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Antibiotic resistance in patients with clinical features of healthcare-associated infections in an urban tertiary hospital in Sierra Leone: a cross-sectional study



Available data on antibiotic resistance in sub-Saharan Africa is limited despite its increasing threat to global public health. As there is no previous study on antibiotic resistance in patients with clinical features of healthcare-associated infections (HAIs) in Sierra Leone, research is needed to inform public health policies. Our study aimed to assess antibiotic resistance rates from isolates in the urine and sputum samples of patients with clinical features of HAIs.


We conducted a cross-sectional study of adult inpatients aged ≥18 years at Connaught Hospital, an urban tertiary care hospital in Freetown between February and June 2018.


Over the course of the study, we enrolled 164 patients. Risk factors for HAIs were previous antibiotic use (93.3%), comorbidities (58.5%) and age (≥65 years) (23.9%). Of the 164 samples, 89.6% were urine. Bacterial growth was recorded in 58.8% of cultured specimens; the type of specimen was an independent predictor of bacterial growth (p < 0.021). The most common isolates were Escherichia coli and Klebsiella pneumoniae; 29.2% and 19.0% in urine samples and 18.8% and 31.3% in sputum samples, respectively.

The overall resistance rates were 58% for all extended-spectrum beta-lactamase (ESBL)-producing organisms, 13.4% for carbapenem-resistant non-lactose fermenting gram-negative bacilli, 8.7% for carbapenem-resistant Acinetobacter baumannii (CRAB) and 1.3% for carbapenem-resistant Enterobacteriaceae (CRE). There were no carbapenem-resistant P. aeruginosa (CRPA) isolates but all Staphylococcus aureus isolates were methicillin-resistant S. aureus.


We demonstrated a high prevalence rate of ESBL-producing organisms which are a significant burden at the main tertiary hospital in Sierra Leone. Urgent action is needed to strengthen microbiological diagnostic infrastructure, initiate surveillance on antibiotic resistance and develop and implement policy framework on antibiotic stewardship.


The growing burden of antibiotic resistance (AR) is a serious global public health problem, presenting a significant threat to the success of treatment, prevention, and control of infectious diseases [1]. While AR poses potential long-term problems globally, currently, patients with AR have worse outcomes including prolonged hospital stays, increased healthcare costs, and increased morbidity and risks of mortality [2]. These factors are worsened in low-and-middle-income countries (LMICs) where infrastructure is lacking and the availability of second- and third-line antibiotic therapies that may be more effective are not widely available [3]. Control of AR requires surveillance to understand the magnitude and burden in LMICs, but this is challenging in many countries because of limited financial and human resources for health capacity and poor laboratory infrastructure for microbiological diagnosis [1, 4]. Increasing antibiotic consumption fueled by improving economies in LMICs poses a threat to the control of AR [5].

In addition to the risks from AR, hospitalized patients in LMICs face a greater risk of contracting hospital-acquired infections (HAIs). The growing burden of HAIs which are driven by poor infection prevention and control (IPC) practices are among the drivers of antibiotic resistance. Evidence indicates a tightly interwoven relationship between antibiotic resistance and HAIs [6].

Multidrug-resistant pathogens are a common cause of HAIs and place a heavy toll on patients and their families by causing illness, potential disability, excess costs and sometimes death [7, 8].HAIs in high-income countries have been estimated to affect 5 to 15% of hospitalized patients in regular wards and 50% or more of patients in intensive care units(ICU) [9]. Although estimates from LMICs suggest that the HAI rate is at least 3 times higher than in the USA [10, 11], however, studies are limited, particularly in Africa, where the burden of HAIs remains largely unknown or underestimated. The lack of surveillance in Africa is due to the complexities in diagnosis and the limited resources required for surveillance to guide interventions. Even though sub-Saharan African countries have committed to control antibiotic resistance in their countries [12], due to a lack of resources and other pressing issues there is, as yet, little effort at scaling up activities on prevention and control of antibiotic resistance. In the WHO African region, only Ethiopia and South Africa had a national antimicrobial resistance plans in place and neither of the countries in this region has a national antimicrobial surveillance system [13].Further compounding the problem is the limited availability of data on antibiotic resistance by a large number of African countries [14]. In a systematic review of the burden of antimicrobial resistance in West Africa, Sierra Leone was singled out among other countries due to paucity of the AR data available [15].

Sierra Leone has a National IPC Policy with eleven core components including surveillance and control of antimicrobial resistance and HAIs [16], and a 5-year strategic plan on antimicrobial resistance for 2017–2021.Yet, there are few activities relating to the implementation of surveillance of AR and HAIs in the country. As there is no previously published study on AR in patients with clinical features of HAI in Sierra Leone, our study aimed to determine the bacterial pathogens and their antibiotic resistance profile among patients with features of these infections in an urban tertiary hospital in Sierra Leone.


Study design and setting

The study used a cross-sectional study design to collect data from 164 adult (≥18 years) inpatients in a 300-bed tertiary hospital in Freetown Sierra Leone.

Connaught Hospital is one of the hospitals within the University of Sierra Leone Teaching Hospitals Complex which was established to provide clinical services, medical training and research. The hospital has four medical and five surgical wards, two private wards and an intensive care unit (ICU). The hospital’s bed occupancy rate at the time of data collection was estimated at 70% during the study.

Participant selection

Participants were recruited sequentially over an 18-week period from February to June 2018. A total sample of 164 participants was conveniently recruited from the medical wards of Connaught Hospital. All hospitalized patients for 48 h or more aged 18 years or older with clinical features of catheter-associated urinary tract infection (CAUTI) and healthcare-associated pneumonia (HAP) with no evidence of an overt or incubating infection at admission or with new-onset symptoms of an infectious process (whether or not they have an underlying structural lung or kidney disease) were eligible for inclusion. None of the patients had ventilator-associated pneumonia (VAP) as the study was limited to the medical wards.

Exclusion criteria were those under 18, patients unable to produce appropriate specimen, and those who declined consent.

Clinical criteria for CAUTI and HAP

Catheter-associated UTI

Patient had an indwelling urinary catheter that had been in place for more than 2 consecutive days in an inpatient location with at least one of the following signs or symptoms: fever (> 38.0 °C), suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency or dysuria [17].

Healthcare-associated pneumonia

Fever (> 38 °C) with at least one of the following features: new-onset cough or worsening cough, dyspnea or tachypnea, rales or bronchial breath sounds and low SPO2 (< 92%) [17, 18].

Specimen and data collection

Two teams of doctors and nurses, trained on the assessment of clinical features of HAI collected data from patients’ files as recorded by the managing teams, and by patients/relatives/ward nurses’ interviews. Baseline information on demographic characteristics and clinical details were collected from patients who met the clinical criteria for HAI. After appropriate labeling of sterile containers, urine and sputum specimens were collected using standard operating procedures.

Although standard criteria were not used to assess sputum quality, the quality of all sputum samples collected was assured by adequately educating the patients and providing appropriate supervision of the sputum collection. As all respiratory samples were sputum collected without induction, sputum samples with poor quality were discarded.

All the patients who had urinary catheters in situ had their catheters changed and urine specimen collected from the new catheters before attaching new urine bags. Latex catheters are routinely used under aseptic conditions in this facility. Severe prostration, urinary retention or incontinence, and altered level of consciousness are some of the indications for catheterizations.

All specimens were immediately transported in a specimen container to the laboratory, situated about 5 km away. As the laboratory was not operational on public holidays and weekends, specimens and data were only collected by the research team on non-holiday week days. When there was a delay in transportation, samples were temporarily stored at 4 °C.

Laboratory materials and methods

Media and reagents

Chromogenic agar (CHROM agar Orientation medium and CHROM agar, France) was used as a selective and differential medium, while brain heart infusion (BHI) agar (Qingdao Hope Biotechnology, China) was used for purification and identification. GN/GP cards and AST-GN09/AST-GP67 cards were used for identification and antibiotic susceptibility testing of gram-negative bacteria/gram-positive bacteria. Gram stain kit (Zhuhai Baso Biotechnology, China) was used for determining gram stain reaction and bacterial morphology of isolates.

Isolation and purification

Upon arrival at the laboratory, urine and sputum samples were streaked onto the chromogenic agar plate within 3 h and incubated aerobically at 37 °C for 18 to 24 h. Where a bacterial growth was observed on the chromogenic agar plate, a single bacterial colony was picked up and then streaked onto a BHI agar plate for purity and a Gram stain. In order to ensure that all isolates were pure, all isolates were cultured at least twice but there were no discordant results.

Identification and antibiotic susceptibility test

A VITEK 2 compact system (bioMérieux, France) was used for identification and antibiotic susceptibility testing of isolates from pure cultures.

A solution of bacteria in saline was prepared in polystyrene tubes (bioMérieux, France) to 0.5~0.63MacFarland turbidity using DensiCHEK Plus turbidimeter (bioMérieux, France). Antibiotic susceptibility test was conducted by adding 145 μl (for gram-negative bacteria) or 280 μl (for gram-positive bacteria) of suspension into a new polystyrene tube as per the manufacturer’s instructions.

The isolates suspensions were loaded on the VITEK 2 compact system and incubated overnight at 37 °C. All results of cultures and resistance testing were dispatched to the research team and service providers within 24 h. Appropriate advice on antibiotic selection was given to the providers.

Data management and analysis

All the data were entered into a Microsoft excel sheet and analyzed using SPSS version 21. Frequency distributions of the variables were produced and examined for inconsistencies and input errors. Quantitative variables were summarized using mean and standard deviation. Using intelligent manual modeling, bivariate and multivariate regression analyses were used to determine the independent predictors of bacterial growth at p < 0.05.

Ethical consideration

Ethical approval was obtained from the Ethics and Scientific Review Committee of Sierra Leone’s Ministry of Health and Sanitation. Inpatients provided informed written consent for the collection of anonymised clinical and demographic data upon recruitment. For all patients, the consent form was explained verbally in their local language. Where patients were illiterate, the study and the consent form content were explained to them verbally, and they indicated consent through a witnessed fingerprint. All the information collected from the participants was kept confidential and only used for the research/academic purposes and remained confidential after the study as data was stored in a secured password-protected device. Patients who declined consent were still eligible for culture as a part of their standard of care, but their data were not included in the study.


Socio-demographic characteristics of participants

A total of 164 patients with clinical features of catheter-associated urinary tract infections or healthcare-associated pneumonia were enrolled in the study. About half (48.2%) were males with a median age of 46.8 years (SD 19.2). Nearly a quarter (23.8%) of participants was elderly (age ≥ 65 years).

Risk factors and clinical features of healthcare associated infections

The majority (93.3%) of the patients were on an antibiotic at the time of recruitment (Table 1). Antibiotics commonly used by these patients were ceftriaxone (90, 38.8%), metronidazole (52, 22.4%) and trimethoprim-sulphamethoxazole (32, 13.8%) (Additional file 1).

Table 1 Risk factors and clinical features of Healthcare Associated Infections

Over half (58.5%) had underlying predisposing medical conditions, with HIV being the most common (25.6%), followed by stroke (15.9%), diabetes mellitus (6.1%), chronic kidney disease (4.3%), and chronic liver disease (3.0%).

Other risk factors for healthcare-associated infections reported by patients were prior admissions for more than 24 h in the last 30 days (22.0%) and prior use of intravenous medications (11.0%). The majority (90.9%) of the patients had a urethral catheter in situ at the time of enrollment, and most (95.7%) had recorded febrile episodes with temperatures of greater than 38 °C. The type of specimen was an independent predictor of positive bacterial growth (p < 0.021, 95% CI: 1.46–94.413) in the multivariate regression analysis.

Cultured specimen and bacteriological profile

A total 172 specimens were collected from the participants, of which 6 specimens (5 sputa and 1 urine) were excluded due to poor quality. An additional 2 urine specimens were duplicate specimens and were excluded from the analysis, leaving a total of 164 specimens.

The majority of specimens were from urine (89.6%), with the rest sputum (10.4%). Over half (58.0%) of the specimens grew bacterial isolates on culture, with 94.1 and 53.7% of sputum and urine specimens having bacterial growth, respectively. Approximately 14.7% (14/95) of urine specimens were polymicrobial (3 or 4 bacterial isolates from one specimen). The most common pathogens found were E. coli and K. pneumoniae, accounting for 48% of urine isolates (29.2% E. coli and 19.0% K. pneumoniae), and 50.1% of sputum isolates (31.3% K. pneumoniae and 18.8% E. coli; Table 2). Other common pathogens included Enterococcus faecalis (11.8%), A. baumannii (9.2%), CoNS (6.5%) and Psedomonas. aeruginosa (5.2%; Table 3).

Table 2 Analysis of association between bacterial growth and risk factors and features of HAI
Table 3 Specimen cultured and bacteria isolates

Antibiotic resistance patterns

As shown in Fig. 1, the overall resistance rates were 58% for all extended-spectrum beta- lactamase (ESBL) producing organisms, 13.4% for carbapenem-resistant non-lactose fermenting gram-negative bacilli, 8.7% for carbapenem-resistant A. baumanii (CRAB) and 1.3% for carbapenem-resistant Enterobacteriaceae (CRE). There were no carbapenem-resistant P. aeruginosa (CRPA) isolates but all S. aureus isolates were methicillin- resistant.

Fig. 1
figure 1

Antibiotics resistance rates of isolates from patients with HAI

Among the Gram-positive isolates, high resistance rates for penicillins (Benzylpenicillin, 44.0%; Ampicillin 60.0%; Ampicillin-sulbactam, 28.0%) as well as quinupristin-dalfopristin (67.0%), gentamicin (71.0%), and the fluoroquinolones (Ciprofloxacin, 56.0%; Levofloxacin, 50.0%; Moxifloxacin, 47.0%) were observed (Table 4). The two S. aureus isolates were methicillin- resistant S. aureus (MRSA), and the CoNS had substantial resistance to tigecycline (11%).Erythromycin resistance was 100% for CoNS and 80% for S. aureus.

Table 4 Antibiotic resistance pattern of Gram-positive bacteria

In the Gram-negative isolates, only A. baumannii, Enterobacter cloacae, and Burkholderia cepacia had resistance to imipenem (8, 13, 100%) and meropenem (10, 13, 100%), while only K. pneumoniae (6.0%), P. aeruginosa (13.0%), and A. baumannii (17.0%) had resistance to amikacin (Table 5). Resistance rates for the penicillins and the quinolones were high across all organisms as well as Nitrofurantoin and trimethoprim-sulphamethoxazole and most cephalosporins.

Table 5 Antibiotic resistance profile of Gram-negative bacteria isolates


This is the first study to assess antibiotic resistance among patients with clinical features of healthcare-associated infections in a tertiary hospital in Sierra Leone.

The proportion of catheterized patients patients in our study with an infection is similar to other studies on HAIs in sub-Saharan Africa (58.0% vs 68.7%) [8] and Asia (58.0% vs 47.7%) [19]. The high rate of infections associated with catheterization in our study could be due to a lack of hospital protocols on aseptic procedures, including catheterization. Therefore, policies and training on catheterization, as well as, other aseptic procedures are needed to prevent HAIs in hospitals in Sierra Leone and other LMICs. Policies on patients’ safety initiatives and education of healthcare workers on urinary catheterization has been shown to be effective preventive strategies for catheter-associated urinary tract infections(CAUTI) [20]. Moreover, similar to an Ethiopian study, underlying co morbidities predisposed patients to HAIs, HIV being the most common [8]. Improving the care of patients with chronic diseases like HIV, stroke and diabetes mellitus, thereby preventing complications and progression to the advanced stage, will help in the reduction of HAIs in LMICs.

A proportion of patients higher than recorded in other studies in LMICs [21, 22] and high-income countries(HICs) [23] used at least one antibiotic prior to enrollment. The high rate of antibiotic use by this cohort could be a predisposing factor to the high levels of resistance observed in this study, although it could also be explained by the effort of service providers to treat the patients’ febrile conditions. As with other studies, the high burden of comorbidities especially the HIV/AIDS burden in this hospital [8, 24, 25] will also have influenced the use of antibiotics by service providers. Although there were existing antibiotic guidelines in this hospital, their use could not provide adequate guidance to the treatment of HAP and CAUTI. Nonetheless, antibiotics used by patients in this study were mainly first or second line similar to findings in a recent study on antibiotic use in this hospital [26].

Participants reported other clinical features such as cough, dyspnea, dysuria and frequency of passage of urine. Even though most of the samples cultured were urine specimens, more patients reported respiratory symptoms than urinary symptoms. This is not surprising as there were difficulties in getting proper respiratory samples from very ill patients.

A retrospective review of culture data in Ghana showed a prevalence of bacterial isolates higher than observed in our study(57.7% vs 16.6%) [27]. However, heterogeneity between study populations (community vs healthcare) and the wider spectrum of the cultured specimen in the Ghanaian study prohibit direct comparison. Similar to a systematic review and meta-analysis on HAIs in developing countries, gram-negative bacillary infections in both urinary and respiratory tract infections are the most recorded bacterial isolates in our study [10]. Again, other studies on antibiotic resistance in the African region noted similar spectrum of bacterial isolates found in our study [14].

Unlike a systematic review on ESBL-producing organisms in Africa [28], a high rate of ESBL-producing gram-negative bacteria was detected in this study (58.0% vs 22.8%). Nonetheless, carbapenem-resistance rate in A. baumannii, P. aeruginosa, and Enterobacteriaceae were lower than reported in other LMICs [29, 30] and some high-income countries [31]. These patterns of antibiotic resistance in this setting could be explained by the high rate of use of third generation cephalosporins and a lack in exposure of admitted patients in this hospital to carbapenems [26]. Moreover, the carbapenem resistance rate to E. cloacae may reflect elevated minimum inhibitory concentrations (MICs) they sometimes display or may also reflect an error on the susceptibility instrument.

Compared to a systematic review on antibiotic resistance in West Africa, resistance of E. coli and K. pneumoniae to ampicillin and ampicillin-sulbactam was slightly higher in our study (ampicillin: 93% vs 81% for E. coli and 93% vs 90.1% for K. pneumoniae) [15], although K. pneumonia resistance to ampicillin and other penicillins is expected as most strains are intrinsically resistant to these agents [32].

Similar proportions of E. coli and K. pneumoniae resistant isolates were recorded for trimethoprim-sulphamethoxazole, though slightly higher than in the West African systematic review [15]. These trends may signify shared risk factors and similar weaknesses in policies on antibiotic resistance in the sub region, indicating urgent action by member states of the West African community.

All the S. aureus isolates were MRSA. But as there were only two isolates, we should be cautious about generalizing this to all S. aureus isolates in our patient population. Moreover, the two MRSA isolates demonstrated excellent susceptibility to vancomycin, linezolid, tigecycline, and rifampicin.

Our study had several limitations, including the small sample size and its restriction to a single, urban study site and regular medical wards, making the findings not readily generalizable. However, as the hospital is the main referral center in the country, there may not be marked variations in antibiotic resistance patterns from inpatients in other hospitals.

The isolation of polymicrobial organisms in some urine specimens could be from delayed transportation of a few specimens to the laboratory, which is a few kilometers away from the hospital, though this is unlikely to affect the rate of antibiotic resistance in this hospital as isolates were pure microorganisms. Convenience sampling and the type of media used in laboratory processing are additional limitations of the study although this ought not to affect the overall results as most healthcare-associated infections are caused by facultative anaerobes that are not typically fastidious.


Our study demonstrated a high prevalence rate of ESBL-producing organisms from patients with clinical features of HAIs at the main tertiary hospital in Sierra Leone. We also observed a significant burden of predisposing factors to HAIs. This is extremely worrying in a country that lacks microbiology laboratories to routinely diagnose infections and antibiotic stewardship programmes to control the use of antibiotics. Acknowledging the need for urgent action, the government should strengthen microbiological diagnostic infrastructure, institute surveillance on antibiotic resistance and develop and implement a policy framework on antibiotic stewardship in Sierra Leone.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.



Acquired Immunodeficiency Syndrome


Antimicrobial Resistance


Brain Heart Infusion


Catheter Associated Urinary Tract Infections


Coagulase Negative S. aureus


Gram Negative


Gram Positive


Healthcare Associated Infections


Healthcare Associated Pneumonia


High Income Countries


Human Immunodeficiency Virus


Intensive Care Unit


Infection Prevention and Control


Low- and Middle-Income Countries


Methicillin-Resistance S. aureus


Standard deviation


Statistical Package for Social Sciences


World Health Organization


  1. Girijala RL, Bush RL. Global impact of antimicrobial resistance. Glo J Med Pub Heal. 2017;6(1):6.

  2. Founou RC, Founou LL, Essack SY. Clinical and economic impact of antibiotic resistance in developing countries: A systematic review and meta-analysis. PLoS ONE. 2017;12(12):e0189621.

    Article  Google Scholar 

  3. Cox JA, Vlieghe E, Mendelson M, Wertheim H, Ndegwa L, Villegas MV, et al. Antibiotic stewardship in low- and middle-income countries: the same but different? Clin Microbiol Infect. 2017;23(11):812–8.

    Article  CAS  Google Scholar 

  4. Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: causes and control strategies. Antimicrob Resist Infect Control. 2017;6(1):1–8.

    Article  Google Scholar 

  5. Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci. 2018;115(15): E3463-E3470.

    Article  CAS  Google Scholar 

  6. Jenks J. Antibiotic resistance needs global solutions. Lancet Infect Dis. 2014;14(7):550.

    Article  Google Scholar 

  7. World Health Organization. The burden of health care-associated infection worldwide: a summary. World Heal Organ. 2011;3 Available from:

  8. Ali S, Birhane M, Bekele S, Kibru G, Teshager L, Yilma Y, et al. Healthcare associated infection and its risk factors among patients admitted to a tertiary hospital in Ethiopia: longitudinal study. Antimicrob Resist Infect Control. 2018;7:2.

    Article  Google Scholar 

  9. Hussein RG. Current issues and forthcoming events. J Adv Nurs. 2005;52(3):340–2Available from:.

    Article  Google Scholar 

  10. Allegranzi B, Nejad SB, Combescure C, Graafmans W, Attar H, Donaldson L. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761):228–41.

    Article  Google Scholar 

  11. Khan HA, Baig FK, Mehboob R. Nosocomial infections: epidemiology, prevention, control and surveillance. Asian Pac J Trop Biomed. 2017;7(5):478–82.

    Article  Google Scholar 

  12. WHO. Implementation of the global action plan on antimicrobial resistance global leaders ratify major declaration to act on AMR antimicrobial Resistance : tackling a threat to the health and wealth of new World Bank research : by 2050. WHO GAP AMR Newsl. 2016;(September):1–4 Available

  13. Essack SY, Desta AT, Abotsi RE, Agoba EE. Antimicrobial resistance in the WHO African region: current status and roadmap for action. J Public Heal (United Kingdom). 2017;39(1):8–13.

    CAS  Google Scholar 

  14. Tadesse BT, Ashley EA, Ongarello S, et al. Antimicrobial resistance in Africa: a systematic review. BMC Infect Dis. 2017;17:616.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Bernabé KJ, Langendorf C, Ford N, Ronat JB, Murphy RA. Antimicrobial resistance in West Africa: a systematic review and meta-analysis. Int J Antimicrob Agents. 2017;50(5):629–39.

    Article  CAS  PubMed  Google Scholar 

  16. The GOF, Of R, Leone S. National Infection Prevention and Control Policy. Available

  17. Horan TC, Andrus M, Dudeck MA. CDC / NHSN surveillance definition of health care – associated infection and criteria for specific types of infections in the acute care setting. Am J Inf Contr. 2008;36–5:309–32.

    Article  Google Scholar 

  18. Module D. Urinary tract infection (catheter-associated urinary tract infection [ CAUTI ] and non-catheter-associated urinary tract infection [ UTI ]) and other urinary system infection [ USI ] events; 2019. p. 1–17. Available from

    Google Scholar 

  19. Cai Y, Venkatachalam I, Tee NW, Yen Tan T, Kurup A, Wong SY, et al. Prevalence of healthcare-associated infections and antimicrobial use among adult inpatients in Singapore acute-care hospitals: results from the first national point prevalence survey. Clin Infect Dis. 2017;64(August):S61–7.

    Article  Google Scholar 

  20. Fakih MG, Krein SL, Rn BE, Msa SRW, Battles JB, Saint S. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control. 2014;42(10):S223–9.

    Article  Google Scholar 

  21. Labi AK, Obeng-Nkrumah N, Nartey ET, Bjerrum S, Adu-Aryee NA, Ofori-Adjei YA, et al. Antibiotic use in a tertiary healthcare facility in Ghana: a point prevalence survey. Antimicrob Resist Infect Control. 2018;7(1):1–9.

    Article  Google Scholar 

  22. Kiguba R, Karamagi C, Bird SM. Extensive antibiotic prescription rate among hospitalized patients in Uganda: but with frequent missed-dose days. J Antimicrob Chemother. 2016;71(6):1697–706.

    Article  CAS  Google Scholar 

  23. Daneman N, Gruneir A, Bronskill SE, Newman A, Fischer HD, Rochon PA, et al. Prolonged antibiotic treatment in long-term care role of the prescriber. JAMA Intern Med. 2013;173(8):673–82.

    Article  CAS  Google Scholar 

  24. Lakoh S, Jiba DF, Kanu JE, Poveda E, Salgado-Barreira A, Sahr F, et al. Causes of hospitalization and predictors of HIV-associated mortality at the main referral hospital in Sierra Leone : a prospective study. BMC Pub Health. 2019;19(1):1320.

  25. Lakoh S, Firima E, Jiba DF, Sesay M, Conteh MM, Deen GF. Low partner testing in high HIV prevalence setting in Freetown, Sierra Leone: A retrospective study. BMC Res Notes. 2019;12(1):629.

  26. Lakoh S, Adekanmbi O, Jiba DF, Deen GF, Gashau W, Sevalie S, et al. Antibiotic Use Among Hospitalized Adult Patients in a Setting with Limited Laboratory Infrastructure in Freetown Sierra Leone, 2017-2018. Int J Infect Dis. 2019;90:71–6.

    Article  CAS  Google Scholar 

  27. Mohammed J, Mahuton Y, Hounmanou G, Thomsen LE. Antimicrobial resistance among clinically relevant bacterial isolates in Accra : a retrospective study. BMC Res Notes. 2018:1–6.

  28. Tansarli GS, Poulikakos P, Kapaskelis A, Falagas ME. Proportion of extended-spectrum β-lactamase (ESBL)-producing isolates among enterobacteriaceae in Africa: evaluation of the evidence-systematic review. J Antimicrob Chemother. 2014;69(5):1177–84.

    Article  CAS  Google Scholar 

  29. Ssekatawa K, Byarugaba DK, Wampande E, Ejobi F. A systematic review: the current status of carbapenem resistance in East Africa. BMC Res Notes. 2018;11(1):1–9.

    Article  Google Scholar 

  30. Okoche D, Asiimwe BB, Katabazi FA, Kato L, Najjuka CF. Prevalence and characterization of carbapenem-resistant enterobacteriaceae isolated from Mulago National Referral Hospital, Uganda. PLoS One. 2015;10(8):1–11.

    Article  Google Scholar 

  31. Cai B, Echols R, Magee G, Arjona Ferreira JC, Morgan G, Ariyasu M, et al. Prevalence of Carbapenem-resistant gram-negative infections in the United States predominated by Acinetobacter baumannii and Pseudomonas aeruginosa. Open Forum Infect Dis. 2017;4(3):1–7.

    Article  CAS  Google Scholar 

  32. Bouza E, Cercenado E. Klebsiella and Enterobacter: antibiotic resistance and treatment implications. Semin Respir Infect. 2002;17:215–30.

    Article  Google Scholar 

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We appreciate the support provided by Chinese Military Medical Expert Group at 34 Military Hospital in Sierra Leone. We are grateful to the research nurses Aminata Bangura and Zainab Kamara. We acknowledge the cooperation of the ward staff, patients and patients’ relatives at Connaught Hospital in Freetown.


This work was supported in part by a grant from the International Society for Infectious Diseases

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Authors and Affiliations



Conceptualization: SL, EYK, SS, OAdeb and AGH. Designed of the research; OAdeb, JMC, SL and EYK. Data analysis: SL, OAdeb, JMC and SS. Laboratory work: LL, XG, GY, LY, SW, TW, WS. Laboratory resources: GY. Writing: SL, EYK, OAdek, LL, XG, GY, LY, SW, TW, WS, SS and OAdeb, AGH. All authors read and approved the final manuscript.

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Correspondence to Sulaiman Lakoh or Xuejun Guo.

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Ethical approval was obtained from the Sierra Leone Ethics and Scientific Review Committee of the Ministry of Health and Sanitation, Government of Sierra Leone.

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Supplementary information

Additional file 1.

Antibiotic use among adult patients with clinical features of HAI.

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Lakoh, S., Li, L., Sevalie, S. et al. Antibiotic resistance in patients with clinical features of healthcare-associated infections in an urban tertiary hospital in Sierra Leone: a cross-sectional study. Antimicrob Resist Infect Control 9, 38 (2020).

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