Assessment of antimicrobial stewardship and perspectives of healthcare professionals on antimicrobial resistance in primary health centres in Cross River State, Nigeria

In many parts of the world, a simple infection that was once easily cured can now become a life-threatening struggle. This shift is driven by a phenomenon called antimicrobial resistance. It happens when the tiny organisms that cause sickness, such as bacteria, change over time to survive the medicines designed to kill them. When these medicines stop working, infections linger, spread more easily, and become harder to treat. A major driver of this problem is the way antibiotics are used in everyday medical care. If these drugs are given when they are not needed, or if patients do not finish the full course of treatment, the surviving bacteria learn to resist the medicine. This creates a cycle where stronger and stronger drugs are required, until eventually, no drugs work at all. For communities relying on basic health clinics, the ability to treat common illnesses safely depends entirely on whether these medicines remain effective.

In the southern Nigerian state of Cross River, a team of researchers set out to understand how this global challenge plays out on the ground. They focused their attention on primary health centers, the small clinics that serve as the first point of contact for most people in the region. These facilities are often staffed by community health extension workers, who are trained to handle a wide range of basic medical needs, including prescribing antibiotics. The researchers wanted to know what these frontline workers actually know about drug resistance, how they decide which medicines to give, and what stops them from following the best practices. Between July and August 2024, the team spoke directly with twenty-nine health workers across eleven local government areas. They conducted in-depth interviews, asking the workers to describe their daily experiences, the challenges they face, and their ideas for improvement. The goal was not just to count mistakes, but to understand the real-world pressures that shape medical decisions in these clinics.

The conversations revealed a complex picture. The health workers generally understood that antibiotics could lose their power if they were misused. They knew that resistance grew when drugs were taken for the wrong reasons, when doses were skipped, or when people bought medicines without a doctor's advice. Many pointed to unregulated shops, often called patent medicine vendors, as a major source of the problem. These vendors frequently sell antibiotics without proper training or oversight, and they sometimes even give injections that should only be administered by qualified staff. The workers also noted that patients often arrive at the clinic expecting to leave with a strong antibiotic, believing that any fever or cough requires one. This pressure sometimes forces health workers to prescribe medicines they know are not strictly necessary, simply to satisfy the patient or because they fear the patient will go elsewhere for treatment.

Despite this awareness, the ability to prescribe correctly was often blocked by the harsh reality of the clinics themselves. The most common obstacle was the simple absence of medicine. When the clinic ran out of the standard antibiotics, health workers had no choice but to send patients to buy drugs from private shops, where the quality and type of medicine were uncertain. Even when medicines were available, the lack of diagnostic tools made it difficult to know exactly what was wrong. Without a laboratory test to confirm an infection, workers had to guess which drug to use based on symptoms alone. This guesswork, known as empirical prescribing, is a necessary part of medicine in resource-limited settings, but it increases the risk of using the wrong antibiotic. Furthermore, the workers reported that they rarely received formal training on how to manage antibiotic resistance. Most relied on old guidelines posted on the walls of their clinics or on their own past experiences, rather than on updated scientific knowledge.

The health workers offered clear and practical solutions to these problems. They asked for regular training sessions to keep their knowledge current and for better supervision to ensure they were following the rules. They emphasized the need for a steady supply of essential medicines so that patients would not have to leave the clinic to find treatment. They also called for improved laboratory services to help them make more accurate diagnoses. Beyond the clinic walls, they suggested that the government needed to enforce stricter rules on the sale of antibiotics by unlicensed vendors and launch public education campaigns to change how the community views these drugs. Many also expressed a desire for more doctors to be posted to their facilities, arguing that the current system places too much responsibility on workers who have limited training and support.

The study concludes that while the health workers in Cross River State recognize the danger of drug resistance and want to do the right thing, they are often trapped by a system that makes it difficult to act on that knowledge. The problem is not a lack of will or understanding, but a lack of resources, training, and support. The researchers found that fixing the issue requires more than just telling workers to be careful; it requires building a system where the right tools and medicines are available, where the rules are enforced, and where the community is educated on how to use these powerful drugs responsibly. Without these changes, the cycle of resistance will continue, leaving the most vulnerable populations with fewer options to treat the illnesses that affect them every day.