According to the Global burden of bacterial antimicrobial resistance study published in 2022, Sub-Saharan Africa (SSA) had the lowest antibiotic consumption (AMC) but the highest burden of antimicrobial resistance (AMR). Contributing factors included the high infection burden in SSA, inadequate access to water and sanitation (WASH), and limited availability of AMC and antimicrobial use (AMU) data. These factors impact patients with antibiotic-susceptible and resistant infections alike.   

Using the Drug Resistant Index (DRI) as a measure of antibiotic effectiveness, where a score of 25% of below is indicative that AMR is under control, most SSA countries reported approximately double this benchmark figure (see infographic below).

Third generation cephalosporin (3GC) resistance has taken a toll on SSA, with some countries such as Nigeria reporting over 80% resistance to E. coli and K.pneumoniae in the Global Antimicrobial Surveillance System (GLASS) report. The 3GC resistant levels are paralleled by the widespread use of 3GCs  across the continent. The WHO AWaRE classification lists ceftriaxone (an example of a 3GC) as a ‘Watch antibiotic’, meaning it is at relatively high risk of selection of bacterial resistance and should be prioritized as a key target of stewardship programs and monitored. However, previous African studies have shown alarming resistance to antibiotics belonging to WHO ‘Access group’, which should have lower resistance potential than most antibiotics. This highlights the need for stewardship programmes based on local antimicrobial susceptibility data. 

Aside from the sub-optimal microbiology susceptibility data in SSA, there is a mismatch between availability of antibiotics, guidelines and surveillance data. These along with other factors present challenges to prescribers  in antibiotic decision making. 

Getting to the root of this complex interplay of science, economics and human behavior is pertinent to tackling AMR and improving antimicrobial stewardship in the SSA setting. This can be achieved through a multidisciplinary approach, targeting all players in the health system such as community-level pharmacists, microbiologists, nurses, and infection preventionists. This approach will be key to monitor antibiotic prescribing, the impact of interventions, and infection and resistance patterns.

Additionally, SSA can learn from, and build on, the triumphs achieved by the HIV/TB  programmes and engage the community by forming partnerships with civil societies.