Antimicrobial resistance preparedness in sub-Saharan African countries

Knowledge and perception on antimicrobial resistance and antibiotics prescribing attitude among physicians and nurses in Lambaréné region, Gabon: a call for setting-up an antimicrobial stewardship program

Background

Africa is challenged by the emergence of antimicrobial resistance (AMR). In order to improve patient management and to optimise approaches to curb the spread of antimicrobial resistance, we examined knowledge and perceptions of AMR and antibiotics prescription practices of HCW (healthcare workers) in Lambaréné, Gabon.

Methods

We conducted a self-administered, questionnaire-based survey in HCW at the regional referral hospital, a medical research centre, and peripheral health care facilities. The proportions of correct responses to questions were determined and compared between physicians and nurses using Fisher’s Exact test.

Results

A total of 47 HCW took part in the survey. Of those, 64% (30/47) recognised antibiotic resistance as a major public health issue in Gabon, but only 14/47 (30%) recognised it as a problem in their health facility. Of note, 37/47 (79%) recognised excessive use of antibiotics without microbiological confirmation in case of infection, and buying antibiotics without a prescription, as possible cause of antimicrobial resistance. Some HCW (28%; 13/47) reported having prescribed antibiotics because the patients asked for them; and a total of 15/47 (32%) responded that antibiotics could help patients recover faster when added to malaria treatment. Compared to nurses, most of the physicians recognised that excessive use of antibiotics without microbiological confirmation of infection could contribute to AMR spread (18/19 (95%) vs 19/28 (68%); p = 0.028).

Conclusion

Most HCW recognised AMR as public health issue. However, a quarter of the participants did not know about the causes fostering the emergence of antimicrobial resistance. There is a need to perform regular HCW training in antimicrobial prescription, and to set up an antimicrobial stewardship program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01079-x.

Assessing transparency and accountability of national action plans on antimicrobial resistance in 15 African countries

BACKGROUND

Antimicrobial resistance (AMR) poses an increasing public health threat to low- and lower-middle income countries. Recent studies found that in fact poor governance and transparency correlate more strongly with AMR than factors such as antibiotic use. While many African countries now have national action plans (NAPs) on AMR, it is unclear whether information is publicly available on their implementation, surveillance and financing.

METHODS

Here, the transparency of information related to AMR national action plans in 15 African countries is assessed, based on a governance framework for AMR action plans. Public availability is assessed for AMR documents, progress reports, AMR surveillance data, budget allocations, as well as bodies and persons responsible for implementation of NAPs. Government websites and search engines were perused using search terms related to the studied criteria and countries.

RESULTS

Results show that most countries have a national action plan publicly available. AMR surveillance data was available for a few countries, but systematic progress reports and funding allocations were absent in all but one country. Information on a body mandated to coordinate NAP implementation was available for most countries, but their functionality remain unclear. Most countries have nominated at least one person responsible for AMR nationally. In general, information was often fragmented and frequently available on external, non-government websites. It appears that commitments on AMR made in the often comprehensive NAPs are rarely met in a timely manner, exhibiting rather weak accountability for AMR results. The article provides concrete policy recommendations on how transparency and accountability may be improved with little effort.

CONCLUSIONS

Making information available can enable stakeholders such as civil society to demand accountability for results and lead to much needed specific actions on curbing AMR in countries.

Comparison of national antimicrobial treatment guidelines, African Union

Objective

To identify and compare antimicrobial treatment guidelines from African Union (AU) Member States.

Methods

We reviewed national government agency and public health institutes’ websites and communicated with country or regional focal points to identify existing treatment guidelines from AU Member States. We included guidelines if they contained disease-, syndrome- or pathogen-specific treatment recommendations and if those recommendations included antimicrobial name or class, dosage and therapy duration. The scope of the review was limited to infections and clinical syndromes that often have a bacterial cause. We assessed treatment guidelines for alignment with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. We compared treatment recommendations for various common bacterial infections or clinical syndromes described across national guidelines and those described in three World Health Organization guidelines.

Findings

We identified 31 treatment guidelines from 20 of the 55 (36%) AU Member States; several countries had more than one treatment guideline that met our inclusion criteria. Fifteen (48%) guidelines from 10 countries have been published or updated since 2015. Methods used to develop the guidelines were not well described. No guidelines were developed according to the GRADE approach. Antimicrobial selection, dosage and duration of recommended therapies varied widely across guidelines for all infections and syndromes.

Conclusion

AU Member States lack antimicrobial treatment guidelines that meet internationally accepted methods and that draw from local evidence about disease burden and antimicrobial susceptibility.

Antimicrobial resistance national level dialogue and action in Ghana: setting and sustaining the agenda and outcomes

BACKGROUND

Antimicrobial resistance (AMR) has gained national and international attention. The design and launch of national policy on antimicrobial use and resistance and action plan marked a milestone in Ghana's commitment to control AMR. These strategies are some outcomes of getting and sustaining AMR issues prominence on government's agenda. Understanding the agenda setting processes, policy actors involved and policy change is important as this provides insights on how and why policy actors defined and framed AMR issues to sustain its prominence despite the changing priorities of government agenda.

OBJECTIVE

To examine the processes of setting and sustaining AMR issues on government agenda, the policy actors involved and resulting outcomes.

METHODS

A qualitative study was conducted and data collected through interviewing twenty-four respondents and reviewing technical working group meeting reports and health sector documents. Data was analysed drawing on Kingdon's agenda setting framework.

RESULT

Members of a multisectoral technical working group (AMR platform) formed in 2011 constantly built consensus on AMR problem definition, solutions and actively engaged decision makers to mobilise support and interest. The AMR platform members sustained AMR attention and prominence on government's agenda through the following multisectoral coordination mechanisms: (1) institutionalising AMR platform activities (2) gathering evidence, sharing findings, and supporting research (3) creating awareness and training (4) gaining and maintaining political support. The activities of the AMR platform contributed to three remarkable outcomes and these are (1) maintained network of AMR Champions, (2) design of a national policy on antimicrobial use and resistance in Ghana (1st edition) and national action plan (2017-2021), and (3) Ghana's hosting of the second Global call to action on AMR.

CONCLUSION

The AMR platform members as influencers concentrated their efforts to move and sustain AMR issues on government agenda. The identified multisectoral coordination mechanisms collectively contributed to agenda setting processes and policy change. The AMR platform engagements are ongoing and it is important the momentum is maintained. As multisectoral coordination and activities are vital especially for AMR 'One Health' approach, we hope this paper presents lessons for better understanding of how and why multisectoral groups influence national level agenda setting processes.

What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus?

The differential spread and impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causing Coronavirus Disease 2019 (COVID-19), across regions is a major focus for researchers and policy makers. Africa has attracted tremendous attention, due to predictions of catastrophic impacts that have not yet materialized. Early in the pandemic, the seemingly low African case count was largely attributed to low testing and case reporting. However, there is reason to consider that many African countries attenuated the spread and impacts early on. Factors explaining low spread include early government community-wide actions, population distribution, social contacts, and ecology of human habitation. While recent data from seroprevalence studies posit more extensive circulation of the virus, continuing low COVID-19 burden may be explained by the demographic pyramid, prevalence of pre-existing conditions, trained immunity, genetics, and broader sociocultural dynamics. Though all these prongs contribute to the observed profile of COVID-19 in Africa, some provide stronger evidence than others. This review is important to expand what is known about the differential impacts of pandemics, enhancing scientific understanding and gearing appropriate public health responses. Furthermore, it highlights potential lessons to draw from Africa for global health on assumptions regarding deadly viral pandemics, given its long experience with infectious diseases.

An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: A roadmap for action

INTRODUCTION

The Global Action Plan (GAP) on antimicrobial resistance (AMR) delivers a 'One Health' strategy for the development of the national action plan. It encourages the optimal use of antimicrobials and strengthens the evidence base through surveillance and research.

METHODS

This study evaluated the current status of implementation of the GAP on AMR in World Health Organization (WHO) African countries via a retrospective, cross-sectional analysis of routinely collected data on AMR. A SWOT analysis was used to identify the strengths, weaknesses, opportunities and threats involved in the GAP implementation. A roadmap for action was proposed.

RESULTS

The overall mean GAP performance score across all the countries that were assessed was 32% ± SD12 (95% CI 27-36%). The mean thematic scores were 59% ± 12 (53-65%) for multi-sector and One Health collaboration; 50% ± 22 (42-58%) for developing national AMR action plans; 38% ± 12 (33-42%) for awareness and training; 18% ± 13 (13-23%) for surveillance; 33% ± 13 (29-38%) for infection prevention and control; and 28% ± 23 (20-37%) for optimal use of antimicrobial medicines in human, animal and plant health. The difference in GAP performance scores between African sub-regions and between income categories was not statistically significant (P > 0.05). While seven countries exhibited strengths in two themes, 25 countries exhibited weaknesses across all themes. Six threats and six opportunities were identified to inform a practical roadmap for AMR action.

CONCLUSION

The findings from this study indicate that the overall GAP implementation on AMR in the WHO African region is inadequate. Some thematic GAP scores appeared to be relatively good, but on closer inspection, individual indicators revealed a lack of progress and implementation, requiring action.

Strengthening capacity for clinical research in sub-Saharan Africa: partnerships and networks

Global research collaboration, through partnerships and networks, is an effective way to deliver highly impactful and sustainable research that is collectively owned and promoted for the global good. Many models exist for effective North-South collaborations that are built on trust and balanced benefits. The European & Developing Countries Clinical Trials Partnership (EDCTP) model emphasises capacity development in clinical trials and product-focused implementation research. To ensure effectiveness and sustainability, capacity development requires a long-term perspective, an integrated system-wide approach, and local ownership and leadership from countries experiencing high disease burdens. Guided by these principles, the EDCTP2 programme, established in 2014, has developed and strengthened human capital and institutional capacities in 39 countries in sub-Saharan Africa to undertake high-quality clinical research guided by good clinical and regulatory practices. Projects in these countries have involved 238 African and 163 European institutions. To date, EDCTP has supported 171 Fellows and 232 postgraduate trainees. EDCTP-short-term training activities have equipped 9628 researchers and medical personnel. The EDCTP capacity-building described here includes its Regional Networks of Excellence and its Consortia for public health emergencies which provide the foundation for sustained efforts against emerging and re-emerging global health threats.

Antimicrobial resistance patterns of bacterial pathogens their distribution in university teaching hospitals in Zambia

Aim: To determine the antimicrobial resistance patterns of bacterial pathogens from urine, blood and wound infections and their distribution by age, sex and location. Materials & methods: A total of 49,168 samples were collected, processed and analyzed. Results: Multidrug resistance was observed in almost all bacterial pathogens in blood urine and wound swabs. In urine and females odds ratio (OR) = 0.864, p = 0.023, OR = 0.909, p = 0.013 urine and neonates were susceptible to antibiotics OR = 0.859, p = 0.003, OR = 0.741, p < 0.001. Ampicillin resistance was above 90% against Escherichia coli in blood, urine and wound swabs. Conclusion: There was a spike in resistance to imipenem, ciprofloxacin and ampicillin against E. coli, Klebsiella pneumoniae, Proteus mirabilis and Proteus species from all three specimen sources.

Antimicrobial resistance in Ethiopia: A systematic review and meta-analysis of prevalence in foods, food handlers, animals, and the environment

Antimicrobial resistance (AMR) has been recognized as one of the greatest global threats for human and animal health. The present review retrieved up to date information on the epidemiology of AMR in the animal-source food chain in Ethiopia focusing on AMR in bacterial species isolated from food handlers, live animals, foods (animal origin and non-animal origin), and in environmental samples. Accordingly, pooled prevalence of AMR in the different sources was estimated. For data analysis, we used random effect meta-analysis and in order to avoid exclusion of studies with zero prevalence of antimicrobial resistance, Freeman-Tukey double arcsine transformation was applied. We identified 152 eligible studies and retrieved 4097 data records (183 in food handlers, 2055 in foods, 1040 in live animals and 819 for environmental samples) which together reported a total of 86,813 AMR tests with 64 different antimicrobial disks for 81 bacteria species. We present the pooled prevalence of AMR for major bacterium-antibiotic combination in different sample types. The pooled prevalence of AMR in bacteria from food producing live animals was 20%. High estimates of AMR pooled prevalence were found in bacteria identified from milk, food handlers and the environmental samples with 29%, and 28% in meat. In foods of non-animal origin, the prevalence was lower with 13%. In milk, the highest AMR estimate was found for penicillin (69%) followed by amoxicillin (51%). Regarding multi-drug resistance (MDR), the overall pooled prevalence was 74% among AMR positive samples. Microbes reported having a higher MDR pattern were: Staphylococcus spp. (96%), Salmonella spp. (81%) and Escherichia coli (77%). The present review revealed a high resistance against commonly used drugs for animal and human treatments and/or prophylaxis. In conclusion, the high estimate of prevalence of AMR observed in bacteria recovered from different sample sources related to the animal-source food chain (food, live animal and environment) can highlight the possible linkage among them. The MDR levels in several bacteria species are a clear indication that the threat is directed to many antimicrobials. Our review demonstrated that the high overall AMR resistance levels call for effective policy and intervention measures, which best address the problem along the food chain through a One Health approach.

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Meta-analysis of antimicrobial resistance conducted from One Health perspectives.

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Pooled prevalence of AMR for bacterium-antibiotic combination in different sample was reported.

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Comparable high AMR prevalence estimates were found from milk, food handler and the environment.

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MDR prevalence was 74%, and higher estimate in E. coli, Staphylococcus, Salmonella and Shigella.

Antibiotic Practices, Perceptions and Self-Medication Among Patients at a National Referral Hospital in Uganda

Background

Antimicrobial resistance (AMR) is a major global health concern with increasing reports of microorganisms resistant to most of the available antibiotics. There are limited data on antibiotic practices, perceptions and self-medication among Ugandans, necessitating this study.

Methods

A cross-sectional study was conducted among patients at Kiruddu National Referral Hospital, Kampala, Uganda. A pre-tested interviewer administered a questionnaire that was used to collect data after an informed consent. Chi-square tests and logistic regression were used to assess associations between outcome and exposure variables. A P<0.05 was statistically significant.

Results

A total of 279 patients (response rate=71%) with a median age of 32 years participated in the study. The majority were females (55.6%, n=155) and from the outpatient department (74.9%, n=209). Overall, 212 (76%) participants had taken an antibiotic in the past 6 months, and some 22.2% (n=47) of the participants had practiced self-medication. Male participants (adjusted odds ratio (aOR)=2.13, 95% confidence intervals (CI): 1.01 to 4.50, P=0.046) and Muslims (aOR=4.37, 96% CI:1.54 to 12.44, P=0.006) were more likely to self-medicate. Employees (aOR=0.06, 95% CI:0.01 to 0.51, P=0.010) and patients with tertiary education (aOR=0.14, 95% CI: 0.02 to 0.81, P=0.028) were less likely to practice self-medication. About 33% (n=70) of the participants had not completed treatment dosage during their last course of antibiotic treatment because of feeling better (60%, n=42), lack of money to purchase the medication (15.7%, n=11) and side effects (10%, n=7). Whereas 169 participants (79.7%) believed that not completing treatment would have an impact on their personal health, only 96 participants (45.3%) believed that this behaviour could affect the health of others.

Conclusion

Antibiotic misuse is significant among patients in Uganda. Continuous health education programs aimed at informing the public on antimicrobial resistance, and its dangers are recommended to curtail this challenge.

Comparative assessment of the prevalence, practices and factors associated with self-medication with antibiotics in Africa

OBJECTIVE

To evaluate and compare the prevalence, reasons, sources and factors associated with self-medication with antibiotics (SMA) within Africa.

METHODS

Systematic review and meta-analysis. An electronic search of PubMed and Google Scholar databases was performed for observational studies conducted between January 2005 and February 2020. Two reviewers independently screened abstracts and full texts using the PRISMA flowchart and performed quality assessment of eligible studies. Both qualitative and quantitative syntheses were carried out.

RESULTS

Forty studies from 19 countries were eligible for qualitative synthesis. The prevalence of SMA in Africa ranged from 12.1% to 93.9% with a median prevalence of 55.7% (IQR 41-75%). Western Africa was the sub-region with the highest reported prevalence of 70.1% (IQR 48.3-82.1%), followed by Northern Africa with 48.1% (IQR 41.1-64.3%). We identified 27 antibiotics used for self-medication from 13 different antibiotic classes. Most frequently used antibiotics were penicillins (31 studies), tetracyclines (25 studies) and fluoroquinolones (23 studies). 41% of these antibiotics belong to the WHO Watch Group. The most frequent indications for SMA were upper respiratory tract infections (27 studies), gastrointestinal tract symptoms (25 studies) and febrile illnesses (18 studies). Common sources of antibiotics used for self-medication were community pharmacies (31 studies), family/friends (20 studies), leftover antibiotics (19 studies) and patent medicine stores (18 studies). The most frequently reported factor associated with SMA was no education/low educational status (nine studies).

CONCLUSIONS

The prevalence of SMA is high in Africa and varies across sub-regions with the highest prevalence reported in Western Africa. Drivers of SMA are complex, comprising of socio-economic factors and insufficient access to health care coupled with poorly implemented policies regulating antibiotic sales.

Zoonotic disease preparedness in sub-Saharan African countries

BACKGROUND

The emergence of high consequence pathogens such as Ebola and SARS-CoV-2, along with the continued burden of neglected diseases such as rabies, has highlighted the need for preparedness for emerging and endemic infectious diseases of zoonotic origin in sub-Saharan Africa (SSA) using a One Health approach. To identify trends in SSA preparedness, the World Health Organization (WHO) Joint External Evaluation (JEE) reports were analysed. JEEs are voluntary, collaborative processes to assess country's capacities to prevent, detect and rapidly respond to public health risks. This report aimed to analyse the JEE zoonotic disease preparedness data as a whole and identify strengths and weaknesses.

METHODS

JEE zoonotic disease preparedness scores for 44 SSA countries who had completed JEEs were analysed. An overall zoonotic disease preparedness score was calculated as an average of the sum of all the SSA country zoonotic disease preparedness scores and compared to the overall mean JEE score. Zoonotic disease preparedness indicators were analysed and data were collated into regions to identify key areas of strength.

RESULTS

The mean 'Zoonotic disease' preparedness score (2.35, range 1.00-4.00) was 7% higher compared to the mean overall JEE preparedness score (2.19, range 1.55-3.30), putting 'Zoonotic Diseases' 5th out of 19 JEE sub-areas for preparedness. The average scores for each 'Zoonotic Disease' category were 2.45 for 'Surveillance Systems', 2.76 for 'Veterinary Workforce' and 1.84 for 'Response Mechanisms'. The Southern African region scored highest across the 'Zoonotic disease' categories (2.87).A multisectoral priority zoonotic pathogens list is in place for 43% of SSA countries and 70% reported undertaking national surveillance on 1-5 zoonotic diseases. 70% of SSA countries reported having public health training courses in place for veterinarians and 30% had veterinarians in all districts (reported as sufficient staffing). A multisectoral action plan for zoonotic outbreaks was in place for 14% countries and 32% reported having an established inter-agency response team for zoonotic outbreaks. The zoonotic diseases that appeared most in reported country priority lists were rabies and Highly Pathogenic Avian Influenza (HPAI) (both 89%), anthrax (83%), and brucellosis (78%).

CONCLUSIONS

With 'Zoonotic Diseases' ranking 5th in the JEE sub-areas and a mean SSA score 7% greater than the overall mean JEE score, zoonotic disease preparedness appears to have the attention of most SSA countries. However, the considerable range suggests that some countries have more measures in place than others, which may perhaps reflect the geography and types of pathogens that commonly occur. The category 'Response Mechanisms' had the lowest mean score across SSA, suggesting that implementing a multisectoral action plan and response team could provide the greatest gains.

The Governance and Implementation of the National Action Plan on Antimicrobial Resistance in Tanzania: A Qualitative Study

Tanzania launched its first National Action Plan (NAP) on antimicrobial resistance (AMR) in 2017 to reduce the burden of AMR in the country and contribute to the global response. We aimed to analyze the implementation of the NAP on AMR in Tanzania using the governance framework. In-depth interviews were conducted with human and animal health practitioners and national-level policy actors. We adapted Chua's AMR governance framework to analyze the development and implementation of the NAP in Tanzania. Implementation of the NAP has realized several achievements, including: (i) the establishment of a functioning Multi-Sectoral Coordinating Committee for coordinating the implementation of AMR activities; (ii) existence of governance structure; (iii) establishment of human and animal surveillance sites; (iv) creation of AMR awareness in the community and (v) availability of guidelines at the health facility level to ensure AMR stewardship. However, some dimensions of the governance areas, including reporting and feedback mechanisms, accountability, transparency and sustainability of AMR plans, are not effectively implemented. Addressing these challenges should involve strengthening the collaboration of the different sectors involved at different NAP implementation levels by careful planning and coordination, and provision of adequate resources to ensure sustainability.

Antibiotics Use in Food Animal Production: Escalation of Antimicrobial Resistance: Where Are We Now in Combating AMR?

The use of antibiotics has been very beneficial to human health, animal wellbeing, and food production, however, there are no alternatives to antimicrobials in treating infectious diseases. Their use can contribute to the development of antimicrobial resistance, but the world has realized the need to combat antimicrobial resistance in recent decades due to the continued escalation of the problem jeopardizing human and veterinary medicine and food and environmental safety. Understanding the AMR and judicious use of antimicrobials are critical, and one health approach involving several sectors and multiple disciplines is important to tackle the problem. National, regional, and global action plans have been instigated to tackle the escalation of AMR. Antimicrobials are frequently used in food animal production. Therefore, food animal producers are important participants to prevent overuse and misuse of antimicrobials. Recent regulations to address the challenges have not been perceived well in animal farming communities. More awareness regarding these action plans and understanding the impact of AMR are needed. A nationwide survey of perceptions of food animal producers regarding AMR mitigation approaches should be conducted to evaluate the effectiveness of the current policies regarding antibiotics use and AMR. These outcomes should be incorporated in future policies and awareness campaigns targeting food animal producers.

Antimicrobial Stewardship Programmes in Saudi Hospitals: Evidence from a National Survey

Saudi hospitals and healthcare facilities are facing increasing rates of antimicrobial resistance and the emergence of new multi-drug resistant strains. This is placing an unprecedented threat to successful treatments and outcomes of patients accessing those facilities. The inappropriate use of antimicrobials is fueling this crisis, warranting urgent implementation of interventions to preserve antimicrobials and reduce resistance rates. Antimicrobial stewardship programmes (ASPs) can improve antimicrobial use, treatment success rates and reduce the levels of antimicrobial resistance. The Saudi Ministry of Health (MOH) devised a national antimicrobial stewardship plan to implement ASPs in hospitals, but little is known about the progress of implementation and the factors affecting it. This study aims to assess the level and the factors affecting the adoption and implementation of ASPs in Saudi hospitals at a national level. A nationwide cross-sectional survey was conducted in 2017 using an online questionnaire sent to all MOH hospitals. Overall, 147 out 247 MOH hospitals responded to the survey (54%). Only 26% of the hospitals reported the implementation of ASPs. Hospitals lack the knowledge, technological and staff resources to adopt and implement ASPs. Alternative models of ASP adoption could be explored to improve the rates of implementation of ASPs.

High prevalence of antibiotic-resistant Escherichia coli in Congolese students

BACKGROUND

Antimicrobial resistance (AMR) is of growing concern worldwide, and the AMR status in sub-Saharan Africa (SSA), including the Republic of the Congo, is largely undetermined due to a lack of real-time monitoring. As the incidence of multi-resistant Escherichia coli has been increasing in recent years, an investigation was performed to determine the antibiotic resistance of E. coli isolated from stool samples of Congolese students. Furthermore, factors associated with the carriage of resistant bacteria were investigated.

METHODS

A total of 339 stool samples from 339 high school students living in the Madibou area of Brazzaville, Republic of Congo, were tested for E. coli. Isolates obtained were tested for susceptibility to 10 antibiotics that are widely used in the region.

RESULTS

One hundred and seventy-three (51%) individuals were E. coli-positive in stool, with 61% being female students. Antimicrobial resistance was highest for ceftazidime (65%), followed by amoxicillin (57%), piperacillin-tazobactam (51%), ofloxacin (11%), azithromycin (8%), ciprofloxacin (4%), nalidixic acid (2%), and amoxicillin-clavulanic acid (1%). Antibiotic procurement from non-legalized local vendors had a significant impact on E. coli positivity and antibiotic resistance when compared to procurement from state-licensed pharmacies (p < 0.05).

CONCLUSIONS

The high prevalence of resistant commensal E. coli in the community justifies further investigation and urges the need for routine monitoring of antimicrobial susceptibility testing in the region.