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).
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.
For more Clinical & Social Pharmacy Projects Click here
===================================================================
Item Type: Ghanaian Topic | Size: 59 pages | Chapters: 1-5
Format: MS Word | Delivery: Within 30Mins.
===================================================================
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.