Abstract
BackgroundResistance among bacterial infections is increasingly well-documented in high-income countries; however, relatively little is known about bacterial antimicrobial resistance in low-income countries, where the burden of infections is high.MethodsWe prospectively screened all adult inpatients at a referral hospital in Rwanda for suspected infection for seven months. Blood, urine, wound and sputum samples were cultured and tested for antibiotic susceptibility. We examined factors associated with resistance and compared hospital outcomes for participants with and without resistant isolates.ResultsWe screened 19,178 patient-days, and enrolled 647 unique participants with suspected infection. We obtained 942 culture specimens, of which 357 were culture-positive specimens. Of these positive specimens, 155 (43.4%) were wound, 83 (23.2%) urine, 64 (17.9%) blood, and 55 (15.4%) sputum. Gram-negative bacteria comprised 323 (88.7%) of all isolates. Of 241 Gram-negative isolates tested for ceftriaxone, 183 (75.9%) were resistant. Of 92 Gram-negative isolates tested for the extended spectrum beta-lactamase (ESBL) positive phenotype, 66 (71.7%) were ESBL positive phenotype. Transfer from another facility, recent surgery or antibiotic exposure, and hospital-acquired infection were each associated with resistance. Mortality was 19.6% for all enrolled participants.ConclusionsThis is the first published prospective hospital-wide antibiogram of multiple specimen types from East Africa with ESBL testing. Our study suggests that low-resource settings with limited and inconsistent access to the full range of antibiotic classes may bear the highest burden of resistant infections. Hospital-acquired infections and recent antibiotic exposure are associated with a high proportion of resistant infections. Efforts to slow the development of resistance and supply effective antibiotics are urgently needed.
Highlights
When accepting the Nobel Prize for the discovery of penicillin in 1945, Alexander Fleming cautioned that bacteria could become resistant to antibiotics that had revolutionized care for infected patients.[1]
Of 92 Gram-negative isolates tested for the extended spectrum beta-lactamase (ESBL) positive phenotype, 66 (71.7%) were ESBL positive phenotype
Our study suggests that low-resource settings with limited and inconsistent access to the full range of antibiotic classes may bear the highest burden of resistant infections
Summary
When accepting the Nobel Prize for the discovery of penicillin in 1945, Alexander Fleming cautioned that bacteria could become resistant to antibiotics that had revolutionized care for infected patients.[1]. The world is divided into low, lower-middle, upper-middle and high income countries by the World Bank, based on gross national income per capita.[4] While it is clear that antimicrobial resistance (AMR) is a threat, most data on bacterial AMR are from high-income countries.[5] The resistance data that do arise from low-income countries (LICs) have been focused largely on tuberculosis, malaria, and human immunodeficiency virus (HIV).[6] In a recent international study examining bacterial infections among critically ill patients in 75 countries, only 1.1% of positive culture data originated from the African continent.[7] A review of the pediatric AMR literature from sub-Saharan Africa since 2005 identified only 18 articles, with evidence ranging from very-low to moderate quality.[8]. Resistance among bacterial infections is increasingly well-documented in high-income countries; relatively little is known about bacterial antimicrobial resistance in lowincome countries, where the burden of infections is high
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