When prevention fails: prescription is inevitable Test article

The first domino in Antimicrobial Stewardship (AMS) has already tipped and initiated a cascade of events by the time the patient enters a hospital hallway seeking medical treatment. AMS does not begin in the consultation room when the doctor writes the prescription, despite the common misconception, it starts outside the hospital walls: in our homes, farms, and our environment through effective infection prevention and control (IPC) practices in each of these settings. Effective infection prevention and control practices encompass precautions to prevent infection, interrupt transmission, promote education, and ensure continuous monitoring and improvement of practices (1). Due to the foundational role IPC plays in Antimicrobial Stewardship, understanding how  IPC practices operate at the household and community level is crucial to achieving better antimicrobial stewardship.

IPC in everyday settings: Households and community 

In our day-to-day home lives, we are consistently engaged in infection prevention and control. The implementation of these practices varies depending on the infrastructure available, individual knowledge, institutional policies/guidelines, cultural and social context, and others. At the Community level, infection prevention and control practices typically comprise basic public health and hygiene practices such as hand hygiene, proper waste disposal, and environmental cleanliness. 

For hand hygiene, it is mainly practiced in the following circumstances: after toilet use, after changing diapers, before food handling, before eating, and after coughing or sneezing. These practices have minimal requirements that are: reliable water supply, soap or alcohol based hand rub (ABHR), clear information on why, when, and how to clean hands, and a conducive physical and social environment. However, the full implementation of these basic hygiene practices is still quite limited worldwide [2]. This could be attributable to infrastructural and socio-economic resource constraints [3,4].  In 2024, it was estimated that 1.7 billion people lacked basic hand hygiene services at home, and 611 million had no handwashing facilities at all (2). This means that while one can have the will and the knowledge to practice hand hygiene, they may be unable to, and this creates an environment where infections easily spread.

On the other hand, in settings where supplies are available, challenges still arise, namely, inconsistent technique and lack of motivation to apply approved hand hygiene practices. In most cases, these instances happen, especially after using the washroom or before eating, where one can underestimate the need for thoroughness in handwashing; this can be due to perceived cleanliness of their hands or because one uses utensils to eat food, and not hands. In such scenarios, handwashing is often performed like a sprint, fast, almost frantic, without thoroughness. While this may seem efficient, it undercuts the very purpose of proper hand hygiene, which requires thorough hand washing for effectiveness in disease prevention. This practice, without thoroughness, transforms from being protective to being symbolic.

Beyond our personal hygiene, environmental conditions also pose undeniable risks depending on the level of cleanliness. These conditions are often evident in places where garbage is strewn across fields, gradually accumulating into small hills that become garbage mounds, or where roadside trash piles into the water drainage trenches, slowly but surely blocking the water drainage trench and creating stagnant water. This situation could be the result of a lack of waste collection services, public dustbins, or bins in private and public vehicles. This is a significant concern, as approximately 2 billion people worldwide live without waste collection services, and waste generation in lower-income cities in Africa is projected to double by 2030 ( 5).

Adding to these risks, over 1.5 billion people worldwide lack access to private toilets or latrines, and 419 million continue to practice open defecation into street gutters, behind bushes, or into open bodies of water (6). In Kenya, according to the 2019 census, it was revealed that 7.4% of households lacked proper sanitation facilities and approximately 10% of the population practiced open defecation (7). In such an environment with trash piling into mounds, blocking water trenches, and open defecation, we collectively create a reservoir for pathogens to live in and multiply, thereby serving as a potential source of infection.

These statistics are not peripheral: they expose structural vulnerabilities and a normalized lack of care for environmental cleanliness that extends beyond our compounds. This creates an environment that is conducive to the thriving of infectious agents, promotes disease transmission, and consequently drives an increase in antimicrobial consumption. Given the critical impact of environmental cleanliness on public health, it is equally important to address infection prevention and control (IPC) in farming, where close human-animal interactions and poor biosecurity measures pose additional risks for disease transmission.

 IPC in farming, livestock, and poultry.

With these risks in mind, it is important to consider Infection Prevention and Control practices in farming. Farming may not involve everyone directly, but we all benefit from or are affected by the current farming practices in operation. Thus, we can’t overlook IPC in farming, which is commonly referred to as biosecurity measures. Biosecurity includes all measures to prevent the introduction of pathogens (bio-exclusion) and reduce the spread of pathogens (bio-containment) (8). While the principles remain similar to human Infection Prevention and Control practices, the methods differ slightly. In biosecurity, the focus is on four key elements to maintain livestock health: isolation, traffic control, sanitation, and animal health management (9)

These biosecurity elements are interconnected and work synergistically. Within the farming premises, isolation serves as the first line of defense, aiming to prevent the introduction of new pathogens. This is achieved by separating new or returning animals from the existing stock, as well as separating sick animals from healthy ones.

Building on the first measure, we have traffic control, which is practiced within the farm premises to reduce the creation of any opportunities for new pathogens to be introduced and spread. This is accomplished through measures such as fencing the farm and having one single point of entry into the farm, disinfecting equipment and vehicles before entry, limiting the number of people accessing the farm, and requiring those who do enter to wear dedicated clothing when interacting with the animals. Additionally, traffic control extends to animal movement within the premises through the application of the all-in, all-out principle, which allows for the complete disinfection of farm premises before introducing a new batch of animals, ensuring the environment does not serve as a potential reservoir for pathogens.

While the measures above focus on preventing the introduction and spread of new pathogens, sanitation compounds their effectiveness through maintaining a clean premise and thus eliminating potential reservoirs where pathogens could persist and undermine the effectiveness of the other measures.

The last measure, animal health management, focuses on enhancing the animals’ innate immunity and reducing factors that predispose them to morbidities. This is achieved through a combination of preventive and curative strategies such as proper housing, high-quality feed and water, vaccination, and routine health monitoring to detect and manage illnesses early. Together, these measures significantly reduce disease incidence and therefore minimize the reliance on antimicrobials within the farming industry. Research supports this connection , for instance, a review of 27 peer-reviewed studies across European countries demonstrated a 51.8% reduction in antimicrobial use linked to enhanced farm biosecurity practices(10). Although some studies do not quantify the exact decrease, they consistently report a lowered need for antibiotic use due to reduced morbidity  as a result of  effective implementation of biosecurity measures (11,12,13,14,15)

However, the benefits of biosecurity measures can only be fully actualized through proper implementation. Poor or inconsistent application undermines their effectiveness, increasing morbidity rates and increasing reliance on antimicrobials. This is a pattern commonly observed in several studies. Examples from African countries such as Ethiopia, Kenya, Cameroon, and Uganda highlight this tendency to substitute antimicrobials for effective biosecurity practices.

In Ethiopia, studies on dairy cow biosecurity revealed poor implementation, particularly in the following measures: sanitation and animal health management (9). Similarly, in Cameroon, sanitation efforts, especially vector control measures and measures ensuring a water and feed quality, were inadequate (16). In Uganda, while health management practices like vaccination, stocking density, and management of sick birds had relatively high compliance at 61%, other biosecurity measures performed poorly by a huge percentage. For instance, cleaning and disinfection of farm premises was only at 33.1%, and traffic control measures, including fencing and visitor protocols, were even lower at 20.8% (17).

Kenya presents a mixed picture based on two separate studies. One, covering three counties: Kajiado, Kiambu, and Machakos counties, found overall biosecurity rated at 67.9%. Measures preventing pathogen introduction, such as visitor and worker protocols, purchase of day-old chicks, and feed and water management, were relatively strong at 42.3%. However, practices aimed at limiting pathogen spread within farms, like sanitation and disease management, were low at 25.6% (18). Another study in Nyanza reported poor implementation across all measures but animal health management. Adoption rates for practices like deworming ranged from 36.2% to 78.7%, vaccination from 67.6% to 97.9%, and carcass disposal from 86% to 91.5%. Conversely, sanitation measures ranged from 13.5% to 45.9%, with routine sanitization as low as 0.3% to 25.6%, though cleaning equipment with soap fared better (53.5% to 76.5%). Traffic control practices such as foot disinfection and use of dedicated clothing were poorly adopted, ranging from 2.2% to 37.3% and 1.6% to 30.3%, respectively(19).

These findings could suggest that farmers often rely on antimicrobials as a crutch or back-up for inadequate biosecurity, using antibiotics prophylactically and giving uneven priority to different biosecurity measures. Regional variations in prioritization may reflect cultural differences or infrastructure challenges. Overall, biosecurity does not appear to be a central focus in farm management, with adoption influenced by perceived cost, risk, and importance. This raises important questions: Are cultural practices influencing which biosecurity measures are prioritized and which ones are overlooked, or could it be that financial constraints are the main factor driving these trends?

Reflecting on these patterns prompts critical inquiry: How much of the modern dependence on antimicrobials stems not from microbial evolution, but from our collective failure to implement effective biosecurity? And how do these gaps perpetuate cycles of infection that affect communities, economies, and health systems?