Antibiotic Seeking Pathways and Patterns of Usage among Patients with Productive Coughs Attending Selected Chest Clinics in Nairobi County, Kenya

This study reveals that antibiotic use among adults with productive coughs in Nairobi, Kenya, is widespread and largely empirical, driven by diverse seeking pathways including over-the-counter access and self-medication, which are significantly influenced by gender, income, and medical history, thereby highlighting an urgent need for stricter prescription enforcement and stewardship programs to combat antimicrobial resistance.

The Gist

🏥 The Big Picture: The "Cough" and the "Magic Pill"

Imagine you have a nagging, productive cough (one that brings up mucus). In Nairobi, Kenya, when people feel this way, they often rush to get a "magic pill" (an antibiotic) to fix it.

This study is like a detective story where researchers followed 400 adults with coughs to answer three big questions:

1. Where did they get their medicine?
2. How did they take it?
3. Who was most likely to make a risky choice?

The bad news? The "magic pill" is being used way too often, often for the wrong reasons, and this is training super-bugs (antibiotic resistance) to become stronger.

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🛤️ The Three Roads to the Medicine Cabinet

The researchers found that people took three different "roads" to get their antibiotics:

1. The Official Highway (GP Prescription): About half the people (46%) went to a doctor, got a proper prescription, and bought the meds. This is the "safe" road.
2. The Shortcut (Over-the-Counter): About 15% went straight to a pharmacy or drug shop and bought antibiotics without a doctor's note. It's like buying a car without a license; it's fast, but illegal and risky.
3. The Back Alley (Self-Medication): Some people (about 7%) just grabbed leftover pills from a cupboard or borrowed them from a neighbor. This is the most dangerous road because you are guessing the dose and the drug.

The Twist: Many people mixed these roads. They might have seen a doctor and also bought extra pills at a shop, or they might have started with a doctor but finished the course with leftover pills.

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🎭 The Characters: Who is Taking the Risks?

The study looked at who was driving which car. Here are the main characters:

• The Caregivers (Women): Women were much more likely to take the "Back Alley" route (self-medication).
  • Analogy: Think of women as the "family managers." They often feel the pressure to fix everyone's sickness quickly. If they don't have time to wait for a doctor, they grab the pills they have at home to keep the family running.
• The "Survivors" (People with TB History): People who had Tuberculosis (TB) before were actually safer. They stuck to the "Official Highway" (doctors).
  • Analogy: Having had TB is like having a scar from a past battle. These patients know the system, they trust the doctors, and they know exactly what they need, so they don't gamble with shortcuts.
• The "Deep Pockets" (Higher Income): People with more money were more likely to mix the "Official Highway" with the "Shortcut" (buying from both doctors and shops).
  • Analogy: When you have extra cash, you might think, "I'll see the doctor, but just in case, I'll buy a backup supply at the shop too."
• The "Low Budget" (Lower Income): People with less money stuck mostly to the doctor, likely because they couldn't afford to buy extra pills at the shop or didn't have access to them.

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💊 The "One-Size-Fits-All" Problem

The biggest issue found in the study is Empirical Use.

• What it means: 71% of people took antibiotics without knowing what was actually causing their cough. They didn't get a lab test (like a sputum test) to see if it was bacteria, a virus, or TB.
• The Analogy: Imagine your car engine is making a weird noise. Instead of opening the hood to see if it's a loose belt or a broken spark plug, you just spray WD-40 everywhere and hope it works.
  • If the noise was a loose belt, the WD-40 didn't help.
  • If the noise was a broken spark plug, the WD-40 didn't help.
  • But now, your engine is full of WD-40, and the next time you need it, it might not work as well.

In this study, Amoxicillin (a common antibiotic) was the "WD-40." It was used in 90% of the cases. People were taking it for viral colds (which antibiotics can't cure) or for TB (which needs specific, stronger drugs).

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🔄 The Cycle of "More is Better"

The study found that 67% of people took antibiotics more than once.

• The Leftover Problem: 14% of people had leftover pills in their house. When they got sick again, they used the old pills instead of going to the doctor.
• The Sharing Problem: People were sharing their pills with friends and family.

The Metaphor: This is like a viral video. One person shares a pill, their friend takes it, their friend shares it with a neighbor. Soon, the whole neighborhood is taking the same pill, but no one knows if it's the right one for their specific illness. This creates a "super-bug" that learns how to ignore the pill.

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🚨 Why Should We Care? (The "Super-Bug" Threat)

When you use antibiotics when you don't need them (like for a virus), you aren't just wasting money. You are training the bacteria.

• The Analogy: Imagine the bacteria are soldiers. Every time you give them a weak antibiotic (or the wrong one), the weak soldiers die, but the strong ones survive. The strong ones then have babies. Soon, you have an army of "Super-Soldiers" that no medicine can kill.
• The Result: If you get a serious infection later, the "magic pills" won't work anymore. This is called Antimicrobial Resistance (AMR).

🏁 The Conclusion: What Needs to Happen?

The researchers are saying:

1. Stop the "Back Alley" sales: Pharmacies need to stop selling antibiotics without a prescription. It's like a liquor store selling alcohol to kids; it has to stop.
2. Test before you treat: Doctors need to do more lab tests to see exactly what is causing the cough before handing out pills.
3. Educate the "Family Managers": We need to teach people (especially women who often manage family health) that antibiotics aren't a cure-all for every cough.

In short: We are treating every cough like a bacterial infection, using the same "magic pill" over and over, and sharing it around. This is making our medicine less effective for everyone. We need to be smarter, test more, and stop the shortcuts.

Technical Summary

1. Problem Statement

Antibiotic misuse is a primary driver of Antimicrobial Resistance (AMR), contributing to an estimated 1.27 million global deaths annually. In Kenya, while provider-driven data indicates high rates of inappropriate prescribing for Respiratory Tract Infections (RTIs), there is a significant gap in understanding the patient-centered "symptom iceberg." Specifically, little is known about how adults with productive coughs independently navigate healthcare systems, acquire antibiotics (e.g., via Over-the-Counter [OTC] or self-medication), and utilize them without formal diagnosis. Existing literature often relies on secondary data (prescription logs) which fails to capture informal acquisition pathways, sociodemographic determinants, and post-acquisition usage behaviors in low-and-middle-income country (LMIC) settings like Nairobi.

2. Methodology

• Study Design: A facility-based cross-sectional study.
• Setting: Four selected chest and tuberculosis (TB) referral clinics in Nairobi County, Kenya (Mbagathi County Referral Hospital, Rhodes Chest Clinic, Riruta Health Centre, and Kibera D.O. Health Centre).
• Population: 400 consenting adult outpatients (≥18 years) presenting with productive coughs.
• Data Collection: Face-to-face interviews using a structured questionnaire covering:
  • Sociodemographics (age, gender, income, education).
  • Clinical history (TB, HIV, smoking, comorbidities).
  • Antibiotic-seeking pathways (GP prescription, OTC, self-medication, sharing).
  • Usage patterns (empirical vs. diagnosed, frequency, specific drug classes, completion rates).
• Statistical Analysis: Data were analyzed using R (v4.5.1).
  • Univariate: Frequencies and percentages.
  • Bivariate: Pearson's Chi-square or Fisher's exact test to assess associations.
  • Multivariate: Binary and multinomial logistic regression to calculate Crude Odds Ratios (cOR), Adjusted Odds Ratios (aOR), and Relative Risk Ratios (RRR/aRRR) with 95% Confidence Intervals (CI). Significance was set at p < 0.05.

3. Key Results

A. Sociodemographic and Clinical Profile

• Demographics: 65% male, 67% employed. 68.3% of employed participants earned below Ksh 10,000 (~USD 80) monthly.
• Clinical History: 37.3% had a history of smoking, 32.0% had a history of TB, and 29.8% had comorbidities (primarily hypertension).

B. Antibiotic Seeking Pathways (N=347 users)

• Prevalence: 86.7% of participants reported using antibiotics.
• Acquisition Routes:
  • GP Prescription Only: 46.4%
  • GP + OTC: 31.4%
  • OTC Only: 15.3%
  • Self-Medication (Borrowing/Leftovers): 6.9%
• Determinants of Pathways:
  • Gender: Females were significantly more likely to self-medicate compared to males (aRRR: 3.83; 95% CI: 1.46–10.03).
  • TB History: A history of TB was a strong predictor of relying solely on GP prescriptions and avoiding alternative pathways (aRRR for self-medication: 0.28; 95% CI: 0.09–0.89).
  • Income: Higher-income earners were more likely to use combined GP+OTC routes compared to low-income earners.

C. Patterns of Usage

• Empirical Use: 71.1% of users took antibiotics without sputum analysis or confirmed diagnosis. Only 28.7% had sputum tested; of those, 61% were diagnosed with TB.
• Drug Classes: Beta-lactams were dominant (66.0%), specifically Amoxicillin (90.8% of beta-lactam users).
• Frequency & Sharing:
  • 67.2% reported multiple instances of antibiotic use.
  • 14.4% had leftover antibiotics at home; 100% of these users consumed them.
  • 58.3% of those who borrowed/shared antibiotics did so repeatedly.

D. Predictors of Antibiotic Use and Frequency

• Likelihood of Use: Females (cOR: 2.00), those with TB history (cOR: 185.99), and HIV-positive individuals (cOR: 4.60) had higher odds of using antibiotics. Smokers had lower odds (cOR: 0.52).
• Frequency of Use: Females (aOR: 2.55) and those with hypertension were more likely to use antibiotics repeatedly. Conversely, a history of TB was associated with lower odds of frequent use (aOR: 0.62), likely due to structured TB treatment adherence.

4. Key Contributions

1. Patient-Centered Perspective: Shifts the focus from provider prescribing habits to patient decision-making, highlighting the "symptom iceberg" where patients bypass formal care or mix formal/informal sources.
2. Pathway Stratification: Identifies distinct behavioral clusters:
   • High-Risk Group: Females and low-income individuals are prone to self-medication and OTC access.
   • Structured Group: Patients with a history of TB demonstrate higher reliance on formal GP pathways, suggesting prior disease experience influences rational seeking behavior.
3. Empirical Dominance: Quantifies the high rate (71.1%) of empirical antibiotic use in a setting with available chest clinics, indicating a failure in diagnostic triage or patient demand for immediate treatment.
4. Specific Drug Risks: Highlights the overwhelming dominance of Amoxicillin/Amoxiclav, suggesting a narrow spectrum of resistance pressure being applied to the community.

5. Significance and Implications

• AMR Acceleration: The combination of high empirical use, OTC availability, and self-medication creates a perfect storm for selecting resistant pathogens (e.g., Staphylococcus aureus, Klebsiella pneumoniae).
• Policy Recommendations:
  • Enforcement: Stricter enforcement of prescription-only laws for antibiotics in pharmacies and drug shops.
  • Stewardship: Strengthening Antimicrobial Stewardship (AMS) programs specifically targeting patient education on the dangers of self-medication and the necessity of diagnostic confirmation (sputum testing).
  • Targeted Interventions: Gender-specific health education campaigns, as females are disproportionately engaging in self-medication.
• Limitations: The study is cross-sectional (cannot prove causality) and relies on self-reported data (potential recall bias). It is also limited to urban adult outpatients, limiting generalizability to rural or pediatric populations.

Conclusion: The study concludes that antibiotic use among adults with productive coughs in Nairobi is widespread, largely empirical, and driven by sociodemographic factors. Urgent interventions are required to curb unregulated access and promote rational use to mitigate the growing threat of AMR in Kenya.