Bacterial Infections and Their Antibiotic Resistance Pattern in Ethiopia: A Systematic Review

Assessment of challenges and opportunities in antibiotic stewardship program implementation in Northwest Ethiopia

Background

Indiscriminate use of antibiotics leads to antibiotic resistance (AMR) and results in mortality, morbidity, and financial burden. Antibiotic stewardship programs (ASPs) with education can resolve a number of barriers recognized in the implementation of successful ASPs. The aim of this study was to assess health professionals' perceptions and status of ASPs in hospitals in 2022.

Methods

A cross-sectional study was conducted from September 1, 2022 to October 30, 2022. A total of 181 health professionals were included, and a self-administered questionnaire was used to collect data. The status of hospitals was assessed using a checklist. The data were analyzed using SPSS version 23, and descriptive statistics and Chi-square tests (X2) at a P-value of <0.05 were used.

Results

Of the 181 respondents, 163 (90.1 %), and 161 (89.0 %) believed that AMR is a significant problem in Ethiopia and globally, respectively. Easy access to antibiotics 155 (85.6 %), and inappropriate use 137 (75.7 %) were perceived as key contributors to AMR. Antibiotics were believed to be prescribed/dispensed without laboratory results 86 (47.5 %), and antibiotic susceptibility patterns were not considered to guide empiric therapy 81 (44.8 %). ASP was believed to reduce the duration of hospital stays and associated costs 137 (75.7 %), and improve the quality of patient care 133 (73.5 %), whereas 151 (83.4 %), 143 (79 %), and 142 (78.5 %) suggested education, institutional guidelines, and prospective audits with feedback interventions to combat AMR in their hospitals, respectively. There were significant differences in perception among professionals based on professional category and attempts by hospitals to implement ASPs. Although ASPs were not functioning according to standard, there have been attempts to implement it in three hospitals. The issue of ASP had never been heard in general hospitals. Currently, it is feasible to implement ASPs in four hospitals.

Conclusion

The status of ASP in hospitals was very poor. Despite a lack of prior knowledge on ASPs, most respondents do have a positive perception of AMR and the implementation of ASPs. Pharmacist-led prospective audits and feedback with education and institutional guidelines for empiric antibiotic use can be better implemented in hospitals. Involvement of representatives from infection prevention and control, and collaboration among hospitals in ASP implementation will help establish a strong ASP in the area.

Bacterial etiology, antimicrobial resistance and factors associated with community acquired pneumonia among adult hospitalized patients in Southwest Ethiopia

Background and Objectives

Antibiotic resistance is a significant problem that restricts the options for treating bacterial pneumonia. This research aimed to determine the bacterial causes of pneumonia and antibiotic resistance among hospitalized patients in southwest Ethiopia.

Materials and Methods

We collected and analyzed 150 sputum samples from individuals with community-acquired pneumonia from April 1st to October 30th, 2019. Standard bacteriological procedures were used to identify the bacteria. Kirby Bauer's disk diffusion method was used to assess the bacteria's susceptibility patterns. Production of carbapenemase and extended-spectrum-lactamase were confirmed phenotypically. Odds ratios and the chi-square test were computed.

Results

On the whole, bacterial pathogens were verified in 50% of the sputum samples. The predominant bacterial isolates were Klebsiella species, followed by Pseudomonas aeruginosa, Staphylococcus aureus and Streptococcus pneumoniae. About 77.5% of isolates were multidrug resistant. Moreover, 40.5% and 10.8% of the isolates were ESBL and carbapenemase producers, respectively. Aging, tobacco smoking, previous history of pneumonia, heart disease, and chronic respiratory disease had association with sputum culture-positivity.

Conclusion

As a result, it is important to regularly monitor the bacterial etiologies and their patterns of resistance. Additionally, sociodemographic and clinical characteristics should all be taken into account while managing patients with pneumonia empirically in this context.

A study of bacteriocin like substances comparison produced by different species of Bacillus related to B. cereus group with specific antibacterial activity against foodborne pathogens

The antibiotic-resistant bacteria are emerging as a great threat worldwide. For this reason it is important to develop new antibiotic substances. Bacillus is considered as a factory of a wide range of chemical compounds with a variety of activities. Among these substances are bacteriocins which are small peptides showing stability in a wide range of pH and temperatures and having a potent antibacterial activity. Bacillus species can be grouped into families such as B. cereus group based on their genetic similarity. It can be helpful to study the bacteriocins presented in these related species identifying the differences and similarities between them to relate the presence of a given bacteriocin with the producer specie. The aim of this study was to isolate the bacteriocins from three related species of B. cereus group such as B. mycoides, B. weihenstephanensis and B. toyonensis and compare among them and with the bacteriocins isolated from B. velezensis. Besides it was analyzed the bactericidal activity of each isolated bacteriocin. Five different bacteriocins of similar molecular mass and specific against foodborne pathogens were isolated from three Bacillus species related to B. cereus group, that were quite different both in molecular mass and bactericidal activity from that was isolated from B. velezensis. The results indicated that bacteriocins can be distinguished according to Bacillus specie from it has been isolated.

High Diversity of emm Types and Marked Tetracycline Resistance of Group A Streptococci and Other ß-Hemolytic Streptococci in Gabon, Central Africa

BACKGROUND

Group A ß-hemolytic streptococcus (GABHS) is a leading pathogen worldwide and post-streptococcal sequelae is a major cause of morbidity and mortality in resource-limited countries. The M protein (coded by the emm gene) is a key virulence factor and a component of GABHS vaccine candidates. As data on BHS in Central Africa are scarce, antibiotic resistance, emm diversity and potential vaccine coverage were investigated.

METHODS

In a prospective cross-sectional study, 1014 Gabonese were screened for streptococcal throat carriage, tonsillopharyngitis and pyoderma by throat and skin smear tests. All BHS were isolated, species were identified and analysis of antibiotic resistance, emm types and emm clusters was performed.

RESULTS

One hundred sixty-five BHS were detected, comprising 76 GABHS, 36 group C ß-hemolytic streptococcus (GCBHS) and 53 group G ß-hemolytic streptococcus (GGBHS) in 140 carrier, 9 tonsillopharyngitis and 16 pyoderma isolates. Eighty percentage of GABHS, 78% of GCBHS and 79% of GGBHS were tetracycline resistant. Forty-six emm types were identified. GABHS emm58, emm65 and emm81 were most prevalent (26%). Emm diversity of GABHS was the highest, GCBHS and GGBHS were less divers. Every second GABHS, every third GCBHS and every tenth GGBHS carrier was colonized with emm types detected in tonsillopharyngitis or pyoderma isolates.

CONCLUSIONS

Tetracycline resistance and emm type diversity was high among BHS carriers in Gabon with a potential coverage of 58% by the 30-valent GABHS vaccine. A relevant overlap of carrier emm types with emm types found in tonsillopharyngitis and pyoderma characterizes a shared pool of circulating BHS strains.

Bacterial Uropathogens, Antimicrobial Susceptibility Profile and Associated Factors among Pediatric Patients in Bahir Dar, Northwest Ethiopia

BACKGROUND

Urinary tract infection (UTI) in the pediatric group may lead to end-stage renal dysfunction later in life. Tracking the type of the isolates and their antimicrobial resistance pattern would impact the management of UTI in these group. The aim of this study was to describe the distribution of bacterial uropathogenes, their antimicrobial susceptibility profile and factors associated with significant bacteriuria (SBU) among pediatric patients at selected facilities in Bahir Dar, Northwest Ethiopia.

METHODS

A cross-sectional study was conducted from 1^st February to 30^th June 2020. About 5-10ml of urine samples were collected from pediatrics presumptive for UTI and a urine sample was considered positive for SBU if a single organism was grown at a concentration of ≥10⁴cfu/ml. Antimicrobial sensitivity testing was performed using the Kirby-Bauer disc diffusion technique. Logistic regression was used to identify factors associated with SBU and statistical significance was set at p-value < 0.05.

RESULTS

Of the total 299 study participants, the majority 173 (57.9%) were females. The mean age of the participants was 6.6 years. The proportion of significant bacteriuria was at 49(16.4%). Most, 37 (75.5%) of the isolates were Gram-negative. The most predominant isolate was E. coli, 21(42.9%) followed by P. aeruginosa, 6(12.2%) and coagulase negative staphylococci, 6(12.2%). The level of multi-drug resistance among Gram-positive and Gram-negatives was at 50% and 78.4%, respectively. Participants' sex, circumcision status, having a flank pain and being malnourished were statistically associated with significant bacteriuria.

CONCLUSION

Actions to minimize antimicrobial resistance should be strengthened to reduce the impact of UTI among the pediatric group.

Streptomycin Sulfate-Loaded Niosomes Enables Increased Antimicrobial and Anti-Biofilm Activities

One of the antibiotics used to treat infections is streptomycin sulfate that inhibits both Gram-negative and -positive bacteria. Nanoparticles are suitable carriers for the direct delivery and release of drug agents to infected locations. Niosomes are one of the new drug delivery systems that have received much attention today due to their excellent biofilm penetration property and controlled release. In this study, niosomes containing streptomycin sulfate were prepared by using the thin layer hydration method and optimized based on the size, polydispersity index (PDI), and encapsulation efficiency (EE%) characteristics. It was found that the Span 60-to-Tween 60 ratio of 1.5 and the surfactant-to-cholesterol ratio of 1.02 led to an optimum formulation with a minimum of size, low PDI, and maximum of EE of 97.8 nm, 0.27, and 86.7%, respectively. The drug release investigation showed that 50.0 ± 1.2% of streptomycin sulfate was released from the niosome in 24 h and reached 66.4 ± 1.3% by the end of 72 h. Two-month stability studies at 25° and 4°C showed more acceptable stability of samples kept at 4°C. Consequently, antimicrobial and anti-biofilm activities of streptomycin sulfate-loaded niosomes against Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa were found significantly higher than those of free drug, and the minimum inhibitory concentration values decreased 4- to 8-fold. Furthermore, niosome-encapsulated streptomycin up to 1,500 μg/ml exhibited negligible cytotoxicity against the human foreskin fibroblasts cell line, whereas the free drug exhibited slight cytotoxicity at this concentration. Desired physical characteristics and low toxicity of niosomal nano-carriers containing streptomycin sulfate made them a demanded candidate for the treatment of current bacterial infections and biofilms.

Spectrum of Microorganisms, Antibiotic Resistance Pattern, and Treatment Outcomes Among Patients With Empyema Thoracis: A Descriptive Cross-Sectional Study From the Bahawal Victoria Hospital Bahawalpur, Punjab, Pakistan

Background: This study involves the analysis of spectrum of microorganisms, antibiotic resistance pattern, and treatment outcomes among empyema thoracis patients. This study also analyzes the factors associated with unsuccessful treatment outcome and duration of hospital stay among the patients.

Methods: This was a descriptive, cross-sectional study carried out in the Pulmonology Ward of the Bahawal Victoria hospital, Bahawalpur, Pakistan. All patients with empyema thoracis registered at the study site during the period of 1 year were included in the study. Multivariate regression analysis was used to analyze the factors associated with duration of hospital stay and unsuccessful treatment outcome among the patients.

Results: A total 110 patients were included in the study. Most of the patients (n = 73, 66.4%) were treated with piperacillin/tazobactam alone and in combination with either one or more than one antibiotics as an empiric therapy. Culture was positive in 58 (52.7%) patients and the most commonly identified organisms included, gram-negative Pseudomonas aeruginosa (n = 20; 18.8%) and Klebsiella sp. (n = 11, 10%) followed by same proportion of E. coli. The most commonly identified bacterial isolates showed high level of resistance against antibiotics used as an empiric therapy, while these showed low level of resistance against amoxicillin, clarithromycin, ertapenem, colistin, tigecycline, fosfomycin, rifampicin, and vancomycin. In this study, 82 (74.5%) patients successfully completed the treatment, while 12 (11%) showed no clinical improvement, 5 (4.5%) lost to follow up and 11 (10%) died. In multivariate binary logistic regression analysis, none of the patient attributes were significantly associated with unsuccessful treatment outcome, while in multivariate linear regression analysis, the factors which were significantly associated with duration of hospital stay included; duration of symptoms <2 weeks prior to admission (p = 0.008, beta = −0.247) and resistance to five antibiotic classes (p = 0.02, beta = 0.280).

Conclusion: Close to 25% of the patients did not complete the treatment successfully. Most of the common bacterial isolates showed high level of resistance against the broad-spectrum antibiotics used as an empiric therapy. This is alarming. However, better sensitivity of common bacterial isolates against standardized first line treatment for empyema thoracis is promising.

Formulation and evaluation of injectable dextran sulfate sodium nanoparticles as a potent antibacterial agent

The purpose of this study was to develop a novel nano antibacterial formulation of dextran sulfate sodium polymer. The dextran sulfate sodium (DSS) nanoparticles were formulated with gelation technique. The nanoparticles exhibited significant physicochemical and effective antibacterial properties, with zeta potential of − 35.2 mV, particle size of 69.3 z d nm, polydispersity index of 0.6, and percentage polydispersity of 77.8. The DSS nanoparticles were stable up to 102 °C. Differential scanning calorimetry revealed an endothermic peak at 165.77 °C in 12.46 min, while XRD analysis at 2θ depicted various peaks at 21.56°, 33.37°, 38.73°, 47.17°, 52.96°, and 58.42°, indicating discrete nanoparticle formation. Antibacterial studies showed that the DSS nanoparticles were effective against Gram-positive and Gram-negative bacteria. The minimum inhibitory concentrations of DSS nanoparticles for Bacillus subtilis (B. subtilis), Staphylococcus aureus (S. aureus), Streptococcus pyogenes (S. pyogenes), Escherichia coli (E. coli), Pseudomonas aeruginosa (P. aeruginosa), Klebsiella pneumoniae (K. pneumoniae) and Proteus vulgaris (P. vulgaris) were 150, 200, 250, 150, 200, 250, 250 µg/mL, respectively. The antibacterial effects of DSS nanoparticles were in the order E. coli (26 ± 1.2 mm) at 150 µg/mL > S. pyogenes (24.6 ± 0.8 mm) at 250 µg/mL > B. subtilis (23.5 ± 2 mm) at 150 µg/mL > K. pneumoniae (22 ± 2 mm) at 250 µg/mL > P. aeruginosa (21.8 ± 1 mm) at 200 µg/mL > S. aureus (20.8 ± 1 mm) at 200 µg/mL > P. vulgaris (20.5 ± 0.9 mm) at 250 µg/mL. These results demonstrate the antibacterial potency of DSS injectable nanoparticles.

Combining vancomycin-modified gold nanorod arrays and colloidal nanoparticles as a sandwich model for the discrimination of Gram-positive bacteria and their detection via surface-enhanced Raman spectroscopy (SERS)

This study reports the development of a highly sensitive antibiotic-based discrimination and sensor platform for the detection of Gram-positive bacteria through surface-enhanced Raman spectroscopy (SERS).

Guideline Recommendations for Empirical Antimicrobial Therapy: An Appraisal of Research Evidence for Clinical Decision-Making in Ethiopia

INTRODUCTION

The rapid spread of drug resistance is forcing standard treatment guidelines (STGs) to become more appropriate with due consideration of the evidence on the antimicrobial resistance (AMR) situation in Ethiopia. Therefore, we aimed to assess the local AMR recommendations in the STGs for empirical antibacterial prescriptions for the five common infectious syndromes. We also determined the quality of AMR reviews conducted in the country.

METHODS

We conducted a review of the STGs used in the health centers, general hospitals, and primary hospitals in Ethiopia and assessed the AMR recommendations in STGs for empirical antibacterial prescriptions for community-acquired pneumonia (CAP), urinary tract infection (UTI), tonsillopharyngitis, acute otitis media (AOM), and bacterial dysentery. Next, we performed an overview of AMR reviews published in Ethiopia. We used the MEDLINE/PubMed, Embase, Cochrane Library, and Google Scholar databases to identify AMR reviews. The review characteristics were extracted. We also evaluated the quality of each included AMR review using a measurement tool to assess the systematic review scale (AMSTAR 2).

RESULTS

A total of 6 STGs and 12 AMR reviews conducted in the country were included. The choice of empirical antibacterials for similar infectious syndromes (and editions) was comparable across the three levels of the health care system. None of the STGs evaluated included the local AMR recommendations for empirical antibacterial prescriptions for five common infectious syndromes. Of all the AMR reviews included, 75% had low and below methodologic quality, and none had a high-quality score using the AMSTAR 2 tool.

CONCLUSION

Standard treatment guidelines did not consider local AMR recommendations for empirically prescribing antibacterials for common infectious syndromes. The AMR reviews published in the country produced poor methodologic quality evidence for clinical applications. This highlights the need to improve the methodologic quality to provide the best available evidence for clinical decision-making and curb the ongoing AMR in Ethiopia.

TRIAL REGISTRATION

Retrospectively registered (15/07/2020).