A systematic review of qualitative literature on antimicrobial stewardship in Sub-Saharan Africa

Abstract

Background Antibiotic resistance is a major problem in every region of the globe and Sub-Saharan Africa (SSA) is no exception. Several systematic reviews have addressed the prevalence of resistant organisms but few have examined the underlying causes in this region. This systematic review of qualitative literature aims to highlight barriers and facilitators to antimicrobial stewardship in SSA. Methods A literature search of Embase and MEDLINE(R) was carried out. Studies were included if they were in English, conducted in SSA, and reported qualitative data on the barriers and facilitators of antimicrobial stewardship or on attitudes towards resistance promoting behaviours. Studies were screened with a simple critical appraisal tool. Secondary constructs were extracted and coded into concepts, which were then reviewed and grouped into themes in light of the complete dataset. Results The literature search yielded 169 results, of which 14 studies from 11 countries were included in the final analysis. No studies were excluded as a result of the critical appraisal. Eight concepts emerged from initial coding, which were consolidated into five major themes: ineffective regulation, health system factors, clinical governance, patient factors and lack of resources. The ineffective regulation theme highlighted the balance between tightening drugstore regulation, reducing over-the-counter sale of antibiotics, and maintaining access to medicines for rural communities. Meanwhile, health system factors explored the tension between antimicrobial stewardship and the need of pharmacy workers to maintain profitable businesses. Additionally, a lack of resources, actions by patients and the day-to-day challenges of providing healthcare were shown to directly impede antimicrobial stewardship and exacerbate other factors which promote resistance. Conclusion Antibiotic resistance in SSA is a multi-faceted issue and while limited resources contribute to the problem they should be viewed in the context of other factors. We identify several contextual factors that affect resistance and stewardship that should be considered by policy makers when planning interventions. This literature base is also incomplete, with only 11 nations accounted for and many studies being confined to regions within countries, so more research is needed. Specifically, further studies on implementing stewardship interventions, successful or not, would be beneficial to inform future efforts.

A Systematic Review of Pharmacist-Led Antimicrobial Stewardship Programs in Sub-Saharan Africa

“…According to the United Nations Program on HIV/AIDS (UNAIDS), the region accounts for 71% of the global HIV burden [17]. e situation is dire, with infections like dysentery and pneumonia no longer treatable with first-line medication [18]. Incidences of resistance in these infections and infectious diseases can result in poor clinical outcomes and increased mortality [18].…”

“…e situation is dire, with infections like dysentery and pneumonia no longer treatable with first-line medication [18]. Incidences of resistance in these infections and infectious diseases can result in poor clinical outcomes and increased mortality [18]. Stewardship activities in the region are low and thus there is a need to increase these activities.…”

Gaps in the implementation of national core elements for sustainable antimicrobial use in the WHO-African region

“…A systematic review of the implementation of AMS programs in Africa included studies primarily from South Africa and a few East African countries, with none of the 13 studies from West Africa (Akpana et al, 2020). A review of 14 Sub-Saharan Africa studies clearly elucidated that the barriers to AMS included the lack of regulations or their enforcement on the prescriptions and sales of antimicrobials at the country or the regional level, the heterogeneity and complex nature of the healthcare system, poor clinical governance typified by the lack of AMS guidelines and poor adherence to such guidelines, when available, and the lack of national support for AMS in terms of human and financial resources and laboratory facilities (Porter et al, 2021). In these developing countries, there are action plans for AMS at the national or sub-national level; however, in principle, implementation is often hindered by low political commitment and the lack of operational policies, as well as legal and regulatory frameworks, with escalated effects on the development of facility-based systems (Kakkar et al, 2020).…”

“…Ineffective national regulations and poorly functioning regulatory strategies are common issues in Africa, immensely contributing to the uncontrolled availability and use of antibiotics across the continent (Akpana et al, 2020). A systematic review of the literature across Sub-Saharan Africa highlighted the deficiencies in the antimicrobial regulations at the country or regional level (Porter et al, 2021). A report documented Ghana having available laws that control the use of antimicrobials in humans, but the enforcement of these laws is weak, leading to the supply of antibiotics to and from unauthorized outlets (Yevutsey et al, 2017).…”

“…A different systematic review of the literature without restrictions on the date of publications until 2020 in Embase and Ovid MEDLINER ® databases determined barriers and facilitators of AMS programs and identified 14 eligible studies from 11 African countries. Many of the studies, rather than being nationally representative, were confined to regions within the countries (Porter et al, 2021). A more recent scoping review of the AMS landscape in eight (Ghana, Nigeria, Sierra Leone, Kenya, Tanzania, Uganda, Malawi, and Zambia) countries in Africa revealed variations in the implementation of AMS programs, with only Kenya having national AMS guidelines for healthcare settings (Kamere et al, 2022).…”