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Cited by 46Antibiotic Resistance in BacteriaAntibiotic Use and ResistanceBacterial Identification and Susceptibility Testing

Multicenter Surveillance of Antimicrobial Resistance among Gram-Negative Bacteria Isolated from Bloodstream Infections in Ghana

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Donkor, Eric S., Muhsen, Khitam, Johnson, Sherry A. M., Kotey, Fleischer C. N., Dayie, Nicholas T. K. D., Tetteh-Quarcoo, Patience B., Tette, Edem M. A., Osei, Mary-Magdalene +12 more·2023·Antibiotics
DOI 10.3390/antibiotics12020255PMC PMC9951917
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Abstract

Background: Antimicrobial resistance (AMR) in Gram-negative bacteria-causing bloodstream infections (BSIs), such as Klebsiella pneumoniae and non-typhoidal Salmonella (NTS), is a major public health concern. Nonetheless, AMR surveillance remains scarce in sub-Saharan Africa, where BSI treatment is largely empirical. The aim of the study was to determine the distribution and AMR patterns of BSI-causing NTS, K. pneumoniae, and other Gram-negative bacteria in Ghana. Methods: A cross-sectional study was conducted between April and December 2021 at eleven sentinel health facilities across Ghana as part of a pilot study on the feasibility and implementation of the human sector AMR surveillance harmonized protocol in sub-Saharan Africa. Gram-negative bacteria recovered from blood specimens of febrile patients were identified using MALDI-TOF and evaluated for antimicrobial resistance using the BD Phoenix M50 analyzer and Kirby-Bauer disc diffusion. The Department of Medical Microbiology at the University of Ghana served as the reference laboratory. Results: Out of 334 Gram-negative blood isolates, there were 18 (5.4%) NTS, 85 (25.5%) K. pneumoniae, 88 (26.4%) Escherichia coli, 40 (12.0%) Acinetobacter baumannii, 25 (7.5%) Pseudomonas aeruginosa, and 77 (23.1%) other Gram-negative bacteria. As a composite, the isolates displayed high resistance to the antibiotics tested—amoxicillin (89.3%), tetracycline (76.1%), trimethoprim-sulfamethoxazole (71.5%), and chloramphenicol (59.7%). Resistance to third-generation cephalosporins [ceftriaxone (73.7%), cefotaxime (77.8%), and ceftazidime (56.3%)] and fluoroquinolones [ciprofloxacin (55.3%)] was also high; 88% of the isolates were multidrug resistant, and the rate of extended-spectrum beta-lactamase (ESBL) production was 44.6%. Antibiotic resistance in K. pneumoniae followed the pattern of all Gram-negative isolates. Antibiotic resistance was lower in NTS blood isolates, ranging between 16.7–38.9% resistance to the tested antibiotics. Resistance rates of 38.9%, 22.2%, and 27.8% were found for cefotaxime, ceftriaxone, and ceftazidime, respectively, and 27.8% and 23.8% for ciprofloxacin and azithromycin, respectively, which are used in the treatment of invasive NTS. The prevalence of multidrug resistance in NTS isolates was 38.9%. Conclusions: Multicenter AMR surveillance of Gram-negative blood isolates from febrile patients was well-received in Ghana, and the implementation of a harmonized protocol was feasible. High resistance and multidrug resistance to first- or second-choice antibiotics, including penicillins, third-generation cephalosporins, and fluoroquinolones, were found, implying that these antibiotics might have limited effectiveness in BSI treatment in the country. Continuation of AMR surveillance in Gram-negative blood isolates is essential for a better understanding of the extent of AMR in these pathogens and to guide clinical practice and policymaking.

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  • MDR prevalence was 17.6% for Shigella spp., 78.4% for Vibrio cholerae, 88% for K. pneumoniae, 89.5% for P. aeruginosa, and 100% for A. baumannii.

    “MDR prevalence of 17.6%, 78.4%, 88%, 89.5% and 100% were reported for Shigella spp. [17], Vibrio cholerae [26], K. pneumoniae [35], P. aeruginosa [28], and A. baumannii [30], respectively.”

    From A Systematic Review on Antimicrobial Resistance in Ghana from a One Health Perspective (2024) · cites this paper as [35]

    The Results (§2.3) report 88.0% multidrug resistance among all Gram-negative blood isolates and say that K. pneumoniae had a similar resistance pattern. They do not report 88% MDR prevalence specifically for K. pneumoniae, the only figure attributed to this source in the citing sentence. (LLM, conf=0.87)

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Research works printed but not linked: 46

  1. [1]Laupland K.B. Incidence of bloodstream infection: A review of population-based studies Clin. Microbiol. Infect. 2013 19 492 500 10.1111/1469-0691.12144 23398633 · DOI
  2. [2]Obeng-Nkrumah N. Labi A.-K. Acquah M.E. Donkor E.S. Bloodstream infections in patients with malignancies: Implications for antibiotic treatment in a Ghanaian tertiary setting BMC Res. Notes 2015 8 742 10.1186/s13104-015-1701-z 26628056 PMC4667459 · DOI
  3. [3]Amanati A. Sajedianfard S. Khajeh S. Ghasempour S. Mehrangiz S. Nematolahi S. Shahhosein Z. Bloodstream infections in adult patients with malignancy, epidemiology, microbiology, and risk factors associated with mortality and multi-drug resistance BMC Infect. Dis. 2021 21 636 10.1186/s12879-021-06243-z 34215207 PMC8254331 · DOI
  4. [4]Ginzburg A. Goldstein G. Raviv D. Cohen H. Weinreb S. Harlev D. Nitsan-Luques A. Saoud M.Y.A. Strahilevitz J. Averbuch D. Bacteremia in children with solid tumors: Etiology, antimicrobial susceptibility, factors associated with multidrug resistance, and mortality Microb. Drug Resist. 2022 28 601 610 10.1089/mdr.2021.0256 35363049 · DOI
  5. [5]Pai S. Enoch D.A. Aliyu S.H. Bacteremia in children: Epidemiology, clinical diagnosis and antibiotic treatment Expert Rev. Anti Infect. Ther. 2015 13 1073 1088 10.1586/14787210.2015.1063418 26143645 · DOI
  6. [6]Obeng-Nkrumah N. Labi A.-K. Addison N.O. Labi J.E.M. Awuah-Mensah G. Trends in paediatric and adult bloodstream infections at a Ghanaian referral hospital: A retrospective study Ann. Clin. Microbiol. Antimicrob. 2016 15 49 10.1186/s12941-016-0163-z 27539221 PMC4991019 · DOI
  7. [7]Hattori H. Maeda M. Nagatomo Y. Takuma T. Niki Y. Naito Y. Sasaki T. Ishino K. Epidemiology and risk factors for mortality in bloodstream infections: A single-center retrospective study in Japan Am. J. Infect. Control 2018 46 e75 e79 10.1016/j.ajic.2018.06.019 30172607 · DOI
  8. [8]Tsuzuki S. Matsunaga N. Yahara K. Shibayama K. Sugai M. Ohmagari N. Disease burden of bloodstream infections caused by antimicrobial-resistant bacteria: A population-level study, Japan, 2015–2018 Int. J. Infect. Dis. 2021 108 119 124 10.1016/j.ijid.2021.05.018 33992765 · DOI
  9. [9]De Kraker M.E. Davey P.G. Grundmann H. BURDEN Study Group Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: Estimating the burden of antibiotic resistance in Europe PLoS Med. 2011 8 e1001104 10.1371/journal.pmed.1001104 22022233 PMC3191157 · DOI
  10. [10]Stewardson A.J. Allignol A. Beyersmann J. Graves N. Schumacher M. Meyer R. Tacconelli E. De Angelis G. Farina C. Pezzoli F. The health and economic burden of bloodstream infections caused by antimicrobial-susceptible and non-susceptible Enterobacteriaceae and Staphylococcus aureus in European hospitals, 2010 and 2011: A multicentre retrospective cohort study Eurosurveillance 2016 21 30319 10.2807/1560-7917.ES.2016.21.33.30319 27562950 PMC4998424 · DOI
  11. [11]Schechner V. Wulffhart L. Temkin E. Feldman S.F. Nutman A. Shitrit P. Schwaber M.J. Carmeli Y. One-year mortality and years of potential life lost following bloodstream infection among adults: A nationwide population based study Lancet Reg. Health Eur. 2022 23 100511 10.1016/j.lanepe.2022.100511 36158527 PMC9490098 · DOI
  12. [12]Marchello C.S. Dale A.P. Pisharody S. Rubach M.P. Crump J.A. A systematic review and meta-analysis of the prevalence of community-onset bloodstream infections among hospitalized patients in Africa and Asia Antimicrob. Agents Chemother. 2019 64 e01974-19 10.1128/AAC.01974-19 31636071 PMC7187598 · DOI
  13. [13]Iroh Tam P.Y. Musicha P. Kawaza K. Cornick J. Denis B. Freyne B. Everett D. Dube Q. French N. Feasey N. Emerging resistance to empiric antimicrobial regimens for pediatric bloodstream infections in Malawi (1998–2017) Clin. Infect. Dis. 2019 69 61 68 10.1093/cid/ciy834 30277505 PMC6579959 · DOI
  14. [14]Musicha P. Cornick J.E. Bar-Zeev N. French N. Masesa C. Denis B. Kennedy N. Mallewa J. Gordon M.A. Msefula C.L. Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998–2016): A surveillance study Lancet Infect. Dis. 2017 17 1042 1052 10.1016/S1473-3099(17)30394-8 28818544 PMC5610140 · DOI · Paper page
  15. [15]Cross A. Levine M.M. Patterns of bacteraemia aetiology Lancet Infect. Dis. 2017 17 1005 1006 10.1016/S1473-3099(17)30491-7 28818542 · DOI
  16. [16]Labi A.-K. Obeng-Nkrumah N. Addison N.O. Donkor E.S. Salmonella blood stream infections in a tertiary care setting in Ghana BMC Infect. Dis. 2014 14 3857 10.1186/s12879-014-0697-7 25528352 PMC4297363 · DOI · Paper page
  17. [17]Marks F. von Kalckreuth V. Aaby P. Adu-Sarkodie Y. El Tayeb M.A. Ali M. Aseffa A. Baker S. Biggs H.M. Bjerregaard-Andersen M. Incidence of invasive salmonella disease in sub-Saharan Africa: A multicentre population-based surveillance study Lancet Glob. Health 2017 5 e310 e323 10.1016/S2214-109X(17)30022-0 28193398 PMC5316558 · DOI
  18. [18]Sader H.S. Castanheira M. Streit J.M. Flamm R.K. Frequency of occurrence and antimicrobial susceptibility of bacteria isolated from patients hospitalized with bloodstream infections in United States medical centers (2015–2017) Diagn. Microbiol. Infect. Dis. 2019 95 114850 10.1016/j.diagmicrobio.2019.06.002 31296360 · DOI
  19. [19]Weiner-Lastinger L.M. Abner S. Edwards J.R. Kallen A.J. Karlsson M. Magill S.S. Pollock D. See I. Soe M.M. Walters M.S. Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015–2017 Infect. Control Hosp. Epidemiol. 2020 41 1 18 10.1017/ice.2019.296 31767041 PMC8276252 · DOI
  20. [20]Weiner-Lastinger L.M. Abner S. Benin A.L. Edwards J.R. Kallen A.J. Karlsson M. Magill S.S. Pollock D. See I. Soe M.M. Antimicrobial-resistant pathogens associated with pediatric healthcare-associated infections: Summary of data reported to the National Healthcare Safety Network, 2015–2017 Infect. Control Hosp. Epidemiol. 2020 41 19 30 10.1017/ice.2019.297 31762428 PMC8276251 · DOI
  21. [21]GBD 2017 Non-Typhoidal Salmonella Invasive Disease Collaborators The global burden of non-typhoidal salmonella invasive disease: A systematic analysis for the Global Burden of Disease Study 2017 Lancet Infect. Dis. 2019 19 1312 1324 10.1016/S1473-3099(19)30418-9 31562022 PMC6892270 · DOI · Paper page
  22. [22]Still W.L. Tapia M.D. Tennant S.M. Sylla M. Touré A. Badji H. Keita A.M. Sow S.O. Levine M.M. Kotloff K.L. Surveillance for invasive salmonella disease in Bamako, Mali, from 2002 to 2018 Clin. Infect. Dis. 2020 71 (Suppl. 2) S130 S140 10.1093/cid/ciaa482 32725229 PMC7388721 · DOI
  23. [23]Mandomando I. Macete E. Sigaúque B. Morais L. Quintó L. Sacarlal J. Espasa M. Vallès X. Bassat Q. Aide P. Invasive non-typhoidal Salmonella in Mozambican children Trop. Med. Int. Health 2009 14 1467 1474 10.1111/j.1365-3156.2009.02399.x 19793081 · DOI
  24. [24]Feasey N.A. Dougan G. Kingsley R.A. Heyderman R.S. Gordon M.A. Invasive non-typhoidal salmonella disease: An emerging and neglected tropical disease in Africa Lancet 2012 379 2489 2499 10.1016/S0140-6736(11)61752-2 22587967 PMC3402672 · DOI
  25. [25]Russo T.A. Johnson J.R. Diseases Caused by Gram-Negative Enteric Bacilli Harrison’s Principles of Internal Medicine 20th ed. Jameson J.L. Fauci A.S. Kasper D.L. Hauser S.L. Longo D.L. Loscalzo J. McGraw-Hill Education/Medical New York, NY, USA 2018
  26. [26]Lee C.-R. Lee J.H. Park K.S. Jeon J.H. Kim Y.B. Cha C.-J. Jeong B.C. Lee S.H. Antimicrobial resistance of hypervirulent Klebsiella pneumoniae: Epidemiology, hypervirulence-associated determinants, and resistance mechanisms Front. Cell. Infect. Microbiol. 2017 7 483 10.3389/fcimb.2017.00483 29209595 PMC5702448 · DOI
  27. [27]Liu C. Guo J. Hypervirulent Klebsiella pneumoniae (hypermucoviscous and aerobactin positive) infection over 6 years in the elderly in China: Antimicrobial resistance patterns, molecular epidemiology and risk factor Ann. Clin. Microbiol. Antimicrob. 2019 18 4 10.1186/s12941-018-0302-9 30665418 PMC6341648 · DOI
  28. [28]Seale A.C. Gordon N. Islam J. Peacock S.J. Scott J.A.G. AMR Surveillance in low and middle-income settings—A roadmap for participation in the Global Antimicrobial Surveillance System (GLASS) Wellcome Open Res. 2017 2 92 10.12688/wellcomeopenres.12527.1 29062918 PMC5645727 · DOI
  29. [29]Collaborators A.R. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis Lancet 2022 399 629 655 35065702 PMC8841637
  30. [30]Murray C.J. Ikuta K.S. Sharara F. Swetschinski L. Aguilar G.R. Gray A. Han C. Bisignano C. Rao P. Wool E. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis Lancet 2022 399 629 655 10.1016/S0140-6736(21)02724-0 35065702 PMC8841637 · DOI · Paper page
  31. [31]O’Neill J. Tackling Drug-Resistant Infections Globally: Final Report and Recommendations 2016 Available online: https://amr-review.org/sites/default/files/160518_Final%20paper_with%20cover.pdf (accessed on 1 May 2020)
  32. [32]O’Neill J. “Review on Antimicrobial Resistance.” Antimicrobial Resistance: Tackling a Crisis for the Health and Wealth of Nations 2014 Available online: https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf (accessed on 16 November 2021)
  33. [33]Simonsen G.S. Tapsall J.W. Allegranzi B. Talbot E.A. Lazzari S. The antimicrobial resistance containment and surveillance approach--a public health tool Bull. World Health Organ. 2004 82 928 934 15654407 PMC2623104
  34. [34]Dar O.A. Hasan R. Schlundt J. Harbarth S. Caleo G. Dar F.K. Littmann J. Rweyemamu M. Buckley E.J. Shahid M. Exploring the evidence base for national and regional policy interventions to combat resistance Lancet 2016 387 285 295 10.1016/S0140-6736(15)00520-6 26603921 · DOI
  35. [35]Laxminarayan R. Duse A. Wattal C. Zaidi A.K.M. Wertheim H.F.L. Sumpradit N. Vlieghe E. Hara G.L. Gould I.M. Goossens H. Antibiotic resistance – the need for global solutions Lancet Infect. Dis. 2013 13 1057 1098 10.1016/S1473-3099(13)70318-9 24252483 · DOI · Paper page
  36. [36]Opintan J.A. Newman M.J. Arhin R.E. Donkor E.S. Gyansa-Lutterodt M. Mills-Pappoe W. Laboratory-based nationwide surveillance of antimicrobial resistance in Ghana Infect. Drug Resist. 2015 8 379 389 10.2147/IDR.S88725 26604806 PMC4655947 · DOI
  37. [37]Opintan J.A. Newman M.J. Prevalence of antimicrobial resistant pathogens from blood cultures: Results from a laboratory based nationwide surveillance in Ghana Antimicrob. Resist. Infect. Control 2017 6 64 10.1186/s13756-017-0221-0 28630688 PMC5470323 · DOI
  38. [38]Kohli R. Omuse G. Revathi G. Antibacterial susceptibility patterns of blood stream isolates in patients investigated at the Aga Khan University Hospital, Nairobi East Afr. Med. J. 2010 87 74 80 10.4314/eamj.v87i2.60592 23057259 · DOI
  39. [39]Toy T. Pak G.D. Duc T.P. Campbell J.I. El Tayeb M.A. Von Kalckreuth V. Im J. Panzner U. Cruz Espinoza L.M. Eibach D. Multicountry distribution and characterization of extended-spectrum beta-lactamase-associated Gram-negative bacteria from bloodstream infections in sub-Saharan Africa Clin. Infect. Dis. 2019 69 (Suppl. 6) S449 S458 10.1093/cid/ciz450 31665776 PMC6821266 · DOI
  40. [41]Lester R. Musicha P. van Ginneken N. Dramowski A. Hamer D.H. Garner P. Feasey N.A. Prevalence and outcome of bloodstream infections due to third-generation cephalosporin-resistant Enterobacteriaceae in sub-Saharan Africa: A systematic review J. Antimicrob. Chemother. 2020 75 492 507 10.1093/jac/dkz464 31742611 PMC7021093 · DOI
  41. [42]Tack B. Vanaenrode J. Verbakel J.Y. Toelen J. Jacobs J. Invasive non-typhoidal Salmonella infections in sub-Saharan Africa: A systematic review on antimicrobial resistance and treatment BMC Med. 2020 18 212 10.1186/s12916-020-01652-4 32677939 PMC7367361 · DOI
  42. [44]Papp-Wallace K.M. Endimiani A. Taracila M.A. Bonomo R.A. Carbapenems: Past, present, and future Antimicrob. Agents Chemother. 2011 55 4943 4960 10.1128/AAC.00296-11 21859938 PMC3195018 · DOI
  43. [45]Legese M.H. Asrat D. Swedberg G. Hasan B. Mekasha A. Getahun T. Worku M. Shimber E.T. Getahun S. Ayalew T. Sepsis: Emerging pathogens and antimicrobial resistance in Ethiopian referral hospitals Antimicrob. Resist. Infect. Control 2022 11 83 10.1186/s13756-022-01122-x 35698179 PMC9195281 · DOI
  44. [46]Labi A.K. Enweronu-Laryea C.C. Nartey E.T. Bjerrum S. Ayibor P.K. Andersen L.P. Newman M.J. Kurtzhals J.A. Bloodstream Infections at two neonatal intensive care units in Ghana: Multidrug resistant Enterobacterales undermine the usefulness of standard antibiotic regimes Pediatr. Infect. Dis. J. 2021 40 1115 1121 10.1097/INF.0000000000003284 34561387 · DOI
  45. [47]Mhondoro M. Ndlovu N. Bangure D. Juru T. Gombe N.T. Shambira G. Nsubuga P. Tshimanga M. Trends in antimicrobial resistance of bacterial pathogens in Harare, Zimbabwe, 2012–2017: A secondary dataset analysis BMC Infect. Dis. 2019 19 746 10.1186/s12879-019-4295-6 31455256 PMC6712611 · DOI
  46. [48]Brink A.J. Epidemiology of carbapenem-resistant Gram-negative infections globally Curr. Opin. Infect. Dis. 2019 32 609 616 10.1097/QCO.0000000000000608 31567571 · DOI

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Authors
Donkor, E. S., Muhsen, K., Johnson, S. A. M., Kotey, F. C. N., Dayie, N. T. K. D., Tetteh-Quarcoo, P. B., Tette, E. M. A., Osei, M.-M., Egyir, B., Nii-Trebi, N. I., Owusu-Okyere, G., Owusu-Ofori, A., Amir, Y., Perlman, S., Lopes, P. H., Mfodwo, A., Gordon, N. C., Gresham, L., Smolinski, M., & Cohen, D.
Affiliations
  • University of Ghana (GH)
  • Tel Aviv University (IL)
  • Department of Medical Microbiology, University of Ghana Medical School, Accra 00233, Ghana
  • Komfo Anokye Teaching Hospital (GH)
  • Mott MacDonald (United Kingdom) (GB)
  • Ending Pandemics, San Francisco, CA 94102, USA
Corresponding author
Cohen, Dani
ORCID
Venue
Antibiotics
Publisher
MDPI AG
Published
2023-01-27
Volume
12
Issue
2
Pages
255
ISSN
2079-6382 (ISSN-L)
DOI
10.3390/antibiotics12020255
PMC
PMC9951917
OpenAlex
W4318479227
Cited by
46
References
0
Citations by year
2026: 10 · 2025: 16 · 2024: 13 · 2023: 7
FWCI
3.93
Type
journal article
Language
en
Open access
Licence
Locations
  • Antibiotics (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
The Fleming Fund (FF49/440)
Topics
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Medicine › Antibiotic Resistance in Bacteria
  • Life Sciences › Immunology and Microbiology › Applied Microbiology and Biotechnology › Antibiotic Use and Resistance
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Clinical Biochemistry › Bacterial Identification and Susceptibility Testing
Keywords
antimicrobial resistance, Gram-negative bacteria, bloodstream infection, Klebsiella pneumoniae, non-typhoidal Salmonella, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, multidrug resistance, extended-spectrum beta-lactamase, third-generation cephalosporin resistance, fluoroquinolone resistance, amoxicillin resistance, tetracycline resistance, trimethoprim-sulfamethoxazole resistance

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