The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis

Benn Sartorius(University of Washington), Authia P Gray(University of Washington), Nicole Davis Weaver(University of Washington), Gisela Robles Aguilar(University of Washington), Lucien R Swetschinski(University of Washington), Kevin S Ikuta(University of Washington), Tomislav Meštrović(University of Washington), Erin Chung(University of Washington), Eve E Wool(University of Washington), Chieh Han(University of Washington), Anna Gershberg Hayoon(University of Washington), Daniel T Araki(University of Washington), Sherief Abd‐Elsalam(University of Washington), Richard Gyan Aboagye(University of Washington), Lawan Hassan Adamu(University of Washington), Victor Abiola Adepoju(University of Washington), Ayman Ahmed(University of Washington), Gizachew Taddesse Akalu(University of Washington), Wuraola Akande‐Sholabi(University of Washington), John Amuasi(University of Washington), Ganiyu Adeniyi Amusa(University of Washington), Ayele Mamo Argaw(University of Washington), Raphael Taiwo Aruleba(University of Washington), Tewachew Awoke(University of Washington), Melese Kitu Ayalew(University of Washington), Ahmed Y. Azzam(University of Washington), François-Xavier Babin(University of Washington), Indrajit Banerjee(University of Washington), Afisu Basiru(University of Washington), Nebiyou Simegnew Bayileyegn(University of Washington), Melaku Ashagrie Belete(University of Washington), James A. Berkley(University of Washington), Julia Bielicki(University of Washington), Denise Dekker(University of Washington), Dessalegn Demeke(University of Washington), Desalegn Getnet Demsie(University of Washington), Anteneh Mengist Dessie(University of Washington), Susanna Dunachie(University of Washington), Abdelaziz Ed‐Dra(University of Washington), Michael Ekholuenetale(University of Washington), Temitope Cyrus Ekundayo(University of Washington), Iman El Sayed(University of Washington), Muhammed Elhadi(University of Washington), Ibrahim Elsohaby(University of Washington), David W. Eyre(University of Washington), Adeniyi Francis Fagbamigbe(University of Washington), Nicholas Feasey(University of Washington), Ginenus Fekadu(University of Washington), Frederick Fell(University of Washington), Karen Forrest(University of Washington), Mesfin Gebrehiwot(University of Washington), Kebede Embaye Gezae, Ramy Mohamed Ghazy, Tewodros Tesfa Hailegiyorgis(University of Washington), Georgina Haines–Woodhouse(University of Washington), Ahmed I Hasaballah(University of Washington), Andrea Haselbeck(University of Washington), Yingfen Hsia(University of Washington), Arnaud Iradukunda(University of Washington), Kenneth Iregbu, Chidozie C D Iwu(University of Washington), Chinwe Juliana Iwu(University of Washington), Assefa N Iyasu(University of Washington), Fatoumatta Jaiteh(University of Washington), Hyonjin Jeon(University of Washington), Charity Ehimwenma Joshua(University of Washington), Gebrehiwot G Kassa(University of Washington), Patrick DMC Katoto(University of Washington), Ralf Krumkamp(University of Washington), Emmanuelle A. P. Kumaran(University of Washington), Hmwe Hmwe Kyu(University of Washington), Aseer Manilal(University of Washington), Florian Marks(University of Washington), Jürgen May(University of Washington), Susan A. McLaughlin(University of Washington), Barney McManigal(University of Washington), Addisu Melese(University of Washington), Kebede Haile Misgina(University of Washington), Nouh Saad Mohamed(University of Washington), Mustapha Mohammed(University of Washington), Shafiu Mohammed(University of Washington), Shikur Mohammed(University of Washington), Ali H. Mokdad(University of Washington), Catrin E. Moore(University of Washington), Vincent Mougin(University of Washington), Neema Mturi(University of Washington), Temesgen Mulugeta(University of Washington), Fungai Musaigwa(University of Washington), Patrick Musicha(University of Washington), Lillian Musila(University of Washington), Muthupandian Saravanan(University of Washington), Pirouz Naghavi(University of Washington), Hadush Negash(University of Washington), Dooshanveer C Nuckchady(University of Washington), Christina W. Obiero(University of Washington), Ismail Ayoade Odetokun(University of Washington), Oluwaseun Adeolu Ogundijo(University of Washington), Lawrence Okidi(University of Washington), Osaretin Christabel Okonji(University of Washington), Andrew T Olagunju(University of Washington), Isaac Iyinoluwa Olufadewa(University of Washington), Gi Deok Pak(University of Washington), Olga Perovic(University of Washington), Andrew J. Pollard(University of Washington), Mathieu Raad(University of Washington), Clotaire Donatien Rafaï(University of Washington), Hazem Ramadan(University of Washington), Elrashdy M. Redwan(University of Washington), Anna Roca(University of Washington), Víctor Rosenthal(University of Washington), Mohamed A. Saleh(University of Washington), Abdallah M Samy(University of Washington), Mike Sharland(University of Washington), Aminu Shittu(University of Washington), Emmanuel Edwar Siddig(University of Washington), Eskinder Ayalew Sisay(University of Washington), Andy Stergachis(University of Washington), Wegen Beyene Tesfamariam(University of Washington), Caroline Tigoi(University of Washington), Marius B. Tincho, Tenaw Yimer Tiruye, Chukwuma David Umeokonkwo(University of Washington), Timothy R. Walsh(University of Washington), Judd L. Walson(University of Washington), Hadiza Yusuf(University of Washington), Naod Gebrekrstos Zeru(University of Washington), Simon I Hay(University of Washington), Christiane Dolecek(University of Washington), Christopher J L Murray(University of Washington), Mohsen Naghavi(University of Washington)
The Lancet Global Health
December 19, 2023
10.1016/s2214-109x(23)00539-9
Cited by 292Open Access
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Abstract

BACKGROUND: A critical and persistent challenge to global health and modern health care is the threat of antimicrobial resistance (AMR). Previous studies have reported a disproportionate burden of AMR in low-income and middle-income countries, but there remains an urgent need for more in-depth analyses across Africa. This study presents one of the most comprehensive sets of regional and country-level estimates of bacterial AMR burden in the WHO African region to date. METHODS: We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen-drug combinations for countries in the WHO African region in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). We obtained data from research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. FINDINGS: In the WHO African region in 2019, there were an estimated 1·05 million deaths (95% UI 829 000-1 316 000) associated with bacterial AMR and 250 000 deaths (192 000-325 000) attributable to bacterial AMR. The largest fatal AMR burden was attributed to lower respiratory and thorax infections (119 000 deaths [92 000-151 000], or 48% of all estimated bacterial pathogen AMR deaths), bloodstream infections (56 000 deaths [37 000-82 000], or 22%), intra-abdominal infections (26 000 deaths [17 000-39 000], or 10%), and tuberculosis (18 000 deaths [3850-39 000], or 7%). Seven leading pathogens were collectively responsible for 821 000 deaths (636 000-1 051 000) associated with resistance in this region, with four pathogens exceeding 100 000 deaths each: Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus. Third-generation cephalosporin-resistant K pneumoniae and meticillin-resistant S aureus were shown to be the leading pathogen-drug combinations in 25 and 16 countries, respectively (53% and 34% of the whole region, comprising 47 countries) for deaths attributable to AMR. INTERPRETATION: This study reveals a high level of AMR burden for several bacterial pathogens and pathogen-drug combinations in the WHO African region. The high mortality rates associated with these pathogens demonstrate an urgent need to address the burden of AMR in Africa. These estimates also show that quality and access to health care and safe water and sanitation are correlated with AMR mortality, with a higher fatal burden found in lower resource settings. Our cross-country analyses within this region can help local governments to leverage domestic and global funding to create stewardship policies that target the leading pathogen-drug combinations. FUNDING: Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

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