The Center for Disease Dynamics, Economics & Policy

Since their discovery in the early 20th century, antibiotics and related medicinal drugs have substantially reduced the threat posed by infectious diseases. Over the years, these antimicrobials have saved the lives and eased the suffering of millions of people, especially in developing countries where infectious diseases remain a big challenge. Even in conditions of abject poverty and poor infrastructure and services, antibiotics have worked wonders. These gains are now seriously jeopardised by the emergence and spread of microbes that are resistant to most commonly available and effective ‘first-line’ drugs. For most of sub-Saharan Africa, the arsenal of antibiotics is already very limited. Any breach on the list leads to near-total loss of treatment choices for many severe infections.

In Kenya, the bacterial infections that contribute most to human disease are often those in which resistance is most evident. Examples are multidrug-resistant enteric bacterial pathogens such as typhoid, diarrhoeagenic Escherichia coli and invasive nontyphi salmonella, penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus and multidrug-resistant Mycobacterium tuberculosis. Resistance to medicines commonly used to treat malaria is of particular concern, as is the emerging resistance to anti-HIV drugs. Often, more expensive medicines are required to treat these infections, and this becomes a major challenge in resource-poor settings.

Although overuse and misuse of antimicrobials have contributed to the emergence and spread of resistance, paradoxically, underuse through lack of access, inadequate dosing, poor adherence, and substandard antimicrobials may play an equally important role. And of course, complete lack of access can mean death, especially for infants and children. A great hindrance to fixing these problems is the difficulty of implementing policies and guidelines, usually a result of inadequate regulatory authority and insufficient resources for enforcement. Loud whispers of ‘capsule! capsule!’ at busy and crowded bus stops are common as pedlars hawk drugs on the street. In many chemist shops across Kenya one easily purchases antibiotics (any proportion of actual dosage) over the counter, without prescription.

Even with the best intentions to implement guidelines for improving the use of antibiotics, we cannot. Local data on usage and resistance are inadequate to give a true reflection of the situation in Kenya, and the resources to do the job are not available. Only well-coordinated national surveillance will provide the necessary data for risk analysis and risk assessment. Our central reference laboratory will require personnel and funding support to take up this role. The situation analysis presented here gives a bird’s-eye view of the usage and resistance data currently available for Kenya, and the recommendations have been tailored to the situation as we understand it. Using this and information from other parts of Africa and the world, we can plot a course for the short term and beyond by thorough analysis of the policy options open to us. We must make the case that taking steps to control antibiotic resistance is worthwhile and that we can make a difference at reasonable cost. That is our challenge for the next year. We welcome ideas, comments and assistance from all quarters.