Journal of the Nigerian Infectious Diseases Society

Original Article

Evaluation of antibiotics sensitivity pattern of bacterial isolate from stool in a referral hospital in North-Central, Nigeria.

Bello S O 1 ∗ S O 1 ∗ SO^(1**) \mathrm{SO}^{1 *} S O 1 ∗ , Zakou A², Audu E S 3 E S 3 ES^(3) \mathrm{ES}^{3} E S 3 , Katoh A D 4 A D 4 AD^(4) \mathrm{AD}^{4} A D 4 , Ogunkunle T O 1 T O 1 TO^(1) \mathrm{TO}^{1} T O 1 , Anazodo M C 5 M C 5 MC^(5) \mathrm{MC}^{5} M C 5 , Joseph B 5 B 5 B^(5) \mathrm{B}^{5} B 5 ,Abubakar Y H 6 Y H 6 YH^(6) \mathrm{YH}^{6} Y H 6 , Ter E 7 E 7 E^(7) \mathrm{E}^{7} E 7 , Rowland M 7 M 7 M^(7) \mathrm{M}^{7} M 7 , Yahaya I O 8 I O 8 IO^(8) \mathrm{IO}^{8} I O 8 , Hassan I I 5 I I 5 II^(5)\mathrm{II}^{5}II5

  1. Department of Paediatrics, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  2. Microbiology unit, Laboratory Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  3. Medical Microbiology Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  4. Pharmacy Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  5. Community Medicine Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  6. Information Communication Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
  7. Nursing Department, Dalhatu Araf Specialist HospitaL, Lafia Nasarawa State, Nigeria.
  8. Family Medicine Department, Dalhatu Araf Specialist Hospital, Lafia Nasarawa State, Nigeria.
*Corresponding author:
surajudeenbello4@gmail.com
Received: 30 June 2023
Revised: 11 September 2023
Accepted: 13 September 2023
Published: 31 October 2023

DOI

10.58539/JNIDS.2023
Abstract
Background: The global burden of antimicrobial resistance is high. Antibacterial resistance is particularly worrisome due to poor hygiene, lack of appropriate storage facility and irrational use of antibiotics. Hence the need for strengthening of prescription surveillance system and evidence-based treatment.
Objectives: To determine the bacteria isolates in stool specimens and their sensitivity pattern among patients managed in Dalhatu Araf Specialist Hospital.
Methods: All patients managed within January 2021 to December 2021, who had stool microscopy done were included in this study while those with incomplete records were excluded. Ethical approval was obtained from the Research Ethics Committee of the Hospital. Data was entered into a computer and Statistical Package for Social Science(SPSS) used for data analysis. A significant p was < 0.05 < 0.05 < 0.05<0.05<0.05
Results: Overall, more than a quarter of culture positive stool sample were among children under five while the least was seen in those ≥ 65 ≥ 65 >= 65\geq 65≥65 years. Salmonella species were isolated in 62.71 % 62.71 % 62.71%62.71 \%62.71% of the patients while 36.31 % 36.31 % 36.31%36.31 \%36.31% grew Escherichia coli. Salmonella sp. showed sensitivity to Ofloxacin, Gentamycin and Ciprofloxacin. Resistance to Salmonella sp. was found with Augmentin in this study. The highest Escherichia coli sensitivity was with Gentamycin, Ofloxacin and Ciprofloxacin. Resistance to Escherichia coli is highest with Augmentin, Cefuroxime and Amoxicillin.
Conclusions: There is good positivity from stool sample in this study. Salmonella species and Escherichia coli were the two commonly cultured bacteria pathogen from stool sample. There are good sensitivities to the Quinolones, Aminoglycosides and Macrolides while resistance was mostly to the Penicillins and Cephalosporins.
Key words: Antimicrobial, Bacteria, Resistance, Sensitivity, Stool.

INTRODUCTION

Antimicrobials are chemical agents that either destroy or diminish the survival of disease-causing microbes such as bacteria, viruses, fungi and parasites. 1 1 ^(1){ }^{1}1 Antimicrobial resistance (AMR) is impacting negatively on public health across the world. 2 , 3 2 , 3 ^(2,3){ }^{2,3}2,3 Low- and Middle-Income Countries (LMICs) are worse affected due to higher infectious disease burden and poorer health indices occasioned by inadequate healthcare services availability and accessibility. 4 4 ^(4){ }^{4}4 Developing countries like Nigeria have enormous AMR burden due to limited regulations, weak enforcement and ineffective control leading to adaptation and or resistance from irrational use of antimicrobials. 5 , 6 5 , 6 ^(5,6){ }^{5,6}5,6 The rise in AMR is particularly worrisome for antibacterial resistance among children as a result of insufficiency of access to potable water, poor environmental sanitation and hygiene coupled with reduced immunity. 7 7 ^(7){ }^{7}7
The World Health Organization (WHO) recognized the huge AMR challenges on human survival and recommended the strengthening of surveillance system(s) on antimicrobial prescription, monitoring usage, enhancing prompt diagnosis and evidence-based treatment through instituting Antimicrobial Stewardship (AMS) 8 8 ^(8){ }^{8}8 A study by Ogunsola et a l 9 a l 9 al^(9)a l^{9}al9 in Lagos over three decades ago showed some sensitivity to the third generation Cephalosporins. In addition, Afolabi et a l 10 a l 10 al^(10)a l^{10}al10 in a 2019 study among under five children in Ilorin reported 28.2% bacterial positivity with Escherichia coli and Klebsiella the commonest isolated pathogen. Bejide and colleagues 11 11 ^(11){ }^{11}11 in the year 2023 in Ibadan found a predominance of Escherichia coli (43.1%) among children. Others are Cryptosporidium and Cyclospora species. A livestock study in Zaria in year 2017 revealed largely Salmonella species and Escherichia coli with both having high resistance to Ampicillin, Cefuroxime, Ceftazidime and Cotrimoxazole. 12 12 ^(12){ }^{12}12
Due to paucity of data involving hospital wide sensitivity and resistance pattern across all age groups in Nasarawa State, this study determines the magnitude, the resistance and sensitivity pattern using stool sample over a period of time. The hospital is the only state-owned tertiary health facility and with a huge patient turn-over in Lafia, the state capital.

MATERIALS AND METHODS

Study Design

This was a retrospective study among patients seen at DASH who were seen from 1 st 1 st  1^("st ")1^{\text {st }}1st  January 2021 to the 31 st 31 st  31^("st ")31^{\text {st }}31st  December 2021.

Study Population

The study was carried out among newborn, children, adolescents and adults attended to at the Special Care Baby Unit (SCBU), Emergency Paediatric Unit (EPU), Children Medical Ward (CMW), Children Surgical Wards (CSW), Casualty, General Outpatient Department, Male Medical and Surgical wards as well as Female Medical and Surgical wards of the DASH Lafia.
Study Site
The study was done at the Dalhatu Araf Specialist Hospital Lafia. Lafia is the state capital of Nasarawa state. The state is one of the six North-Central states of Niger, Kwara, Kogi, Plateau and Benue alongside the Federal Capital Territory (FCT). The Hospital is a 377 bedded Health facility with various cadres of healthcare workers including specialist doctors as the facility has accreditations to train specialist doctors in Paediatrics, Internal Medicine, Family Medicine, Surgery and Obstetrics & Gynaecology departments.

Sample Size

Sample size determination was done using the Fischer's formula
n = z 2 p q d 2 n = z 2 p q d 2 n=(z^(2)pq)/(d^(2))\mathrm{n}=\frac{\mathrm{z}^{2} \mathrm{pq}}{\mathrm{d}^{2}}n=z2pqd2
n n n\mathrm{n}n is the calculated sample size.
Z Z Z\mathrm{Z}Z is the standard deviate at 95 % = 1.96 95 % = 1.96 95%=1.9695 \%=1.9695%=1.96
P P P\mathrm{P}P is the prevalence from previous study, where p = 29 % , 0.29 p = 29 % , 0.29 p=29%,0.29\mathrm{p}=29 \%, 0.29p=29%,0.29
q q q\mathrm{q}q is 1 − p = 1 − 0.29 = 0.71 1 − p = 1 − 0.29 = 0.71 1-p=1-0.29=0.711-\mathrm{p}=1-0.29=0.711−p=1−0.29=0.71
d is the degree of precision which will be 5% in this study, i.e d = d = d=d=d= 0.05
n = 1.96 2 × 0.29 × 0.71 0.05 2 n = 3.8416 × 0.29 × 0.71 0.0025 n = 1.96 2 × 0.29 × 0.71 0.05 2 n = 3.8416 × 0.29 × 0.71 0.0025 n=(1.96^(2)xx0.29 xx0.71)/(0.05^(2))n=(3.8416 xx0.29 xx0.71)/(0.0025)\mathrm{n}=\frac{1.96^{2} \times 0.29 \times 0.71}{0.05^{2}} \mathrm{n}=\frac{3.8416 \times 0.29 \times 0.71}{0.0025}n=1.962×0.29×0.710.052n=3.8416×0.29×0.710.0025
n = 0.79098544 0.0025 n = 0.79098544 0.0025 n=(0.79098544)/(0.0025)\mathrm{n}=\frac{0.79098544}{0.0025}n=0.790985440.0025
n = 316 n = 316 n=316\mathrm{n}=316n=316
calculating for attrition at 10 % = 32 10 % = 32 10%=3210 \%=3210%=32. Hence, a minimum sample size of 348 was calculated for this study.
All patients managed within the study period who had the investigation of interest done at DASH were included in this study while those with incomplete records were excluded from the study.

Sampling Technique

All records of patients managed within the period was retrieved.

Sampling Procedure

Secondary data from the medical records and laboratory departments were used to generate data retrospectively over twelve months (January 2021 to December 2021).

Data Analysis

Data was entered into a computer. Statistical Package for Social Science (SPSS) version 23 was used for data analysis. Categorical variables were reported as frequencies with percentages in tables or graphs. A significant p p p\mathrm{p}p was < 0.05 < 0.05 < 0.05<0.05<0.05

RESULTS

Of the 4,140-stool sample sent to the laboratory within the study period, there are 1,366 positive culture (33.0%). A total of 1171 (85.7%) had complete records with 195 (14.3%) missing data (age, gender or both).
Our findings revealed that children under the age of five years accounted for most 317 (27.1%) culture positive stool sample, with the least 28 ( 2.4 % ) 28 ( 2.4 % ) 28(2.4%)28(2.4 \%)28(2.4%) been those ≥ 65 ≥ 65 >= 65\geq 65≥65 years. There were more 649 (55.4%) females with a male to female ratio of 1:1.2 Table 1.
Table 1: Socio-demographics of the patient
Variables Frequencies n Percentages %
Age (years)
1 − < 5 1 − < 5 1- < 51-<51−<5 317 27.1
5 − 14 5 − 14 5-145-145−14 179 15.3
15 − 24 15 − 24 15-2415-2415−24 131 11.1
25 − 34 25 − 34 25-3425-3425−34 147 12.6
35 − 44 35 − 44 35-4435-4435−44 130 11.1
45 − 54 45 − 54 45-5445-5445−54 170 14.5
55 − 65 55 − 65 55-6555-6555−65 69 5.9
≥ 65 ≥ 65 >= 65\geq 65≥65 28 2.4
Total 1171 100.0
Gender
Male 522 44.6
Female 649 55.4
Total 1171 100.0
Variables Frequencies n Percentages % Age (years) 1- < 5 317 27.1 5-14 179 15.3 15-24 131 11.1 25-34 147 12.6 35-44 130 11.1 45-54 170 14.5 55-65 69 5.9 >= 65 28 2.4 Total 1171 100.0 Gender Male 522 44.6 Female 649 55.4 Total 1171 100.0| Variables | Frequencies n | Percentages % | | :---: | :--- | :--- | | Age (years) | | | | $1-<5$ | 317 | 27.1 | | $5-14$ | 179 | 15.3 | | $15-24$ | 131 | 11.1 | | $25-34$ | 147 | 12.6 | | $35-44$ | 130 | 11.1 | | $45-54$ | 170 | 14.5 | | $55-65$ | 69 | 5.9 | | $\geq 65$ | 28 | 2.4 | | Total | 1171 | 100.0 | | Gender | | | | Male | 522 | 44.6 | | Female | 649 | 55.4 | | Total | 1171 | 100.0 |
Missing data = 195 = 195 =195=195=195
A total of 857 (62.74%) cultured Salmonella species, 496 (36.31%) grew Escherichia coli. Others are Shigella species 7 (0.51 % ) % ) %)\%)%) and S S SSS. aureus 6 ( 0.44 % ) 6 ( 0.44 % ) 6(0.44%)6(0.44 \%)6(0.44%) Table 2 below.
Table 2: Distribution of cultured pathogen
Organism Frequency n Percentage %
Salmonella species 857 62.74
E. coli 496 36.31
Shigella species 7 0.51
S. aureus 6 0.44
Total 1366 100.00
Organism Frequency n Percentage % Salmonella species 857 62.74 E. coli 496 36.31 Shigella species 7 0.51 S. aureus 6 0.44 Total 1366 100.00 | Organism | Frequency n | Percentage % | | :--- | :--- | :--- | | Salmonella species | 857 | 62.74 | | E. coli | 496 | 36.31 | | Shigella species | 7 | 0.51 | | S. aureus | 6 | 0.44 | | Total | 1366 | 100.00 | | | | |
Salmonella species showed 61.8 % 61.8 % 61.8%61.8 \%61.8% sensitivity to Ofloxacin , 46.2 % 46.2 % 46.2%46.2 \%46.2% to Gentamycin and 45.4 % 45.4 % 45.4%45.4 \%45.4% to Ciprofloxacin respectively . While, high resistance to Salmonella sp. was found with Augmentin in this study . The Escherichia coli had its highest sensitivity to Gentamycin (67.9%). Others are, Ofloxacin (64.1%), Ciprofloxacin (45.4%) and Streptomycin (39.9%) respectively. E. coli resistance is highest with Augmentin (56.5%), Cefuroxime (39.9%) and Amoxicillin (25.0%).
Shigella species had very good sensitivities to Ofloxacin (100%) and Gentamycin (85.7%). Others are ; Ceftriaxone and Ceftazidime respectively. Shigella resistance was highest with the Ampicillin (85.7%), Ciprofloxacin (28.6%) and Imipenem (14. 3 % ) 3 % ) 3%)3 \%)3%). Also , in this study , S. aureus susceptibility was found with Ciprofloxacin (80%) and Erythromycin (60%) while resistance was with Cotrimoxazole (60%). Others are, Ceftazidime and Amoxycillin at 40% each Table 3.

Table 3: Bacterial Isolates from stool and their percentage sensitivities

Susceptibility to Antibiotics

Isolate AM CT GM AMC OF CP NA NT LV CF CFT CFZ ER ST
Salmonella 75.6 72.3 46.2 NT 61.8 45.4 75.1 24.0 21.7 21.0 17.9 19.7 NT NT
E. coli 75.0 77.2 67.9 43.5 64.1 45.4 78.0 NT 37.3 60.1 24.0 NT 79.6 39.9
Shigella NT 28.6 85.7 14.3 100 71.4 71.4 28.6 NT 28.6 42.9 42.9 NT 14.3
S. aureus 60.0 40.0 20.0 20.0 20.0 80.0 NT 20.0 NT 20.0 NT 60.0 60.0 20.0
AM CT GM AMC OF CP NA NT LV CF CFT CFZ ER ST Salmonella 75.6 72.3 46.2 NT 61.8 45.4 75.1 24.0 21.7 21.0 17.9 19.7 NT NT E. coli 75.0 77.2 67.9 43.5 64.1 45.4 78.0 NT 37.3 60.1 24.0 NT 79.6 39.9 Shigella NT 28.6 85.7 14.3 100 71.4 71.4 28.6 NT 28.6 42.9 42.9 NT 14.3 S. aureus 60.0 40.0 20.0 20.0 20.0 80.0 NT 20.0 NT 20.0 NT 60.0 60.0 20.0| | AM | CT | GM | AMC | OF | CP | NA | NT | LV | CF | CFT | CFZ | ER | ST | | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | :--- | | Salmonella | 75.6 | 72.3 | 46.2 | NT | 61.8 | 45.4 | 75.1 | 24.0 | 21.7 | 21.0 | 17.9 | 19.7 | NT | NT | | E. coli | 75.0 | 77.2 | 67.9 | 43.5 | 64.1 | 45.4 | 78.0 | NT | 37.3 | 60.1 | 24.0 | NT | 79.6 | 39.9 | | Shigella | NT | 28.6 | 85.7 | 14.3 | 100 | 71.4 | 71.4 | 28.6 | NT | 28.6 | 42.9 | 42.9 | NT | 14.3 | | S. aureus | 60.0 | 40.0 | 20.0 | 20.0 | 20.0 | 80.0 | NT | 20.0 | NT | 20.0 | NT | 60.0 | 60.0 | 20.0 |
NT: Not Tested, AM: Amoxycillin, CT: Cotrimoxazole, GM: Gentamycin, AMC: Amoxycillin-clavulanic acid, OF: Ofloxacin, CP: Ciprofloxacin , NA: Nalidixic acid, NT: Nitrofurantoin , LV: Levofloxacin , CF: Cefuroxime , CFT: Ceftriaxone , CFZ: Ceftazidime, ER: Erythromycin, ST: Streptomycin.

DISCUSSION

A third of the stool samples yielded a culture positive with a bacterial microbial agent in this study. This is similar to an earlier finding among children in Ilorin Nigeria. 10 10 ^(10){ }^{10}10 This may also not be unconnected with the well-known knowledge of bacterial agent not being the commonest cause of diarrhea disease especially among children, as buttressed by the fact that almost half of the subjects in this study are children. Our finding is lower compared with the report of Bejide et a l 11 a l 11 al^(11)\mathrm{al}^{11}al11 in Ibadan among children, using a much smaller size and some of their study population known to be HIV infected. These probably explains the discrepancy observed.
Of the five bacterial agents under consideration in the present study, two featured prominently with Salmonella species and E. coli accounting for approximately two-thirds and a third of the cases cultured respectively. Others, such as Shigella species and S. aureus accounted for less than 1 percent in this study. Bejide et a l 11 a l 11 al^(11)\mathrm{al}^{11}al11 in Ibadan reported both Salmonella and E. coli in their study but with the predominance of the latter. Unlike the present study which cut across various ages, their study was among children. Besides, E. coli is known to be the commonest bacteria pathogenic agents from stools of children under the age of five years. 11 11 ^(11){ }^{11}11
Salmonella specie are highly susceptible to Ofloxacin in this study. Others with high sensitivities included Gentamycin and Ciprofloxacin. The highest resistance to Salmonella species was found with Amoxycillin - clavulanic acid, Amoxycillin and Nalidixic acid in this study. The Salmonella resistance in this study is comparable to that of Ifeanyi et a l 13 a l 13 al^(13)a l^{13}al13 in an earlier study which largely cultured Salmonella species as well. 13 13 ^(13){ }^{13}13
E. coli was mostly sensitive to Gentamycin, Ofloxacin, Ciprofloxacin and Streptomycin but resistant to Augmentin, Cefuroxime and Amoxicillin in that order. This resistance pattern is similar to earlier studies. 14 , 15 14 , 15 ^(14,15){ }^{14,15}14,15 In this study also, sensitivities to Shigella were found to be quite perfect with Ofloxacin and Gentamycin. It equally showed some sensitivities to Ceftriaxone and Ceftazidime respectively. While, resistance to Shigella was highest with the Penicillin, others with some resistance to Shigella are Ciprofloxacin and Imipenem in that order. This is in contrast to a study by Ogunsola et a l 9 a l 9 al^(9)a l^{9}al9 in Lagos that reported a high sensitivity to both the Quinolones and the third generation Cephalosporins. This study was done almost three decades ago, with the rampant and irrational use of antibiotics partly to blame for this finding. Others are, quackeries, fake medications and poor drug storage etc. S. aureus had good sensitivities to Ciprofloxacin and Erythromycin. It is resistant to Cotrimoxazole, Ceftazidime and Amoxycillin respectively.
Non distinction of the cultured organism based on the ages of participants for comparison with other findings is a limitation. That could have afforded us the opportunity of knowing the age group commonly affected with E. coli and Salmonella species respectively. This however, does not invalidate our study findings.
Salmonella species and E. coli were the two commonly cultured bacteria pathogen from stool sample in this study. Most organisms cultured in this study are sensitive to the Quinolones, Aminoglycosides and Macrolides respectively. Resistance on the other hand were mostly to the Penicillin and the Cephalosporins. This will be of guide clinical practice and be of great help to reducing unnecessary prescriptions especially in low-income countries like ours where healthcare coverage is not universal yet.

DECLARATIONS

Competing Interest: None
Funding: None
Authors Contributions: BSO, AES, KAD, OTO, AMC, AYH, MMH and HII: Conceive the idea; All authors (BSO, AES, KAD, OTO, AMC, AYH, MMH, HHI, BJO, IYO, TE, RM): Design the work, participate in acquisition, analysis and interpretation of data; revise the manuscript and approved the final version to be published; as well as agreed to be accountable for all aspects of the work.
Acknowledgement: We appreciate all the clinicians as well as the laboratory scientists and technicians working at the microbiology unit for their contributions to the success of this study.
Ethical Consideration: Ethical approval was obtained from the Research Ethics Committee of the Dalhatu Araf Specialist Hospital. Permission was sought from the head of the laboratory and medical records departments of DASH. Complete privacy and confidentiality of participants were ensured.

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How to cite this article :Bello SO, Audu ES, Katoh AD, et al Evaluation of antibiotics sensitivity pattern of bacterial isolate from stool in a referral hospital in North-Central, Nigeria . J Nig Infect Dis 2023; 2(1):59-64.