Antimicrobial resistance patterns of isolates from bloodstream infections at Jinja Regional Referral Hospital in Uganda

  1. Fahad Lwigale

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Abstract

Background: Bloodstream infections (BSIs) are common acute syndromes of variable origin with high chances for extreme health effects including death. Empirical therapy is usually employed to manage the BSIs despite the high resistance to the antibacterial agents used including cefriaxone and/or metronindazole. This study determined the aetiologic agents responsible for bloodstream infections, their antimicrobial susceptibility patterns, and infection sources in Eastern-central Uganda. Patients and methods: This retrospective cross-sectional study involved analysis of data from all non-duplicate blood culture reports from 2019 to 2021. These were earlier generated using single set blood culture, conventional microbiology techniques and disc diffusion-based antimicrobial susceptibility testing (AST) guided by the Clinical and Laboratory Standards Institute (CLSI) guidelines. World Health Organization Network (WHONET) 2022 desktop software and Microsoft Excel were utilised for data analysis. Results: The 1364 reports showed a diagnostic yield of 6.8% (93/1364) and a 1.5%(21/1364) contamination rate. Overall, 37% and 13% of infections were hospital-acquired and community-acquired respectively. Most etiologic agents were Gram-positive bacteria dominated by Staphylococcus aureus 39/114 (34.2%). Polymicrobial growth existed in 4/1364(0.3%) cases. Staphylococcus aureus was mainly resistant to penicillin G (100%) and most susceptible to gentamicin (%S=74.1, 95% C.I:53.4-88.1).  Escherichia coli and unspecified Coliforms together showed high resistance to ampicillin (87.5%) and third-generation cephalosporins (100%). The least resistance was to chloramphenicol and carbapenems. Conclusion: Staphylococcus aureus highly sensitive to gentamicin was the commonest cause of BSIs in this setting. Therefore, empirical management of suspected BSI cases in the region should include gentamicin. Use of Microbiology services including culture and sensitivity to guide targeted antimicrobial use and monitor resistance trends is required to strengthen antimicrobial stewardship.

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  1. Version published to 10.1099/acmi.0.000874.v3 on Access Microbiology
  3. Access Microbiology

    Comments to Author

    In conclusion, paper suggested empirical treatment based on cumulative data of hospital and community acquired isolates. The resistance pattern of hospital and community acquired BSIs is quite different. In Conclusion section, it is suggested to add a recommendation of monitoring both hospital and community acquired resistance pattern to strengthen antimicrobial stewardship and surveillance policies.

    Please rate the manuscript for methodological rigour

    Good

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Strongly support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  4. Access Microbiology

    Comments to Author

    An interesting epidemiologic study carried out in one of limited-resources countries. However, several issues are raised for authors to be addressed carefully. -What exactly the study type? Authors mentioned that it is a retrospective study, but this is not sufficient. Besides, what are the guidelines used by authors to ensure transparency and validity of their work. -Introduction seems to be too long. It should be shortened to be concise and informative. -Authors used 48 hs-admission as definition of hospital acquired infection. This is inaccurate. Indeed, this is the definition of nosocomial infection, while hospital-acquired infection has another more specific definition. Please see CDC definitions available at CDC website. -Authors did not mention how are blood samples collected? how many bl. culture sets were collected from each patient. It seems crucial as authors define CoNS positivity was excluded as contaminant!! This is unclear and inaccurate. CoNS might be contaminant, but also have been implicated as true pathogens in BSIs. -Authors used many antibiotics in disc diffusion method. What is the value of using chloramphenicol. They used tetracycline while this antibiotic is not included in CLSI guidelines. Authors should revise carefully their antibiotics pannel. -Authors used WHONET software program supported by WHO for microbiological, epidemiological and IC surveillance activities. However, authors did not use this excellent program professionally. The program provide many tools as %R, isolate listing, cross-resistance, predicting outbreaks, flagging unusual pathogens, usual pathogen with unusual antibiogram, etc. Authors should present more detailed findings as per WHONET tools. -Authors mentioned lack of many clinical/demographic data during analyisis as one of the limitation. I think this is a major flaw in the work. Research studies for epidemiologic purpose and while using WHONET, all details should be included. Please jsutify. -Identification of MRSA based on cefoxitin-resistance is insufficient as per CLSI guidelines. Authors should revised the criteria used to identify MRSA. -In table 1: What is the meaning of significant growth? how authors judge significance. Also, who authors define contaminants. It seems very important to be defined clearly.

    Please rate the manuscript for methodological rigour

    Poor

    Please rate the quality of the presentation and structure of the manuscript

    Satisfactory

    To what extent are the conclusions supported by the data?

    Partially support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    Yes: The study is lacking Approval/consent by Ethics or Research Committee or Institution Review Board (IRB). Besides, the study is lacking the study design checklist for its type. For author, please, revise the Equator.org website to specify your study type and what is the suitable study type guidelines for your work. Finally, the study should declare that it was conducted as per Helsinki declaration

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  5. Access Microbiology

    Comments to Author

    Abas Mahammed Abdi Access Microbiology Manuscript ACMI-D-24-00128 Titled "Antimicrobial resistance patterns of isolates from bloodstream Infections at Jinja Regional Referral Hospital: A cross-sectional study" COMMENTS: 1. Line 1-3 Please edit your title as "Antimicrobial resistance patterns of isolates from bloodstream infections at Jinja Regional Referral Hospital" Avoid" A cross-sectional study" from title part line 3 or also add "A retrospective " 2. The abstract should be rewritten after updating the rest of the manuscript. It must include all parts of the study, including the objectives or aim of the study, laboratory method, and study design. 3. Clearly state The methodological part of your study and better to add - Study Setting, Design, Population, Sampling Techniques, - Data Collection Methods, - Laboratory Methods (Blood Sample Collection, Culture and Identification, Antimicrobial Susceptibility Test, Quality Control) 4. In the result part please try to state Gram-negative bacteria and Gram-Positive Bacterial or try to present the respective results in two separate table 5. Discussion part declare your main finding and compare your finding with both supporting and opposing current existing literature. - Clearly state what your research uncovered. 6. Line-340: you recommended that " routinely utilise microbiology services" - Please clearly state what microbiology services should be recommended briefly - Propose future research: Identify areas for further investigation.

    Please rate the manuscript for methodological rigour

    Good

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Partially support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  6. Access Microbiology

    Please rate the manuscript for methodological rigour

    Satisfactory

    Please rate the quality of the presentation and structure of the manuscript

    Good

    To what extent are the conclusions supported by the data?

    Partially support

    Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?

    No

    Is there a potential financial or other conflict of interest between yourself and the author(s)?

    No

    If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?

    Yes

  7. Version published to 10.1099/acmi.0.000874.v2 on Access Microbiology
  8. Access Microbiology

    Many thanks for the author for his interesting piece of work. Understanding antimicrobial resistance trends are indeed vital in influencing empiric antimicrobial prescribing guidelines. I do think your manuscript is of value but am issuing an early Major Revise as I do think it can be polished before inviting reviewers. As it stands, I do believe reviewers would have a hard time agreeing to review. Your abstract needs to be revised, it is what reviewers read first before agreeing to review. At the moment your data needs to be presented more impactful. You have collected so much interesting data but the abstract does not effectively reflect this. I think it would be useful to preface what are usually used for treatment and then highlight the resistance rates to show how your review has direct implications on patient care. The rest of the manuscript needs to be thoroughly reviewed for grammatical errors throughout, especially in terms of capitalization and italicization. The Introduction can also be significantly condensed, as well as the Discussion. Your Conclusion is important, but it does not connect your data with what is being used in real-world Uganda. Do they have empiric antimicrobial prescribing guidelines? How do these connect with your findings. The Results could be made clearer, double-check your Figures especially for titles and axes. I would highly recommend you to revise your manuscript and resubmit as it is a great piece of work that just requires a few changes.

  9. Version published to 10.1099/acmi.0.000874.v1 on Access Microbiology