiella species, and Streptococcus species, macrolide-resistant Escherichia species, Klebsiella species, and aminopenicillin-resistant Klebsiella species and Escherichia species.

In 2017, there were high rates 75percent) for beta-lactam-resistant Staphylococcus species and Serratia species, macrolide-resistant Enterococcus species and aminopenicillin-resistant Pantoea species.

In 2018, the highest rates 75percent) of macrolide-resistant Vibrio species, Enterococcus species and Escherichia species and aminopenicillin-resistant Vibrio species were observed.

The least consumed antimicrobial classes across the study years were carbapenems and glycopeptides. Even though the consumption of these antimicrobial classes was low, there were high resistance rates across many pathogen-antimicrobial class combinations. For example, in 2016 and 2017, resistance rates were more than 50 percent for carbapenem-resistant Acinetobacter species.

In 2018, resistance rates to carbapenem were more than 75 percent in Vibrio species and Acinetobacter species.

The study recommends the need for inter-departmental collaborations, increased community awareness and improved stewardship practices to control AMR. strengthening the delivery of services by the laboratories, by mapping all laboratories across a range of indicators, including population coverage, infectious disease burden, testing capabilities, and quality compliance. This mapping exposes unmet needs and informs the laboratory network expansion plan.

Staff training on laboratory standards, common pathogens identification, and data management skills are essential for high quality microbiology testing and reporting. This can be done through frequent staff capacity building which can be achieved by leveraging in-house expertise or outsourcing to external organizations or tertiary facilities.

It also suggests that countries should curate the correct data that will generate evidence which is essential to strengthening AMR surveillance. It further advises that data collection done through standardized formats at all levels (laboratories, clinics and pharmacies) and data analysis automation and establishing a system of assigning permanent identification numbers for tracking patients.