Evidencing the Intersection of Environmental, Socioeconomic, Behavioural and Demographic Drivers of Antibacterial Resistance in East Africa

Abstract

Background: Risk factors for antibiotic-resistant infections are multi-scalar and interdependent, but few studies investigate them in an integrated way. We investigated how location, the environment, socioeconomics, behaviours, attitudes, and demographics are jointly associated with multi-drug resistant urinary tract infection (MDR UTI).

Methods: Between 2018-2020, the Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium recruited outpatients with UTI symptoms in healthcare facilities in Kenya, Tanzania, and Uganda. We collected urine samples and questionnaires from patients and households. Our primary outcome was MDR UTI, defined as resistance to 3 or more categories of antibiotics. We used linked individual-level data on 67 variables capturing geographic, environmental, socioeconomic, demographic, attitudinal, and behavioural characteristics. We employed bivariate analyses and Bayesian profile regression to investigate the joint association of risk factors with MDR UTI.

Findings: Out of 2332 patients with microbiologically-confirmed UTI, we analysed 1610 with linked microbiological, social, and environmental data. Most were female (1369 [85·0%]), younger than 45 years (1206 [74·9%]), and nearly half had MDR UTI (766 [47.6%]). Profile regression generated 10 high-risk and 7 low-risk MDR UTI clusters. High-risk MDR clusters contained patients that were on average older, with lower education, more chronic illness, and lived in resource-deprived households. They were also more likely to have contact with animals, and human/animal waste.

Interpretation: Risk factors for antibiotic resistance are interrelated through multidimensional poverty. We need studies which explore how these factors interact longitudinally to shape inequalities, and to design appropriate interventions.

Funding: The Holistic Approach to Unravel Antibacterial Resistance in East Africa is a Global Context Consortia Award (MR/S004785/1) funded by the National Institute for Health Research, Medical Research Council, and the Department of Health and Social Care. This paper was funded in part by a grant from the National Institutes of Health (grant number U01CA207167), and a Scottish Funding Council GCRF Consolidator Award.

Declaration of Interest: None.

Ethical Approval: Ethical approval for this project was obtained from the University of St Andrews, UK (No. MD14548, 10/09/19); National Institute for Medical Research, Tanzania (No. 2831, updated 26/07/19), CUHAS/BMC research ethics and review committee (No. CREC/266/2018, updated on 02/2019), Mbeya Medical Research and Ethics Committee (No. SZEC-2439/R. A/V.1/303030), Kilimanjaro Christian Medical College, Tanzania (No. 2293, updated 14/08/19). Uganda National Council for Science and Technology (number HS2406, 18/06/18); Makerere University, Uganda (number 514, 25/04/18); and Kenya Medical Research Institute (04/06/19, Scientific and Ethics Review Committee (SERU) number KEMRI/SERU/CMR/P00112/3865 V.1.2). For Uganda, administrative letters of support were obtained from the district health officers to allow the research to be conducted in the respective hospitals and health centres.

Keywords: antibacterial resistance, One Health, risk factors, urinary tract infection, antibiotic use, East Africa, multi-drug resistant