How unregulated antibiotics are fueling drug-resistant UTIs

A silent crisis is unfolding in Malawi. A new study shows that nearly half of all urinary tract infections are resistant to first-line treatments, making once-treatable infections dangerous, especially for vulnerable groups. Antimicrobial resistance, or AMR, occurs when germs no longer respond to the drugs designed to kill them. The World Health Organization warns that AMR threatens global health, food systems, and development, and could increase poverty and death rates around the world. In Malawi, the impact of antimicrobial resistance on UTIs is especially severe for women and girls aged 15–45, who are disproportionately affected by UTIs. As AMR spreads, their access to effective, affordable treatments is declining — turning common infections into more serious conditions. As in many other sub-Saharan African countries, the unchecked use of antibiotics and widespread self-prescription are major drivers of AMR in Malawi’s UTI patients. Patients often purchase antibiotics over the counter without a doctor's prescription, a practice that Victor Mithi, president of the Society of Medical Doctors in Malawi, recently told SciDev is rapidly accelerating AMR. The challenge is further compounded by limited access to health care and diagnostic testing, making it even more difficult to tackle the problem. "We need to strengthen the enforcement of prescription-only antibiotic sales. Most patients in Malawi can just walk into a pharmacy and buy antibiotics without a prescription,” Mithi said. Malawi's UTI crisis serves as a warning to the broader sub-Saharan Africa community that AMR is a growing threat that demands urgent attention, Pizga Kumwenda, senior lecturer in microbiology and immunology at Mzuzu University, said. Sub-Saharan Africa faces the highest toll from AMR-related deaths. Inadequate health care infrastructure, widespread poverty, and the unchecked use of antibiotics fuel the problem. Most health facilities often lack basic diagnostic tools, leaving doctors to treat infections blindly and contributing to rising resistance. Research from Tanzania also suggests that gender dynamics play a significant role in the use and misuse of antibiotics for common infections. The country's antibiotic use patterns are influenced by gender, with implications for antimicrobial resistance. "Gender and age are significantly associated with the use of antibiotics without a prescription," said Agricola Joachim, senior lecturer at Muhimbili University of Health and Allied Sciences. "While men are more likely to purchase unprescribed antibiotics, the administration of these drugs is more common among women, which can increase the risk of AMR." Tanzania faces a significant public health challenge from AMR, with 12,500 deaths attributable to AMR and 54,000 deaths associated with AMR in 2019 alone. The country has the 30th highest age-standardized mortality rate per 100,000 population associated with AMR across 204 countries. Fueling a black market George Jobe, a Malawian health rights activist, said self-prescription of antibiotics is connected to corruption, where drugs are pilfered from public pharmacies and sold on the black market. Drug pilferage in Malawi is a huge problem; in 2017 alone, at least 1.5 billion Kwacha worth of drugs and medical supplies were stolen in the 2016-2017 financial budget. “Sadly, most of these drugs are sold expired due to improper storage, and wrong doses are administered as drug vendors on the illicit market are not qualified to administer the drugs, resulting in resistance to diseases like malaria and urinary tract infections,” Jobe said. The problem is compounded by long distances from one health facility to another, where patients on long-term antibiotic treatment plans, in some instances, travel a day before their appointment day to get medication. This, according to Russell Msiska, executive director at Beyond Our Hearts Foundation, or BOHF, a community-based organization in Malawi, creates a fertile ground for a black market for prescription-only antibiotics. “With no option, people in remote areas that are far from a nearest health care facility thus resort to these back-market drugs, which are, in most cases, pilfered from a public health facility,” said Msiska. He said aside from the risk of buying expired drugs, these markets also fuel treatment resistance to the antibiotics, as many patients do not usually take full drug doses, stopping medication midway. WHO has recognized antibiotic resistance as one of the top 10 global threats to public health, annually causing around 700,000 deaths, and endangering the possibility of achieving Sustainable Development Goal number 3 — ensuring healthy lifestyles and promoting well-being for everyone at all ages. A survey conducted in 2019-2020 revealed that 88% of 136 responding countries had a national action plan to contain AMR following the World Health Assembly call for a global action plan on AMR. However, many countries are struggling to implement their action plans due to limited resources. In Zambia, antibiotic resistance is recognized as a major public health threat, but despite having a comprehensive action plan, the lack of domestic funding has stalled its rollout and coordination. Victor Mukonka, director-general of the Zambia National Public Health Institute, acknowledged that while COVID-19 dominated recent public health efforts, AMR remains a national priority. Zambia is now exploring sustainable financing solutions to keep the fight on track. “Catalytic funding, combined with a gradual increase in domestic investment, could offer a replicable model for other countries in the region and beyond,” he said.