Egwu Kenneth Chukwuebuka, Estelle Mbadiwe and Erick Venant
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Antimicrobial resistance (AMR) is a global threat and continues to get worse with time. Antimicrobial resistance is high due to misuse of antimicrobial agents, which encompasses poor diagnosis of diseases before treatment, inaccurate prescription of drugs, easy accessibility of antimicrobials in our society, self-medication and dosage incompleteness.
AMR and related courses are minutely incorporated into the pharmacy curriculum for undergraduates. Pharmacy students are prepared for the heavy responsibilities after school, but since infectious diseases are a major problem in Sub-Saharan Africa and across the globe, it is expected that these potential apothecaries are effectively coached on the rudiments of disease handling, drug choices, and antimicrobial stewardship. Such an eldorado has remained significantly unattainable as the curriculum is deficient and does not cover the necessary topics needed to equip these students with the necessary knowledge. The aim of this study is to review the undergraduate pharmacy student curriculum to determine the efficiency of the curriculum towards impacting students with the right awareness of antimicrobial resistance. For the study, a survey was carried out to analyze the lecturers’ views on the quality or sufficiency of the undergraduate AMR curriculum towards gearing the students to be experts in safe antimicrobial use and dispensing and also antimicrobial stewardship. The undergraduate student handbook was reviewed to determine the workload of AMR and related courses in the curriculum.
AMR occurs when microorganisms develop protection and no longer respond to drugs that normally kill or inhibit their growth. It can also be defined as the development of resistance by various bacteria and other disease-causing microbes against antimicrobial agents or antibiotics. AMR poses a great threat to the health of patients and the economy. Antimicrobial agents are drugs that inhibit the growth or kill microorganisms. Long before the discovery of antibiotics, humans were plagued by a variety of infectious diseases, and for most of these infections, the cause and treatment revolved around superstitious beliefs. The first antibiotic, penicillin, was discovered by Alexander Fleming at St. Mary’s Hospital, London, in the year 1928. This led to a massive reduction in the number of deaths from infections. Penicillin was developed on a large scale in the United States of America during the 1939–1945 World War, led by scientists and engineers at the Northern Regional Research Laboratory of the US Department of Agriculture.
In his Nobel Lecture in 1945, Fleming sternly warned about antimicrobial abuse. He opined that “the time may come when penicillin can be bought by anyone in the shops.” Then there is the danger that an ignorant man may easily under-dose himself and, by exposing his microbes to non-lethal quantities of the drug, make them resistant” (Fleming, 1945).
The first comprehensive analysis of the global impact of AMR estimates that it caused 1.27 million deaths in 2019 – more deaths than HIV/AIDS or malaria and that antimicrobial-resistant infections played a role in 4.95 million deaths (Oxford University, 2022). The causes of AMR are multisectoral, but while much attention is focused on the improper use of antimicrobials, there is increasing evidence that the quality of medicine is another underlying factor. Major challenge to tackling AMR is understanding the true burden of resistance, particularly in locations where surveillance is minimal and data is inadequate. A crucial approach to addressing this global challenge and ensuring ethical use of antimicrobials is to ensure that health workers acquire, through their education and training, the relevant skills and knowledge required to prevent and combat AMR.
Different institutions and nations have their own curricula by which they teach their students the rudiments of AMR. This curriculum is expected to follow the World Health Organization’s specifications, but such is not normally the case, especially in developing countries.
This paper involved the review of the University of Nigeria Nsukka Pharmacy students’ undergraduate curriculum to determine the status of the inclusion of AMR in the curriculum. The identified topics were compared with the WHO AMR Competency Framework to identify gaps. A survey was also implemented to analyze the lecturers’ views on the inclusion of AMR in the curriculum and source recommendations to improve its inclusion.
Lecturers suggested an internship program as a way to implement changes in the AMR-related content in the curriculum. Three out of the four lecturers suggested that students be assigned to experts in AMR in the academy or hospital. While others maintain that the kind of expertise required to make the changes involves the inclusion of AMR stewardship as a course in pharmaceutical microbiology. A lecturer in the field of pharmaceutical chemistry suggested that scientists and researchers in academia are the ones to lead the revision, implementation, and use of the preservice AMR curriculum. Two of the lecturers suggested that the bottleneck that exists in the integration of AMR into the curriculum is inadequate time for the program, while others opined that the school does not prioritize AMR, which they marked as being bad.
Overview of The Undergraduate Student Curriculum
The program spans for five years for students that gained Admission through UTME and 4 years for Direct-entry students. The first years (Pre-Pharmacy) of school focus on knowledge about general science. Students are taught algebra, trigonometry, and calculus. In physics, the lecture focuses on general physics for life science and practical physics. Basic principles of chemistry, basic practical chemistry, and general biology are also taught as the core courses. In year two, students are introduced properly to the pharmacy profession. Pharmaceutical calculations, Introduction to Unit Operations, Practical Unit Operations, Pharmaceutics (also titled dispensing), Practical Pharmaceutics, Basic Pharmaceutical Medical Microbiology, Practical Basic Pharmaceutical Microbiology, Pharmaceutical Chemistry, and Practical, Pharmacognosy 1A and 1B, Human Physiology, and Practical, Basic and Applied Pharmaceutical Biochemistry, Pharmacy Practice, and Anatomy & Histology are taught. Of all these, only the core topics that prepare the students for antimicrobial use and AMR are taught in basic pharmaceutical microbiology, which is only done in the first semester. Many of the topics highlighted include sterilization, bacterial structure, mycology, virology, microscopy, preparation and use of buffers, microbial variation, and genetics.
In the practical laboratory, students are taught the use of different techniques to identify microorganisms, asceptic transfer, and determination of microbial load contamination. In the third year, which constitutes the 2nd professional session for the five-year degree program, students are introduced to pharmacology. Courses that border on microbiology are shifted to the 4th year (third professional session). Major areas of focus are pharmacology, pharmacognosy, pharmacy administration (economics and management), phytoevaluation, and biopharmaceutics. In pharmacology, areas like cardiovascular drugs, endocrine drugs, autonomic pharmacology, autocoids, skeletal muscle relaxants, haemantinics, and plasma subsititutes are broadly covered. Pharmaceutical microbiology is reintroduced in the fourth year, with a focus on antimicrobial agents used as chemotherapeutic agents, antibiotics, general evaluation techniques in microbiology, antibiotic assay, pharmaceutical preparation preservation, antiseptics, and disinfectants, among other topics. General areas of focus in the 4th year session include pharmacology, pharmaceutics (Microbiology), pharmaceutical chemistry, pathology, and forensics. In the second semester, principles of chemotherapy are taught and the students learn about the wide array of antimicrobial agents. In the final year, AMR is introduced as a topic under pharmaceutics. Other topics taught include immunology, serology, and antibiotics. In pharmocology, advances in chemotherapy are taught. In pharmacotherapeutics, areas of study include protozoa infestation, infectious diseases, and treatment of selected diseases states are taught.
From the variety of courses taught in the pharmacy school, only a few cover the necessary topics that will equip the students with competent knowledge concerning AMR. These include courses such as Basic Pharmaceutical Microbiology, Practical Basic Pharmaceutical Microbiology, Pharmaceutics III, Pharmacology IV, Pharmaceutics IV, Pharmacology V, and Pharmacotherapeutics.
Comparison of The Curriculum With WHO AMR Competency Framework
While the curriculum is robust and embossed with numerous courses, it’s factual that the inclusion of AMR and AMR-related topics in the curriculum is poor. The World Health Organisation (WHO) Competency Framework for Health Workers highlights key areas of knowledge and necessary skills the pharmacist must possess to have the right attitude to tackle AMR. WHO remarks on the pharmacist’s understanding of the significance of antimicrobial choice, dosage, duration, and preparation in the treatment of infections. In this domain, pharmacists are expected to develop relevant skills to advise patients and prescribers on the appropriate use of antimicrobials and practice safe disposal of unused antimicrobial medicines.
The undergraduate school curriculum to a significant extent covers the area of understanding the significance of antimicrobial choice but does not emphasize or spare more knowledge on the appropriate dosage, duration, and preparation in the treatment of infections. Because of the teaching style, not many students are capable of handling mild infections or accurately advising patients and prescribers on the appropriate use of antimicrobials in their penultimate and final year. In pharmacokinetics, routes of therapy, the concept of bioavailability, dosing, frequency, therapeutic drug monitoring, and clearance are effectively taught in third year pharmacology and fourth year clinicals, but Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used as examples in study cases other than antimicrobial agents. Students struggle to explain the tissue/organ toxicity.
The WHO AMR Competency Framework highlights the complete understanding of pharmacists in giving advice on dosage forms, preparations, and administration, but this is uncommon as the curriculum does not effectively teach students. The WHO Competency Framework notes that pharmacists should understand the link between antimicrobial stewardship and IPC measures. However, students are not adequately provided with enough knowledge concerning AMR stewardship and infection prevention and control. As highlighted in the competency framework, the curriculum covers hygiene and safety practices to control cross transmission but, it does not cover relevant topics that will enable the student pharmacist to understand the principles and practice of diagnostic stewardship, techniques and data required for effective surveillance of antimicrobial use and AMR in hospitals and the community. As a result, students lack the skills to support diagnostic stewardship implementation and, act as the first line of surveillance in the correct use and reporting of microbiology tests and diagnostic tools, and generation of hospital-specific antimicrobial susceptibility data.
This study supports the inclusion of thorough modular foundations that build AMR awareness amongst the students. This should be designed as module to equip the students with the appropriate knowledge of the use of antimicrobial agents, and effective implementation of IPC, diagnostic stewardship, ethics, and surveillance. The curriculum should be expanded to increase the coverage of AMR and related topics in the undergraduate curriculum by at least 2 hours in major AMR courses (USAID, 2013). The schools should also integrate World Antimicrobial Awareness Week into their curriculum and encourage students to actively participate. This can also be integrated into the students’ continuous assessment and final grading. Antimicrobial stewardship ward round should be introduced for final year students (Opanga, 2021), and begin in the third year to improve clinical knowledge and experience with disease handling and treatment. Finally, to raise awareness about AMR, pharmacy schools should encourage the formation of AMR clubs.
The WHO AMR Competency Framework outlines the necessary areas that the AMR curricula should focus on. This study highlighted how some of these areas are omitted in the University of Nigeria Pharmacy School curriculum and most likely in other universities in Nigeria. There is an urgent need to amend pharmacy curricula to equip pharmacists and other healthcare providers with the right skills to combat AMR.
Fleming A. (1945). Penicillins. Nobel Lecture. Accessed February 7, 2022.
Opanga S. (2021). Antimicrobial stewardship opportunities and gaps in education. Accessed February 7, 2022.
Oxford University (2022). An estimated 1.2 million people died in 2019 from antibiotic-resistant infection. Accessed July 18, 2022.
USAID. (2013). Revising preservice curriculum to incorporate rational medicine use topics. Accessed February 7, 2022.
About The Authors:
Egwu Kenneth Chukwuebuka is a 400 level Pharmacy student at the University of Nigeria Nsukka. He is a scriptwriter and editor for Student Against Covid-19 (SAC) and the Media and Publicity Team Lead at Community Health Awareness Network (CHANET). He is also a member of the British Society for Antimicrobial Chemotherapy.
Estelle Mbadiwe is a Founding Partner of Ducit Blue Solutions. She is a Pharmacist, with an MSc in Health Policy, Planning & Financing. She has substantial expertise in multiple healthcare institutions in project and change management. She has worked on various projects to develop strategies to improve patient safety and deliver quality healthcare services and systems both in Nigeria and the United Kingdom. She is a strong voice for AMR in Africa and globally. Her organization holds an annual internship/mentorship program to build capacity of students and fresh graduates on solutions for the mitigation of Antimicrobial resistance and misuse.
Erick Venant is the founder of the Roll Back Antimicrobial resistance Initiative (RBA Initiative) an NGO in Tanzania dedicated to containing antimicrobial resistance(AMR). He also serves as a coordinator for Stop Superbugs, a Global Health Initiative of the British Society for Antimicrobial Chemotherapy (BSAC). Erick has received several awards for his work to contain AMR, including the Princess Diana Legacy award. He is also an educator for different global courses on AMR.
This study was carried out in fulfilment of the Ducit Blue Foundation (DBF) 2021–2022 Antimicrobial Resistance One-Health Pan-African Internship/Mentorship Programme: Cohort 2 (Title: Involving Youth in the Mitigation of Antimicrobial Misuse & Antimicrobial Resistance (AMR)) with supervision from Erick Venant and Estelle Mbadiwe (Executive Director of Ducit Blue Foundation). My sincerest appreciation to the entire DBF team and my lecturers from the University of Nigeria, Nsukka (UNN) who shared their opinions.