Abstract
BackgroundThe relationship between antibiotic use and antimicrobial resistance varies with cultural, socio-economic, and environmental factors. We examined these relationships in Kibera, an informal settlement in Nairobi—Kenya, characterized by high population density, high burden of respiratory disease and diarrhea.MethodsTwo-hundred households were enrolled in a 5-month longitudinal study. One adult (≥ 18 years) and one child (≤ 5 years) participated per household. Biweekly interviews (n = 1516) that included questions on water, sanitation, hygiene, and antibiotic use in the previous two weeks were conducted, and 2341 stool, 2843 hand swabs and 1490 drinking water samples collected. Presumptive E. coli (n = 34,042) were isolated and tested for susceptibility to nine antibiotics.ResultsEighty percent of presumptive E. coli were resistant to ≥ 3 antibiotic classes. Stool isolates were resistant to trimethoprim (mean: 81%), sulfamethoxazole (80%), ampicillin (68%), streptomycin (60%) and tetracycline (55%). Ninety-seven households reported using an antibiotic in at least one visit over the study period for a total of 144 episodes and 190 antibiotic doses. Enrolled children had five times the number of episodes reported by enrolled adults (96 vs. 19). Multivariable linear mixed-effects models indicated that children eating soil from the household yard and the presence of informal hand-washing stations were associated with increased numbers of antimicrobial-resistant bacteria (counts increasing by 0·27–0·80 log10 and 0·22–0·51 log10 respectively, depending on the antibiotic tested). Rainy conditions were associated with reduced carriage of antimicrobial-resistant bacteria (1·19 to 3·26 log10 depending on the antibiotic tested).ConclusionsAntibiotic use provided little explanatory power for the prevalence of antimicrobial resistance. Transmission of resistant bacteria in this setting through unsanitary living conditions likely overwhelms incremental changes in antibiotic use. Under such circumstances, sanitation, hygiene, and disease transmission are the limiting factors for reducing the prevalence of resistant bacteria.
Highlights
Numerous organizations have called attention to the increasing prevalence of antimicrobial resistance (AMR) worldwide [1]
These characteristics promote the spread of infectious diseases and the demand for antibiotics, when available [6,7,8], and support the observations by Collignon et al [9] that countries with poor infrastructure, poor governance and limited public health expenditures have a higher prevalence of antimicrobial-resistant bacteria compared with countries that rank better by these metrics
While encouraging antibiotic stewardship might be important for limiting AMR, it may not be an effective strategy for communities where exposure to unhygienic conditions and rapid spread of pathogens overwhelm individual decisions regarding antibiotic use, whether within or outside the healthcare system
Summary
Numerous organizations have called attention to the increasing prevalence of antimicrobial resistance (AMR) worldwide [1]. Omulo et al Antimicrob Resist Infect Control (2021) 10:18 to reduce unnecessary antibiotic use This “stewardship focus” is led by high-income countries in North America, Europe, and Oceania where robust healthcare infrastructure and regulatory frameworks are present. In 2013 the United Nations Human Settlements Program estimated that a quarter of the world’s urban population lived in slums [5]; informal settlements characterized by high population density, poor sanitation and lack of consistent access to clean water These characteristics promote the spread of infectious diseases and the demand for antibiotics, when available [6,7,8], and support the observations by Collignon et al [9] that countries with poor infrastructure, poor governance and limited public health expenditures have a higher prevalence of antimicrobial-resistant bacteria compared with countries that rank better by these metrics. We examined these relationships in Kibera, an informal settlement in Nairobi— Kenya, characterized by high population density, high burden of respiratory disease and diarrhea
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