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Cephalosporin resistance in Malawi

2020; Elsevier BV; Volume: 20; Issue: 3 Linguagem: Inglês

10.1016/s1473-3099(20)30047-5

1474-4457

Kathryn Haigh, Queen Dube, Watipaso Kasambara, Nicholas Feasey, Rebecca Lester,

Global Maternal and Child Health

Uduak Okomo and colleagues1Okomo U Akpalu ENK Le Doare K et al.Aetiology of invasive bacterial infection and antimicrobial resistance in neonates in sub-Saharan Africa: a systematic review and meta-analysis in line with the STROBE-NI reporting guidelines.Lancet Infect Dis. 2019; 19: 1219-1234Summary Full Text Full Text PDF PubMed Scopus (39) Google Scholar reviewed available data on the cause of neonatal infection in sub-Saharan Africa and highlighted the high prevalence of resistance to WHO-recommended empirical antibiotic regimens and the restricted access to last-resort antibiotics, the clinical consequences of which are likely to be severe. In Malawi, 20 years of surveillance data have captured a recent and concerning rise in antimicrobial resistance among invasive bacterial infections in patients of all ages.2Musicha P Cornick JE Bar-Zeev N et al.Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998–2016): a surveillance study.Lancet Infect Dis. 2017; 17: 1042-1052Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar These data, collected as part of routine clinical care from adult and paediatric patients who presented to the largest hospital in the country, describe results from 194 539 blood cultures but fall outside the inclusion criteria of Okomo and colleagues’ study by not delineating the neonatal subset.2Musicha P Cornick JE Bar-Zeev N et al.Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998–2016): a surveillance study.Lancet Infect Dis. 2017; 17: 1042-1052Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 3Iroh Tam PY Musicha P Kawaza K et al.Emerging resistance to empiric antimicrobial regimens for pediatric bloodstream infections in Malawi (1998–2017).Clin Infect Dis. 2019; 69: 61-68Crossref PubMed Scopus (22) Google Scholar Between January, 2013, and June, 2018, 1392 cultures grew Klebsiella spp (636 total, 345 from neonates) or Escherichia coli (756 total, 89 from neonates). In total, 85·7% of Klebsiella spp isolates (56·9% of isolates from neonates) and 31·7% of E coli isolates (9·2% of isolates from neonates) were resistant to third-generation cephalosporins. By contrast, 95·7% of Klebsiella spp isolates and 95·0% of E coli isolates were susceptible to amikacin. Access to an effective range of antibiotics is restricted in most Malawian health-care settings—even those on the WHO access list2Musicha P Cornick JE Bar-Zeev N et al.Trends in antimicrobial resistance in bloodstream infection isolates at a large urban hospital in Malawi (1998–2016): a surveillance study.Lancet Infect Dis. 2017; 17: 1042-1052Summary Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 3Iroh Tam PY Musicha P Kawaza K et al.Emerging resistance to empiric antimicrobial regimens for pediatric bloodstream infections in Malawi (1998–2017).Clin Infect Dis. 2019; 69: 61-68Crossref PubMed Scopus (22) Google Scholar, 4Årdal C Outterson K Hoffman SJ et al.International cooperation to improve access to and sustain effectiveness of antimicrobials.Lancet. 2016; 387: 296-307Summary Full Text Full Text PDF PubMed Scopus (86) Google Scholar—frequently rendering the third-generation cephalosporin ceftriaxone as both the first-line and last-line treatment for severe bacterial infection. Antibiotics that retain their efficacy against extended-spectrum β lactamase-producing bacteria, such as amikacin and carbapenems, are not routinely available. Carbapenems are prohibitively expensive in Malawi—a day's course of meropenem costs US$53—and amikacin is difficult to procure because of restricted access to preserve it for the management of multidrug-resistant tuberculosis;5Pharmacy Medicines and Poisons BoardRestricting use of second line ANTI-TB medicines.http://www.pmpb.mw/restricting-use-of-second-line-anti-tb-medicinesDate: April 19, 2018Date accessed: November 14, 2019Google Scholar therefore, patients with third-generation cephalosporin resistant bacterial infection frequently remain untreated with an effective antibiotic. Although the outcomes for patients with resistant bacterial infection in Malawi are unknown, they are likely to be poor. Antimicrobial resistance is a global public health problem, the challenges of which are context specific. The combination of most hospitals not having access to culture and sensitivity testing, the rising prevalence of antimicrobial resistance, and severely restricted access to a range of effective antibiotics are part of Malawi's antimicrobial resistance challenge, which will no doubt be shared by many other low-income settings. Although improved access to antibiotics is now critical in Malawi, especially for neonates, this must go hand in hand with careful stewardship and improved infection prevention and control to avoid the rapid emergence of resistance to these drugs. We declare no competing interests. RL is supported by the Wellcome Trust (clinical PhD fellowship, University of Liverpool, Liverpool, UK; block award grant number 203919/Z/16/Z ). Aetiology of invasive bacterial infection and antimicrobial resistance in neonates in sub-Saharan Africa: a systematic review and meta-analysis in line with the STROBE-NI reporting guidelinesHospital-acquired neonatal infections and AMR are a major burden in Africa. More population-based neonatal infection studies and improved routine surveillance are needed to improve clinical care, plan health systems approaches, and address AMR. Future studies should be reported according to standardised reporting guidelines, such as STROBE-NI, to aid comparability and reduce research waste. Full-Text PDF