Bloodstream infections at a tertiary hospital in The Gambia - A one-year retrospective study

Bloodstream infections at a tertiary hospital in The Gambia - A one-year retrospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bloodstream infections at a tertiary hospital in The Gambia - A one-year retrospective study Paul Rahden, Ebrima Barrow, Haddy Bah, Sheikh Omar Bittaye, David Nygren, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4378140/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted 12 You are reading this latest preprint version Abstract Introduction Antimicrobial resistance is a significant global health concern, particularly in western Sub-Saharan Africa. This study describes causes of bacteraemia and antimicrobial resistance at a tertiary hospital in The Gambia. Methods This retrospective analysis included all blood cultures performed at the Edward Francis Small Teaching Hospital, Banjul, The Gambia, from September 2022 to August 2023. Blood culture positivity-rates and pathogens were described. Antimicrobial susceptibility testing was performed using disk diffusion (CLSI). Results In total, 288/645 (45%) blood cultures were positive. A majority were drawn in intensive care units (63%) and in neonatal or paediatric patients (56%). The most common pathogens were Staphylococcus aureus 106/288 (37%), Klebsiella spp. 41/288 (14%), other bacteria within the Enterobacterales order 33/288 (11%), Pseudomonas spp. 22/288 (8%) and Acinetobacter spp. 19/288 (7%). 28/288 (10%) were classified as contaminants. Methicillin-resistant S. aureus (MRSA) was seen in 34/58 (59%) tested. Extended-spectrum beta-lactamases (ESBL) were seen in 36/40 (90%) of Klebsiella spp. and in 16/28 (57%) of other bacteria within the Enterobacterales order. Acquired antibiotic resistance, beyond wild-type, was reported in 17/20 (85%) of Pseudomonas spp. and 16/19 (84%) of Acinetobacter spp. Conclusion Overall, blood culture positivity rates were high, indicating restrictive testing. The presented data highlight blood culture findings primarily among critically ill and neonatal or paediatric patients, with nosocomial infections likely overrepresented. Despite probable selection bias, alarmingly high MRSA- and ESBL-rates were described. These findings highlight the urgent need of accessible microbiological diagnostics, antibiotic stewardships and infection control measures in West Africa. Importantly, generalizability of findings to community-acquired infections remains restricted. Bacteraemia Antimicrobial Resistance Sub-Sahara Africa The Gambia Figures Figure 1 Figure 2 Background Antimicrobial resistance (AMR) is a growing public health concern and the Western Sub-Saharan Region has been estimated to suffer from the highest burden worldwide ( 1 , 2 ). Scarcity of diagnostics, effective drugs, and reliable surveillance systems increase the impact of AMR in Sub-Saharan Africa ( 3 , 4 ). In The Gambia, most microbiological surveillance data has been described by the Medical Research Council Gambia (MRCG), a research institute and secondary health care facility in Fajara, outside of the capital Banjul. Previously, they have described Streptococcus pneumoniae , Staphylococcus aureus , Escherichia coli and Non-typhoidal Salmonella ( NTS ) as the most prevalent causes of bacteraemia ( 5 ). Resistance rates to first and second-line antibiotics recommended in national and African CDC treatment guidelines have been low in studies from MRCG ( 6 , 7 ). MRSA has been described in 1–13% of infections caused by S. aureus while presence of ESBL in Klebsiella spp. and E. coli was seen in up to 35% and 23% based on cultures on varying patient samples (e.g. urine, blood, faeces) ( 5 , 8 , 9 ). However, regional data from selected patient groups, especially paediatric and neonatal patients, have shown much higher resistance rates, with ESBL rates in E. coli and Klebsiella spp. infections ranging up to 50 and 100%, respectively ( 10 – 12 ). Conversely, in one Gambian study investigating ESBL-carriage in faeces, a relatively low rate of 5% was described among food handlers ( 13 ). As there is no continuous national surveillance and reporting system in The Gambia, the burden of antimicrobial resistance among hospitalized patients and in the community largely remains unknown with varying rates previously reported. The lack of microbiological laboratories represents a major challenge throughout The Gambia ( 3 ). Stock-outs of basic consumables, including blood culture bottles and antibiotics for susceptibility testing, occur regularly. Additionally, while paediatric care for children < 5 years of age is free and subsidized for children from 5 to 14 years of age, most health care interventions in The Gambia require out-of-pocket payments for diagnostics and therapeutics for adults ( 14 ). This may partly drive restrictive testing and discontinuation of treatment due to financial constraints. Varying quality of administered drugs, mis- and overuse of antibiotics as well as shortage of trained staff and laboratory facilities might be further drivers of AMR regionally ( 3 , 4 , 15 ). Objectives We aimed to identify the most common causes of bacteraemia and their resistance patterns to evaluate the burden of AMR at the main teaching and referral hospital in The Gambia. The study objectives included the identification of causes of bacteraemia in children and adults at the only tertiary hospital in The Gambia during 12 months. antimicrobial resistance rates to first- and second-line drugs ( 6 , 7 ) in bacteraemia. Methods Study Design and Setting This retrospective study was conducted at the Edward Francis Small Teaching hospital (EFSTH) in Banjul, The Gambia. EFSTH is the only tertiary hospital in the country offering specialist care, dialysis and intensive care, in addition to around the clock services for laboratory requests. We extracted baseline characteristics (age, gender, and ward), bacterial findings and antimicrobial susceptibility testing (AST) in patients who had blood cultures drawn over a 12-month period from September 2022 to August 2023. Data was retrieved from paper-based records at the Department of Microbiology at EFSTH, pseudonymized and then analysed using Microsoft Excel (Version 16.83). Graphs were designed using datawrapper software ( https://www.datawrapper.de/ ). Study Participants Case eligibility was any patient with a blood culture (one pair) drawn from September 2022 to August 2023 at the EFSTH. No patients were excluded. Samples were drawn in all departments of emergency and acute medicine, surgery, internal medicine, paediatrics, paediatric surgery, outpatient clinics, obstetrics and gynaecology. In general, patients 14 years or younger are defined and treated as children ( 28 day to 14 years as paediatric patients) while patients aged 15 years or older are treated in adult departments at EFSTH. We defined patients from neonatal intensive care unit (NICU) as neonates if information on age was not documented. Patient results from intensive care unit (ICU) were labelled as adults, if information on age was missing. Microbiological methods Specimen collection procedures followed established protocols for the collection of blood cultures. Typically, they were drawn prior to the administration of antibiotics or upon deterioration in a patient despite ongoing antibiotic therapy. Samples were drawn via venepunctures from new sites and preceded by sterilization of the access sites. Ideally, eight to ten millilitres of blood were collected and inoculated into a set of BD BACTEC™ PLUS culture bottles each (one aerobic and one anaerobic) for adults and for children a minimum of 0.5 ml blood was drawn to a maximum of 5 ml in one BD BACTEC™ PLUS paediatric culture bottle. Blood culture bottles were incubated in a BD BACTEC™ FX40 incubator for 5 days. A gram stain was performed from positive bottles for preliminary identification followed by sub-culturing onto blood, Chocolate and MacConkey agar. Blood agar was prepared using 5% human blood obtained from expired blood donated for transfusions from the hospital blood bank. Sheep blood is not routinely available. Capacity for anaerobic culture were limited due to the lack of an anaerobic chamber or gas packs for producing an anaerobic atmosphere in jars. Blood and MacConkey plates were incubated aerobically whereas Chocolate plates were incubated in 5% CO 2 . All were kept at 35℃ and reviewed after 24 hours when growth was compared across the plates. Species identification Species identification was based on the following procedures. Most gram-positive organisms will grow on blood and chocolate media, while gram-negative cocci may grow on either or both of blood and chocolate agar and gram-negative bacilli on all three plates. In case of polymicrobial growth across the various plates or growth patterns that do not conform to the above, contamination was suspected and the plates were discarded if confirmed. Phenotypic species identification was performed using manual biochemical methods. In gram-positive cocci, identified through gram stain and morphology appearance, a catalase test was performed using 1% hydrogen peroxide. If positive, the isolate was further speciated using Staphaurex™ Plus Latex Agglutination Test. This classified isolates as either Staphylococcus aureus or coagulase negative Staphylococcus . Should clinical information suggest further need, a novobiocin disc test was performed to differentiate S. epidermidis from S. saprophyticus . For catalase negative gram-positive cocci, the haemolytic pattern was considered. β-haemolytic colonies on blood agar were subjected to a bacitracin disk susceptibility test with Group A streptococci, specifically S. pyogenes , exhibiting sensitivity while Group B ( S. agalactiae ), Group D (including Enterococci spp.) were expected to demonstrate resistance. For resistant β-haemolytic cocci a CAMP test was done to confirm Group B streptococci. For α-haemolytic organisms an optochin disc test was performed to differentiate Streptococcus pneumoniae from other α-haemolytic Streptococci. NaCl 6.5% growth media were used to differentiate Enterococcus from non-enterococcal group D Streptococci. Gram-negative bacilli identified as lactose fermenters from MacConkey agar were phenotypically identified using triple sugar iron (TSI), 2% urea and citrate media. In these instances identification was generally done to genera level. Should the identification process give ambiguous results or subsequent antimicrobial testing showed a multidrug resistant organism BIOMÉRIEUX API® ID 20E was used for further species identification if available. Lactose negative bacilli were screened using the oxidase test. Oxidase negative isolates would be further tested as for the lactose fermenters. Pseudomonas spp. isolates (lactose negative) were identified through colonial morphology, gram stain and oxidase reaction (oxidase positive). Finally gram-negative coccobacilli, if isolates grew only on chocolate agar, would be screened using factor X and V on nutrient agar to speciate Haemophilus spp . Suspected Neisseria species on the other hand would be identified based on gram stain, colonial morphology, and a positive oxidase test. Antimicrobial susceptibility testing AST was done per Clinical and Laboratory Standards Institute (CLSI) guidelines with Kirby-Bauer disk diffusion ( 16 ). Inoculum for plating were prepared using MacFarland saline suspension of target organism. For the identification of methicillin-resistant Staphylococcus aureus (MRSA) , a cefoxitin test was performed. Extended-spectrum beta-lactamase production was defined as resistance to third generation cephalosporins in pathogens of the Enterobacterales group using double disc synergy testing. Acquired antimicrobial resistance in Acinetobacter spp . or Pseudomonas spp. was defined as any additional acquired resistance beyond wild-type susceptibility ( 16 ). Antibiotic discs available were often impacted by stock outs and availability. Isolates identified as coagulase negative Staphylococci , Bacillus spp. , Micrococcus spp. , Streptococcus viridans and coryneform bacteria were regarded as contaminants unless they were isolated in two or more independent blood culture specimens from the same patient within a 48-hour period, in which case they were included as a pathogen. If bacteraemia was polymicrobial, each separate finding was noted regarding species distribution of positive cultures, with the exception of if polymicrobial growth was due to contaminants. Then they were specified as one contaminant. Outcomes and Variables The primary analysis focused on blood culture positivity rates and distribution of pathogens identified grouped in neonatal, paediatric or adult patients, highlighting the five most common pathogens identified. The secondary analyses highlighted resistance patterns in the five most commonly identified pathogens and investigated differences in distribution of pathogens and AMR in patients cultured in ICU vs non-ICU. Bias The aim of the study was to assess patterns and frequency of AMR at the EFSTH. Given its retrospective design, selection bias is expected with an overrepresentation of severely ill as well as children due to restrictive testing. Hence, to highlight the extent of bias, secondary analyses compared distribution of pathogens and AMR in ICU vs non-ICU patients as well as between age groups. Additionally, constraints in funding and supply shortages at the hospital, the availability of kits for species identification and antibiotic discs for AST were often limited. Consequently, our analysis focus on the most commonly encountered pathogens and antibiotics. If data on AST were unavailable due to not having been performed, complete case analysis was performed. To minimize seasonal bias, we designed the study to cover a 12-months period to include seasonal variations. Data analysis Descriptive statistics were mainly reported. For categorical variables, counts and percentages were presented with Fischer’s exact test used for statistical comparisons. For continuous variables, median and interquartile range (IQR) were presented. The study sample size was determined by the total amount of blood cultures performed during the study period. No formal power analysis was performed a priori. Solely complete case analysis is presented due to the lack of reliable predictors for multiple imputation to be valid. If data was missing on age or where the blood culture was drawn, age group could not be defined, why potential blood culture findings were presented in total numbers, yet not in sub-groups. Results Participants baseline characteristics In total, 645 patients had blood cultures performed. Their baseline characteristics are summarised by age group in Table 1 . 268 (42%) of the patients were neonatal, 92 (14%) paediatric and 277 (43%) were adults. 406 (63%) of the overall samples were drawn in an ICU, with an overwhelming majority of samples in neonates, 264/267 (99%), drawn in the NICU. Table 1 Baseline characteristics and blood culture positivity rates Characteristics Neonatal ≤ 28 d Paediatrics > 28 d-15 y Adults ≥ 15 y Total Age, median (IQR) 5 ( 3 – 10 ) d 4.0 (0.7-7) y 35 (27–53) y Female, % * 119/262 (45%) 32/92 (35%) 142/277 (51%) 297/639 (46%) Blood culture drawn in ICU, % * 265/268 (99%) 24/92 (26%) 117/277 (42%) 406/645 (63%) Blood culture positivity rate, % *, ** 140/268 (58%) 33/92 (36%) 84/277 (30%) 260/645 (40%) * Some patients had missing data on gender (n = 6) or age group (n = 8). If a definite allocation was not possible samples were included in the total column but not in the age specific columns. ** Excluding contaminants . Main Results Most common pathogens identified in blood cultures Out of 645 patients from which blood cultures were obtained, 288 (45%) had bacteraemia, of which 28 (10%) were defined as contaminants. The most common pathogens identified were S. aureus with 106 cases (37%), and Klebsiella spp. with 41 cases (14%). Other pathogens of the Enterobacterales group identified were 33 cases (11%), Pseudomonas spp. with 22 cases (8%) and Acinetobacter spp. with 19 cases (7%). Findings are displayed in Fig. 1 . When cases with bacteraemia were grouped as neonatal, paediatric or adult, S. aureus bacteraemia was most commonly seen among paediatric and adult cases, while neonatal S. aureus bacteraemia was slightly less common (Table 2 ). Differences were smaller for gram-negative pathogens. No cases with contaminants identified were seen among paediatric patients, whereas it was relatively common in both neonates and adults. Given the lack of clinical data, it was not possible to ascertain whether these represented catheter-associated infections or truly represented skin contaminants. Table 2 Blood culture findings by age groups Characteristics Neonatal ≤ 28 d* Paediatrics > 28 d-15 y Adults ≥ 15 y Proportion of all positive blood cultures* Staphylococcus aureus (%) 45/156 (29%) 16/33 (48%) 43/95 (45%) 106/288 (37%) Klebsiella spp. (%) 24/156 (15%) 3/33 (9%) 14/95 (15%) 41/288 (14%) Enterobacterales group (%) 22/156 (14%) 4/33 (12%) 7/95 (7%) 33/288 (11%) Pseudomonas spp. (%) 13/156 (8%) 5/33 (15%) 4/95 (4%) 22/288 (8%) Acinetobacter spp. (% ) 16/156 (10%) 0/33 (0%) 3/95 (3%) 19/288 (7%) Contaminants** 16/156 (10%) 0/33 (0%) 12/95 (13%) 28/288 (10%) Other 20/156 (13%) 5/33 (15%) 14/95 (15%) 39/288 (14%) * n = 4 of positive cultures had missing data on age group. If a definite allocation was not possible samples were included in the total column but not in the age specific columns. One blood culture had a polymicrobial infection. ** Contaminants include results labelled as contaminants, typically coagulase-negative Staphylococcus. When cases with bacteraemia were grouped as ICU or non-ICU regardless of age group (Table 3 ), blood culture positivity rates were higher in the ICU (Fischer’s exact test, p < 0.001). S. aureus represented the most common finding in both groups, 32% in ICU patients and 49% in non-ICU patients. Rates of MRSA were higher in ICU patients, yet not statistically significant (Fischer’s exact test, p = 0.16). Gram-negative pathogens had similar distribution and resistance rates, except for Acinetobacter spp . which was solely identified in ICU patients. Table 3 Blood culture findings and resistance rates by sampling in the ICU or not. Characteristics ICU Non-ICU Resistance rate * ICU Resistance rate * Non-ICU Blood culture positivity rate (%) 204/406 (50%) 84/239 (35%) - - Staphylococcus aureus (%) 65/204 (32%) 41/84 (49%) 25/38 (66%) 9/20 (45%) Klebsiella spp. (%) 31/204 (15%) 10/84 (12%) 27/30 (90%) 9/10 (90%) Enterobacterales group (%) 26/204 (13%) 7/84 (8%) 40/53 (75%) 12/15 (80%) Pseudomonas spp. (%) 16/204 (8%) 6/84 (7%) 12/14 (86%) 5/6 (83%) Acinetobacter spp. (% ) 19/204 (9%) 0/84 (0%) 16/19 (84%) 0/0 (0%) Contaminants** 21/204 (10%) 7/84 (8%) N/A N/A Other 26/204 (13%) 15/84 (18%) N/A N/A * Resistance was defined as MRSA, ESBL (for Klebsiella spp. or Enterobacterales group), any acquired resistance beyond wild-type for Pseudomonas spp. or Acinetobacter spp. **No resistance rates are reported for contaminants or other pathogens. Results in Resistance Patterns Among the five most common pathogens identified, AST was evaluated if performed. Of a total of 106 cases of S. aureus -bacteraemia, 58 (55%) samples had available data on AST. Among these isolates, 34 (59%) were defined as MRSA. In the isolates defined as MRSA (n = 34), resistance to other non-beta lactam antibiotics were described. Resistance was seen in 21/32 (66%) to macrolides, in 16/17 (94%) to fluroquinolones, in 11/14 (79%) to aminoglycosides, in 16/26 (62%) to tetracyclines and in 5/8 (63%) to trimethoprim-sulphonamide. For pathogens of the Enterobacterales group, presence of ESBL was investigated. First Klebsiella spp. were specifically investigated, since it was the most common gram-negative finding. In 40/41 (98%) isolates, AST were performed. Among these isolates, 36 (90%) were defined as ESBL. For Klebsiella spp. isolates defined as ESBL, the resistance rates for other antibiotics were investigated and reported if tested. Resistance was seen in 16/28 (55%) for fluoroquinolones, in 20/20 (100%) for trimethoprim-sulphonamide and in 8/11 (73%) for aminoglycosides. Carbapenems or amikacin were not tested for in any of the Klebsiella spp . isolates. Among other pathogens of the Enterobacterales group, 28/33 (85%) were investigated for ESBL. Among these isolates, 16 (57%) were defined as ESBL. The resistance rates for other antibiotics were investigated and reported if tested. Resistance was seen in 5/12 (42%) for fluoroquinolones, 10/12 (83%) for trimethoprim-sulphonamide and 7/8 (88%) for aminoglycosides. Carbapenems were investigated in three isolates, all were susceptible. Amikacin resistance was not tested for. For Pseudomonas spp. 20/22 (91%) were investigated for any acquired resistance beyond wild-type. Acquired resistance were seen in 7/14 (50%) to fluoroquinolones, in 7/11 (64%) to beta-lactam antibiotics and in 9/10 (90%) to aminoglycosides. Beta-lactams investigated were ceftazidime, for which 7/10 (70%) were resistant, and imipenem-cilastatin for which 0/1 (0%) was resistant. Amikacin resistance was not tested for. For Acinetobacter spp. 19/19 (100%) were evaluated for any acquired resistance beyond wild-type. Acquired resistance were seen in 5/17 (29%) for fluoroquinolones, in 5/14 (36%) for beta-lactam antibiotics, in 13/14 (93%) for trimethoprim-sulphonamide and in 3/3 (100%) for aminoglycosides. Beta-lactams investigated were ceftazidime, for which 5/14 (36%) were resistant, and imipenem-cilastatin, for which 0/1 (0%) was resistant. Amikacin resistance was not tested for. Discussion Key Results/Objectives Our analysis describes the blood culture positivity rates, distribution of isolated pathogens and their antimicrobial resistance rates in bacteraemia at a tertiary hospital in The Gambia over a 12-month period. The study revealed an overall blood culture positivity rate of 42% when contaminants were excluded. The highest positivity rate was found in neonates and among ICU-patients. The most frequently identified pathogens in descending order were S. aureus , Klebsiella spp., other Enterobacterales , Pseudomonas spp., and Acinetobacter spp. Among S. aureus , MRSA-rates were surprisingly high, as were ESBL-rates in Klebsiella spp. and other Enterobacterales spp. Similarly, most strains with Pseudomonas spp. or Acinetobacter spp. had acquired resistance beyond their wild-type susceptibilities. These findings highlight the severe impact of bacteraemia and antimicrobial resistance in The Gambia. High blood culture positivity and resistance rates were seen in all age groups, emphasising the threat of blood stream infections in our setting ( 2 , 17 , 18 ). Particularly concerning is the high positivity rate observed in neonates as they are susceptible to poor outcome in infections due to poor immune response. The high resistance rates found will contribute to the morbidity and mortality of infants in The Gambia accentuating the impact of sepsis in childhood and neonatal mortality in sub-Saharan Africa ( 17 , 19 ). In comparison to most previous regional data, resistance rates presented in this study are worse ( 5 , 8 , 9 ). It is likely that patients presenting to the tertiary hospital (EFSTH) are selected and often have had prior antibiotic exposure. Similarly, the high blood culture positivity rate indicates restrictive testing, where possibly only patients who are failing on antibiotic therapy or are severely ill are cultured. The identification of pathogens revealed a predominance of S. aureus , Klebsiella spp. and other Enterobacterales , along with Pseudomonas spp. and Acinetobacter spp. We reported other Enterobacterales as a group as shortages of supplies made definite species identification uncertain. In general, the rate of gram-negative bacteria identified surpassed previous reports, which could be due to EFSTH’s status as sole referral hospital in the country ( 5 , 8 ). The influx of patients with complex infections referred from other facilities may also have contributed to these findings. Unfortunately, clinical data regarding onset and type of symptoms, previous or current treatment or patient’s outcomes was not available, due to the retrospective design and the lack of integrated and electronic medical records. Nevertheless, our data has shown alarmingly high results of rates MRSA, ESBL and acquired resistance beyond wild type in Pseudomonas and Acinetobacter spp. The fact that 64% of overall samples came from ICU or NICU settings emphasize the selection of critically ill and vulnerable patients in this study. Nosocomial infections and multi-drug resistant pathogens are therefore likely overrepresented. However, the differences in resistance rates in cultures from patients admitted to the ICU and non-ICU patients were relatively small (Table 3 ). In summary, these findings highlight the burden of infections with resistant gram-negative pathogens and are in line with previous reports from in Sub-Saharan and particularly Western Africa ( 1 , 20 – 24 ). Previous studies have identified S. aureus , S. pneumoniae , E. coli and non-typhoidal Salmonella ( NTS) as the most prevalent pathogens in bacteraemia ( 5 , 8 , 25 , 26 ) of which Streptococcus spp. and Salmonella spp. were not commonly seen in our analysis. Efficacious outpatient antibiotic treatment, no or late microbiological assessments as well as lack of appropriate testing options might cause underreporting of these cases due to the retrospective study design ( 11 , 15 ). Nevertheless, our findings are in line with previous data suggesting higher proportions of gram-negative bacteraemia both at the EFSTH as do previous analyses from the West African region ( 10 – 12 , 20 , 27 ). Importantly, given the high proportion of cultures drawn in ICU settings and the study site being a tertiary care hospital, generalizability of findings to community-acquired infections in all of The Gambia is limited. While our findings can inform empirical treatment in nosocomial sepsis in the region, further prospective studies are needed to investigate distribution of pathogens and AMR specifically in community-acquired bacteraemia to inform antibiotic therapy guidelines in community-acquired sepsis regionally. Limitations The study limitations are mainly due to its retrospective single centre design. Selection bias of severe cases restrictive testing at this tertiary hospital have been highlighted. Likely, this impacts both species distribution and resistance rates. As mentioned, a vast majority of patients who had blood cultures drawn, were admitted to ICU-departments, and the majority of patients are neonatal or paediatric which impacts interpretation. Additionally, during the study period, diagnostic precision and AST was impacted by stock-outs. Also, anaerobic incubation conditions are insufficient highlighted by no isolated anaerobic bacteraemia identified. Since antibiotics beyond first- and second-line antibiotics are rarely available, a need for increased availability of broader antimicrobials, AST to guide when to use them, efficient infection control measures and antibiotic stewardships are highlighted. Future studies should include clinical data as well as early initiation of microbiological assessments. Unfortunately, the preparedness for rising AMR rates in The Gambia remains low and our findings underline the need to refocus on infection control measures, develop continuous surveillance systems of bloodstream and other infections, increase the availability of antibiotics beyond 2nd line following AST and improve local policies while respecting a one health approach and update local treatment guidelines ( 28 – 30 ). Given the limitations of the study design, a prospective study to assess and compare species distribution and resistance patterns in nosocomial vs. community-acquired bacteraemia in The Gambia is currently being designed. Conclusion Our study reveals high blood culture positivity rates at the tertiary hospital in The Gambia primarily based on data from critically ill, neonatal and paediatric patients. The most common pathogens identified were S. aureus , Klebsiella spp. among other Enterobacterales, Pseudomonas and Acinetobacter spp., which differs to previous findings regionally. This is the first study examining neonates and critically ill to this extent in The Gambia, who here were overrepresented. Alarmingly, we show high rates of MRSA and ESBL. These findings suggest the urgent need for the implementation of AMR surveillance systems, an increase in availability of microbiological diagnostics, a review of infection control measures and improved access to broader antibiotic therapies to mitigate the impact of sepsis due to multi-drug resistant pathogens regionally. Abbreviations AMR Antimicrobial Resistance AST Antimicrobial Susceptibility Testing CLSI Clinical & Laboratory Standards Institute EFSTH Edward Francis Small Teaching Hospital ESBL Extended–Spectrum Beta Lactamase ICU Intensive Care Unit ICQ Interquartile Range MRCG Medical Research Council Gambia MRSA Methicillin Resistant Staphylococcus aureus NTS Non – typhoidal Salmonella NICU Neonatal Intensive Care Unit Declarations Ethical approval The protocol and study procedures were approved by EFSTH Research Ethics Committee (Reference number EFSTH_REC_2023_121; approval 23 rd of October 2023). Consent for publication In accordance with ethical guidelines and institutional policies, this retrospective study has been conducted using previously collected data. Analysis of existing data sets, and all personal identifiers have been removed to ensure confidentiality and compliance with data protection regulations. Necessity to obtain informed consent was waived by the EFSTH Research Ethics Committee since data was obtained and presented anonymously without presence of a code. Availability of data and material The datasets generated and analyzed during the current study are available from the corresponding author on request. This data availability is consistent with ethical guidelines and institutional policies concerning privacy and confidentiality. Competing interests None of the authors has competing interests in relation to this study. This includes any financial, personal, or professional affiliations that could influence the content or interpretation of the findings presented in this manuscript. Our commitment to transparency and scientific integrity ensures that all aspects of the study, from data collection to publication, have been conducted free from any undue influence. Funding None of the authors received any kind of funding for this study. None of the authors had any competing interests in the design, conduction or reporting outcomes of our findings. Authors Contribution PR and AB conceptualised the study. PR and EB extracted the data. PR, DN and AB analysed the data and wrote the first draft. SOB, HB and AB reviewed and helped interpreting the study results. All authors read and approved the final manuscript. Acknowledgements We would like to thank the staff of EFSTH especially the department of microbiology for the support during the duration of the study. References Antimicrobial Resistance C. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55. Collaborators AR. The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis. Lancet Glob Health. 2024;12(2):e201–16. Essack SY, Desta AT, Abotsi RE, Agoba EE. Antimicrobial resistance in the WHO African region: current status and roadmap for action. J Public Health (Oxf). 2017;39(1):8–13. Iwu CD, Patrick SM. An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: A roadmap for action. Int J Antimicrob Agents. 2021;58(4):106411. Darboe S, Okomo U, Muhammad AK, Ceesay B, Jallow M, Usuf E, et al. Community-acquired Invasive Bacterial Disease in Urban Gambia, 2005–2015: A Hospital-based Surveillance. Clin Infect Dis. 2019;69(Suppl 2):S105–13. CDC A. African Antibiotic Treatment Guidelines for Common Bacterial Infections and Syndromes. 2021;1. Welfare DoSfHS. The Gambia - Standard Drug Treatment Guidelines. 2001. Darboe S, Mirasol R, Adejuyigbe B, Muhammad AK, Nadjm B, De St Maurice A et al. Using an Antibiogram Profile to Improve Infection Control and Rational Antimicrobial Therapy in an Urban Hospital in The Gambia, Strategies and Lessons for Low- and Middle-Income Countries. Antibiot (Basel). 2023;12(4). Darboe S, Dobreniecki S, Jarju S, Jallow M, Mohammed NI, Wathuo M, et al. Prevalence of Panton-Valentine Leukocidin (PVL) and Antimicrobial Resistance in Community-Acquired Clinical Staphylococcus aureus in an Urban Gambian Hospital: A 11-Year Period Retrospective Pilot Study. Front Cell Infect Microbiol. 2019;9:170. Okomo UA, Darboe S, Bah SY, Ayorinde A, Jarju S, Sesay AK, et al. Maternal colonization and early-onset neonatal bacterial sepsis in the Gambia, West Africa: a genomic analysis of vertical transmission. Clin Microbiol Infect. 2023;29(3):386. e1- e9. Chaw PS, Schlinkmann KM, Raupach-Rosin H, Karch A, Pletz MW, Huebner J, et al. Antibiotic use on paediatric inpatients in a teaching hospital in the Gambia, a retrospective study. Antimicrob Resist Infect Control. 2018;7:82. Bah SY, Kujabi MA, Darboe S, Kebbeh N, Kebbeh BFK, Kanteh A, et al. Acquisition and carriage of genetically diverse multi-drug resistant gram-negative bacilli in hospitalised newborns in The Gambia. Commun Med (Lond). 2023;3(1):79. Sanneh B, Kebbeh A, Jallow HS, Camara Y, Mwamakamba LW, Ceesay IF, et al. Prevalence and risk factors for faecal carriage of Extended Spectrum beta-lactamase producing Enterobacteriaceae among food handlers in lower basic schools in West Coast Region of The Gambia. PLoS ONE. 2018;13(8):e0200894. Frimpong AA, Arthur E. Effects of public and external health spending on out-of-pocket payments for healthcare in sub-Saharan Africa. Health Policy Plan. 2022;37:1129–37. Holmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176–87. Institute CaLS. Performance Standards for Antimicrobial Susceptibility Testing. 2020;30th Edition. Bassat Q, Blau DM, Ogbuanu IU, Samura S, Kaluma E, Bassey IA, et al. Causes of Death Among Infants and Children in the Child Health and Mortality Prevention Surveillance (CHAMPS) Network. JAMA Netw Open. 2023;6(7):e2322494. Collaborators GBoDAR. Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2022;400(10369):2221–48. Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395(10219):200–11. Bernabe 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. Solomon S, Akeju O, Odumade OA, Ambachew R, Gebreyohannes Z, Van Wickle K, et al. Prevalence and risk factors for antimicrobial resistance among newborns with gram-negative sepsis. PLoS ONE. 2021;16(8):e0255410. Odonkor ST, Simpson SV, Morales Medina WR, Fahrenfeld NL. Antibiotic-Resistant Bacteria and Resistance Genes in Isolates from Ghanaian Drinking Water Sources. J Environ Public Health. 2022;2022:2850165. Anning AS, Baah E, Buabeng SD, Baiden BG, Aboagye B, Opoku YK, et al. Prevalence and antimicrobial resistance patterns of microbes isolated from individuals attending private diagnostic centre in Cape Coast Metropolis of Ghana. Sci Rep. 2022;12(1):14282. Okomo U, Akpalu ENK, Le Doare K, Roca A, Cousens S, Jarde A, 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(11):1219–34. Kwambana-Adams B, Darboe S, Nabwera H, Foster-Nyarko E, Ikumapayi UN, Secka O, et al. Salmonella Infections in The Gambia, 2005–2015. Clin Infect Dis. 2015;61(Suppl 4):S354–62. Secka F, Herberg JA, Sarr I, Darboe S, Sey G, Saidykhan M, et al. Bacteremia in Childhood Life-Threatening Infections in Urban Gambia: EUCLIDS in West Africa. Open Forum Infect Dis. 2019;6(9):ofz332. Olatunji YA, Banjo AA, Jarde A, Salaudeen R, Ndiaye M, Galega LB, et al. Invasive bacterial disease in young infants in rural Gambia: Population-based surveillance. J Glob Health. 2023;13:04106. Elton L, Thomason MJ, Tembo J, Velavan TP, Pallerla SR, Arruda LB, et al. Antimicrobial resistance preparedness in sub-Saharan African countries. Antimicrob Resist Infect Control. 2020;9(1):145. Laxminarayan R, Matsoso P, Pant S, Brower C, Rottingen JA, Klugman K, et al. Access to effective antimicrobials: a worldwide challenge. Lancet. 2016;387(10014):168–75. Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis. 2013;13(12):1057–98. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 24 Jun, 2024 Reviews received at journal 19 Jun, 2024 Reviews received at journal 16 Jun, 2024 Reviews received at journal 10 Jun, 2024 Reviewers agreed at journal 09 Jun, 2024 Reviewers agreed at journal 07 Jun, 2024 Reviewers agreed at journal 31 May, 2024 Reviewers invited by journal 24 May, 2024 Editor invited by journal 09 May, 2024 Submission checks completed at journal 08 May, 2024 Editor assigned by journal 08 May, 2024 First submitted to journal 06 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4378140","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":301460312,"identity":"e069ea61-c292-481e-8f8c-b3c897fac30b","order_by":0,"name":"Paul Rahden","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYHACxgNAIoHhAAPjYwYGCZCIAUE9MC3MxkAtEiRpYZNmgFiDX4s5+xmDA4x77PL4jvceqy7cYVGn28C88QE+LZY9OQYHGJ4lF0ueOZd2e+YZCQmzA2zFeK0xOADScoA5ccONHLPbvG0gLTxmEni1nH8D0lKfuOH+G7NiqBbzH3i13ADbchhoC48ZM8wWfDoYLGc8KziQcOB44swzOcbSM9skJLcdZivG6zBz/uSNDz4cqE7sO37G8HNhWx2/2fHmjR/wOgxEJKAIMeN1FjERPQpGwSgYBaMAAFKHTz65xTOTAAAAAElFTkSuQmCC","orcid":"","institution":"Edward Francis Small Teaching Hospital","correspondingAuthor":true,"prefix":"","firstName":"Paul","middleName":"","lastName":"Rahden","suffix":""},{"id":301460313,"identity":"60cf251e-1e79-4285-83e8-2f155c754f46","order_by":1,"name":"Ebrima Barrow","email":"","orcid":"","institution":"Edward Francis Small Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ebrima","middleName":"","lastName":"Barrow","suffix":""},{"id":301460314,"identity":"1034236f-f162-4b84-9e68-eefa9f03f8be","order_by":2,"name":"Haddy Bah","email":"","orcid":"","institution":"Edward Francis Small Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Haddy","middleName":"","lastName":"Bah","suffix":""},{"id":301460315,"identity":"56ac7c95-ff2f-4d55-8a98-99d0fdbca62e","order_by":3,"name":"Sheikh Omar Bittaye","email":"","orcid":"","institution":"Edward Francis Small Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sheikh","middleName":"Omar","lastName":"Bittaye","suffix":""},{"id":301460316,"identity":"c6e7a9b0-5879-4b6e-b66c-5ccb129b0a0a","order_by":4,"name":"David Nygren","email":"","orcid":"","institution":"Lund University","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Nygren","suffix":""},{"id":301460317,"identity":"cdbb0bc5-56de-4467-ac82-54221cffca06","order_by":5,"name":"Abdoulie Badjan","email":"","orcid":"","institution":"Edward Francis Small Teaching Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdoulie","middleName":"","lastName":"Badjan","suffix":""}],"badges":[],"createdAt":"2024-05-06 16:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4378140/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4378140/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-10533-1","type":"published","date":"2025-02-05T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56809293,"identity":"32b38bb8-b27a-4272-bf46-0a2ba5519e66","added_by":"auto","created_at":"2024-05-20 18:47:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":81103,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of pathogens isolated from positive blood cultures.\u003c/p\u003e\n\u003cp\u003e* Other Enterobacterales include all identified pathogens in the Enterobacterales group, except Klebsiella spp, which is reported separately since it was the most common finding of this group.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e** Contaminants include results labelled as contaminants, typically coagulase-negative Staphylococci.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4378140/v1/a03730995608aaab351f7289.png"},{"id":56809292,"identity":"ea7e82c9-43fb-4a6a-9afb-51b7e6897028","added_by":"auto","created_at":"2024-05-20 18:47:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90888,"visible":true,"origin":"","legend":"\u003cp\u003eResistance patterns of the five most common pathogens in positive blood cultures. Total numbers of positive blood cultures where antimicrobial susceptibility testing was performed are presented (n) with resistance rates presented for each. Other Enterobacterales include all Enterbacterales except Klebsiella spp..\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e* MRSA was defined as any resistance to methicillin (or similar) as well as cephalosporins (except Ceftazidime) or carbapenems\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e** ESBL was defined as any resistance to third generation cephalosporins\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e***Defined as any acquired resistance beyond wild-type resistance in Acinetobacter spp. or Pseudomonas spp.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4378140/v1/ec178b0ef754face66b6b51e.png"},{"id":75930397,"identity":"86267a39-fa54-4bc0-aed4-4bf1ee1fdc44","added_by":"auto","created_at":"2025-02-10 16:11:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":992743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4378140/v1/d180286c-ea76-4603-9874-436bc8610f70.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bloodstream infections at a tertiary hospital in The Gambia - A one-year retrospective study","fulltext":[{"header":"Background","content":"\u003cp\u003eAntimicrobial resistance (AMR) is a growing public health concern and the Western Sub-Saharan Region has been estimated to suffer from the highest burden worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Scarcity of diagnostics, effective drugs, and reliable surveillance systems increase the impact of AMR in Sub-Saharan Africa (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e In The Gambia, most microbiological surveillance data has been described by the Medical Research Council Gambia (MRCG), a research institute and secondary health care facility in Fajara, outside of the capital Banjul. Previously, they have described \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e, \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eNon-typhoidal Salmonella\u003c/em\u003e (\u003cem\u003eNTS\u003c/em\u003e) as the most prevalent causes of bacteraemia (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Resistance rates to first and second-line antibiotics recommended in national and African CDC treatment guidelines have been low in studies from MRCG (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). MRSA has been described in 1\u0026ndash;13% of infections caused by \u003cem\u003eS. aureus\u003c/em\u003e while presence of ESBL in \u003cem\u003eKlebsiella spp.\u003c/em\u003e and \u003cem\u003eE. coli\u003c/em\u003e was seen in up to 35% and 23% based on cultures on varying patient samples (e.g. urine, blood, faeces) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, regional data from selected patient groups, especially paediatric and neonatal patients, have shown much higher resistance rates, with ESBL rates in \u003cem\u003eE. coli\u003c/em\u003e and \u003cem\u003eKlebsiella spp.\u003c/em\u003e infections ranging up to 50 and 100%, respectively (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Conversely, in one Gambian study investigating ESBL-carriage in faeces, a relatively low rate of 5% was described among food handlers (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). As there is no continuous national surveillance and reporting system in The Gambia, the burden of antimicrobial resistance among hospitalized patients and in the community largely remains unknown with varying rates previously reported.\u003c/p\u003e \u003cp\u003eThe lack of microbiological laboratories represents a major challenge throughout The Gambia (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Stock-outs of basic consumables, including blood culture bottles and antibiotics for susceptibility testing, occur regularly. Additionally, while paediatric care for children\u0026thinsp;\u0026lt;\u0026thinsp;5 years of age is free and subsidized for children from 5 to 14 years of age, most health care interventions in The Gambia require out-of-pocket payments for diagnostics and therapeutics for adults (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This may partly drive restrictive testing and discontinuation of treatment due to financial constraints. Varying quality of administered drugs, mis- and overuse of antibiotics as well as shortage of trained staff and laboratory facilities might be further drivers of AMR regionally (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eWe aimed to identify the most common causes of bacteraemia and their resistance patterns to evaluate the burden of AMR at the main teaching and referral hospital in The Gambia.\u003c/p\u003e \u003cp\u003eThe study objectives included\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003ethe identification of causes of bacteraemia in children and adults at the only tertiary hospital in The Gambia during 12 months.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eantimicrobial resistance rates to first- and second-line drugs (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) in bacteraemia.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis retrospective study was conducted at the Edward Francis Small Teaching hospital (EFSTH) in Banjul, The Gambia. EFSTH is the only tertiary hospital in the country offering specialist care, dialysis and intensive care, in addition to around the clock services for laboratory requests. We extracted baseline characteristics (age, gender, and ward), bacterial findings and antimicrobial susceptibility testing (AST) in patients who had blood cultures drawn over a 12-month period from September 2022 to August 2023. Data was retrieved from paper-based records at the Department of Microbiology at EFSTH, pseudonymized and then analysed using Microsoft Excel (Version 16.83). Graphs were designed using datawrapper software (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.datawrapper.de/\u003c/span\u003e\u003cspan address=\"https://www.datawrapper.de/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Participants\u003c/h2\u003e \u003cp\u003eCase eligibility was any patient with a blood culture (one pair) drawn from September 2022 to August 2023 at the EFSTH. No patients were excluded. Samples were drawn in all departments of emergency and acute medicine, surgery, internal medicine, paediatrics, paediatric surgery, outpatient clinics, obstetrics and gynaecology. In general, patients 14 years or younger are defined and treated as children (\u0026lt;\u0026thinsp;28 days as neonates, \u0026gt;\u0026thinsp;28 day to 14 years as paediatric patients) while patients aged 15 years or older are treated in adult departments at EFSTH. We defined patients from neonatal intensive care unit (NICU) as neonates if information on age was not documented. Patient results from intensive care unit (ICU) were labelled as adults, if information on age was missing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMicrobiological methods\u003c/h2\u003e \u003cp\u003eSpecimen collection procedures followed established protocols for the collection of blood cultures. Typically, they were drawn prior to the administration of antibiotics or upon deterioration in a patient despite ongoing antibiotic therapy. Samples were drawn via venepunctures from new sites and preceded by sterilization of the access sites. Ideally, eight to ten millilitres of blood were collected and inoculated into a set of BD BACTEC\u0026trade; PLUS culture bottles each (one aerobic and one anaerobic) for adults and for children a minimum of 0.5 ml blood was drawn to a maximum of 5 ml in one BD BACTEC\u0026trade; PLUS paediatric culture bottle.\u003c/p\u003e \u003cp\u003eBlood culture bottles were incubated in a BD BACTEC\u0026trade; FX40 incubator for 5 days. A gram stain was performed from positive bottles for preliminary identification followed by sub-culturing onto blood, Chocolate and MacConkey agar. Blood agar was prepared using 5% human blood obtained from expired blood donated for transfusions from the hospital blood bank. Sheep blood is not routinely available. Capacity for anaerobic culture were limited due to the lack of an anaerobic chamber or gas packs for producing an anaerobic atmosphere in jars.\u003c/p\u003e \u003cp\u003eBlood and MacConkey plates were incubated aerobically whereas Chocolate plates were incubated in 5% CO\u003csub\u003e2\u003c/sub\u003e. All were kept at 35℃ and reviewed after 24 hours when growth was compared across the plates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSpecies identification\u003c/h2\u003e \u003cp\u003eSpecies identification was based on the following procedures. Most gram-positive organisms will grow on blood and chocolate media, while gram-negative cocci may grow on either or both of blood and chocolate agar and gram-negative bacilli on all three plates. In case of polymicrobial growth across the various plates or growth patterns that do not conform to the above, contamination was suspected and the plates were discarded if confirmed. Phenotypic species identification was performed using manual biochemical methods. In gram-positive cocci, identified through gram stain and morphology appearance, a catalase test was performed using 1% hydrogen peroxide. If positive, the isolate was further speciated using Staphaurex\u0026trade; Plus Latex Agglutination Test. This classified isolates as either \u003cem\u003eStaphylococcus aureus\u003c/em\u003e or coagulase negative \u003cem\u003eStaphylococcus\u003c/em\u003e. Should clinical information suggest further need, a novobiocin disc test was performed to differentiate \u003cem\u003eS. epidermidis\u003c/em\u003e from \u003cem\u003eS. saprophyticus\u003c/em\u003e. For catalase negative gram-positive cocci, the haemolytic pattern was considered. β-haemolytic colonies on blood agar were subjected to a bacitracin disk susceptibility test with Group A streptococci, specifically \u003cem\u003eS. pyogenes\u003c/em\u003e, exhibiting sensitivity while Group B (\u003cem\u003eS. agalactiae\u003c/em\u003e), Group D (including Enterococci spp.) were expected to demonstrate resistance. For resistant β-haemolytic cocci a CAMP test was done to confirm Group B streptococci. For α-haemolytic organisms an optochin disc test was performed to differentiate \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e from other α-haemolytic Streptococci. NaCl 6.5% growth media were used to differentiate Enterococcus from non-enterococcal group D Streptococci.\u003c/p\u003e \u003cp\u003eGram-negative bacilli identified as lactose fermenters from MacConkey agar were phenotypically identified using triple sugar iron (TSI), 2% urea and citrate media. In these instances identification was generally done to genera level. Should the identification process give ambiguous results or subsequent antimicrobial testing showed a multidrug resistant organism BIOM\u0026Eacute;RIEUX API\u0026reg; ID 20E was used for further species identification if available. Lactose negative bacilli were screened using the oxidase test. Oxidase negative isolates would be further tested as for the lactose fermenters.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePseudomonas spp.\u003c/em\u003e isolates (lactose negative) were identified through colonial morphology, gram stain and oxidase reaction (oxidase positive). Finally gram-negative coccobacilli, if isolates grew only on chocolate agar, would be screened using factor X and V on nutrient agar to speciate \u003cem\u003eHaemophilus spp\u003c/em\u003e. Suspected \u003cem\u003eNeisseria species\u003c/em\u003e on the other hand would be identified based on gram stain, colonial morphology, and a positive oxidase test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAntimicrobial susceptibility testing\u003c/h2\u003e \u003cp\u003eAST was done per Clinical and Laboratory Standards Institute (CLSI) guidelines with Kirby-Bauer disk diffusion (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Inoculum for plating were prepared using MacFarland saline suspension of target organism. For the identification of methicillin-resistant \u003cem\u003eStaphylococcus aureus (MRSA)\u003c/em\u003e, a cefoxitin test was performed. Extended-spectrum beta-lactamase production was defined as resistance to third generation cephalosporins in pathogens of the \u003cem\u003eEnterobacterales\u003c/em\u003e group using double disc synergy testing. Acquired antimicrobial resistance in \u003cem\u003eAcinetobacter spp\u003c/em\u003e. or \u003cem\u003ePseudomonas spp.\u003c/em\u003e was defined as any additional acquired resistance beyond wild-type susceptibility (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Antibiotic discs available were often impacted by stock outs and availability.\u003c/p\u003e \u003cp\u003eIsolates identified as \u003cem\u003ecoagulase negative Staphylococci\u003c/em\u003e, \u003cem\u003eBacillus spp.\u003c/em\u003e, \u003cem\u003eMicrococcus spp.\u003c/em\u003e, \u003cem\u003eStreptococcus viridans\u003c/em\u003e and coryneform bacteria were regarded as contaminants unless they were isolated in two or more independent blood culture specimens from the same patient within a 48-hour period, in which case they were included as a pathogen.\u003c/p\u003e \u003cp\u003eIf bacteraemia was polymicrobial, each separate finding was noted regarding species distribution of positive cultures, with the exception of if polymicrobial growth was due to contaminants. Then they were specified as one contaminant.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eOutcomes and Variables\u003c/h2\u003e \u003cp\u003eThe primary analysis focused on blood culture positivity rates and distribution of pathogens identified grouped in neonatal, paediatric or adult patients, highlighting the five most common pathogens identified. The secondary analyses highlighted resistance patterns in the five most commonly identified pathogens and investigated differences in distribution of pathogens and AMR in patients cultured in ICU vs non-ICU.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eBias\u003c/h2\u003e \u003cp\u003eThe aim of the study was to assess patterns and frequency of AMR at the EFSTH. Given its retrospective design, selection bias is expected with an overrepresentation of severely ill as well as children due to restrictive testing. Hence, to highlight the extent of bias, secondary analyses compared distribution of pathogens and AMR in ICU vs non-ICU patients as well as between age groups.\u003c/p\u003e \u003cp\u003eAdditionally, constraints in funding and supply shortages at the hospital, the availability of kits for species identification and antibiotic discs for AST were often limited. Consequently, our analysis focus on the most commonly encountered pathogens and antibiotics. If data on AST were unavailable due to not having been performed, complete case analysis was performed. To minimize seasonal bias, we designed the study to cover a 12-months period to include seasonal variations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were mainly reported. For categorical variables, counts and percentages were presented with Fischer\u0026rsquo;s exact test used for statistical comparisons. For continuous variables, median and interquartile range (IQR) were presented. The study sample size was determined by the total amount of blood cultures performed during the study period. No formal power analysis was performed a priori.\u003c/p\u003e \u003cp\u003eSolely complete case analysis is presented due to the lack of reliable predictors for multiple imputation to be valid. If data was missing on age or where the blood culture was drawn, age group could not be defined, why potential blood culture findings were presented in total numbers, yet not in sub-groups.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eParticipants baseline characteristics\u003c/h2\u003e \u003cp\u003eIn total, 645 patients had blood cultures performed. Their baseline characteristics are summarised by age group in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. 268 (42%) of the patients were neonatal, 92 (14%) paediatric and 277 (43%) were adults. 406 (63%) of the overall samples were drawn in an ICU, with an overwhelming majority of samples in neonates, 264/267 (99%), drawn in the NICU.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and blood culture positivity rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeonatal\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;28 d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePaediatrics\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;28 d-15 y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdults\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ge;\u003c/em\u003e\u0026thinsp;15 y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) d\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0 (0.7-7) y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35 (27\u0026ndash;53) y\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale, %\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119/262 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32/92 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e142/277 (51%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e297/639 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood culture drawn in ICU, %\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e265/268 (99%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24/92 (26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117/277 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e406/645 (63%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood culture positivity rate, %\u003csup\u003e*, **\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140/268 (58%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33/92 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84/277 (30%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e260/645 (40%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e*\u003c/sup\u003e \u003cem\u003eSome patients had missing data on gender (n\u0026thinsp;=\u0026thinsp;6) or age group (n\u0026thinsp;=\u0026thinsp;8). If a definite allocation was not possible samples were included in the total column but not in the age specific columns.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003csup\u003e**\u003c/sup\u003e \u003cem\u003eExcluding contaminants\u003c/em\u003e.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMain Results\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eMost common pathogens identified in blood cultures\u003c/h2\u003e \u003cp\u003eOut of 645 patients from which blood cultures were obtained, 288 (45%) had bacteraemia, of which 28 (10%) were defined as contaminants. The most common pathogens identified were \u003cem\u003eS. aureus\u003c/em\u003e with 106 cases (37%), and \u003cem\u003eKlebsiella\u003c/em\u003e spp. with 41 cases (14%). Other pathogens of the \u003cem\u003eEnterobacterales\u003c/em\u003e group identified were 33 cases (11%), \u003cem\u003ePseudomonas\u003c/em\u003e spp. with 22 cases (8%) and \u003cem\u003eAcinetobacter\u003c/em\u003e spp. with 19 cases (7%). Findings are displayed in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eWhen cases with bacteraemia were grouped as neonatal, paediatric or adult, \u003cem\u003eS. aureus\u003c/em\u003e bacteraemia was most commonly seen among paediatric and adult cases, while neonatal \u003cem\u003eS. aureus\u003c/em\u003e bacteraemia was slightly less common (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Differences were smaller for gram-negative pathogens. No cases with contaminants identified were seen among paediatric patients, whereas it was relatively common in both neonates and adults. Given the lack of clinical data, it was not possible to ascertain whether these represented catheter-associated infections or truly represented skin contaminants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood culture findings by age groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNeonatal\u003c/p\u003e \u003cp\u003e\u0026le;\u0026thinsp;28 d*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePaediatrics\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;28 d-15 y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdults\u003c/p\u003e \u003cp\u003e\u0026ge;\u0026thinsp;15 y\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProportion of all positive blood cultures*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45/156 (29%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/33 (48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43/95 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e106/288 (37%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella\u003c/em\u003e spp. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24/156 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/33 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14/95 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41/288 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterobacterales\u003c/em\u003e group (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22/156 (14%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/33 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7/95 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33/288 (11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas spp.\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13/156 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/33 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/95 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22/288 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAcinetobacter spp. (%\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/156 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/33 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/95 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19/288 (7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContaminants**\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/156 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/33 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12/95 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28/288 (10%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20/156 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/33 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14/95 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39/288 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003e* n\u0026thinsp;=\u0026thinsp;4 of positive cultures had missing data on age group. If a definite allocation was not possible samples were included in the total column but not in the age specific columns. One blood culture had a polymicrobial infection.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e** Contaminants include results labelled as contaminants, typically coagulase-negative Staphylococcus.\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen cases with bacteraemia were grouped as ICU or non-ICU regardless of age group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), blood culture positivity rates were higher in the ICU (Fischer\u0026rsquo;s exact test, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). \u003cem\u003eS. aureus\u003c/em\u003e represented the most common finding in both groups, 32% in ICU patients and 49% in non-ICU patients. Rates of MRSA were higher in ICU patients, yet not statistically significant (Fischer\u0026rsquo;s exact test, p\u0026thinsp;=\u0026thinsp;0.16). Gram-negative pathogens had similar distribution and resistance rates, except for \u003cem\u003eAcinetobacter spp\u003c/em\u003e. which was solely identified in ICU patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBlood culture findings and resistance rates by sampling in the ICU or not.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNon-ICU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResistance rate\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResistance rate\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNon-ICU\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBlood culture positivity rate (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204/406 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84/239 (35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65/204 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41/84 (49%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25/38 (66%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9/20 (45%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella\u003c/em\u003e spp. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31/204 (15%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/84 (12%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27/30 (90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9/10 (90%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterobacterales\u003c/em\u003e group (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26/204 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/84 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40/53 (75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12/15 (80%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas spp.\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16/204 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/84 (7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12/14 (86%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5/6 (83%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAcinetobacter spp. (%\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19/204 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/84 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16/19 (84%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0/0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eContaminants**\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21/204 (10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7/84 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26/204 (13%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/84 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e*\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eResistance was defined as MRSA, ESBL (for Klebsiella spp. or Enterobacterales group), any acquired resistance beyond wild-type for Pseudomonas spp. or Acinetobacter spp.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e**No resistance rates are reported for contaminants or other pathogens.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eResults in Resistance Patterns\u003c/h2\u003e \u003cp\u003eAmong the five most common pathogens identified, AST was evaluated if performed. Of a total of 106 cases of \u003cem\u003eS. aureus\u003c/em\u003e-bacteraemia, 58 (55%) samples had available data on AST. Among these isolates, 34 (59%) were defined as MRSA. In the isolates defined as MRSA (n\u0026thinsp;=\u0026thinsp;34), resistance to other non-beta lactam antibiotics were described. Resistance was seen in 21/32 (66%) to macrolides, in 16/17 (94%) to fluroquinolones, in 11/14 (79%) to aminoglycosides, in 16/26 (62%) to tetracyclines and in 5/8 (63%) to trimethoprim-sulphonamide.\u003c/p\u003e \u003cp\u003eFor pathogens of the \u003cem\u003eEnterobacterales\u003c/em\u003e group, presence of ESBL was investigated. First \u003cem\u003eKlebsiella\u003c/em\u003e spp. were specifically investigated, since it was the most common gram-negative finding. In 40/41 (98%) isolates, AST were performed. Among these isolates, 36 (90%) were defined as ESBL. For \u003cem\u003eKlebsiella\u003c/em\u003e spp. isolates defined as ESBL, the resistance rates for other antibiotics were investigated and reported if tested. Resistance was seen in 16/28 (55%) for fluoroquinolones, in 20/20 (100%) for trimethoprim-sulphonamide and in 8/11 (73%) for aminoglycosides. Carbapenems or amikacin were not tested for in any of the \u003cem\u003eKlebsiella spp\u003c/em\u003e. isolates.\u003c/p\u003e \u003cp\u003eAmong other pathogens of the \u003cem\u003eEnterobacterales\u003c/em\u003e group, 28/33 (85%) were investigated for ESBL. Among these isolates, 16 (57%) were defined as ESBL. The resistance rates for other antibiotics were investigated and reported if tested. Resistance was seen in 5/12 (42%) for fluoroquinolones, 10/12 (83%) for trimethoprim-sulphonamide and 7/8 (88%) for aminoglycosides. Carbapenems were investigated in three isolates, all were susceptible. Amikacin resistance was not tested for.\u003c/p\u003e \u003cp\u003eFor \u003cem\u003ePseudomonas\u003c/em\u003e spp. 20/22 (91%) were investigated for any acquired resistance beyond wild-type. Acquired resistance were seen in 7/14 (50%) to fluoroquinolones, in 7/11 (64%) to beta-lactam antibiotics and in 9/10 (90%) to aminoglycosides. Beta-lactams investigated were ceftazidime, for which 7/10 (70%) were resistant, and imipenem-cilastatin for which 0/1 (0%) was resistant. Amikacin resistance was not tested for.\u003c/p\u003e \u003cp\u003eFor \u003cem\u003eAcinetobacter\u003c/em\u003e spp. 19/19 (100%) were evaluated for any acquired resistance beyond wild-type. Acquired resistance were seen in 5/17 (29%) for fluoroquinolones, in 5/14 (36%) for beta-lactam antibiotics, in 13/14 (93%) for trimethoprim-sulphonamide and in 3/3 (100%) for aminoglycosides. Beta-lactams investigated were ceftazidime, for which 5/14 (36%) were resistant, and imipenem-cilastatin, for which 0/1 (0%) was resistant. Amikacin resistance was not tested for.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eKey Results/Objectives\u003c/h2\u003e \u003cp\u003eOur analysis describes the blood culture positivity rates, distribution of isolated pathogens and their antimicrobial resistance rates in bacteraemia at a tertiary hospital in The Gambia over a 12-month period. The study revealed an overall blood culture positivity rate of 42% when contaminants were excluded. The highest positivity rate was found in neonates and among ICU-patients. The most frequently identified pathogens in descending order were \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eKlebsiella\u003c/em\u003e spp., other \u003cem\u003eEnterobacterales\u003c/em\u003e, \u003cem\u003ePseudomonas\u003c/em\u003e spp., and \u003cem\u003eAcinetobacter\u003c/em\u003e spp. Among \u003cem\u003eS. aureus\u003c/em\u003e, MRSA-rates were surprisingly high, as were ESBL-rates in \u003cem\u003eKlebsiella\u003c/em\u003e spp. and other \u003cem\u003eEnterobacterales\u003c/em\u003e spp. Similarly, most strains with \u003cem\u003ePseudomonas\u003c/em\u003e spp. or \u003cem\u003eAcinetobacter\u003c/em\u003e spp. had acquired resistance beyond their wild-type susceptibilities.\u003c/p\u003e \u003cp\u003eThese findings highlight the severe impact of bacteraemia and antimicrobial resistance in The Gambia. High blood culture positivity and resistance rates were seen in all age groups, emphasising the threat of blood stream infections in our setting (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Particularly concerning is the high positivity rate observed in neonates as they are susceptible to poor outcome in infections due to poor immune response. The high resistance rates found will contribute to the morbidity and mortality of infants in The Gambia accentuating the impact of sepsis in childhood and neonatal mortality in sub-Saharan Africa (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In comparison to most previous regional data, resistance rates presented in this study are worse (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). It is likely that patients presenting to the tertiary hospital (EFSTH) are selected and often have had prior antibiotic exposure. Similarly, the high blood culture positivity rate indicates restrictive testing, where possibly only patients who are failing on antibiotic therapy or are severely ill are cultured.\u003c/p\u003e \u003cp\u003eThe identification of pathogens revealed a predominance of \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eKlebsiella\u003c/em\u003e spp. and other \u003cem\u003eEnterobacterales\u003c/em\u003e, along with \u003cem\u003ePseudomonas\u003c/em\u003e spp. and \u003cem\u003eAcinetobacter\u003c/em\u003e spp. We reported other \u003cem\u003eEnterobacterales\u003c/em\u003e as a group as shortages of supplies made definite species identification uncertain. In general, the rate of gram-negative bacteria identified surpassed previous reports, which could be due to EFSTH\u0026rsquo;s status as sole referral hospital in the country (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The influx of patients with complex infections referred from other facilities may also have contributed to these findings. Unfortunately, clinical data regarding onset and type of symptoms, previous or current treatment or patient\u0026rsquo;s outcomes was not available, due to the retrospective design and the lack of integrated and electronic medical records. Nevertheless, our data has shown alarmingly high results of rates MRSA, ESBL and acquired resistance beyond wild type in \u003cem\u003ePseudomonas\u003c/em\u003e and \u003cem\u003eAcinetobacter\u003c/em\u003e spp. The fact that 64% of overall samples came from ICU or NICU settings emphasize the selection of critically ill and vulnerable patients in this study. Nosocomial infections and multi-drug resistant pathogens are therefore likely overrepresented. However, the differences in resistance rates in cultures from patients admitted to the ICU and non-ICU patients were relatively small (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In summary, these findings highlight the burden of infections with resistant gram-negative pathogens and are in line with previous reports from in Sub-Saharan and particularly Western Africa (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious studies have identified \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eS. pneumoniae\u003c/em\u003e, \u003cem\u003eE. coli\u003c/em\u003e and non-typhoidal \u003cem\u003eSalmonella\u003c/em\u003e (\u003cem\u003eNTS)\u003c/em\u003e as the most prevalent pathogens in bacteraemia (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) of which \u003cem\u003eStreptococcus spp.\u003c/em\u003e and \u003cem\u003eSalmonella\u003c/em\u003e spp. were not commonly seen in our analysis. Efficacious outpatient antibiotic treatment, no or late microbiological assessments as well as lack of appropriate testing options might cause underreporting of these cases due to the retrospective study design (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Nevertheless, our findings are in line with previous data suggesting higher proportions of gram-negative bacteraemia both at the EFSTH as do previous analyses from the West African region (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Importantly, given the high proportion of cultures drawn in ICU settings and the study site being a tertiary care hospital, generalizability of findings to community-acquired infections in all of The Gambia is limited. While our findings can inform empirical treatment in nosocomial sepsis in the region, further prospective studies are needed to investigate distribution of pathogens and AMR specifically in community-acquired bacteraemia to inform antibiotic therapy guidelines in community-acquired sepsis regionally.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study limitations are mainly due to its retrospective single centre design. Selection bias of severe cases restrictive testing at this tertiary hospital have been highlighted. Likely, this impacts both species distribution and resistance rates. As mentioned, a vast majority of patients who had blood cultures drawn, were admitted to ICU-departments, and the majority of patients are neonatal or paediatric which impacts interpretation. Additionally, during the study period, diagnostic precision and AST was impacted by stock-outs. Also, anaerobic incubation conditions are insufficient highlighted by no isolated anaerobic bacteraemia identified.\u003c/p\u003e \u003cp\u003eSince antibiotics beyond first- and second-line antibiotics are rarely available, a need for increased availability of broader antimicrobials, AST to guide when to use them, efficient infection control measures and antibiotic stewardships are highlighted. Future studies should include clinical data as well as early initiation of microbiological assessments.\u003c/p\u003e \u003cp\u003eUnfortunately, the preparedness for rising AMR rates in The Gambia remains low and our findings underline the need to refocus on infection control measures, develop continuous surveillance systems of bloodstream and other infections, increase the availability of antibiotics beyond 2nd line following AST and improve local policies while respecting a one health approach and update local treatment guidelines (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Given the limitations of the study design, a prospective study to assess and compare species distribution and resistance patterns in nosocomial vs. community-acquired bacteraemia in The Gambia is currently being designed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study reveals high blood culture positivity rates at the tertiary hospital in The Gambia primarily based on data from critically ill, neonatal and paediatric patients. The most common pathogens identified were \u003cem\u003eS. aureus\u003c/em\u003e, \u003cem\u003eKlebsiella\u003c/em\u003e spp. among other Enterobacterales, \u003cem\u003ePseudomonas\u003c/em\u003e and \u003cem\u003eAcinetobacter\u003c/em\u003e spp., which differs to previous findings regionally. This is the first study examining neonates and critically ill to this extent in The Gambia, who here were overrepresented. Alarmingly, we show high rates of MRSA and ESBL. These findings suggest the urgent need for the implementation of AMR surveillance systems, an increase in availability of microbiological diagnostics, a review of infection control measures and improved access to broader antibiotic therapies to mitigate the impact of sepsis due to multi-drug resistant pathogens regionally.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAMR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial Resistance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAST\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntimicrobial Susceptibility Testing\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCLSI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eClinical \u0026amp; Laboratory Standards Institute\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEFSTH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEdward Francis Small Teaching Hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtended\u0026ndash;Spectrum Beta Lactamase\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eICQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRCG\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council Gambia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMethicillin Resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNTS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eNon\u003c/em\u003e\u0026ndash;\u003cem\u003etyphoidal Salmonella\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNICU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNeonatal Intensive Care Unit\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval\u003c/h2\u003e\n\u003cp\u003eThe protocol and study procedures were approved by EFSTH Research Ethics Committee (Reference number EFSTH_REC_2023_121; approval 23\u003csup\u003erd\u003c/sup\u003e of October 2023).\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIn accordance with ethical guidelines and institutional policies, this retrospective study has been conducted using previously collected data. Analysis of existing data sets, and all personal identifiers have been removed to ensure confidentiality and compliance with data protection regulations. Necessity to obtain informed consent was waived by the EFSTH Research Ethics Committee since data was obtained and presented anonymously without presence of a code.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAvailability of data and material\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on request. This data availability is consistent with ethical guidelines and institutional policies concerning privacy and confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNone of the authors has competing interests in relation to this study. This includes any financial, personal, or professional affiliations that could influence the content or interpretation of the findings presented in this manuscript. Our commitment to transparency and scientific integrity ensures that all aspects of the study, from data collection to publication, have been conducted free from any undue influence.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNone of the authors received any kind of funding for this study. None of the authors had any competing interests in the design, conduction or reporting outcomes of our findings.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthors Contribution\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003ePR and AB conceptualised the study. PR and EB extracted the data. PR, DN and AB analysed the data and wrote the first draft. SOB, HB and AB reviewed and helped interpreting the study results. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe would like to thank the staff of EFSTH especially the department of microbiology for the support during the duration of the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAntimicrobial Resistance C. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollaborators AR. The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis. Lancet Glob Health. 2024;12(2):e201\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEssack SY, Desta AT, Abotsi RE, Agoba EE. Antimicrobial resistance in the WHO African region: current status and roadmap for action. J Public Health (Oxf). 2017;39(1):8\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIwu CD, Patrick SM. An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: A roadmap for action. Int J Antimicrob Agents. 2021;58(4):106411.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarboe S, Okomo U, Muhammad AK, Ceesay B, Jallow M, Usuf E, et al. Community-acquired Invasive Bacterial Disease in Urban Gambia, 2005\u0026ndash;2015: A Hospital-based Surveillance. Clin Infect Dis. 2019;69(Suppl 2):S105\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCDC A. African Antibiotic Treatment Guidelines for Common Bacterial Infections and Syndromes. 2021;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWelfare DoSfHS. The Gambia - Standard Drug Treatment Guidelines. 2001.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarboe S, Mirasol R, Adejuyigbe B, Muhammad AK, Nadjm B, De St Maurice A et al. Using an Antibiogram Profile to Improve Infection Control and Rational Antimicrobial Therapy in an Urban Hospital in The Gambia, Strategies and Lessons for Low- and Middle-Income Countries. Antibiot (Basel). 2023;12(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarboe S, Dobreniecki S, Jarju S, Jallow M, Mohammed NI, Wathuo M, et al. Prevalence of Panton-Valentine Leukocidin (PVL) and Antimicrobial Resistance in Community-Acquired Clinical Staphylococcus aureus in an Urban Gambian Hospital: A 11-Year Period Retrospective Pilot Study. Front Cell Infect Microbiol. 2019;9:170.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkomo UA, Darboe S, Bah SY, Ayorinde A, Jarju S, Sesay AK, et al. Maternal colonization and early-onset neonatal bacterial sepsis in the Gambia, West Africa: a genomic analysis of vertical transmission. Clin Microbiol Infect. 2023;29(3):386. e1- e9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaw PS, Schlinkmann KM, Raupach-Rosin H, Karch A, Pletz MW, Huebner J, et al. Antibiotic use on paediatric inpatients in a teaching hospital in the Gambia, a retrospective study. Antimicrob Resist Infect Control. 2018;7:82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBah SY, Kujabi MA, Darboe S, Kebbeh N, Kebbeh BFK, Kanteh A, et al. Acquisition and carriage of genetically diverse multi-drug resistant gram-negative bacilli in hospitalised newborns in The Gambia. Commun Med (Lond). 2023;3(1):79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanneh B, Kebbeh A, Jallow HS, Camara Y, Mwamakamba LW, Ceesay IF, et al. Prevalence and risk factors for faecal carriage of Extended Spectrum beta-lactamase producing Enterobacteriaceae among food handlers in lower basic schools in West Coast Region of The Gambia. PLoS ONE. 2018;13(8):e0200894.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrimpong AA, Arthur E. Effects of public and external health spending on out-of-pocket payments for healthcare in sub-Saharan Africa. Health Policy Plan. 2022;37:1129\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolmes AH, Moore LS, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute CaLS. Performance Standards for Antimicrobial Susceptibility Testing. 2020;30th Edition.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBassat Q, Blau DM, Ogbuanu IU, Samura S, Kaluma E, Bassey IA, et al. Causes of Death Among Infants and Children in the Child Health and Mortality Prevention Surveillance (CHAMPS) Network. JAMA Netw Open. 2023;6(7):e2322494.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollaborators GBoDAR. Global mortality associated with 33 bacterial pathogens in 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2022;400(10369):2221\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990\u0026ndash;2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395(10219):200\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernabe 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\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSolomon S, Akeju O, Odumade OA, Ambachew R, Gebreyohannes Z, Van Wickle K, et al. Prevalence and risk factors for antimicrobial resistance among newborns with gram-negative sepsis. PLoS ONE. 2021;16(8):e0255410.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOdonkor ST, Simpson SV, Morales Medina WR, Fahrenfeld NL. Antibiotic-Resistant Bacteria and Resistance Genes in Isolates from Ghanaian Drinking Water Sources. J Environ Public Health. 2022;2022:2850165.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnning AS, Baah E, Buabeng SD, Baiden BG, Aboagye B, Opoku YK, et al. Prevalence and antimicrobial resistance patterns of microbes isolated from individuals attending private diagnostic centre in Cape Coast Metropolis of Ghana. Sci Rep. 2022;12(1):14282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkomo U, Akpalu ENK, Le Doare K, Roca A, Cousens S, Jarde A, 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(11):1219\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwambana-Adams B, Darboe S, Nabwera H, Foster-Nyarko E, Ikumapayi UN, Secka O, et al. Salmonella Infections in The Gambia, 2005\u0026ndash;2015. Clin Infect Dis. 2015;61(Suppl 4):S354\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSecka F, Herberg JA, Sarr I, Darboe S, Sey G, Saidykhan M, et al. Bacteremia in Childhood Life-Threatening Infections in Urban Gambia: EUCLIDS in West Africa. Open Forum Infect Dis. 2019;6(9):ofz332.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOlatunji YA, Banjo AA, Jarde A, Salaudeen R, Ndiaye M, Galega LB, et al. Invasive bacterial disease in young infants in rural Gambia: Population-based surveillance. J Glob Health. 2023;13:04106.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElton L, Thomason MJ, Tembo J, Velavan TP, Pallerla SR, Arruda LB, et al. Antimicrobial resistance preparedness in sub-Saharan African countries. Antimicrob Resist Infect Control. 2020;9(1):145.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaxminarayan R, Matsoso P, Pant S, Brower C, Rottingen JA, Klugman K, et al. Access to effective antimicrobials: a worldwide challenge. Lancet. 2016;387(10014):168\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis. 2013;13(12):1057\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bacteraemia, Antimicrobial Resistance, Sub-Sahara Africa, The Gambia","lastPublishedDoi":"10.21203/rs.3.rs-4378140/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4378140/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eAntimicrobial resistance is a significant global health concern, particularly in western Sub-Saharan Africa. This study describes causes of bacteraemia and antimicrobial resistance at a tertiary hospital in The Gambia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective analysis included all blood cultures performed at the Edward Francis Small Teaching Hospital, Banjul, The Gambia, from September 2022 to August 2023. Blood culture positivity-rates and pathogens were described. Antimicrobial susceptibility testing was performed using disk diffusion (CLSI).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn total, 288/645 (45%) blood cultures were positive. A majority were drawn in intensive care units (63%) and in neonatal or paediatric patients (56%). The most common pathogens were \u003cem\u003eStaphylococcus aureus\u003c/em\u003e 106/288 (37%), \u003cem\u003eKlebsiella spp.\u003c/em\u003e 41/288 (14%), other bacteria within the \u003cem\u003eEnterobacterales\u003c/em\u003e order 33/288 (11%), \u003cem\u003ePseudomonas spp.\u003c/em\u003e 22/288 (8%) and \u003cem\u003eAcinetobacter spp.\u003c/em\u003e 19/288 (7%). 28/288 (10%) were classified as contaminants. Methicillin-resistant \u003cem\u003eS. aureus\u003c/em\u003e (MRSA) was seen in 34/58 (59%) tested. Extended-spectrum beta-lactamases (ESBL) were seen in 36/40 (90%) of \u003cem\u003eKlebsiella\u003c/em\u003e spp. and in 16/28 (57%) of other bacteria within the \u003cem\u003eEnterobacterales\u003c/em\u003e order. Acquired antibiotic resistance, beyond wild-type, was reported in 17/20 (85%) of \u003cem\u003ePseudomonas\u003c/em\u003e spp. and 16/19 (84%) of \u003cem\u003eAcinetobacter\u003c/em\u003e spp.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOverall, blood culture positivity rates were high, indicating restrictive testing. The presented data highlight blood culture findings primarily among critically ill and neonatal or paediatric patients, with nosocomial infections likely overrepresented. Despite probable selection bias, alarmingly high MRSA- and ESBL-rates were described. These findings highlight the urgent need of accessible microbiological diagnostics, antibiotic stewardships and infection control measures in West Africa. Importantly, generalizability of findings to community-acquired infections remains restricted.\u003c/p\u003e","manuscriptTitle":"Bloodstream infections at a tertiary hospital in The Gambia - A one-year retrospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-20 18:47:47","doi":"10.21203/rs.3.rs-4378140/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-24T08:38:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-19T07:21:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-16T14:39:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-10T18:49:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132989442872265948008728196578738263392","date":"2024-06-09T13:50:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"255645094501721860109050578489364125883","date":"2024-06-07T21:06:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"279788190873074687819736261074830457309","date":"2024-05-31T17:59:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-24T18:05:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-09T05:20:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-08T12:59:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-08T12:59:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-05-06T16:12:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50c59f12-8662-49b4-aa2d-28278f53c5a2","owner":[],"postedDate":"May 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:01:30+00:00","versionOfRecord":{"articleIdentity":"rs-4378140","link":"https://doi.org/10.1186/s12879-025-10533-1","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-02-05 15:57:27","publishedOnDateReadable":"February 5th, 2025"},"versionCreatedAt":"2024-05-20 18:47:47","video":"","vorDoi":"10.1186/s12879-025-10533-1","vorDoiUrl":"https://doi.org/10.1186/s12879-025-10533-1","workflowStages":[]},"version":"v1","identity":"rs-4378140","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4378140","identity":"rs-4378140","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}