Surveillance of Antimicrobial Drug Resistance in Ghana

SURVEILLANCE OF ANTIMICROBIAL DRUG RESISTANCE IN GHANA

Prof. Mercy J. Newman Dr. Japheth A. Opintan Dr. Eric Sampane-Donkor

February 2015

MoH/DM-UGMS/2014 SSI 09

1 SURVEILLANCE OF ANTIMICROBIAL DRUG RESISTANCE IN GHANA

Prof. Mercy J. Newman Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana Dr. Japheth A. Opintan Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana Dr. Eric S. Donkor Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, University of Ghana

Funding: Ghana National Drug Programme & ADMER (http://admerproject.org/)

2 SUMMARY, RECOMMENDATIONS AND ACKNOWLEDGEMENTS

SUMMARY routine microbiological investigations on

Background: Antimicrobial resistance all clinical specimens received, using in-

(AMR) is now a global health threat. house standard operating procedures. Bi-

The World Health Organization (WHO) weekly, Biomedical Scientists sent recognizes surveillance as one of the completed data sheets, together with pillars for AMR control. AMR bacterial isolates to a central point, using surveillance systems are often active and in-country courier systems. Further operational in resource rich countries. microbiological tests like Minimum

Contrarily, resource limited countries Inhibitory Concentration (MIC), such as Ghana do not have an active Extended Spectrum Beta-Lactamase surveillance systems, and there is limited (ESBL) and Methicillin resistance or no data on AMR. Data on AMR is Staphylococcus aureus (MRSA) needed to improve patient management, detection were performed on randomly and to inform policy in Ghana. Aim: To selected isolates at the central point. generate a nation-wide baseline data on Data was stored and analyzed using

AMR. Methods: A three-day residential WHONET programme files. Results: A workshop was organized to harmonize total of 24 laboratories participated in susceptibility testing protocols, and to the surveillance, and 1598 data sets were initiate a six-month laboratory-based included in the final analysis. A wide surveillance of AMR. All ten (10) variety of both Gram-positive and Gram- regions of Ghana were represented. negative bacterial species were isolated

Selected study laboratories performed from in-patients 428 (26.8%) and

3 outpatients 963 (60.3%). The sources for Staph aureus had reduced MICs (0.05 - the rest 207 (12.9%) were not indicated. 48 µg/ml) to vancomycin. MIC levels to

Urine was the commonest 617 (38.6%) amikacin were relatively low (<128 clinical specimen from which bacteria µg/ml), but high for ciprofloxacin and were isolated, compared to blood 100 ceftriazone (>250 µg/ml). MRSA

(6.3%). Less than half of the 24 study prevalence was 26% (13/50) by Slidex laboratories performed blood culture. test. Conclusion: In this laboratory-

Some organisms isolated included based surveillance, antimicrobial

Escherichia coli (27.5%), Pseudomonas resistance to most antimicrobials was spp (16.6%), Staphylococcus aureus generally high, across the country. An

(11.5%), Streptococcus spp (2.3%) and effective surveillance system is urgently

Salmonella Typhi (0.6%). Resistance needed for continuous monitoring of profiles were generally high (>50%) for AMR in Ghana. most of the antimicrobial agents tested.

Over 80% of the bacteria were extended RECOMMENDATIONS spectrum beta-lactamase producing. ü All district and regional hospitals

Antimicrobials like the penicillins, must have functional microbiological cephalosporins, quinolones, tetracycline laboratories, with capacity for and erythromycin had greater than 50% culture and susceptibility testing. resistance, and majority of the isolates ü Good quality, regular and readily were multiple drug resistant. Greater available laboratory materials for than 70% (17/23) of E. coli isolates had culture and susceptibility testing is high MICs (>256 µg/ml) to urgently needed. ciprofloxacin, and about 78% (21/27)

4 ü Clinical laboratories across the ACKNOWLEDGEMENTS

country need to be strengthened, The Ghana National Drug Programme

especially, to do much more and the ADMER project jointly provided

investigations on all infections, funding for this surveillance, grant

especially, blood-stream infections. numbers MoH/DM-UGMS/2014 and

ü As part of the reporting systems, SSI 99, respectively. The technical

laboratories within the country support provided by the staff of the

should be mandated to collate and Medical Microbiology Department,

share data on AMR. University of Ghana Medical School

ü To ensure credible AMR data, a (now School of Biomedical & Allied

well-coordinated internal and Health Sciences), and all the

external quality assurance system is participating hospitals is sincerely

needed. acknowledged. We appreciate the

ü A designated focal point/place is invaluable role played by Reuben Arhin-

needed to coordinate AMR activities, Essel and Amos Akanwena.

for both local and global action. The following biomedical scientists were

ü AMR activities must be included in involved in the microbiological analysis

both national and facility budgets, and data collation at the health facility

and an effective monitoring and levels, and are gratefully acknowledged:

evaluation mechanisms must be put Hodogbe P and Adade NE, Korle-Bu

in place. Teaching Hospital, Accra; Ampah EO,

ü There is the need to study AMR Ridge Hospital, Accra; Arthur F and

from non-governmental health care Derban I, University of Cape Coast

facilities as well. Hospital, Cape Coast; Mensah E, Holy

5 Family Hospital, Nkawkaw; Twasam J Hospital; Tetteh I, Komfo Anokye and Opoku CN, LEKMA Hospital; Teaching Hospital, Kumasi; Asiedu B,

Mensah E and Amedzro I, Sekondi Upper East Regional Hospital; Bobzah

Public Health Reference Laboratory; BP, Tamale Teaching Hospital, Tamale.

Agede C, Volta Regional Hospial;

Tetteh F, Tema General Hospital, Accra; Finally, we are grateful to the Ghana Kwakye R and Ehiem RC, St. Patrick’s Health Service (GHS), especially, Hospital, Offinso; Tetteh-Ocloo G, Clinical Laboratory Unit (CLU) and Koforidua Regional Hospital, Koforidua; Institutional Care Division (ICD) for Ayivase J, Holy Family Hospital, allowing the Laboratories to Berekum; Kuma GK, Sunyani Regional participate in this surveillance.

6 Table of Contents

SUMMARY, RECOMMENDATIONS AND ACKNOWLEDGEMENTS ...... 3 LIST OF TABLES ...... 7 LIST OF FIGURES ...... 7 LIST OF APPENDICES ...... 8 LIST OF ABBREVIATIONS ...... 9 CHAPTER ONE ...... 10 INTRODUCTION ...... 10 CHAPTER TWO ...... 12 METHODS AND MATERIALS ...... 12 CHAPTER THREE ...... 16 FINDINGS ...... 16 CHAPTER FOUR ...... 31 DISCUSSION AND CONCLUSIONS ...... 31 REFERENCES ...... 36

List of Tables Table 1: Nationwide surveillance data received from health care facilities, Ghana, June - November 2014 ...... 17

Table 2: Bacterial species isolated during surveillance of antimicrobial resistance, Ghana, June - November 2014 ...... 19

Table 3: Specimen types cultured by study laboratories during surveillance of antimicrobial resistance, Ghana, June - November 2014 ...... 20

Table 4: Distributions of antimicrobial agents tested during six-month nationwide surveillance, Ghana, June - November 2014 ...... 23

Table 5: MIC ranges of selected multiple drug resistant surveillance organisms ...... 28

List of Figures Figure 1: Resistance profiles for all bacteria (Fig 1a), Gram-positives (Fig 1b) and Gram- negatives (Fig 1c), June - November 2014 ...... 24

Figure 2: Resistance profiles of Gram-positives from southern (Fig 2a), middle (Fig 2b) and northern (Fig 2c) sectors of Ghana, June - November 2014 ...... 25

7 Figure 3: Resistance profiles of Gram-negatives from southern (Fig 3a), middle (Fig 3b) and northern (Fig 3c) sectors of Ghana, June - November 2014 ...... 26

Figure 4: Comparison of selected antimicrobial in the southern, middle and northern sectors of Ghana ...... 27

Figure 5: Susceptibility profile of ESBL positive isolates (Double Disk Synergy test) ...... 29

Figure 6: Susceptibility profile of MRSA and MSSA isolates, by the Slidex test ...... 30

List of Appendices Appendix 1: Sample of surveillance data collection sheet ...... 40

Appendix 2: Resistance profile of the Greater Accra Region (Korle-Bu, Ridge, Tema, LEKMA) .... 41

Appendix 3: Resistance profile of Central Region (Regional hospital, University hospital) ...... 42

Appendix 4: Resistance profile of the Eastern Region (Tetteh Quarshie, Koforidua, Holy family, Nkawkaw) ...... 43

Appendix 5: Resistance profile of the Volta Region (Volta Regional hospital) ...... 45

Appendix 6: Resistance profile of the Western Region (Sekondi Public Reference Laboratory) .. 45

Appendix 7: Resistance profile of Brong Ahafo Region (Suyani Regional hosp, Holy Family Berekum, Kintampo) ...... 46

Appendix 8: Resistance profile of the Ashanti Region (Komfo Anokye Teaching hosp, St. Patrick Offinso) ...... 47

Appendix 9: Resistance profile of the Northern Region (Tamale Teaching hospital) ...... 48

Appendix 10: Resistance profile of the Upper East Region (Bolgatanga Regional hospital) ...... 49

Appendix 11: List of Biomedical Scientist trained for the current surveillance ...... 50

Appendix 12: Group photograph of BMS ...... 51

Appendix 13: Training session photographs and some preparations before training ...... 52

8 LIST OF ABBREVIATIONS

AMC Amoxicillin/Clavulanic acid LNZ Linezolid

AMK Amikacin LVX Levofloxacin

AZM Azithromycin MEM Meropenem

CAZ Ceftazidime NAL Nalidixic acid

CHL Chloramphenicol NIT Nitrofurantoin

CIP Ciprofloxacin NOR Norfloxacin

CLO Cloxacillin OFX Ofloxacin

CRO Ceftriaxone PIP Piperacillin

CTX Cefotaxime PNV Penicillin

CXM Cefuroxime PPA Pipemidic acid

CZX Ceftizoxime RXT Roxithromicin

ERY Erythromycin SAM Ampicillin/Sulbactam

FLC Flucoxacillin SRX Sparfloxacin

FOX Cefoxitin SXT Trimethroprim/Sulfamethoxazole

GEN Gentamicin MRSA Methicillin Resistant Staph aureus IPM Imipenem MSSA Methicillin Susceptible Staph LEX Cephalexin aureus LIN Lincomycin

9 Chapter One

INTRODUCTION

Globally, antimicrobial resistance (AMR) these interventions seem to have been has become an important public health well implemented in the developed world, threat. Resistant bacteria associated with lack of resources constrains life-threatening infections are becoming implementation in many developing increasingly prevalent, and this limits countries where therapeutic options also therapeutic options 1,2. AMR ultimately tend to be relatively limited. Though the affects both economic and social origin of AMR may be local, it is a global development. The problem has been problem. Discussions are therefore on attributed to the misuse of antimicrobial going for a global surveillance of AMR in drugs, which provide selective pressure, humans. Between 2012 and 2014, the favouring the emergence of resistant WHO technical consultations have held strains. To contain the problem of AMR, several discussions for a possible global the World Health Organization developed AMR surveillance. These discussions some interventions to be implemented by identified gaps in AMR data, and also countries. These included creating a defined the scope and steps necessary for national task force, developing indicators a global platform for AMR surveillance to monitor and evaluate the impact of collaboration and data sharing 5,6. WHO

AMR, and designing reference member states and other important microbiological facilities that would stakeholders reached a consensus to coordinate effective surveillance of AMR commence an early implementation phase among common pathogens 3,4. While for a global AMR surveillance in March

10 2015, at a meeting in Stockholm, Sweden an effective AMR surveillance system in

7. Ghana, to feed into larger global

platforms of AMR monitoring. An up-to- Antimicrobial therapy constitutes a major date AMR surveillance data will not only form of treatment for infectious diseases direct policy issues in Ghana, but also in many parts of Ghana. Additionally, assess the country’s preparedness to due to a relative lack of culture and participate in such global AMR data susceptibility testing of bacteria in several sharing and collaboration. The aim of the health facilities, therapy is mainly current study is to conduct a six-month empirical. This highlights the importance human ABR surveillance, to provide of AMR surveillance in Ghana, which is baseline data, and to identify potential currently very weak or almost non- gaps that may affect future collaboration existent. The first nationwide surveillance and data sharing. of AMR in Ghana was carried out between 2003 - 2004, more than a decade ago 8. There is an urgent need to develop

11 Chapter Two

METHODS AND MATERIALS

Training workshop training workshop was done in May 19 -

21, 2014 in Kumasi, at the Biochemistry A three-day residential workshop was Laboratory, Graduate Complex, Kwame organized to harmonize protocols for Nkrumah University of Science and carrying out susceptibility testing, and to Technology (KNUST). In total, 33 initiate the nationwide surveillance. laboratory technologists participated in the Invitation letters were sent to all ten (10) three-day workshop, and the training regional hospitals, Teaching hospitals, included classroom lectures, discussions some selected District and Mission and hands-on practical sessions. A hospitals. Request and approval was surveillance data collection sheet, pre- sought from the medical directors of the designed by the training resource persons participating hospitals, to release was thoroughly discussed and adapted laboratory technologists within their (Appendix 1). A pre- and post-workshop facilities for the training workshop. The survey was administered to participants. geographical belt of Ghana was divided At the end of the three-day workshop, agar into two parts (southern and northern slants, control strains, and arch files sectors) for training purposes. The training containing data collection sheets were workshop for the southern sector was done given to participants. Some facilities in May 12 - 15, 2014 in Accra, at the received additional laboratory materials Medical Microbiology Department, like antibiotic discs, Mueller Hinton agar School of Biomedical and Allied Health powders, McFarland standards and sterile Sciences (SBAHS). The northern sector swab sticks. Each facility was requested to 12 collect all multiple-drug resistant isolates SBAHS. In-country courier system was from all specimen types. Additionally, mostly used in the transportation of each facility was required to stock all materials between the facilities and the isolates from Cerebrospinal fluid (CSF) central point. A research assistant was regardless of whether they were multiple employed to be liaising with the facilities. drug resistant or not. Multiple drug- The research assistant worked under the resistance was defined as resistance to supervision of the research team. He was three or more antibiotics of different scheduled to be doing quality checks, classes to which these are previously further microbiological analysis like known to be susceptible 9. Minimum Inhibitory Concentration (MIC),

Extended Spectrum Beta-Lactamase Antimicrobial resistance surveillance (ESBL) and methicillin resistance The six-month antimicrobial resistance screening on randomly selected isolates. surveillance commenced shortly after the Additionally, he entered all the data training workshop, June - November 2014. received into WHONET database files 10. Biomedical Scientists from the trained Further microbiological analysis facilities performed their routine microbiological analysis, completed a Generally, bacteria isolates that required surveillance data sheet (Appendix 1) and further identification and those that did not stocked the isolates on agar slants. Zone meet the full panel of antimicrobial agents sizes of antimicrobials tested were of interest to the study were further measured and reported in milliliters. On processed at the Medical Microbiology weekly basis, they sent the data sheets Department, SBAHS. For example, all together with the isolates to a central point, Pseudomonas spp were further tested for the Medical Microbiology Department, their susceptibility to meropenem if not 13 tested previously or if there was the need ESBL positive were additionally tested for to authenticate the viability of the disk their susceptibility to meropenem (MAST, used for testing in the facility from which Germany). MIC test was carried out on the data and the isolate was received. randomly selected isolates observed to be

Secondly, other bacteria were sub-cultured resistant to more than five antibiotic for further phenotypic analysis like classes’ and also representative of the

Extended Spectrum Beta-Lactamase various regions, using the E-test. Gram-

(ESBL), Minimum Inhibitory positives were tested using vancomycin,

Concentration (MIC) and Methicillin and Gram-negatives were tested using

Resistance Staphylococcus aureus ceftriaxone, ciprofloxacin and amikacin

(MRSA). MIC test was done on isolates (bioMERIEUX, SA, France). The that were resistant to three (3) or more manufacturer’s instructions and antimicrobial agents. In total, 773 isolates recommendations from the CLSI 9 were were sub-cultured for further processing. used to interpret results. We additionally

tested for the presence of Penicillin

Binding Proteins in 59 randomly selected Klebsiella sp and Escherichia coli isolates Staphylococcus aureus strains, using the found to be resistant to the third generation Slidex MRSA detection kit cephalosporins were tested for the (bioMERIEUX, SA, France). These presence of ESBLs using the double disc Staphylococcus aureus strains were method 11. We used cefotaxime- previously confirmed using the tube clavulanate combination versus coagulase test, and recommendations of cefotaxime or ceftazidime-clavulanate the manufacturer were adhered to. combination versus ceftazidime disc

(MAST, Germany). Isolates that were 14 Data management and analysis surveillance data into tables and graphs.

Ghana was divided into southern, middle All surveillance data and isolates received and northern sectors for analysis purposes from the healthcare facilities were (Appendix 2). Chi-square was used for catalogued and kept at the Microbiology associations of antibiotic resistance Department, UGMS. Separate record files profiles between the different sectors, after were maintained for each of the 10 regions data was exported into Epi Info 12. from which data was received. Data was Statistical significance was determined at also entered into WHONET data files 10. P-value less than 0.05. Data was cleaned before analysis, and the

WHONET was used to summarize all

15 Chapter Three

FINDINGS

Pre- and post-training survey Data received from facilities

A major challenge identified during the Nine (9) out of the ten (10) regions of training was that most of the facilities Ghana submitted data. Out of a total of usually run out of the logistics needed 1606 data sets received from the 24 for performing susceptibility testing. health care facilities, 1598 were included

They therefore often do not conform to in the final analysis, the rest (8) were standards. For example, where Mueller excluded during data cleaning. Data

Hinton agar is not available, some received from the southern, middle and facilities use nutrient or blood agar base. northern sectors were 1069, 417 and

Where sterile swab sticks are not 112, respectively (Table1). Six (6) available, some also inoculated agar facilities did not submit any data within plates by ‘flooding and pouring away’ the surveillance period. Data received the excess inoculum. Availability and from the teaching hospitals, Public quality of antibiotic discs is also a major Health Reference Laboratories and a concern. The post-training survey District hospital were as follows; Korle- indicated that participants now Bu 699 (43.7 %), Tamale 102 (6.4%), appreciated the need for standards, Komfo Anokye 7 (0.4%), Sekondi especially, the use of quality control Public Health Reference Laboratory 152 strains in the performance of (9.5%), National Public Health susceptibility testing. Reference Laboratory 0 (0%) and

LEKMA Hospital 110 (6.9%), (Table 1).

16 Table 1: Nationwide surveillance data received from health care facilities, Ghana, June - November 2014

Sector Facility Code Data received (%)

Greater Accra Region

Tema General Hospital AcT 18 (1.1)

Korle Bu Teaching Hospital AcK 699 (43.7)

LEKMA Hospital AcL 110 (6.9)

National Public Health Reference

Laboratory AcP 0 (0)*

Ridge Hospital AcR 25 (1.6)

37 Military Hospital Ac3 0 (0)*

Central Region

Central Region Teaching Hospital CeT 6 (0.4)

Southern (n=1069) University Hospital Cape Coast CeU 3 (0.2)

Volta Region

Volta Regional Hospital VoV 56 (3.5)

Western Region

Sekondi Public Health Laboratory WsE 152 (9.5)

Eastern Region

Tetteh Quarshie Memorial Hospital EaT 13 (0.8)

Koforidua Regional Hospital EaK 142 (8.9)

Holy Family Hospital, Nkawkaw EaN 11 (0.7)

Ashanti Region

Komfo Anokye Teaching Hospital AsK 7 (0.4)

St. Patricks Hospital Offinso AsO 14 (0.9)

Agogo Hospital AsA 0 (0)*

Kumasi South Public Health AsP 0 (0)* Middle (n=417) Middle

Brong Ahafo Region

Sunyani Regional Hospital BaS 209 (13.1)

Holy Family Hospital, Nkawkaw BaB 19 (1.2)

Kintampo Municipal Hospital BaK 2 (0.1)

Upper East Region

Wa Regional Hospital UeB 10 (0.6)

Navrongo War Memorial Hospital UeW 0 (0)*

Northern Region

Tamale Teaching Hospital NoT 102 (6.4)

Upper West Region

Northern (n=112) Upper West Regional Hospital UwR 0 (0)* 1598

* These facilities did not submit any data during the surveillance period though they participated in the training workshop.

17 Bacterial species isolated lacked the capacity for blood culture

A wide variety of both Gram-positive (Table 3). The gender of the patients and Gram-negative bacterial species from whom the bacteria isolates were were isolated, including Staphylococcus obtained was females 839 (53%) and aureus (183), Coagulase negative males 660 (41%). In 99 (6%) cases, data staphylococcus (CoNS) (45), on gender was missing. The age

Streptococcus spp (37), Salmonella distributions of the patients in years were

Typhi (9), Non-Typhoidal salmonella as follows; < 1, 113 (7.1%); 1-40, 373

(NTS) (7), Escherichia coli (440), (23.3%); 41-60, 234 (14.6%); >61, 246

Klebsiella spp (114), Pseudomonas (15.4%) and un-indicated ages 396 aeruginosa (118), Citrobacter spp (163) (24.8%). and Vibrio cholerae (19) (Table 2). The Antimicrobial agents screened bacteria were isolated from in-patients Table 4 summaries the antimicrobial 428 (26.8%), outpatients 963 (60.3%), agents that were screened against all the and the sources for the rest were not bacterial isolates obtained from the 24 indicated on the data sheets 161 (10.1%). health care facilities in Ghana, disc Specimen types that grew the bacterial concentrations, and their resistance isolates were diverse and varied. They profiles. In terms of absolute numbers, included blood, urine, stool, swabs (ear, antimicrobials like azithromycin, eye, wound etc) and sputum (Table 3). imipenem, linezolid, oxacillin, pipemidic In 2.8% (46/1598) of the data sets, the acid, ampicillin/sulbactam and specimen type was not indicated. sparfloxacin were least tested, and seem Though most of the healthcare facilities to rather have an unreliable wide range have capacity for urine culture, many

18 Table 2: Bacterial species isolated during surveillance of antimicrobial resistance, Ghana, June - November 2014

Source Number of In- Out- not Organism isolates patients patients indicated Acinetobacter baumannii 1 - - 1 Acinetobacter sp. 24 9 11 4 Citrobacter freundii 3 1 1 1 Citrobacter koseri (diversus) 17 1 15 1 Citrobacter sp. 143 42 86 15 Enterobacter sp. 149 42 83 24 Enterococcus faecalis 1 - 1 - Enterococcus sp. 2 1 1 - Escherichia coli 440 94 309 37 Klebsiella oxytoca 9 4 5 - Klebsiella pneumoniae 17 3 12 2 Klebsiella sp. 88 26 52 10 Moraxella sp. 3 - 3 - Morganella morganii 12 4 8 - Morganella sp. 1 - 1 - Proteus mirabilis 60 12 39 9 Proteus rettgeri 2 1 1 - Proteus sp. 33 7 24 2 Proteus vulgaris 7 2 5 - Providencia sp. 5 3 1 1 Pseudomonas aeruginosa 118 17 83 18 Pseudomonas sp. 147 46 90 11 Salmonella Enteritidis 2 2 - - Salmonella sp. 4 2 1 1 Salmonella Typhi 9 3 5 1 Salmonella, non-Typhi 1 1 - - Serratia marcescens 13 10 2 1 Serratia sp. 2 2 - - Staphylococcus aureus 183 57 111 15 Staphylococcus saprophyticus 4 1 2 1 Coagulase negative Staphylococcus 37 22 15 4 Stenotrophomonas maltophilia 1 - 1 - Streptococcus pneumoniae 2 2 Streptococcus pyogenes 11 5 4 2 Streptococcus sp. 19 13 5 1 Streptococcus, beta-haemolytic 5 4 1 Vibrio cholerae 7 4 3 - Vibrio cholerae O1 Ogawa 12 5 6 1 Totals 1598 442 992 164

19 Table 3: Specimen types cultured by study laboratories during surveillance of antimicrobial resistance, Ghana, June - November 2014

Southern Middle Northern Specimen type # of isolates AcK AcL AcR AcT CeT CeU VoV WsE AsK AsO BaB BaK BaS EaK EaN EaT NoT UeB Abdominal fluid 3 1 1 Abscess 4 1 1 1 1 Aspirate 33 20 1 3 3 2 Blood 100 * 16 1 14 7 1 1 41 1 13 1 Burns 1 1 Catheter 3 3 Cerebrospinal fluid 5 3 1 1 Cervix 2 2 Cornea 3 2 1 Ear 80 24 10 1 10 7 1 16 1 2 1 Eyes 25 18 1 1 1 2 1 Gastric fluid 1 1 Heart valve 1 1 Joint 1 1 Nose 2 1 1 Pleural fluid 3 1 1 1 Prosthesis 1 1 Pus 8 3 1 1 2 Rectal 2 2 Sputum 69 18 5 2 1 24 3 5 7 Stool 26 1 2 1 5 17 Swab 5 4 Throat 2 1 1 Urethra 26 3 2 5 2 11 1 Urine 617 293 40 9 2 1 23 29 4 66 58 2 4 63 3 Vagina 110 1 6 2 4 1 2 5 34 2 15 25 1 9 2 Wound 415 187 19 3 7 3 7 33 5 10 2 40 18 8 3 7 3 Wound, surgical 4 4 Not indicated 46 26 4 8 1 4 Totals 1598 613 108 25 18 6 3 53 150 7 14 18 2 199 142 11 10 100 10 * Korle-Bu Teaching Hospital was not performing blood culture during the surveillance period

Southern)sector:"AcT"&"Tema"General"Hospital,"AcK"&"Korle&Bu"Teaching"Hospital,"AcL"&"LEKMA"Hospital,"AcP"&"National"Public"Health"Reference"Laboratory AcR"&"Ridge"Hospital,"Ac3"&"37"Military"Hospital,"CeT"&"Cape"Coast"Teaching"Hospital,"CeU"&"University"Hospital,"Cape"Coast,"VoV"&"Volta"Regional"Hospital WsE"&"Public"Health"Laboratory,"Sekondi."Middle)sector:"EaT"&"Tetteh"Quarshie"Memorial"Hospital,"EaK"&"Eastern"Regional"Hospital,"Koforidua, EaN"&"Holy"Family"Hospital,"Nkawkaw,"AsK"&"Komfo"Anokye"Teaching"Hospital,"AsO"&"St."Patrick's"Hospital,"Offinso,"AsA"&"Agogo"Presbyterian"Hospital AsP"&"Public"Health"Laboratory,"Kumasi,"BaS"&"Brong"Ahafo"Regional"Hospital,"Sunyani,"BaB"&"Holy"Family"Hospital,"Nkawkaw," BaK"&"Kintampo"Health"Research"Centre."Northern)sector:"UeB"&"Upper"East"Rgional"Hospital,"Bolgatanga,"UeW"&"War"Memorial"Hospital,"Navorongo," NoT"&"Tamale"Teaching"Hospital,"UwR"&"Upper"West"Regioanal"Hospital,"Wa."#"&"number

20 of percentage resistance confidence Brong Ahafo, Ashanti, Northern and the interval (95% CI, 0.0 - 97.3) (Table 4). Upper East regions of Ghana,

The other antimicrobials relatively respectively. seemed to have a reliable narrow range MRSA results of percentage resistance confidence Out of the 50 randomly screened interval (Table 4). Staphylococcus aureus tested for MRSA, Resistance profiles 11 (22%) were positive. The positive

For both Gram-positive and Gram MRSA isolates showed 100% resistance negative organisms, antimicrobial to beta lactam antimicrobials like the resistance levels were very high, greater penicillins and the cephalosporins than 50 %, and ESBLs even approaching (Figure 4). Quinolones like nalidixic

100%, according to the WHONET acid and ofloxacin also showed 100% expert rule (Figure 1). There was greater resistance to the MRSA strains than 50 % resistance for the penicillins, compared with the MSSA (Figure 4). cephalosporins, quinolones, MIC results chloramphenicol, erythromycin and Table 5 shows the MIC results of the tetracycline for the Gram-positives. randomly selected isolates that were Some few antimicrobials like multiple-drug resistant. Whilst some tetracycline and nalidixic acid had isolates had relatively low MIC ranges resistance levels greater than 80% between 0.012 - 3.0 μg/ml, some isolates (Figure 1). Appendix 3 -12 show the had ranges > 256 μg/ml. Though antibiogram profiles for the Greater majority of Staph aureus 78% (21/27) Accra, Central, Eastern, Volta, Western,

21 had low MIC values to vancomycin isolates tested had high MIC values

(0.05 - 48 μg/ml), about 22% (6/27) of (>256 μg/ml) to ciprofloxacin. In general, them had high MIC values (>256 μg/ml). injectables like amikacin had reduced

For E. coli, more than half (17/27) of the MICs to the bacteria tested.

22 Table 4: Distributions of antimicrobial agents tested during six-month nationwide surveillance, Ghana, June - November 2014

Number %R Antimicrobial agent, Code tested %R %I %S % 95%C.I. Amoxicillin/Clavulanic acid, AMC 816 75.6 6.9 16.4 1.1 72.5-78.5 Amikacin, AMK 1049 9 1.8 89.2 7.4-10.9 Ampicillin, AMP 1378 90.6 0.8 6.1 0.1 91.5-94.3 Azithromycin, AZM 2 50 0 50 2.7-97.3 Ceftazidime, CAZ 417 45.8 9.8 44.4 41.0-50.7 Chloramphenicol, CHL 668 67.4 6.3 26.3 63.7-70.9 Ciprofloxacin, CIP 1287 52.9 6.8 40.3 50.1-55.7 Cloxacillin, CLO 134 11.2 0 0 88.8 6.6-18.1 Ceftriaxone, CRO 468 57.9 10 31.6 0.2 53.5-62.6 Cefotaxime, CTX 869 63.9 4.3 29.9 0.1 62.4-68.8 *Cefuroxime, CXM 29 0 0 0 100 0.0-14.6 Cefuroxime, CXM 1232 58.1 5.8 33.9 2.1 55.3-60.9 Ceftizoxime, CZX 167 65.9 12 22.2 58.1-72.9 Erythromycin, ERY 223 48.9 19.3 31.8 42.2-55.6 Flucloxacillin, FLC 85 4.7 0 0 95.3 1.5-12.3 Cefoxitin, FOX 81 39.5 1.2 59.3 29.0-51.0 Gentamicin, GEN 1431 41.9 4.3 53.7 39.3-44.5 Imipenem, IPM 7 71.4 0 28.6 30.2-94.9 Cephalexin, LEX 182 2.2 0 0 97.8 0.7-5.9 Lincomycin, LIN 79 0 0 0 100 0.0-5.8 Linezolid, LNZ 2 0 0 100 0.0-80.2 Levofloxacin, LVX 514 54.1 8 37.9 49.7-58.5 Meropenem, MEM 717 22.3 3.8 72.8 1.1 19.3-25.6 Nalidixic acid, NAL 404 85.4 2.7 11.9 81.5-88.6 Nitrofurantoin, NIT 436 36.9 8 55 32.4-41.6 Norfloxacin, NOR 193 80.8 1 18.1 74.4-86.0 Ofloxacin, OFX 219 59.4 7.8 32.9 52.6-65.9 Oxacillin, OXA 14 42.9 0 35.7 14 .3 24.0-76.0 Piperacillin, PIP 269 34.9 13.4 51.7 29.3-41.0 Penicillin V, PNV 224 7.1 0 0 92.9 4.2-11.5 Pipemidic acid, PPA 10 0 0 0 100 0.0-34.5 Roxithromicin, RXT 73 0 0 0 100 0.0-6.2 Ampicillin/Sulbactam, SAM 17 0 0 0 100 0.0-22.9 Sparfloxacin, SRX 51 82.4 5.9 11.8 68.7-91.2 Trimethoprim/Sulfamethoxazole, SXT 1369 81 1.6 15 2.3 78.8-83.0 Tetracycline, TCY 1116 85.3 3 11.7 83.1-87.3 Vancomycin, VAN 90 0 0 1.1 92.2 2.8-14.5 ^ percentage queried by WHONET expert rule, *questionable CXM results, %, percentage; R, resistant; I, intermediate resistant; S, susceptible; C.I, 95% confidence interval

23 Fig. 1a: All isolates (n=1598)

Fig. 1b: All Gram-positives (n=267)

Fig. 1c: All Gram negatives (n=1331)

Figure 1: Resistance profiles for all bacteria (Fig 1a), Gram-positives (Fig 1b) and Gram- negatives (Fig 1c), June - November 2014

24 Fig 2a: Southern sector (n=150)

Fig 2b: Middle sector (n=95)

Fig 2c: Northern sector (n=22)

Figure 2: Resistance profiles of Gram-positives from southern (Fig 2a), middle (Fig 2b) and northern (Fig 2c) sectors of Ghana, June - November 2014

25 Fig 3a: Southern sector (n=919)

Fig 3b: Middle sector (n=322)

Fig 3c: Northern sector (n=90)

Figure 3: Resistance profiles of Gram-negatives from southern (Fig 3a), middle (Fig 3b) and northern (Fig 3c) sectors of Ghana, June - November 2014

26 Southern"sector" 100" Middle"sector" Northern"sector" 90"

80"

70"

60" %"Resistance" 50" " 40"

30"

20"

10"

0" NAL"≤"18" CIP"≤"13" CXM"≤"14" CTX"≤"14" CRO"≤"14"

An@microbial"agents"and"break"points"used"for"comparison"

Southern"sector" 100" Middle"sector" 90" Northern"sector"

80"

70"

60"

%"Resistance" 50"

40"

30"

20"

10"

0" PEN"≤"14" AMC"≤"16" TYC"≤"14" CHL"≤"18" ERY"≤"14" An@microbial"agents"and"break"points"used"for"comparison"

Southern"sector" 100" Middle"sector" 90" Northern"sector" 80"

70"

60"

%"Resistance" 50"

40"

30"

20"

10"

0" PIP"≤"18" NIT"≤"14" GEN"≤"9" AMK"≤"14" " An?microbial"agents"and"break"points"used"for"comparison"

Figure 4: Comparison of selected antimicrobial in the southern, middle and northern sectors of Ghana

Table 5: MIC ranges of selected multiple drug resistant surveillance organisms

Organism N Antimicrobial drugs MIC range (ug/ml) Staph aureus 27 Vancomycin 0.05 - 48 (*6 isolates >256) E. coli 23 Ciprofloxacin 0.019 -1.5 (*17 isolates >256) 9 Ceftriazone 0.125 - 0.75 (*7 isolates >256)

Pseudomonas spp 17 Ciprofloxacin 0.012 - 8 (*10 isolates >256) 8 Ceftriazone 0.38 - 4 (*5 isolates >256) 17 Amikacin 0.75 - 128

Kleb siella spp 7 Ciprofloxacin 0.016 - 3 (*4 isolates >256) 2 Ceftriazone 0.19 (*1 isolates >256) Citrobacter spp 8 Ciprofloxacin 0 - 24 3 Ceftriazone 0.016 (*2 isolates >256)

Enterobacter spp 7 Ciprofloxacin > 256 Proteus spp 3 Ciproflox acin 0.032 (*1 isolates >256) Morganella spp 1 Ciprofloxacin >256 Vibrio cholerae 1 Ciprofloxacin >256

* Number of isolates with high MIC values

28 All ESBLs positives tested by DDC (n=112)

Figure 5: Susceptibility profile of ESBL positive isolates (Double Disk Synergy test)

MRSA positives (n=13)

MSSA negatives (n=37)

Figure 6: Susceptibility profile of MRSA and MSSA isolates, by the Slidex test

30 Chapter Four

DISCUSSION AND CONCLUSIONS

In the current study, 24 laboratories PHRLs, one each in the Greater Accra, participated in the training workshop. Ashanti, Western and the Northern

However, some laboratories like the 37 regions. The Greater Accra doubles up

Military Hospital, the National Public as the National Public Health Reference

Health Reference Laboratory (NPHRL), Laboratory (NPHRL). Two out of these

Kumasi South Public Health Reference regional PHRLs participated in the

Lab, Agogo Hospital and the Navorongo current surveillance, and data was

War Memorial Hospital did not submit received from only one, Sekondi PHRL, any data during the surveillance period. in the Western Region. Perhaps the

Our preliminary investigations revealed NPHRL is not yet ready to spearhead that, lack of some critical logistics and such nationwide AMR activities, and equipment for culture and susceptibility must be strengthened to play a major testing, unwillingness of clinicians to role in such AMR activities. The make requests for cultures due to observed lack of data from the NPHRL apparent delays in results release, as well could also be attributed to the fact that it as internal managerial issues accounted does not receive routine clinical for the lack of data from these facilities. specimens for analysis. A strengthened

NPHRL could play a vital role in AMR

Some researchers had suggested that surveillance, and coordinate antibiotic

AMR surveillance systems should be quality assessment in Ghana. coordinated by Public Health Reference

Laboratories (PHRL)13. Ghana has four

31 More than two-thirds of the data and blood formed over 70% of all analyzed in the current surveillance were clinical specimens received by the study from the southern sector, with less than laboratories. Though this observation is one-tenth from the northern sector. In consistent with studies elsewhere 16,17,

2003, a similar nationwide surveillance majority of the study laboratories did not of AMR also received relatively small perform blood cultures. For example, number of isolates from the Northern KBTH, the largest tertiary referral parts of Ghana 8. These disparities need hospital in Ghana, with over 2500-bed thorough investigations. But it basically capacity, did not process any blood reflects the health seeking behaviours culture during the surveillance period. and quality of health facilities of the two Blood stream infections can be fatal 18,19. sectors (northern and southern). The Breakdown of blood culture facility in a

Korle-Bu Teaching Hospital (KBTH) large tertiary hospital like KBTH for alone submitted about 44% of the total such a long duration has serious data sets. Academic teaching hospitals consequences for patients. This is are known to be over represented in unacceptable and the problem requires national and multi-center surveillance urgent action. systems 14,15. Such disparities may introduce some biases in the formulation Varied bacteria species were isolated of treatment guidelines. similar to an earlier study with one year

duration by Newman et al 8. However,

Clinical specimens submitted for the current study did not isolate bacteria cultured were diverse in the current like Neisseria meningitides and N study. Urine, swabs (especially wound) gonorrhoea, compared to the earlier

32 study 8. The relatively short duration of These older antimicrobials are cheap, the current study may account for this and their continued use (whether finding. Gram-negative pathogens top appropriate/unappropriate) in both the list of bacteria identified in the humans and animals contribute to the current surveillance. This finding is high resistance levels. similar with both short and long duration surveillance conducted elsewhere 20. In the present study, high levels (>50%)

Vibrio cholerae strains were however of resistance was also observed in the identified in the current study. This third generation cephalosporines and the typified the last phases of the worst fluoroquinolones. Syndromic infections cholera outbreak that hit Ghana, starting are often treated with third generation

January 2014 and lasting several months cephalosporins, and high levels of

21. resistance in these antimicrobials is

worrisome 26,27. Multiple drug reistant

Across the southern, middle and ESBL-producing bacteria were also northern sectors of Ghana, varied levels observed in the current study. These of reistance was oberved in some of the bacteria were generally resistant to antimicrobials (Figure 4). Mainstay ampicillin, third generation antimicrobials like ampicillin, cephalosporins and fluoroquinolones. tetracycline, chloramphenicol and Several studies in Ghana 28,29 and trimethroprim-sulphamethoxazole elsewhere have reported this showed very high (> 70%) resistance phenomenon 30. levels. This is consistent with studies in For treatment of urinary tract and blood

Nigeria 22, Uganda 23, and Tanzania 24,25. stream infections, the Standard

33 Treatment Guideline, Ghana 31, methods, Odonkor et al reported a recommends use of ciprofloxacin. The prevalence of about 33% in Accra 35. high levels of ciprofloxacin resistance This contrasts sharply with about 2% observed in the current study shows that, prevalence in resent findings from Egyir we are gradually narrowing down et al 36. In the current study, the MRSA available treatment options. Globally, isolates were pan-resistant. A major fluoroquinolons have been abused both health care facility in Ghana was in human infections 32 and animal temporially closed because of a production 33,34. suspected MRSA outbreak 37. A major

Most of the organisms in the current limitation of the current study was the study had lowered MIC levels, fact that only multiple drug reistant especially for ciprofloxacin. In an earlier isolates were submitted for analyses. study conducted in Ghana, MIC levels This could account for the high for ciprofloxacin were in the ranges of resistance levels obsereved in some

0.004 - 32 µg/ml 8. MIC levels for specific antimicrobials. ciprofloxacin in the current study ranged from 0.019 - >256 µg/ml. CONCLUSIONS

This laboratory based surveillance shows

The current study observed MRSA that most clinical isolates are multiple prevalence to be around 20% by the drug resistant, to most important

Slidex test. There seemed to be some antimicrobial agents. The study also controvesies over the ‘true’ MRSA highlights the need for a continuous prevalence in Ghana, depending on surveillance of AMR, for local and methods used. Using phenotypic national action. Additionally, the

34 capacity and infrastructure for culture and susceptibility testing across Ghana needs improvement, especially for facilities with the northern parts of the country.

35 REFERENCES 1. Andersson, D. I. & Hughes, D. Sweden, 2 - 3 December 2014. Persistence of antibiotic resistance in (2014). bacterial populations. FEMS 8. Newman, M. J., et al. Resistance to Microbiol Rev 35, 901-911 (2011). antimicrobial drugs in Ghana. Infect 2. Planson, A. G., et al Engineering Drug Resist 4, 215-220 (2011). antibiotic production and 9. CLSI. Clinical Laboratory Standard overcoming bacterial resistance. Institute. Performance Standards for Biotechnol J 6, 812-825 (2011). Antimicrobial Susceptibility Testing: 3. Simonsen, G. S., et al. The Eighteenth Informational antimicrobial resistance containment Supplement. Wayne: Clinical and and surveillance approach--a public Laboratory Standards Institute health tool. Bull World Health Organ (2010). 82, 928-934 (2004). 10. Stelling, J. M. & O’Brien, T. F. 4. Smith, R. D. & Coast, J. Surveillance of antimicrobial Antimicrobial resistance: a global resistance: the WHONET program. response. Bull World Health Organ Clinical infectious diseases 24, 80, 126-133 (2002). S157-S168 (1997). 5. Huttner, A. et al. Antimicrobial 11. Ejaz, H., et al. Detection of resistance: a global view from the extended-spectrum beta-lactamases 2013 World Healthcare-Associated in Klebsiella pneumoniae: Infections Forum. Antimicrob Resist comparison of phenotypic Infect Control 2, 31 (2013). characterization methods. Pak J Med 6. Paphitou, N. I. Antimicrobial Sci 29, 768-772 (2013). resistance: action to combat the 12. CDC. Centers for Disease Control rising microbial challenges. Int J and Prevention. Epi-info version 7. Antimicrob Agents 42 Suppl, S25- Atlanta, GA 30333. (2004). S28 (2013). 13. Grundmann, H. et al. A framework 7. Stockholm. Surveillance of for global surveillance of antibiotic Antimicrobial Resistance for Local resistance. Drug Resist Updat 14, and Global Action - Stockholm, 79-87 (2011).

36 14. Laupland, K. B., et al. Investigation admitted at a tertiary Hospital, of sources of potential bias in North-Western Tanzania. Int Arch laboratory surveillance for anti- Med 5, 28 (2012). microbial resistance. Clin Invest Med 20. Xiao, Y. et al. Bacterial-resistance 30, E159-E166 (2007). among outpatients of county 15. Rempel, O., et al. Antimicrobial hospitals in China: significant resistance surveillance systems: Are geographic distinctions and minor potential biases taken into account? differences between central cities. Can J Infect Dis Med Microbiol 22, Microbes Infect (2015). e24-e28 (2011). 21. UNICEF. Cholera outbreak in the 16. Holloway, K., et al. Surveillance of West and Central Africa: Regional community antimicrobial use in Update, 2014-WEEK 52; Available resource-constrained settings-- at: experience from five pilot projects. http://www.unicef.org/cholera/files/ Trop Med Int Health 16, 152-161 Cholera_regional_update_W52_201 (2011). 4_West_and_Central_Africa.pdf. 17. Lesho, E. P. et al. The antimicrobial Accessed April 2015. (2014). resistance monitoring and research 22. Dada-Adegbola, H. O. & Muili, K. (ARMoR) program: the US A. Antibiotic susceptibility pattern of Department of Defense response to urinary tract pathogens in Ibadan, escalating antimicrobial resistance. Nigeria. Afr J Med Med Sci 39, 173- Clin Infect Dis 59, 390-397 (2014). 179 (2010). 18. Al-Hazmi, H. H., et al. Hospital 23. Andabati, G. & Byamugisha, J. acquired blood stream infection as an Microbial aetiology and sensitivity adverse outcome for patients of asymptomatic bacteriuria among admitted to hospital with other ante-natal mothers in Mulago principle diagnosis. Saudi J Anaesth hospital, Uganda. Afr Health Sci 10, 8, S84-S88 (2014). 349-352 (2010). 19. Meremo, A. et al. High prevalence of 24. Moyo, S., et al. Bacteria isolated Non-typhoid salmonella bacteraemia from bloodstream infections at a among febrile HIV adult patients tertiary hospital in Dar es Salaam,

37 Tanzania--antimicrobial resistance of lactamases in a major teaching isolates. S Afr Med J 100, 835-838 hospital in Ghana: the need for (2010). regular monitoring and evaluation of 25. Moyo, S. J., et al. Antimicrobial antibiotic resistance. Am J Trop Med resistance among producers and non- Hyg. 2013 Nov;89(5):960-4. doi: producers of extended spectrum 10.4269/ajtmh.12-0642. beta-lactamases in urinary isolates at 30. Storberg, V. ESBL-producing a tertiary Hospital in Tanzania. BMC Enterobacteriaceae in Africa - a non- Res Notes 3, 348 (2010). systematic literature review of 26. Marzouk, M., et al. Profile and research published 2008-2012. Infect susceptibility to antibiotics in urinary Ecol Epidemiol 4, (2014). tract infections in children and 31. MOH. Ministry of Health, Ghana. newborns from 2012 to 2013: Data Standard Treatment Guidelines. from 1879 urine cultures. Arch Sixth Edition, 2010. Available at: Pediatr (2015). who.int/medicinedocs/documents/s1 27. Ntirenganya, C., et al. High 8015en/s18015en.pdf. (2010). prevalence of antimicrobial 32. Ena, J. et al. Emergence of resistance among common bacterial ciprofloxacin resistance in isolates in a tertiary healthcare Escherichia coli isolates after facility in rwanda. Am J Trop Med widespread use of fluoroquinolones. Hyg 92, 865-870 (2015). Diagn Microbiol Infect Dis. 1998 28. Feglo, P. et al. Emergence of a novel Feb;30(2):103-7. extended-spectrum-beta-lactamase 33. Poppe, C. et al. Trends in (ESBL)-producing, fluoroquinolone- antimicrobial resistance of resistant clone of extraintestinal Salmonella isolated from animals, pathogenic Escherichia coli in foods of animal origin, and the Kumasi, Ghana. J Clin Microbiol 51, environment of animal production in 728-730 (2013). Canada, 1994-1997. Microbial Drug 29. Obeng-Nkrumah, N., Twum-Danso, Resistance 7, 197-212 (2001). K. & Krogfelt…, K. A. High levels 34. Silbergeld, E. K., et al. Industrial of extended-spectrum beta- food animal production,

38 antimicrobial resistance, and human 36. Egyir, B., et al. Molecular health. Annu. Rev. Public Health 29, epidemiology and antimicrobial 151-169 (2008). susceptibility of clinical 35. Odonkor, S. T., et al. Prevalence and Staphylococcus aureus from antibiotic susceptibility profile of healthcare institutions in Ghana. methicillin resistant Staphylococcus PloS one (2014). aureus in Accra, Ghana. 37. Gyansa-Lutterodt, M. Antibiotic Microbiology Research (2012). resistance in Ghana. Lancet Infect Dis 13, 1006-1007 (2013).

39 Chapter Five

APPENDIX

Antimicrobial,Resistance,Surveillance,3,Ghana:,Weekly,recording,sheet

Name%of%reporting%facility…………………………………………………………………………………………………….%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%(Please&indicate&measured&zone&size)

Isolate/code&&&&&&&&&&&&&&&&&&&& INP/&& (Enter&species&where&

Date S.&# Path&#& Age&(yr) OPD Sex& Diagnosis Specimen&type appropriate) Aug,3,Augmentin,3,30,ug Cip,3,Ciprofloxacin,3,5ug Nal,3,Nalidixic,Acid,30ug Nor,3,Norfloxacin,3,20ug Lev,3,Levofloxacin,3,5ug Crx,3,Cefuroxme,330ug Ctx,3,Cefotaxime,330ug Cef,3,Ceftriaxone,3,30ug Cft,3,Ceftadizime,3,20ug Gen,3,Gentamicin,3,10ug Pip,3,Piperacilin,320,ug Amk,3,Amikacin,3,30,ug Nit,3,Nitrofurantoin,3,300ug Tet,3,Tetracycline,3,30ug Amp,3,Ampicillin,310ug Cot,3,Cotrimoxazole,3,25ug Chl,3,Chloramphenicol,310ug Mem,3,Meropenem,3,30ug Pen,3,Penicillin,1.5ug Cxc,3,Cloxacillin,35ug Flx,3,Flucloxacillin,35ug Ery,3,Erythromycin,35ug Van,3,Vancomycin,330ug Azi,3,Azithromycin,315ug

Key Code Isolate Code Isolate Code Isolate Code Others Out3patient OPD 1 E.,coli 6 Salmonella,Typhi 11 N.,meningitidis 16 In3patient INP 2 Klebsiella 7 Non3typhoidal,Salmonella 12 Staph,aureus 17 3 Enterobacter 8 Citrobacter 13 Staph,epidermidis 18 4 Proteus 9 Haemophilus,influenzae 14 Strep,pneumoniae 19 5 Pseudomonas 10 N.,gonorrhoeae 15 Enterococci/Strept,faecalis

Reporting%officer's%name%&%Signature……………………………………………………………. Head%of%unit%&%Signature…………………………………………………………….

Phone%#:……………..……………….…… Phone%#:……………..……………………………

Appendix 1: Sample of surveillance data collection sheet

All organisms (n=834)

Gram positives (n=106)

Gram negatives (n=728)

Appendix 2: Resistance profile of the Greater Accra Region (Korle-Bu, Ridge, Tema, LEKMA)

41 All organisms (n=9)

Gram positives (n=4)

Gram negatives (n=5)

Appendix 3: Resistance profile of Central Region (Regional hospital, University hospital)

42 All organisms (n=166)

Gram positives (n=10)

Gram negatives (n=156)

Appendix 4: Resistance profile of the Eastern Region (Tetteh Quarshie, Koforidua, Holy family, Nkawkaw)

43 All organisms (n=56)

Gram positives (n=20)

Gram negatives (n=36)

44 Appendix 5: Resistance profile of the Volta Region (Volta Regional hospital)

All organisms (n=152)

Gram positives (n=19)

Gram positives (n=133)

Appendix 6: Resistance profile of the Western Region (Sekondi Public Reference Laboratory)

45 All organisms (n=133)

Gram positives (n=80)

Gram negatives (n=150)

Appendix 7: Resistance profile of Brong Ahafo Region (Suyani Regional hosp, Holy Family Berekum, Kintampo)

All organisms (n=21)

Gram positives (n=5)

Gram negatives (n=16)

Appendix 8: Resistance profile of the Ashanti Region (Komfo Anokye Teaching hosp, St. Patrick Offinso)

All organisms (n=102)

Gram positive (n=17)

Gram negatives (n=85)

Appendix 9: Resistance profile of the Northern Region (Tamale Teaching hospital)

48 All organisms (n=10)

Gram positives (n=5)

Gram negatives (n=5)

Appendix 10: Resistance profile of the Upper East Region (Bolgatanga Regional hospital)

49 6.3 List of participating technologists and facilities

TRAINING'FOR'SURVEILLANCE'OF'ANTIMICROBIAL'RESISTANCE''2'GHANA'PROGRAMME'–'' SOUTHERN'SECTOR''12TH'–'14TH'MAY'2014' ' NO' NAME' HOSPITAL' TELEPHONE' E2MAILS'ADDRESS' NO.' 1" ISAAC"DERBAN"" UCC"-"HOSPITAL" 0246-215"712" [email protected]""" 2" RUDOLF"AARON"ARTHUR" UCC-"HOSPITAL" 0243-713"260" [email protected]" 3" GEORGINA"TETTEH-OCLOO" KOFORIDUA""REGIONAL""HOSPITAL" 0242-814134" [email protected]" 4" RICHARD"KWAKYE" HOLY"FAMILY"HOSPITAL"" 0508-950"692" [email protected]" 5" FELIX"A."TETTEH" TEMA"GENERAL"HOSPITAL"" 0244-578"654" [email protected]" 6" IRENE"AMEDZRO" PUBLIC"HEALTH"LAB"(SEK)" 0208-418471" [email protected]" 7" CHARLES"Y."AGEDE" VOLTA"REGIONAL"HOSPITAL" 0244-721513" [email protected]" 8" PROSPER"MENSAH" VOLTA"REGIONAL"HOSPITAL" 0246-982957" [email protected]" 9" EBENEZER"KOFI"MENSAH" PUBICL"HEALTH"LAB"(SEKONDI)" 0244-528615" [email protected]" 10" KENNEDY"SAKYI" TETTEH-QUARSHIE"HOSPITAL" 0203-468500" [email protected]" 11" PASCAL"HODOGBE" KORLE"BU"TEACHING"HOSPITAL" 0264-587350" [email protected]" 12" NANA"E."ADADE" KORLE"BU"TEACHING"HOSPITAL" 0268-320375" [email protected]" 13" ANI-AMPONSAH"JOHN" 37"MILITARY"HOSPITAL" 0244-663645" [email protected]" 14" EMMANUEL"OFORI"AMPAH" RIDGE"HOSPITAL" 0263-273898" [email protected]" 15" PATRICK"OFORI-ATTA"" HO"MUNICIPAL"HOSPITAL" 0246-891311" [email protected]" 16" FRANCIS"K."ARTHUR" CAPE"COAST"TEACHING"HOSPITAL" 0244-474912" [email protected]" 17" EUNICE"MENSAH"(NKWAKAW)" HOLY"FAMILY"HOSPITAL" 0267-484896" [email protected]" 18" COMFORT"N."OPOKU" GAR/RHD" 0277-844496" [email protected]" 19" JOANA"TWASAM" LEKMA" 0243-159054" [email protected]" 20" GIFTY"BOATENG"" NPHRL" 0277-456019" [email protected]""" "

NO# NAME# HOSPITAL# TELEPHONE# E.MAILS#ADDRESS# NO.# 1" JOHN"AYIVASE" HOLY"FAMILY"HOSPITAL,"BEREKUM" 0208799760" [email protected]" 2" ROSE"HILDA"FOSU" PHL,"KUMASI" 0244836200" [email protected]" 3" George"K."Kuma" Sunyani"Regional"Hospital" 0244180430" [email protected]" 4" Ishmael"Tetteh" KATH/SMS" 0244695247" [email protected]" 5" Bernard"Asiedu" Upper"East"Regional"Hospital" 0246964961" [email protected]" 6" Bernard"P."Bobzah" Tamale"Teaching"Hospital" 0245847286" [email protected]" 7" Godwin"Kwao" Agogo"Presbyterian"Hospital" 0243678814" [email protected]" 8" William"A."Mills\Pappoe" CLU\ICD,"GHS" 0244227941" [email protected]" 9" Samuel"Ahiabah" Kintampo"Municipal"Hospital" 0242705424" [email protected]" 10" Raymond"Charles"Ehiem" Offinso"\"St."Patrick’s"Hospital"" 0244211072" [email protected]" 11" John"Asamoah" KATH" 0209481358" [email protected]" 12" Samuel"Yaw"Oduro" Wa"Regional"Hospital" 0242101311" [email protected]" 13" JAPHETH"A."OPINTAN" UGMS" 0244\789209" [email protected]" 14" MERCY"J."NEWMAN" UGMS" 0244\329266" [email protected]" 15" ERIC"SAMPANE\DONKOR" UGMS" 0277\532027" [email protected]" 16" REUBEN"ESSEL"ARHIN" UGMS" 0208862855" [email protected]" 17" " " " " 18" " " " " 19" " " " " "

Appendix 11: List of Biomedical Scientist trained for the current surveillance

Appendix 12: Group photograph of BMS

Appendix 13: Training session photographs and some preparations before training