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