University of Ghana http://ugspace.ug.edu.gh 
SCHOOL OF PUBLIC HEALTH 
COLLEGE OF HEALTH SCIENCES 
UNIVERSITY OF GHANA 
  
 
MULTIDRUG-RESISTANT BLOODSTREAM ORGANISM INFECTION AT THE 
NEONATAL INTENSIVE CARE UNIT IN THE GREATER ACCRA REGIONAL 
HOSPITAL IN GHANA 
 
BY 
 ABENA ODUROWAA YEBOAH  
ID – 10401994 
 
 
THIS DISSERTATION IS SUBMITTED TO UNIVERSITY OF GHANA, LEGON IN 
PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER 
OF PUBLIC HEALTH (MPH) DEGREE 
 
 
MARCH, 2022  
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DECLARATION 
I Abena Odurowaa Yeboah, hereby declare that except for the references of other people’s 
work which have been cited, this dissertation is the result of my own original work, and that 
this work either in whole or part has not been presented for a degree in another institution. 
 
 
 
 
30-09-2022 
         …………………………. 
 
Abena Odurowaa Yeboah            Date 
(Student) 
 
 
 
 
 
 
  30-09-2022 
……………………………      ………………………….. 
Dr Kwabena Opoku-Mensah             Date  
(Supervisor) 
  
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DEDICATION 
This work is dedicated to God Almighty for the strength and grace given me to undertake this 
remarkable journey. I would also like to acknowledge my parents for the support and my 
mentors for the tireless encouragement given to me to be the best version of myself. Lastly, I 
would like to dedicate this work to my hopes and dreams and to my future self.  
 
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ACKNOWLEDGEMENT 
My deepest gratitude goes to the Almighty God for His grace and ever sustained mercy. I would 
like to say a special thank you to my supervisor Dr. Kwabena Opoku-Mensah, for his patience 
and constant guidance throughout the time of my study. It has been an absolute honour to be 
your student sir.  
Special regards to the research department at Ridge Hospital for their support. A round of 
applause goes to the Head of Research department GARH, Mr. Abrokwah-Jampin for his 
kindness and ever persistent support and enthusiasm about my work endeavours. 
  
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LIST OF ABBREVIATION 
ADR- Antimicrobial drug resistance  
CLABSI - Central line-associated bloodstream infections  
CoNS – Coagulase Negative Staphylococcus  
ESBL - Extended spectrum beta lactamase 
GARH - Greater Accra Regional Hospital  
GNB - Gram Negative Bacteria  
HAI – Hospital acquired infections 
HGT - Horizontal gene transfer  
ICU- Intensive care Unit  
LMICs - Low and middle-income countries  
MDR – Multidrug resistance  
MDR-GNB - Multidrug resistant Gram-Negative Bacteria  
MDR-TB - Multi-drug resistant Tuberculosis 
MDRO- Multidrug resistant Organism  
MDROI- Multidrug resistant Organism Infection 
MRSA - Methicillin-resistant Staphylococcus aureus  
NICU- Neonatal Intensive care Unit  
RCR - Retrospective chart review  
RR-TB - Rifampicin-resistant Tuberculosis 
TB – Tuberculosis  
VRSA - Vancomycin resistant S. aureus   
  
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ABSTRACT   
Abstract  
Background: 
Antimicrobial drugs since their inception have improved contemporary medicine. Blood 
stream infections (BSIs) are a significant source of morbidity and mortality among the neonatal 
population in hospitalized settings with a penchant for Low and middle-income countries 
(LMICs). Data on newborn BSIs showing Multidrug resistance (MDR) using a mixed 
technique approach are few. As a result, it has become critical to identify and analyze the scope 
of this hidden health problem in a vulnerable and at-risk population in order to raise awareness 
and prompt action. The general objective was to assess the multidrug resistant-organism 
infections in Neonatal Intensive care unit (NICU) in Greater Accra Regional Hospital in Ghana. 
 
Methods: 
The study was conducted using a mixed method research design at a tertiary level in a neonatal 
intensive care unit (NICU) in Greater Accra Regional Hospital (GARH), Ghana. All blood 
cultures taken for newborns admitted to the NICU within the period of 1st June 2020 to 31st 
May 2021were included. Multidrug resistance (MDR) in BSI rates were analysed, and the 
effect of antimicrobial resistance (AMR) on outcomes and duration of hospitalization were 
analysed. Participants in the qualitative study were Neonatal ICU nurses, Microbiologists, and 
Laboratory technicians. The sampling approach used for interviewing health workers was 
convenience sampling in view of the tight work scheduled of many of the qualified 
respondents. All interviews were conducted in the facility with prior notice to the participants. 
Data was analyzed into proportions as per total sample size. Analyzed data, together with 
interview findings, together forming quantitative and qualitative data, were compared with the 
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secondary data extracted to answer the proposed research questions. P values <0.05 were 
considered significant. 
 
Results: 
Of 1,043 blood culture samples taken from neonates in the NICU, 195 cultured Multidrug 
resistant organisms (MDROs). Overall incidence of MDR BSI was 18.7% (195/1043). The 
predominantly isolated pathogenic organism was Klebsiella spp 31.2% (61/195) and 
Staphylococcus aureus 20.5% (40/195). Additionally, 38 coagulase negative Staphylococci 
were isolates. Among the Klebsiella spp resistance to ampicillin, cefotaxime and gentamicin 
was 72.1%, 39.3% and 52.4%, respectively, while carbapenem resistance was 10.4%. Mortality 
among neonates with MDR BSI was 26.2% (51/195).  
Results also indicated that knowledge of MDROs amongst Health care workers and control 
measures to curtail their development and spread were very general and lacked. Qualitative 
results also indicated that public education and sensitization at the community level as well as 
providing a framework and guidelines for antimicrobial stewardship at the facility level is a 
basic and urgent need in the management of MDR. 
 
Conclusion: 
This study corroborates existing literature, reiterating the urgent need for intervention. The 
empirical regimen in the setting of low- and middle-income countries such as Ghana is unlikely 
to lead to advancement substantial enough to improve outcomes associated with MDR BSI. 
The required improvement would require advancements in various medical fields including 
improvement in clinical microbiological services.  
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TABLE OF CONTENTS 
DECLARATION ........................................................................................................................ i 
DEDICATION ...........................................................................................................................ii 
ACKNOWLEDGEMENT ....................................................................................................... iii 
LIST OF ABBREVIATION ..................................................................................................... iv 
ABSTRACT ............................................................................................................................... v 
LIST OF TABLES  ................................................................................................................... xi 
LIST OF FIGURES .................................................................................................................. xi 
DEFINITION OF TERMS ......................................................................................................xii 
CHAPTER ONE ........................................................................................................................ 1 
INTRODUCTION ..................................................................................................................... 1 
1.1 Background ...................................................................................................................... 1 
1.2 Problem Statement ........................................................................................................... 2 
1.3 Research Questions .......................................................................................................... 4 
1.4 Objectives ........................................................................................................................ 5 
1.4.1 General Objective ..................................................................................................... 5 
1.4.2 Specific Objectives ................................................................................................... 5 
1.5 Significance of the Study ................................................................................................. 6 
1.6 Theoretical Framework .................................................................................................... 7 
1.6.1 Domains .................................................................................................................... 7 
1.6.2 Knowledge ................................................................................................................ 8 
1.6.3 Belief in capabilities ................................................................................................. 8 
1.6.4 Environmental Factors .............................................................................................. 9 
1.6.5 Belief in consequences:........................................................................................... 10 
1.6.6 Behavioral regulation: ............................................................................................. 10 
1.6.7 Reinforcement: ........................................................................................................ 10 
1.7 Conceptual Framework .................................................................................................. 11 
1.7 Justification .................................................................................................................... 12 
CHAPTER TWO ..................................................................................................................... 16 
LITERATURE REVIEW ........................................................................................................ 16 
2.1 Antimicrobial Resistance (AMR) .................................................................................. 16 
2.2 Risk Factors of Antimicrobial Resistance (AMR) ......................................................... 18 
2.2.1 Natural Occurrence ................................................................................................. 18 
2.2.2 General Risk Factors for development of Antibiotic resistance. ............................ 19 
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2.2.3 Pharmaceutical Industry’s Decreased Interest ........................................................ 20 
2.3 Multi-Drug Resistant Organisms (MDRO) ................................................................... 21 
2.3.1 Mycobacterium tuberculosis ................................................................................... 22 
2.3.2 Clostridium difficile ................................................................................................ 23 
2.3.3 Neisseria gonorrhea ................................................................................................ 23 
2.3.4 Methicillin-resistant Staphylococcus aureus (MRSA) ............................................ 25 
2.3.5 Vancomycin-resistant Enterococci (VRE) .............................................................. 25 
2.3.6 Carbapenem-resistant Enterobacteriaceae (CRE) ................................................... 26 
2.4 MDRO Infections in Neonatal ICU ............................................................................... 26 
2.4.1 Blood Stream Infections (BSI)................................................................................ 27 
2.4.2 AMR in Nosocomial Infections in Infants and Neonates ....................................... 27 
2.5 Management of MDROs ................................................................................................ 28 
2.6 Conclusion ..................................................................................................................... 29 
CHAPTER THREE ................................................................................................................. 32 
RESEARCH METHODS ........................................................................................................ 32 
3.1 Introduction .................................................................................................................... 32 
3.2 Study Approach ............................................................................................................. 32 
3.2.1 Study Design ........................................................................................................... 32 
3.3 Area of Study ................................................................................................................. 33 
3.4 Study Variables .............................................................................................................. 34 
3.5 Population of the Study .................................................................................................. 34 
3.6 Inclusion/Exclusion criteria ........................................................................................... 34 
3.7 Sample Size patient records ........................................................................................... 35 
3.7.1 Selection of participants for the Qualitative study .................................................. 35 
3.7.2 Sampling Technique ............................................................................................... 35 
3.8 Data Collection Techniques ........................................................................................... 36 
3.8.1 Extraction of Research Data from Records ............................................................ 37 
3.8.2 Data Collection Instruments ................................................................................... 37 
3.9 Data Analysis ................................................................................................................. 37 
3.10 Quality Control ............................................................................................................ 38 
3.10.1 Good Clinical Practice .......................................................................................... 38 
3.10.2 Monitoring ............................................................................................................ 38 
3.10.3 Data Management ................................................................................................. 38 
3.11 Ethical Consideration ................................................................................................... 39 
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3.11.1 Informed consent .................................................................................................. 39 
3.11.2 Criteria for stopping and discontinuing Research ................................................. 39 
3.11.3 Ethical Approval ................................................................................................... 39 
3.11.4 Safety Considerations ........................................................................................... 39 
3.11.5 Covid Safety Measures ......................................................................................... 40 
CHAPTER FOUR .................................................................................................................... 41 
PRESENTATION OF RESULTS ........................................................................................... 41 
4.1 NICU Quantitative Results ............................................................................................ 41 
4.1.1 Demographic Characteristics of NICU Patient Samples ........................................ 41 
4.2 Diagnosis Associated With MDRO ............................................................................... 43 
4.3 Prevalence of MDRO Infection in the NICU ................................................................ 44 
4.4 Antibiotics Prescribed .................................................................................................... 44 
4.5 Morbidity and Mortality Associated with MDROS in the NICU .................................. 45 
4.6 Organisms Isolated......................................................................................................... 47 
4.7 Antimicrobial Susceptibility and Resistance Profile of NICU Blood Cultures ............. 49 
4.8 Qualitative Results ......................................................................................................... 55 
4.9 Conclusion ..................................................................................................................... 60 
CHAPTER FIVE ..................................................................................................................... 61 
DISCUSSION .......................................................................................................................... 61 
5.1 Demographic Distribution ............................................................................................. 61 
5.2 Antimicrobial Susceptibility .......................................................................................... 61 
5.3 Most Frequently Prescribed First-Line Antibiotics ....................................................... 63 
5.4 Morbidity and Mortality Associated with Multidrug-Resistant Organisms .................. 65 
5.5 Impact of BSIs on Cost, Length of Stay and Case Fatality ........................................... 66 
5.6 Knowledge of MDROs amongst Health Workers ......................................................... 66 
5.7 Factors Contributing to MDROs .................................................................................... 67 
5.8 Measures in Place to Prevent Antimicrobial Resistance................................................ 68 
CHAPTER SIX ........................................................................................................................ 70 
6.1 Conclusion ..................................................................................................................... 70 
6.2 Recommendations .......................................................................................................... 71 
6.3 Importance of the Study ................................................................................................. 71 
6.4 Limitations of the Study................................................................................................. 72 
REFERENCES ........................................................................................................................ 73 
APPENDIX A: PARTICIPANTS INFORMATION SHEET ................................................. 80 
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APPENDIX B (CONSENT FORM) ........................................................................................ 83 
APPENDIX C (DATA EXTRACTION FORM) .................................................................... 85 
APPENDIX D: INTERVIEW GUIDE .................................................................................... 86 
APPENDIX E: ETHICAL CLEARANCE .............................................................................. 90 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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LIST OF TABLES  
Table 1: Sex distribution of NICU patients ............................................................................. 41 
Table 2: First-line Antibiotics Prescribed ................................................................................ 45 
Table 3 : Organisms Isolated ................................................................................................... 48 
Table 4: Cross tabulation of Most Frequently Prescribed Firstline Antimicrobials against 
Gentamicin Susceptibility ........................................................................................................ 52 
Table 5: Crosstabulation of Most Frequently Prescribed First Antimicrobials Against 
Ampicillin Susceptibility ......................................................................................................... 53 
Table 6 : Crosstabulation of Most Frequently Prescribed First Line Antimicrobials against 
Cefotaxime Susceptibility ........................................................................................................ 54 
Table 7 - Socio demographics of health care professionals ..................................................... 55 
 
 
 
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LIST OF FIGURES 
Figure 1 - Conceptual Framework ........................................................................................... 15 
Figure 2 : Sex Distribution of NICU Patients .......................................................................... 42 
Figure 3 : Age of diagnosis and admission in days of NICU patients ..................................... 42 
Figure 4: Diagnosis associated with MDRO ........................................................................... 43 
Figure 5: prevalence of MDRO in the NICU at GARH .......................................................... 44 
Figure 6: First line antibiotics prescribed ................................................................................ 45 
Figure 7: Outcome of management.......................................................................................... 46 
Figure 8 - Number of days on admission ................................................................................. 47 
Figure 9 : Resistance and Susceptibility Profile of Most Used Antibiotics [N > 55] .............. 49 
Figure 10 Percentage resistance and susceptibility of antimicrobials used in susceptibility 
testing ....................................................................................................................................... 51 
 
 
 
 
 
 
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DEFINITION OF TERMS  
ANTIMICROBIALS: Medicines used to diagnose and reduce infections in people, animals, 
and plants are referred to as antimicrobials. Antibiotics, antivirals, antifungals, and antiparasitic 
are among them. 
ANTIMICROBIAL DRUG RESISTANCE (ADR): Refers to the phenomenon of microbes 
such as bacteria, viruses and fungi changing their physiological make – up to render 
medications used for treatment ineffective, thus resulting in continued illness and death.  
 
MULTIDRUG RESISTANCE (MDR): When a single bacterium is resistant to more than 
one antibiotic, this is referred to as multi-drug resistance. MDR is clinically defined as an 
isolate that is resistant to at least one antimicrobial agent from one of three groups. 
 
NEONATE: An infant less than four (4) weeks old.  
 
INFANT: A baby zero (0) to one (1) year old.  
 
BACTERAEMIA:  Viable bacteria that are present in the bloodstream. They could be 
associated with an active disease or not. 
 
GRAM NEGATIVE BACTERIA: Refers to a wide range of bacteria found in environments 
that support life on earth.  
 
MORBIDITY: The state of being afflicted with a sickness or medical condition. 
 
MORTALITY: Refers to the state or situation of being subject to death.  
 
NOSOCOMIAL INFECTIONS: Refers to infectious diseases acquired from contact with 
various transmission channels of a healthcare facility, 48 hours after admission or post 
admission.  
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CHAPTER ONE 
INTRODUCTION 
1.1 Background  
Neonatal ICU patients require extremely critical care and around the clock assistance with the 
management of health their conditions (Comisso et al., 2018). This unfortunately and more 
often than not, results in the onset of nosocomial infections (Comisso et al., 2018).   
Hospital-acquired (nosocomial) infection is a primary health problem for premature and term 
neonates requiring long term hospitalization due to mild to serious medical disorders with the 
most common being central line-associated bloodstream infections (CLABSI) and nosocomial 
pneumonia (Knowles, 2009). Sepsis has been found to be the most frequent infection in 
neonates in NICU (Zou et al., 2021), while premature birth, severe infection and suffocation 
have been to be the leading causes of neonatal mortality (Comisso et al., 2018). Late-onset 
sepsis (sepsis that occurs after 72 hours) on admission affects up to about 5% of NICU 
admissions (Ramirez & Cantey, 2019) 
According to demographic studies conducted during the last two decades, the global estimate 
of the incidence of new-born sepsis was 2202 per 100,000 live births (LBs), with death ranging 
between 11 and 19 percent  (Zou et al., 2021). Nevertheless, despite recording global reductions 
in paediatric mortality during the period, there hasn’t been much improvement regarding 
neonatal mortality, currently accounting for nearly half of death of children under age five (Zou 
et al., 2021). Infections caused by multi-drug resistant gram-negative bacteria are linked with 
increased morbidity, mortality, length of stay, as well as patient healthcare costs. Zhou et al., 
(2013) in a study conducted at Johns Hopkins medical institution revealed that patients 
hospitalized for infections caused by antimicrobial-resistant organisms have significantly 
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higher costs ranging from approximately 6,000 to 30,000 dollars more than those with 
antimicrobial susceptible organisms (Cosgrove, 2006) 
Appropriate treatment of severe infections, especially Sepsis, is crucial for neonatal survival 
and an improvement in neonatal mortality records.  However, increased development of 
antimicrobial resistance (AMR) microorganisms continues to complicate the management of 
these diseases. 
1.2 Problem Statement  
In health care delivery pertaining to the management of microbial infections, the ultimate aim 
is to successfully treat patients while ensuring that no harm is caused in the process. Comisso 
et al. (2018) showed that, to achieve this, there are stipulated guidelines to be adhered to when 
attending to a patient. Rennie and Kendall (2013) explained that adhering to these guidelines 
ensure that there is little to no risk at all to patients when receiving the best possible healthcare 
that could be afforded them. 
Neonates in the intensive care unit (NICU) are susceptible to Hospital acquired infections. 
Transmitted through consistent contact with healthcare professionals as well as contaminated 
objects/instrument. Asare et al., (2009) explained that high infection rates in intensive care 
facilities can be linked to various factors including, but not limited to effective hand hygiene 
practices as well as instrumentation and highly invasive procedures (Ulu-Kilic et al., 2013). 
Surgical and mechanical procedures such as arterial and venous catheters, tracheal cannulas, 
peritoneal shunts, chest drains, and other similar devices increase the chance of transmission. 
(Raj Bhatta et al., 2020). 
S. aureus, including methicillin-resistant S. aureus (MRSA), Klebsiella species, E. coli, 
Pseudomonas species, Acinetobacter species, and Enterococcus species are some of the 
bacteria that are commonly transmitted (Raj Bhatta et al., 2020). Raj Bhatta et al., (2020) and 
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Inusah et al., (2021) in their studies showed that, increased antibiotic resistance and the rise of 
multidrug resistant (MDR) organisms such as MRSA, vancomycin resistant S. aureus (VRSA), 
extended spectrum beta lactamase (ESBL) generating Enterobacteriaceae and Acinetobacter 
species in the NICU result in significant morbidity and mortality. 
Multidrug Resistance (MDR) leads to upscaling of antibiotics and the use of comparatively 
higher doses which perpetuates a cycle of resistance.  Low and middle-income countries 
(LMICs) have higher antimicrobial resistance and concomitant higher mortality rates than 
higher-income countries (Saharman et al., 2021). Multidrug-resistant gram-negative species 
have been found to also play a much more significant role in LMIC’s Intensive care units than 
in higher-income countries. Studies conducted in Africa in Northern Tanzania and Rwanda by 
(Kumburu et al., 2017) and (Carroll et al., 2016) respectively, revealed alarming rates of 
antimicrobial resistance (AMR) and exposed the need for a review in antibiotic stewardship.  
Resistant microbial strains provide a challenge to paediatric healthcare practitioners because 
they are more likely to be passed to and cause difficult to treat illnesses in high-risk children. 
(Milstone et al., 2010).  
Martinez and  Baquero, (2009) explained that this has compelled healthcare practitioners in 
this field to consider combining and trying out antimicrobial drugs with impaired activity to 
ascertain whether their combined chemical formulations will make it possible to easily treat 
infections Also, the use of old antimicrobial agents have been employed. An example is re-
introducing an old antibiotic, vancomycin as treatment for MRSA infections.  
Unfortunately, inadequate antibiotic stewardship as well as a lack of detailed and practical 
treatment protocols in health care facilities in Ghana is nurturing a man-made pandemic of 
antibiotic resistance within the country’s healthcare facilities (Newman et al., 2011)  The result 
is an ever soaring rate of  self-medication and the inappropriate as well as overuse of antibiotics 
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is fast depleting the level the effectives of common and even sometimes, strong antibiotics in 
the management of the microbial infection of the average Ghanaian patient. The country is at 
the brink of developing extreme drug-resistant strains of microbes as is in the case of 
tuberculosis. A study conducted in Ghana observed a higher prevalence of MDR-GNB among 
inpatients 80.5% compared to outpatients which accounted for only 19.5%. (Agyepong et al., 
2018) 
To make matters worse, though there is a high rate of nosocomial or hospital acquired 
infections (HAIs) in the country’s health care facilities requiring successful antimicrobial 
treatment, infections caused by resistant bacteria are extremely difficult, probably almost 
impossible to treat (Inusah et al., 2021) 
The spectrum of organisms inhabiting the NICU environment alter with time and vary from 
hospital to hospital, both inside and outside the nation. As a result, this study was conducted to 
assess the bacterial contamination of routinely handled NICU objects/instruments.           
It has therefore become imperative to identify and assess the extent of this burgeoning health 
concern for prompt intervention. Hence, the need for a study into Multidrug Resistance that 
focuses on Neonatal intensive care units at the Greater Accra Regional Hospital to identify the 
extent of the problem there for possible intervention. 
1.3 Research Questions 
The study was carried out to find answers to the following research questions: 
1. What is the antibiotic susceptibility profile of infections in patients admitted to the 
NICU with bloodstream infections at the Greater Accra Regional Hospital? 
2. What is the level of prevalence of Multidrug-resistant organism Blood Stream infection 
in the NICU of Greater Accra Regional Hospital? 
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3. What are the most frequently prescribed first-line antibiotics in the NICU of Greater 
Accra Regional Hospital? 
4. What is the rate of morbidity and mortality associated with multidrug-resistant 
organisms in the NICU of Greater Accra Regional Hospital? 
5. What are the measures currently in place to prevent the emergence of antimicrobial 
resistance in Greater Accra Regional Hospital? 
 
1.4 Objectives 
1.4.1 General Objective  
The General objective for the study was to assess the multidrug resistant-organism infections 
in Neonatal Intensive care unit (NICU) in Greater Accra Regional Hospital in Ghana. 
1.4.2 Specific Objectives  
Specific Objectives were as follows: 
1. To determine antibiotic susceptibility profile of infections in patients admitted to 
the NICU with bloodstream infections at the Greater Accra Regional Hospital. 
2. To determine the prevalence of Multidrug-resistant organism Blood Stream 
infection in the NICU  
3. To determine the most frequently prescribed first-line antibiotics in the NICU to 
treat infection. 
4. To assess morbidity and mortality associated with multidrug-resistant organisms in 
the NICU of the Greater Accra Regional Hospital.  
5. To identify the measures that are currently in place to prevent the emergence of 
antimicrobial resistance in Greater Accra Regional Hospital. 
 
 
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1.5 Significance of the Study 
Prior investigations to this study revealed that though multidrug resistance is prevalent in 
Ghana, and having a clearly significant negative impact on the effective treatment of infections, 
no study on antimicrobial resistance had yet been carried out at the NICU of the Greater Accra 
Regional Hospital (GARH), The UK Government commissioned a report on antimicrobial 
resistance, which claimed that by 2050, AMR might kill 10 million people each year (Murray 
et al., 2022a). According to systematic review of global AMR trends in 2019 bacterial AMR is 
known to be a concern in many regions; it was projected that Sub-Saharan Africa had the 
greatest rates of AMR burden in 2019. Six pathogens were responsible for 73.4 percent of 
bacterial AMR-related mortality (95 percent confidence interval: 669–788). (Murray et al., 
2022a). An empirical study revealing the current status of events is important as deduced 
findings could help salvage the development of Multidrug resistant strains of bacteria within 
local communities, and the hospital environments to which children, infants and neonates are 
more susceptible.  
Through this study, healthcare practitioners at GARH will be informed about how the 
hospital’s antimicrobial use correlates with antimicrobial resistance data of patients in NICU 
data on which id currently unknown. By being privy to such empirical data, they can deduce 
an effective strategy for prescribing groups of antibiotics and dosage trends that could prevent 
resistance as well as ways of monitoring and evaluating the administration of antibiotics. To 
conserve the efficacy of the current antibiotics and stall the development of AMR, development 
of Antimicrobial Stewardship Programs (ASPs) is a very essential step (Dramowski et al., 
2020).  According to Dramowski et al., (2020) Neonatal units must first be enabled to measure 
and monitor trends in their antimicrobial usage in order to create robust and effective ASPs and 
to provide locally suitable treatment guidelines, institutions need data on pathogen profiles and 
AMR trends which are not currently known in GARH. This Study identified the most 
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frequently prescribed antibiotic, the AMR trends and the antibiotic organism resistance profile 
in the NICU. This information is invaluable and provides a robust foundation for more 
extensive AMR research and the development of ASPs in the facility. The findings of this study 
will bridge the knowledge gap about antibiotic prescription and misuse, provide data for 
developing antibiotics prescription protocols at the Neonatal Intensive Care Units of the 
Greater Accra Regional Hospital.  
 
1.6 Theoretical Framework  
Antimicrobial resistance (AMR) is becoming more common as a consequence of diverse, 
complicated prescription and eating behaviors. As a result, behavior modification is a crucial 
component of AMR response. Little is known about the most effective methods for changing 
antibiotic usage practices and behaviors (Lohiniva et al., 2022). 
The Theoretical Domains Framework (TDF) is a theoretical framework rather than a theory; it 
does not provide testable correlations between aspects but rather gives a theoretical lens 
through which to observe the cognitive, emotional, social, and environmental impacts on 
behavior (Atkins et al., 2017). The employment of the TDF provides a methodical and 
reproducible approach to identification of the determinants of antimicrobial resistance (AMR) 
in low resource settings. Theoretical Domains Framework’s conceptualization of the 
determinants and identification of behavior change utilizing the Behavior Change Wheel 
(BCW) method allows for specific recommendations for intervention design and future 
research (Lohiniva et al., 2022). 
1.6.1 Domains 
The TDF comprises fourteen different domains with constructs under each given domain. 
These domains include Knowledge, Skills, Social role, Beliefs about capabilities, Beliefs about 
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consequences, Motivation and goals, Memory and attention, Environmental contest and 
resources, social influence, emotion, Behavioral regulation and Nature of beliefs (Atkins et al., 
2017).  
1.6.2 Knowledge  
The domains of knowledge is based on the awareness of existence of something. The constructs 
that underlie this are general knowledge, knowledge about condition or scientific rationale and 
procedural knowledge. The levels of knowledge about AMR and antibiotics misuse and its 
consequences, that are readily available within a community reflects a great deal in how the 
people manage infections and use of antibiotics. Patients tend to not complete antibiotics 
dosage courses due to lack of adequate knowledge base on how the antimicrobials enact their 
actions against bacteria. 
This construct also pertains to the hospital setting where adequate knowledge of the type of 
infections and the appropriate antibiotic class prescribe for which type of infection as per the 
tentative causative organism is an important aspect of the construct of knowledge in relation to 
the Hospital staff.  
Intervention: educating the public and hospital staff and equipping them with theoretical and 
practical information to prevent spread of nosocomial infections and community acquired 
Antimicrobial resistant infections. 
1.6.3 Belief in capabilities  
Acceptance of the truth, realism, or validity of a skill, talent, or aptitude that a person can put 
to good use. The constructs that underpin this are Self-confidence, Perceived competence, Self-
efficacy, Perceived behavioral control, Beliefs, Self-esteem, Empowerment and Professional 
confidence.  Self-confidence and perceived competence of prescribers and dispensers of 
antibiotics to patients without evidence of active susceptible bacterial infection is a major 
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contributory factor to the development and persistence of AMR. Diagnostic inefficiencies and 
delays have led to widespread use of empirical antibiotic therapy and as a result AMR prevails 
in our setting. 
Intervention: Adherence to Antimicrobial prescription guidelines provided for health care 
workers, developing surveillance systems monitoring antibiotic use in the communities and 
providing checks and balances within the health care system to prevent over-prescription and 
under-prescription of medication as well as correct medication per weight measurements 
especially for pediatric and neonatal care.  
 
1.6.4 Environmental Factors  
Any aspect of a person's condition or environment that hinders or stimulates the development 
of skills and talents, independence, social competence, and adaptive behavior. The constructs 
that describe this domain are as follows - Environmental stressors, Resources/material 
resources, Organizational culture/climate, Salient events/critical incidents, Person and 
environment interaction as well as Barriers and facilitators. The environmental stressors such 
as polluted water bodies, lack of proper disposal of unused antibiotics, animal farms overusing 
antibiotics and exposing humans to low doses of antibiotics, poor sanitation and hygiene 
practices contribute to the overall problem of AMR. The organizational culture concerning 
AMR or lack thereof in communities and hospitals contributes to the spread of AMR which is 
a constant threat to current Antibiotics in existence  
 
Intervention:  Environmental protection and preservation is also an essential and fairly 
neglected aspect of AMR prevention. The maintenance of clean water, good sanitation and 
environmental hygiene protects humans.  Interactions with the environment is an important 
way that human beings pick up different types of Multidrug resistant infections.  
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1.6.5 Belief in consequences:  
Acceptance of the truth, actuality, or validity of the results of a behavior in a specific situation. 
The constructs such as Beliefs, Outcome expectancies, Characteristics of outcome 
expectancies, Anticipated regret and Consequents are fundamental to discussing the domain of 
Belief in consequences. This provides a cause-and-effect model for individuals. The exposure 
to AMR and its various causative factors as well as behavioral concepts underlying making an 
impact in the society is also an important way to help reduce antimicrobial resistance. 
Intervention:  Frequent review of AMR rates in the hospital as well as associated morbidity 
and mortality rates associated with the vulnerable populations such as neonates. 
 
 
1.6.6 Behavioral regulation:   
The domain of behavioral modification is anything that involves regulating or modifying acts 
that are objectively seen or measured. This is an innate quality or trait which involves with 
constructs such as Self-monitoring, Breaking habit and Action planning. This quality in 
individuals can be harnessed especially at the professional level as part of the oath in physician 
practice to do no harm, physicians have to be reminded that Non-maleficence can also involve 
withholding medication which may harm the patient and medical community in the long run   
 
1.6.7 Reinforcement:  
Increasing the likelihood of a reaction by establishing a dependent link, or contingency, 
between the response and a specific stimulus. 
 
 
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1.7 Conceptual Framework 
The chart below is a representation of the Conceptual Framework of the study. It explains how 
factors interact leading to health complications that cause morbidity of neonates resulting in 
their admission NICU, with MDRO infection. 
While on admission, patients are susceptible to Hospital Acquired Infections (HAIs), also 
known as nosocomial infections. Ideally, these infections should be treated using antimicrobial 
therapy. However, patients have an increased risk of aggravated morbidity and eventual 
mortality due to the use Antimicrobial and Multidrug Resistance.  
The factors that lead to and promote the development of antibiotic resistance in our 
communities are represented in four major classes, known as institutional factors, 
environmental factors, socioeconomic factors and individual factors. 
The institutional factors encompass the many factors emanating from the facilities that 
individuals in our communities seek health. The first point of call is the prescriber and health 
care workers in the facilities who have the power to prescribe medication to patients. 
Indiscriminate and irresponsible prescription of medication not taking into consideration the 
patient factors and susceptibility of the antibiotics to the prescribed drugs. Evidence-based 
medicine is stressed at all levels of health care delivery however not adhered to a large extent. 
Infection prevention and control strategies in health facilities in our subregion are ill equipped 
to manage the scale of Hospital acquired infections developing in our facilities. The 
antimicrobial stewardship frameworks in our hospitals are not extensive in nature and do not 
provide frameworks that adequately and realistically guide the use of antibiotics.  
Environmental factors implicated in the framework include poor hygiene and sanitation 
practices in our communities and improper drug disposal. Indiscriminate disposal of antibiotics 
onto open refuse dumps leads to the development antimicrobial resistance from the fertile 
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ground of microbes found in the dumpsite, soil and run off seepage leading to development of 
‘super bugs’ which are resistant to a wide range of antimicrobials.  
Socioeconomic factors involved in the development of antimicrobial resistance include, 
educational factors, living conditions and income. These factors interact with each other to 
determine the extent to which individuals can afford medication, the timing of antibiotic dosing 
is usually indicated by prescribers or dispensers. However, patients require a level of education 
and understanding to promptly administer medication to themselves and their wards in a timely 
fashion with correct dosages. 
Individual factors are arguably the most compelling factors that are leading to the development 
of antimicrobial resistance. The abuse and misuse of drugs and over and under dosing of 
prescriptions. The development of MDRO infections may originate from the community or 
may be Hospital acquired infections. These lead to neonatal morbidity warranting hospital 
admission which exposes patients further to nosocomial infections. Morbidity leads to increase 
in cost and length of stay in the hospitals and ultimately if not well managed mortality.  
 
1.7 Justification  
Most antimicrobial resistant (AMR) pathogens exhibit high resistance to first-line drugs 
recommended by the World Health Organization such as ampicillin, gentamicin, and 
cefotaxime. This is evident of developing a multidrug-resistant (MDR) phenotype (Zou et al., 
2021), especially in Gram-negative bacteria (Folgori et al., 2017). Gram negative bacteria form 
much of bacteraemia affecting neonatal health and survival and are of the greatest concern, 
globally regarding neonatal health issues (Folgori et al., 2017) 
A recent meta-analysis of Chinese literature on new-born sepsis from 2009 to 2014 indicated 
that more than 50% of E. coli and Klebsiella spp. were resistant to third-generation 
cephalosporin, and approximately. In Ghana, studies in two teaching, seven regional and two 
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district hospitals revealed   the existence of Anti-microbial drug resistance, with over microbes 
such as Streptococci, Salmonella, and E. coli showing resistance levels as high as 78.7% 
(Newman et al., 2011b). Antibiotic resistance caused by multidrug-resistant Gram-negative 
bacteria has been seen in Ghanaian hospitals; however, methods to ameliorate the problem, 
such as surveillance studies that offer accurate data, are not in place. A study conducted by 
(Agyepong et al., 2018) in the Komfo Anokye Teaching hospital in the Ashanti region of Ghana 
revealed Multidrug resistance was found in 89.5 percent of the bacterial isolates, ranging from 
53.8 percent in Enterobacter spp. to 100.0 percent in Acinetobacter spp. and Pseudomonas spp. 
According to the Centres for Disease Control and Prevention, more than 70% of the bacteria 
presently cause hospital-acquired illnesses are resistant to at least one of the medications most 
routinely used to treat them. (Muto, 2005) 
Bacterial infections are a major cause of morbidity and mortality in neonates cared for in the 
NICU (Rennie & Kendall, 2013). In 1997 the paediatric prevention network was launched to 
assess antimicrobial resistance rates in hospitalized paediatric patients. In the late 1990s, multi-
drug resistant organisms and hospital-acquired infections were found to have a low prevalence 
of methicillin‐resistant Staphylococcus aureus (MRSA) and vancomycin‐resistant enterococci 
(VRE), this was done through a point prevalence study conducted in the neonatal ICU and 
paediatric ICU (Milstone et al., 2010). A more serious situation is the emergence of gram – 
negative bacteria that are resistant to almost all available ant-microbial agents. 
Infections secondary to multi-drug-resistant gram-negative bacilli some of which include 
Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter species, have surged, 
particularly in intensive care units (ICUs), attributable to various factors including 
antimicrobial selectivity pressure, horizontal acquisition of genes that encode for antimicrobial 
resistance, contamination of the healthcare environment with bacteria and the subsequent 
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transmission to patients, and patient-to-patient spread through the handling by healthcare 
workers (Zhou et al., 2013) 
A study was conducted by (Zhou et al., 2013) to assess the attitudes and practices of clinicians 
regarding infections and MDR-GNB. This study revealed that most clinicians in institutions 
surveyed did not have adequate knowledge about the prevalence of antibiotic resistance in their 
current facility, large percentages of ICU up to about 97% of staff believed antimicrobials were 
overused in their facility. Multidrug resistance in bacteria is induced by the accumulation of 
genes, each of which codes for resistance to a specific agent, on resistance (R) plasmids or 
transposons, and/or the activation of multidrug efflux pumps, each of which may pump out 
more than one drug type. (Nikaido, 2009a) 
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Figure 1 - Conceptual Framework 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER TWO 
LITERATURE REVIEW  
 
This chapter reviews relevant literature in the field of study. Many infectious diseases are 
curable by antibiotic therapy and their use, since its first discovery in 1928, antibiotics have 
been significant to sustaining the quality of human life on earth and maintaining the existence 
of the human race (Nikaido, 2009). It is estimated that annually, about 100,000 tons of 
Antibiotics are produced by manufacturers worldwide (Nikaido, 2009)  
Antimicrobial therapy's purpose is thus to eliminate germs at the site of infection. Bacterial 
eradication is not often examined as a main objective within the confines of current clinical 
trial design guidelines (Song, 2003). This chapter reviews literature on antimicrobial resistance 
(AMR), risk factors of AMR, Multidrug resistant organisms (MDROs), management of 
MDROs and related issues to inform the study. 
 
2.1 Antimicrobial Resistance (AMR) 
Antimicrobial resistance (AMR) is an evolving global health threat such that it has caught the 
attention of global health agencies like the World Health Organization (WHO) for which 
ambitious projects have been earmarked to adequately handle it (Carroll et al., 2016) 
Antimicrobial resistance (AMR) has gradually emerged as one of the major public health issues 
of the twenty-first century, threatening the effective prevention and subsequent treatment of an 
ever-increasing variety of infections caused by bacteria, parasites, viruses, and fungi that are 
no longer susceptible to the conventional medications designed to treat them (Prestinaci et al., 
2015).  Antimicrobial medications have had a profound impact on humanity's fate as well as 
how infectious infections are treated. The great advancements in antimicrobial chemotherapy 
led to the unduly optimistic belief that infectious illnesses will soon be eradicated (Saga and 
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Yamaguchi, 2010). In actuality, though, newly and re-emerging infectious illnesses have made 
humans vulnerable to infections. Drug-resistant infections are still a significant and challenging 
issue in clinical practice (Saga & Yamaguchi, 2010).  
It is now a global health and development threat and has been declared by the World Health 
Organization as one of the top 10 threats to global public health facing humanity. Antibiotics 
are over the years, becoming increasingly ineffective as medication resistance grows over the 
world, resulting in more difficult-to-treat diseases and death (WHO, 2014). Globally, high 
resistance rates against anti-biotics have been observed for pathogens that cause common 
infections including sepsis, urinary tract infections, sexually transmitted infections and some 
forms of diarrhoea (World Health Organization., 2012). This is a strong indication that the 
world is running out of effective anti-biotics. E.g., Resistance to fluoroquinolone antibiotics, 
which are used to treat urinary tract infections, is common in E. coli. In many nations across 
the world, this medication is unsuccessful for more than half of the population. (World Health 
Organization, 2012) 
Widespread resistance in extremely variable strains of N. gonorrhoeae makes Gonorrhoea 
treatment and control challenging. Over the years, Resistance to fluoroquinolones, macrolides, 
sulphonamides, penicillin, tetracycline and early generation cephalosporins has been on the 
ascendency (World Health Organization., 2012). Unemo and Nicholas, (2012) showed that, the 
only remaining only remaining empiric monotherapy for gonorrhoea in most countries 
currently is the injectable extended-spectrum cephalosporin (ESC).  
Antimicrobial Resistance has a significant impact on the economies of nations as it renders 
patients and their care givers less productive through prolonged hospital admissions as well as 
requiring for more expensive and intensive care to help save lives (World Health Organization., 
2012). Without effective measures for preventing and treating drug-resistant infections, as well 
as enhanced access to current and future quality-assured antimicrobials, the number of 
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individuals who are unable to get treatment or who die as a result of infections may rise yearly. 
(Anderson et al., 2020) 
 
 2.2 Risk Factors of Antimicrobial Resistance (AMR) 
The main cause of antimicrobial resistance is the use of antimicrobial drugs to treat a wide 
range of infections caused by pathogens including bacteria, viruses and fungi (Selgelid & 
Jamrozik, 2020). When antimicrobials are used, some pathogens die and some survive and 
develop resistance to the particular drug used (Choffnes et al., 2010) the more frequently a 
patient uses antimicrobials the higher the chances of developing resistance to them. Implying 
that the same microbial agent may not work for that individual when required in future. If 
frequency of use is decreased, their effectiveness could be restored to some extent. (Selgelid & 
Jamrozik, 2020)  
 
2.2.1 Natural Occurrence 
AMR occurs naturally over time, often through genetic changes. Through mutation and natural 
selection, bacteria can develop defence mechanisms against antibiotics (World Health 
Organization, 2009).  Lin et al., (2015) showed that bacteria develop three fundamental 
mechanisms in the form of enzymatic degradation of antimicrobial agents, alteration of 
bacterial proteins that are targeted by antimicrobial agents such that the agents cannot function 
on the altered proteins, and changes the permeability of their membranes to antimicrobial 
agents, preventing drugs from permeating bacterial cells. E.g., some bacteria have developed 
biochemical secretions that can remove an antibiotic before it reaches its target, while others 
have developed the ability to produce enzymes to completely inactivate the antibiotic.  
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People, animals, food, plants, and the environment, i.e., water, soil, and air, all include 
antimicrobial resistant microbes. They are passed on from person to person or between humans 
and animals. (World Health Organization, 2012). For example, for Methicillin-resistant 
Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and other multidrug 
resistant Gram-negative bacteria are spread primarily from person to person by direct or 
indirect contact (Rao, 1998) 
 
2.2.2 General Risk Factors for development of Antibiotic resistance. 
The genesis and spread of antibiotic resistance are mostly owing to the overuse and often 
unneeded use of antibiotics in people and animals. Overuse, self-medication, overcrowding, 
and lapses in cleanliness or poor infection control management are all general risk factors for 
the development of resistant bacteria in hospitals and the community. (Fair & Tor, 2014) 
The WHO (2012) showed that the main drivers of antimicrobial resistance include their misuse 
and overuse, lack of access to clean water, sanitation and hygiene (WASH) for both humans 
and animals, often making them susceptible to epidemic, poor infection and disease prevention 
and control in health-care facilities and farms, insufficient access to quality and affordable 
health care, often resulting in self-medication, insufficient availability of vaccines and 
diagnostics, a lack of awareness and knowledge, and a lack of legislative enforcement as well 
as the slow development and improvement of antimicrobial. 
For resistant bacteria such as Methicillin-resistant Staphylococcus aureus (MRSA), risk factors 
for making it resistant include the use of broad-spectrum antibiotics in an attempt to effectively 
treat it, as well as the presence of decubitus ulcers and prosthetic devices (Rao, 1998).   
Martinez and Baquero, (2009) in a study showed that factors for the spread of resistance for 
vancomycin-resistant enterococci (VRE) include hospitalization for an extended period of time 
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and treatment with glycopeptides or broad-spectrum antibiotics overcrowding, tracheostomies, 
and excessive use of penicillin for viral respiratory infections are all risk factors for the 
emergence of penicillin-resistant pneumococci (PRP). 
 
2.2.3 Pharmaceutical Industry’s Decreased Interest 
A major contributing factor to the increasing occurrence of bacterial resistance is the rescinding 
interest of the pharmaceutical industry (Gould, 2012). Antibiotics regimens are typically 
administered for very limited durations making them far less profitable than drugs used to treat 
chronic ailments. Hence, pharmaceutical companies do not have much interest in investing in 
them, let alone developing new ones as existing ones become resistant (Gould, 2012).  
Dougherty and Pucci, (2011) showed that in 2004, only 1.6% of drugs in clinical development 
by the world’s 15 largest drug companies were antibiotics.  
Cumbersome regulatory procedures also contribute to the reducing interest of pharmaceutical 
companies. Regulation presents pharmaceutical companies with a paradoxical situation. In 
certain countries, regulatory bodies support the development of new antimicrobials and their 
immediate use, while simultaneously, regulatory companies in some countries enact policies 
supporting the reservation of newly approved antimicrobials (Dinkel et al., 1991). They further 
indicated that for other ailments, newly approved drugs are immediately prescribed, whereas 
for bacterial infections, newly approved antibiotics were reserved and only prescribed for 
infections that already existing antibiotics were unable to treat.  Although this regulatory policy 
helped to delay the emergence of resistant strains, it also limited returns on investments for 
pharmaceutical companies. Hence, their gradual lack of business in investing in the production 
of newer antimicrobials. 
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Such policy also totally erases competition from the pharmaceutical since it results in almost 
every company producing generic antimicrobials. This further reduces profit, because 
consumers have a wide range of different brands of the same drug to choose from (Martinez & 
Baquero, 2009). 
Requirements for approval coupled with a lack of clear trial guidelines for antibiotics, in 
particular, were found to be contributing factors (Dinkel et al., 1991). 
 
2.3 Multi-Drug Resistant Organisms (MDRO) 
Many pathogen strains have developed resistance to antimicrobial medicines throughout time, 
and some have developed resistance to a wide range of antibiotics and chemotherapeutic 
treatments. This is a case of multidrug resistance. (World Health Organization, 2012) 
Deficiencies in infection control practices, overcrowding and a lack of antimicrobial 
stewardship programs in hospitals and within the health sectors of many developing countries 
greatly increases the risk of multidrug resistant hospital acquired infections. More often than 
not, healthcare workers choice of antimicrobial agents is deficient in the guidance of adequate 
and prompt microbiological services and inappropriately based on the availability of a given 
medication, the funds of the patient or guardian and the assumed severity of illness (Enweronu-
Laryea & Newman, 2007). 
Multi-drug resistant organism (MDRO) infection is not only medically tasking on the patient’s 
immune system and body but it is also a financially strenuous on many families (World Health 
Organization., 2012). MDROs are defined as microorganisms, that are resistant to one or more 
classes of antimicrobial agents for example Methicillin resistant Staphylococcus aureus 
(MRSA) (Lederberg & Harrison, 1998). A study conducted in multiple health care facilities in 
Ghana on resistance to antimicrobial drugs by Newman et al., (2011) showed that generally the 
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prevalence of multidrug resistant organisms’ isolates was high. Specifically for four 
antimicrobial agents namely tetracycline (82%), ampicillin (76%), chloramphenicol (75%), 
and cotrimoxazole (73%) the prevalence of resistance is higher in the regional hospitals than 
in the teaching hospitals (Anderson et al., 2020). 
 
2.3.1 Mycobacterium tuberculosis 
Tuberculosis (TB) is a potentially fatal airborne infection caused by a bacterial infection. The 
condition primarily affects the lungs; however, it can affect other sections of the body in certain 
cases. (Selgelid & Jamrozik, 2020). It is often treated with a regimen of various antimicrobial 
medications administered over a period of 6 months to two years, depending on the kind and 
degree of infection. Though curable in many cases, tuberculosis (TB) is becoming increasingly 
difficult to cure because to the causative bacterium, tuberculosis. Mycobacterium tuberculosis 
has become multidrug resistant (Selgelid & Jamrozik, 2020). 
Antibiotic resistant Mycobacterium tuberculosis strains are a threat to the global efforts to 
combat Tuberculosis.  These strains cause Multidrug Resistant TB (MDR TB). MDR-TB 
necessitates longer, less effective, and significantly more expensive treatment regimens than 
non-resistant TB. Less than 60% of those who are treated for MDR/RR-TB are effectively 
cured. (WHO, 2009).  
In 2018, half a million new instances of rifampicin-resistant tuberculosis (RR-TB) were 
detected worldwide, with the majority of these cases being multi-drug resistant TB (MDR-TB). 
Rifampicin-resistant tuberculosis (RR-TB) is a kind of tuberculosis that is resistant to the two 
most potent anti-TB medications. (WHO, 2009). 
 
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2.3.2 Clostridium difficile 
Clostridium difficile a major healthcare problem in the United States, causing mild to severe 
diarrhoea. About half a million people are infected each year, resulting in approximately 15,000 
deaths. Janssen et al., (2016) showed that the infection is scarce in Sub-Saharan Africa.  
C. difficile is a bacterium that infects individuals' colons after antibiotic therapy. C. difficile 
colonization is typically prevented and C. difficile-associated illness is suppressed by the 
communities of bacteria that ordinarily exist in the gut (WHO, 2009). Antibiotics such as 
aminoglycosides, cephalosporins, penicillin, erythromycin, lincomycin, tetracyclines, 
clindamycin, and fluoroquinolones, which are routinely used in the treatment of bacterial 
infections in clinical settings, are known to be resistant to C. difficile. (WHO, 2009) 
 
2.3.3 Neisseria gonorrhea 
Gonorrhoea is a sexually transmitted infection that can cause severe reproductive 
complications if left untreated. To be able to successfully manage and control the prevalence 
of Gonorrhoea within a particular location, diagnosis and treated of infected persons must be 
done promptly (Anderson et al., 2019) Ophthalmia neonatorum is a suppurative conjunctivitis 
in neonates in which the Gram stain of an eye swab shows at least one polymorphonuclear 
leukocyte per high-power field. The two most common causes of the disorder are Neisseria 
gonorrhoea and Chlamydia trachomatis.(Abazi et al., 2011) 
Gonococcal ophthalmia neonatorum (GCON) is significant in terms of public health since it 
can cause blindness quickly. The prevalence of maternal gonococcal infection is what 
determines the frequency of GCON. In most developed nations, the prevalence of gonorrhoea 
in pregnant women is less than 1%; in underdeveloped countries, rates range from 3% to 15%, 
with penicillinase-producing Neisseria gonorrhoeae strains accounting for more than half of 
the cases (PPNG).(Laga et al., 1989) 
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Antimicrobial susceptibility patterns in gonococci are constantly changing, and they can difer
 significantly between and within geographic regions. Healthcare practitioners must stay on   
the lookout for changes to treatment recommendations in their areas. In 2003, the Gonococcal
 Isolate Surveillance Project found that 16.4% of gonococcal isolates tested were resistant to 
penicillin, tetracyclines, or both in the United States. At the moment, spectinomycin               
resistance is uncommon. Although a few isolates with reduced susceptibility to cefixime were 
discovered in 2003, there has been no evidence of ceftriaxone resistance.(Woods, 2005) 
In order to prevent gonorrhoea, infected people and their sexual partners must be identified and 
treated as soon as possible. The CDC recently changed its treatment guidelines for gonorrhoea 
to limit the establishment of medication resistance as some treatments become less effective 
(WHO, 2009). 
Gonorrhoea is a worldwide issue. Although action in the United States alone is unlikely to 
prevent the development of resistance, early diagnosis and good treatment of patients and their 
partners may help to delay the spread of resistance (Martinez and Baquero, 2009). 
Widespread resistance in highly variable strains of N. gonorrhoeae has made the disease 
difficult to manage. Over the years, there has been an emergence of resistance to several 
antimicrobials in Neisseria gonorrhoea, making the disease difficult to treat (World Health 
Organization, 2009)  they include sulphonamides, penicillin, tetracyclines, macrolides, 
fluoroquinolones, and early generation cephalosporins (Kon et al., 2016).  
In many countries, the injectable extended-spectrum cephalosporin (ESC) ceftriaxone is now 
the sole empiric treatment for gonorrhoea (Anderson et al., 2019).  
 
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2.3.4 Methicillin-resistant Staphylococcus aureus (MRSA) 
Staphylococcus aureus bacteria are found in the skin flora and are a major source of illness in 
both the community and health-care settings (Hemeg et al., 2019). MRSA infection is caused 
by a type of staphylococcus bacteria that has become resistant to many of the antibiotics used 
to treat common staphylococcus infections. It more often than not transmitted by contact with 
the skin of an infected person. RSA is not only resistant to Methicillin but also to penicillin, 
oxacillin, cefazolin, daptomycin amoxicillin and other common antibiotics collectively known 
as cephalosporins (Kon et al., 2016). 
Over the past four decades, methicillin-resistant Staphylococcus aureus (MRSA), has evolved 
from a controllable infection within small communities of people into a serious public health 
concern. MRSA is one of the most common hospital-acquired infections. Unfortunately, 
resistant strains keep increasing within local communities, causing severe infections (Kon et 
al., 2016). Studies show that people with methicillin-resistant Staphylococcus aureus (MRSA) 
infections are 64% more likely to die than people with drug-sensitive staphylococcus infections 
(Hemeg et al., 2019). 
 
2.3.5 Vancomycin-resistant Enterococci (VRE) 
Enterococci are bacteria that are commonly found colonizing the human digestive tract and 
female genital tract. VRE infections tend to occur in people who are in hospitals or other health 
care facilities (World Health Organization, 2009). They also often occur in people who are 
susceptible to infection due to their peculiar medications or the presence of certain catheters or 
other devices. Health care providers commonly use the antibiotic vancomycin to treat 
Enterococci infections, unfortunately, VRE are resistant to the drug (Selgelid & Jamrozik, 
2020) 
 
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2.3.6 Carbapenem-resistant Enterobacteriaceae (CRE) 
CRE is a family of highly resistant bacteria, including Klebsiella species and Escherichia coli 
(E. coli). CRE primarily affect patients on admission in hospitals, especially those who have 
compromised immune systems (Anderson et al., 2019) The bacteria can enter the body through 
medical devices like ventilators or catheters (Andersen, 2019). Some CRE infections are 
resistant to most available antibiotics and can be life-threatening (WHO, 2009). Multiple 
structural adaptations and antibiotic degradation enzymes, such as expanded spectrum beta-
lactamases (ESBL), AmpC cephalosporinases, and carbapenemases, have resulted in Gram-
negative bacteria developing the broadest range of resistance. Carbapenemase-producing 
Enterobacteriaceae (CRE) are especially dangerous bacteria.(Smith & Kendall, 2021) 
According to a study conducted by Birgy et al., (2012) Nosocomial outbreaks of 
carbapenemase-producing Entero-bacteriaceae infection have been described, notably in 
Greece as well as certain subspecies of this bacteria have also been isolated in water sources in 
New Delhi.  
 
2.4 MDRO Infections in Neonatal ICU 
The non-specific clinical appearance of neonatal illness is a major obstacle to correctly 
diagnosing severe bacterial infection in this population (Russell & Kumar, 2015). 
Distinguishing bacterial infection, viral infection or respiratory failure can be challenging 
bacterial infections are also known to lead to rapid deterioration and patient demise, and undue 
delays in diagnosis and management tend to have lethal consequences (Osvald & Prentice, 
2014). Thus, patients tend to be treated routinely with first line empiric broad spectrum 
antibiotics (Gezmu et al., 2021). 
 
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2.4.1 Blood Stream Infections (BSI) 
Bloodstream infections are infectious disease defined by the presence of bacterial or fungal 
microorganisms in the bloodstream that elicit or have elicited an inflammatory response 
characterized by alterations of clinical, laboratory and hemodynamic parameters (Viscoli, 
2016). Fascinatingly the pattern of pathogens causing BSI have changed over the years with 
rising numbers of gram negative and fungal infections, nevertheless the last few decades have 
witnessed an upsurge in resistance to antibiotics especially for gram negative rods. The 
diagnosis of a bloodstream infection is based on obtaining one or more positive cultures, for 
common skin contaminants two positive cultures are required to ascribe etiology of BSI to the 
organism in question (Viscoli, 2016) 
Bloodstream infections (BSI) are a significant cause of illness and death and require early and 
suitable empiric therapy. In the information age the management of BSI are complicated by 
antimicrobial resistant patterns that are emerging in the communities. Most especially in 
resource deficient countries where inadequate support for culture and antimicrobial 
surveillance exists makes management even more (Opintan & Newman, 2017).  
Studies conducted on neonatal infections such as Zou et al., (2021) have shown that is a serious 
emerging challenge among hospitalized neonates. Gram-negative bacteria gradually became 
the main pathogenic bacteria of neonatal sepsis, with E. coli and K. pneumoniae contributing 
the largest proportion. Moreover, late-onset sepsis and antibiotic exposure were significantly 
associated with MDR infection 
 
2.4.2 AMR in Nosocomial Infections in Infants and Neonates 
Neonates by design do not have optimally functioning immune capacity. They spend the first 
few years developing their immunity both passively and actively through breastfeeding, 
infection and reinfection. Nevertheless, a study conducted with data from Eunice Kennedy 
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Shriver National Institute of Child health and human development found that commonly 
occurring infections in the NICU are becoming increasingly difficult to treat (Stoll et al., 2010). 
For instance, Neonatal sepsis has such substantial morbidity and mortality and is challenging 
to diagnose on initial presentation and as such most neonates with sepsis are subjected to 
empirical therapy pending culture results when sepsis can be rules out. The consequent overuse 
of antibiotics aids in the development of antibiotic resistant organisms (ARO) (Ballot et al., 
2012). Work done by Laxminarayan et al., (2013)  showed that approximately 60,000 neonates 
die from Antibiotic resistant neonatal infections in India.  
Klebsiella pneumoniae are common intestinal bacteria that can cause life-threatening 
infections. Resistance in K. pneumoniae to carbapenem antibiotics, which is currently the last 
resort treatment for the infection is spread to many parts of the world.   Colistin is the only last 
resort treatment for life-threatening infections caused by carbapenem resistant 
Enterobacteriaceae, e.g., E. coli, Klebsiella, etc. Other bacteria resistant to colistin have also 
been detected in several countries and regions, causing infections for which there is no effective 
antibiotic treatment, currently. 
 
2.5 Management of MDROs 
Antibiotics have played, and continue to play the extremely essential role of reducing morbidity 
and mortality from infectious diseases. However, indiscriminate use and unrestricted access, 
coupled with inadequate knowledge of user protocols by healthcare workers are contributing 
to the emergence of bacterial resistance (WHO, 2014) 
Many researchers have suggested that antimicrobial cycling may slow the evolution and spread 
of resistant bacteria strains and even multiply them.  Selgelid and Jamrozik, (2020) defined 
Multidrug Resistance as a system of empiric use of two or more classes of antibiotics is 
alternated over a time scale of months to years, Hence, in case resistance to a particular drug 
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reaches its peak in a hospital’s ward, it would be switched scheduled classes of antibiotics, thus 
making most resistant bacteria strains susceptible to the new therapy. 
Studies have also shown that, fluctuating patterns of antimicrobial use may reduce the rate at 
which drug-sensitive strains can acquire resistance to single or multiple antibiotics. In addition 
to the intuitive appeal of these arguments, more than two decades of experience have shown 
that a one-time formulary shift can effectively control a hospital epidemic of antibiotic-resistant 
strains in a rotation through a series of alternative drugs (Selgelid and Jamrozik, 2020)  
Continued increase in AMR & MDR worldwide suggests the need for empirical therapy be 
guided by local susceptibility to enhance improved therapeutic outcomes. (Obeng-Nkrumah 
et al., 2016). Patel and Saiman, (2010) showed that management of requires a more measured 
approached involving multiple disciplines, judicious use of antimicrobial agents and effective 
hand hygiene practices.  
Recent developments in the genomic mapping of many bacteria and advances in combinatorial 
chemistry promise to usher in a new era of antibiotic development. While this may result in 
our regaining some of the ground lost to resistant bacteria, there will still be a continuing need 
to minimise the spread of antibiotic resistance through the rational use of antibiotic agents and 
stringent infection control practice (Ahmad et al., 2019).  
 
2.6 Conclusion  
Antibiotics have played a pivotal role in saving the human race and achieving major milestone 
victories in the practice of Medicine and Surgery throughout the 18th and 19th centuries to 
present day. With the aid of Antibiotics, microbial infections and opportunistic infections have 
been treated saving countless lives even in the most delicate cases such as disseminated 
opportunistic infections in patients receiving chemotherapy, patients with Uncontrolled 
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Diabetes, End-stage renal disease and HIV-AIDS. The treatment of opportunistic infections in 
patients’ complex cases such as patients recovering from organ transplants, major surgeries 
and joint replacements cannot be over emphasized. A review of existing literature in this study 
revealed that unfortunately, the rapid worldwide emergence of resistance in the late 19th century 
and its persistence through-out the 20th century into n the 21st century has gradually made 
microbial infections a massive threat to the future of the practice of medicine and even to the 
human race at large, if proper precaution is not taken is not taken.  The rate of development of 
AMR is leading to a future that is set-up for surges in drug resistant epidemics destined to set 
the world back several decades. 
The surge in antimicrobial resistance has through empirical studies by researchers and 
scientists globally, been mainly attributed to the misuse and over use of antibiotics and the lack 
of new drug developments by the pharmaceutical industry due to reduced interests borne out 
of a reduction in the economic returns as well as cumbersome industry regulations. 
Epidemiological studies have demonstrated a direct relationship between antimicrobial use and 
the emergence and dissemination of resistant bacteria strains. In many other countries, 
antibiotics are unregulated and available over the counter without a prescription. Hence, they 
are easily accessible to the lay person, plentiful, and cheap, resulting in misuse and overuse 
and eventually, resistance. Even in countries where antibiotics are regulated, one will find that 
most common antibiotics are readily available for purchase online. 
 In bacteria, genes can be inherited from relatives or can be acquired from nonrelatives on 
mobile genetic elements such as plasmids. This horizontal gene transfer (HGT) can allow 
antibiotic resistance to be transferred among different species of bacteria. Resistance can also 
occur spontaneously through mutation. Antibiotics remove drug-sensitive competitors, leaving 
resistant bacteria behind to reproduce as a result of natural selection. Despite warnings 
regarding overuse, antibiotics are overprescribed worldwide.  
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The effects of AMR to the economies of nations are significant. In addition to death and 
disability, prolonged illness results in longer hospital stays, that require more expensive 
medicines, posing financial challenges for those impacted and for governments as they fund 
their health sectors. (WHO, 2012) Without effective antimicrobials, the success of modern 
medicine in treating infections, including during major surgery and cancer chemotherapy, 
would be at an increased risk (WHO, 2012) 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER THREE 
RESEARCH METHODS 
3.1 Introduction 
This chapter discusses the methodology employed in carrying out the study. The Chapter 
focuses on the Area of Study, Research Design, Population of Study, Data Collection and Data 
collection Techniques are discussed into detail. The chapter concludes with ethical issues 
considered during the study. 
 
3.2 Study Approach 
A mixed method study approach was employed for conducting this study. Quantitative and 
qualitative methods were applied for data collection. The approach employed involved is 
pragmatism as stated by Grover, (2015) which mainly focusses on what works. Grover, (2015) 
stated that where theories fail pragmatism begins with techniques that may be traditional or 
self-invented all leading to the delivery of valid results.  
 
3.2.1 Study Design 
A retrospective chart review (RCR), also known as a medical record review, is a research 
design for which pre-recorded, patient-centered data is used to answer one or more research 
questions (Matt & Matthew, 2013). The quantitative aspect of this study is a retrospective 
Medical Record review of blood cultures from NICU of the Greater Accra Regional Hospital 
over a one-year period beginning from 1st June 2020 through to 31st May 2021.  
A descriptive research design allows the incorporation of a several research methods in one 
study to facilitate the successful investigation of more than one variable, such that information 
regarding the study is collected without making changes to the environment or area of study 
(Kothari, 2008). It is useful when not much is known yet about the topic or area of study and 
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it reveals an understanding of how, when and how something happens. These answers enable 
further studies to be carried out to determine why it happens (Kothari, 2008).  
Being a mixed method study, it incorporated both qualitative and quantitative research methods 
which involved the collection and analysis of both qualitative and quantitative data. The 
justification for blending methodologies is that neither quantitative nor qualitative methods are 
suitable to represent the patterns and subtleties of a problem, such as the complicated issue of 
multidrug resistant organism infection (Ivankova, 2002). Other well-known and researched 
rationales or benefits for doing a mixed methods study includes the ease of which this method 
allows corroboration of both quantitative and qualitative data in leading to an increase 
in the validity of the study.  
Completeness is also an added benefit which aims at combining research methodologies to 
bring about a more comprehensive and thorough view of the phenomenon under inquiry 
(Doyle et al., 2009) 
 
3.3 Area of Study  
Ghana currently has 162 district hospitals, 10 regional hospitals and five teaching hospitals in 
the public sector. District hospitals serve as the first referral points for other peripheral facilities 
whereas regional hospitals for secondary level referral points (Nsiah-Asare, 2017) 
The study was conducted at the Greater Accra Regional Hospital (GARH), formerly known as 
the Ridge Hospital, situated at North Ridge, within the Osu Clottey Sub-Metro Municipality of 
the Greater Accra Region (GAR).  
GARH occupies a total land area of about 15.65 acres. As the regional hospital for the GAR, 
its catchment area is the whole of the Greater Accra Region, with an estimated population of 
over 4,671,363. People living in nearby communities in adjoining regions also seek health care 
services from the GARH. 
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Data from Greater Accra Regional Hospital (GARH) records show that the NICU admits 
approximately 800 - 900 neonates, every year. The units is managed by the Pediatric 
department of the GARH. The NICU consists of 2 parts a Babies unit. Each part can 
accommodate 30 neonates each thus making a grand total of 60 patients when unit is at full 
capacity  
 
3.4 Study Variables  
The variables which formed the main focus of this study are blood stream infections and 
multidrug resistant organisms. Multidrug-resistance in this study was defined as isolates that 
were resistant to at least one agent in three or more antibiotic classes (Agyepong et al., 2018). 
Other factors such as age, sex, payment method, patient diagnosis, days on admission, First 
line antibiotics prescribed and outcome of management served as independent variables.  
 
3.5 Population of the Study  
The study population comprised of blood culture samples of patients in the Neonatal Intensive 
Care Units of the Greater Accra Regional Hospital.  
 
 3.6 Inclusion/Exclusion criteria  
Patients admitted to the NICU with blood stream infections are eligible for this study following 
the criteria  
• Microbiology samples taken on admission in GARH of both patients who were 
primarily admitted and referred from other facilities  
Exclusion criteria  
• Patients with Covid-19 infection. 
 
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3.7 Sample Size patient records 
The sample size was calculated with reference to a study conducted by (Agyepong et al., 2018) 
on multidrug resistant gram-negative bacteria infection showed the prevalence within the age 
group <10 years was 24% in Komfo Anokye Teaching Hospital (KATH).  
𝑍2 𝛼𝑃(1−𝑃) 
1−
≈ 𝑛 = 2 2    formula sample size calculation.  𝑀𝑂𝐸
n = estimated sample size, 
Z = the z-score that corresponds with 95% confidence interval (1.96), 
p = estimated proportion of ITN usage (24%) = 0.24 
q = estimated proportion of households who do not use the ITN (1 – 0.24 = 0.76), 
MOE = margin of error set at 5% (0.05). 
n = 280.283 
n = 281 participants  
 
3.7.1 Selection of participants for the Qualitative study 
The number of health professionals to be recruited depended on achievement of saturation, 
level of availability from their work schedules as well as time limitations. The expectation at 
the facility in question is to conduct 10 in-depth interviews with Nurses in the NICU, lab 
technicians, NICU nurses, NICU doctors and parents of patients on admission in NICU. There 
was also one focused group discussions with 6-8 lab technicians and/or neonatal nurses at 
GARH microbiology lab. 
 
3.7.2 Sampling Technique 
Simple random sampling technique was used to identify the month to begin with within the 12-
month period of retrospective study. This affords equal chance of each month being selected 
and thus controlling for inherent biases that may be in the data.  
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Researchers can generalize their findings to the population from which the sample was drawn
by using random selection to account for sampling bias (Matt & Matthew, 2013).  
The sampling used for the quantitative study data was a Convenience sampling technique when 
selecting the individual members of the sample per month this was according to chronology of 
how the patient samples have been taken and recorded in these specialized neonatal units. 
Convenience sampling is a type of nonprobability in which members of the target population 
who meet certain practical criteria (Etikan et al., 2015). This method allowed the researcher to 
collect thorough data not leaving out any important patient data from the study start date to the 
study end date. The population's elements were chosen in a chronological fashion as per 
month, which means that each medical record has were duly collected and codded as 
required.  
 
3.8 Data Collection Techniques 
Based on the qualitative and quantitative aspects of the study. The quantitative study design 
was a medical desk-based review of laboratory data over the period of one year. The qualitative 
aspect involves in-depth interviews and focused group discussions (FGDs). 
In the quantitative approach an electronic data extractions form, was used to extract data on 
blood cultures that were conducted at the GARH microbiology lab of patients on admission in 
the NICU over the one-year period in question. Only neonates i.e., babies aged 0-28 days of 
life were considered as NICU patients.  
Qualitative data collection involved interviewing stakeholders of the Greater Accra Regional 
Hospital, comprising Doctors, Nurses at the NICU, Laboratory Technicians as well as some 
Parents of the patients. 
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Focus group discussions was carried out to gather first hand qualitative data from Laboratory 
Technicians. One Focused group discussion comprising 6-8 Laboratory Technicians and or 
neonatal nurses was conducted.   
 
3.8.1 Extraction of Research Data from Records  
This research adopted a retrospective medical records review which employed the use of 
research data extraction forms to gather information from the hospital’s laboratory records on 
microbiological specimen cultures conducted during the period under study. 
Microbiological specimen culture reports of all with MDR Blood stream infection in the NICU 
patients was retrieved from the laboratory data on all clinical cultures from the NICU. Blood 
culture results from neonates born in the hospital and secondarily referred was also included.  
 
3.8.2 Data Collection Instruments 
A Data Extraction form was used in collecting laboratory data. On the following demographic 
and health data of the study population: age, sex/gender, date of admission, diagnoses, isolated 
organisms, resistance profile, year of infection, date of first culture, days on admission and 
outcome of management.  
The qualitative aspect involved the use of an interview guide whereas a semi-structured 
discussion guide was used for the focused group discussions. 
 
3.9 Data Analysis  
Data collected was analyzed using with descriptive statistics using STATA/SE version 16 for 
windows. Continuous variables such as age at diagnosis and days on admission were 
summarized using univariate analysis as means and standard deviations. Categorical variables 
such as sex, patient diagnosis, first-line antibiotics prescribed and outcome of management 
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were summarized in proportions. Bivariate analysis was done using cross tabulations of first 
line antibiotics with specific antimicrobial sensitivity. All analyses were considered 
statistically significant at probability value less than 0.05. 
 
 Data collected was sorted and queued into Microsoft office excel 2019 for further 
categorization and coding to ease subsequent analysis that was done using Stata version 16 
processing software. Analyzed data, together with interview findings, together forming 
quantitative and qualitative data, was compared with the secondary data extracted to answer 
the proposed research questions.  
 
3.10 Quality Control 
The assistance of a well-trained data collector at the GARH and IT Officer to provide access 
to patient records was employed in the collection of data, after which it was reviewed 
periodically by the principal investigator before final analysis is performed. 
 
3.10.1 Good Clinical Practice  
The principal investigator is good clinical practice (GCP) certified professional. 
3.10.2 Monitoring  
Data collected by the team was queued into Google spread sheets for remote access and review 
prior to finally being arranged into Microsoft Office Excel 2019.  The data collected was 
meticulously reviewed by the Principal Investigator of this study for continuous monitoring 
purposes.  
3.10.3 Data Management 
To assure good quality of data, the obtained data was entered twice in the data management 
system by the research assistant and principal investigator. 
 
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3.11 Ethical Consideration  
3.11.1 Informed consent  
The quantitative aspect of the study involves the review of collected laboratory investigations 
ran on patients who had parental consent for the procedure and assent in cases applicable. The 
qualitative aspect involves the provision of a clearly worded informed consent sheet which was 
provided to literate participants and administered to non-literate participants to acquire the 
consent of all participating. Judging by the nature of individuals participating in the qualitative 
interviews and focused group discussions, consideration was given for the time spent away 
from work to avoid decrease in productivity. 
 
3.11.2 Criteria for stopping and discontinuing Research 
Individuals are at liberty to refuse, discontinue or withdraw their consent at any given time 
without consequence. 
 
3.11.3 Ethical Approval 
Ethical Approval was sought from the Ghana Health Service Ethics Review Committee. No 
study procedures took place prior to receiving approval.  
 
3.11.4 Safety Considerations 
There is no increased risk of the study in data extraction process as it is mainly about collecting 
and organizing data from electronic laboratory records. To ensure personal patient records are 
kept safe and secure. The study relied only on de-identified data. Every study subject was given 
a specific and completely anonymous study identification number.  There was no disclosure of 
participants’ information to others. 
 
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3.11.5 Covid Safety Measures  
Interviews and focused group discussions which involve face-to-face and in person interactions 
was organized with all Covid-19 safety protocols observed. Including but not limited to 
appropriate social distancing measure, wearing of facemasks and using alcohol hand rub.  
  
 
 
 
 
  
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CHAPTER FOUR 
PRESENTATION OF RESULTS 
This Chapter outlines results of the study following analysis of data collected. The data from 
this study are both qualitative and quantitative in nature. This chapter gives the general 
overview of data collected during research process. 
 
4.1 NICU Quantitative Results 
4.1.1 Demographic Characteristics of NICU Patient Samples  
 
Majority of the 195 NICU blood culture samples with MDROs sampled were of male patients 
comprising one hundred and seven of 195 blood culture samples representing 54.87%. The 
females were 88 in number representing 45.13% as represented in table-3 below  
 
Table 1: Sex distribution of NICU patients 
 
SEX        Frequency  Percent 
Female 88 45.13 
Male 107 54.87 
Total 195 100 
 
 
 
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Sex Distribution of NICU Patients   
120 107
100 88
80
60 54.87
45.13
40
20
0
Female Male
Freq. Percent
 
 
Figure 2 : Sex Distribution of NICU Patients 
 
The age at diagnosis in days is negatively skewed as per the gaussian distribution and thus the 
appropriate summary statistic is the Median. The median age at diagnosis and admission is the 
first day of life. The amount of days life for admission ranged between (0-10) days as shown 
in figure 2 below. The mean number of days 1.0 95% CI (0.8-1.3) 
 
 
 
Figure 3 : Age of diagnosis and admission in days of NICU patients 
 
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4.2 Diagnosis Associated With MDRO 
The diagnosis most commonly associated with neonates with MDROs was prematurity 
diagnosed (33.3%) of the time followed by neonatal sepsis and acute respiratory distress 
accounting for (23.6%) and 16.4% respectively. Meconium Aspiration syndrome was the fifth 
most common diagnosis associated with NICU admissions who had Multidrug resistant 
organism infection contributing a total of 9.7% of all admissions with MDROIs 
 
120
100
80
60
40
20
0
Transie
Meconi Hypoxic
nt
Acute um Severe Ischea Neonat
Mild modera Modera bronch Tachyp
Premat Neonat Respirat Aspirati Birth mic Hydroc al
birth te birth te birth opneu noea of
urity al sepsis ory on Asphyxi Enceph ephalus juandic
ashyxia ashyxia ashyxia monia the
Distress Syndro a alopath e
newbor
me y
n
Percent 33.3333 23.5897 16.4103 9.74359 5.64103 4.10256 2.05128 1.53846 1.02564 1.02564 0.51282 0.51282 0.51282
Freq. 65 46 32 19 11 8 4 3 2 2 1 1 1
Freq. Percent
 
 
Figure 4: Diagnosis associated with MDRO 
 
 
 
 
 
 
 
 
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4.3 Prevalence of MDRO Infection in the NICU 
Out of all records reviewed, a total of 1,043 blood samples were taken and processed 
successfully for blood cultures in the NICU. One hundred and ninety-five of them cultured 
multidrug resistant organisms constituting about 18.7%. As indicated in Figure 4 below. 
 
 
Multidrug resistant 
Organism,  (195)
Non multidrug 
resistant Organism, 
(848)  
 
 Figure 5: prevalence of MDRO in the NICU at GARH 
 
4.4  Antibiotics Prescribed 
Ampicillin and Gentamicin were the most often given antibiotics combination in the NICU, 
accounting for 58.9 percent of all prescriptions for patients with blood cultures indicating 
MDRO infections. The second and third most common were Ampicillin and Cefotaxime, and 
Amikacin and Flucloxacillin accounting for 25.6% and 9.7% respectively. Thus, the single 
most prescribe antibiotic for patient in the NICU within the study period June 2020 to May 
2021 was Ampicillin.  Ampicillin formed part of about 84.5% of all initial first line antibiotics 
prescribed for patients with MDRO infections. 
 
 
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140
120 115
100
80
58.97
60 50
40
25.64
19
20 9.74
2 1.03 2 1.03 1 0.51
0
Ampicillin Ampicillin Amikacin Meronem Cefotaxime Amikacin
Gentamicin Cefotaxime Flucloxacillin Gentamicin
 
 
Figure 6: First line antibiotics prescribed 
 
 
Table 2: First-line Antibiotics Prescribed 
 
FIRST LINE ANTIBIOTIC PRESCRIBED Frequency Percent 
Ampicillin Gentamicin 115 58.97 
Ampicillin Cefotaxime 50 25.64 
Amikacin Flucloxacillin 19 9.74 
Meronem 2 1.03 
Cefotaxime Gentamicin 2 1.03 
Amikacin 1 0.51 
Amikacin Tobramycin eye drops 1 0.51 
Cefotaxime Flucloxacillin 1 0.51 
Ciprofloxacin Tobramycin eye drops 1 0.51 
Tobramycin eye drops 1 0.51 
X-Penicillin Ampicillin 1 0.51 
X-Penicillin Gentamicin 1 0.51 
   
Total 195 100 
 
 
4.5 Morbidity and Mortality Associated with MDROS in the NICU 
The case fatality rate associated with patients in the NICU infected with Multidrug resistant 
organisms at GARH was found to be about (51/195) 26.2 % over the study time period  
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(1st June 2020- 31st May 2021) as indicated in figure 6 below. The burden of morbidity 
associated with patients admitted to the NICU with MDRO over the study period was noted to 
be 18.7% as shown in figure 4 above. 
Deceased (26.2%)
Discharged (73.8%)
 
 
 
Figure 7: Outcome of management 
 
The median duration of stay in the NICU for patient with MDRO Infection was 11 days 
however the days on admission ranged between (73-1) days as indicated in Figure 7 below. 
The Mean number of days spent on admission for patients diagnosed with MDRO infections 
is 14.6 95% CI (12.7 -16.4) 
 
 
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Figure 8 - Number of days on admission 
 
4.6 Organisms Isolated 
The most commonly isolated specific organism causing MDRO infection in the MICU of 
GARH was Staphylococcus aureus contributing 40 samples (20.51%) out of 195 MDRO 
cultured as shown in Table 6 below. The predominantly isolated pathogenic organism species 
was Klebsiella spp 31.2% (61/195) and Staphylococcus aureus 20.5% (40/195). Additionally, 
38 coagulase negative Staphylococci such as Staphylococcus hemolyticus and Staphylococcus 
epidermidis also contributed 10.8% and 5.1% respectively. Gram negative rods such as 
Klebsiella spp, E Coli, Klebsiella Pneumoniae, Pseudomonas spp and Pseudomonas aeruginosa 
contributed a total of (83/195) 42.6% of all MDROs cultured in the NICU over the period of 
1st June 2020 to 31st May 2021.  
Among the Klebsiella spp resistance to ampicillin, cefotaxime and gentamicin was 72.1%, 
39.3% and 52.4%, respectively, while carbapenem resistance was 10.4%. Mortality among 
neonates with MDR BSI was 26.2% (51/195).  
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Table 3 : Organisms Isolated 
 
ORGANISM(S) ISOLATED Freq. Percent 
Staph aureus 40 20.51 
Klebsiella spp 32 16.41 
Klebsiella pneumoniae 25 12.82 
Staph haemolyticus 21 10.77 
E. Coli 11 5.64 
Staph epidermidis 10 5.13 
Pseudomonas aeruginosa 7 3.59 
Enterobacter spp 5 2.56 
Pseudomonas spp 4 2.05 
Enterobacta claocae 3 1.54 
Klebsiella oxytoca 3 1.54 
Citrobacter spp 3 1.54 
Staph capitis 3 1.54 
Aerococcus spp 2 1.03 
Empedobacter brevis 2 1.03 
Acinetobacter baumannii 2 1.03 
Enteroccocus faecalis 2 1.03 
Micrococcus sp 2 1.03 
Neisseria spp 2 1.03 
Staphylococcus capitis 2 1.03 
Acinetobacter Iwoffi 1 0.51 
Enteroccocus spp 1 0.51 
Enterococcus faecium 1 0.51 
Klebsiella aerogenes 1 0.51 
Kluyvera ascorbata 1 0.51 
Pantonea spp 1 0.51 
Staph horminis 1 0.51 
Staph intermedius 1 0.51 
Staph saprophyticus 1 0.51 
Staphylococcus intermedius 1 0.51 
Streptococcus group B 1 0.51 
Streptococcus pneumoniae 1 0.51 
Total 195 100 
 
 
 
 
 
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4.7 Antimicrobial Susceptibility and Resistance Profile of NICU Blood Cultures 
100
93.5
90 92.1 90.1 89.1
82.7 84.9
86.1
80
75.9
70 71.4
67.3
63.6
60 62.8 61.7
50 49.6 51.7
43.3
40
36.4 37.2
31.3 33.330
25.7 24.1
20
10 11.9
13.4 13.9
9.9 10.9
5.4 6.6 2.9 5 4.8 50 1.3 1.7 0.8 0 1.3 0 0 0 1.6 0 0
Intermediate Resisitant Sensitive
 
 
 
Figure 9 : Resistance and Susceptibility Profile of Most Used Antibiotics [N > 55] 
 
The above graph in Figure 8 shows the antibiotic susceptibility and resistance profiles of the 
most frequently used antibiotics or microbial susceptibility testing. Amikacin showed the 
overall lowest percentage resistance at 6.6% and the highest percentage susceptibility at 92.1%. 
In the NICU however, Amikacin was used only used as a first line medication 9.8% of the time.  
 
The antibiotics with the lowest percentage sensitivities were Cefuroxime, Cefotaxime, 
Penicillin, Ampicillin and Ceftriaxone at 4.8%, 9.9%, 10.9%, 13.4% and 13.9%, respectively. 
Ciprofloxacin and Vancomycin showed the second and third best susceptibility at 82.7% and 
49.6% respectively. 
Gentamicin which formed part of the most prescribed first line antimicrobial combination was 
noted to have a percentage resistance point of 67.3% and a percentage susceptibility point of 
31.3%. 
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The figure below shows a representation of all antibiotics used during the study period on 
organisms isolated in decreasing order of resistance and increasing order of susceptibility. The 
figure also shows the variations noted in intermediate susceptibility and resistance amongst 
isolates.  
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120.00
100.00
80.00
60.00
40.00
Intermediate
Resistant
20.00
Sensitive
0.00
Axis Title
 
  
Figure 10 Percentage resistance and susceptibility of antimicrobials used in susceptibility testing
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Axis Title
Amoxicillin
Colistin
Cefotaxime/Clavulanate (ESBL)
Pefloxacin
Cefuroxime
Cefotaxime
Augmentin
Penicillin
Ampicillin
Oxacillin
Ceftriaxone
Cefoxitin
Aztreonam
Meropenem
Pipercillin
Ceftazidime
Cefepime
Gentamicin
Imipenem
Cloxacilin
Cotrimoxazole
Chloramphenicol
Tetracycline
Clindamycin
Erythomycin
Nalidixic acid
Vancomycin
Mupirocin
Tigercycline
Teicoplanin
Nitrofurantoin
Norfloxacin
Ciprofloxacin
Ertapenem
Amikacin
Daptomycin
Linezolid
Levofloxacin
Moxifloacin
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Table 4: Cross tabulation of Most Frequently Prescribed Firstline Antimicrobials 
against Gentamicin Susceptibility 
 
CROSSTABULATION OF MOST FREQUENTLY PRESCIBED FIRSTLINE ANTIMICROBIALS 
AGAINST GENTAMICIN SUCEPTIBILITY 
  Gentamicin 
- I R S 
FIRST LINE ANTIBIOTIC Amikacin 0 0 1 0 
PRESCRIBED Amikacin 5 0 8 2 
Flucloxacillin 
Amikacin 0 0 1 0 
Tobramycin eye drops 
Ampicillin 11 1 22 8 
Cefotaxime 
Ampicillin 16 1 46 31 
Gentamicin 
Cefotaxime 0 0 1 0 
Flucloxacillin 
Cefotaxime  0 0 1 0 
Gentamicin 
Ciprofloxacin 1 0 0 0 
Tobramycin eye drops 
Gentamycin 0 0 0 1 
Cefotaxime 
Meropenem 0 0 2 0 
Tobramycin eye drops 0 0 1 0 
X-Penicillin 1 0 0 0 
Ampicillin 
X-Penicillin 0 0 1 0 
Gentamicin 
Total 34 2 84 42 
 
 
Gentamicin susceptibility cross tabulated against first line antibiotic prescribed revealed that 
46 (49%) out of the 94 times that the antibiotic combination of ampicillin gentamicin was 
prescribed as first line the micro-organism isolated was resistant to gentamicin. The 
antimicrobial has intermediate susceptibility to gentamicin on one occasion when prescribed 
as first line in combination with ampicillin. Gentamicin sensitivity percentage when prescribed 
was 34%. The study data revealed that 16 (17%) out of 94 times gentamicin was used as first 
line antibiotic in the NICU, antimicrobial sensitivity testing for Gentamicin was not conducted 
on the isolated organism. 
 
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Gentamicin was most frequently prescribed in combination with Ampicillin as first line 
antibiotic in the NICU. However, it was also prescribed in combination with Cefotaxime and 
X-penicillin.  
 
Table 5: Crosstabulation of Most Frequently Prescribed First Antimicrobials Against 
Ampicillin Susceptibility 
 
CROSSTABULATION OF MOST FREQUENTLY PRESCIBED FIRST ANIT MICROBIALS 
AGAINST AMPICILLIN SUCEPTIBILITY 
  Ampicillin 
- I R S 
FIRST LINE ANTIBIOTIC Amikacin 0 0 1 0 
PRESCRIBED Amikacin 5 1 8 1 
Flucloxacillin 
Amikacin 0 0 1 0 
Tobramycin eye drops 
Ampicillin 10 0 26 6 
Cefotaxime 
Ampicillin 27 1 57 9 
Gentamicin 
Cefotaxime 0 0 1 0 
Flucloxacillin 
Cefotaxime  0 0 1 0 
Gentamicin 
Ciprofloxacin 0 0 1 0 
Tobramycin eye drops 
Gentamycin 0 0 1 0 
Cefotaxime 
Meropenem 1 0 1 0 
Tobramycin eye drops 0 0 1 0 
X-Penicillin 0 0 1 0 
Ampicillin 
X-Penicillin 0 0 1 0 
Gentamicin 
Total 43 2 101 16 
 
 
Ampicillin susceptibility cross tabulated against first line antibiotic prescribed revealed that 57 
(61%) out of the 94 times that the antibiotic combination of ampicillin gentamicin was 
prescribed as first line the microorganism isolated was resistant to Ampicillin. Ampicillin was 
prescribed in combination with Cefotaxime 42 times, and 62% of the time the organism isolated 
was resistant to ampicillin. Organism isolated had intermediate susceptibility to Ampicillin on 
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one occasion when prescribed as first line in combination with gentamicin was used when the 
organism showed intermediate susceptibility.  
 
Ampicillin sensitivity percentage when prescribed with both gentamicin and cefotaxime was 
11%. The study data also revealed that 37 (27%) out of 137 times Ampicillin was used as first 
line antibiotic in the NICU, antimicrobial sensitivity testing for Ampicillin was not conducted 
on the isolated organism. 
 
Table 6 : Crosstabulation of Most Frequently Prescribed First Line Antimicrobials 
against Cefotaxime Susceptibility 
 
CROSSTABULATION OF MOST FREQUENTLY PRESCIBED FIRST LINE 
ANTIMICROBIALS AGAINST CEFOTAXIME SUCEPTIBILITY 
  Cefotaxime 
- R S 
FIRST LINE ANTIBIOTIC Amikacin 0 0 1 
PRESCRIBED Amikacin 10 5 0 
Flucloxacillin 
Amikacin 1 0 0 
Tobramycin eye drops 
Ampicillin 27 14 1 
Cefotaxime 
Ampicillin 61 30 3 
Gentamicin 
Cefotaxime 1 0 0 
Flucloxacillin 
Cefotaxime  1 0 0 
Gentamicin 
Ciprofloxacin 1 0 0 
Tobramycin eye drops 
Gentamycin 1 0 0 
Cefotaxime 
Meropenem 2 0 0 
Tobramycin eye drops 1 0 0 
X-Penicillin 1 0 0 
Ampicillin 
X-Penicillin 0 1 0 
Gentamicin 
Total 107 50 5 
 
 
Cefotaxime susceptibility cross tabulated against first line antibiotic prescribed revealed that 
14 (33%) out of the 42 times that the antibiotic combination of Ampicillin Cefotaxime was 
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prescribed as first line the microorganism isolated was resistant to Cefotaxime. Cefotaxime 
was prescribed in combination with Gentamicin 2 times. The study data also revealed that 29 
(66 %) out of 44 times Cefotaxime was used as first line antibiotic in the NICU, antimicrobial 
sensitivity testing for Cefotaxime was not conducted on the isolated organism. 
 
4.8 Qualitative Results  
 
Table 7 - Socio demographics of health care professionals 
Demographic 
Age (yrs.) Sex occupation Work experience  Years in health 
care  
24 female Lab tech <1yr 1-2 yrs 
47 male Microbiologist 1-2 yrs >10 yrs 
26 Male Microbiologist 1-2 yrs 1-2 yrs  
30 female NICU nurse  3-5 yrs 3-5 yrs 
25 female NICU Nurse 1-2 yrs 3-5yrs 
27 Female  NICU nurse  <1yr 1-2 yrs 
23 Female  NICU Nurse  <1 yr <1yr 
28 male Lab Tech 3-5 yrs 3-5 yrs 
22 Female  Microbiologist  <1yr  1-2yrs  
30 Female  NICU Nurse  3-5yrs >10yrs  
 
 
 
Initially a total of 20 health care professionals who worked in the NICU as well as the 
Microbiology labs were invited to take part in the in-depth interviews and focused group 
discussions. Six lab technicians and microbiologists declined on account of busy work 
schedules and sample backlog in the labs and were unable to honour rescheduled interview 
dates. Three NICU nurses invited were unable to join the Focused Group Discussion due to 
high work load and patient emergencies.  
 
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In-depth interviews were carried out amongst 5 healthcare workers and one focused group 
discussion was carried out amongst 5 health care professionals. The Healthcare professionals 
constituted (n= 5, 50%) NICU nurses (n= 3, 30%) microbiologists and (n= 2, 20%) laboratory 
technicians working in the Microbiology lab. Majority of Health care workers (n= 7, 70%) 
interviewed were between the ages of 20-29 years. More than half (n= 7, 70%) of the 
Healthcare workers interviewed have worked in this facility for between 1-5years with the 
remaining minority (n= 3, 30%) having under 1 years’ experience. Sixty percent (60%) of 
participants were female with the remaining 40% being male. 
 
Important themes that emerged from the interviews and focused group discussion with Health 
care professionals who had experience culturing Multidrug resistant organisms and taking care 
of patients with MDRO infections include the following; 
 
1. The understanding of the concept and definitions of Multidrug resistance   
2. Existing factors contributing to development of MDR in the hospitals and in the 
communities  
3. Possible interventions already in place in the facility and in the communities  
4. Factors in place to prevent the rise of Multidrug resistant antimicrobial infection 
 
 
THEME 1: THE UNDERSTANDING OF THE CONCEPT AND DEFINITIONS OF 
MULTIDRUG RESISTANCE   
 
Definition 
The phenomenon of multidrug resistance was conceptualized amongst respondents as 
microbes building an opposition or resistance to at least 2 classes of antimicrobials. The 
knowledge of this concept was very general and not exceptionally in-depth.  
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“They are organisms that build resistance to drugs”.   
(Lab Technician, 1-2yrs experience) 
 
“Is it when particular bacteria are able to resist let’s say different classes of medication.” 
(NICU nurse, 3-5 yrs. experience) 
 
“….. Multidrug resistance occurs with resistance being seen in more than 2 antibiotic 
classes” 
(Senior microbiologist, >10yrs experience) 
 
First encounter and Frequency of encounter with MDROs 
Accounts of interviewees revealed that there is an increase in frequency of encounter of such 
organisms cultured in the laboratory in recent time and also an increase in morbidity and 
mortality associated with such patients admitted to the NICU.  
 
“…Yeah, yeah. It was quite unusual because for some patients it wasn’t the case but for one 
particular patient, he was actually resistant. I think it was E. coli yeah, I think it was E. coli. 
We used all the antibiotics and we did a sensitivity test and all of them were resistant but that 
was not the case for some of the patients but for that particular patient all the antibiotics 
were resistant”  
(Lab Technician, 3-5yrs experience) 
 
“So, I think the baby came…. they were twins and one passed so we were trying as much as 
possible to keep the other one. Unfortunately, we lost the baby. So, we started with ampicillin 
and gentamicin then when…as at that time the second twin was around yeah, was better so 
we started with ampicillin and gentamicin for that one and then when one started 
deteriorating, we changed ampicillin and gentamicin to flucloxacillin and amikacin. ……. 
But both passed away after initiating flucloxacillin and amikacin” 
(NICU nurse, 3-5 yrs. experience) 
 
“Well, TB gene expert, TB gene expert is what makes me aware of that. Also, ESBL and 
MRSA. Frequency is Maybe once in three days ….” 
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(Senior microbiologist, >10yrs experience) 
 
“First encounter was this isolate, proteus, the amikacin and some of the antibiotics, it was 
like sensitive and at the same time resistant. That’s the intermediate…. But normally we have 
a ruler. So, after you’re about to read the plate, you measure. Each of them if it’s resistant it 
has a dimension. The sensitive ones have theirs as well as the intermediate” 
(Lab Technician, 1-2yrs service) 
 
THEME 2: EXISTING FACTORS CONTRIBUTING TO DEVELOPMENT OF MDR 
IN THE HOSPITALS AND IN THE COMMUNITIES  
 
Community factors  
The existence and persistence of taking ‘over the counter’ medication was noted from 
discussions to be a major contributory factor to the development of MDROs in the 
community.  
“Personally, I think that people have been taking too much of unprescribed drugs like 
anytime they feel unwell they just go to the pharmacy.” (Microbiologist, 2yrs work 
experience) 
 
THEME 3: FACTORS IN PLACE TO PREVENT THE RISE OF MULTIDRUG 
RESISTANT ANTIMICROBIAL INFECTION 
 
According to Healthcare workers interviewed the factors in place to prevent the development 
of MDR were noted to be few and insufficient at best.  
 
 “Well, I’ve not seen any input. I mean you are the first person I’ve seen conducting this 
study no one has really come out to talk about these things.” (22yrs, Lab Tech, 1-2yrs 
experience in health) 
 
“…. there are more processes in place for adverse drug reactions and none for MDRO 
reporting in this facility.” (47yrs, microbiologist, >10yrs work experience) 
 
 
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THEME 4: POSSIBLE INTERVENTIONS TO PUT PLACE IN THE FACILITY AND 
IN THE COMMUNITIES  
 
Education, awareness and Prescriber retraining  
The thoughts garnered from the Healthcare workers reflected that educating the public and 
creating an awareness was the primary way of introducing the concept to the community and 
promoting understanding amongst health care workers, providing a framework and guidelines 
for antimicrobial stewardship was also recommended as a possible intervention to prevent the 
emergence of MDROs in both the hospitals and community at large.  
“Yeah, I mean to raise awareness, people are always talking about the disease, disease but 
then they are not talking about the fact that the patient is not getting well and actually that is 
not on the doctors’ part but related to the drug. Like we should actually talk about that.” (22yrs, 
Lab Tech, 1-2yrs experience in health) 
 
“I think always they should try and get tested, like bring the specimen for us to know which 
isolate which bacteria is causing that particular infection. If we’re able to get that type of 
bacteria, we’ll be able to know which antibiotics to be able to treat them...”  
(26yrs, Microbiologist, 1-2yrs experience in current job) 
 
Adequacy of antibiotics 
The issue of inadequate antibiotics to treat existing infections was also explored as a possible 
factor leading to MDROs and the need for review of current standard operating procedures was 
emphasized  
 
“We not coming up reviewing our data. Maybe if we would come up with reviewing all our 
labs, we know that yeah now ampicillin and gentamicin is not really working for our babies 
then we know that we are stopping ampicillin and gentamicin as our first line then we start 
with our second line.” 
(NICU nurse, 4 years’ work experience) 
 
 
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4.9 Conclusion  
In this research, I discovered that 18.5 percent of new born blood samples had MDRO blood 
culture positive. Negative for coagulase although the specific pathogenic function of 
Staphylococcus species could not be identified, they were the second most usually isolated 
gram-positive bacteria. Members of the Enterobacteriaceae family (Pseudomonas species, 
Enterobacter species, Klebsiella species) were the most often isolated Gram-negative bacteria. 
The isolated bacterium showed very strong resistance to ampicillin/gentamicin and 
ampicillin/cefotaxime combinations, while showing comparatively high sensitivity to 
Amikacin.  
The qualitative results surmised healthcare workers interviewed were aware of the presence 
and existence or MDROs, and a collective reportage of increased encounter with MDROs in 
recent times. The study also revealed that factors currently in place to manage and curb AMR 
are insufficient. The study showed that suggested ways to improve and mitigate the current 
situation of AMR in GARH included public education programs, awareness creation activities 
and provider in-service training.  
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CHAPTER FIVE 
DISCUSSION 
The goal of this study was to investigate multidrug-resistant-organism bloodstream infections 
in the Greater Accra Regional Hospital's Neonatal Intensive Care Unit (NICU).  
 
5.1 Demographic Distribution 
In a tertiary hospital in the Greater Accra region of Ghana, a total of 195 cases of multidrug 
resistant bacterial isolates were identified from 1,043 NICU samples taken throughout the year.  
The patient samples consisted of (n = 88, 45.1%) females and (n = 107, 54.9%) males. A recent 
multicenter prospective cohort study conducted by Labi et al. (2021) in Korle-Bu Teaching 
hospital and 37 military hospitals showed a similar sex distribution of (n = 1878, 45.3%) 
females and, (n = 2266, 54.7%) males as well as (n = 592, 46.5%) females and (n = 680, 53.5%) 
males respectively. About a third of patients who came in with prematurity were also at risk of 
sepsis (AROS). The average age of admission to the facility was one day after birth. 
Approximately 90% of all patients were seen within the 48 hours following birth, and about 
96.9% of patients were seen within the first week after delivery. A study conducted by Yadav 
et al. (2021) in the NICU of a tertiary hospital in Nepal also noted that 82.4% of patients seen 
with neonatal blood stream infection were seen in the first week of life. 
 
 5.2 Antimicrobial Susceptibility 
In this study it was found that Gram negative organisms formed the majority of all cultured 
multidrug resistant organisms from the NICU samples taken, which are a significant cause of 
neonatal blood stream infections. Gram negative rods such as Klebsiella spp, E Coli, Klebsiella 
Pneumoniae, Pseudomonas spp and Pseudomonas aeruginosa contributed a total percentage 
of (83/195) 42.6% of all MDROs cultured. A similar study conducted in the NICU of Korle-
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Bu Teaching Hospital (KBTH) by Enweronu-Laryea and Newman, (2007) showed similar 
findings with gram negative bacteria such as Klebsiella spp, E Coli, Pseudomonas spp and 
Enterobacter spp causing 54% of infections. Research conducted by Yadav et al., (2021) in 
Nepal also showed gram negative rod Pseudomonas spp had contributed to 78.4% of positive 
cultures followed by Coagulase negative staphylococci contributing about 23.0%. Out of 195 
MDRO cultured, Staphylococcus aureus was responsible for (20.51%) of the samples which 
shows differing findings to work done in KBTH by Enweronu-Laryea and Newman, (2007) 
which recorded isolation of Staphylococcus aureus at 10.7% and 10.8% in 2002 and 1992 
respectively. Findings similar to other research work conducted as a systematic review of data 
in sub-Saharan Africa which shows that Staphylococcus aureus accounted for 25% of culture 
positive bacteremia or sepsis (Okomo et al., 2019). A study also conducted by (Sharma et al., 
2013) showed that Staphylococcus aureus accounted for about 51.9% of culture isolated 
bacteria. 
 
Another study also showed Coagulase negative Staphylococcus (CoNS) contributed a much 
higher percentage of 31.9%; however, this study showed CoNS such as Staphylococcus 
hemolyticus and Staphylococcus epidermidis contributed a total of 15.9 % that is 10.8% and 
5.1% respectively. According to a study conducted in KBTH by Enweronu-Laryea and 
Newman, (2007) Coagulase Negative Staphylococci (CoNS) were not isolated in 1992 
however in 2002 it accounted for 31.9% being the most frequently isolated gram-positive 
coccus. Further research conducted in the same facility a decade on by  Labi et al., (2016) 
revealed CoNS accounted for the most common pathogen isolated in early onset infections 
(EOS) (59.1%) and late onset infections (LOS) (52.8 percent). The study does not show the 
same alarming trend of the rise of CoNS however it shows that CoNS is the second most 
common gram-positive coccus in the NICU. The pathogenicity of CoNS is usually called in 
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question as it is considered a skin contaminant that is found in blood due to inappropriate skin 
preparation prior to blood cultures rather than a pathogenic cause of Blood stream infections. 
Work done by Labi et al., (2021) showed case fatality rates of CoNS infection similar to culture 
negative Neonates. 
 
5.3 Most Frequently Prescribed First-Line Antibiotics 
The majority of bacteria identified were found to be resistant to the first-line medicines. Most 
organisms cultured were resistant to gentamicin and ampicillin; however, Ampicillin and 
Gentamicin were the most commonly administered antibiotics combination as first line in the 
NICU, accounting for 58 percent of all prescriptions for patients with blood cultures 
with MDRO infections. Research conducted by Enweronu-Laryea and Newman, 2007 showed 
that in the KBTH NICU less than 40% of all bacterial isolates were susceptible to gentamicin 
ampicillin and cloxacillin. Gentamicin which formed part of the prescribed first line 
antimicrobial combination was noted to have a percentage resistance point of 65.63% and a 
percentage susceptibility point of 32.81%. The resistance trends in the above sited work are 
similar to the work conducted in GARH. Streptococcus agalactiae (Group B Strep) had a low 
percentage amongst isolated MDRO of 0.62% which is consistent with the low levels noted in 
a metanalysis done in sub-Saharan African population where 0.06% of the samples were found 
to have Streptococcus agalactiae. Research conducted by Slotved et al., (2017) shows a 25.5% 
carriage rate of Group B Strep in pregnant women in Ghana. 
 
Amikacin showed the overall lowest percentage resistance at 6.58% and the highest percentage 
susceptibility at 92.11%. In the NICU Amikacin was used as a first line medication 10.5% of 
the time. The antibiotics with the lowest percentage sensitivities were noted to be Cefuroxime 
(5.77 %,), Cefotaxime (9.09 %,), Penicillin (11.76 %,), Ampicillin (13.45%) and Ceftriaxone 
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(17.24%). Ciprofloxacin and Vancomycin showed the second and third highest percentage of 
susceptibility at 81.29% and 51.75% respectively.  
 
Prematurity was the most prevalent diagnosis linked with newborns with MDROIs in this 
study, accounting for 29 percent of the cases, followed by neonatal sepsis and acute respiratory 
distress, which accounted for 24 percent and 17 percent of the cases, respectively. Birth 
asphyxia was the fourth most common diagnosis associated with NICU admissions who had 
multidrug resistant organism infection contributing a total of 15.4% of all admissions with 
MDROIs. A study by Abdul-Mumin et al., (2021) conducted in Tamale Teaching hospital also 
showed similarly that Preterm delivery problems (49.6%) and birth asphyxia (21.7%) to be 
some of the leading causes of neonatal deaths over the 5-year study period. Prematurity tends 
to increase length of stay in hospitals and predispose patients to more severe morbidity.  
 
In this study, the multidrug resistant organism culture positivity was 18.7%, comparable to 
similar studies conducted in Ghana by Labi et al. (2016) which found a 21.9% culture 
positivity. A study conducted in two centers by Labi et al., (2021) showed an overall culture 
positivity rate of 24.2 %. The above sited studies were conducted in the same facility and have 
shown a significant rising trend in culture positivity. The study conducted however the first of 
its type in GARH is and thus more work should be done retrospectively on existing data to 
reveal trends. There is an urgent need for antimicrobial stewardship programs (ASP) in all 
hospitals. To conserve the efficacy of the current antibiotics and stall the development of AMR, 
ASPs are a very essential step (Dramowski et al., 2020).  According to Dramowski et al., (2020) 
Neonatal units must first be enabled to measure and monitor trends in their antimicrobial usage 
in order to create robust and effective ASPs and to provide locally suitable treatment guidelines, 
institutions need data on pathogen profiles and AMR trends. This Study found the most 
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frequently prescribed antibiotic and the AMR trends and infectious organism isolates in the 
NICU. this provides a foundation for more extensive AMR research and the development of 
ASPs in the facility. 
 
 5.4 Morbidity and Mortality Associated with Multidrug-Resistant Organisms 
The antimicrobial resistance (AMR) crisis refers to the rising global occurrence of infectious 
illnesses affecting humans that are resistant to all known antibiotics. As noted in an earlier 
study as the incidence and scope of both disabling and deadly illnesses rise, this catastrophe 
will have a disastrous impact on human civilization (Michael et al., 2014). In this study 
morbidity associated with AMR in the NICU is 18.7% and the case fatality rate associated with 
patients in the NICU infected with Multidrug resistant organisms at GARH was found to be 
about (51/195) 26.2 %. The factors contributing to the development of AMR according to this 
study was over use of antimicrobials and lack of adequate stewardship frameworks for 
antibiotic monitoring, over prescription of antimicrobials when not required is another 
pertinent and obvious cause of AMR and its attendant issues. Michael et al., (2014) support the 
conclusions that antimicrobials' widespread, strong, and polarized use has resulted in 
widespread, strong, and polarized selection pressure on the microbial world. As a result, today's 
AMR rates are on the rise. The patients who still rely on the paying out of pocket for services 
in hospitals are very high; thus, patient care is unduly delayed leading to longer stays in 
hospitals and reduction in quality of patient care. This study showed that a staggering total of 
about 97.5% of patients who had blood cultures preformed paid out of pocket and did not have 
insurance coverage. The average age at diagnosis in this study was found to be on the first day 
of life comparable to studies conducted in low and middle income countries show that earl 
onset neonatal sepsis dominates the conversation on neonatal blood stream infections. In a 
study conducted by Sharma et al., (2013) it was noted that 63.35% of the total number of 
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isolates causes early onset neonatal sepsis. However late onset neonatal sepsis as seen in a 
study conducted by Mudzikati and Dramowski, (2015) showed that the pattern of late onset 
sepsis was associated with horizontal infection transmission involving hospital acquired 
infections and were by and large preventable.  
 
5.5 Impact of BSIs on Cost, Length of Stay and Case Fatality 
In this study the duration of hospital stays ranges between 1-73 days with a median of 11 days. 
These findings were similar to findings from research conducted by  Labi et al., (2021) which 
showed a median duration of stay for neonates with Blood stream infections to be 14 days. 
Another study conducted by Mudzikati and Dramowski, (2015) showed a median hospital stay 
duration of 15 days. Although longer hospital stays tend to be associated with late onset 
neonatal sepsis, participants of this study developed early onset neonatal sepsis. Research work 
conducted on cost analysis and length of stay by Fenny et al., (2021) showed an association 
between neonatal Blood Stream Infection (BSI) and higher costs of hospital bills as well as 
longer duration of stay (LOS).  Patients infected with antimicrobial-resistant organisms incur 
higher expenses ($6,000–$30,000) than patients infected with antimicrobial-susceptible 
organisms (Cosgrove, 2006).  
The case fatality associated with MDR BSI in the NICU of this study was 24.1% comparable 
to the case fatality rate of 19.7% found in a similar study conducted by Labi et al., (2021) in 
Korle-Bu Teaching Hospital and 37 Military Hospital. The case fatality rate of Multidrug 
resistance is higher in this study which is cause for increased interest and a more in-depth look. 
 
5.6 Knowledge of MDROs amongst Health Workers  
The study showed that healthcare workers had acceptable knowledge of MDROs. A few did 
not have adequate information on MDROs. Research by Kose and Colak, (2021) showed that 
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following graduation, further training may be critical in minimizing antibiotic overuse which 
is a contributory factor to MDROs. Overuse, self-medication, overcrowding, and lapses in 
cleanliness or poor infection control management are all general risk factors for the 
development of resistant bacteria in hospitals and the community (Fair & Tor, 2014).   
 
 
5.7 Factors Contributing to MDROs 
In 2004, just 1.6 percent of medications in clinical development by the world's 15 major pharma 
corporations were antibiotics, according to work done by Dougherty and Pucci, (2011). From 
this research conducted, one of the main factors notably absent from responses was the lack of 
adequate back up antibiotics and lack of overall interest of pharmaceutical companies in 
developing new antimicrobials. According to work done by Renwick et al. (2016) the 
antimicrobial discovery void shows that despite the growing problem of antimicrobial 
resistance, pharmaceutical and biotechnology corporations are hesitant to research new 
antibiotics due to a number of commercial failures. Work done by Klein et al., (2018)  shows 
that antibiotic consumption increased globally from 2000 to 2015 by 68 percent and the 
sharpest increase was observed in LMICs with 114 percent over the 15-year period. This 
exponential increase is consistent with the rising levels of antimicrobial resistance that has been 
seen in LMICs. The lack of reliable AMR surveillance data is an important missing component 
of the fight against AMR in the study site. Work done by Malania et al., (2021) showed that 
the implementation of quality management systems, standardization of guidelines, and 
training, together with focused capacity building, resulted in enhanced laboratory standards 
and bloodstream infection control. 
The current study also noted that educating the public and raising awareness were the primary 
methods of introducing the concept to the public and promoting understanding among health 
care workers. Providing a framework and guidelines for antimicrobial stewardship was also 
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suggested as a possible intervention to prevent the emergence of MDROs in both hospitals and 
the general public. 
 
5.8 Measures in Place to Prevent Antimicrobial Resistance 
The qualitative results aspect of the study revealed that the measures in place to address 
antimicrobial resistance in the Greater Accra Regional Hospital were inadequate. The 
interventions that exist in literature as strategies to handle AMR according to work done by 
Murray et al., (2022) tend to fall into five main groupings. Majority of these groupings were 
noted in the responses gathered in the qualitative results. The First of which is the principle of 
infection control and prevention. This encompasses both hospital-based measures of infection 
control and prevention and community-based measures to promote clean water, sanitation and 
hygiene. The study results showed that hospital workers suggested that infection control and 
sanitation was one of the ways to improve upon AMR control and transmission both in the 
hospitals and the community at large. However, there was more emphasis placed on educating 
the public on the existence of AMR and raising awareness on prevention techniques.  
The second principle as discussed by Murray et al., (2022) is prevention through vaccinations. 
Vaccine development is a sure way to dramatically reduce the need for antibiotics and is a 
crucial player in the fight against AMR. Of the six leading pathogens as described by WHO 
only S pnemoniae has a vaccine. During the research study this method of preventing AMR 
was not mentioned or discussed as viable option for prevention. The third strategy is to reduce 
human exposure to antibiotics through control of antibiotic misuse in farming. The direct causal 
link of animal related antibiotic exposure is yet inconclusive. A study conducted by Wu et al., 
(2013) on ESBL (extended spectrum beta-lactamase) positive E. coli isolates from both animals 
and humans noted that efforts in public health should be maintained at controlling human to 
human transmission as Animal served as a reservoir.  
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The fourth strategy to minimise the development of AMR was the misuse of antibiotics that 
are not necessary to improve human health. For instance, in the case of viral infections there is 
a lot of antibiotics misuse when clinicians are unable to differentiate between bacterial and 
viral infections. In this regard work done by van Houten et al., (2017) to externally validate a 
protein-based assay differentiating bacterial from viral infections in children with lower 
respiratory tract infection revealed potential to reduce antibiotic misuse. The fifth option to 
prevent AMR is to improve upon development and access to second line antibiotics in areas 
without access the study revealed that there is a general paucity of measures in place to prevent 
the rise of AMR in the GARH. According to Healthcare workers interviewed the factors in 
place to prevent the development of MDR were noted to be few and insufficient at best. A 
study conducted by (Hervas et al., 2001) noted that adherence to infection prevention measures 
reduced the propagation of multidrug resistant organism infection.  
 
  
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CHAPTER SIX 
 
6.1 Conclusion  
This Study was conducted to assess multidrug resistant-organism Bloodstream infections in 
Neonatal Intensive care unit (NICU) in Greater Accra Regional Hospital in Ghana. The 
prevalence of Multidrug resistant organism blood stream infections was 18.7% in the NICU of 
GARH. Within the NICU the most frequently prescribed first line antimicrobials to treat 
infections were ampicillin and gentamicin, accounting for 58 percent of all prescriptions for 
patients with blood cultures with MDRO infections. The Antibiotic susceptibility profile 
revealed that the most commonly isolated organism causing MDRO infections in the NICU 
was Staphylococcus aureus however cefotaxime, the second most prescribed antibiotic showed 
a resistance point of 90.1%. The case fatality rate associated with MDRO infections in the 
NICU was 24.1%. The current measures in place are insufficient and inadequate  
 
The findings show the need to review antibiotic protocols, the need for extensive health 
education for both prescribers and general public on the present problem of antimicrobial 
resistance that exists in our communities and hospitals. According to research work conducted 
by Michael et al., (2014)  the CDC described the world to be in a ‘post-antibiotic’ era as far 
back as 2013, the WHO also stated that the AMR crisis is becoming dire in 2014. AMR and 
MDRO are no longer an imminent or emerging problem they are a now public health 
emergency requiring urgent attention from the health sector, country and the world at large. 
The issue of MDRO in the NICU of GARH is only a microcosm of the much larger problem 
occurring in our communities and hospitals nationwide and on a much more global scale.  
This Study was conducted to keep the conversation about antimicrobial resistance and 
multidrug resistance going. Standard empirical therapy is unlikely to improve the outcome of 
BSIs in poor and medium income countries due to the variety of etiologic agents and the high 
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probability of antibiotic resistance. Access to dependable clinical microbiologic services would 
be required for such advancements.(Labi et al., 2021) 
 
6.2 Recommendations 
 
1. According to the findings of this study there is a need for the NICU in collaboration 
with the microbiology department to have an in-depth evaluation of the current first 
line antibiotics in the NICU of GARH due to high levels of antimicrobial resistance 
against current first line options.  
2. The Management of the GARH, to bridge the knowledge gap amongst both health care 
providers and community is recommended to organize in-service training and health 
promotion activities in the for the health care providers and the general public 
respectively.  
3. The management of the GARH should in collaboration with the heads of the NICU 
develop and implement infection prevention measures incorporated into routine 
practice in the NICU to guard against development and spread of AMR.  
 
 
6.3 Importance of the Study 
This research project is the first of its kind assessing Multidrug resistance in such a vulnerable 
population neonatal ICU patient in this department. Additionally, the study opens the door for 
further work to be carried out on existing data on other microbiological sample specimen within 
this population that will furnish the local and global scientific community. This study shows 
AMR patterns in the NICU during the height of the Covid-19 pandemic. The Mixed method 
approach of using both qualitative and quantitative methods provide data that complements 
each other and hence improving upon the authenticity of the work done. Interviewing health 
care professionals who come into contact with and are familiar with isolating and culturing 
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such organisms and also caring for patients with such organism infections provides an in-depth 
view of the experiential knowledge of MDROs and not only quantitative analysis of figures.  
 
PROPOSED AREAS FOR FURTHER RESEARCH 
This initial research endeavor provides the platform for future research endeavors that build 
up on the findings of this study. 
• A more extensive review of all types MDROs over a longer period to make 
comparison over time periods. 
• A study on MDROs cultured in the emergency room over time in the GARH. 
 
6.4 Limitations of the Study 
The time period of review does not allow comparison of patterns over time to show AMR 
patterns before and after Covid-19 pandemic. The study was conducted on specifically of 
blood cultures. The study was conducted in only one hospital and cannot be generalized to 
other facilities  
 
 
  
72 
 
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Zhou, J. J., Patel, S. J., Jia, H., Weisenberg, S. A., Furuya, E. Y., Kubin, C. J., Alba, L., Rhee, 
K., & Saiman, L. (2013). Clinicians’ Knowledge, Attitudes, and Practices regarding 
Infections with Multidrug-Resistant Gram-Negative Bacilli in Intensive Care Units. 
Infection Control & Hospital Epidemiology, 34(3), 274–283. 
https://doi.org/10.1086/669524 
Zou, H., Jia, X., He, X., Su, Y., Zhou, L., Shen, Y., Sheng, C., Liao, A., Li, C., & Li, Q. 
(2021). Emerging Threat of Multidrug Resistant Pathogens From Neonatal Sepsis. 
https://doi.org/10.3389/fcimb.2021.694093 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX A: PARTICIPANTS INFORMATION SHEET 
 
Title of Study:  
MULTIDRUG-RESISTANT ORGANISM AT THE NEONATAL INTENSIVE CARE UNIT 
(NICU) IN THE GREATER ACCRA REGIONAL HOSPITAL IN GHANA 
 
Introduction:  
My Name is Abena Odurowaa Yeboah, a Masters student of University of Ghana, School of 
Public Health. I am the Principal Investigator (PI). I am responsible for the activities of this 
project and can be contacted via email at odurowaayeboah@gmail.com.  
 
Background and Purpose of research:  
This research topic aims to assess multidrug resistant organism infection at the neonatal 
intensive care unit in the Greater Accra Regional Hospital. This work being carried out seeks 
to assess the burden and understand from varying perspectives the causes and influences of this 
phenomenon and proposed ways resolution.  
 
Nature of research:  
The study is interested in identifying what is known to be an increasing trend of microbial 
resistance that is changing the trend of antibiotic usage and efficacy in the field of medicine. 
This study is a mixed method study which involves both qualitative and quantitative aspects. 
The qualitative aspect involves interviews and focused group discussions with medical 
professionals involved in the diagnosis and treatment of multidrug resistant organism infection 
in the neonatal ICU and Microbiology lab.   
 
 
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Participant’s involvement: 
• Duration /what is involved: Participants in this study who partake in the In-depth 
interviews will spend about 40 minutes of their time. Participants involved in the 
Focused group discussion with spend about an hour.  
• Potential Risks: Partaking in this study will not involve any risk to the participants 
involved.  
• Benefits: There will be no direct benefits to the study participants for volunteering 
their time to this study. The findings of this study will however enrich the scientific 
community at large, influence the choice of antibiotics and improve upon antibiotic 
stewardship within the NICU of Greater Accra Regional Hospital. 
• Costs: There is no direct monetary cost to the participants involved in this study. 
Nevertheless, it will come at a cost of work hours. 
• Compensation: Participants will be given refreshment after their participation in the 
study.  
• Confidentiality: Participant information will be kept confidential. Participant 
identification numbers to ensure anonymity.  Audio Recordings from interview 
sessions and Focused group discussions will be kept by principal investigator only.  
• Voluntary participation/ Withdrawal: Participants are free to withdraw from the 
study at any time with no consequence.  
• Outcome and Feedback: The outcome of the project will be shared with the scientific 
community, the units from which the data was collected. 
• Funding Information: This study is fully funded by the principal investigator (PI). 
• Provision of Information: Participants will be given copies of the information sheet 
as well as consent forms after signing  
 
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Kindly note that for further information you can contact 
Dr Abena Odurowaa Yeboah, 0547587478, odurowaayeboah@gmail.com  
Nana Abena Apatu, 0503539896, ethics.research@ghsmail.org  
  
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APPENDIX B (CONSENT FORM) 
CONSENT FORM 
STUDY TITLE:  MULTIDRUG-RESISTANT ORGANISM AT THE NEONATAL 
INTENSIVE CARE UNIT (NICU) IN THE GREATER ACCRA REGIONAL HOSPITAL 
IN GHANA 
 
PARTICIPANTS’ STATEMENT 
 
I acknowledge that I have read or have had the purpose and contents of the Participants’ 
Information Sheet read and all questions satisfactorily explained to me in a language I 
understand (English, Twi) I fully understand the contents, give permission to have my audio 
recorded and acknowledge any potential implications as well as my right to change my mind 
(i.e., withdraw from the research) even after I have signed this form. 
 
I voluntarily agree to be part of this research. 
Name of Participant…………………………...    
Participants’ Signature ……………………...      OR Thumb Print………………………… 
Date………………………………. 
 
 
INTERPRETERS’ STATEMENT 
 
I interpreted the purpose and contents of the Participants’ Information Sheet to the afore 
named participant to the best of my ability in the (English,  Twi) language to his 
proper understanding. 
All questions, appropriate clarifications sort by the participant and answers were also duly 
interpreted to his/her satisfaction. 
 
Name of Interpreter…………………………… 
Signature of Interpreter……………………….. OR Thumb Print ………............................ 
Date:……………………… 
 
 
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STATEMENT OF WITNESS 
 
I was present when the purpose and contents of the Participant Information Sheet was read 
and explained satisfactorily to the participant in the language he/she understood (English, 
Twi ). 
I confirm that he/she was given the opportunity to ask questions/seek clarifications and same 
were duly answered to his/her satisfaction before voluntarily agreeing to be part of the 
Research. 
Name:………………………… 
 
Signature…………………………... OR Thumb Print ………............................ 
 
Date:…………………………… 
 
INVESTIGATOR’S STATEMENT AND SIGNATURE 
 
I certify that the participant has been given ample time to read and learn about the study. All 
Questions and clarifications raised by the participant have been addressed. 
 
Researcher’s name: ……………………………………… 
 
Signature …………………………………………………. 
 
Date…………………………………………………………. 
 
 
 
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APPENDIX C (DATA EXTRACTION FORM) 
 
NICU Research Data extraction form 
 
No Age Sex Location/ Diagnosis Date of Date of 1st Organism(s) Antibiotic Antibiotic Antibiotic Days on Outcome of 
(days)  Address diagnosis culture isolated resistance susceptibility prescribed  admission management  
profile profile 
             
             
             
             
             
             
             
             
             
             
 
 
 
 
 
 
 
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APPENDIX D: INTERVIEW GUIDE 
 
 
Participant ID:………………. 
1. Age:…………………………………………………………………… 
2.  Are you: (please tick as necessary)        □ Male  □ Female 
3. What is your professional background? 
□ Neonatal ICU Nurse  
□ Lab Technician/ Microbiologist 
□ Pediatrician/Neonatologist/ Medical officer 
□ Other: (please describe) __________________________________ 
4. How many years of experience have you had in this current job? 
□ <1 Year                 □ 1-2 Years 
□ 3-5 Years              □ 5-10 Years 
□ >10 Years   
5. Experience in Health Care (optional): 
□ <1 Year                  □ 1-2 Years 
3-5 Years                □ 5-10 Years 
□ >10 Years 
Guiding questions 
• What is multidrug resistant organism infection?  
• What was your first encounter with this and how often do you come into contact with 
them?  
• How do you think these infections come about?  
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• How concerning do you think these infections are to patients and healthcare workers? 
And why? 
• What factors do you think are contributing to this phenomenon?  
• Do you think the antibiotics we have are adequate to handle the current climate of 
infection?  
• In your experience during your practice, how much have the frequently used 
antibiotics changed over time? 
• In your view what is the antibiotic situation in your facility?   
• What factors are in place to curb this in our communities and in our hospitals?  
•  What else can be done to curb this emerging problem? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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FOCUSED GROUP DISCUSSION GUIDE 
 
Participant ID: ………… 
Please answer the following questions in the spaces provided, circle or tick the most 
appropriate options. 
1. Age: ……………………… 
2.  Are you: (please tick as necessary)          □ Male  □ Female 
3. What is your professional background? 
□ Neonatal ICU Nurse  
□ Lab Technician/ Microbiologist 
□ Pediatrician/Neonatologist/ Medical officer 
□ Other: (please describe) __________________________________ 
 
5. How many years of experience have you had in this current job? 
□ <1 Year                 □ 1-2 Years 
□ 3-5 Years              □ 5-10 Years 
□ >10 Years   
 
6. Experience in Health Care (optional): 
□ <1 Year                  □ 1-2 Years 
3-5 Years                □ 5-10 Years 
□ >10 Years 
Round of Introductions 
• First, I’d like everyone to introduce themselves.  
 
Introductory question 
I am just going to give you a couple of minutes to think about your experience of diagnosis 
and/or managing a neonatal patient with Multidrug resistant infection. Is anyone happy to 
share his or her experience? 
 
 
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Guiding questions 
• What is multidrug resistant organism infection?  
• What was your first encounter with this and how often do you come into contact with 
them?  
• How do you think these infections come about?  
• How concerning do you think these infections are to patients and healthcare workers? 
And why? 
• What factors do you think are contributing to this phenomenon?  
• Do you think the antibiotics we have are adequate to handle the current climate of 
infection?  
• In your experience during your practice, how much have the frequently used 
antibiotics changed over time? 
• In your view what is the antibiotic situation in your facility?   
• What factors are in place to curb this in our communities and in our hospitals?  
•  What else can be done to curb this emerging problem? 
Concluding question 
• Of all the things we’ve discussed today, what would you say are the most important 
issues you would like to express about multidrug resistant organism infection?  
 
Concluding remarks. 
Thank you for taking the time to participate. This has been a really productive discussion; your 
input will be quite useful to the study. I hope you enjoyed the discussion Please speak with me 
later if there is anything you are unsatisfied with or wish to complain about. I'd like to remind 
you that any comments you make will remain anonymous in this report. Please turn in your 
completed personal information questionnaire before leaving. 
 
 
 
 
 
 
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APPENDIX E: ETHICAL CLEARANCE  
 
 
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