The Role of Pseudomonas aeruginosa in Surgical Site Infections in Sub-Saharan Africa

The Role of Pseudomonas aeruginosa in Surgical Site Infections in Sub-Saharan Africa | 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 Systematic Review The Role of Pseudomonas aeruginosa in Surgical Site Infections in Sub-Saharan Africa Sarah Kindiki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5535461/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We aimed at understanding the role of Pseudomonas aeruginosa (PA) on the seemingly growing and concerning infections of surgical sites in sub-Saharan Africa (SSA). We therefore searched PubMed and other relevant databases for articles (2015-2023) relevant to antimicrobial resistance (AMR) and predominance of Pseudomonas aeruginosa (PA) in sub-Saharan Africa (SSA). In this review, we examined 26 relevant articles out of 225 that matched the initial search. Through an in-depth analysis of the relevant literature, the low number of studies in the region focused on PA and AMR. Nevertheless, the relatively few studies demonstrate the high rates of PA involvement in surgical site infections. The studies further show high levels of multi-drug resistance and points to subsequent nosocomial clinical outcomes. In conclusion with the increased AMR threat, there is a need for increased studies on SSI, PA biology and genomics and AMR. Infectious Diseases Pseudomonas aeruginosa Surgical Site Infections predominance Sub-Saharan Africa Figures Figure 1 Significance The present research unravels the alarming prevalence of P. aeruginosa and its implication in surgical site infections in SSA, while underscoring the urgent need to implement targeted interventions in order to address a growing regional public health concern. 1.0 Introduction Among the Caucasians, the colonization of the airways of persons living with cystic fibrosis (pwCF) by Pseudomonas aeruginosa (PA) is well-documented. 10 , 50 These patients are susceptible to airway attack by PA owing to frequent buildup of thick mucus in the airways, sufficing for an ideal environment for PA to thrive and outcompete other microbes, thus chronic respiratory infections. 11 , 13 , 4 Such infections by PA often can lead to reduced quality of life, contributing significantly to the burden of disability-adjusted life years (DALYs) leading to high morbidity and mortality rates. 25 In contrast, Sub-Sahara African populations have a lower CF rate coupled by lower access to healthcare services but may not experience the same degree of PA-related respiratory infections. 1 Nevertheless, PA has proven a major health concern as far as surgical site infections are concerned in sub-Saharan Africa. We therefore sort to establish how much is currently known about the role and involvement of PA in SSI in sub-Saharan Africa. Surgical site infections (SSIs) remain a global challenge in healthcare systems, significantly contributing to increased healthcare costs, patient morbidity and mortality. 26 , 27 , 30 Whereas studies have well-documented the burden of SSIs globally, Sub-Saharan Africa (SSA) context still presents unique challenges intensifying the impact of Pseudomonas aeruginosa (PA) infections on wounds, thus implicating a serious threat to healthcare delivery mechanisms and patient safety in the region. 60 , 39 , 49 In its Bacterial Priority Pathogens List (BPPL), the World Health Organization (WHO) featured 15 families of AMR bacterial pathogens into three categories including critical, high and medium in line with prioritization and combating the spread of AMR. Pseudomonas aeruginosa features among high-priority pathogen with high infection burden among others like Salmonella, Shigella and Staphylococcus aureus , in healthcare settings. 76 Pseudomonas aeruginosa is considered one of the most successful bacterial pathogens owing to several factors including antibiotic resistance which stems from the possession of efflux pumps, low permeability of outer membrane to antibiotics, acquisition of resistance genes and adaptive resistance. 64 , 16 , 47 , 23 Moreover, important aspects including virulence factors like proteases, pigments, and exotoxins 34 , 43 , 65 , which are known to immensely contribute to the organism’s ability to cause disease, biofilm formation attributed to survival and adaptation of PA in hospital environments through quorum sensing mechanism 41 , have not been demonstrated for isolates recovered previously from SSA. Therefore, there is a need to understand them. The emergence and reduced costs of whole genome sequencing now provide hope that these isolates can now be subjected to these assays and genomes sequenced to shade more light on their adaptation to SSIs in SSA. Therefore, this review aims to explore just how much is known about the biology of PA in SSA and thus the extent of knowledge surrounding AMR, virulence factors, and biofilm-formation capabilities. Moreover, the emergence of genome sequencing, it is now possible to explore the organism’s genetic diversity and identify novel resistance mechanisms as well as how much isolation and sequencing on PA have been done in the region. A broad understanding of the epidemiology, antimicrobial resistant patterns, virulence carriage and distribution risk factors and subsequent implications of PA SSIs clinically in Sub-Saharan Africa, is crucial in line with guiding policy decisions and interventions. Through the revelation of the unique challenges SSA faces in the context of PA infections on surgical sites, this review seeks to underscore the urgent need for mitigation strategies on the impact of SSIs on healthcare sector in this region. 2.0 Methods 2.1 Literature strategy search In this review, “sub-Saharan Africa” refers to the countries constituting the WHO- Africa region. A systematic search of electronic databases including PubMed, Google scholar and Scopus was conducted to identify all relevant studies which were published between 2015 and 2023. Medical subject headings (MeSH) and other Keywords related to “ Pseudomonas aeruginosa ”, “Surgical site infections”, “sub-Saharan Africa”, and “Antimicrobial resistance” were used in various combinations such that the search sensitivity is maximized. Next, Boolean operators “AND” and “OR” were used to combine these search terms, which was inclined to syntax and filters of each database while incorporating truncation and where applicable, proximity operators. Moreover, references list for various relevant articles and review papers were manually searched to identify any additional studies. 2.2 Inclusion and Exclusion Criteria In this review, studies reporting on the epidemiology, antimicrobial resistance patterns, virulence, risk factors, and interventions in line with PA in SSIs in SSA were included. Moreover, articles in peer-reviewed journals, conference abstracts were included. However, those studies not specific to sub-Saharan Africa as well as those only focusing on other pathogens or those lacking primary research data were excluded. Nevertheless, all non-English articles which are relevant were translated and included. 2.3 Study Selection For this review, two independent reviewers screened titles and abstracts of retrieved articles for eligibility based on the inclusion and exclusion criteria. For eligibility, full-text articles for relevant studies were obtained and assessed for eligibility. Any differences between the reviewers were resolved through consultations with a third reviewer. 2.4 Data Extraction A standardized data extraction form was developed to capture relevant information from the selected studies which included characteristics of the study (author, year, study design), demographics of study participants, PA prevalence, risk factors, AMR profiles and interventions. 2.5 Quality Assessment In this review, the methodological quality of the selected studies was evaluated using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for studies that were randomized controlled trials. Quality assessment here helped inform the interpretation and synthesis of findings with higher quality studies. 2.6 Data Synthesis and Analysis In this review, findings from the studies included were synthesized narratively, organized in line with key themes and outcomes. Additionally, subgroup analyses were conducted as appropriate in line with exploring heterogeneity of results. 2.7 Reporting The preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) ( Fig. 1 ) were followed to ensure comprehensive and transparent reporting of the findings of this review. 3.0 Results A total of 225 articles were initially identified by use of the systematic literature search across PubMed, Scopus and Google Scholar, while focusing on the role of PA in surgical site infections in Sub-Saharan Africa. After screening titles and abstract, 26 articles of the 225 were deemed eligible for full-text review. The included studies embedded a number of themes around PA, including the epidemiology, risk factors, AMR patterns, clinical outcomes and interventions surrounding the infection incidences (Table 1). The results of this analysis are presented as follows. 3.1 Epidemiology of Pseudomonas aeruginosa SSI in Sub-Saharan Africa Among the articles reviewed, a consistent trend emerged underscoring the predominance of PA in SSIs across various healthcare settings in Sub-Saharan Africa from 4 articles. Based on table 2 , several studies reported high rates of PA isolation from surgical wound specimens ranging from 12%-33%, with one particular study in Ethiopia reporting 27 (12.86%) and 74 (19.3%) of all the wound cultures 22 , 73 , 15(30%) in Ghana 8 and 3/9 (33.3%) on samples from post-renal transplant patients in Nigeria 32 . Currently, most of the studies available were done in west Africa, and the other regions were under represented. Nevertheless, these ranges depended on the type of surgery and patient population sampled. Noteworthy, Omoyibo 62 and Eman 20 also appreciated PA as one of the most prevalent pathogens responsible for SSIs alongside other common pathogens like Staphylococcus aureus and Escherichia coli in Sub-Saharan Africa. 3.2 Risk Factors Associated with Pseudomonas aeruginosa Surgical Site Infections The search was able to unravel 4 risk factors, which appeared to contribute to the acquisition as well as the development of SSIs by PA in Sub-Saharan Africa. While Kakupa 35 and Dégbey 17 identified prolonged hospitalization, inadequate control measures for infections, use of indwelling medical devices as significant risk factors, Moremi 57 underscored the role of surgical procedures in the increased risk of infections by PA, especially among patients undergoing or recovering from abdominal surgeries. These findings highlight the importance of targeted strategies aimed at preventing SSIs attributed to PA in Sub-Saharan Africa. 3.3 Antimicrobial Resistance Patterns of Pseudomonas aeruginosa In the review, AMR among several PA isolates in the studies in SSA was notably high and therefore of concern. Reports indicate high resistance levels to piperacillin-tazobactam Sierra Leone, Uganda, Nigeria and Malawi at 83.3%, 100%, 91.3% and 66% respectively. 39,49,62,15 ( Table 3 ) . Moreover, PA has continued showing high levels of resistance to Ciprofloxacin in these countries with rates as high as 83.3% and levofloxacin at 83.3% in Sierra Leone. 39 Elsewhere, Al-Orphaly 2 and Mostapha 58 underscored the importance of resistance of PA to commonly used antibiotics like beta-lactams, fluoroquinolones, and aminoglycosides, to the onset of SSIs. Additionally, multi-drug resistance appeared to be prevalent, with some important studies appreciating the resistance of PA to multiple antibiotics classes attributed to derailment of treatment processes or options therefore exacerbating the risk of treatment failure. For example, as Imipenem appears effective against PA (only 7.4% resistance rate), the pathogen appears commonly resistant to Gentamycin (63% resistance and only 30% sensitivity rate) in the recent study. 22 These levels of resistance can also draw from the genes encoding resistance in these strains. Not many studies in SSA have highlighted the AMR genes. However, a few studies have shed light into several AMR genes in PA. For example, carbapenem resistance is observed in multiple regions, suggesting the possible presence of carbapenemase genes like, blaIMP, blaVIM or blaNDM. On their study of MDR organisms in a teaching facility in Ghana 8 , 352 isolates were cultured out of 438 SSIs noted. Majority of these organisms were MDR, calling for re-evaluation of antibiotic prophylaxis in surgical practices. Other cases of MDR appeared in other studies. 53 , 31 3.4 Virulence The success of PA in infecting surgical wounds has been attributed to its virulence factors which include exotoxins, pigments, proteases, and biofilm formation. 38 While there is much data on this globally, there still remains a significant gap on PA strain isolated in SSA. A few studies have made efforts on the isolation of PA, but this remains region-specific following resource constraints 38 . For example, eight (14%) out of 57 samples were positive for PA in a study in Tanzania 57 and 26.1% isolated from surgical wounds in Ethiopia 40 . Nevertheless, some reports on the virulence mechanisms of PA have started coming in 38 . However, the extent of this activity on tissues still remains underexplored. Elsewhere 38 , 40 , the role of biofilm formation in chronic infections and antibiotic resistance has been documented. However, there’s limited data on the molecular mechanisms-the driving forces behind the surging infections. Similarly, research data on QS genes and a correlation with virulence expression remains unexplored sufficiently, despite available data on QS as a survival mechanism of PA. 3.5 Impact and clinical outcomes of Pseudomonas aeruginosa in SSIs The severity of infection within the host organism on these wounds have been attributed to extended hospital stays and increased healthcare costs 57 , period of surgery 28 due to prolonged use of invasive devices like exposure to pathogens thus heightened morbidity and mortality rates. 30 , 49 Additionally, Patients presenting with PA have been reported to experience delayed healing of wounds 28 , systemic complications and sepsis 12 hence decreased quality of life. Furthermore, other reports attribute the economic burden of PA to weak infrastructure, underscoring the need for effective prevention and other management strategies in line with mitigating the menace. 48 3.5 Preventive and management of PA in SSIs Despite the challenges posed by PA, most studies identified a number of prevention and interventions strategies, that can help alleviate the impact of PA SSIs in sub-Saharan Africa. While some sensitized on the enhanced surveillance of SSIs, implementation of infection control programs (ICPs) 72 , 56 , others underscored the importance of promotion of AMR stewardship 15 , improved access to effective antibiograms in line with reducing the incidence of PA in the region. 3 Moreover, strengthening of infrastructure, community engagement and capacity building appeared in several studies as a recommendation as approach to fighting AMR by PA. 24 , 2 Although there are not many studies in SSA done on PA infecting surgical sites, the result of this review highlights the concerning trend of PA predominance in surgical site infections on the few sampled clinical settings in SSA. While there’s data on AMR and virulence of PA, its regional variability could spell challenges in infection control for surgical site infections. Incomplete understanding of epidemiology of PA affects surveillance efforts. Moreover, gaps in the sequencing data could have severe implications to control of antibiotic resistance and novel therapies. 4.0 Discussion In this review, the results point out a concerning trend of the prevalence and impact of PA in SSIs within sub-Saharan Africa. This trend is indicative of a significant predominance of PA. This serves as an alarm owing to PA’s well-documented propensity for AMR and the associated clinical outcomes. 4.1 Prevalence and risk factors of Pseudomonas aeruginosa in Surgical Site Infections This study serves to demonstrate that PA is understudied in Africa. Bearing in mind that our review focused on studies in the recent 8 years, with only four articles revealed PA as the prevalent pathogen in SSIs. There is however consistency in the studies which highlighted the predominance of PA in SSI within the context of SSA, that the organism shows potential of outcompeting other microbes on wounds. This phenomenon is possible owing to the presence of virulence factors, biofilm formation, antibiotic-degrading enzymes, metabolic versatility, and immune evasion. 38 , 40 Additionally, what emerges from the studies are high rates of PA recovery from SSIs, demonstrating a considerable burden of PA in SSA, and underscoring the role of PA in nosocomial infections in the region. Additionally, the variability of risk factors is important since it underscores the influence local factors have on the AMR trends. Inadequate control measures, prolonged hospital stays, and prolonged surgery heavily influence the prevalence and severity of infections by PA on surgical wounds. These factors are especially pertinent in SSA owing to unexplored gaps in clinical research, leading to limited surveillance data and inadequate monitoring of resistant strains. These trends therefore call for localized surveillance. Studies reviewed here point out that these nosocomial infections are a major source of PA, a disturbing trend in the region and perhaps no differences from wound samples across the globe. Nevertheless, most of the studies on SSI and PA appear to be based in West Africa with other regions in SSA underrepresented. This limitation in geography may perhaps not give the true representation of the situation in SSA and calls for more comprehensive research across other regions. AS the review indicates, the prevalence of PA is documented in West Africa primarily may be predictive of increased nosocomial infections in the underserved regions in the future thus increasingly problematic since there is limited surveillance. Moreover, AMR crisis will likely worsen in healthcare facilities due to lack of AMR stewardship programs, consequently leading to untreatable PA thus extended hospital stays and increased mortality rates. 4.3 Antimicrobial Resistance Patterns of Pseudomonas aeruginosa PA is listed by WHO as a microbe of priority and public concern. From the studies clearly SSA studies don’t point to this, there is little effort to show that its being monitored and important resistance being monitored. This is indicative of the challenges attributed to SSIs. 19 , 9 , 36 The numbers of antibiotics tested and how this corresponding to resistance seems directly proportional, and therefore the impacts of such representation especially when the numbers captured the antimicrobial sensitivity tests are quite low. Moreover, certain environmental reservoirs have been attributed to this spread. Resistant strains of PA have been isolated from water sources 57 , medical devices and hospital surfaces. 5 Additionally, the high resistance rates to the commonly used antibiotics in the region including fluoroquinolones, beta-lactams, and aminoglycosides 61 , 71 , 36 , 59 , limit the available treatment options which further pose a major challenge in line with patient care. Several other studies have attributed this cause to the multi-drug resistance nature of PA, rendering the organism capable of surviving amidst several classes of antibiotics, consequently leading to treatment failure. 44 , 63 , 51 This problem is further expedited by unregulated prophylactic administration of antibiotics especially 3rd generation cephalosporins that is basically abused in the SSA region, increasing the risk of AMR emerging and spreading. The rise of AMR observed, therefore, outlines the urgent need to promote enhanced antimicrobial stewardship programs, and studies pointing to what genetic markers for resistance are circulating in the region, in line with developing an alternative treatment options or strategies, for example, novel antimicrobial agents. 4.4 Virulence Biofilm formation is a key component of PA virulence, enabling the organism to thrive on wounds, medical and hospital surfaces. After attachment, maturation and detachment follows, which disperses them not only to hospital settings, but also community settings. Nevertheless, most isolation on PA in SSA has focused heavily on hospital settings where PA infections are more prevalent like intensive care units, isolation from community settings remains limited and thus incomplete picture on the pathogen’s distribution. Other implications for lack of widespread and systematic isolation of the pathogen is difficulty in monitoring the pathogen’s dynamics in SSA, as well as limited sequencing data which cripples the efforts to identify region-specific virulence factors which may guide its control. Additionally, the underrepresentation of some data on virulence of PA could be the driving force behind the success of PA in infecting surgical wounds in SSA, looking at the already available data in West Africa. For example, a dearth of information on genomic data to compare PA from other regions, toxin production and host-pathogen interaction cripples the full understanding of virulence potential of the organism in SSA. The limited focus seen here, thus, leaves much to be explored. There is therefore a compelling need to address these gaps on genome sequencing, to reduce the burden of PA in SSA. 14 , 74 4.5 Preventive and management of PA in SSIs There is need for an interdisciplinary approach in addressing the trend of PA predominance in SSIs in sub-Saharan Africa to enhance both therapeutic and preventive interventions. 19 , 33 Additionally, this would enable comprehensive understanding of the organism through genomics, enhanced infection control, improved surgical practices and postoperative care, as well as strengthened research and innovation. Sub-Saharan Africa comprises different countries including lower-and-middle income countries with varying degree of resources and healthcare infrastructure 70 , 52 , possibly prompting a challenge in the mitigation and management of SSIs 66 . In this region, the heightened risk of healthcare-associated infections like SSIs stems from a limited access to resources. 55 , 39 Additionally, such socioeconomic factors as poverty, overcrowding and malnutrition furthers the SSI burden especially those by PA. 57 , 37 , 54 , 29 Recent studies have emphasized the need to mitigate the widespread overuse and misuse of antibiotics, owing to a likely oversight by medical institutions and pharmacies, as well as limited surveillance. 46 , 69 Perhaps the number of scientists interested in PA in SSA may be low. Or because of the miss conception of the role of PA, and its role in SSI. This makes the region particularly vulnerable to attack by multi-drug resistant (MDR) strains of PA. 6 , 36 Beside this incident compromising the efficacy of available antimicrobial treatment, it seems to heighten the risk of adverse clinical outcomes drawing from treatment “flops” and extended hospital stays. 4.6 Need to strengthen IPCs programs to reduce the incidence of the infections in resource-poor settings Recent studies have also emphasized on the IPCs to curb the transmission of PA 72 , 56 . This could span from the implementation of strict hand hygiene to the optimization of sterilization process of the surgical equipment. Additionally, antimicrobial prophylaxis may be administered pre-operatively according to local AMR patterns and any risk factors that may be patient-specific. 7 Recent reports indicate that early recognition and initiation of antimicrobial therapy can help kick-start this. 42 .Furthermore, such programs as antimicrobial stewardship can be reinforced and expanded to marginalized areas within SSA such that the community is sensitized on the appropriate use of antimicrobials 21 , 18 . This could entail more initiatives like surveillance on regular basis of the patterns of antimicrobial susceptibility as well as educating pharmacists on the specific guidelines for dispensing antimicrobials. 67 , 75 Improving access to diagnostic testing procedures could also be significant in fighting AMR of PA. In the broader demesne of the fight against antimicrobial resistance, more effort is needed to expedite the management of the seemingly established PA in SSA, such that patient outcomes are optimized. For other cases observed like localized infections, wound irrigation and surgical debridement could be ideal 45 while other complicated cases like sepsis may need more delicate support like intensive care. While looking into the clinical aspect of it, it is also important to address the underlying socio-economic and other environmental factors attribute to healthcare infections. For example, recent studies have suggested an improvement of access to clean water and sanitation points and to a greater extent, strengthening the healthcare infrastructure in sub-Saharan Africa. 68 In summary, the review highlights data discrepancy on PA research with only a few studies identifying PA as a pathogen of interest on SSIs. While these studies demonstrate the dominance of PA in SSA, they are concentrated in West Africa, hence underrepresentation of other regions and thus need for more studies in the other countries on the pathogen. Additionally, there’s need for localized surveillance efforts due to lack of comprehensive surveillance on the pathogen. Finally. The rise of AMR and virulence continues to be a growing challenge in the region due to the above gaps and therefore addressing these gaps will be critical in reducing the burden of the organism in SSA. 5.0 Conclusion This review underscores the important challenges in the healthcare sector across sub-Saharan-Africa, owing to the epidemiology, antimicrobial resistant patterns, virulence carriage and distributionrisk factors and subsequent implications of PA SSIs clinically in Sub-Saharan Africa. This is crucial in line with guiding policy decisions and interventions. The low rates of PA isolation and antimicrobial resistance highlight an urgent need for mitigation measures to combat this seemingly growing problem. When IPC programs are strengthened, rational antimicrobial use will be enhanced, as well as a stronger healthcare infrastructure in line with mitigating the burden posed by PA. Declarations 6.0 Acknowledgements I thank all the co-authors for their contributions 7.0 Author Contribution Sarah Karauki Kindiki, Sifuna Anthony Wawire, Martin Welch, Oleg Reva and Sabella Kiprono were involved in conceptualization of the study and methodology and writing the original manuscript draft. Sarah Karauki Kindiki, Peter Kuloba and Nyabera Nicholas Mogoi were involved in data curation and writing - revisions. 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PLoS ONE 17(6):e0269530. https://doi.org/10.1371/journal.pone.0269530 Hou Y, Collinsworth A, Flutura Hasa, Griffin L (2022) Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. 11:1–18. https://doi.org/10.1016/j.sopen.2022.10.004 Hussain MA, Suliman Mohamed M, Altayb HN, Mohamed AO, Ashour A, Osman W, Sherif AE, Ghazawi KF, Miski SF, Ibrahim M, Mohamed GA, Sindi IA, Alshamrani AA (2023) & Abdelaziz Elgaml. Comparative Genomic Analysis of Multi-Drug Resistant Pseudomonas aeruginosa Sequence Type 235 Isolated from Sudan. Microorganisms , 11 (6), 1432–1432. https://doi.org/10.3390/microorganisms11061432 Iliyasu G, Abdu A, Dayyab FM, Tiamiyu AB, Habib ZG, Adamu B, Habib AG (2016) Post-renal transplant infections: single-center experience from Nigeria. 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Frontiers in Microbiology , 13 . https://doi.org/10.3389/fmicb.2022.835403 ‌Lakoh S, Yi L, Sevalie S, Guo X, Adekanmbi O, Smalle IO, Williams N, Barrie U, Koroma C, Zhao Y, Kamara MN, Cummings-John C, Jiba DF, Namanaga ES, Deen B, Zhang J, Maruta A, Kallon C, Liu P, Wurie HR (2022) Incidence and risk factors of surgical site infections and related antibiotic resistance in Freetown, Sierra Leone: a prospective cohort study. Antimicrob Resist Infect Control 11(1). https://doi.org/10.1186/s13756-022-01078-y Chimi LY, Noubom M, Bisso BN, Sedar G, Jean Paul Dzoyem (2024) &. Biofilm Formation, Pyocyanin Production, and Antibiotic Resistance Profile of Pseudomonas aeruginosa Isolates from Wounds. International Journal of Microbiology (Print) , 2024 , 1–10. https://doi.org/10.1155/2024/1207536 Lee J, Zhang L (2014) The hierarchy quorum sensing network in Pseudomonas aeruginosa. Protein Cell 6(1):26–41. https://doi.org/10.1007/s13238-014-0100-x ‌Leekha S, Terrell CL, Edson RS (2011) General Principles of Antimicrobial Therapy. Mayo Clinic Proceedings , 86 (2), 156–167. https://doi.org/10.4065/mcp.2010.0639 Liao C, Huang X, Wang Q, Yao D, Lu W (2022) Virulence Factors of Pseudomonas Aeruginosa and Antivirulence Strategies to Combat Its Drug Resistance. Front Cell Infect Microbiol 12(926758). https://doi.org/10.3389/fcimb.2022.926758 Lister PD, Wolter DJ, Hanson ND (2009) Antibacterial-resistant Pseudomonas aeruginosa: clinical impact and complex regulation of chromosomally encoded resistance mechanisms. Clin Microbiol Rev 22(4):582–610. https://doi.org/10.1128/CMR.00040-09 ‌Liu Y-F, Ni P-W, Huang Y, Xie T (2022) Therapeutic Strategies for Chronic Wound Infection. Chin J Traumatol 25(1):11–16. https://doi.org/10.1016/j.cjtee.2021.07.004 Llor C, Bjerrum L (2014) Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Therapeutic Adv Drug Saf 5(6):229–241. https://doi.org/10.1177/2042098614554919 Lorusso AB, Carrara JA, Barroso CDN, Tuon FF, Faoro H (2022) Role of Efflux Pumps on Antimicrobial Resistance in Pseudomonas aeruginosa. Int J Mol Sci 23(24):15779. https://doi.org/10.3390/ijms232415779 Lowe H, Woodd S, Lange IL, Janjanin S, Barnett J, Graham W (2021) Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study. Confl Health 15(1). https://doi.org/10.1186/s13031-021-00428-8 Lubega A, Joel B, Justina Lucy N (2017) Incidence and Etiology of Surgical Site Infections among Emergency Postoperative Patients in Mbarara Regional Referral Hospital, South Western Uganda. Surgery Research and Practice , 2017 , 1–6. https://doi.org/10.1155/2017/6365172 Mainz JG, Baier M, Jaudszus A, Tabori H, Ribeiro JD, Lorenz M (2019) Pseudomonas aeruginosa colonization in the upper and lower airways of a child with cystic fibrosis: a father’s meticulous approach to successful eradication. Jornal Brasileiro de Pneumologia 45. https://doi.org/10.1590/1806-3713/e20190191 ‌Mancuso G, Midiri A, Gerace E, Biondo C (2021) Bacterial Antibiotic Resistance: The Most Critical Pathogens. Pathogens 10(10):1310. https://doi.org/10.3390/pathogens10101310 Mehtar S, Wanyoro A, Ogunsola F, Ameh EA, Nthumba P, Kilpatrick C, Revathi G, Antoniadou A, Giamarelou H, Apisarnthanarak A, Ramatowski JW, Rosenthal VD, Storr J, Osman TS, Solomkin JS (2020) Implementation of surgical site infection surveillance in low- and middle-income countries: A position statement for the International Society for Infectious Diseases. Int J Infect diseases: IJID : official publication Int Soc Infect Dis 100:123–131. https://doi.org/10.1016/j.ijid.2020.07.021 ‌Mekonnen H, Seid A, Fenta M, G., Gebrecherkos T (2021) Antimicrobial resistance profiles and associated factors of Acinetobacter and Pseudomonas aeruginosa nosocomial infection among patients admitted at Dessie comprehensive specialized Hospital, North-East Ethiopia. A cross-sectional study. PLoS ONE 16(11):e0257272. https://doi.org/10.1371/journal.pone.0257272 ‌Mezemir R, Seid A, Gishu T, Demas T, Gize A (2020) Prevalence and root causes of surgical site infections at an academic trauma and burn center in Ethiopia: a cross-sectional study. Patient Saf Surg 14(1). https://doi.org/10.1186/s13037-019-0229-x ‌Misha G, Chelkeba L, Melaku T (2021) Incidence, risk factors and outcomes of surgical site infections among patients admitted to Jimma Medical Center, South West Ethiopia: Prospective cohort study. Annals Med Surg 65:102247. https://doi.org/10.1016/j.amsu.2021.102247 Mmari EE, Pallangyo ES, Ali A, Kaale DA, Mawalla IH, Abeid MS (2021) Perceptions of surgeons on surgical antibiotic prophylaxis use at an urban tertiary hospital in Tanzania. PLoS ONE 16(8):e0256134. https://doi.org/10.1371/journal.pone.0256134 Moremi N, Claus H, Vogel U, Mshana SE (2017) Surveillance of surgical site infections by Pseudomonas aeruginosa and strain characterization in Tanzanian hospitals does not provide proof for a role of hospital water plumbing systems in transmission. Antimicrob Resist Infect Control 6(1). https://doi.org/10.1186/s13756-017-0216-x Mostapha Abourrich N, Mourabit S, Boussaa, Ghalit M, Elbarghmi R, Guerrouj N, Aich F, Hossain El Ouarghi (2023) Antibiotic resistance patterns in nosocomial infections: preliminary data from Hospital of Al-Hoceima, Morocco. J Infect Developing Ctries 17(09):1310–1316. https://doi.org/10.3855/jidc.17454 ‌Moyo P, Moyo E, Mangoya D, Mhango M, Mashe T, Imran M, Dzinamarira T (2023) Prevention of antimicrobial resistance in sub-Saharan Africa: What has worked? What still needs to be done? J Infect Public Health 16(4). https://doi.org/10.1016/j.jiph.2023.02.020 Nejad SB, Allegranzi B, Syed S, Ellis B, Pittet D (2011) Health-care-associated infection in Africa: a systematic review. Bull World Health Organ 89(10):757–765. https://doi.org/10.2471/blt.11.088179 Ntirenganya C, Muvunyi CM, Manzi O, Ogbuagu O (2015) High Prevalence of Antimicrobial Resistance Among Common Bacterial Isolates in a Tertiary Healthcare Facility in Rwanda. Am J Trop Med Hyg 92(4):865–870. https://doi.org/10.4269/ajtmh.14-0607 ‌Omoyibo E, Oladele A, Ibrahim M, Adekunle O (2018) Antibiotic susceptibility of wound swab isolates in a tertiary hospital in Southwest Nigeria. Ann Afr Med 17(3):110. https://doi.org/10.4103/aam.aam_22_17 ‌Pachori P, Gothalwal R, Gandhi P (2019) Emergence of antibiotic resistance Pseudomonas aeruginosa in intensive care unit; a critical review. Genes Dis 6(2):109–119. https://doi.org/10.1016/j.gendis.2019.04.001 Pang Z, Raudonis R, Glick BR, Lin T-J, Cheng Z (2019) Antibiotic Resistance in Pseudomonas aeruginosa: Mechanisms and Alternative Therapeutic Strategies. Biotechnol Adv 37(1):177–192. https://doi.org/10.1016/j.biotechadv.2018.11.013 Qin S, Xiao W, Zhou C, Pu Q, Deng X, Lan L, Liang H, Song X, Wu M (2022) Pseudomonas aeruginosa: pathogenesis, Virulence factors, Antibiotic resistance, Interaction with host, Technology Advances and Emerging Therapeutics. Signal Transduct Target Therapy 7(1). https://doi.org/10.1038/s41392-022-01056-1 Rickard J, Beilman G, Forrester J, Sawyer R, Stephen A, Weiser TG, Valenzuela J (2020) Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs. Surg Infect 21(6):478–494. https://doi.org/10.1089/sur.2019.142 eem Z, Hassali MA, Hashmi FK, Godman B, Saleem F (2019) Antimicrobial dispensing practices and determinants of antimicrobial resistance: a qualitative study among community pharmacists in Pakistan. Family Med Community Health 7(3):e000138. https://doi.org/10.1136/fmch-2019-000138 Seward N, Hanlon C, Abdella A, Abrahams Z, Alem A, Araya R, Bachmann M, Bekele A, Bogale B, Brima N, Chibanda D, Curran R, Davies J, Beyene A, Fairall L, Farrant L, Frissa S, Gallagher J, Gao W, Gwyther L (2022) HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies. Global Health Action 15(1). https://doi.org/10.1080/16549716.2021.1987044 Shallcross LJ, Davies DSC (2014) Antibiotic overuse: a key driver of antimicrobial resistance. Br J Gen Pract 64(629):604–605. https://doi.org/10.3399/bjgp14x682561 Shears P (2007) Poverty and infection in the developing world: Healthcare-related infections and infection control in the tropics. J Hosp Infect 67(3):217–224. https://doi.org/10.1016/j.jhin.2007.08.016 Tadesse BT, Ashley EA, Ongarello S, Havumaki J, Wijegoonewardena M, González IJ, Dittrich S (2017) Antimicrobial resistance in Africa: a systematic review. BMC Infect Dis 17(1). https://doi.org/10.1186/s12879-017-2713-1 ‌Talaat M, El-Shokry M, El-Kholy J, Ismail G, Kotb S, Hafez S, Attia E, Lessa FC (2016) National surveillance of health care–associated infections in Egypt: Developing a sustainable program in a resource-limited country. Am J Infect Control 44(11):1296–1301. https://doi.org/10.1016/j.ajic.2016.04.212 Tsigereda Asamenew, Worku S, Motbainor H, Mekonnen D, Awoke Deribe (2023) Antimicrobial Resistance Profile of Pseudomonas aeruginosa from Different Clinical Samples in Debre Tabor Comprehensive Specialized Hospital, Northwest Ethiopia. PubMed 33(3):423–432. https://doi.org/10.4314/ejhs.v33i3.5 Verhoeve VI, Brammer JA, Driscoll TP, Kambouris AR, Rasko DA, Cross AS, Gillespie JJ (2022) Genome sequencing of Pseudomonas aeruginosa strain M2 illuminates traits of an opportunistic pathogen of burn wounds. G3 , 12 (5). https://doi.org/10.1093/g3journal/jkac073 Vieira E, Joana L, Santos, Cerqueira-Santos S, Rocha S, Silva S, Pereira D (2022) Evaluation of pharmacist’s practices regarding the antimicrobials dispensing: a simulated patient study. BMC Health Serv Res 22(1). https://doi.org/10.1186/s12913-022-08853-y WHO updates Bacterial Priority Pathogens List to combat antimicrobial resistance (2024), May 20 News-Medical. https://www.news-medical.net/news/20240520/WHO-updates-Bacterial-Priority-Pathogens-List-to-combat-antimicrobial-resistance.aspx Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. 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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-5535461","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":383382096,"identity":"e004061c-62b0-4e10-87c5-49341bcf9785","order_by":0,"name":"Sarah Kindiki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDACHsYGBh6DBB5+ECehgBQtkg0gLQZEaQHjBAaDAyAeMVrkew63PXhTkCZjfH514ocHBgzy/GIH8GsxONvYbjjHIIfH7MbbzRJAhxnOnJ1AQAs/Y5s0j0EFUMvZDSAtCQa3CWiR74dqMZ5xdvMPorQwnG0EacnhMeDv3UacLQZnDrZJzjFI45G4wbvNIsFAgrBf5HvSn0m8+ZNsz99/dvPNHxU28vzShBwGBxJglRLEKgcB/gOkqB4Fo2AUjIKRBAB+CECAAn4dzAAAAABJRU5ErkJggg==","orcid":"","institution":"Masinde Muliro University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Kindiki","suffix":""}],"badges":[],"createdAt":"2024-11-27 12:43:38","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-5535461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5535461/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70479706,"identity":"3de35b6d-3346-4554-b36e-c81cb8e6b1e5","added_by":"auto","created_at":"2024-12-03 14:50:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75567,"visible":true,"origin":"","legend":"\u003cp\u003eThe PRISMA flow diagram showing the process of identifying, screening, and selecting articles for inclusion in the review.\u003c/p\u003e\n\u003cp\u003eNb. The numbers represent the cumulative count of articles at each stage of the review process, and where applicable, reasons for exclusion or removal.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5535461/v1/97069d9b97a6dde688d8f13b.png"},{"id":70481697,"identity":"62c89da5-bb88-49b9-a11a-12a0be885176","added_by":"auto","created_at":"2024-12-03 15:06:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":733621,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5535461/v1/0930737b-f3da-43f7-a593-5c6cefbdfb0c.pdf"},{"id":70479317,"identity":"8fe8c7c9-ef2a-4b74-a775-3fecf89160b3","added_by":"auto","created_at":"2024-12-03 14:42:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":23453,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5535461/v1/21ffc2599d15732e41a78f8b.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe Role of Pseudomonas aeruginosa in Surgical Site Infections in Sub-Saharan Africa\u003c/p\u003e","fulltext":[{"header":"Significance","content":"\u003cp\u003eThe present research unravels the alarming prevalence of \u003cem\u003eP. aeruginosa\u0026nbsp;\u003c/em\u003eand its implication in surgical site infections in SSA, while underscoring the urgent need to implement targeted interventions in order to address a growing regional public health concern.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"1.0 Introduction","content":"\u003cp\u003eAmong the Caucasians, the colonization of the airways of persons living with cystic fibrosis (pwCF) by \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (PA) is well-documented.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e These patients are susceptible to airway attack by PA owing to frequent buildup of thick mucus in the airways, sufficing for an ideal environment for PA to thrive and outcompete other microbes, thus chronic respiratory infections.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Such infections by PA often can lead to reduced quality of life, contributing significantly to the burden of disability-adjusted life years (DALYs) leading to high morbidity and mortality rates.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e In contrast, Sub-Sahara African populations have a lower CF rate coupled by lower access to healthcare services but may not experience the same degree of PA-related respiratory infections.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Nevertheless, PA has proven a major health concern as far as surgical site infections are concerned in sub-Saharan Africa. We therefore sort to establish how much is currently known about the role and involvement of PA in SSI in sub-Saharan Africa.\u003c/p\u003e \u003cp\u003eSurgical site infections (SSIs) remain a global challenge in healthcare systems, significantly contributing to increased healthcare costs, patient morbidity and mortality.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e Whereas studies have well-documented the burden of SSIs globally, Sub-Saharan Africa (SSA) context still presents unique challenges intensifying the impact of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (PA) infections on wounds, thus implicating a serious threat to healthcare delivery mechanisms and patient safety in the region.\u003csup\u003e\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e In its Bacterial Priority Pathogens List (BPPL), the World Health Organization (WHO) featured 15 families of AMR bacterial pathogens into three categories including critical, high and medium in line with prioritization and combating the spread of AMR. \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e features among high-priority pathogen with high infection burden among others like \u003cem\u003eSalmonella, Shigella\u003c/em\u003e and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, in healthcare settings.\u003csup\u003e\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e is considered one of the most successful bacterial pathogens owing to several factors including antibiotic resistance which stems from the possession of efflux pumps, low permeability of outer membrane to antibiotics, acquisition of resistance genes and adaptive resistance.\u003csup\u003e\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Moreover, important aspects including virulence factors like proteases, pigments, and exotoxins\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e\u003c/sup\u003e, which are known to immensely contribute to the organism\u0026rsquo;s ability to cause disease, biofilm formation attributed to survival and adaptation of PA in hospital environments through quorum sensing mechanism\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e, have not been demonstrated for isolates recovered previously from SSA. Therefore, there is a need to understand them. The emergence and reduced costs of whole genome sequencing now provide hope that these isolates can now be subjected to these assays and genomes sequenced to shade more light on their adaptation to SSIs in SSA. Therefore, this review aims to explore just how much is known about the biology of PA in SSA and thus the extent of knowledge surrounding AMR, virulence factors, and biofilm-formation capabilities. Moreover, the emergence of genome sequencing, it is now possible to explore the organism\u0026rsquo;s genetic diversity and identify novel resistance mechanisms as well as how much isolation and sequencing on PA have been done in the region.\u003c/p\u003e \u003cp\u003eA broad understanding of the epidemiology, antimicrobial resistant patterns, virulence carriage and distribution risk factors and subsequent implications of PA SSIs clinically in Sub-Saharan Africa, is crucial in line with guiding policy decisions and interventions. Through the revelation of the unique challenges SSA faces in the context of PA infections on surgical sites, this review seeks to underscore the urgent need for mitigation strategies on the impact of SSIs on healthcare sector in this region.\u003c/p\u003e"},{"header":"2.0 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Literature strategy search\u003c/h2\u003e \u003cp\u003eIn this review, \u0026ldquo;sub-Saharan Africa\u0026rdquo; refers to the countries constituting the WHO- Africa region. A systematic search of electronic databases including PubMed, Google scholar and Scopus was conducted to identify all relevant studies which were published between 2015 and 2023. Medical subject headings (MeSH) and other Keywords related to \u0026ldquo;\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u0026rdquo;, \u0026ldquo;Surgical site infections\u0026rdquo;, \u0026ldquo;sub-Saharan Africa\u0026rdquo;, and \u0026ldquo;Antimicrobial resistance\u0026rdquo; were used in various combinations such that the search sensitivity is maximized. Next, Boolean operators \u0026ldquo;AND\u0026rdquo; and \u0026ldquo;OR\u0026rdquo; were used to combine these search terms, which was inclined to syntax and filters of each database while incorporating truncation and where applicable, proximity operators. Moreover, references list for various relevant articles and review papers were manually searched to identify any additional studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Inclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eIn this review, studies reporting on the epidemiology, antimicrobial resistance patterns, virulence, risk factors, and interventions in line with PA in SSIs in SSA were included. Moreover, articles in peer-reviewed journals, conference abstracts were included. However, those studies not specific to sub-Saharan Africa as well as those only focusing on other pathogens or those lacking primary research data were excluded. Nevertheless, all non-English articles which are relevant were translated and included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study Selection\u003c/h2\u003e \u003cp\u003eFor this review, two independent reviewers screened titles and abstracts of retrieved articles for eligibility based on the inclusion and exclusion criteria. For eligibility, full-text articles for relevant studies were obtained and assessed for eligibility. Any differences between the reviewers were resolved through consultations with a third reviewer.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data Extraction\u003c/h2\u003e \u003cp\u003eA standardized data extraction form was developed to capture relevant information from the selected studies which included characteristics of the study (author, year, study design), demographics of study participants, PA prevalence, risk factors, AMR profiles and interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Quality Assessment\u003c/h2\u003e \u003cp\u003eIn this review, the methodological quality of the selected studies was evaluated using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for studies that were randomized controlled trials. Quality assessment here helped inform the interpretation and synthesis of findings with higher quality studies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data Synthesis and Analysis\u003c/h2\u003e \u003cp\u003eIn this review, findings from the studies included were synthesized narratively, organized in line with key themes and outcomes. Additionally, subgroup analyses were conducted as appropriate in line with exploring heterogeneity of results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Reporting\u003c/h2\u003e \u003cp\u003eThe preferred Reporting Items for Systematic Reviews and Meta Analyses \u003cb\u003e(PRISMA) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e were followed to ensure comprehensive and transparent reporting of the findings of this review.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3.0 Results","content":"\u003cp\u003eA total of 225 articles were initially identified by use of the systematic literature search across PubMed, Scopus and Google Scholar, while focusing on the role of PA in surgical site infections in Sub-Saharan Africa. After screening titles and abstract, 26 articles of the 225 were deemed eligible for full-text review. The included studies embedded a number of themes around PA, including the epidemiology, risk factors, AMR patterns, clinical outcomes and interventions surrounding the infection incidences \u003cstrong\u003e(Table\u0026nbsp;1).\u003c/strong\u003e The results of this analysis are presented as follows.\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Epidemiology of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e SSI in Sub-Saharan Africa\u003c/h2\u003e\n\u003cp\u003eAmong the articles reviewed, a consistent trend emerged underscoring the predominance of PA in SSIs across various healthcare settings in Sub-Saharan Africa from 4 articles. Based on \u003cstrong\u003etable 2\u003c/strong\u003e, several studies reported high rates of PA isolation from surgical wound specimens ranging from 12%-33%, with one particular study in Ethiopia reporting 27 (12.86%) and 74 (19.3%) of all the wound cultures\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e\u003c/sup\u003e, 15(30%) in Ghana\u003csup\u003e8\u003c/sup\u003e and 3/9 (33.3%) on samples from post-renal transplant patients in Nigeria\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. Currently, most of the studies available were done in west Africa, and the other regions were under represented. Nevertheless, these ranges depended on the type of surgery and patient population sampled. Noteworthy, Omoyibo\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e62\u003c/span\u003e\u003c/sup\u003e and Eman\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e also appreciated PA as one of the most prevalent pathogens responsible for SSIs alongside other common pathogens like \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and \u003cem\u003eEscherichia coli\u003c/em\u003e in Sub-Saharan Africa.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Risk Factors Associated with \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e Surgical Site Infections\u003c/h2\u003e\n\u003cp\u003eThe search was able to unravel 4 risk factors, which appeared to contribute to the acquisition as well as the development of SSIs by PA in Sub-Saharan Africa. While Kakupa\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e and D\u0026eacute;gbey\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e identified prolonged hospitalization, inadequate control measures for infections, use of indwelling medical devices as significant risk factors, Moremi\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e underscored the role of surgical procedures in the increased risk of infections by PA, especially among patients undergoing or recovering from abdominal surgeries. These findings highlight the importance of targeted strategies aimed at preventing SSIs attributed to PA in Sub-Saharan Africa.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Antimicrobial Resistance Patterns of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eIn the review, AMR among several PA isolates in the studies in SSA was notably high and therefore of concern. Reports indicate high resistance levels to piperacillin-tazobactam Sierra Leone, Uganda, Nigeria and Malawi at 83.3%, 100%, 91.3% and 66% respectively.\u003csup\u003e39,49,62,15\u003c/sup\u003e \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. Moreover, PA has continued showing high levels of resistance to Ciprofloxacin in these countries with rates as high as 83.3% and levofloxacin at 83.3% in Sierra Leone.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Elsewhere, Al-Orphaly\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e and Mostapha\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e\u003c/sup\u003e underscored the importance of resistance of PA to commonly used antibiotics like beta-lactams, fluoroquinolones, and aminoglycosides, to the onset of SSIs. Additionally, multi-drug resistance appeared to be prevalent, with some important studies appreciating the resistance of PA to multiple antibiotics classes attributed to derailment of treatment processes or options therefore exacerbating the risk of treatment failure. For example, as Imipenem appears effective against PA (only 7.4% resistance rate), the pathogen appears commonly resistant to Gentamycin (63% resistance and only 30% sensitivity rate) in the recent study.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e These levels of resistance can also draw from the genes encoding resistance in these strains. Not many studies in SSA have highlighted the AMR genes. However, a few studies have shed light into several AMR genes in PA. For example, carbapenem resistance is observed in multiple regions, suggesting the possible presence of carbapenemase genes like, blaIMP, blaVIM or blaNDM. On their study of MDR organisms in a teaching facility in Ghana\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, 352 isolates were cultured out of 438 SSIs noted. Majority of these organisms were MDR, calling for re-evaluation of antibiotic prophylaxis in surgical practices. Other cases of MDR appeared in other studies.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003e3.4 Virulence\u003c/h2\u003e\n\u003cp\u003eThe success of PA in infecting surgical wounds has been attributed to its virulence factors which include exotoxins, pigments, proteases, and biofilm formation.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e While there is much data on this globally, there still remains a significant gap on PA strain isolated in SSA. A few studies have made efforts on the isolation of PA, but this remains region-specific following resource constraints\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. For example, eight (14%) out of 57 samples were positive for PA in a study in Tanzania\u003csup\u003e57\u003c/sup\u003e and 26.1% isolated from surgical wounds in Ethiopia\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Nevertheless, some reports on the virulence mechanisms of PA have started coming in\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. However, the extent of this activity on tissues still remains underexplored. Elsewhere\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e, the role of biofilm formation in chronic infections and antibiotic resistance has been documented. However, there\u0026rsquo;s limited data on the molecular mechanisms-the driving forces behind the surging infections. Similarly, research data on QS genes and a correlation with virulence expression remains unexplored sufficiently, despite available data on QS as a survival mechanism of PA.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003e3.5 Impact and clinical outcomes of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e in SSIs\u003c/h2\u003e\n\u003cp\u003eThe severity of infection within the host organism on these wounds have been attributed to extended hospital stays and increased healthcare costs\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e, period of surgery\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e due to prolonged use of invasive devices like exposure to pathogens thus heightened morbidity and mortality rates.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Additionally, Patients presenting with PA have been reported to experience delayed healing of wounds\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, systemic complications and sepsis\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e hence decreased quality of life. Furthermore, other reports attribute the economic burden of PA to weak infrastructure, underscoring the need for effective prevention and other management strategies in line with mitigating the menace.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n\u003ch2\u003e3.5 Preventive and management of PA in SSIs\u003c/h2\u003e\n\u003cp\u003eDespite the challenges posed by PA, most studies identified a number of prevention and interventions strategies, that can help alleviate the impact of PA SSIs in sub-Saharan Africa. While some sensitized on the enhanced surveillance of SSIs, implementation of infection control programs (ICPs)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e, others underscored the importance of promotion of AMR stewardship\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, improved access to effective antibiograms in line with reducing the incidence of PA in the region.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Moreover, strengthening of infrastructure, community engagement and capacity building appeared in several studies as a recommendation as approach to fighting AMR by PA.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAlthough there are not many studies in SSA done on PA infecting surgical sites, the result of this review highlights the concerning trend of PA predominance in surgical site infections on the few sampled clinical settings in SSA. While there\u0026rsquo;s data on AMR and virulence of PA, its regional variability could spell challenges in infection control for surgical site infections. Incomplete understanding of epidemiology of PA affects surveillance efforts. Moreover, gaps in the sequencing data could have severe implications to control of antibiotic resistance and novel therapies.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4.0 Discussion","content":"\u003cp\u003eIn this review, the results point out a concerning trend of the prevalence and impact of PA in SSIs within sub-Saharan Africa. This trend is indicative of a significant predominance of PA. This serves as an alarm owing to PA\u0026rsquo;s well-documented propensity for AMR and the associated clinical outcomes.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Prevalence and risk factors of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e in Surgical Site Infections\u003c/h2\u003e \u003cp\u003eThis study serves to demonstrate that PA is understudied in Africa. Bearing in mind that our review focused on studies in the recent 8 years, with only four articles revealed PA as the prevalent pathogen in SSIs. There is however consistency in the studies which highlighted the predominance of PA in SSI within the context of SSA, that the organism shows potential of outcompeting other microbes on wounds. This phenomenon is possible owing to the presence of virulence factors, biofilm formation, antibiotic-degrading enzymes, metabolic versatility, and immune evasion.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e Additionally, what emerges from the studies are high rates of PA recovery from SSIs, demonstrating a considerable burden of PA in SSA, and underscoring the role of PA in nosocomial infections in the region. Additionally, the variability of risk factors is important since it underscores the influence local factors have on the AMR trends. Inadequate control measures, prolonged hospital stays, and prolonged surgery heavily influence the prevalence and severity of infections by PA on surgical wounds. These factors are especially pertinent in SSA owing to unexplored gaps in clinical research, leading to limited surveillance data and inadequate monitoring of resistant strains. These trends therefore call for localized surveillance. Studies reviewed here point out that these nosocomial infections are a major source of PA, a disturbing trend in the region and perhaps no differences from wound samples across the globe. Nevertheless, most of the studies on SSI and PA appear to be based in West Africa with other regions in SSA underrepresented. This limitation in geography may perhaps not give the true representation of the situation in SSA and calls for more comprehensive research across other regions.\u003c/p\u003e \u003cp\u003eAS the review indicates, the prevalence of PA is documented in West Africa primarily may be predictive of increased nosocomial infections in the underserved regions in the future thus increasingly problematic since there is limited surveillance. Moreover, AMR crisis will likely worsen in healthcare facilities due to lack of AMR stewardship programs, consequently leading to untreatable PA thus extended hospital stays and increased mortality rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Antimicrobial Resistance Patterns of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/h2\u003e \u003cp\u003ePA is listed by WHO as a microbe of priority and public concern. From the studies clearly SSA studies don\u0026rsquo;t point to this, there is little effort to show that its being monitored and important resistance being monitored. This is indicative of the challenges attributed to SSIs.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e The numbers of antibiotics tested and how this corresponding to resistance seems directly proportional, and therefore the impacts of such representation especially when the numbers captured the antimicrobial sensitivity tests are quite low. Moreover, certain environmental reservoirs have been attributed to this spread. Resistant strains of PA have been isolated from water sources\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e\u003c/sup\u003e, medical devices and hospital surfaces.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Additionally, the high resistance rates to the commonly used antibiotics in the region including fluoroquinolones, beta-lactams, and aminoglycosides\u003csup\u003e\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e,\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e\u003c/sup\u003e, limit the available treatment options which further pose a major challenge in line with patient care. Several other studies have attributed this cause to the multi-drug resistance nature of PA, rendering the organism capable of surviving amidst several classes of antibiotics, consequently leading to treatment failure.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e,\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e This problem is further expedited by unregulated prophylactic administration of antibiotics especially 3rd generation cephalosporins that is basically abused in the SSA region, increasing the risk of AMR emerging and spreading. The rise of AMR observed, therefore, outlines the urgent need to promote enhanced antimicrobial stewardship programs, and studies pointing to what genetic markers for resistance are circulating in the region, in line with developing an alternative treatment options or strategies, for example, novel antimicrobial agents.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Virulence\u003c/h2\u003e \u003cp\u003eBiofilm formation is a key component of PA virulence, enabling the organism to thrive on wounds, medical and hospital surfaces. After attachment, maturation and detachment follows, which disperses them not only to hospital settings, but also community settings. Nevertheless, most isolation on PA in SSA has focused heavily on hospital settings where PA infections are more prevalent like intensive care units, isolation from community settings remains limited and thus incomplete picture on the pathogen\u0026rsquo;s distribution. Other implications for lack of widespread and systematic isolation of the pathogen is difficulty in monitoring the pathogen\u0026rsquo;s dynamics in SSA, as well as limited sequencing data which cripples the efforts to identify region-specific virulence factors which may guide its control. Additionally, the underrepresentation of some data on virulence of PA could be the driving force behind the success of PA in infecting surgical wounds in SSA, looking at the already available data in West Africa. For example, a dearth of information on genomic data to compare PA from other regions, toxin production and host-pathogen interaction cripples the full understanding of virulence potential of the organism in SSA. The limited focus seen here, thus, leaves much to be explored. There is therefore a compelling need to address these gaps on genome sequencing, to reduce the burden of PA in SSA.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Preventive and management of PA in SSIs\u003c/h2\u003e \u003cp\u003eThere is need for an interdisciplinary approach in addressing the trend of PA predominance in SSIs in sub-Saharan Africa to enhance both therapeutic and preventive interventions.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Additionally, this would enable comprehensive understanding of the organism through genomics, enhanced infection control, improved surgical practices and postoperative care, as well as strengthened research and innovation. Sub-Saharan Africa comprises different countries including lower-and-middle income countries with varying degree of resources and healthcare infrastructure\u003csup\u003e\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e,\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u003c/sup\u003e, possibly prompting a challenge in the mitigation and management of SSIs\u003csup\u003e\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e\u003c/sup\u003e. In this region, the heightened risk of healthcare-associated infections like SSIs stems from a limited access to resources.\u003csup\u003e\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Additionally, such socioeconomic factors as poverty, overcrowding and malnutrition furthers the SSI burden especially those by PA.\u003csup\u003e\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e,\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Recent studies have emphasized the need to mitigate the widespread overuse and misuse of antibiotics, owing to a likely oversight by medical institutions and pharmacies, as well as limited surveillance.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e\u003c/sup\u003e Perhaps the number of scientists interested in PA in SSA may be low. Or because of the miss conception of the role of PA, and its role in SSI. This makes the region particularly vulnerable to attack by multi-drug resistant (MDR) strains of PA.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Beside this incident compromising the efficacy of available antimicrobial treatment, it seems to heighten the risk of adverse clinical outcomes drawing from treatment \u0026ldquo;flops\u0026rdquo; and extended hospital stays.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Need to strengthen IPCs programs to reduce the incidence of the infections in resource-poor settings\u003c/h2\u003e \u003cp\u003eRecent studies have also emphasized on the IPCs to curb the transmission of PA\u003csup\u003e\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e,\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u003c/sup\u003e. This could span from the implementation of strict hand hygiene to the optimization of sterilization process of the surgical equipment. Additionally, antimicrobial prophylaxis may be administered pre-operatively according to local AMR patterns and any risk factors that may be patient-specific.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Recent reports indicate that early recognition and initiation of antimicrobial therapy can help kick-start this.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e.Furthermore, such programs as antimicrobial stewardship can be reinforced and expanded to marginalized areas within SSA such that the community is sensitized on the appropriate use of antimicrobials\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. This could entail more initiatives like surveillance on regular basis of the patterns of antimicrobial susceptibility as well as educating pharmacists on the specific guidelines for dispensing antimicrobials.\u003csup\u003e\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e,\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e\u003c/sup\u003e Improving access to diagnostic testing procedures could also be significant in fighting AMR of PA. In the broader demesne of the fight against antimicrobial resistance, more effort is needed to expedite the management of the seemingly established PA in SSA, such that patient outcomes are optimized. For other cases observed like localized infections, wound irrigation and surgical debridement could be ideal\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e while other complicated cases like sepsis may need more delicate support like intensive care. While looking into the clinical aspect of it, it is also important to address the underlying socio-economic and other environmental factors attribute to healthcare infections. For example, recent studies have suggested an improvement of access to clean water and sanitation points and to a greater extent, strengthening the healthcare infrastructure in sub-Saharan Africa.\u003csup\u003e\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn summary, the review highlights data discrepancy on PA research with only a few studies identifying PA as a pathogen of interest on SSIs. While these studies demonstrate the dominance of PA in SSA, they are concentrated in West Africa, hence underrepresentation of other regions and thus need for more studies in the other countries on the pathogen. Additionally, there\u0026rsquo;s need for localized surveillance efforts due to lack of comprehensive surveillance on the pathogen. Finally. The rise of AMR and virulence continues to be a growing challenge in the region due to the above gaps and therefore addressing these gaps will be critical in reducing the burden of the organism in SSA.\u003c/p\u003e \u003c/div\u003e"},{"header":"5.0 Conclusion","content":"\u003cp\u003eThis review underscores the important challenges in the healthcare sector across sub-Saharan-Africa, owing to the epidemiology, antimicrobial resistant patterns, virulence carriage and distributionrisk factors and subsequent implications of PA SSIs clinically in Sub-Saharan Africa. This is crucial in line with guiding policy decisions and interventions. The low rates of PA isolation and antimicrobial resistance highlight an urgent need for mitigation measures to combat this seemingly growing problem. When IPC programs are strengthened, rational antimicrobial use will be enhanced, as well as a stronger healthcare infrastructure in line with mitigating the burden posed by PA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e6.0 Acknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI thank all the co-authors for their contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7.0 Author Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSarah Karauki Kindiki, Sifuna Anthony Wawire, Martin Welch, Oleg Reva\u003c/strong\u003e and \u003cstrong\u003eSabella Kiprono\u003c/strong\u003e were involved in conceptualization of the study and methodology and writing the original manuscript draft. \u003cstrong\u003eSarah Karauki Kindiki, Peter Kuloba\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;Nyabera Nicholas Mogoi\u003c/strong\u003e were involved in data curation and writing - revisions. \u003cstrong\u003eMartin Welch\u003c/strong\u003e, \u003cstrong\u003eSifuna Anthony Wawire, Oleg Reva\u003c/strong\u003e and \u003cstrong\u003eSabella Kiprono\u003c/strong\u003e were involved in reviewing, editing and approving the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e8.0 Conflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbubakar Bobbo K, Ahmad U, Chau D-M, Nordin N, Abdullah S (2023) A comprehensive review of cystic fibrosis in Africa and Asia. 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BMC Health Serv Res 22(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-022-08853-y\u003c/span\u003e\u003cspan address=\"10.1186/s12913-022-08853-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO updates Bacterial Priority Pathogens List to combat antimicrobial resistance (2024), May 20 News-Medical. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.news-medical.net/news/20240520/WHO-updates-Bacterial-Priority-Pathogens-List-to-combat-antimicrobial-resistance.aspx\u003c/span\u003e\u003cspan address=\"https://www.news-medical.net/news/20240520/WHO-updates-Bacterial-Priority-Pathogens-List-to-combat-antimicrobial-resistance.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Masinde Muliro University of Science and Technology","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Pseudomonas aeruginosa, Surgical Site Infections, predominance, Sub-Saharan Africa","lastPublishedDoi":"10.21203/rs.3.rs-5535461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5535461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe aimed at understanding the role of \u003cem\u003ePseudomonas\u003c/em\u003e \u003cem\u003eaeruginosa\u003c/em\u003e(PA) on the seemingly growing and concerning infections of surgical sites in sub-Saharan Africa (SSA). We therefore searched PubMed and other relevant databases for articles (2015-2023) relevant to antimicrobial resistance (AMR) and predominance of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e(PA) in sub-Saharan Africa (SSA). In this review, we examined 26 relevant articles out of 225 that matched the initial search. Through an in-depth analysis of the relevant literature, the low number of studies in the region focused on PA and AMR. Nevertheless, the relatively few studies demonstrate the high rates of PA involvement in surgical site infections. The studies further show high levels of multi-drug resistance and points to subsequent nosocomial clinical outcomes. In conclusion with the increased AMR threat, there is a need for increased studies on SSI, PA biology and genomics and AMR.\u003c/p\u003e","manuscriptTitle":"The Role of Pseudomonas aeruginosa in Surgical Site Infections in Sub-Saharan Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-03 14:42:01","doi":"10.21203/rs.3.rs-5535461/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"16105c9c-6ce9-45f4-87c6-44ab35f66b8e","owner":[],"postedDate":"December 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":40837953,"name":"Infectious Diseases"}],"tags":[],"updatedAt":"2024-12-03T14:42:01+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-03 14:42:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5535461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5535461","identity":"rs-5535461","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}