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[Preprint]. 2023 Mar 20:2023.03.04.23286801.
doi: 10.1101/2023.03.04.23286801.

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance: A study of urinary tract infection patients in Kenya, Tanzania and Uganda

Keina Sado  1 , Katherine Keenan  1 , Areti Manataki  1 , Mike Kesby  1 , Martha F Mushi  2 , Stephen E Mshana  2 , Joseph Mwanga  2 , Stella Neema  3 , Benon Asiimwe  3 , Joel Bazira  4 , John Kiiru  5 , Dominique L Green  1 , Xuejia Ke  1 , Antonio Maldonado-Barragán  1 , Mary Abed Al Ahad  1 , Kathryn Fredricks  1 , Stephen H Gillespie  1 , Wilber Sabiiti  1 , Blandina T Mmbaga  6 , Gibson Kibiki  7 , David Aanensen  8 , V Anne Smith  1 , Alison Sandeman  1 , Derek J Sloan  1 , Matthew Tg Holden  1
Affiliations

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance: A study of urinary tract infection patients in Kenya, Tanzania and Uganda

Keina Sado et al. medRxiv. .

Update in

Abstract

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviours, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from 6,827 adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Among 6,388 patients we analysed patterns of self-reported treatment seeking behaviours ('patient pathways') using process mining and single-channel sequence analysis. Of those with microbiologically confirmed UTI (n=1,946), we used logistic regression to assessed the relationship between treatment seeking behaviour, AB use, and likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathways for UTI-like symptoms included attending health facilities, rather than other providers (e.g. drug sellers). Patients from the sites sampled in Tanzania and Uganda, where prevalence of MDR UTI was over 50%, were more likely to report treatment failures, and have repeated visits to clinics/other providers, than those from Kenyan sites, where MDR UTI rates were lower (33%). There was no strong or consistent relationship between individual AB use and risk of MDR UTI, after accounting for country context. The results highlight challenges East African patients face in accessing effective UTI treatment. These challenges increase where rates of MDR UTI are higher, suggesting a reinforcing circle of failed treatment attempts and sustained selection for drug resistance. Whilst individual behaviours may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of ABR.

Keywords: Sub-Saharan Africa; Urinary tract infection; antibacterial resistance; antibiotic use; healthcare use.

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Conflict of interest statement

Conflict of Interest None

Figures

Figure 1
Figure 1. Selection of the analysis samples
Figure 2:
Figure 2:. Treatment-seeking questions from the HATUA questionnaire and derived outcomes in this study
Figure 3
Figure 3. A-D: Stages in data management, analysis and visualization for process mining
Figure 4:
Figure 4:. Treatment seeking pathways visualized with heuristic miner among patients in Kenya, Tanzania and Uganda.
The numbers in boxes represent the numbers of participants who took that step, and how many people transition from that step to others. The thickness of the edges represent the number of participants taking that step (thickest- more than 1,000, next thickest, 500-1,000, next thickest 100-500, and thinnest, less than 100).
Figure 5:
Figure 5:. Ten most common treatment-seeking patterns visualized in Kenya (panel A), Tanzania (panel B) and Uganda (panel C).
Number on the left represents the number of participants who experienced the trace. The percentage shows the proportion of participants who experienced the trace compared to the total patients from that country.
Figure 6:
Figure 6:. Percentage of patients taking ABs for their UTI-like symptoms at any point prior to being recruited, by country and type of provider.
See this image and copyright information in PMC

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