Antibiotics resistance is a major threat to public health, especially in sub-Saharan Africa (SSA) where incidence of death from antimicrobial resistance (AMR) exceeds 100 deaths per 100,000 individuals.
Because of their high potential for resistance acquisition, Enterobacteriaceae play a major role in this situation. They are among the most frequently found bacteria in blood cultures in resource-limited countries. However, only a few reviews have been conducted on third-generation cephalosporins (3GC) resistance of Enterobacteriaceae carriage and infections in children in sub-Saharan Africa.
We therefore conducted our own systematic reviews on both carriage and infections. We included a total of 160 publications published between 2005 and 2022. Of these, 120 studies focused on Enterobacteriaceae infections and 38 focused on carriage. Two studies looked at both infections and carriage. The studies on infections provided data from more than 30 000 bacterial isolates. They showed high non-susceptibility rates to 3GC, especially in blood cultures, in E coli (40.6%, 95%CI: 27.7-55) and in Klebsiella spp (84.9%, 95%CI: 72.8-92.2). The studies on carriage prevalence of Enterobacteriaceae yielded results for 9146 children. Overall the prevalence of Extended-spectrum cephalosporin-resistant Enterobacteriaceae (ESCR) carriage reported in the studies was extremely heterogeneous, with a cumulative pooled prevalence of 32.2% (95%CI: 25.2-40.2) for the carriage of at least one Enterobacteriaceae. The prevalence of 3GC non-susceptibility rate of Enterobacteriaceae rose to 75.6% (95%CI: 52.0-89.9) after more than 48 hours of hospitalization. Because 3GC represents the first line of treatment for sepsis in children, these results are extremely alarming.
Fighting against antimicrobial resistance (AMR) is particularly complex in sub-Saharan Africa where it is hampered by many factors. These include poor sanitary conditions, poor water quality and extensive use of antibiotics for agriculture and animal husbandry. The health care system in the region is also suboptimal. Primary care facilities and hospitals are often overcrowded and understaffed, resulting in indiscriminate prescription of antibiotics. In other areas, limited access to health care leads patients to self-medicate and antibiotics can be easily obtained over-the-counter. While national action programs on AMR are gradually being established, the paucity of microbiology capacities complicates the implementation of surveillance networks.
The fight against antibiotic resistance is typically based on four pillars: optimizing the use of antimicrobial medicines; reducing the incidence of healthcare-associated infections; implementing monitoring systems; and implementing a coordinated action plan. Access to laboratory facilities is central to each of these aspects. However, this remains a largely neglected area in sub-Saharan Africa. Projects aimed at implementing affordable, transportable and quality-assured clinical bacteriology laboratories (min-lab) are being developed, in particular by the organization Médecins sans Frontières. Data from these efforts will be of great interest, as they represent a particularly interesting and useful area of future research.
