In this article Hilja Eelu, AMR Centre student liaison officer, interviews Dr Gordon Cupido, head of internal medicine at the Katutura State Hospital (KSH) in Windhoek, Namibia. They discuss the problem of antibiotic resistance at the KSH, a public hospital serving an estimated 310,000 individuals. Namibia is an upper middle-income country in Sub Saharan Africa, and represents some of the issues experienced in other African countries.

There are three main issues impeding successful management of the antibiotic resistance crisis in the public sector: reflexive prescribing, institutional culture and limited surveillance and diagnostic data. They also discussed public health solutions to the issue, the role of private sector healthcare and how the COVID-19 pandemic might be exacerbating the spread of resistant infections.

Reflexive prescribing and institutional culture

Patients who are asthmatic or have upper respiratory infections are sometimes prescribed an antibiotic as a ‘reflex action’ if it’s suspected they have an underlying bacterial infection. This is instead of clinicians using the ‘watch and wait’ approach, to see if symptoms improve on their own. There are specific guidelines for diagnosis, however, at times clinicians with limited time and resources make assumptions and prescribe an antibiotic where it’s not needed.

Institutional culture plays a large role in awareness of AMR issues and clinicians’ practices in AMR management – at KSH, the antibiotic guidelines are unfortunately not always widely circulated. In light of this, he acknowledges that it is a responsibility of hospital leadership to encourage clinicians to critically review processes and consider newly published literature and the aetiology of disease as opposed to “tradition” in antimicrobial use.

Limited surveillance and diagnostic data

Another issue is the limited information regarding present microbial resistance patterns, for surveillance and diagnosis. Dr Cupido explained: “In other countries with older populations, there may be longer hospital stays from transplants or oncology, and better surveillance of these patients over time as pathogens exhibit resistance.” Considering the population structure in Namibia, patients admitted to hospital are often young HIV positive individuals treated for opportunistic infections, most commonly TB, and older patients that come in specifically for surgical or orthopaedic procedures and are rapidly discharged. As such, for these shorter stays, patients are discharged before the consequences of poor AMR management are evident, and newly-developed resistance may only discovered upon readmission or an extended hospital stay.

Previously the Namibia Institute of Pathology (NIP) produced cross-sectional AMR reports used in the formation of the initial guidelines, however, this is not done on a regular basis, and little published data exists on the state of AMR in Namibia. This contributes to challenges in diagnostic decision-making in the absence of surveillance data.

Public health solutions

While there are many issues in the diagnosis and treatment of patients with bacterial infections, there are also public health solutions that could reduce the spread of infection and lessen the burden on hospitals.

“In Namibia, there tends to be an overemphasis on clinical practice”, Dr Cupido states. He observes that eradication of TB, depends not on treatment, but on stopping the transmission of infection in social settings, specifically, shebeens (informal establishments that sell alcohol for on-site consumption) and taverns. These are issues that would require state investment into epidemiology and other applied sciences.

The role of the private sector

The state regulates both the public and private sector, but the private sector is more difficult to monitor. At times, the public health care system imports cases from private and bears the burden of unregulated use of antimicrobials in the private sector. This refers to instances in which patients are prescribed antibiotics at private health care facilities, select for existing resistant pathogen strains, and as a last resort visit public health care facilities for further assistance.

Healthcare-seeking behaviour during COVID-19

The COVID-19 pandemic has naturally disrupted health-seeking behaviours across both sectors. “Specifically, around the SARS-COV-2 pandemic, there has been a decrease in patients presenting to the hospital for treatable disease. Fewer patients have presented for TB testing and diagnosis, and routine data reports lower multi-drug resistant (MDR)-TB numbers than expected. Many individuals will likely transmit undiagnosed, leading to untreated and uncontrolled TB in the community.” The KSH anticipates a wave of patients when restrictions ease and is apprehensive of shortages in the hospital due to resources that were allocated to the pandemic. Within hospitals, antibiotic usage has also increased, with azithromycin administered for COVID-induced pneumonia despite the lack of evidence for patient benefit.

The future of AMR management

In short, the AMR crisis in the Namibian public sector requires improvements in clinicians’ modus operandi, backed by data and the investments in the applied health sciences. It would also require stricter monitoring of antimicrobial use in the public and private sector. Dr Cupido notes a change in the medical landscape over time: “as society matures, we progress towards a critical mass of critical thinking”. This will in turn, challenge the status quo and improve decision making in AMR management, in the best interests of society.