Resistance Status of Bacteria from a Health Facility in Ghana: A Retrospective Study

Background Regardless of the global concerted effort to control the development and spread of antimicrobial resistance, increasing cases are continually documented at many medical centres. This situation is reinforced by inadequate information on the trend of resistance resulting from lack of regular antimicrobial resistance surveillance. The present study sought to detect the number of multidrug-resistant (MDR), extended drug-resistant (XDR), and pandrug-resistant (PDR) bacterial isolates at a health facility in Ghana from January 2018 to July 2020. Method A total of 800 data on antimicrobial testing results were extracted from the records of the health facility. The extracted data were explored for the detection of MDR, XDR, and PDR. The study further determined the use of antibiotics using the multiple-drug resistance index (MDRI). Results Except for Staphylococcus and Neisseria spp., all bacterial isolates showed extremely high (100%) proportion of MDR. Although only Staphylococcus spp. (38 (4.8%)) was observed to be XDR, the rest of the bacteria showed the potential to attain the status of XDR or PDR. MDRI indicated high use of antibiotics in the health facility. Conclusion The high antimicrobial resistance observed by the study underscores the need for prompt and effective antibiotic resistance control strategies.


Background
Antibiotics constitute one of the most routinely used medications in clinical settings. In Ghana, recent evidence shows more than half (51.4%) of admitted patients receive one or more antibiotics [1]. A recent study revealed that about 65% of pregnant women are administered antibiotics at some stage during pregnancy [2]. Nonetheless, there have been growing reports of high levels of antibiotic resistance and emerging resistance mechanisms in many health facilities in Ghana [3,4]-it is thought to be particularly high in the northern part [5].
e growing menace of antibiotic resistance (AMR) is more worrying against the backdrop of limited discovery of new antibiotics [6]. In fact, AMR remains one of the top priorities for the World Health Organization following the increasing antibiotic treatment failures recorded in many health facilities worldwide [7,8]. Its potential to derail the progress of modern medicine-treatment and management of debilitating medical conditions including cancer, organ transplantation, diabetes, and caesarean sections-is a cause for serious concern [8]. e problem is attributed to the inappropriate and indiscriminate use of antibiotics which engenders a gradual evolution of multidrug resistance (MDR), extended drug resistance (XDR), and pandrug resistance (PDR) microbes. Skipping of the antibiotic regimen and suboptimal medication exert drug pressure on target bacteria, which select for the resistant (MDR, XDR, and PDR) subpopulations. Subsequent clonal expansion and horizontal resistant gene transfer ensure a complete, if not near complete, ineffectiveness of the frequently used antibiotics.
A myriad of studies have shown that bacteria exhibiting MDR, XDR, and PDR are the principal organisms that undermine successful treatment of nosocomial infections [9][10][11]. Lack of information on the resistant trend of these "superbugs" ensures their continual evolution over time and also retards appropriate control strategies in any case [12]. In light of this, there is the need for every health facility to periodically assess antibiotic use and understand the trend of resistance. e extrapolation of the multiple-drug resistance index (MDRI) has long been one of the most effective tools used to assess the overuse of antibiotics in health facilities. MDRI simplifies effective communication of antimicrobial resistance to policymakers and nonexperts and thereby facilitates informed and concerted response [13]. e present study retrospectively evaluates the trend of antimicrobial resistance by detecting MDR, XDR, and PDR in clinically recovered bacterial isolates at Bolgatanga Regional Hospital, Ghana.

Study Area.
e study was carried out at Bolgatanga Regional hospital, Ghana. e facility serves as a referral hospital to all the district health centres within the Upper East Region of Ghana and other health facilities situated at Ghana's border with Burkina Faso and the Republic of Togo. Recent expansion has increased the total bed capacity of the facility to 556.

Study Design.
is study is a retrospective analysis of routine recovered bacterial isolates subjected against a panel of antibiotics for susceptibility testing. e study spun from January 2018 to July 2020. Records were gathered from May 2020 to July 2020.

Data Extraction.
e data extracted from the health facility's record included the type of specimens, year of bacteria isolation, names of the pathogens, and the results of antibiotic susceptibility testing. Data of positive bacterial culture with susceptibility test records were included. Records that showed no bacteria growth were excluded. All information was confirmed by all the microbiology laboratory staff and reconfirmed by the microbiology unit supervisor and the chief biomedical scientist.

Collection and Identification of Clinical Isolates.
e laboratory recovered bacterial isolates from varying specimens including urine, blood, sputum, seminal fluid, aspirate, cerebrospinal fluid, and swabs from various body sites (vagina, ear, throat, urethral, and wound). Gram staining and morphological identification were done following procedures previously described [14]. A set of biochemical tests including coagulase and catalase (for Gram-positive cocci), lactose fermentation, indole, citrate utilization, urease, triple sugar iron reaction, and oxidase test were performed by the laboratory.

Data Analysis.
Analysis was done with the assumption of unequal variance due to unequal sample sizes of the indexed variables. Mann-Whitney test was used to compare two independent continuous variables. Analysis was done with IBM SPSS statistical software (version 21). Graphs were generated using GraphPad Prism 8.0.2. All analyses were done at an alpha value of 0.05.
e PIs showed >60% resistance against meropenem and >40 resistance against the inexpensive antibiotics (tetracycline, cotrimoxazole, cefuroxime, and chloramphenicol). Approximately 90% of Pseudomonas was resistant to meropenem. Noticeably, amikacin (AMK) appeared to be the most potent antibiotic against all the isolates. e proportion of Staphylococcus and Streptococcus spp. resistant against vancomycin was 74% and 71%, respectively.
Of the total 800 isolates, high proportions of 141 (17.6%), 202 (25.3%), 181 (22.6%), 162 (20.3%) were found to be resistant to at least one antibiotic in 6, 7, 8, and 9 different classes of antibiotics, respectively. One Staphylococcus isolate was found to be resistant to at least one antibiotic in all 12 antibiotic classes but one. e frequency distribution of the resistance status of the isolates is shown in Figure 2.

Discussion
Owing to the existing research data on antibiotic resistance available in Ghana [4,[19][20][21][22][23], it appears that health facilities in the northern zone are disproportionately disadvantaged resulting in the sparsity of empirical evidence needed for local and regional action. Surprisingly, a large amount of quality data is generated by health facilities in the northern part of Ghana but remain underutilized due to lack of interest. To understand the resistance pattern and status of bacterial isolates from Bolgatanga Regional Hospital, secondary data covering a total of 800 bacteria isolates were collected and evaluated. e data revealed that high proportions of Gram-negative isolates relative to Gram-positive isolates were involved in clinical infections frequently recorded at Bolgatanga Regional Hospital. Notably, E. coli and Staphylococcus spp. were the most prevalent Gramnegative and Gram-positive isolates, respectively, as observed in many previous studies in Ghana and elsewhere [24,25].
Overall, the isolates were highly resistant to ampicillin, tetracycline, cotrimoxazole, cefuroxime, chloramphenicol, ceftriaxone, and ceftazidime. e foregoing antibiotics are from five different classes of antibiotics: penicillins, tetracyclines, sulfamethoxazole/trimethoprim, chloramphenicols, and cephalosporins, which suggest wide-range resistance capabilities of the bacterial isolates. In particular, the frequently isolated bacteria, Staphylococcus spp., E. coli, Klebsiella spp., Pseudomonas spp., and Proteus spp., showed high (>40%) resistance to the generally inexpensive broadspectrum antibiotics: tetracycline, cotrimoxazole, cefuroxime, and chloramphenicol; this observation concurs with findings from a number of previous studies in Ghana [5,25,26]. On the contrary, amikacin was found to be the most effective antibiotic agent against all bacterial species-both Gram-negative and Gram-positive isolates. is finding corroborates the findings that showed amikacin as the most effective antibiotic agent against clinical isolates in Ghana [5,27]. e high-resistance pattern of bacterial isolates from Bolgatanga Regional Hospital could be explained by its geographical location as previously explained [5].
A myriad of studies affirm that patients infected with MDR bacteria often have prolonged hospital stay and poor prognosis [28,29]. is outcome is even worse in patients infected with XDR and PDR isolates. In this present study, except for Neisseria spp. and Staphylococcus spp., all the isolates were found to be 100% multidrug resistant. e high proportion of MDR isolates recorded in this present study is aberrant to an earlier study that reported lower proportions (11.8%-78.7%) of multidrug resistance bacteria at eleven hospitals in Ghana [25]. Paradox to the 0.0% PDR bacteria reported by this present study, a proportion of PDR clinical bacterial isolates have been documented at a medical center in Ethiopia [30]. e difference in study sites, time of study,   and the subtle difference in bacterial species and number could argue for the disparities observed between these studies. Among the Gram-positive cocci, comparable XDR proportions of Staphylococcus (38 (15.1%)) and Streptococcus (0 (0.0%)) were observed as reported in India [10]. Although only Staphylococcus spp. was found to be XDR, worryingly, high proportions (686 (85.5%)) of the isolates were resistant to at least one antibiotic from 6, 7, 8, and 9 different categories of antibiotics ( Figure 2). Against this finding, there is an ominous likelihood of MDR isolates to traverse into XDR or PDR "superbugs." Accordingly, prompt and effective control strategies at Bolgatanga Regional Hospital would be required to prevent any quantum leap from MDR to XDR or PDR. e relative high resistance proportion of Staphylococcus spp. observed in this present study could be attributed to its notorious ability to accumulate enormous antibioticresistant determinants. e present study further determined the trend of use or disuse of antibiotics using MDRI. is was to provide a clear view on the extent of antibiotic pressure in the environment within which the bacterial isolates thrived. Results from this present study showed that all bacterial species in 2018 and 2019 had MDRI >0.2, whereas only 5 (3.3%) bacterial species in 2020 had MDRI <0.2. e MDRI somewhat concludes that nearly all the bacterial isolates originated from an environment where there is high use of antibiotics.
It is worthwhile to note that the overall prevalence of XDR should be interpreted with caution as Staphylococcus spp. was the only composite isolate. e MDRI should also be interpreted with caution as it was possibly influenced by the high proportions of resistant Staphylococcus spp. as described earlier [31].

Conclusion
Against the findings of this present study, there were highresistant bacterial isolates at Bolgatanga Regional Hospital, January 2018-July 2020. Resistance in Staphylococcus spp. was high. Also, there are high levels of MDR isolates which are likely to attain XDR or PDR status if immediate action is not taken. Finally, the findings suggest that there is high use of antibiotics at Bolgatanga Regional Hospital, and as such, it is important to critically evaluate and continually track the use of antibiotics to ensure sustained efficacies of the routinely used antibiotics.

Data Availability
All the data generated or analysed during this study are included within this published article.

Ethical Approval
is is a retrospective study, which involves collection of secondary data covering bacteria isolates and their respective antimicrobial sensitivity. e study did not access any patient information, but a letter of consent for using the data was obtained from the health facility. e study outcome will be made available to the health facility to inform and guide decisions at the facility.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
ID, AI, and KF conceptualized and gathered the data for the study. EQ conducted all analyses and drafted the manuscript. All authors read and approved the manuscript for publication.   Journal of Pathogens 5