Antibiotic resistance and use among adult inpatients in a large urban tertiary hospital in Sierra Leone

Background: The growing burden of antibiotic resistance (AR) is a global public health problem. Despite the threats to global efforts to combat infectious diseases, data to guide its prevention and control in sub-Saharan Africa is limited. This study aimed to assess AR and antibiotic use among adult inpatients in an urban tertiary hospital in Sierra Leone. Methods and materials: Using a cross-sectional study design, data on antibiotic use was collected from consecutive adult inpatients (≥18 years) between October 2017 and February 2018 at Connaught Hospital in Freetown, Sierra Leone. Antibiotic resistance rates of bacterial isolates from urine and sputum of adult inpatients (≥ 18 years) were assessed from February through June 2018. Results: Of the 920 patients interviewed, 753 (81.8%) were prescribed an antibiotic. Before antibiotics use, 85.1% had no leucocytes count and none had a bacterial culture. Antibiotics commonly prescribed were cephalosporins (25.0%), penicillins (23.2%) and imidazoles (20.8%). Indications for prescribing were surgical prophylaxis (15.7%), pneumonia (15.1%), and trauma (5.8%). Of the 164 samples, 90.8% was urine. The common urinary isolates were Escherichia coli (29.2%), Klebsiella pneumoniae (19.0%), Enterococcus faecalis (13.1%) and Acinetobacter baumanii (9.4%), while that of sputum were K. pneumoniae (31.3%), E. coli (18.8%), S. aureus (12.5%) and P. aeruginosa (12.5%). Penicillin resistance rate for E. faecium and S. aureus was 100%. Gram negative resistance patterns were ampicillin (93% for both E. coli and A. baumanii and 90% K. pneumoniae), ampicillin-sulbactam (67% for both E. coli and K. pneumoniae), ciprofloxacin (82% K. pneumoniae, 70%E. coli, and 50% P. aeruginosa) and ceftriaxone (70%E. coli, 68%K. pneumoniae and 67% E. cloacae). The resistance rate to carbapenems for all Enterobacteriaceae was 13%, and 32% for all Gram-negative organisms. Conclusion: We found high rates of AR, and antibiotic use, most of which were not guided by laboratory evidence. Drivers of poor prescribing practices and AR are lack of microbiological support and oversight. These are common factors in many developing countries, which lack funds and serve a sicker population. Greater investments are needed to establish antimicrobial stewardship programs and provide clinicians with diagnostic support to enable improvements in patient outcomes and rational use of antibiotics.