An assessment of antibiotic use practices among caregivers of under-5 children in Kaduna Metropolis, Northwest Nigeria

INTRODUCTION

Antibiotics are medicines used for the treatment of bacterial infections. The discovery of antibiotics remains a significant and highly beneficial landmark in the history of medical science and health care. However, the inappropriate use or administration of antibiotics is identified and recognized by the World Health Organization (WHO) as well as the general health community and governments of nations as a major public health challenge.^[1,2] Described by numerous terminologies such as misuse, abuse, overuse, and/or even under-use, this menace comes with many consequences and carries a number of implications on global health.^[3] A significant one being antibiotic resistance, which is a phenomenon where bacteria, which usually were susceptible and sensitive to certain antibiotics gradually, become non-responsive to them; thus, making such antibiotics less efficacious and the bacterial diseases they cause no longer amenable to treatment.^[1,2] This has been largely attributed to the inappropriate use of antibiotics including the indiscriminate prescription of the same, although it could also occur naturally.^[2,3]

Globally, it is reported that certain bacterial infections are increasingly becoming difficult to treat with hitherto conventional antibiotics.^[1-3] These include diseases such as pneumonia, tuberculosis, and gonorrhea caused by bacteria such as Streptococcus pneumoniae, Mycobacterium tuberculosis, and Neisseria gonorrhoeae among others.^[1-3] This results in longer durations of treatment (including in-patient hospital stay), heavier morbidity, and mortality burdens and also higher costs of treatment, as newer and more expensive brands of antibiotics become the only alternatives to resort to.^[1,3-5] These consequences carry both economic and clinical implications for individuals, families, communities, and health systems.^[2,3,5] Moreover, they certainly do not augur well for many national economies, particularly in the resource-constrained contexts of many developing countries alongside myriad other competing demands from both health-related and other sectors.^[5,6]

Since the discovery of penicillin by Alexander Fleming in 1928, the inappropriate and unnecessary use of antibiotics has steadily risen over the years with accentuated increases reported in the past four decades.^[2-5] Globally, it is estimated that up to 50% of antibiotic use is inappropriate with both prescribers and end-users contributing to the burden by either over-prescribing or over-demanding, respectively.^[4,6-8] Antibiotics remain freely available, over-the-counter drugs virtually worldwide and are even hawked in public places in some parts of the world such as Africa (including Nigeria), Asia, and Latin America.^[2,4-6,9] Many studies have reported that the inappropriate use of antibiotics is relatively predominant in relation to children.^[4,8,10,11] This is of utmost concern.^[8] Part of the strategies employed in addressing and resolving the misuse of antibiotics includes behavioral change, and the individual and corporate commitment to discontinue the untoward practice,^[1,3] which will involve the identification and recognition of the root and remote factors that drive and propel the inappropriate administration of antibiotics within communities, based on empirical evidence.^[3] When this is successfully achieved, and such evidence is applied in the fight against antibiotic misuse, then this global combat would become a feasible conquest. This study’s objective is to assess the practices of caregivers of under-5 children in Unguwan Dosa area of Kaduna metropolis in Northwest Nigeria, regarding the use of antibiotics.

MATERIAL AND METHODS

RESULTS

Majority of the caregivers were in their twenties (44.4%) and thirties (37.4%). Most (78.1%) were female and the predominant occupations were civil servants (34.8%), housewives (26%), and traders (22.2%). About half (51.1%) of them had tertiary level of formal education and majority (82.2%) were married. Most (88.9%) of the caregivers were the biological parents of the children (mothers = 63% and fathers = 25.9%).

The predominant inappropriate practices of antibiotic use reported as always being practiced among the respondents include storing (or keeping) of antibiotics at home for future use (23%), discontinuing courses of antibiotics when the health of children improves (17%), reusing antibiotics previously used, if children present with similar symptoms (16%), and directly requesting for antibiotics from physicians (16%). Furthermore, about 15% of the caregivers admitted to the habit of keeping “leftover” antibiotics at home for future use and reducing the frequency of antibiotics administration when their children’s health improves.

Majority of the respondents (97%) were assessed to have good practices with regard to antibiotic usage, scoring at least 50%.

DISCUSSION

Antibiotics ought to be judiciously and responsibly used, to address the insidious development of antibiotic resistance, a global public health menace threatening the erstwhile conquest over bacterial infections in the early half of the 20^th century.^[1-9] To curtail the spread and persistence of this phenomenon, the involvement and commitment of individuals, families and communities, as well as health professionals, institutions, and systems are indispensable.^[1,3-6,11] The WHO recognizes this and has stipulated interventions to mitigate it’s burden, which includes roles and responsibilities at different levels for these aforementioned stakeholders.^[3] However, a relative paucity of data regarding antibiotic use and resistance exists in many developing countries (including Nigeria) as compared to the plethora of such information in most of the Western world, particularly with regard to children.^[4,6-8,11] Furthermore, many studies have focused on the appropriateness and rationality of antibiotic use from the prescribers’ and/or health facility angles.^[4,7] However, antibiotic misuse could also occur at the level of the end-users within community settings.^[11] These aspects range from issues regarding access to and purchase of antibiotics as well as user compliance to the standard and appropriate use and administration of the same.^[6]

Some of the preventive and control measures proffered by the WHO as well as the Nigerian government at individual (and by extension, family, and community) levels include the procurement of antibiotics only following prescription by qualified health professionals, the use of antibiotics based on and according to medical counsel and guidance, the avoidance of sharing of or using “leftover” antibiotics and eschewing the habit of demanding (or requesting for) antibiotics from prescribers, among others.^[3,6] In this study, the poor practices noted among them contravened many of the WHO strategies for the prevention and control of antibiotic misuse, and the ensuing resistance.^[2] They include storing (or keeping) of antibiotics at home for future use (23%); including leftover antibiotics (15%), sharing of antibiotics among children presenting with similar symptoms (16%), discontinuing courses of antibiotics (17%) or reducing the frequency of administration (15%) when the health of children improves, obtaining antibiotics for children without prescription (14%), and directly requesting for antibiotics prescribers (16%) [Table 2]. Such poor practices may not be entirely unconnected from the fact that majority (88.9%) of the care-givers in this study are the direct biological parents of the respondents [Table 1]; thus, sentimental attachments to the children would not be completely ruled out in their decision-making processes. These findings are corroborated by other studies across Nigeria and in other countries.^[4,8,12-14] For instance, a study in Southwest Nigeria reported that about 24.4% of caregivers of under-5 children administered self-recommended antibiotics (without any prescription) to children, largely based on previous experience of effectiveness of use in their older children.^[12] Furthermore, another study in Northern Nigeria reports that about 46.7–71.1% of under-5 children receive antibiotics without prescription in the country.^[13] Similar findings have also been reported by other Nigerian studies among diverse (other) subgroups in the population.^[15-17]

Another study conducted in Southeast Nigeria also reported the administration of antibiotics without prescription to under-5 children by their caregivers (88.6%) as well as other poor practices such as the use of “leftover” antibiotics (20%) and demanding for antibiotics from physicians (92.9%).^[18] Such practices in relation to children expose them to unnecessary varieties and quantities of antibiotics, as well as suboptimal doses and/or durations of therapy. Children represent a vulnerable subgroup; in the sense that, being minors, they are incapable of making decisions for themselves and are, therefore, dependent on their caregivers, who are often uninformed regarding such matters, for decision-making. Secondly, their organ systems and metabolic processes are at varying stages of development and may not be able to handle the adverse effects and consequences resulting from such uncensored antibiotic exposures.^[8]

Furthermore, several authors in Nigeria have reported the inappropriate use of antibiotics in children for conditions such as diarrheal diseases and upper respiratory tract infections,^[18-21] which are often self-limiting and of viral origin.^[5,6,8,11] Similar practices have also been reported in other countries within Asia, Latin America, and subSaharan Africa as well as some high-income countries in the Western hemisphere.^{[4,5,8,11,22,23]} These practices would ultimately lead to the development of antimicrobial resistance, which will not augur well for the already high childhood morbidity and mortality indices in developing countries, which are largely accounted for by infectious diseases.^[4-6] Moreover, many developing countries, such as Nigeria, still grapple with issues such as poor sanitary conditions which make the environment rife for the multiplication of infectious disease agents and vectors as well as a prevailing low uptake of routine immunization against vaccine-preventable, childhood diseases.^[5,6,8] All these factors carry a number of implications; some of which include their setting the stage for a “post-antibiotic era,” a terminology coined and predicted by a number of experts; which is a situation where antibiotics are no longer effective for their intended curative purposes.^[2,3,5,9] Secondly, they also interplay to create a vicious cycle of higher disease burdens and costly health-care services (with newer and more expensive antibiotics becoming the next options) in the resource-constrained settings of most low- and medium-income nations.^[5] Fortunately, the antibiotic use practices among majority (97%) of the respondents in this study was assessed to be good, which is commendable [Table 3].

CONCLUSION

This study reported a commendably high level of good antibiotic use practices among caregivers of under-5 children with a few poor practices also noted. In view of this, the rational use of drugs by not only prescribers but also end-users within community settings remains the better and more cost-effective option amidst other competing demands. This is particularly so, in the context of most developing countries, where the morbidity pattern of high burdens of communicable diseases is gradually transiting to depict an additional trend of non-communicable diseases. This could be attained through coordinated and concerted efforts targeted at continuous public health education and enlightenment regarding the demerits of poor stewardship of antibiotic use coupled with strict regulatory control measures in the dispensing and sale of antibiotics as over-the-counter medications.