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Background Bloodstream infections (BSIs) are a major cause of morbidity and mortality in hospitalized neonates. Data on antibiotic resistance in neonatal BSIs and their impact on clinical outcomes in Africa are limited. Methods We conducted a prospective cohort study at 2 tertiary level neonatal intensive care units (NICUs) in Ghana. All neonates admitted to the NICUs were included from October 2017 to September 2019. We monitored BSI rates and analyzed the effect of BSI and antibiotic resistance on mortality and duration of hospitalization. Results Out of 5433 neonates included, 3514 had at least one blood culture performed and 355 had growth of a total of 368 pathogenic microorganisms. Overall incidence of BSI was 1.0 (0.9-1.1) per 100 person days. The predominant organisms were Klebsiella pneumoniae 49.7% (183/368) and Streptococcus spp. 10.6% (39/368). In addition, 512 coagulase negative Staphylococci were isolated but considered probable contaminants. Among K. pneumoniae, resistance to gentamicin and amikacin was 91.8% and 16.4%, respectively, while carbapenem resistance was 4.4%. All-cause mortality among enrolled neonates was 19.7% (1066/5416). The mortality rate was significantly higher in neonates with BSI compared with culture-negative neonates in univariate analysis (27.9%, n = 99/355 vs. 16.5%, n = 520/3148; hazard ratio 1.4, 95% confidence interval 1.07-1.70) but not in multivariate analysis. Conclusion The diversity of etiological agents and the high risk of antibiotic resistance suggest that standard empirical treatment is unlikely to improve the outcome of BSIs in low and middle income. Such improvements will depend on access to reliable clinical microbiologic services.

Aim: This study aimed to characterize ciprofloxacin-resistance genes in clinical Escherichia coli isolates obtained from a six-month antimicrobial resistance (AMR) surveillance from Ghana. Methods: Eighty-three of 440 archived E. coli isolates were confirmed by biochemical reactions and resistance profiles by the disc diffusion method. These isolates were cultured from urine (42), stool (23), vaginal swabs (12), wounds (5) and heart valve (1) during AMR surveillance. Minimum Inhibition Concentration (MIC) by E-test method was performed on all E. coli isolates that were resistant to ciprofloxacin by the disc diffusion method. Additionally, all isolates with reduced MIC to ciprofloxacin (>32 µg/ml) were selected for molecular assays. Three chromosomal and nine plasmid-mediated resistance genes were screened in all Ciprofloxacin resistant E. coli (CRE) by polymerase chain reaction (PCR). Randomly selected amplified genes were commercially sequenced and analyzed. Results: In total, 47/83 (56.6%) E. coli isolates were resistant to ciprofloxacin and 29 (61.7%) had MIC values greater than 32 µg/ml. Chromosomal mediated genes (gyrA, gyrB and parC) were present in all 29 CRE isolates (100%). Distribution of the plasmid-mediated genes were as follows; qnrA 16/29 (55.1%), qnrB 16/29(55.1%), qnrC 22/29(75.8%), qnrS 26/29(89.6%), qepA 5/29(17.2%) and oqxB 19/29(65.5%). Genes encoding for altered aminoglycoside acetyltransferase [aac(6’)1bcr] were also present in all 29 CRE isolates. The majority (72.4%) of the CRE isolates had gyrA mutations at codons 83 and 87. In parC, the mutations were at codons 71 and 80. Five isolates had mutations at codon 56 and four each had mutations at positions 79 and 80. Conclusion: In this study, fluoroquinolone resistance genes were identified in all CRE isolates, mostly with putative mutations in the Quinolone Resistance Determining Region (QRDR). These chromosomal and plasmid-mediated genes may be widespread in Ghana and associated with CRE from the AMR surveillance. Although new mutations points were identified in parC, they may not be linked to the CRE.

Summary Background Surveillance systems for surgical site infections (SSIs), as a measure of patient safety, help health institutions devise strategies to reduce or prevent them. No surveillance systems exist to monitor SSIs in Ghana. Aim To establish a system for monitoring trends and detecting outbreaks in order to create awareness of and control SSIs. Methods An active 30-day surveillance was undertaken at the general surgical unit of the Korle Bu Teaching Hospital, from July 1st, 2017 to December 31st, 2018 to identify SSI. It involved a daily inpatient surveillance of patients who had had a surgical procedure, followed by post-discharge surveillance by means of a healthcare personnel-based survey and a patient-based telephone survey. We supplied quarterly feedback of results to surgeons. Findings Among the 3267 patients included, 331 were identified with an SSI, a 10% incidence risk. Patients who acquired an SSI experienced increased morbidity including nine extra days in hospital and an adjusted relative mortality risk of 2.3 (95% confidence interval: 1.3 - 4.1; P=0.006) compared to patients without SSI. Forty-nine per cent (161/331) of SSIs were diagnosed post discharge using the healthcare personnel-based survey. The patient-based telephone survey contributed 12 additional cases. SSI incidence risk decreased from 12.8% to 7.5% during the study period. Conclusion Post-discharge surveillance is feasible using existing healthcare personnel, and the results highlight the high risk and burden of SSIs in Ghana. A surveillance system with feedback for monitoring SSIs may contribute to reducing SSIs; however, firm conclusions regarding the impact need longer observation time.

We investigated the evolution, phylogeny and antimicrobial resistance of Vibrio cholerae O1 isolates (VCO1) from Ghana. Outbreak and environmental sources of VCO1 were characterized, whole-genome sequenced and compared to globally available seventh pandemic (7P) strains of V. cholerae at SNP resolution. Final analyses included 636 isolates. Novel Ghanaian isolates clustered into three distinct clades (clades 1, 2 and 3) in wave 3 of the 7P lineage. The closest relatives of our novel Ghanaian isolates were from Benin, Cameroon, Togo, Niger and Nigeria. All novel Ghanaian isolates were multi-drug resistant. Environmental isolates clustered into clade 2, despite being isolated years later, showing the possibility of persistence and re-emergence of older clades. A lag phase of several years from estimated introduction to reported cases suggests pathogen persistence in the absence of reported cholera cases. These results highlight the importance of deeper surveillance for understanding transmission routes between bordering countries and planning tailored vaccination campaigns in an effort to eradicate cholera.

Background The study objective was to determine the carriage and serotype distribution of Streptococcus pneumoniae among children in Accra, Ghana, five years after the introduction of the pneumococcal conjugate vaccine (PCV-13) in 2012. Methods Nasopharyngeal swab samples were collected from 410 children below 5 years of age in Accra, Ghana, from September to December, 2016. Pneumococcal isolates were identified by optochin sensitivity and bile solubility. Serotyping was performed using the latex agglutination kit and Quellung reaction. The isolates were furthermore tested for antimicrobial susceptibility for different antimicrobials, including penicillin (PEN). Twelve isolates including seven non-typeable (NT) isolates were characterized using whole-genome sequencing analysis (WGS). Results The overall carriage prevalence was found to be 54% (95% CI, 49–59%), and 20% (95% CI, 49–59%) of the children were carrying PCV-13 included serotypes, while 37% (95% CI, 33–42%) of the children were carrying non-PCV-13 serotypes. Based on the serotype distribution, 33% of all observed serotypes were included in PCV-13 while 66% were non-PCV-13 serotypes. The dominating non-PCV-13 serotypes were 23B, 16F, and 11A followed by PCV-13 serotypes 23F and 19F. The PCV-13 covers the majority of resistant isolates in Accra. A proportion of 22.3% of the isolates showed intermediate resistance to penicillin G, while only one isolate showed full resistance. Forty-five isolates (20.5%) were defined as multidrug-resistant (MDR) as they were intermediate/resistant to three or more classes of antimicrobials. Of the seven NT isolates characterized by WGS, four showed highest match to genotype 38, while the remaining three showed highest match to genotype 14. Four MDR serotype 19A isolates were found to be MLST 320. Conclusion PCV-13 introduced in Ghana did not eliminate PCV-13 covered serotypes, and the carriage rate of 54% in this study is similar to carriage studies from pre PCV-13 period. However, the penicillin non-susceptible isolates have been reduced from 45% of carriage isolates before PCV-13 introduction to 22.3% of the isolates in this study. Continuous monitoring of serotype distribution is important, and in addition, an evaluation of an alternative vaccination schedule from 3 + 0 to 2 + 1 will be important to consider. Electronic supplementary material The online version of this article (10.1186/s12887-019-1690-5) contains supplementary material, which is available to authorized users.

Background Improper use of antibiotics leads to the emergence of resistant microorganisms as well as drug toxicity, increased healthcare costs, morbidity and mortality. Globally, an estimated 25–68% of hospitalized patients receive suboptimal antibiotic regimes. Information on the extent of this problem in Ghana is currently limited, particularly in surgical units. To strategize for interventions, we estimated the antibiotic use prevalence in surgical departments in a country-wide point prevalence survey (PPS) in Ghana. Methods Between October 2016 and December 2016, we conducted a cross-sectional multi-center country-wide PPS. This involved an audit of in-patients’ records from all units/departments of ten systematically selected hospitals in Ghana. Data were collected with a standardized questionnaire, adopted from the European Centre for Disease Prevention and Control. In this report, we present data on antibiotic use from the surgical units. Results Of 2107 eligible patients included in the PPS, 540 patients were identified in surgical units, of which 70.7% (382/540) received antibiotic therapy. A total of 636 antibiotic prescriptions were issued to these surgical patients; 224 (58.6%) for treatment, including 50 for treatment of hospital-acquired infections, and 144 (37.7%) for prophylaxis (medical and surgical). Median duration of antibiotic therapy prior to the survey was 5 days (interquartile range (IQR): 3-8 days). Surgical prophylaxis was administered for longer than the recommended one day in 107 of 144 (88.4%) patients. The choice of antibiotics was largely similar for community- and hospital-acquired infections as well as for prophylaxis. Only 3.7% of patients had microbiological analysis done on clinical samples. Conclusion We found a high prevalence of antibiotic use, with the choice of antibiotics, in some cases, inconsistent with the country’s treatment guidelines. Antibiotics were administered for long duration including antibiotics for prophylactic purposes and the majority was started without supporting microbiological analysis. Prescription practices that encourage rational use of antibiotics guided by microbiology and enforcement of antibiotic policy guidelines should be the target for future interventions. Electronic supplementary material The online version of this article (10.1186/s12889-019-7162-x) contains supplementary material, which is available to authorized users.

Background Antimicrobial resistance (AMR) is a public health crisis of global proportions. Data is required to understand the local drivers of antimicrobial resistance and support decision-making processes including implementation of appropriate antimicrobial stewardship strategies. Objectives To measure antimicrobial usage in hospitals in Ghana. Methods Using the Global Point Prevalence instruments and processes, we conducted point prevalence surveys across AMR surveillance sentinel hospitals in Ghana, between September and December 2019. Hospital records of all inpatients on admission at 0800 hours on a specific day were reviewed for antimicrobial use at the time of the survey. Data on antibiotic use, including indication for use and quality of prescribing were recorded. Results Overall prevalence of antibiotic use across the sentinel sites was 54.9% (n = 1591/2897), ranging between 48.4% (n = 266/550) and 67.2% (n = 82/122). The highest prevalence of antibiotic use 89.3% (n = 25/28) was observed in adult ICUs. The average number of antibiotics prescribed per patient was 1.7 (n = 1562/2620), with the majority (66%, n = 728/2620) administered via the parenteral route. The five most-commonly used antibiotics were metronidazole (20.6%, n = 541/2620), cefuroxime (12.9%, n = 338/2620), ceftriaxone (11.8%, n = 310/2620), amoxicillin/clavulanic acid (8.8%, n = 231/2620) and ciprofloxacin (7.8%, n = 204/2620). The majority (52.2%; n = 1367/2620) of antibiotics were prescribed to treat an infection, whilst surgical prophylaxis accounted for 26.1% (n = 684/2620). Conclusions We observed a high use of antibiotics including metronidazole and cephalosporins at the participating hospitals. Most antibiotics were empirically prescribed, with low use of microbiological cultures. High usage of third-generation cephalosporins especially for community-acquired infections offers an opportunity for antibiotic stewardship interventions.

Background There is limited data to guide the prevention and management of surgical site infections (SSI) in low- and middle-income countries. We prospectively studied aetiological agents associated with SSI and their corresponding antibiotic susceptibility patterns in a tertiary hospital in Ghana. Methods As part of a cohort study carried out at the surgical department of the Korle Bu Teaching Hospital (KBTH) from July 2017 to April 2019, wound swabs were collected from patients diagnosed with SSI. Isolates cultured from the wound swabs were identified by MALDI TOF and susceptibility testing was conducted according to EUCAST 2020 guidelines. Clinical data were monitored prospectively. Results Of 4577 patients, 438 developed an SSI and 352 microbial isolates were cultured. Isolates were predominantly Gram negative (286, 81%), a pattern seen for all kinds of surgery and all wound classes. The most common species included Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Acinetobacter baumannii. The majority of organisms were multi-drug resistant including 86% of E. coli, 52% of A. baumannii and 86% of K. pneumoniae; and 65% (17/26) of the cefotaxime-resistant K. pneumoniae were extended spectrum β-lactamase producing. One of 139 E. coli, 15 of 49 P. aeruginosa, and 6 of 23 A. baumannii were meropenem resistant, but no clonal pattern was found. There was a 1% (5/428) prevalence of methicillin-resistant S. aureus. Conclusions The predominance of Gram-negative organisms and the high level of multi-drug resistance indicate a need to re-evaluate antibiotic prophylaxis and treatment protocols in surgical practice in low- and middle-income countries.

Background Carriage of multidrug resistant (MDR) Gram-negative bacteria (GN) in hospitalized neonates may increase the risk of difficult-to-treat invasive infections at neonatal intensive care units (NICUs). Data on MDRGN carriage among hospitalized newborns in Africa are limited. Methods We conducted a cross-sectional study at the NICUs of 2 tertiary hospitals in Ghana. Swabs from the axilla, groin, perianal region, and the environment were cultured, GN were identified, and antibiotic susceptibility was tested. We obtained blood culture isolates from neonates with sepsis. Whole-genome sequencing was used to characterize carbapenemase-producing Klebsiella pneumoniae. Typing was done by multilocus sequence typing (MLST) and single nucleotide polymorphism (SNP) analysis. Results A total of 276 GN were isolated from 228 screened neonates. Pathogenic GN were cultured in 76.8% (175 of 228) of neonates. Klebsiella spp (41.7%; 115 of 276) and Escherichia coli (26.4%; 73 of 276) were the commonest organisms. Carriage rates of MDRGN and third-generation cephalosporin resistant organisms were 49.6% (113 of 228) and 46.1% (105 of 228), respectively. Among Klebsiella spp, 75.6% (87 of 115) phenotypically expressed extended-spectrum β-lactamase activity, whereas 15.6% expressed carbapenemase and harbored bla-OXA-181 and bla-CTX-M-15. Overall, 7.0% (16 of 228) of neonates developed GN bloodstream infection. In 2 of 11 neonates, sequencing showed the same identity between carriage and the bloodstream isolate. Length of stay before specimen collection and antibiotic use were independently associated with carriage rates, which increased from 13% at admission to 42% by day 2 and reached a plateau at 91% by day 15. Conclusions High carriage rates of MDRGN, including carbapenemase-producing enterobacterales may be an emerging problem in NICUs in Africa., We show carriage rate of MDR enterobacterales among neonates in 2 NICUs in Ghana. MDR carriage is associated with duration of stay and antibiotic use. We also report OXA-181 carbapenemase-producing organism from Ghana. WGS showed identity between carriage and BSI.

Background/objective: A nationwide survey on the resistance to first line anti-tuberculosis (anti-TB) drugs was conducted in Ghana from 2007-2008 by Noguchi Memorial Institute for Medical Research in collaboration with the National Tuberculosis Control Programme. We aimed to characterize mycobacterial species causing pulmonary tuberculosis (PTB) and determine the resistance pattern to first line anti-TB drugs among newly diagnosed and previously treated PTB patients in Ghana. Methods: Two sputum samples from consented new smear positive PTB patients who had never been treated for TB or had been on anti-TB treatment for less than a month and patients who had been treated for TB previously for more than a month in selected diagnostic centres nationwide were collected for culture, identification and drug susceptibility test. Culture positive isolates were tested against streptomycin (S), isoniazid (H), rifampicin (R) and ethambutol (E) using the simplified proportion method and line probe assay (LPA). The LPA was performed in mid-2017. Results: Among 410 samples, 345 positive cultures were obtained and identified as Mycobacterium tuberculosis complex (MTBC). Of the 345 isolates, 133 were further differentiated by GenoType MTBC® as M. tuberculosis, 126 (94.7%) and M. africanum 7 (5.3%). The overall drug resistance patterns were as follows: 43/345 (12.5%), 6/345 (1.7%), 9/345 (2.6%) and 71/345 (20.6%) were resistant to H, R, E and S respectively and 5/345 (1.4%) were multi-drug resistant (MDR). Conclusion: The results indicate high levels of resistance to S and H among new and previously treated TB patients. We recommend adequate surveillance systems including periodic national anti-TB drug resistance surveys.

(1) Background: Present methods for drug susceptibility tests (DST) rely on culture methods that are sophisticated and relatively faster, or a slow and cheaper option. These methods frustrate disease control, therefore, there is a need for methods that incorporate key functions of microscopy and culture, with reduced cost burden and sophistry. Thus, the purpose of this study was to identify which, among the most commonly used (in Ghana) methods, can conveniently be used at health centers located in rural areas for effective DST determination of Mycobacterium tuberculosis (MTB). (2) Methods: Mycobacterium tuberculosis isolates were tested for their susceptibility to streptomycin, isoniazid, rifampicin, ethambutol (SIRE), and pyrazinamide by microscopic observation drug susceptibility (MODS) and BACTEC MGIT 960 methods. Evaluations were based on shorter turnaround periods, rapidity, ease of use, cost, etc. A comparative analysis was statistically expressed as kappa values. (3) Results: Endpoints for drug susceptibilities by MODS averaged 13 days (7&ndash, 32), whilst that for BACTEC MGIT 960 was 10 days with a further 12 days to detect resistance. Therefore, a turnaround period of 22 days was needed for DST by BACTEC MGIT 960, compared to 13 days for MODS. There were differences in correlation levels between the two methods, as determined by their kappa values. (4) Conclusion: The MODS assay was found to be less costly, more user-friendly, and still able to be conveniently used at health centers located in rural areas known to be endemic for TB, particularly in Ghana.

We sequenced 29 carbapenemase-producing Klebsiella pneumoniae isolates from a neonatal intensive care unit in Ghana. Twenty-eight isolates were sequence type 17 with blaOXA-181 and differed by 0-32 single-nucleotide polymorphisms. Improved surveillance and infection control are needed to characterize and curb the spread of multidrug-resistant organisms in sub-Saharan Africa.

Major surgery carried out in low- and middle-income countries is associated with a high risk of surgical site infections (SSI), but knowledge is limited regarding contributory factors to such infections. This study explores factors related to patients developing an SSI in a teaching hospital in Ghana. A prospective cohort study of patients undergoing abdominal surgical procedures was conducted at Korle Bu Teaching Hospital. Patient characteristics, procedures and environmental characteristics were recorded. A 30-day daily surveillance was used to diagnose SSI, and Poisson regression analysis was used to test for association of SSI and risk factors; survival was determined by proportional hazard regression methods. We included 358 patients of which 58 (16.2%; 95% CI 12.7–20.4%) developed an SSI. The median number of door openings during an operation was 79, with 81% being unnecessary. Door openings greater than 100 during an operation (P = 0.028) significantly increased a patient's risk of developing an SSI. Such patients tended to have an elevated mortality risk (hazard ratio 2.67; 95% CI 0.75–9.45, P = 0.128). We conclude that changing behaviour and practices in operating rooms is a key strategy to reduce SSI risk.

OBJECTIVES: To assess the prevalence and clinical importance of previously unrecognised tuberculosis (TB) and isolation of non-tuberculous mycobacteria (NTM) among HIV-infected individuals in a teaching hospital in Ghana.METHODS: Intensified mycobacterial case finding was conducted among HIV-positive individuals before initiation of antiretroviral therapy (ART). Data were collected on socio-demographic characteristics, medical history and TB-related signs and symptoms, and participants were followed for six months to determine treatment and vital status. Two sputum samples were obtained and examined for mycobacteria with smear microscopy, culture and Xpert MTB/RIF assay. NTM species were identified with the GenoType Mycobacterium CM/AS or sequence analysis of 16S rRNA gene.RESULTS: Of 473 participants, 60 (12.7%) had confirmed pulmonary TB, and 38 (8.0%) had positive cultures for NTM. Mycobacterium avium complex was identified in 9/38 (23.7%) of NTM isolates. Participants with NTM isolated were more likely to have CD4 cell count< 100 cells/μL (aOR 2.37; 95% CI: 1.10-5.14), BMICONCLUSIONS: Intensified mycobacterial screening of HIV-infected individuals revealed a high burden of unrecognised pulmonary TB before ART initiation, which increased risk of death within six months. NTM were frequently isolated and associated with signs of poor clinical status but not with increased mortality.

SUMMARYPoultry are possible sources of non-typhoidalSalmonellaserovars which may cause foodborne human disease. We conducted a cross-sectional study to determine the prevalence ofSalmonellaserovars in egg-laying hens and broilers at the farm level and their susceptibility to antimicrobials commonly used in the poultry industry in Ghana. Sampling of faeces by a sock method (n= 75), dust (n= 75), feed (n= 10) and drinking water (n= 10) was performed at 75 commercial egg-laying and broiler farms in two regions of Ghana and skin neck (n= 30) at a local slaughterhouse from broilers representing different flocks.Salmonellawas detected in 94/200 (47%) samples with an overall flock prevalence of 44·0%. Sixteen different serovars were identified withS. Kentucky (18·1%),S. Nima (12·8%),S. Muenster (10·6%),S. Enteritidis (10·6%) andS. Virchow (9·6 %) the most prevalent types. The predominant phage type ofS. Enteritidis was PT1. All strains were susceptible to cefotaxime, ceftazidime and cefoxitin. Fifty-seven (60·6%) strains were resistant to one or more of the remaining nine antimicrobials tested by disk diffusion, of which 23 (40·4%) showed multi-resistance (resistance to ⩾3 classes of antimicrobials). Of the resistant strains (n= 57), the most significant were to nalidixic acid (89·5%), tetracycline (80·7%), ciprofloxacin (64·9%), sulfamethazole (42·1%), trimethoprim (29·8%) and ampicillin (26·3%). AllS.Kentucky strains were resistant to more than two antimicrobials and shared common resistance to nalidixic acid or ciprofloxacin and tetracycline, often in combinations with other antimicrobials. PFGE analysis usingXbaI ofS. Kentucky demonstrated one dominant clone in the country. In conclusion, poultry produced in Ghana has a high prevalence of multi-resistantSalmonellaand the common finding of clonalS.Kentucky in the Kumasi area warrants further investigations into the epidemiology of this serovar. There is an urgent need for surveillance and control programmes onSalmonellaand use of antimicrobials in the Ghanaian poultry industry to protect the health of consumers.

Neisseria gonorrhoeae antimicrobial resistance (AMR) surveillance is essential for tracking the emergence and spread of AMR strains in local, national and international populations. This is crucial for developing or refining treatment guidelines. N. gonorrhoeae multiantigen sequence typing (NG-MAST) is beneficial for describing the molecular epidemiology of gonococci at national and international levels. Elucidation of AMR determinants to β-lactam drugs, is a means of monitoring the development of resistance. In Ghana, little is known about the current gonococcal AMR prevalence and no characterization of gonococcal isolates has been previously performed. In this study, gonococcal isolates (n = 44) collected from five health facilities in Ghana from 2012 to 2015, were examined using AMR testing, NG-MAST and sequencing of penA. High rates of resistance were identified to tetracycline (100%), benzylpenicillin (90.9%), and ciprofloxacin (81.8%). One isolate had a high cefixime MIC (0.75 μg/ml). Twenty-eight NG-MAST sequence types (STs) were identified, seventeen of which were novel. The isolate with the high cefixime MIC contained a mosaic penA-34 allele and belonged to NG-MAST ST1407, an internationally spreading multidrug-resistant clone that has accounted for most cefixime resistance in many countries. In conclusion, AMR testing, NG-MAST, and sequencing of the AMR determinant penA, revealed high rates of resistance to tetracycline, benzylpenicillin, and ciprofloxacin; as well as a highly diverse population of N. gonorrhoeae in Ghana. It is imperative to continue with enhanced AMR surveillance and to understand the molecular epidemiology of gonococcal strains circulating in Ghana and other African countries.

Background Understanding the knowledge, attitudes and practices of physicians towards antibiotic resistance is key to developing interventions aimed at behavior change. The survey aimed to investigate physicians’ knowledge and attitudes towards antibiotic resistance in a tertiary-care hospital setting in Ghana. Methods We conducted a cross-sectional respondent-driven survey using a 40-item, anonymous, voluntary, traditional paper-and-pencil self-administered questionnaire among 159 physicians at Korle-Bu Teaching Hospital. Single and multi-factor analysis were conducted to assess the study objectives. Results The survey was completed by 159 of 200 physicians (response rate of 79.5%). Of physicians, 30.1% (47/156) perceived antibiotic resistance as very important global problem, 18.5% (29/157) perceived it as very important national problem and only 8.9% (14/157) thought it as a very important problem in their hospital. Methicillin resistant Staphylococcus aureus was the most known about antibiotic resistant bacteria of public health importance followed by extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem resistant Enterobacteriaceae (CRE) and vancomycin resistant enterococci (VRE). In multiple logistic regression analysis, senior physicians were nearly 3 times more likely to know about CRE than junior physicians. The odds of knowing about VRE increased over 4.5 times from being a junior to becoming senior physician. Among junior physicians, age had no associated effect on their knowledge of VRE or CRE. Conclusions Physicians in this survey showed variable knowledge and perceptions on antibiotic resistance. Introducing educational programs on antibiotic resistance would be a useful intervention and should focus on junior physicians. Electronic supplementary material The online version of this article (10.1186/s12913-018-2899-y) contains supplementary material, which is available to authorized users.

Summary Background There is a paucity of data describing hospital-acquired infections (HAIs) in Africa. Objective To describe the prevalence and distribution of HAIs in acute care hospitals in Ghana. Methods Between September and December 2016, point-prevalence surveys were conducted in participating hospitals using protocols of the European Centre for Disease Prevention and Control. Medical records of eligible inpatients at or before 8am on the survey date were reviewed to identify HAIs present at the time of the survey. Findings Ten hospitals were surveyed, representing 32.9% of all acute care beds in government hospitals. Of 2107 inpatients surveyed, 184 HAIs were identified among 172 patients, corresponding to an overall prevalence of 8.2%. The prevalence values in hospitals ranged from 3.5% to 14.4%, with higher proportions of infections in secondary and tertiary care facilities. The most common HAIs were surgical site infections (32.6%), bloodstream infections (19.5%), urinary tract infections (18.5%) and respiratory tract infections (16.3%). Device-associated infections accounted for 7.1% of HAIs. For 12.5% of HAIs, a micro-organism was reported; the most commonly isolated micro-organism was Escherichia coli. Approximately 61% of all patients surveyed were on antibiotics; 89.5% of patients with an HAI received at least one antimicrobial agent on the survey date. The strongest independent predictors for HAI were the presence of an invasive device before onset of infection and duration of hospital stay. Conclusion A low HAI burden was found compared with findings from other low- and middle-income countries.

BackgroundBuruli ulcer (BU) disease, a skin condition caused by Mycobacterium ulcerans (M. ulcerans) is endemic in remote rural areas. Disease diagnosis on clinical basis alone can be misleading, requiring definitive diagnosis based on laboratory tests. Resource constraints in BU endemic areas make microscopy for the detection of acid fast bacilli (AFB) an important and useful method. It is rapid, user-friendly, convenient and cheap. Despite its usefulness, its performance is relatively low. This study investigated modifications of the current method aimed at improving its performance. Forty (IS) 2404 polymerase chain reactions (PCR) positive BU samples were processed by eight physical (centrifugation and overnight sedimentation) and chemical (phenol ammonium sulphate and sodium hypochlorite) modifications of the current direct method. Assessments were based on standard AFB evaluation coupled with in house criteria; positivity (P), clarity and contrast (C) release of bacilli from specimen (R). Overall AFB positivity rate was 64% (409/640). Each protocol had 80 smears. The percentage positivity (P) for the conventional method was 58% (46/80) smears. The highest positivity rate of 57/80 (%) was by protocol 7 (5% phenol in 4% ammonium sulphate (PhAS) and concentrated by overnight gravitational sedimentation). The least positivity rate at 35% (28/80) was by protocol 1 (smears from direct application of swab tips). The differences in performance between the two chemical tested; 5% phenol in 4% ammonium sulphate (PhAS) and 3.5% NaHOCl was significant (p0.05). This study concluded that BU samples treated with a solution of 5% phenol in 4% ammonium sulphate and concentrated by either centrifugation or overnight sedimentation is useful for maximizing AFB detection by bright field microscopy. This can be useful in rural health facilities with resource constraints.

Streptococcus pneumoniae is a major cause of morbidity and mortality worldwide. Pneumococcal strains are classified according to their capsular polysaccharide and more than 90 different serotypes are currently known. In this project, three distinct groups of pneumococcal carriage isolates from Ghana were investigated; isolates from healthy children in Tamale and isolates from both healthy and children attending the outpatient department at a hospital in Accra. The isolates were previously identified and characterized by Gram staining, serotyping and susceptibility to penicillin. In this study, isolates of the common serotype 19F were further investigated by Multi-Locus Sequence Typing (MLST). Overall, 14 different Sequence Types (STs) were identified by MLST, of which nine were novel based on the international MLST database. Two clones within serotype 19F seem to circulate in Ghana, a known ST (ST 4194) and a novel ST (ST 9090). ST 9090 was only found in healthy children in Accra, whereas ST 4194 was found equally in all children studied. In the MLST database, other isolates of ST 4194 were also associated with serotype 19F, and these isolates came from other West African countries. The majority of isolates were penicillin intermediate resistant. In conclusion, two clones within serotype 19F were found to be dominating in pneumococcal carriage in Accra and Tamale in Ghana. Furthermore, it seems as though the clonal distribution of serotype 19F may be different from what is currently known in Ghana in that many new clones were identified. This supports the importance of continued monitoring of pneumococcal carriage in Ghana and elsewhere when vaccines, e.g., PCV-13, have been introduced to monitor the possible future spread of antimicrobial resistant clones.

The objective of this study was to provide baseline information on circulating methicillin-resistant Staphylococcus aureus (MRSA) clones in Ghana. Thirty MRSA isolates collected between 2010 and 2013 from patients and healthy carriers were characterised by DNA microarray analysis, staphylococcal protein A (spa) typing, multilocus sequence typing (MLST) and minimum inhibitory concentration (MIC) determination to 21 antimicrobial agents. Phenotypic resistance was detected to tetracycline (67%), norfloxacin (40%), moxifloxacin (37%), erythromycin (37%), clindamycin (33%), gentamicin (30%), kanamycin (30%) and ceftaroline (20%), whereas no resistance was observed for glycopeptides, linezolid, daptomycin and tigecycline. DNA microarray analysis showed that tet(M) (43%), tet(K) (33%), aphA3 (23%), aacA-aphD (17%) and erm(C) (13%) were the most prevalent resistance genes. ST88-IV (WA MRSA-2) (n=8), ST8-IV (USA300) (n=5) containing arginine catabolic mobile element (ACME) and Panton-Valentine leukocidin (PVL), and ST247-I (North German/Iberian EMRSA) (n=4) were the most frequent clones detected. All MRSA contained sak and scn genes, one isolate (ST36-II) harboured the gene encoding the toxic shock syndrome toxin (TSST) and none contained exfoliative toxin genes. In conclusion, the relatively high levels of resistance to easily accessible non-β-lactam agents further complicate the treatment of MRSA infections in Ghana. The occurrence of USA300 and other epidemic multidrug-resistant MRSA clones in this African country is a matter of public health concern due to the lack of adequate infrastructures for MRSA surveillance and control in this geographical setting.

Background The global rise and spread of antibiotic resistance is limiting the usefulness of antibiotics in the prevention and treatment of infectious diseases. The use of antibiotic stewardship programs guided by local data on prescribing practices is a useful strategy to control and reduce antibiotic resistance. Our objective in this study was to determine the prevalence and indications for use of antibiotics at the Korle-Bu Teaching Hospital Accra, Ghana. Methods An antibiotic point prevalence survey was conducted among inpatients of the Korle-Bu Teaching Hospital between February and March 2016. Folders and treatment charts of patients on admission at participating departments were reviewed for antibiotics administered or scheduled to be administered on the day of the survey. Data on indication for use were also collected. Prevalence of antibiotic use was determined by dividing the number of inpatients on antibiotics at the time of survey by the total number of patients on admission. Results Of the 677 inpatients surveyed, 348 (51.4%, 95% CI, 47.6–55.2) were on treatment with antibiotics. Prevalence was highest among Paediatric surgery where 20/22 patients (90.9%, 95% CI, 70.8–98.9) were administered antibiotics and lowest among Obstetrics patients with 77/214 (36%, 95% CI, 29.5–42.8). The indications for antibiotic use were 245/611 (40.1%) for community-acquired infections, 205/611 (33.6%) for surgical prophylaxis, 129/611 (21.1%) for healthcare associated infections and 33/611 (5.4%) for medical prophylaxis. The top five antibiotics prescribed in the hospital were metronidazole 107 (17.5%), amoxicillin-clavulinic acid 82 (13.4%), ceftriaxone 17(12.1%), cefuroxime 61 (10.0%), and cloxacillin 52 (8.5%) respectively. Prevalence of meropenem and vancomycin use was 12(2%) and 1 (.2%) respectively. The majority of patients 181 (52%) were being treated with two antibiotics. Conclusion This study indicated a high prevalence of antibiotic use among inpatients at the Korle-Bu Teaching Hospital. Metronidazole was the most commonly used antibiotic; mainly for surgical prophylaxis. There is the need to further explore factors contributing to the high prevalence of antibiotic use and develop strategies for appropriate antibiotic use in the hospital. Electronic supplementary material The online version of this article (10.1186/s13756-018-0299-z) contains supplementary material, which is available to authorized users.

Background Data on adult meningitis among patients infected with the human immunodeficiency virus (HIV) is scarce in western sub-Saharan Africa, including Ghana. Methods HIV-infected adults with a provisional diagnosis of meningitis were consecutively enrolled, between August 2014 and January 2016. After patient data collection, cerebrospinal fluid (CSF) was obtained and evaluated for microbiological aetiologies, cell counts and biochemistry. Caregiver clinicians provided limited data for inpatients at the end-point of discharge or death. Results Complete data sets from 84 patients were analysed (inpatients=63, outpatients=21). Median age was 40 years with 56% (47/84) being females. Only 30% (25/84) of the patients were on antiretroviral therapy (ART). CD4+ T-cell count was available for 81% (68/84) of patients and 61.9% (52/84) had counts below 150 cells/μL [median and interquartile range=56 (13.8-136)]. Microbiological aetiologies were detected in 60.7% (51/84) patients with the following distribution-Toxoplasmosis (25%), Epstein-Barr virus (28.6%), Cytomegalovirus and Cryptococcus (2.4%) each. Co-infection was identified in 20.7% (17/84) of the patients. Conclusion Patients presenting with symptoms of meningitis had advanced HIV/AIDS, a quarter of whom had cerebral toxoplasmosis or infection with EBV. A high index of suspicion, laboratory exclusion of cryptococcal meningitis and prompt patient management with anti-toxoplasmosis empiric therapy may thus be required for optimal treatment.

Background Blood stream infections (BSI) are critical medical conditions with high morbidity and mortality. There is paucity of information on BSI from surveillance studies in Ghana. Aim This study sought to demonstrate how useful BSI data can be gleaned from population-based surveillance, especially from resource-limited settings. Methods Data from a nationwide surveillance of antimicrobial drug resistance (AMR) in Ghana were extracted and analyzed. Secondly, we revived archived Staphylococcus aureus isolates from blood cultures that were cefoxitin resistant (CRSA), and screened these for protein A (spa) and mec A genes. Results Overall blood culture positivity was 11.2% (714/6351). All together, participating laboratories submitted 100 multidrug resistant blood culture isolates (Gram-negative = 49 and Gram-positive = 51). Prevalence of some Gram-negative isolates was as follows; Escherichia coli (20.4%), Pseudomonas aeruginosa (16.3%), Enterobacter spp. (14.3%), Salmonella serotype Typhi (8.2%) and Non-typhoidal Salmonella [NTS] (8.2%). Gram-positive pathogens included Staphylococcus aureus (66.7%), coagulase negative S. aureus [CoNS] (17.6%) and Streptococcus pneumoniae (11.8%). No methicillin resistance was confirmed in our CRSA isolates. Most blood stream associated infections were from inpatients (75%) and cultured bacteria were resistant to common and cheaper antimicrobials. Conclusion E. coli and S. aureus are common pathogens associated with BSI in Ghana and they are resistant to several antimicrobials. Active and continuous AMR surveillance can serve multiple purposes, including data generation for BSI.

Background.The current definitive treatment of Buruli ulcer with antibiotics makes the issue of antimicrobial drug resistance an unavoidable one. This is as a result of drug misuse by health personnel and patients’ noncompliance to treatment regimen. Monitoring of these factors and screening for new effective antimicrobials are crucial to effective management of Buruli ulcer disease. This study therefore investigated the inhibitory activity of some antibiotics against isolates ofMycobacterium ulcerans.Methods.Activity of eight antibiotics was tested against twelveM. ulceransisolates (2 reference strains and 10 clinical isolates). The anti-M. ulceransactivities were determined by the agar dilution method and the minimum inhibitory concentrations (MICs) were determined by the agar proportion method.Results.All antimicrobials investigated had activity againstM. ulceransisolates tested. The MICs ranged from 0.16 μg/mL to 2.5 μg/mL. Azithromycin recorded the highest inhibitory activity at a mean MIC of 0.39 μg/mL, whilst clofazimine a second-line antileprosy drug, recorded the lowest at a mean MIC of 2.19 μg/mL. Among the four antituberculosis drugs, rifampicin had the highest activity with a mean MIC of 0.81 μg/mL.Conclusion.Azithromycin could be considered as a lucrative alternative to existing treatment methods for inhibitingM. ulceransin Ghana.

BackgroundNon-typhoidal Salmonella (NTS) is a public health problem worldwide and particularly in Africa with high disease burden. This study characterized Salmonella isolates from humans in Ghana to determine serovar distribution, phage types, and antimicrobial resistance. Further, the clonal relatedness among isolates was determined.MethodsOne hundred and thirty-seven Salmonella isolates (111 clinical and 26 public toilet) were characterized using standard serotyping, phage typing, and antimicrobial susceptibility testing methods. The molecular epidemiology of common serovars (Salmonella Typhimurium and Salmonella Enteritidis) was established by pulsed field gel electrophoresis (PFGE).ResultsTwenty-two serovars were identified with S. Enteritidis, S. Typhimurium, and Salmonella Derby as the most dominant. One hundred and twelve isolates showed resistance to more than one antimicrobial. Fifty-eight (n = 58/112; 54.5%) strains were multi-resistant with low resistance to cephalosporins ceftazidime (8.0%), cefotaxime (4.5%), and cefoxitin (2.7%) with synergy to clavulanic acid indicating possible ESBLs. Isolates showed high resistance to trimethoprim (66.1%), tetracycline (61.6%), ampicillin (57.1%), sulfamethoxazole (46.4%), chloramphenicol (33.9%), and ciprofloxacin (25.0%). The most common resistance pattern of multi-resistant serovars was to ampicillin, chloramphenicol, sulphonamide, and trimethoprim. S. Enteritidis (18/43) strains reacted with typing phages but did not conform to any phage type with PT14B and PT4 as predominant definitive phage types. Six S. Typhimurium strains reacted but did not conform to any recognized phage type while seven were non-typable. The predominant definitive phage types were DT1 and DT22. PFGE patterns of human S. Enteritidis were closely related to patterns of poultry isolates obtained in a previous study in Ghana.ConclusionsCephalosporin resistance is uncommon among Salmonella from humans in Ghana. Poultry may be an important source of human salmonellosis. There is an urgent need for the implementation of routine surveillance of antimicrobial use and bacterial resistance among humans in Ghana.

Consumers perceive packaged drinking water, usually distributed as bottled or in polyethylene packages (sachets), as healthier and safer alternatives to tap water. The objective of this study was to determine the microbiological quality of different types of packaged drinking water available in Accra, Ghana. Sixty samples of sachet water and ten of (PET) bottled water were randomly purchased from various locations in Accra. Bacteriological and parasitological analyses of the packaged (sachet and bottled) and tap water (as control) were done according to standard procedures. Fifty-two out of 60 sachet water samples (86.7%) had HPC levels well above the internationally recommended limits. For the bottled water, nine out of the ten (90%) were within the recommended limits for HPC. Two out of the five (40%) tap water samples (control samples) had HPC above the recommended limits of 500 cfu/mL. While none of the bottled water samples showed the presence of protozoa, two out of the five tap water and 31 out of the 60 sachet water samples had a wide range of protozoa including rotifers. The findings clearly indicate that while PET bottled water sold in Accra may be generally safe, the same cannot be said for the sachet water; since the study found its microbiological quality not significantly different from tap water.

Background Mycobacterium ulcerans (M. ulcerans) is the causative agent of Buruli Ulcer (BU) disease. In order to inhibit the growth of the microbial contaminants during culture of M. ulcerans, it is necessary to decontaminate BU samples with effective chemical agents. This study aimed at investigating some selected chemicals as potential decontamination agents for the isolation of M. ulcerans from swabs. Results Povidone iodine at 0.5 and 1% exhibited the lowest contamination and recovery rate for microbial contaminants and M. ulcerans. The most effective decontamination method was the protocol using 2% cetylpyridinium chloride/4% sodium chloride (recovery rate = 53%, contamination rate = 14%). The observed difference between the recovery rate of 2% CPC/4% NaC and the other protocols was however not statistically significant (p = 0.76). Conclusions Two percent (2%) cetylpyridinium chloride/4% sodium chloride can be conveniently used as an alternative decontamination method for the isolation of M. ulcerans from swabs.

Infections with bacteria producing extended-spectrum beta-lactamases (ESBLs) are increasing across Africa. This study reports on ESBL-producing Enterobacteriaceae as significant causes of infections and antibiotic resistance at Korle-Bu Teaching Hospital in Accra, Ghana. Of 300 isolates examined, 49.3% produced ESBLs. The prevalence of ESBLs was significantly high among isolates from neonates (28 of 43, 65.1%; relative risk = 1.62, 95% confidence interval = 1.33-2.13, P = 0.002) and adult patients > 65 years of age (36 of 51, 70.5%; relative risk = 1.89, 95% confidence interval = 1.41-2.40, P = 0.001). A marked increase in minimum inhibitory concentrations of ESBL-positive species was noticed compared with those for the other strains. Using these concentrations, we found that 26 (17%) ESBL producers were resistant to two or more antibiotics (aminoglycosides, fluoroquinolones, sulfonamide, and carbapenems) whereas 5 (3.2%) non-ESBL producers were multidrug resistant. Regular ESBL detection and evaluation of antibiotic resistance may help reduce the spread of ESBLs and antibiotic resistance in Ghana.

Background Diagnosis of bloodstream infections (BSI) in neonates is usually difficult due to minimal symptoms at presentation; thus early empirical therapy guided by local antibiotic susceptibility profile is necessary to improve therapeutic outcomes. Methods A review of neonatal blood cultures submitted to the microbiology department of the Korle-Bu Teaching Hospital was conducted from January 2010 through December 2013. We assessed the prevalence of bacteria and fungi involved in BSI and the susceptibility coverage of recommended empiric antibiotics by Ghana Standard Treatment guidelines and the WHO recommendations for managing neonatal sepsis. The national and WHO treatment guidelines recommend either ampicillin plus gentamicin or ampicillin plus cefotaxime for empiric treatment of neonatal BSI. The WHO recommendations also include cloxacillin plus gentamicin. We described the resistance profile over a 28-day neonatal period using multivariable logistic regression analysis with linear or restricted cubic splines. Results A total of 8,025 neonatal blood culture reports were reviewed over the four-year period. Total blood culture positivity was 21.9 %. Gram positive organisms accounted for most positive cultures, with coagulase negative staphylococci (CoNS) being the most frequently isolated pathogen in early onset infections (EOS) (59.1 %) and late onset infections (LOS) (52.8 %). Susceptibility coverage of early onset bacterial isolates were 20.7 % to ampicillin plus cefotaxime, 32.2 % to the combination of ampicillin and gentamicin, and 71.7 % to cloxacillin plus gentamicin. For LOS, coverage was 24.6 % to ampicillin plus cefotaxime, 36.2 % to the combination ampicillin and gentamicin and 63.6 % to cloxacillin plus gentamicin. Cloxacillin plus gentamicin remained the most active regimen for EOS and LOS after exclusion of BSI caused by CoNS. For this regimen, the adjusted odds of resistance decreased between 12-34 % per day from birth to day 3 followed by the slowest rate of resistance increase, compared to the other antibiotic regimen, thereafter until day 28. The trend in resistance remained generally unchanged after excluding data from CoNS. Multidrug resistant isolates were significantly (p-value

Objectives To provide insights into the epidemiology of antibiotic usage in animal husbandry in Ghana and its effect on resistance. Methods Three hundred and ninety-five randomly sampled commercial livestock keepers who practised intensive or extensive farming were interviewed about their antibiotic usage practices using a structured questionnaire. Escherichia coli isolated from stool specimens of farmers and their animals were tested against eight antibiotics using the Kirby Bauer method. Results Ninety-eight percent (387) of the farmers used antibiotics on animals and the main purpose was to prevent infections in animals; 41% applied antibiotics monthly. The overall prevalence of multiple drug resistance among the E. coli isolates was 91.6%; rates in human and animal isolates were 70.6% and 97.7%, respectively. The prevalence of resistance in animal isolates to the various drugs ranged from 60.8% (amikacin) to 95.7% (ampicillin); the prevalence of resistance in human isolates to the drugs ranged from 2% (cefuroxime) to 94.1% (gentamicin). Animal E. coli isolates showed higher resistance than that of human isolates for five of eight drugs tested. Conclusion It is concluded that antibiotic usage in animal husbandry in Ghana is more driven by the interest of livestock keepers to prevent and treat animal infections than growth enhancement. Both animal and human E. coli showed high levels of antibiotic resistance, although resistance of animal isolates appeared to be higher than that of humans. There is the need for the development of an antibiotic-resistance management programme in Ghana that will focus simultaneously on human and animal use of antibiotics. Objectifs: Fournir un apercu de l’epidemiologie de l’utilisation des antibiotiques dans l’elevage des animaux au Ghana et son effet sur la resistance. Methodes: Un echantillon aleatoirement de 395 eleveurs commerciaux qui pratiquaient une agriculture intensive ou extensive ont ete interroges sur leurs pratiques d’utilisation des antibiotiques a l’aide d’un questionnaire structure. Des isolats d’E. coli obtenus a partir d’echantillons de selles des eleveurs et de leurs animaux ont ete testes contre 8 antibiotiques en utilisant la methode Kirby Bauer. Resultats: 98% (387) des agriculteurs utilisaient des antibiotiques pour prevenir les infections chez les animaux; 41% appliquaient des antibiotiques mensuellement. La prevalence globale de la resistance multiple aux medicaments parmi les isolats d’E. colietait de 91,6%, les taux parmi les isolats humains et animaux etaient de 70,6% et 97,7% respectivement. La prevalence de la resistance parmi les isolats animaux pour les differents medicaments variait de 60,8% (amikacine) a 95,7% (ampicilline). La prevalence de la resistance aux medicaments parmi les isolats humains variait de 2% (cefuroxime) a 94,1% (gentamicine). Les isolats animaux d’E. coli montraient une plus grande resistance que les isolats humains pour 5 des 8 medicaments testes. Conclusion: Il a ete conclu que l’utilisation des antibiotiques dans l’elevage au Ghana est plus guidee par l’interet des eleveurs a prevenir et traiter les infections des animaux que pour l’amelioration de la croissance. Les isolats animaux et humains d’E. coli ont tous revele des niveaux eleves de resistance aux antibiotiques, quoique la resistance des isolats animaux semblent etre plus elevee que celles des isolats humains. Il est necessaire de developper un programme de gestion de la resistance aux antibiotiques au Ghana, qui portera simultanement sur l’utilisation humaine et animale des antibiotiques. Objetivos: Aportar informacion sobre la epidemiologia del uso de antibioticos en la cria de animales en Ghana y sus efectos sobre la resistencia a los mismos. Metodos: Se entrevistaron 395 granjeros comerciales que practicaban ganaderia intensiva o extensiva, y mediante un cuestionario estructurado se les pregunto acerca de sus practicas en el uso de antibioticos. A las cepas de E. coli aisladas de las muestras de heces de los ganaderos y sus animales se les realizo una prueba de susceptibilidad frente a 8 antibioticos mediante el metodo de Kirby Bauer. Resultados: Un 98% (387) de los ganaderos daba antibioticos a sus animales para prevenir infecciones; y un 41% aplicaba los antibioticos mensualmente. La prevalencia general de resistencia multiple entre las cepas de E. coli era del 91.6%; las tasas en cepas aisladas de hombres y animales eran del 70.6% y 97.7% respectivamente. La prevalencia de resistencia en cepas aisladas de animales a los diferentes antibioticos testados estaban en un rango de 60.8% (amikacina) a 95.7% (ampicilina); la prevalencia de resistencias a los antibioticos en aislados provenientes de humanos estaban en un rango del 2% (cefuroxima) al 94.1% (gentamicina). Las cepas de E. coli aisladas de animales, mostraban una mayor resistencia que las aisladas de humanos, para 5 de los 8 antimicrobianos evaluados. Conclusion: En Ghana, el uso de antibioticos en ganaderia se debe principalmente al interes de los ganaderos de prevenir y tratar las infecciones de los animales, mas que en inducir una mejora en el crecimiento y el engorde. Las cepas aisladas de E. coli, tanto de humanos como de animales, mostraron altos niveles de resistencia a los antibioticos, aunque la resistencia de las cepas aisladas de animales parecia ser mayor que la de cepas aisladas de humanos. En Ghana es necesario desarrollar un programa para el manejo de las resistencias a los antibioticos, que se centre simultaneamente en el uso de antibioticos tanto en animales como en humanos.

In Ghana and many developing countries, little is known about food safety in relation to antibiotic residues. The objectives of the study were to (i) determine the prevalence of antibiotic residues in animal source food and estimate the risk to consumers (ii) identify factors predisposing animal source food to contamination with antibiotic drug residues. A total of 634 samples of various animal source foods, including beef, chevon, mutton, pork and egg were screened for drug residues. Additionally, epidemiological data related to antibiotic usage on animals and consumption patterns of animal source food was collected from animal farmers and consumers of animal source food respectively. Overall, the prevalence of drug residues in animal source food was 21.1%, which translates to an average risk of exposure every fifth time animal source food is consumed. The prevalence rates of drug residues in the various animal source foods were; 30.8% (beef); 29.3% (chevon); 28.6% (pork); 24% (mutton); and 6.8% (egg). The trends of consumption of the animal source foods were similar, and majority of the consumers consumed the food every week. Considering the relatively high contamination rates of animal source food as well as their high rates of consumption, it is likely that consumers experience a high risk of exposure to drug residues, especially through beef. Specific causal factors associated with non-adherence of withdrawal requirements of drugs, and therefore contaminations of food were mainly knowledge related factors. This underscores the importance of health education of farmers in dealing with the problem of drug residues contaminating animal source food.

This study was carried out primarily to evaluate the public health burden related to Streptococcus pneumoniae in Ghana and to provide related preliminary molecular epidemiological data on the organism. Invasive and nasopharyngeal specimens were screened for S. pneumoniae, and isolates were subjected to serotyping, multilocus sequence typing (MLST) and antibiotic susceptibility testing. Overall, the prevalence of S. pneumoniae in cerebrospinal fluid (CSF) was 1.7%, in blood was 0.2%, and in nasopharyngeal specimens was 15.3%. The prevalence of multiple drug resistance among the isolates was 48.6%, while the percentage resistance to various drugs was in the range of 11.1-84.0%. Serotyping of the S. pneumoniae isolates showed 7 different serotypes (3, 6B, 9, 10, 14, 16 and 23F). The extent of coverage of serotypes by the 7-valent pneumococcal conjugate vaccine was 57.1%, for the 10-valent vaccine was 57.1%, and for the 13-valent vaccine was 71.4%. MLST of 7 housekeeping genes of the organism showed a high level of genetic diversity among the isolates. S. pneumoniae appears to be an important organism in invasive infections in Ghana, being the most prevalent organism in CSF in this study. The high multiple drug resistance of the organism observed heightens the public health burden, which may be controlled by pneumococcal conjugate vaccines to a large extent.

Objectives: Vibrio cholerae O1 from a 2006 outbreak in Accra were commonly resistant to multiple antimicrobials and, in particular, to trimethoprim/sulfamethoxazole, drugs commonly used in the treatment of cholera. We sought to determine the genetic basis for trimethoprim/sulfamethoxazole resistance in outbreak isolates. Methods: Twenty-seven isolates from the outbreak were screened by PCR and sequencing for class 1 and 2 integrons and for the SXT element. Results: Twenty-one of the 27 isolates examined, all from the Accra metropolitan area, carried both SXT, an integrated chromosomal element, and a class 2 integron bearing dfrA1, sat and aadA1 cassettes. All these isolates had identical random amplification of polymorphic DNA profiles and two of them also carried a class 1 integron. Conclusions: Most strains characterized carried multiple elements conferring resistance to trimethoprim. This suggests that trimethoprim/sulfamethoxazole should not be used empirically in cholera treatment.

Streptococcus pneumoniae is the cause of high mortality among children worldwide. Antimicrobial treatment and vaccination are used to control pneumococcal infections. In Ghana, data on antimicrobial resistance and the prevalence of multidrug-resistant pneumococcal clones are scarce; hence, the aim of this study was to determine the antibiogram of S. pneumoniae recovered from Ghanaian children younger than six years of age and to what extent resistances were due to the spread of certain sero- and multilocus sequence typing (MLST) types. The susceptibility of 115 pneumococcal isolates, recovered in a previous study, to six antimicrobials was determined by disk diffusion test. Overall, 90.4% of isolates were intermediate penicillin resistant, 99.1% were trimethoprim resistant, 73.0% were tetracycline resistant, and 33.9% were sulfamethoxazole resistant. Low resistance was recorded for erythromycin (2.6%) and cefotaxime (5.2%). Overall, 72.2% of isolates were resistant to penicillin (I or R) and at least two other antimicrobials. MLST of 20 isolates showing resistance to at least four antimicrobials revealed a high diversity documented by 16 different clones, none of which had previously been associated with multidrug resistance. The resistances found may have emerged due to nonprudent antimicrobial use practices and there is a need to monitor and promote prudent antimicrobial usage in Ghana.

Background Buruli ulcer (BU) is one of the neglected tropical diseases. Mycobacterium ulcerans is the aetiologic agent of Buruli ulcer. Many extensive studies have failed to isolate M. ulcerans in pure culture from the environment, even in highly endemic areas of BU. We investigated the role of macro-invertebrates as possible hosts or vectors for M. ulcerans by attempting to cultivate M. ulcerans from these organisms. Methods The study was conducted in 5 villages in the Asante Akim District of Ghana for 10 months. Primary detection of M. ulcerans was done by real-time PCR targeting insertion sequence IS2404 coupled with the detection of IS2606 and Ketone reductase genes for increased sensitivity and specificity. Primary cultures were done using routine bacteriological media for culturing mycobacteria, L-J and special enrichment liquid broth, BACTEC®. Results The overall rate of detection of IS2404 in the general macro-invertebrate population was 12.8%. Cluster of CT-values was observed around a mean value of 35.88 and range values of 28.35–38.61. Statistically, there were no significant differences between the various CT-values obtained, p>0.05. The difference in ∆CT values (IS2606-IS2404) for homogenate sample obtained from Naucoridae which was positive for the three targets on M. ulcerans genome was estimated to be 1.77. The present study reports the cultivation of two IS2404 positive Mycobacteria spp. from two aquatic macro-invertebrates of the families Belostomidae and Notonectidae both of the order Hemiptera. The isolate from Belostomidae was identified as either M. ulcerans or M. marinum with 98% identities that from Notonectidae was 98% identical to M. neoaurum. The organisms are yet to be passaged through mice footpad and fully characterised. Conclusions For the first time M. neoaurum species was reported to have harboured IS2404 element. Aquatic Hemiptera are highly suspected to be vectors or hosts for M. ulcerans and they may transmit the pathogen to humans through biting.

Diarrhoeagenic Escherichia coli (DEC) were sought in stool specimens from 72 adults and children aged over 3 years, who presented with diarrhoea at a hospital in Accra, Ghana, and 72 matched controls. Only diffusely-adherent E. coli were significantly associated with disease in these older individuals (P=0.029). We additionally tested 53 specimens from infants among whom DEC were collectively associated with disease (P=0.012). Enteropathogenic, enterotoxigenic and enteroaggregative E. coli, the most commonly isolated pathotypes from infants with diarrhoea, were frequently recovered from healthy adults. Asymptomatic carriage of DEC by older individuals in Accra may place young children at risk for diarrhoea.

Objective: This study was undertaken to determine the relationship among cervical lactoferrin concentration, other cervical markers potentially related to infection, and spontaneous preterm birth. Study Design: Cervical lactoferrin concentrations obtained at 22 to 24 weeks' gestation among 121 women who had a spontaneous preterm birth Results: Cervical lactoferrin concentrations ranged from not measurable (19% of the concentrations were below the threshold for this assay) to a titer of ≥1:64. There was no significant difference in the overall distributions of lactoferrin concentrations between the case patients and control subjects ( P =.18). Only when the highest titers of lactoferrin were considered were there more women in the spontaneous preterm birth group (6/121 vs 0/121; P =.03). According to Spearman correlation analyses the cervical lactoferrin concentrations were strongly related to interleukin 6 concentration ( r =.51; P =.0001), sialidase activity ( r =.38; P =.0001), and bacterial vaginosis ( r =.38; P =.0001), were weakly related to fetal fibronectin ( r =. 16; P =.01), and were not related to cervical length. With the 90th percentile (a dilution of 1:32) used as a cutoff to establish a dichotomous variable, lactoferrin concentration had the following odds ratios and 95% confidence intervals for associations with other potential markers of infection: bacterial vaginosis odds ratio, 4.8 (95% confidence interval, 2.2-10.3); interleukin 6 concentration odds ratio, 2.8 (95% confidence interval, 1.2-6.5); sialidase activity odds ratio, 5.5 (95% confidence interval, 2.2-13.7); fetal fibronectin concentration odds ratio, 0.6 (95% confidence interval, 0.2-2.0); chlamydiosis odds ratio, 2.3 (95% confidence interval, 0.8-6.9); and short cervix odds ratio, 0.5 (95% confidence interval, 0.2-1.4). Conclusions: Lactoferrin found in the cervix correlated well with other markers of lower genital tract infection. High lactoferrin levels were associated with spontaneous preterm birth but had a very low predictive sensitivity. (Am J Obstet Gynecol 2000;182:631-5.)

This report shows the impact of a pentavalent vaccine that includes Haemophilus influenzae type b (Hib) conjugate vaccine on bacterial meningitis in children younger than 5 years in Ghana. A review of the first 3 years of a pediatric bacterial meningitis surveillance program, started in August 2001 in Accra, Ghana, was undertaken. There was a significant reduction, P = 0.042 and 0.017, in percentage of purulent meningitis in children younger than 1 year, comparing the first year when the vaccine was introduced, to the second and third years, respectively.

Background The objective of this study was to determine the prevalence of nasopharyngeal carriage, serotype distribution, and penicillin resistance of Streptococcus pneumoniae in children ≤6 years of age in Ghana. Methods A cross-sectional study was carried out on a cluster-randomized sample of children ≤6 years of age attending nurseries and kindergartens in Accra and Tamale, Ghana. Basic data on age, sex and exposure to antimicrobials in the previous month were collected on all study subjects. Nasopharyngeal swabs were obtained from participants and all pneumococcal isolates were characterized by serotyping and their penicillin resistance determined. Results The overall prevalence of pneumococcal carriage among the children was 34% in Accra and 31% in Tamale. The predominant serotypes were 19F, 6B, 23F, and 6A with 23% of the isolates being non-typable in Accra and 12% in Tamale. Only two isolates (serotypes 19F and 6B) from Tamale had a MIC >2 μg/ml and were classified as fully penicillin resistant with 45% of the isolates having intermediate resistance. Conclusions These findings indicate that the 13-valent pneumococcal conjugate vaccine (PCV-13) recently introduced in Ghana will cover 48% and 51% of the serotypes identified in Accra and Tamale, respectively. The 23-valent pneumococcal polysaccharide vaccine (PPV-23) will cover 54% of all serotypes detected. The two penicillin resistant isolates (MIC 32 μg/ml) were serotypes included in both PCV-13 and PPV-23. A nationwide monitoring system of penicillin susceptibility patterns and pneumococcal serotypes is recommended.

There is a paucity of data on Staphylococcus aureus epidemiology in Africa. Prevalence of nasal carriage and genetic diversity of S. aureus were determined among hospital staff (HS) and inpatients (IP) at the largest hospital in Ghana. In total, 632 nasal swabs were obtained from 452 IP and 180 HS in the Child Health Department (CHD) and Surgical Department (SD). S. aureus carriage prevalences were 13.9% in IP and 23.3% in HS. The chance of being a carrier was higher in HS ( P = 0.005) and IP staying ≤7 days in hospital ( P = 0.007). Resistance to penicillin (93%), tetracycline (28%) and fusidic acid (12%) was more common than for other agents ( S. aureus carriage was observed among IP compared with HS ( P = 0.01). High genetic diversity was shown by spa typing, with 55 spa types found among 105 isolates; the predominant spa types were t355 (10%) and t084 (10%). MRSA was detected in six IP with an overall carriage prevalence of ca. 1.3%, but not in HS. All three MRSA isolates from SD belonged to ST88–SCC mec IV, and two of them displayed the same spa type and antibiograms; three MRSA isolates from CHD belonged to distinct lineages (ST88–SCC mec IV, ST8–SCC mec V and ST72–SCC mec V). Altogether, these data indicate a high diversity of S. aureus , low levels of MRSA carriage, and a higher chance of nasal carriage of multidrug-resistant S. aureus among IP compared with HS in this hospital.

Buruli ulcer (BU), caused by Mycobacterium ulcerans is a chronic necrotizing skin disease. It usually starts with a subcutaneous nodule or plaque containing large clusters of extracellular acid-fast bacilli. Surrounding tissue is destroyed by the cytotoxic macrolide toxin mycolactone produced by microcolonies of M. ulcerans. Skin covering the destroyed subcutaneous fat and soft tissue may eventually break down leading to the formation of large ulcers that progress, if untreated, over months and years. Here we have analyzed the bacterial flora of BU lesions of three different groups of patients before, during and after daily treatment with streptomycin and rifampicin for eight weeks (SR8) and determined drug resistance of the bacteria isolated from the lesions. Before SR8 treatment, more than 60% of the examined BU lesions were infected with other bacteria, with Staphylococcus aureus and Pseudomonas aeruginosa being the most prominent ones. During treatment, 65% of all lesions were still infected, mainly with P. aeruginosa. After completion of SR8 treatment, still more than 75% of lesions clinically suspected to be infected were microbiologically confirmed as infected, mainly with P. aeruginosa or Proteus miriabilis. Drug susceptibility tests revealed especially for S. aureus a high frequency of resistance to the first line drugs used in Ghana. Our results show that secondary infection of BU lesions is common. This could lead to delayed healing and should therefore be further investigated., Author Summary Buruli ulcer (BU) can lead to large ulcerative lesions due to extensive skin loss caused by the necrotizing effect of the main virulence factor mycolactone. For a long time the general perception was that BU lesions are not infected by other bacteria because of a postulated antimicrobial effect of the macrolide toxin, mycolactone. In this study, we analyzed laboratory confirmed BU lesions before, during, and after streptomycin/rifampicin treatment. Contrary to popular belief, our findings show that BU lesions are frequently co-colonized with other potential bacterial pathogens before, during, and after antibiotic treatment. For example, 75% of cases that were clinically indicative of being infected after treatment were microbiologically confirmed as infected. Most microbiologically infected cases were also confirmed by histopathological analysis. The most prominent bacterial species isolated included Pseudomonas aeruginosa, S. aureus, and P. mirabilis. When we tested the isolates against first line drugs used in Ghana, the isolates were found to be resistant to most of these drugs. This study indicates that wound care practices need to be improved and that wound infection may be a common cause of wound healing delay in BU.

AIMS--Suppurative keratitis is a serious problem in all tropical countries, but very little information is available about the causative organisms in Africa. The objectives were to identify the causative organisms and the proportion of cases caused by fungi in southern Ghana, and to determine whether correct decisions about treatment could be made on the basis of Gram stain in the eye clinic. METHODS--Scrapings were taken from corneal ulcers of consecutive new patients presenting at Korle Bu Hospital, Accra, and inoculated on 'chocolate' and Sabouraud's agars. Further scrapings were taken for Gram staining and interpretation in the eye clinic. Duplicate slides were assessed by an experienced microbiologist in the UK. RESULTS--One or more organisms were cultured from 114 of 199 patients (57.3%), the most common being Fusarium species, Pseudomonas aeruginosa, and Staphylococcus epidermidis. Fungi, alone or in combination, were isolated from 56% of the patients who had positive cultures. In total, 122 patients (61.3%) had their treatment either determined or altered based on the results of the microbiological diagnosis; in 87 of these solely on the basis of direct microscopic examination. CONCLUSIONS--Infection by filamentous fungi accounted for more than half of the ulcers from which cultures were obtained. Both training in technique and experience in interpretation are necessary for microscopy based diagnosis by staff in the clinic to be of greatest value. Direct microscopy was particularly useful for detecting fungi.

To provide insights into the epidemiology of antibiotic usage in animal husbandry in Ghana and its effect on resistance.Three hundred and ninety-five randomly sampled commercial livestock keepers who practised intensive or extensive farming were interviewed about their antibiotic usage practices using a structured questionnaire. Escherichia coli isolated from stool specimens of farmers and their animals were tested against eight antibiotics using the Kirby Bauer method.Ninety-eight percent (387) of the farmers used antibiotics on animals and the main purpose was to prevent infections in animals; 41% applied antibiotics monthly. The overall prevalence of multiple drug resistance among the E. coli isolates was 91.6%; rates in human and animal isolates were 70.6% and 97.7%, respectively. The prevalence of resistance in animal isolates to the various drugs ranged from 60.8% (amikacin) to 95.7% (ampicillin); the prevalence of resistance in human isolates to the drugs ranged from 2% (cefuroxime) to 94.1% (gentamicin). Animal E. coli isolates showed higher resistance than that of human isolates for five of eight drugs tested.It is concluded that antibiotic usage in animal husbandry in Ghana is more driven by the interest of livestock keepers to prevent and treat animal infections than growth enhancement. Both animal and human E. coli showed high levels of antibiotic resistance, although resistance of animal isolates appeared to be higher than that of humans. There is the need for the development of an antibiotic-resistance management programme in Ghana that will focus simultaneously on human and animal use of antibiotics.