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Alarming rates of drug-resistant Gram-negative bloodstream infections among hospitalized patients in Ethiopia: an urgent call to strengthen diagnostic bacteriology and antimicrobial stewardship in low-resource settings

  • St. Paul's Hospital and Millennium Medical college
P0947 Alarming rates of drug-resistant Gram-negative bloodstream infections among
hospitalized patients in Ethiopia: an urgent call to strengthen diagnostic bacteriology
and antimicrobial stewardship in low-resource settings
Workeabeba Abebe Taye2, Tinsae Alemayehu3, Ling Yuan Kong7, Temesgen Beyene4,
Barbara Ann Jardin7, Alina Dyachenko6, Oystein Johansen5, Wondewossen Amogne Degu3,
Michael Libman1, Cedric Yansouni1, Makeda Semret*1
1McGill University Health Centre, Infectious diseases and J.D. MacLean Centre for Tropical Diseases,
Montreal, Canada, 2School Of Medicine, Addis Ababa University , Department of Pediatrics and Child
Health, 3School Of Medicine, Addis Ababa University , Department of Medicine, 4School of Medicine,
Addis Ababa University, 5Vestfold Hospital Trust, Norway, 6St Mary's Hospital Centre, MOntreal,
Canada, 7McGill University Health Centre
Background: The extent to which antimicrobial resistance (AMR) contributes to the morbidity and
mortality of patients in Sub-Saharan Africa is unknown. Gaps in diagnostics fuel empiric antibiotics
when managing fever in patients in low-resource settings (LRS). In an ongoing 4-year study of
hospital-associated infections and AMR in Ethiopia, we performed a prospective analysis of blood
stream infections among inpatients. We correlated clinical outcomes with antimicrobial susceptibility
profiles of enterobacteriacea and antibiotic use in the preceding 4 weeks, to inform antibiotic
stewardship strategies in LRS
Materials/methods: Tikur Anbessa Specialized Hospital (TASH) is a 700-bed tertiary care referral
center in Addis Ababa, Ethiopia. Patients admitted for longer than 48 hours and presenting fever or
other signs of infection had systematic blood culture testing; bacterial isolates were identified using
phenotypic methods, and antimicrobial susceptibility was assessed by disk diffusion method using
CLSI breakpoints. Data on 14-day outcomes, comorbidities and antibiotic use in the preceding 4
weeks were collected.
Results: Between Sept 2016-Sept 2017, we enrolled 1260 patients; 226 (18%) patients died within 14
days. Enterobacteriacea were cultured from the blood of 175 (14%) patients of which 42 (24%) died.
Resistance to antibiotics was widespread: 70% of E. coli and 89% of Klebsiella sp were resistant to 3rd
generation cephalosporins (C3); 7% of E. coli and 24% of Klebsiella sp were resistant to
carbapenems. Compared with patients who were alive at 14 days, those who died were more
frequently infected with multidrug-resistant strains (resistance to C3: 78% vs 90%, to carbapenems:
16% vs 24%; to ciprofloxacin: 54% vs 67%; to gentamycin: 55% vs 79%), though these differences did
not reach statistical significance. Almost all patients (96%) had received antibiotics in the 4 weeks
preceding microbiological testing; those who died were more likely to have received 3 or more
antibiotics (67% vs 48%, p<0.001) and to have comorbid illnesses (71% vs 62%, p=0.012)
Conclusions: AMR has reached alarming proportions in Ethiopia; patients with comorbidities and
recent use of multiple antibiotics are at high risk of drug-resistant infection and associated mortality.
Further studies to assess the impact of a laboratory-supported antimicrobial stewardship intervention
are underway.
Full-text available
Objective Effective antimicrobial containment strategies such as Antimicrobial Stewardship Programs (ASPs) require comprehensive data on antibiotics use which are scarce in Ethiopia. This study sought to assess antibiotics use and healthcare-associated infections (HCAIs) in Ethiopian public hospitals. Design We conducted a cross-sectional study using the WHO point-prevalence survey protocol for systemic antibiotics use and HCAIs for low/middle-income countries. Setting The study was conducted among 10 public hospitals in 2021. Participants All patients admitted to adult and paediatric inpatient and emergency wards before or at 08:00 on the survey date were enrolled. Outcome measure The primary outcome measures were the prevalence of antibiotic use, HCAIs and the hospitals’ readiness to implement ASP. Results Data were collected from 1820 patient records. None of the surveyed hospitals had functional ASP. The common indication for antibiotics was for HCAIs (40.3%). Pneumonia was the most common bacterial infection (28.6%) followed by clinical sepsis (17.8%). Most treatments were empiric (96.7%) and the overall prevalence of antibiotic use was 63.8% with antibiotics prescription per patient ratio of 1.77. Ceftriaxone was the most commonly prescribed antibiotic (30.4%) followed by metronidazole (15.4%). Age, having HIV infection, ward type, type of hospital, catheterisation and intubation history had significant association with antibiotic use. Patients who were treated in paediatric surgical wards were about four times more likely to be on antibiotics compared with patients treated at an adult emergency ward. Patients on urinary catheter (adjusted OR (AOR)=2.74, 95% CI: 2.04 to 3.68) and intubation device (AOR=2.62, 95% CI: 1.02 to 6.76) were more likely to be on antibiotics than their non-intubated/non-catheterised counterparts. Patients treated at secondary-level hospitals had 0.34 times lower odds of being on antibiotics compared with those in tertiary hospitals. Conclusions Antibiotic use across the surveyed hospitals was common and most were empiric which has both practical and policy implications for strengthening ASP and promoting rational antibiotics use.
Full-text available
This review provides an update on the factors fuelling antimicrobial resistance and shows the impact of these factors in low-resource settings. We detail the challenges and barriers to integrating clinical bacteriology in hospitals in low-resource settings, as well as the opportunities provided by the recent capacity building efforts of national laboratory networks focused on vertical single-disease programmes. The programmes for HIV, tuberculosis and malaria have considerably improved laboratory medicine in Sub-Saharan Africa, paving the way for clinical bacteriology. Furthermore, special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings. Traditionally, clinical bacteriology laboratories have been a part of higher levels of care, and, as a result, they were poorly linked to clinical practices and thus underused. By establishing and consolidating clinical bacteriology laboratories at the hospital referral level in low-resource settings, routine patient care data can be collected for surveillance, antibiotic stewardship and infection prevention and control. Together, these activities form a synergistic tripartite effort at the frontline of the emergence and spread of multi-drug resistant bacteria. If challenges related to staff, funding, scale, and the specific nature of clinical bacteriology are prioritized, a major leap forward in the containment of antimicrobial resistance can be achieved. The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories. The future clinical bacteriology laboratory in a low-resource setting will not be an “entry-level version” of its counterparts in high-resource settings, but a purpose-built, well-conceived, cost-effective and efficient diagnostic facility at the forefront of antimicrobial resistance containment.
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