Response to: 'letter to the editor : "A multifaceted strategy is needed to limit the over-the-counter sale of antimicrobials"'

We thank the authors for their letter relating to our paper ‘Selling antibiotics without prescriptions among community pharmacies and drug outlets: a simulated client study from Ghana’ [Citation1,Citation2]. We also appreciate the opportunity given to us to respond to the points raised by the authors

Utilising cumulative antibiogram data to enhance antibiotic stewardship capacity in the Cape Coast Teaching Hospital, Ghana

Background: Antimicrobial resistance (AMR) is a major public health challenge with its impact felt disproportionately in Western Sub-Saharan Africa. Routine microbiology investigations serve as a rich source of AMR monitoring and surveillance data. Geographical variations in susceptibility patterns necessitate regional and institutional tracking of resistance patterns to aid in tailored Antimicrobial Stewardship (AMS) interventions to improve antibiotic use in such settings. This study focused on developing a cumulative antibiogram of bacterial isolates from clinical samples at the Cape Coast Teaching Hospital (CCTH). This was ultimately to improve AMS by guiding empiric therapy. Methods: A hospital-based longitudinal study involving standard microbiological procedures was conducted from 1st January to 31st December 2020. Isolates from routine diagnostic aerobic cultures were identified by colony morphology, Gram staining, and conventional biochemical tests. Isolates were subjected to antibiotic susceptibility testing using Kirby-Bauer disc diffusion. Inhibitory zone diameters were interpreted per the Clinical and Laboratory Standards Institute guidelines and were entered and analysed on the WHONET software using the “first isolate only” principle. Results: Overall, low to moderate susceptibility was observed in most pathogen-antibiotic combinations analysed in the study. Amikacin showed the highest susceptibility (86%, n = 537/626) against all Gram-negatives with ampicillin exhibiting the lowest (6%, n = 27/480). Among the Gram-positives, the highest susceptibilities were exhibited by gentamicin (78%, n = 124/159), with clindamycin having the lowest susceptibility (27%, n = 41/154). Among the Gram-negatives, 66% (n = 426/648) of the isolates were identified phenotypically as potential extended-spectrum beta-lactamase producers. Multiple multidrug-resistant isolates were also identified among both Gram-positive and Gram-negative isolates. Low to moderate susceptibility was found against first- and second-line antibiotics recommended in the National standard treatment guidelines (NSTG). Laboratory quality management deficiencies and a turnaround time of 3.4 days were the major AMS barriers identified. Conclusions: Low to moderate susceptibilities coupled with high rates of phenotypic resistance warrant tailoring NSTGs to fit local contexts within CCTH even after considering the biases in these results. The cumulative antibiogram proved a key AMS programme component after its communication to clinicians and subsequent monitoring of its influence on prescribing indicators. This should be adopted to enhance such programmes across the country

Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana : a point prevalence survey study

Introduction Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes. Methods The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded. Results A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). “Access” antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed “Watch” antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available. Conclusions There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing “Watch” antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa

Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana: A point prevalence survey study

Introduction: Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes. Methods: The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded. Results: A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). “Access” antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed “Watch” antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available. Conclusions: There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing “Watch” antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa

Hibernoma cervicofacial. Presentación de un paciente

An unusual case is presented, diagnosed as recidivant cervicofacial hibernoma. An updated literature review is performed, exposing clinical features and outcome.Se presenta un caso poco común de un hibernoma cervicofacial recidivante. Se realiza una revisión actualizada de la enfermedad y se exponen las características clínicas y la evolución del paciente

Selling antibiotics without prescriptions among community pharmacies and drug outlets : a simulated client study from Ghana

Background Selling antibiotics without prescriptions is mostly illegal, including in Ghana, and promotes antimicrobial resistance. We evaluated the prevalence and practice of selling antibiotics without prescriptions among community pharmacies (CPs) and drug outlets, for the first time, in Ghana to quantify and characterise this issue to inform future interventions. Research design/methods Two scenarios utilising the Simulated Client Methodology were enacted: an upper respiratory tract infection of viral origin (scenario one); and paediatric diarrhoea (scenario two). CPs/Outlets were selected by stratified proportional random sampling from four metropolitan cities (~14% of the total Ghanaian population). Selling of antibiotics was assessed at three demand levels and its overall prevalence was estimated, then stratified by the study variables. Results Out of the 265 sampled CPs/outlets, the prevalence of selling antibiotic without prescription was 88.3% (n=234/265), with variations not only across the four regions [92.5% (n=123/133) in Kumasi, 87.5% (n=14/16) in Cape Coast, 84.1% (n=69/82) in Accra, and 82.4% (n=28/34) in Tamale] but also across CPs [90% (n=121/134)] and drug outlets [86% (n=113/131)]. Conclusions A very high prevalence/sub-optimal practice of selling antibiotics without prescriptions was found. This highlights the need to increase compliance with antibiotic dispensing legislation through evidence-based interventions including education of key stakeholders

Additional file 5 of Utilising cumulative antibiogram data to enhance antibiotic stewardship capacity in the Cape Coast Teaching Hospital, Ghana

Additional file 5. Inpatient and outpatient raw data for Chi-square analysis. Raw inpatient and outpatient data used in E. coli Chi-square statistical analysis against amikacin, ceftriaxone, cefotaxime, and ciprofloxacin

Additional file 4 of Utilising cumulative antibiogram data to enhance antibiotic stewardship capacity in the Cape Coast Teaching Hospital, Ghana

Additional file 4. Gram-negative multidrug-resistant isolates raw data. Total number of Gram-negative isolates classified as multidrug-resistant together with the number of classes of antibiotics they were tested against and zone diameters against antibiotics tested

Additional file 1 of Utilising cumulative antibiogram data to enhance antibiotic stewardship capacity in the Cape Coast Teaching Hospital, Ghana

Additional file 1. Gram-negative Cumulative Antibiogram Raw Data. Total number of Gram-negative isolates tested against each antibiotic to produce cumulative antibiogram percentage susceptibilities

Antibiotic prescribing proportion by AWaRe category, route of administering, and ward classifications in CCTH.

Antibiotic prescribing proportion by AWaRe category, route of administering, and ward classifications in CCTH.</p