A Qualitative Study of Antibiotic Use Practices in Intensive Small-Scale Farming in Urban and Peri-Urban Blantyre, Malawi: Implications for Antimicrobial Resistance

Antimicrobial Resistance and Its Impact on Food Safety Determinants Along the Beef Value Chain in Sub-Saharan Africa-A Scoping Review

Antimicrobial resistance (AMR) poses a significant threat to human, animal, and public health, particularly in Sub-Saharan Africa (SSA), where the beef sector is vital to food security and livelihoods. We conducted a scoping review to explore the determinants and impacts of AMR within the beef value chain in SSA, highlighting the challenges and progress in mitigating AMR risks in livestock production. This review identifies key factors contributing to AMR, including the overuse and misuse of antimicrobials, inadequate veterinary oversight, and weak regulatory frameworks. These practices are prevalent across various stages of the beef value chain, from farm to slaughterhouse, and are exacerbated by informal markets and insufficient infrastructure. Our findings also highlight the role of environmental factors, such as contamination of feed, water, and manure, in the spread of resistant pathogens. Additionally, gaps in AMR surveillance, education, and enforcement limit effective control measures in the region. While efforts to combat AMR have gained momentum in some countries, including the development of national action plans and surveillance systems, substantial challenges remain. These include poor adherence to antimicrobial guidelines, insufficient veterinary training, and the lack of integration between sectors. There is a need for targeted research to better understand antimicrobial misuse, socio-economic drivers, and the environmental pathways of AMR, as well as the need for stronger regulatory frameworks and cross-border cooperation. Addressing these challenges will be essential to safeguarding food safety, public health, and the sustainability of the beef industry in SSA.

"Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

BACKGROUND

The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not.

OBJECTIVE

We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi.

METHODS

Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting.

RESULTS

Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred.

CONCLUSIONS

Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care.

Antibiotic Utilization and Its Implications Among Ruminant Farmers and Stakeholders in Sumbawa Regency, Indonesia

The rise in antimicrobial resistance is a vital concern, and various factors, such as the overuse of antibiotics in agriculture, have contributed to its development and spread. Livestock farmers, veterinarians, and pharmacies are key prescribers of antibiotics for disease prevention, control, and treatment of ruminant animals. A qualitative study in the Sumbawa District examined their awareness, attitudes, and practices concerning antibiotic use, residues, and resistance, underscoring their vital role in tackling this challenge. The study utilized nine key informant interviews, sixteen in-depth interviews, a single focus group discussion, and on-farm observations using semistructured formats and thematic analysis to identify and explore themes. This revealed a common practice of antibiotic self-medication among ruminant farmers in the Sumbawa Regency, driven by limited knowledge and leading to medicine store purchases based on advice from veterinary paraprofessionals or for unregulated self-treatment. Factors contributing to antibiotic misuse include trust in veterinary paraprofessionals, economic limitations, lack of targeted antiresistance programs, and insufficient regulation of antibiotic sales. Enhancing veterinary paraprofessionals' awareness of their ethical duties, launching educational programs for actors, providing financial support for these initiatives, and strict enforcement of regulations by the local government are strategies that could collectively promote responsible antibiotic use and stewardship.

A nationwide survey of antimicrobial resistance of Escherichia coli isolated from broiler chickens in Malawi

Background

Antimicrobial resistance is a global health challenge with profound implications across sectors. Livestock, a significant field at the One Health interface, lacks sufficient information, particularly in low-resource settings such as Malawi.

Objectives

We determined the antimicrobial resistance rates of Escherichia coli isolated from broiler chickens in Malawi and explored the relationship between resistance genes across sectors using genomic analysis.

Methods

In 2023, we isolated 115 E. coli strains from 116 faecal and caecal samples from broiler chickens across Malawi. Antimicrobial susceptibility tests were performed using agar dilution method according to the Clinical Laboratory Standard Institute guidelines. Whole-genome sequencing was performed using Illumina sequencing.

Results

Notably, 50 isolates (44%) were resistant to cefotaxime. We detected ESBL bla CTX-M genes (bla CTX-M-55, bla CTX-M-14, bla CTX-M-65, bla CTX-M-27, bla CTX-M-15, bla CTX-M-1, and bla CTX-M-3) in 48 cefotaxime-resistant isolates, which exhibited higher resistance rates to levofloxacin than non-ESBL-encoding isolates (29/48; 60% versus 20/67; 30%). All isolates were susceptible to colistin and carbapenems. High resistance rates were observed for tetracycline and co-trimoxazole commonly used in broiler chickens (90% and 70%, respectively). Sequence type 206 and phylogroup A were predominant (14% and 65%, respectively). In the genetic context of bla CTX-M genes, whole-genome alignment of the ESBL-producing isolates with reference plasmids from E. coli of various origins indicated significant similarity.

Conclusions

Antimicrobial resistance is highly prevalent among E. coli from broiler chickens in Malawi. Genomic analysis suggests potential transmission pathways for ESBL genes across sectors, necessitating further studies from One Health perspective.

Understanding the veterinary antibiotic flow in Malawi: complexities, gaps and needs

Introduction

Veterinary antibiotics are essential for maintaining animal health and welfare, however, small-scale farmers in Malawi face challenges in accessing them due to limited availability, affordability, and long distances to rural drug retailers.

Methods

This study mapped the veterinary antibiotic distribution chain, examined the governance structure of the chain, and analyzed access and usage practices among stakeholders in Malawi. Data were collected through focus group discussions (n = 15), key informant interviews (n = 6) and individual interviews (n = 189).

Results

The key stakeholders identified included regulators, local pharmaceutical manufacturers, wholesalers, veterinary clinics, veterinary retail shops, animal health practitioners, and farmers. The distribution of veterinary antibiotics was characterized by both formal and informal pathways for importing and distributing veterinary medicines. Additionally, there were issues with antibiotic mishandling such as improper storage on open shelves in direct sunlight and disposal in pit latrines. There was a marked lack of proper antibiotic dispensation training among veterinary medicine shop attendants, and in terms of regulation, there were gaps in coordination and overlapping mandates among regulatory authorities hindering effective regulation.

Discussion

Regulatory agencies need to strengthen oversight of veterinary antibiotics, conduct trainings on antibiotic stewardship with various stakeholders, and enhance public-private partnerships to better manage the informal pathways for importing and distributing veterinary medicines. This multi-sectoral approach aims to ensure responsible use and improve the pharmacovigilance of veterinary antibiotics.

Environmental Antimicrobial Resistance: Implications for Food Safety and Public Health

Antimicrobial resistance (AMR) is a serious global health issue, aggravated by antibiotic overuse and misuse in human medicine, animal care, and agriculture. This study looks at the different mechanisms that drive AMR, such as environmental contamination, horizontal gene transfer, and selective pressure, as well as the severe implications of AMR for human and animal health. This study demonstrates the need for concerted efforts across the scientific, healthcare, agricultural, and policy sectors to control the emergence of AMR. Some crucial strategies discussed include developing antimicrobial stewardship (AMS) programs, encouraging targeted narrow-spectrum antibiotic use, and emphasizing the significance of strict regulatory frameworks and surveillance systems, like the Global Antimicrobial Resistance and Use Surveillance System (GLASS) and the Access, Watch, and Reserve (AWaRe) classification. This study also emphasizes the need for national and international action plans in combating AMR and promotes the One Health strategy, which unifies environmental, animal, and human health. This study concludes that preventing the spread of AMR and maintaining the effectiveness of antibiotics for future generations requires a comprehensive, multidisciplinary, and internationally coordinated strategy.

Antimicrobial use on pig farms in Thailand: Farmer perceptions of use and resistance

Limiting the use of antimicrobial agents in intensive livestock production is a challenge due to different perceptions between the short-term benefits of antimicrobial use (AMU) by livestock producers and the long-term social costs of antimicrobial resistance (AMR) and its impact on human, animal, and environmental health. Pig farmers are key stakeholders supporting Thailand's national strategic plan on AMR which aims to reduce antimicrobial consumption in the livestock sector. Consequently, this study explored the knowledge, perceptions, attitudes, and practices of pig farmers towards AMU and AMR, expecting to provide information that would help guide policymakers in the development of a proper interventional program for antimicrobial stewardship. The qualitative approach utilized individual, face-to-face, in-depth, semi-structured interviews with the 20 owners of middle- and large-scale pig farms in eastern Thailand. The major themes identified in this finding were: (1) the use of antimicrobials on farms and the knowledge of antimicrobials; (2) AMU on pig farms (the purpose of AMU, antimicrobial prescription practices, and performing antimicrobial susceptibility testing); (3) attitudes towards prescribing practices and record keeping; (4) farm animal husbandry practices and AMU; (5) factors influencing AMU; and (6) awareness regarding AMR. Most of the pig farm owners recognized that achieving Good Agricultural Practices certification required following the legislation and regulations for AMU. Other observations were that the respondents had positive attitudes towards prescribing practices, performing antimicrobial susceptibility testing before antimicrobial therapy, and recording drug use on farms; however, there was low awareness of AMR. In addition, alternative substances, such as medicinal plants, and proper biosecurity practices were mentioned. Factors influencing AMU on pig farms were intensive enforcement of legislation and regulations, the implementation of farm management practices, the provision of information and consultancy services by veterinary professionals, farmer experience, and consumer trends.

Patterns and drivers of antibiotic use in small-scale broiler production systems in Lilongwe District, Malawi

Reducing the inappropriate use of antibiotics in food animals is a global priority to address antimicrobial resistance (AMR). We investigated practices and factors associated with antibiotic use in small-scale commercial broiler farms in Lilongwe district, Malawi. We used structured questionnaires to collect data on recent antibiotic use practices among 128 broiler farmers, who kept between 50 and 1 000 birds, from December 2022 to March 2023. Logistic regression analysis was used to identify risk factors associated with antibiotic use. Over half (53.1 %, n=68) of the farms reported using antibiotics at least once in the previous production cycle. Overall, 11 different types of antibiotics were used either for treatment and/or preventive purposes, with oxytetracycline (88.2 %), erythromycin (29.4 %), and enrofloxacin (26.5 %) reported as the frequently used. One-third of all antibiotic formulations contained multiple active antibiotic ingredients, with 12 % containing four antibiotics. Covariates associated with an increased likelihood of antibiotic use include disease incidence (OR=13.8, 95 % CI 5.27-42.50, p<0.001) and entry of wild birds into poultry houses (OR=3.56, 95 % CI =1.44-9.61, p=0.008). Our study highlights inappropriate usage of antibiotics, largely associated with reduced biosecurity and disease incidence. These findings underscore the need to strengthen veterinary services, reinforce regulations on antibiotic access and use, and farmer education programs promoting proper husbandry, biosecurity, and responsible antibiotic use.

Knowledge and practices related to antibiotics among poultry producers and veterinarians in two Indian states

Background

Antibiotics are frequently utilized in livestock, particularly poultry, for therapy and growth promotion, resulting in antimicrobial resistance. Multidrug-resistant bacteria are frequent in poultry samples from India. The purpose of this study was to better understand main antibiotic consumption patterns in poultry value chains, as well as antibiotic knowledge and practices among the stakeholders.

Methods

A cross-sectional survey was conducted in Assam and Karnataka, India. The poultry farmers were interviewed on antibiotic usage, antibiotic knowledge, feeding practices, and preventive measures on the farm. Poultry farmers reported their veterinarians, and we also interviewed them on knowledge and practices related to antimicrobial use in poultry and antimicrobial resistance. Item response theory (IRT) was used to assess the association between the answers and demographic factors.

Results

This survey interviewed 62 poultry farmers and 11 veterinarians. Small poultry farms with fewer than 4000 birds were owned by 51.6% of farmers. Most poultry farmers had heard about antibiotics, and 62.9% thought they cured all diseases. If one chicken is sick, 72.6% said others should be given antibiotics to prevent the disease. All veterinarians utilized tetracyclines, aminoglycosides, and cephalexin on the poultry farms. Over half (54.5%) stated antibiotics prevent diseases, and 72.7% said they treat and prevent diseases. Some (45.5%) said antibiotics boost growth. IRT analysis showed that 8 questions assessed a knowledge scale well. Univariable analysis showed that Assam farmers and women were likely to have have more knowledge.

Conclusion

The poultry farmers were mostly unaware of the relation between antibiotic use and antimicrobial resistance. Despite being aware, the veterinarians agreed with use antibiotics as a prophylactic measure. It is vital that these stakeholders understand the repercussions of such widespread antibiotic use. In order to increase knowledge, frequent trainings and antimicrobial stewardship programmes with effective communication and incentives for behaviour change should be conducted.

Longitudinal analysis within one hospital in sub-Saharan Africa over 20 years reveals repeated replacements of dominant clones of Klebsiella pneumoniae and stresses the importance to include temporal patterns for vaccine design considerations

BACKGROUND

Infections caused by multidrug-resistant gram-negative bacteria present a severe threat to global public health. The WHO defines drug-resistant Klebsiella pneumoniae as a priority pathogen for which alternative treatments are needed given the limited treatment options and the rapid acquisition of novel resistance mechanisms by this species. Longitudinal descriptions of genomic epidemiology of Klebsiella pneumoniae can inform management strategies but data from sub-Saharan Africa are lacking.

METHODS

We present a longitudinal analysis of all invasive K. pneumoniae isolates from a single hospital in Blantyre, Malawi, southern Africa, from 1998 to 2020, combining clinical data with genome sequence analysis of the isolates.

RESULTS

We show that after a dramatic increase in the number of infections from 2016 K. pneumoniae becomes hyperendemic, driven by an increase in neonatal infections. Genomic data show repeated waves of clonal expansion of different, often ward-restricted, lineages, suggestive of hospital-associated transmission. We describe temporal trends in resistance and surface antigens, of relevance for vaccine development.

CONCLUSIONS

Our data highlight a clear need for new interventions to prevent rather than treat K. pneumoniae infections in our setting. Whilst one option may be a vaccine, the majority of cases could be avoided by an increased focus on and investment in infection prevention and control measures, which would reduce all healthcare-associated infections and not just one.

Characterisation of colistin resistance in Gram-negative microbiota of pregnant women and neonates in Nigeria

A mobile colistin resistance gene mcr was first reported in 2016 in China and has since been found with increasing prevalence across South-East Asia. Here we survey the presence of mcr genes in 4907 rectal swabs from mothers and neonates from three hospital sites across Nigeria; a country with limited availability or history of colistin use clinically. Forty mother and seven neonatal swabs carried mcr genes in a range of bacterial species: 46 Enterobacter spp. and single isolates of; Shigella, E. coli and Klebsiella quasipneumoniae. Ninety percent of the genes were mcr-10 (n = 45) we also found mcr-1 (n = 3) and mcr-9 (n = 1). While the prevalence during this collection (2015-2016) was low, the widespread diversity of mcr-gene type and range of bacterial species in this sentinel population sampling is concerning. It suggests that agricultural colistin use was likely encouraging sustainment of mcr-positive isolates in the community and implementation of medical colistin use will rapidly select and expand resistant isolates.

Antimicrobial use and resistance in food animal production: food safety and associated concerns in Sub-Saharan Africa

The use of antimicrobials in food animal (FA) production is a common practice all over the world, with even greater usage and dependence in the developing world, including Sub-Saharan Africa (SSA). However, this practice which serves obvious economic benefits to producers has raised public health concerns over the last decades, thus driving the selection and dissemination of antimicrobial resistance and adversely impacting food safety and environmental health. This review presents the current and comprehensive antimicrobial usage practices in food animal production across SSA. We further highlighted the overall regional drivers as well as the public health, environmental, and economic impact of antimicrobial use in the production of food animals. Antimicrobial use is likely to increase with even exacerbated outcomes unless cost-effective, safe, and sustainable alternatives to antibiotics, especially probiotics, prebiotics, bacteriocins, antimicrobial peptides, bacteriophages, vaccines, etc. are urgently advocated for and used in food animal production in SSA. These, in addition to the implementation of strong legislation on antimicrobial use, and improved hygiene will help mitigate the public health concerns associated with antimicrobial use in food animals and improve the well-being and safety of food animals and their products.

Mapping the effect of antimicrobial resistance in poultry production in Senegal: an integrated system dynamics and network analysis approach

The impact of antimicrobial resistance (AMR) extends beyond the farm-level to other stakeholders warranting the need for a collaborative approach to combat AMR while optimising production objectives and safeguarding human health. This study maps out the effect of AMR originating from poultry production in Senegal and highlights the entry points for interventions from stakeholders' perspectives. A causal loop diagram (CLD) was developed following a group model building procedure with 20 stakeholders and integrated with network analysis by translating the CLD into an unweighted directed network. Results indicate that with an eigenvector centrality of 1, 0.85, and 0.74, the production cost, on-farm profit, and on-farm productivity, respectively are the most ranked influential variables driving the complexity of AMR in the poultry production system. Two reinforcing feedback loops highlight the dual benefits of improving on-farm productivity and increasing on-farm profit. However, one balancing feedback loop that revolves around the causal link between producers' investment in qualified human resource personnel to ensure good farm management practices underline the financial implication of producers' investment decisions. The findings provide precursory groundings for the development of a quantitative SD model, the formulation of intervention scenarios and ex-ante impact assessment of the cost-effectiveness of the interventions.

Investigating One Health risks for human colonisation with extended spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in Malawian households: a longitudinal cohort study

BACKGROUND

Low-income countries have high morbidity and mortality from drug-resistant infections, especially from enteric bacteria such as Escherichia coli. In these settings, sanitation infrastructure is of variable and often inadequate quality, creating risks of extended-spectrum β-lactamase (ESBL)-producing Enterobacterales transmission. We aimed to describe the prevalence, distribution, and risks of ESBL-producing Enterobacterales colonisation in sub-Saharan Africa using a One Health approach.

METHODS

Between April 29, 2019, and Dec 3, 2020, we recruited 300 households in Malawi for this longitudinal cohort study: 100 each in urban, peri-urban, and rural settings. All households underwent a baseline visit and 195 were selected for longitudinal follow-up, comprising up to three additional visits over a 6 month period. Data on human health, antibiotic usage, health-seeking behaviours, structural and behavioural environmental health practices, and animal husbandry were captured alongside human, animal, and environmental samples. Microbiological processing determined the presence of ESBL-producing E coli and Klebsiella pneumoniae, and hierarchical logistic regression was performed to evaluate the risks of human ESBL-producing Enterobacterales colonisation.

FINDINGS

A paucity of environmental health infrastructure and materials for safe sanitation was identified across all sites. A total of 11 975 samples were cultured, and ESBL-producing Enterobacterales were isolated from 1190 (41·8%) of 2845 samples of human stool, 290 (29·8%) of 973 samples of animal stool, 339 (66·2%) of 512 samples of river water, and 138 (46·0%) of 300 samples of drain water. Multivariable models illustrated that human ESBL-producing E coli colonisation was associated with the wet season (adjusted odds ratio 1·66, 95% credible interval 1·38-2·00), living in urban areas (2·01, 1·26-3·24), advanced age (1·14, 1·05-1·25), and living in households where animals were observed interacting with food (1·62, 1·17-2·28) or kept inside (1·58, 1·00-2·43). Human ESBL-producing K pneumoniae colonisation was associated with the wet season (2·12, 1·63-2·76).

INTERPRETATION

There are extremely high levels of ESBL-producing Enterobacterales colonisation in humans and animals and extensive contamination of the wider environment in southern Malawi. Urbanisation and seasonality are key risks for ESBL-producing Enterobacterales colonisation, probably reflecting environmental drivers. Without adequate efforts to improve environmental health, ESBL-producing Enterobacterales transmission is likely to persist in this setting.

FUNDING

Medical Research Council, National Institute for Health and Care Research, and Wellcome Trust.

TRANSLATION

For the Chichewa translation of the abstract see Supplementary Materials section.

Determinants of Knowledge, Attitude, and Practices of Veterinary Drug Dispensers toward Antimicrobial Use and Resistance in Main Cities of Malawi: A Concern on Antibiotic Stewardship

Antimicrobial resistance (AMR) is an emerging challenge to global public health. The use of antibiotics in the veterinary field is one of the contributing factors to AMR mostly due to poor knowledge, attitudes, and practices (KAP) of dispensers. Veterinary drug dispensers are expected to guide clients on indications, contraindications, and withdrawal periods of veterinary drugs. This study assessed veterinary drug dispensers' KAP toward AMR and associated potential contributing factors. A cross-sectional study, using a structured questionnaire, was conducted in three main cities of Malawi, namely Mzuzu, Lilongwe, and Blantyre. A total of 68 agrovet shops were selected using a simple random sampling technique. The KAP level was presented descriptively. Bivariate and multivariable analyses were run to investigate the relationships between the independent and outcome variable. Overall, the KAP score for knowledge, attitude, and practices was 46.7%, 49.2%, and 41.6%, respectively. The significant determinants of the knowledge were the practice of asking for a written prescription (OR: 16.291, 95% CI: 11.6-24.2) (p = 0.024), female (OR: 0.609, 95% CI: 0.3-0.9) (p = 0.001), and old age (≥35) (OR: 0.227, 95% CI: 0.1-0.5) (p = 0.04). Poor knowledge, negative attitude, and poor practices were observed among most of the participants. Sensitization and training on AMR and antimicrobial stewardship are recommended to address the KAP score gaps and the observed determinants among veterinary drug dispensers.