Neonatal Sepsis in a Resource-Limited Setting: Causative Microorganisms and Antimicrobial Susceptibility Profile.

Background: Empiric treatment of suspected neonatal sepsis must be based on data on setting-specific causative pathogens and their respective susceptibilities to antimicrobials, as well as universal treatment guidelines. This approach will ensure better therapeutic outcomes and reduce mortality. Objectives: The objectives of this study were to determine the bacteriological profile and antibiotic susceptibility pattern of isolated microorganisms responsible for neonatal sepsis in a regional hospital in Ghana. Methods: This was a retrospective study that assessed causative microorganisms and antimicrobial susceptibility profiles of neonates suspected of sepsis at the Greater Accra Regional Hospital from January 2018 to December 2019. Blood culture was done using a fully automated BACTEC 9240 blood culture system. Bacteria isolates were identified by Gram staining and conventional biochemical methods. Antimicrobial susceptibility testing was done by Kirby-Bauer's disc diffusion method, and interpretations were carried out according to clinical and laboratory standards. Culture and antibiotic sensitivity reports were obtained and the data subsequently analyzed. Results: Of 2514 blood samples collected from neonates suspected of neonatal sepsis, 528 (21.0%) of the samples were found to be culture-positive. The majority of these positive cultures were from male neonates (68.9%). A total of 11 different pathogens were isolated, of which Gram-positive organisms had a preponderance of 72.0% over Gram-negative organisms (28.0%). Staphylococcus epidermidis was the most common pathogen identified, accounting for 60.0% of isolates. The most prevalent Gram-negative bacteria were Klebsiella spp. (13.6%). Most Gram-positive microorganisms showed sensitivity to amikacin, meropenem, vancomycin, and piperacillin/tazobactam. Gram-positive isolates were found to be resistant to ampicillin and penicillin, but moderately susceptible to flucloxacillin. Most Gram-negative isolates were sensitive to meropenem. Conclusion: The prevalence of culture-proven sepsis was 21.0%. The most prevalent Gram-negative bacteria were Klebsiella spp. As there is some level of antibiotic resistance observed in the current study, it is necessary for routine microbial analysis of samples and their antibiogram.

Possible future trajectory of COVID-19: emphasis on Africa.

Coronavirus disease 2019 (COVID-19) has caused morbidity and mortality in many countries. COVID-19 has also negatively affected the economy of several nations. The dynamics of interaction between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and host, and possible evolution of the virus into more virulent strains pose a threat to global eradication. With the advent of vaccination in most countries, vaccine hesitancy, especially in Africa, is expected to reduce. We also believe that the COVID-19 vaccine would have substantial impact on reducing incidence, hospitalizations, and deaths. A predictor model for COVID-19 infection pattern through to 2025 suggests that recurrent outbreaks are likely to occur. There is a prediction that Africa would not fully recover from the economic crises posed by the pandemic; nonetheless, we expect that economic activities on the continent will improve as countries undertake mass vaccinations and populace attain herd immunity. The growth of e-commerce has been remarkable during the pandemic and we don´t expect trend to decline anytime soon. The pandemic has led to technology and digital platform utilization and/or improvement, which invariably has the tendency to improve quality of lives in the future. These include effective big data monitoring, online shopping, among others. Our future trajectory for recurrent waves of COVID-19 is that these may occur in winter months in temperate climates. We believe that COVID-19 has strengthened Africa´s resilience to future pandemics.

Assessment of prescribing patterns of antibiotics using National Treatment Guidelines and World Health Organization prescribing indicators at the Ghana Police Hospital: a pilot study.

INTRODUCTION: irrational or inappropriate prescribing of antibiotics is a major problem in healthcare and leads to antibiotic resistance. There is the need to understand the prescribing patterns and antibiotic stewardship in health facilities to support appropriate antibiotic use. A study was carried out to evaluate prescribing pattern of antibiotics at the Ghana Police Hospital using National Standard Treatment Guidelines (STG) and World Health Organization (WHO) prescribing indicators. METHODS: a cross-sectional descriptive study was conducted at the Ghana Police Hospital. Data on prescriptions of antibiotics for both out-patients and in-patients was collected between December 2019 and March 2020. A pretested self-designed tool was used for data collection. All sampled prescriptions were assessed for appropriateness using the STG of 2017 and WHO "AWaRe" classification. The criteria used in assessment included dose, frequency, duration of treatment and choice of antibiotic prescribed for disease condition. Descriptive statistics were used in data analysis. RESULTS: a total of 184 patient prescriptions (286 antibiotics) were included in this study. Results showed that antibiotics were mostly prescribed for dental and dental-related conditions (20.7%) and obstetric post-delivery prophylaxis (18.1%). Appropriateness of indicators for antibiotics prescribed assessed ranged between 89.2% to 97.6%. The most frequently prescribed antibiotics were metronidazole (25.9%), amoxicillin with clavulanic acid (22.0%), amoxicillin (16.4%) and ciprofloxacin (10.1%). Based on WHO "AWaRe" classification, the "access" group of antibiotics (74%) was the most prescribed, followed by "watch" group (24%). There were no antibiotics prescribed from the "reserve" group of antibiotics and another 2% that was not part of AwaRe classification. CONCLUSION: study revealed that the level of appropriateness for prescribing indicators assessed was relatively high and majority of prescribed antibiotics were from the "access" and "watch" group. These observations suggest responsible prescribing of antibiotics at the Ghana Police Hospital and effective antibiotic stewardship should be sustained and improved.

One year after first case of COVID-19 in Ghana: epidemiology, challenges and accomplishments.

Coronavirus disease 2019 (COVID-19) caused by the novel coronavirus, has affected many lives, health systems and economies across the globe. Countries in both resource-rich and poor have equally been affected. In Ghana, COVID-19 has caused morbidity and mortality among the populace. The first two cases of COVID-19 were reported in Ghana in March 2020. At the onset of the pandemic in Ghana, there were challenges in securing isolation centers and quarantine facilities. Nonetheless, the government of Ghana put in place a number of measures in line with World Health Organization (WHO) guidelines, to halt the spread of the virus. Some measures taken by the government included partial lockdown of areas deemed hotspots for the spread of the virus. In April 2020, Ghana was ranked number one among African countries in administering tests per million people, because of the effective "trace and test" approach. The government of Ghana also encouraged local manufacturing of personal protective equipment, antivirals and hand sanitizers to help meet the demand of the nation. There were also restrictions on public gathering within the early parts of 2020, and these were eased with time. In February 2021, Ghana became the first country to receive vaccines through the COVAX initiative with a delivery of 600,000 doses of Oxford-AstraZeneca vaccines. The efforts by Ghana to deal with the COVID-19 pandemic have been commendable. Not withstanding, the adverse impact of the COVID-19 on public health in Ghana has been significant, and there is still a lot to learn from other countries in the sub-region, and the world as whole.

COVID-19 pandemic in resource-poor countries: challenges, experiences and opportunities in Ghana.

The novel coronavirus, SARS-CoV-2, which causes COVID-19, is seen world-wide. In developing countries, adequate health facilities and staff numbers are a concern. Ghana recorded its first 2 cases of COVID-19 on 12 March 2020. On 30 March 2020, a partial lockdown for 14 days was imposed and later extended along with other measures. By the end of the initial lockdown, 19 April 2020, an estimated 86,000 people had been traced and 68,591 tests performed. Of the 68,591 tests, there were 1,042 (1.5%) positive cases, 9 deaths, and 99 recoveries, with Ghana ranked number one among African countries in administering tests per million people. Ghana's effective track and trace system, as well as lockdown and other measures, have helped limit mortality with only 85 recorded deaths by 23 June 2020. Scientists from three facilities of the University of Ghana have also successfully sequenced the genomes of COVID-19 from 15 confirmed cases, and the Food and Drugs Authority in Ghana have also helped address shortages by fast-tracking certification of hand sanitizers and local production of 3.6 million standardized personal protective equipment. There has also been the development of prototypes of locally-manufactured mechanical ventilators to meet local need at intensive care units. Most people have also resorted to changing diets and the use of supplements to boost their immune system. Although initial results are encouraging, further research is needed to understand the dynamics of COVID-19 in Ghana and provide additional guidance.

Adherence to Oral Hypoglycemic Drugs among Type 2 Diabetic Patients in a Resource-Poor Setting.

OBJECTIVE: Diabetes mellitus is a growing public health problem in many countries including Ghana. Adherence to drugs, especially among patients with type 2 diabetes mellitus (T2DM) is often poor is some resource-poor settings. The objective of this study was to assess adherence to oral hypoglycemic drugs and factors that affect adherence among patients with T2DM in the Volta Region of Ghana. METHODS: The study was cross-sectional and conducted among 400 patients with T2DM attending diabetic clinics at 4 randomly selected hospitals in the Volta Region of Ghana between January 10 and March 30, 2015. Patients were interviewed using a structured questionnaire and other data collection tools to determine the commonest self-reported reason(s) for nonadherence. Adherence was assessed using the 8-item Morisky Medication Adherence Scale. Multivariate analysis was performed between adherence and statistically significant patient variables. RESULTS: Adherence to oral hypoglycemic drugs among T2DM patients was 47.75%. The odds of adherence with fasting blood glucose between 1 and 6 mmol/L was approximately two-fold (adjusted odd ratio [aOR] =1.92, confidence interval [CI]: 1.11-3.32) versus the odds of having fasting blood glucose of above 10 mmol/L. The odds of adherence among patients with tertiary education was approximately three-fold (aOR = 3.01 CI: 1.44-6.269) versus patients with no formal education. The commonest self-reported reason for nonadherence was forgetfulness. CONCLUSION: Adherence to oral hypoglycemic drugs among T2DM patients in the current study was sub-optimal. Therefore, in such settings, management of T2DM must include strategies to identify nonadherent patients, and regular patient education and counseling.

Antimicrobial point prevalence surveys in two Ghanaian hospitals: opportunities for antimicrobial stewardship.

BACKGROUND: Improved knowledge regarding antimicrobial use in Ghana is needed to reduce antimicrobial resistance (AMR). This includes point prevalence studies (PPSs) in hospitals. Objectives were to: (i) provide baseline data in two hospitals [Keta Municipal Hospital (KMH) and Ghana Police Hospital (GPH)] and identify priorities for improvement; (ii) assess the feasibility of conducting PPSs; and (iii) compare results with other studies. METHODS: Standard PPS design using the Global PPS paper forms, subsequently transferred to their template. Training undertaken by the Scottish team. Quality indicators included: rationale for use; stop/review dates; and guideline compliance. RESULTS: Prevalence of antibiotic use was 65.0% in GPH and 82.0% in KMH. Penicillins and other ß-lactam antibiotics were the most frequently prescribed in both hospitals, with third-generation cephalosporins mainly used in GPH. Antibiotic treatment was mainly empirical and commonly administered intravenously, duration was generally short with timely oral switching and infections were mainly community acquired. Encouragingly, there was good documentation of the indications for antibiotic use in both hospitals and 50.0%-66.7% guideline compliance (although for many indications no guideline existed). In addition, almost all prescribed antibiotics had stop dates and there were no missed doses. The duration of use for surgical prophylaxis was generally more than 1 day (69.0% in GPH and 77.0% in KMH). CONCLUSIONS: These two hospitals were the first in Ghana to use the Global PPS system. We found the PPS was feasible, relatively rapid and achieved with limited training. Targets for improvement identified included reduction of broad-spectrum antibiotics and duration of treatment.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis.

BACKGROUND: The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work. METHODS: MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted. RESULTS: This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis. CONCLUSIONS: There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Supporting antimicrobial stewardship in Ghana: evaluation of the impact of training on knowledge and attitudes of healthcare professionals in two hospitals.

BACKGROUND: A Commonwealth Partnership for Antimicrobial Stewardship was created between the Scottish Antimicrobial Prescribing Group (SAPG), Ghana Police Hospital and Keta Municipal Hospital. During a scoping visit, requirements for implementing antimicrobial stewardship (AMS), areas for improvement and training needs were identified. METHODS: A multidisciplinary team from SAPG and health psychologists from The Change Exchange developed and delivered multi-professional evidence-based teaching incorporating behavioural science, supported by partner pharmacists in each hospital. Four sessions were delivered over 2 days to 60 participants across both sites. Before and after the sessions, participants were asked to complete a knowledge quiz and a behaviours survey. Results were analysed using t-tests. RESULTS: Comparison of the participants' pre- and post-test quiz scores (Keta Municipal Hospital 9.4 and 10.9, Ghana Police Hospital 9.2 and 11.1, respectively) demonstrated statistically significant improvement in knowledge of antimicrobial resistance and appropriate use of antibiotics. Comparison of survey responses before and after the education sessions indicated that the education had a positive impact on participants' attitudes towards the issue of antimicrobial resistance, their role in AMS and confidence in using the Ghana Standard Treatment Guidelines. Participants were also more likely to question colleagues about compliance with guidelines. Forty-eight participants (80%) completed a training evaluation and all responded positively. CONCLUSIONS: The education sessions appeared to be successful in improving knowledge and behaviours of hospital staff. Cascade of an abbreviated version of the training by partner pharmacists and AMS teams in Ghana will ensure that all staff have the opportunity to develop skills and knowledge to support AMS.

Adherence to drug therapy among hypertensive patients attending two district hospitals in Ghana.

BACKGROUND: A major drawback to the management of hypertension among patients is poor adherence to pharmacotherapy. Factors that influence non-adherence to antihypertensive drugs could vary, depending on the prevailing condition of patient and setting. Knowledge of adherence patterns and behavior of hypertensive patients to pharmacotherapy could improve health-directed policies towards hypertension management. OBJECTIVE: The objective of this study was to determine factors that influence adherence to oral antihypertensive drugs among patients attending two district hospitals in the Volta Region of Ghana. METHODS: The study was cross-sectional. Respondents were hypertensive patients attending Krachi West District (n=187) and Hohoe Municipal (n=183) hospitals between March 2016 to May 2016. Data was collected using a structured questionnaire and Morisky 8 Item Measurement of adherence scale. RESULTS: Adherence to oral antihypertensive drugs was 89.2%. However, more than half of these respondents appeared to have uncontrolled blood pressure; and this may be due to self-response bias, blood pressure being measured only on the day of the interview or use of fake drugs (which was not assessed in this study). The strongest predictors of adherence were; knowledge on hypertension, perception of severity of condition and the amount of alcohol consumed in a day by respondents. CONCLUSION: Good adherence to oral antihypertensive drugs was observed in this population despite uncontrolled hypertension in a number of the respondents. The three independent predictors of adherence to antihypertensive medications in this study were respondent's knowledge about hypertension, perception of severity of their condition and the amount of alcohol consumed in a day. Regular patient education and counseling by medical practitioners should be encouraged in these settings to improve patient adherence.

Self-medication practice in Akuse, a rural setting in Ghana.

OBJECTIVE: In most resource-poor settings, there is a paucity of data on self-medication and possible factors that influence this practice. The current study assesses self-medication among the people of Akuse, a rural setting in the Eastern Region of Ghana. METHODS: A quantitative cross-sectional study was carried out in Akuse from 4th January 2016 to 27th February 2016. Using a questionnaire, interviews were conducted to assess self-medication: class of drugs taken, sources of drugs, knowledge of potential adverse effects, among others. RESULTS: Of the 363 participants enrolled, 361 completed questionnaires administered. Of the 361 respondents, 58.4% were female. A majority of the respondents were within the ages of 30 and 45 years. Respondents were mainly farmers (40.2%), and a majority (44.6%) had primary level as the highest education. One major reason for self-medication was influence from family and friends (32.7%). Antibiotics (32.1%) and analgesics (21.0%) were the most common self-medicated drugs, and these drugs were mostly obtained from licenced chemical sellers (32.5%). A little more than a third (39.9%) of the respondents said that their condition did not change after self-medication. A greater number of the respondents (81.7%) did not have knowledge of potential adverse reactions associated with self-medicated drugs. However, respondents with high educational level had the most knowledge of adverse drug reactions. CONCLUSION: The study found self-medication as a common practice among a number of residents of Akuse. Findings from this study provide data that could be used for targeted education and sensitisation of self-medication and its demerits in similar resource-poor rural settings.

Comparative in vitro activity of ciprofloxacin and levofloxacin against isolated uropathogens in Ghana: a pilot study.

INTRODUCTION: Studies on urinary tract infections (UTIs) in West Africa from 1990 to 2012 have showed moderate to high antimicrobial resistance to commonly prescribed antibiotics. Fluoroquinolones have been the main stay in the management of UTIs, but recent reports show emergence of resistance. Levofloxacin and ciprofloxacin still remain the commonest fluoroquinolones prescribed for UTIs in many settings. objective: this study sought to compare activity of ciprofloxacin and levofloxacin against clinical isolates obtained from patients with suspected UTI at the Ghana Police Hospital. METHODS: Midstream urine samples from 153 suspected UTI patients who visited the Ghana Police Hospital from July 2016 to March 2017 were examined. Urine samples were cultured and isolates identified by standard biochemical and serological methods. The Kirby-Bauer disc diffusion method was used to determine susceptibility of isolates to ciprofloxacin and levofloxacin. RESULTS: UTI prevalence was significantly (p < 0.05) higher among female patients (74.5%) than male patients (25.5%). Clinical uropathogens isolated from urine samples were Escherichia coli (28.1%), Coliform spp (43.2%), Klebsiella spp (26.1%) and Staphylococcus aureus (2.6%). Overall sensitivity of the uropathogens to ciprofloxacin and levofloxacin were 77.1% and 62.8%, respectively. Staphylococcus aureusshowed greater resistance to levofloxacin (75%) compared to ciprofloxacin (25%). All Gram-negative isolates showed a higher sensitivity to ciprofloxacin compared to levofloxacin: Escherichia coli; 69.8% vrs 62.8%, Coliform spp; 80.3% vrs 65.2%, and Klebsiella spp; 80% vrs 62.5%. CONCLUSION: This study revealed emergence of resistance of uropathogens to quinolones. The isolates showed higher sensitivity to ciprofloxacin compared to levofloxacin. Rational prescribing and use of these fluoroquinolones following local susceptibility data is thus recommended.

A pilot study evaluating the prescribing of ceftriaxone in hospitals in Ghana: findings and implications.

BACKGROUND AND OBJECTIVES: Widespread empiric use of antibiotics exists especially in developing countries. This is a concern since inappropriate use of antibiotics, including their extended inappropriate use, will increase resistance rates. Consequently, there is a need to evaluate antibiotic utilisation across healthcare sectors to improve future use. This includes ceftriaxone, widely used among hospitals including those in Ghana. METHODS: A cross-sectional study to evaluate the appropriateness of ceftriaxone prescribing in a leading hospital in Ghana. Ceftriaxone prescribing in patient-record cards was assessed using a modified WHO drug-utilization evaluation criteria as well as referencing the national standard treatment guidelines in Ghana and the ceftriaxone package insert. RESULTS: A total of 251 patients were assessed. Ceftriaxone was most commonly prescribed for comorbid malaria with bacterial infections, urinary tract infections, sepsis and gastroenteritis. The appropriateness of the indication was 86% (n = 218). The doses most prescribed were 1g (41%) and 2g (39%). Stat dose and once-daily dosage regimen constituted 51.4% and 84.5%, respectively. The most common duration of treatment was 1 (51.4%) and 2 days (35.1%). The overall appropriateness of prescribing was 93% against a pre-set threshold of 97%. CONCLUSION: The appropriateness of ceftriaxone prescribing was high in this leading hospital in Ghana; however, there is room for improvement with targeted education initiatives, with further research planned.

Prescribing trend of antimalarial drugs at the Ghana Police Hospital.

INTRODUCTION: Malaria ranks among the top three leading causes of morbidity and mortality in developing countries. Appropriate use of recommended antimalarial drugs is vital in the effective management of malaria. METHODOLOGY: This study sought to assess the prescribing trend of antimalarial drugs at the Ghana Police Hospital. Antimalarial drug prescribing trends from 3,127 patient cards were assessed at the pharmacy unit of the hospital between December 2012 and May 2013 using modified World Health Organization rational drug prescribing indicators. RESULTS: Of the 6,697 drugs assessed from the patient cards, antimalarial drugs prescribed included artemether-lumefantrine, 4,226 (63.1%), artemether injection with artemether-lumefantrine tablets, 1,741 (26%), artesunate injection, 241 (3.6%), artemether injection, 194 (2.9%), and artesunate-amodiaquine tablets, 188 (2.8%). The average number of drugs prescribed per encounter was 2.1. A total of 4,052 (60.5%) drugs were prescribed by their generic names, and 2,645 (39.5%) were prescribed by their brand names. There were 2,250 (33.6%) encounters with injection (33.6%), and 6,001 (89.6%) of the prescribed drugs were from the essential drugs list. Prescriptions conforming to recommended dosage regimen totaled 6,328 (94.5%). CONCLUSION: The antimalarial prescribing pattern at the hospital was generally satisfactory. However, the use of injectable antimalarials appeared to be high.

Susceptibility pattern of uropathogens to ciprofloxacin at the Ghana police hospital.

INTRODUCTION: Reports of increasing resistance of uropathogens to antimicrobials is of global concern. Culture and drug susceptibility tests remain a vital guide to effective therapy. The aim of this study was to determine the susceptibility pattern of isolated uropathogens to ciprofloxacin at the Ghana Police Hospital. METHODS: A total of 705 mid-stream urine samples were collected from patients suspected of having urinary tract infection, and visited the Ghana Police Hospital's laboratory from December 2013 to March 2014. Samples were cultured and isolates identified by standard methods, after which isolates susceptibility to ciprofloxacin was determined. RESULTS: Prevalence of urinary tract infection among patients' whose samples were analyzed was 15.9%. Predominant uropathogens isolated were E. coli (46.4%), Coliform (41.1%) and Coliform spp. with Candida (6.2%). Other isolates were Pseudomonas spp. (2.7%), Salmonella spp. (1.8%), Candida spp. (0.9%) and Klebsiella spp (0.9%). The overall resistance among the top three isolated uropathogens to ciprofloxacin was 35.9%. Resistance pattern demonstrated by respective isolates to ciprofloxacin were: E. coli (38.5%), Coliform (54.3%), and Coliform spp. with Candida (15%). The other isolates showed 100% sensitivity. CONCLUSION: This study revealed a relatively high ciprofloxacin resistance among isolated uropathogens, hence, the need for prudent prescribing and use of ciprofloxacin in urinary tract infection management.