Antimicrobial Resistance Profile among clinical isolated bacteria at Wolaita Sodo University Teaching Referral Hospital, three year retrospective cohort study

Background Antibiotic resistance is public threats in globally and its problem not well concerned in sub Saharan Africa including Ethiopia due to inadequate set up. However, there is information gap in resistance of antibiotic and its pattern for physicians who prescribe. Therefore, the aim of this study was to review the antimicrobial resistance pattern of bacterial isolated from different specimens inoculated retrospectively at Wolaita Sodo University Teaching Referral Hospital, Southern Ethiopia. Methods A 3 year retrospective data of culture and antibiotic sensitivity pattern analyzed from 2016–2018 among 330 patients records at Wolaita Sodo university Teaching Referral hospital. The data extracted were clinical samples taken, age, sex, bacteria growth status, bacteria isolated, antibiotic resistance profile and trend in each year.The data entry was done using Epidata version 3.5.1 and exported to SPSS version 21 software for cleaning and statistical analysis.Bivariable analysis was done and variables with p-value of less than 0.25 were made candidate for multiple logistic regression analysis. The relative contribution of each selected variables to the outcome of interest was assessed using multiple logistic regression and variables with P-value less than 0.05 were considered as statically significant.


Introduction
Antibiotic resistance is a major threat to health and human development affecting our ability to treat a range of infectious microorganisms [1]. AMR is the ability of Microorganism to resist antimicrobials which may happen naturally, but misuse of antibiotics in humans and animals, for inappropriate microorganisms. As consequence, the antibiotics become ineffective and infection continues in the body, increasing the risk of multiply to person to person of [2]. Resistance to antibiotics occurs through modified antimicrobial target, enzymatic hydrolysis, the outflow of cell membrane and impermeability. Multi antibiotic resistance bacteria acquire resistance by mutation, and gene transfer via conjunctions, transformation, or transduction by which treatment becomes difficult [3]. The expenditure of health care for patients with resistant infections is higher than care for patients with non-resistant infections because of longer duration of illness, additional tests and the need for more expensive medicines. [4] The rise in resistance not only impedes our ability to treat infections, but has broader societal and economic effects, and endangers the achievement of the Sustainable Development Goals [5,6]. The direct and indirect impact of AMR will mostly fall on low-and middleincome countries, which often lack the infrastructure, and human and financial resources to adequately counter drug resistance epidemics [6]. The consequences of AMR are aggravated in volatile situations such as civil unrest, violence, famine and natural disasters, as well as in settings with poor health care services or without access to health care [5,7] AMR is a major public health concern in both developed and developing countries and it can affect anyone, any age, both sex, any country. AMR is high prevalent in low and middle in because of high prevalent of infectious disease, lack of trained health professionals, irrational use of drugs and limited set up of microbiological laboratory [4,8].
According to WHO report of 2014, five out of six WHO regions had more than 50% resistance to third generations Cephalosporin and fluoroquinolones in Escherichia coli and methicillin resistance in Staphylococcus auras in hospital setting. The report attributed 45% of deaths in both Africa and South-East Asia to multi-antibiotic resistant bacteria. It further revealed that K. pneumonia resistant to third generation cephalosporin was associated with elevated deaths in Africa (77%), the Eastern Mediterranean region (50%), South East Asia (81%)and Western Pacific region(72%)[ [8]. According to death attributed in 2016 of AMR in Asia was 4,730,000 and that of Africa was 4,150,000 [9].
Surveillance provides data that can be easily compared, exchanged or used locally, nationally and globally. Unfortunately, many low-and middle income countries including Ethiopia lack the capacity to establish and maintain systems to collect and make use of data on antimicrobial consumption.
Thus, obtaining periodical estimates of the local epidemiological picture of antimicrobial resistance by monitoring various risk groups is essential for guiding clinical action, resource allocation, and intervention protocols to make clinical staff aware. Since start of culturing and antimicrobial testing at Wolaita Sodo University Teaching Referral, utilization of services was very low

Study setting and design
The study was conducted at Wolaita Sodo University Teaching Referral Hospital (WSUTRH), which is

Inclusion criteria and Exclusion criteria
All completed patient data with full information registered in the logbook during the study period was included and patient data with incomplete data were excluded.

Data collection:
Demographic data of patients, the bacteria isolated and the antimicrobial susceptibility profiles were retrieved from Wolaita Sodo teaching referral University hospital (WSUTRH) microbiology, laboratory unit registration records using a standard data collection form. Laboratory records which had incomplete information of either age, sex or culture and drug susceptibility test results were excluded.

Quality assurance:
A standard bacteriological procedure was followed to maintain correct laboratory test results before testing patient sample inoculated. American Type Culture collection (ATCC) standard reference strains Escherichia coli (E. coli) ATCC-25922, Staphylococcus auras (S. auras) ATCC 25923 and Pseudomonas aeruginosa (P. aeruginosa) ATCC-25853 were used to control quality of culture and drug susceptibility testing. All data was checked for consistency and completed registration or recording document.

Ethical considerations
The ethical clearance was obtained from the Ethical review committee of Wolaita Sodo University, College of Health Science and medicine. Formal permission was also obtained from Wolaita Sodo University Referral Hospital. For reasons of privacy, all data were kept confidential. Anonymity of records was maintained by using registration number and unique code numbers used by service providers at Wolaita Sodo University teaching referral hospital.

Data Processing and Analysis
The preliminary data were checked and processed depending on the variables.Data analysis was done by using SPSS Version-20 software and results were summarized using means and percentages and presented by using graphs and tables Result Socio demographic characteristics of the subjects In total 330 patients data recorded over 2016 to 2018 and those that fulfill the inclusion criteria were extracted. Based on their sex, 167 (50.6%) were male and 163 were female (49.4%). The majority of the patients (26.45) included in this study were in the age range of 25 to 34 years. From total 330 patients, 124(37.6%) visited microbiological laboratory in the year of 2017 (See Table 1).   Table 3).  Table 4).   Table   6).    [14][15][16].
This could be due to some updates in microbiological set ups and knowledge of prescriber in choices of drugs or creation of awareness in prescriber that Ethiopia Public Health institute Made [13].
The findings of this study is higher than studies conducted in the Africa countries indicated, Benin 34.6%, Congo 31.9%, Togo 14.3%, Madagascar 16.3% [10]. This might be due to the difference between geographical areas.
In the present study, Staphylococcus was predominate and E. coli the next prevalent which was similar to the study conducted in Gabon, central Africa [4]. Overall resistance of E.coli in this study was 52% and meta-analysis study conducted in the Ethiopia E.coli was 45.38%(33.5%-57.7%) and the highest resistance in Addis Ababa and the lower resistance found in the Tigray 27.5% [17].
Resistance of S.auras for all antimicrobial testing was 53% at this study which is lower than study conducted in Greek which was 88% [18]. The low finding this study compared to Greek was that this, the sample isolation was skin infection which is increased normal flora.

Strength and limitation of the study
For the nature of retrospective study, detail information of socio demographic and clinical of patients was not incorporated. The number of drug tested on some pathogens was small in number which indicated high or lower resistance.

Conclusion and recommendation
The high prevalent bacteria pathogens isolated were S. auras from gram positive and of negative E. coli. Most of pathogens isolated showed high resistance of antimicrobial against ampicillin, gentamicin, chloramphenicol, ceftrazone, Nalidxic acid, amoxicillin, tetracycline, and vancomycine. Therefore, the study indicating collaboration among clinicians, laboratory personnel and pharmacy professionals to be guided all investigation of infectious diseases should be based on the culture and antimicrobial Sensitivity testing.

Declarations Availability of data & materials
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