When Medicines Fail: Many Nigerians battle antimicrobial resistance, AMR

On a quiet July night in 2020, Moshood Lawal woke up feeling pain in his abdomen. It was sharp, relentless, and spreading from the right side. As a long-time ulcer patient, this was not like the pain he was used to.

As the pain intensified, the 64-year-old pharmacist knew something was wrong. Before dawn, Mr Lawal was already admitted to the National Hospital in Abuja, where doctors revealed the source of his pain to be kidney stones.

“After the diagnosis, I was given two options; either go for surgery or try an advanced technology to break the stones into particles I could urinate out,” Mr Lawal told PREMIUM TIMES.

Moshood Lawal, an antimicrobial resistance (AMR) survivor and member of the World Health Organisation (WHO) Task Force on AMR survivors (PHOTO CREDIT: Moshood Lawal)

Although he initially chose the non-invasive procedure at a private facility in Abuja, he eventually underwent the surgical procedure on 15 August 2020, after which he was placed on antibiotics as part of post-surgery prophylaxis. However, complications set in when the kidney stones led to fluid retention in his kidney.

“They had to put a stent between my kidney and bladder to drain the liquid that had gathered. About three and half months later – on 21 November 2020 — the stent was removed following an X-ray that showed no more water in the kidney,” he narrated.

At this point, Mr Lawal thought he was done with all medications, he had no idea he was beginning a long battle with antibiotic resistance – a type of antimicrobial resistance (AMR) that has become one of the top global public health and development threats.

Public health threats

The World Health Organisation (WHO) said AMR occurs when bacteria, viruses, fungi, and parasites no longer respond to antimicrobial medicines.

As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability, and death.

According to WHO, the emergence and spread of AMR is accelerated by human activity, mainly the misuse and overuse of antimicrobials, including antibiotics, to treat, prevent or control infections in humans, animals and plants.

Over the last two decades, the health body has repeatedly flagged AMR as a global health priority and one of the leading public health threats of the 21st century.

In 2019, estimates for 204 countries and territories, published in the Lancet, show that AMR is now a leading cause of death worldwide, higher than HIV/AIDS or malaria, with the worst impacts in low- and middle-income countries (LMIC).

It is estimated that bacterial AMR was directly responsible for 1.27 million deaths in 2019 and contributed to 4.95 million deaths. If unchecked, this number could rise to 10 million global deaths annually by 2050, 4.1 million of them in Africa.

Global Bacterial AMR Impact

Nigeria ranked 19th highest in AMR-related mortality out of 204 countries surveyed. In 2019 alone, there were 64,500 deaths attributable to AMR and 263,400 deaths associated with AMR in the country.

Also, a new report by Africa CDC warns that AMR is becoming a more significant threat to Africa than HIV/AIDS, tuberculosis (TB), and malaria, with children and vulnerable groups most at risk.

According to the report, these three diseases combined now account for fewer deaths than AMR, which has a mortality rate of 27.3 deaths per 100,000 people, making it the highest in the world.

“AMR is a silent threat disproportionately affecting the continent’s most vulnerable population,” Jean Kaseya, director-general of Africa CDC, said in reaction to the report.

A case of resistance

Mr Lawal’s ordeal with kidney stones and subsequent complications marked the beginning of microorganisms in his body developing resistance to medications.

Barely 48 hours after the stent removal, he developed a cold and a high fever. Suspecting malaria, he took anti-malaria medication, which provided temporary relief, but the symptoms returned within days.

A laboratory test later confirmed he had both malaria and typhoid, requiring a minimum of 10 days antibiotic course.

“I started an antibiotic for typhoid and also changed my ACT to another combination for malaria. Sadly, around the eighth day of taking the drugs, the symptoms came back even stronger,” he recounted.

His doctor switched him to a different antibiotic, but the problem persisted. Further tests of his urine revealed a heavy growth of Escherichia coli (E. coli), a bacterial infection that is commonly found in the gut of humans and warm-blooded animals.

“The infection was sensitive to a particular antibiotic of which I bought the best brand and used as prescribed. However, even this treatment offered only short-term relief as my symptoms returned while I was on the second pack,” he said.

In December 2020, his condition took another turn when he tested positive for COVID-19. He was taken to the COVID-19 isolation centre at Asokoro, Abuja, Nigeria’s capital territory. However, his case could not be handled so he was transferred to the National Hospital, where he spent seven days on oxygen and was given a mix of medications, including antibiotics.

“By this time I was on over 22 different drugs, morning and evening,” Mr Lawal said, reflecting on the physical and emotional toll of his condition.

While in isolation, he continued to test positive for E. coli, indicating that the bacteria had developed resistance to yet another antibiotic. After his COVID-19 symptoms improved, he was discharged, only to find the E. coli infection still lingering.

Bacterial AMR Impact (2019)

Mr Lawal’s case shows that the bacterial infection he attempted to treat many times failed to respond to various antibiotics medications prescribed.

More survivors

After multiple abdominal surgeries for bowel perforation due to ruptured diverticulitis at a private hospital in Lagos, 77-year-old Blessing Sunday was transferred to Lagos State University Teaching Hospital (LASUTH) after developing an infection.

As of 14 November, Mrs Sunday had been admitted to the hospital’s Critical Care Unit (CCU) for about four months. The hospital said she initially did not respond well to treatments due to multiple resistance to medications.

Critical Care Unit, Lagos State University Teaching Hospital (LASUTH)

The hospital’s Director of Clinical Services and Training, Bamidele Ayodele, gave PREMIUM TIMES approval to conduct interviews.

Ibrahim Dada, a doctor at LASUTH, provided details about the case. “The patient presented with a significantly elevated white blood cell count. Despite initial treatment, she developed multi-resistance. We have had to adjust her antibiotic regimen repeatedly to address her susceptibility to various infections.”

According to Mr Dada, the hospital often encounters patients with antibiotic-resistant infections, particularly those with sepsis, septic shock, or post-surgical complications.

“Some patients develop resistance after prolonged bed rest or multiple surgeries,” he said. “In such cases, we employ alternative antibiotics like Cilastin or Colistin, sometimes combining them to achieve desired results.”

“When faced with complex cases, we consult clinical microbiologists for guidance on effective treatment strategies. Their expertise helps us navigate the complexities of AMR. Unfortunately, we have lost several patients to AMR due to underlying comorbidities and critical conditions,” he added.

Speaking with PREMIUM TIMES, Mrs Sunday’s son, Emmanuel Sunday, acknowledged the hospital’s efforts but expressed limited awareness about his mother’s condition.

“I told them to do everything in their power to make my mom get better, and they are doing that. So I don’t think they are giving me information on all the antibiotics they are using, the ones she’s resistant to, or the ones she’s responding to,” Mr Sunday said.

Similarly, a young woman identified simply as Ruth was diagnosed with TB in 2021 at the age of 17. Her symptoms started with a persistent cough that lasted for weeks, accompanied by weakness and weight loss.

Ruth, a survivor of Drug-Resistant Tuberculosis (DR-TB)

Despite being placed on medication, Ruth’s condition showed no significant improvement. She described the period as challenging for her and her family. “The treatment I was receiving at the early stage of diagnosis was not working well. I was very ill and almost unrecognisable.”

After several months without progress, Ruth was referred to Abubakar Tafawa Balewa University Teaching Hospital (ATBUTH) in Bauchi State. There, she was diagnosed with Drug-Resistant Tuberculosis (DR-TB), a more severe and complex form of the disease.

Although the diagnosis was devastating, Ruth’s doctor assured her that recovery was possible with proper medication. “The doctor and other persons there at the time mentioned that I was the first patient to be placed on a particular type of TB treatment, and they assured me of recovering fully,” she said.

Investment case for AMR

Data from the study on the economic case for AMR investment requested by the Global Leaders Group (GLG) on AMR shows that the already staggering human toll of AMR will be compounded by a catastrophic hit to the global economy unless bolder and more urgent action is taken. 

The study shows that without a stronger response, there would be an average loss of 1.8 years of life expectancy globally by 2035. It also estimates that AMR would cost the world $412 billion a year in additional healthcare costs and $443 billion per year in lost workforce productivity.

The GLG in a report titled “Towards Specific Commitments and Action in the Response to AMR” said some low- and low-middle-income countries would see life expectancy fall by 2.5 years within the same period.

The report indicates that committed financing from domestic and external sources, particularly for the LMICs that bear the highest burden of drug-resistant infections and deaths, would also help the implementation of National Action Plans on AMR.

The report notes that while 90 per cent of countries have developed National Action Plans, only 25 per cent have funded them.

“We have the tools to mitigate the AMR crisis and this data point to a devastating future if we do not take bolder action now,” GLG on AMR Chair Mia Mottley, who is the Prime Minister of Barbados, said.

Speaking at a recent event, Laxmikant Chavan, the coordinator for One Health, WHO, explained that AMR is already common in Nigeria, and is similar to the outbreaks of diphtheria and fungal infections resistant to multiple treatments.

Mr Chavan explained that AMR could push an estimated 28 million people into extreme poverty globally and exacerbate existing socio-economic challenges.

“The economic toll of AMR for Nigeria and other LMICs could lead to a reduction in GDP of up to four per cent by 2030,” he said.

“LMICs like Nigeria stand to suffer the most, where healthcare costs could skyrocket and millions of people could be pushed into extreme poverty.”

Drivers of AMR, need for One Health approach

According to Ifeyinwa George, AMR programme manager at Dr Ameyo Stella Adadevoh (DRASA) Health Trust, an organisation founded in honour of Nigerian Ebola heroine, the major drivers of AMR in Nigeria are the “overuse and misuse of antimicrobials in human, animal, and food sectors.”

Ms George noted that environmental contamination from hospital, pharmaceutical, and agricultural effluents, as well as limited access to essential antimicrobials and diagnostics, also contribute to AMR.

Ifeyinwa George, AMR programme manager at Dr Ameyo Stella Adadevoh (DRASA)

She emphasised the importance of adopting a One Health Approach to tackling AMR, citing its ability to spotlight the interdependence of human, animal, plant, and environmental health.

“It highlights the benefits of proactive cross-sectoral collaboration and partnerships,” she said.

“Basically, adopting a one health approach is a faster route to achieving sustainable AMR containment as it addresses the full spectrum of disease control.”

The AMR programme manager at the Nigeria Centre for Disease Control (NCDC), Ridwan Yahaya, said the major drivers of AMR are behavioural issues. He said irrational drug prescription without diagnostic tests makes those organisms resistant, especially to antibiotics.

He said Nigeria is adopting the one health approach in addressing AMR.

“As a country, we have identified AMR as a priority and in 2017, Nigeria joined the global community and agreed to develop a National Action Plan for a five-year period to address AMR,” Mr Yahaya said.

“The action plan, which was developed with other stakeholders, encompasses animal health, environment and human health. For the five years, we achieved an implementation rate of 44 per cent across the five strategic areas and across the three sectors.”

He said the government has also developed National Action Plan 2.0 with almost the same strategic objective but now to include “how to strengthen governance, leadership and coordination to ensure that all multi-sectoral stakeholders are carried along.”

Antibiotic misuse, abuse

Rashidat Salawu, 35, was drenched in sweat as she laid on the floor inside her shop located in Kubwa, a suburb of Nigeria’s capital city, Abuja.

Mrs Salawu, a mother of one, disclosed that she had been grappling with illness for about a week.

When questioned by PREMIUM TIMES about the nature of her ailment, she said it was “fever and maybe infection”. She said her husband had already purchased some medicines from a local patent store, commonly known as ‘chemist’ located just around the corner of their home.

“My husband explained my symptoms to Baba, the store owner, and he gave me these drugs to take,” she said.

Mrs Salawu is one of many Nigerians who rely on patent stores to get quick remedies to tackle their symptoms, a habit health experts describe as ‘dangerous’ to human health.

According to experts, this habit is one of the major factors fuelling antibiotic resistance.

Many other Nigerians have the habit of not completing their full course of treatment, a trend that has proven to be dangerous to human health and also leads to AMR.

Ngozi, residing in Mararaba, Nasarawa State, said she could not remember ever completing her antibiotics doses. “I don’t think anybody ever completes their doses. Once you feel better, you just move on,” she said.

Health experts said this is rampant because many people are unaware of the danger of microorganisms’ resistance to medications.

Knowledge gap

Despite being a critical public health concern, AMR awareness lags behind other health issues, various studies suggest.

A 2020 study conducted across six Nigerian states – Lagos, Ebonyi, Delta, Plateau, Borno, and Jigawa – illustrates this knowledge gap.

The study analysed responses from 482 individuals (242 females, 240 males) and revealed concerning trends. Nearly 67 per cent (322 respondents) had taken antibiotics in the preceding six months, with 31.3 per cent obtaining them without a prescription. 26.1 per cent believed completing the full dosage was unnecessary once symptoms subsided.

Although 56.5 per cent recognised the term “antibiotic resistance,” only 8.3 per cent demonstrated a comprehensive understanding of AMR.

Notably, a majority (76.6 per cent) believed that they were powerless to stop the spread of AMR.

The study concluded that respondents have a poor overall understanding of AMR and proper use of antibiotics.

Mr Yahaya, the AMR programme manager at NCDC, said everybody has a role to play in combating AMR, “at the individual level, community, organisational and societal level.”

He said there are strategic objective areas in the National Action Plan 2.0 that emphasise more awareness.

“What it means is that when people are aware of the dangers of AMR, they make informed decisions. In doing that, we piloted the community AMR stewardship programme where we engaged Patent Medicine Vendors, school children, and individual adults on the dangers of misusing Antibiotics.”

Promoting awareness

Mr Chavan, the WHO technical officer on AMR, said it is important to carry out more holistic public enlightenment programmes to increase awareness of AMR and promote responsible use of antibiotics.

He said the theme for the 2024 World AMR Awareness Week (WAAW) “Educate. Advocate. Act now.” emphasises the importance of increased awareness in the fight against AMR.

WAAW is a global campaign to raise awareness and understanding of AMR and promote best practices among the public, One Health stakeholders, and policymakers to reduce the emergence and spread of drug-resistant infections.

The week is celebrated annually from 18-24 November.

Mr Lawal was initially unaware of the cause of failed antibiotic medications against bacteria infections, emphasising the need for increased awareness of AMR.

After months of ineffective treatments against E. coli, Mr Lawal turned to research to get answers on his path to recovery.

“As a pharmacist, I brought out my books and started reading. I googled a specific antibiotic, which became my saving grace. I discovered it was targeted for multi-drug-resistant E.coli,” he said.

“I contacted a pharmacy to confirm the availability of the drugs and my consultant also gave me the go-ahead. There was improvement after the first day of taking the drug, more improvement on the second day, and by the third day, I was completely free.”

Mr Lawal carried out a culture test of his urine, which confirmed that not a single bacterium was present. “That was how I survived both COVID-19 and antibiotic resistance,” he said.