title: High prevalence of multidrug resistant Enterobacteriaceae isolated from outpatient urine samples but not the hospital environment in Bo, Sierra Leone.
abstract: BACKGROUND
  The rising level of antimicrobial resistance among bacterial pathogens is one of the most significant public health problems globally. While the antibiotic resistance of clinically important bacteria is closely tracked in many developed countries, the types and levels of resistance and multidrug resistance (MDR) among pathogens currently circulating in most countries of sub-Saharan Africa are virtually unknown.
  
  
  METHODS
  From December 2013 to April 2014, we collected 93 urine specimens from all outpatients showing symptoms of urinary tract infection (UTI) and 189 fomite swabs from a small hospital in Bo, Sierra Leone. Culture on chromogenic agar combined with biochemical and DNA sequence-based assays was used to detect and identify the bacterial isolates. Their antimicrobial susceptibilities were determined using a panel of 11 antibiotics or antibiotic combinations.
  
  
  RESULTS
  The 70 Enterobacteriaceae urine isolates were identified as Citrobacter freundii (n = 22), Klebsiella pneumoniae (n = 15), Enterobacter cloacae (n = 15), Escherichia coli (n = 13), Enterobacter sp./Leclercia sp. (n = 4) and Escherichia hermannii (n = 1). Antimicrobial susceptibility testing demonstrated that 85.7 % of these isolates were MDR while 64.3 % produced an extended-spectrum ß-lactamase (ESBL). The most notable observations included widespread resistance to sulphonamides (91.4 %), chloramphenicol (72.9 %), gentamycin (72.9 %), ampicillin with sulbactam (51.4 %) and ciprofloxacin (47.1 %) with C. freundii exhibiting the highest and E. coli the lowest prevalence of multidrug resistance. The environmental cultures resulted in only five Enterobacteriaceae isolates out of 189 collected with lower overall antibiotic resistance.
  
  
  CONCLUSIONS
  The surprisingly high proportion of C. freundii found in urine of patients with suspected UTI supports earlier findings of the growing role of this pathogen in UTIs in low-resource countries. The isolates of all analyzed species showed worryingly high levels of resistance to both first- and second-line antibiotics as well as a high frequency of MDR and ESBL phenotypes, which likely resulted from the lack of consistent antibiotic stewardship policies in Sierra Leone. Analysis of hospital environmental isolates however suggested that fomites in this naturally ventilated hospital were not a major reservoir for Enterobacteriaceae or antibiotic resistance determinants.
authors.affiliation: Naval Research Laboratory, Code 6910, 4555 Overlook Avenue SW, Washington, DC, 20375, USA. tomasz.leski@nrl.navy.mil.
authors.forename: Tomasz A
authors.initials: TA
authors.lastname: Leski
authors.affiliation: Naval Research Laboratory, Code 6910, 4555 Overlook Avenue SW, Washington, DC, 20375, USA.
authors.forename: Chris R
authors.initials: CR
authors.lastname: Taitt
authors.affiliation: Mercy Hospital Research Laboratory, Bo, Sierra Leone.|Njala University, Bo, Sierra Leone.
authors.forename: Umaru
authors.initials: U
authors.lastname: Bangura
authors.affiliation: Naval Research Laboratory, Code 6910, 4555 Overlook Avenue SW, Washington, DC, 20375, USA.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Stockelman
authors.affiliation: Mercy Hospital Research Laboratory, Bo, Sierra Leone.|Liverpool School of Tropical Medicine, Liverpool, UK.|Njala University, Bo, Sierra Leone.
authors.forename: Rashid
authors.initials: R
authors.lastname: Ansumana
authors.affiliation: Bowie State University, Bowie, Maryland, USA.
authors.forename: William H
authors.initials: WH
authors.lastname: Cooper
authors.affiliation: Naval Research Laboratory, Code 6910, 4555 Overlook Avenue SW, Washington, DC, 20375, USA.
authors.forename: David A
authors.initials: DA
authors.lastname: Stenger
authors.affiliation: Naval Research Laboratory, Code 6910, 4555 Overlook Avenue SW, Washington, DC, 20375, USA.
authors.forename: Gary J
authors.initials: GJ
authors.lastname: Vora
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D004269:DNA, Bacterial / Q000737:chemistry / Q000235:genetics / Q000378:metabolism; D024901:Drug Resistance, Multiple, Bacterial / Q000187:drug effects*; D004755:Enterobacteriaceae / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification; D005260:Female; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D010045:Outpatients; D017422:Sequence Analysis, DNA; D012807:Sierra Leone; D014552:Urinary Tract Infections / Q000175:diagnosis / Q000382:microbiology; D001618:beta-Lactamases / Q000235:genetics
chemical_list: D000900:Anti-Bacterial Agents; D004269:DNA, Bacterial; D001618:beta-Lactamases
keywords: CHROMagar; Citrobacter; ESBL; MDR; Sierra Leone