ANTIBACTERIAL USE AND RESISTANCE PATTERN AT THE ACCIDENT AND EMERGENCY DEPARTMENT OF KOMFO ANOKYE TEACHING HOSPITAL

ABSTRACT
Background and Objectives: Antimicrobial resistance is a major problem all over the world due to indiscriminate and inappropriate use of antimicrobials both in healthcare facilities and in communities. The Accident and Emergency Department (AED) serves as a major area where antimicrobial therapy is initiated for severe infections but data on use of antimicrobial agents in these setting are lacking in Africa. This study aim was to determine the appropriateness of antibacterial use as well as antibacterial resistance patterns of commonly isolated bacteria at AED of Komfo Anokye Teaching Hospital (KATH).
Methodology: This was prospective observational study undertaken from 1st March to 30th April, 2014. Two hundred and eighty-two patients at the AED wards were selected by systematic random sampling from 1119 patients exposed to antibacterials out of total 1942 admitted within the study period. These patients were then followed on daily for data on antibacterial use. From 85 of the admitted patients, 90 specimens were taken for culture and sensitivity testing at the Medical Microbiology laboratory of KATH. The specimens included blood (n=37), others such as ascitic fluid, pleural fluid and knee joint aspirate (n=28), urine (n=15), cerebrospinal fluid (n=5) and wound swab (n=5). Appropriateness of antibacterial use was assessed based on recommendations in the Standard Treatment Guidelines-2010 of Ghana and other international standard guidelines accepted globally and adapted by clinicians at KATH.
Results: In all 1119 out of 1942 patients encountered within the study period were prescribed antibacterials, representing a prevalence of 57.6%. Of the 282 sampled, 61.7% (n=174) were on curative antibacterial therapy and 38.3% (n=108) were on prophylactic therapy. Cefuroxime was the most prescribed antibacterial agent (DDD/100days: parenteral 36.119; oral 75.850) and Doxycycline (DDD/100days: oral 16.689) was the least prescribed. Seventy percent (n=196) of antibacterial prescriptions were considered appropriate based on recommendations in the approved standard guidelines. For those patients on curative antibacterial therapy who were followed (n=123), 15.4% (n=19) died, 56.1% (n=69) had improvement in their clinical status and general well-being, and 28.5% (n=35) had their symptoms worsening.
Twenty-six percent (n=23) of the 90 specimens recorded bacterial growth. The most common isolates were E. coli (n=10), Coagulase Negative Staphylococcus (n=6, possibly contaminants of blood and ascitic fluid specimens), Klebsiella spp (n=4), Pseudomonas spp (n=2) and MRSA (n=1). Over 70% of the E. coli isolates tested were resistant to ceftriaxone, cefuroxime, ciprofloxacin and cotrimoxazole. The Klebsiella isolates were resistant to cefuroxime, cotrimoxazole and ceftriaxone.

Conclusion: The rate of antibacterial prescribing at AED was high, with a third of the prescriptions considered inappropriate. Klebsiella and E coli isolates from patient samples sent to the laboratory were resistant to broad spectrum antibacterial agents like ceftriaxone and cefuroxime. Antimicrobial agents should therefore be used more responsibly, guided by culture and sensitivity data for definitive therapy. This would minimize morbidity and mortality from infectious diseases as well as the risk of emergence and spread of antimicrobial resistance in hospitals.


CHAPTER ONE 
1.1 INTRODUCTION
Inappropriate use of antibacterial agents is a global health concern because of the increasing rate of bacteria resistance to antibacterial agents and poor treatment outcomes from antimicrobial therapy (1). In 2001, the World Health Organization (WHO) announced a global strategy involving all stakeholders to combat the emergence and spread of antimicrobial resistance (2). Also on 7th April, 2011 during the World Health Day, WHO further reiterated a policy package to combat the spread of antimicrobial resistance with a call ―to action today to protect our antibiotics tomorrow‖ (3). In 2013, the Centers for Disease Control and Prevention (CDC) in its maiden report on antimicrobial resistance threats in the United States reiterated the global threat of antibacterial resistance (4).

In Ghana, there is paucity of data on the appropriateness of use of antibacterial agents in the clinical setting although resistance of bacteria to some of these agents is high. Newman et al (2006) in their study established that commonly isolated bacteria in Ghana including Staphylococcus aureus and Salmonella typhi were multidrug resistant (5,6). A study also done in Korle bu Teaching hospital identified nasal colonization of drug resistant strains in children under five (7). Another study by Sanaa et al in 2013 identified the presence of resistant strains of Staphyloccocus aureus isolates to most of the commonly used antibacterial agents in three hospitals in Kumasi (8).

The hospital and societal cost of antibacterial misuse is high. In a study in Chicago involving a sample of 1391, 13.5 % had a resistant bacteria with the societal cost estimated to be $13.35 million in 2008 dollars (9).

There is a decline in development of new antibacterial agents by pharmaceutical companies (10) as result of poor return on their investments and failure of discovery of new antibacterial agents based on traditional models of discovery among other reasons (11,12). This places much responsibility on all stakeholders to protect the antibacterial agents currently in use.

In Emergency department of hospitals, because of the urgent needs of most patients‘ conditions, the interaction between patients and physicians is at times sporadic in nature. This results in most antibacterial prescriptions being empirical or prophylactic. From a study in an emergency department of a tertiary hospital in Taiwan, inadequate empirical antibacterial therapy has been shown to be associated with higher mortality rates (13). A study by Kang et al, also showed the increased mortality among bacteraemic patients is associated with inappropriate first antimicrobial therapy (14).

The strategic position of emergency departments makes the prompt and appropriate antibacterial therapy a major contributory factor in good patients‘ outcomes as antibacterial therapy often start at the department for most patients.

There are various means of determining outcomes of antibacterial therapy in an infection. This includes clinical cure (where resolution of signs and symptoms are used)(15,16), microbiological cure (which involves microbial eradication after treatment), economic (which includes hospital stay days) and ecological outcomes (where resistance rates of commonly isolated organism are determined)(17). However, clinical studies on antibacterial efficacy mostly use two main parameters for the study; clinical improvement/clinical cure and microbiological cure (18).

1.2 Rational of the study
Inadequate data on antibacterial use at Accident and Emergency Department (AED) of the Komfo Anokye Teaching Hospital (KATH) poses a great challenge to rational use of antibacterials in the department and KATH at large. KATH does not currently have an antibacterial stewardship program which includes antibacterial prescribing guidelines. Thus the extent of use of antibacterials whether rationally or irrationally is unknown. This study will provide evidence on the appropriateness of antibacterial use at AED and also highlight the resistance pattern of commonly isolated bacteria during the study period. This study will serve as a baseline study and a guide to the implementation of KATH antibacterial stewardship programme. It will also inform all stakeholders and policy makers in their effort towards promoting rational antibacterial use and support incorporating appropriate antibacterial use in our antimicrobial surveillance system in KATH.

1.3 Main Aim
The aim of this study is to describe antibacterial resistance patterns of commonly isolated bacteria and the appropriate use of antibacterials at the AED of KATH.

1.3.1 Specific Objectives
* To assess the prevalence of use of antibacterials at the AED of KATH.

* To assess the antibacterial prescription pattern at AED and calculate the DDD/100 bed-days of commonly used antibacterial agents.

* To assess the quality (or appropriateness) of antibacterial prescriptions at the AED.

* Ascertain the extent of microbiological culture and sensitivity request at the AED.

* Determine the sensitivity and resistance pattern of commonly isolated bacteria from specimen collected at the AED during the study period.

* Assess  the  outcome  (or  clinical  status)  of  patients  following  curative  antibacterial therapy.

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Item Type: Ghanaian Project Material  |  Attribute: 59 pages  |  Chapters: 1-5
Format: MS Word  |  Price: GH50  |  Delivery: Within 30Mins.
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