Dr Rose Kakai is a professor in the School of Public Health and Community Development at Maseno University in Kenya. She is a member of the GARP-Kenya Working Group.
My interest in rural health developed when I joined Moi University, Faculty of Health Science (now School of Medicine), and was appointed to coordinate the rural health Community Based Education and Service (COBES), and later, the Public Health Programme in Maseno University. This exposed me to common health problems encountered in rural communities in Western Kenya. Since then, I have strived to explore ways and means of making the livelihood of rural populations better through advocating for improved peripheral health diagnostic lab services to enhance evidence based patient management, including rational use of antibiotics. The rural community deserves special consideration because that is where 60% of the total population of Kenya lives, yet there are multiple challenges including poverty, limited healthcare resources, high prevalence of infant mortality, human immunodeficiency virus infection, malnutrition and low immunization rates. For a family that is struggling to put food on the table, these challenges can be substantial. Published data on rural community based antibiotic use and resistance is limited. Most studies have concentrated on healthcare institutions and urban areas.
Concern exists worldwide about the threat posed to human health by antibiotic resistance to common microbial pathogens. Use of antibiotics is associated with development of resistance. In Kenya, there is substantial resistance to the antibiotics most frequently prescribed for common illnesses such as septrin, ampicillin and tetracycline, as opposed to ciprofloxacin and nalidixic acid. Whereas many people receive medication to which their infecting bacteria are not susceptible, the clinical impact of these findings (e.g., duration of illness, mortality, or bacterial shedding) has not been evaluated. Whether this translates into treatment failure or not is unknown. Further clarification on when and where such data provide added benefit is required. Nonetheless, strategies to improve practices that use surveillance data to rationally guide more judicious antibiotic use warrant consideration. No doubt antibiotics are used in rural communities but the extent to which this takes place and the level of resistance is unknown. Most prescribing occurs in the community, either by healthcare workers, self or friends and relatives. Sources of antibiotics include pharmacies scattered all over including the smallest shopping centres in rural areas. Although antibiotics should be dispensed on prescription, there is evidence that this is not strictly adhered to by most dispensers. Over 50% of antibiotic prescription is for presumptive respiratory tract infection, some of which may be due to non bacterial causes such as viruses. Although reduced use is an essential component of the strategies to combat antibiotic resistance, we must approach such measures with caution when the reason for this reduction is unknown, or else it might be followed by harm. It is necessary to rely upon clinical microbiology laboratory to determine the pathogens and their antibiotic susceptibility to stay aware of local microbial patterns. Since most common health problems are preventable, laying more emphasis on creating infection prevention awareness could substantially reduce their incidence, the resultant need for antibiotics, and the pressures favouring increased antimicrobial resistance.
There is need to generate more data to guide antibiotic use and resistance in rural communities. No doubt we need antibiotics but if we are to sustain their usefulness, the drive for more appropriate use in the community should continue as an effort unending.