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Antimicrobial Resistance & Infection Control (2023) 12:146 https://doi.org/10.1186/s13756-023-01351-8 Antimicrobial Resistance & Infection Control *Correspondence: Naiki Attram npuplampu@noguchi.ug.edu.gh 1Naval Medical Research Unit-EURAFCENT, Accra, Ghana 2Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana 3Ghana Armed Forces Health Directorate, 37 Military Hospital, Accra, Ghana 4Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany 5Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany Abstract Background Unregulated and inappropriate antimicrobial use are major contributors to the evolution of antimicrobial resistance worldwide. It is important to monitor and collect data on the use of antibiotics at health facilities and in the general population in order to support antimicrobial stewardship programs. Methods As part of a gonorrhea surveillance study that was conducted from June 2012 to Jan 2018, we administered a questionnaire to elicit information on the types of antimicrobials used by individuals to treat symptoms of a gonorrhea infection prior to presenting at five health facilities in Southern Ghana. Results Almost one-third (383/1,349; 28%) of study participants admitted taking one or more antimicrobial types before hospital presentation, while 138/383 (36%) of those who took antimicrobials could not remember what they ingested. A greater percentage of individuals who reported prior antimicrobial use before presentation at a health facility tested positive for gonorrhea by NAAT (30%), in contrast to 24% for those without prior treatment (p = 0.004). Penicillin and its derivatives, as well as ciprofloxacin and doxycycline, were the most used, while a few individuals reported taking drugs such as kanamycin and rifampin. Males were more likely than females to take an antimicrobial prior to attending a health center. Conclusion In order to curb excessive and inappropriate antimicrobial use, antibiotics used by patients before presenting at hospitals ought to be investigated by healthcare providers. It is recommended that health professionals receive continuing education on the consequences of unregulated antimicrobial use. Keywords Antimicrobial use, Antimicrobial resistance, Antimicrobial stewardship, Gonorrhea treatment Antimicrobial use of patients with sexually transmitted infection symptoms prior to presentation at five health facilities in Southern Ghana Naiki Attram1*, Helena Dela1,2, Eric Behene1,2, Nicholas N.A. Kyei3,4,5, Karen Ocansey1,2, Jennifer N. Yanney1,2, Edward O. Nyarko3, Kennedy K. Addo2, Kwadwo A. Koram2, Anne Fox1, Andrew Letizia1 and Terrel Sanders1 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s13756-023-01351-8&domain=pdf&date_stamp=2023-12-13 Page 2 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 Background The World Health Organization (WHO) considers the rising trend of AMR as one of the top threats to global public health systems [1]. The direct impact of AMR on healthcare is severe [2, 3]. Global annual mortality from AMR has been estimated at 700,000 [4]. Consistent mon- itoring of AMR rates in low- and middle-income settings is scarcely done [5]. However, the available data indicate that AMR rates in several disease pathogens have been increasing worldwide [6–9]. Unregulated use of medi- cines strongly contributes to the release of antimicrobials into the environment [1, 4, 8]. Currently,there is no known effective drug on the market for empirical gonorrhea monotherapy [10]. Cef- triaxone-azithromycin, one of the combination drugs recommended by the WHO for empirical treatment of gonorrhea, was recently reported to have failed to treat gonorrhea infections in England and Australia [11–13]. Additionally, treatment failure to a ceftriaxone-dox- ycycline combination was reported in France in 2017 [14]. Suspected cases of gonorrhea in Ghana are usually treated with cefixime or ceftriaxone with azithromycin or doxycycline, although ciprofloxacin is recommended on a case-by-case basis as per the Ghana Standard Treatment Guidelines [15], [clinician, personal communication]. Data on antimicrobial use can be applied to support stewardship programmes that help to counter the spread of AMR. This study sought to comprehensively inves- tigate and analyze the patterns of prior antimicrobial use among patients seeking treatment for urethritis or cervicitis symptoms, focusing on the prevalence, types, and sources of antimicrobials, as well as the association between prior treatment and the incidence of gonorrhea, to inform targeted interventions for improved antimicro- bial stewardship and effective management of sexually transmitted infections. Methods Inclusion criteria comprised one or more of the follow- ing symptoms: urethral or vaginal discharge, painful uri- nation, pain or swelling in one testicle (males), painful intercourse, and post-coital bleeding (females). Patients who visited five health facilities from June 2012 to Janu- ary 2018 in the Southern part of Ghana with symptoms of urethritis as described above were enrolled in a study approved by the following Institutional Review Boards: Noguchi Memorial Institute for Medical Research, 37th- Military Hospital, Ghana Health Service, and the Naval Medical Research Centre. Four of the health facilities were part of a gonorrhea surveillance study and were selected based on their involvement with the study authors in prior surveillance studies [16, 17]. The fifth health facility is a Sexually Transmitted Diseases care center with attendance of high-risk groups like men who have sex with men and commercial sex workers. Written informed consent was obtained from each participant as previously described [16]. A nucleic acid amplification test (NAAT) was performed to detect N. gonorrhoeae in patients’ urine specimens, and bacterial culture was attempted on each genital swab specimen [17]. Addi- tionally, a questionnaire was used to collect data on demographics and antimicrobial use, among other infor- mation. Condom use, alcohol use, and other risk factor data were collected and reported elsewhere [17]. The Chi-square test was used to determine associations between sex with age group, education, and self-reported treatment of the study participants. The Chi-square or Fisher’s exact tests were used to determine associations between sex and the type of antimicrobials taken. Results The study involved the participation of 1,349 patients, with a breakdown of 1,339 participants of known gender: 60% (805) identified as female, while 40% (534) identi- fied as male. Most study participants were aged 18–38 years (89%, n = 1194) and had some formal education (96%,n = 1276). Notably, 28% (383) acknowledged using one or more antimicrobials/herbal drugs before seeking medical attention at the health facility. No statistically significant association was observed between educational level and self-reported prior use of antimicrobials. However, there was a strong statisti- cal association seen between sex and self-reported prior treatment with antimicrobials (p < 0.001) (Table 1). Approximately two-thirds (66%,n = 252) of the people who took antimicrobials/herbal drugs before present- ing at the health center remembered the names of the drugs they ingested. The most consumed antibiotics were amoxicillin, ciprofloxacin, and doxycycline, representing almost half (47%,n = 179) of the drugs taken. Penicillin- based drugs represented nearly a third (27%,n = 104) of the drugs used (Fig. 1). A minority of those seeking treatment before reach- ing the health center opted for herbal medicine (5%). In contrast, a minimal percentage, specifically 0.2% (1) and 1% (4), underwent treatment with cefuroxime and cef- triaxone, respectively—both drugs recommended for empirical gonorrhea treatment. On the other hand, the remaining study participants reported the use of drugs not approved for gonorrhea treatment. These drugs included kanamycin, metronidazole, trimethoprim-sul- famethoxazole, chloramphenicol, potassium citrate, co- trimoxazole, secnidazole, rifampin, and cetirizine. There were no statistically significant associations observed between the sex of the study participants and the antimicrobial ingested, except for those who took amoxicillin. However, a noteworthy association was identified between the sex of the study participants and Page 3 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 their ability to recall the specific drug they had ingested (Table 2). A majority of study participants (72%) reportedly did not take any drugs, as compared to 28% who admitted to receiving medication before hospital presentation. Nota- bly, a higher percentage of those who underwent treat- ment before presentation tested positive for gonorrhea by NAAT (30%), contrasting with 24% for those who did not receive prior treatment (p = 0.004). There was no significant difference between the age groups of the study participants and their self-reported antimicrobial intake before hospital presentation (p = 0.802) (Fig. 2). Among the study participants, some took antimicrobi- als in combination as follows: ciprofloxacin with doxy- cycline (4%), ciprofloxacin with metronidazole (2%), ciprofloxacin with co-trimoxazole (1%), ciprofloxacin with amoxicillin (0.4%) and ciprofloxacin with penicillin (0.4%). Almost a fifth (18%) of those who reported anti- biotic treatment took two or more types in combination. Among the study participants who reported taking medication before hospital presentation, 50% obtained the drugs from a pharmacy, 36% obtained their drugs from a doctor, and 7% each from a traditional healer and friends . Discussion This study investigates prior antimicrobial use among patients seeking treatment for urethritis symptoms to characterize and inform targeted interventions for improved antimicrobial stewardship and effective man- agement of sexually transmitted infections. The key findings of this study offer valuable insights into the dynamics of prior antimicrobial use and its implications. Approximately one-third of individuals reported engag- ing in prior antimicrobial use before presenting at a health facility, with a noteworthy preference for specific antimicrobials such as amoxicillin, ciprofloxacin, and doxycycline. Less than a quarter of patients consumed two or more types of antimicrobials during prior-treat- ment, while the rest consumed just one type. Pharmacies emerged as the predominant source for obtaining these medications. We also observed an interesting association between prior antimicrobial use and a higher incidence of gonorrhea positivity, particularly evident in individuals who engaged in prior-treatment. The revelation that approximately one-third of patients sought treatment for urethritis or cervicitis symptoms after engaging in prior antimicrobial use underscores a significant aspect of healthcare-seeking behavior in this population. This finding suggests a noteworthy level of autonomy in healthcare decisions in this population, highlighting the need for targeted patient education ini- tiatives. A prevailing belief in Ghana indicates that self- medicating with purchased drugs is quicker and more cost-effective, particularly for minor ailments [18]. Thus, a significant proportion of individuals first treat their genital infections and only resort to clinical care when there is no improvement in their health condition. Data from this study also suggests that this tendency is dem- onstrated more in males than in females. Emphasizing the importance of seeking professional medical advice and testing before procuring medications. The types of antimicrobials chosen by the patients also merit closer scrutiny. The identification of specific anti- microbials, such as amoxicillin, ciprofloxacin, and doxy- cycline, raises questions about the appropriateness of these choices for the targeted symptoms. These antibiot- ics were historically employed for gonorrhea monother- apy but have gradually lost effectiveness [19]. Current guidelines recommend dual therapy involving cefixime or ceftriaxone in conjunction with azithromycin or doxy- cycline, as endorsed by the World Health Organization [20]. Despite being classified in 2017 as prescription-only medicines by Ghana’s Food and Drugs Authority (FDA) [21], half of the drugs reportedly used in this study were obtained from pharmacists, raising concerns about adherence to existing regulations. In Ghana, the Health Professions Regulatory Body Act (857) of 2013, stipulates Table 1 Demographic and prior-drug use information of study participants Total N(%) Malea n(%) Femalea n(%) p- value Age groupb 0.233 18–24 years 384(29.0) 138(26.2) 246(30.6) 25–31 years 553(41.7) 234(44.0) 319(39.7) 32–38 years 257(19.3) 98(18.6) 159(19.8) 39–45 years 96(7.2) 37(7.0) 59(7.3) 46 years and above 41(3.1) 20(3.8) 21(2.6) Educational levelc 0.283 No education 50(3.8) 18(3.4) 32(4.0) Primary/Junior High School 238(18.0) 85(16.1) 153(19.2) Secondary and above 1038(78.3) 425(80.5) 613(76.8) Antimicrobial use within 2 weeks prior to clinic presentation < 0.001 Yes 383(28.4) 201(37.6) 182(22.6) No 966(71.6) 333(62.4) 623(77.4) aOut of a total of 1349 enrolees, 10 patients are missing data on sex b18 patients missing data on age c23 patients missing data on the educational level p-value was obtained via the chi-square test Page 4 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 that only specific healthcare professionals should pre- scribe antimicrobials. However, legal structures to enforce adherence do not exist. Unauthorized groups, including licensed chemical sellers and traditional practi- tioners, contribute to the unauthorized sale of antibiotics [22]. Identification of pharmacists as the primary source for obtaining antimicrobials for symptomatic treatment of urethritis or cervicitis aligns with previous research and signifies a persistent and crucial aspect of healthcare access and medication distribution [23]. The convenience and accessibility of community pharmacies, especially for individuals seeking treatment for potential sexually trans- mitted infections, may contribute to the high percentage observed in this study. The influence of pharmacies on patient decision-making is noteworthy, and understand- ing the factors that drive patients to choose pharmacies is essential. The unregulated use of antimicrobials in LMICs, such as Ghana, is influenced by factors like a lack of aware- ness regarding the long-term consequences of unchecked antimicrobial use on AMR, a shortage of qualified pharmaceutical staff, and economic pressures on drug retailers [24]. Administering antimicrobials before diag- nostic evaluations may impede pathogen growth, leading to false-negative culture results and complicating treat- ment decisions [25]. Additionally, this practice may prove ineffective against the pathogen due to antimicrobial resistance, resulting in the unwarranted and excessive use of antibiotics. Notably, our study revealed signifi- cantly higher gonorrhea Nucleic Acid Amplification Test (NAAT) positivity among individuals reporting antimi- crobial use before presenting at a health facility compared to those without prior treatment. This substantiates the ineffectiveness of most antimicrobials consumed before hospital presentation in treating the underlying infec- tion. The AMR surveillance data gathered from the study participants detailed in this research reveals a concern- ing scenario with prevalence rates exceeding 80% for resistance to tetracycline, penicillin, and ciprofloxacin among N. gonorrhoeae specimens collected through- out the study period [17]. This underscores the critical Fig. 1 Description of the most commonly used antimicrobials by study participants before hospital presentation (N=383) This figure includes multiple responses Page 5 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 necessity for heightened awareness among the Ghanaian public regarding the judicious use of antibiotics. The case of gonorrhea infections serves as a poignant example, signaling that the pathogen is teetering on the verge of becoming untreatable due to escalating antimicro- bial resistance against commonly employed antibiotics. Urgent and concerted efforts are imperative to promote responsible antibiotic usage and curb the dangerous rise of resistance in the context of STIs. Several limitations should be considered in interpreting the findings of this study. Firstly, the study questionnaire did not comprehensively address whether participants obtained antimicrobials with a prescription, leaving a gap in understanding the regulatory context of antimi- crobial access. Additionally, the absence of information on whether study participants had been referred from other healthcare centers limits the contextualization of antimicrobial self-use among patients with urethritis/ cervicitis. Furthermore, the study’s data was derived from a specific subset of the Ghanaian population, poten- tially impacting the generalizability of the findings to a broader demographic. Nonetheless, while confined to individuals exhibiting symptoms of Sexually Transmit- ted Infections (STIs) within a specific segment of the Ghanaian population, the findings from this study align with prior research on antimicrobial utilization across diverse patient cohorts. For instance, a study encom- passing patients awaiting laboratory tests in the Ashanti and Eastern Regions, primarily for conditions like diar- rhea, aches, pains, or urinary tract infections, reported a similar trend, with approximately a fifth disclosing prior Table 2 Antibiotics and other medication taken by patients within two weeks prior to hospital presentation Type of antibiotic or treatment Totala (N%) Male (n%) Female (n%) p- value Amoxycillin 79(20.6) 32(15.9) 47(25.8) 0.022b Ciprofloxacin 77(20.1) 43(21.4) 34(18.7) 0.526b Doxycycline 23(6.1) 10(5.0) 13(7.1) 0.397b Herbal medicine 20(5.2) 13(6.5) 7(3.9) 0.358c Penicillin 10(2.6) 7(3.5) 3(1.7) 0.343c Trimethoprim/ sulfamethoxazole 10(2.6) 5(2.5) 5(2.8) 1.000c Ampicillin 8(2.1) 5(2.5) 3(1.7) 0.726c Flucloxacillin 7(1.8) 4(2.0) 3(1.7) 1.000c Metronidazole 6(1.6) 1(0.5) 5(2.8) 0.106c Ceftriaxone 4(1.0) 1(0.5) 3(1.7) 0.350c Chloramphenicol 2(0.5) 2(1.0) 0(0.0) 0.500c Kanamycin 2(0.5) 2(1.0) 0(0.0) 0.500c Cefuroxime 1(0.3) 0(0.0) 1(0.6) 0.475c Tetracycline 1(0.3) 0(0.0) 1(0.6) 0.475c Others 55(14.4) 28(13.9) 27(14.8) 0.884b Cannot remember drug name 138 (36) 82(40.8) 56(30.8) 0.041b aTotal drugs taken do not add up to the number of patients because some reported taking more than one antimicrobial bp-value was obtained via the chi-square test cp-value was obtained via Fisher’s exact test Fig. 2 Trends of antimicrobial use within age groups stratified by sex Page 6 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 antimicrobial use before seeking medical attention [8]. Notably, in that study, urine bioassays revealed a signifi- cantly higher antimicrobial activity rate (31.6%) than the self-reported treatment rates but comparable to the self- reported treatment rates observed in the current investi- gation. Unfortunately, the present study did not perform antimicrobial activity tests of patients’ urine for com- parison. Such assay results could have helped confirm the reported antimicrobial use of study participants. These limitations underscore the need for caution in extrapolat- ing the results and emphasize avenues for more extensive investigation, including a nuanced exploration of pre- scription practices and referrals in future studies. Conclusion The utilization of penicillin-based drugs, ciprofloxacin, and trimethoprim-sulfamethoxazole for empirical gon- orrhea treatment in Ghanaian health facilities should be reassessed. Investigating prior antimicrobial intake, pro- moting reliance on laboratory test results for treatment decisions, and conducting targeted public education, especially for males with urethral discharge, can curb unsupervised antimicrobial use. Continuous education for healthcare providers, informed by available AMR surveillance data, will ensure the judicious use of recom- mended antimicrobials in empirical treatment. Finally, strengthening law enforcement capabilities is vital for addressing non-compliance with established regulations and policies governing antimicrobial importation, sale, and usage. This multifaceted approach will enhance treat- ment efficacy, reduce AMR, and promote responsible antimicrobial practices. Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s13756-023-01351-8. Supplementary Material 1 Acknowledgements The authors would like to express their gratitude to the Public Health Directors and staff of the 37th Military Hospital, Adabraka STI clinic, and the three health centers that make up the 2Garrison at Sekondi-Takoradi for permission to perform the surveillance at their facilities. Author contributions Conceptualization (NA), study implementation (NA, AL, AF, HD), study coordination (NA, HD, EB, EON, NNAK, CK), manuscript draft (NA), Specimen testing (HD, JY, KO), manuscript editing (HD, EB, NNAK, AF, AL, KAK), Data analysis (EB), data acquisition (NA, HD, EB, EON, CK, NNAK), acquisition of funding (AL, TS). Funding The views expressed in this article reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, the Department of Defense, the U.S. Government, or the institutions affiliated with the authors. Financial support for this study was from the Armed Forces Health Surveillance Division (AFHSD), Global Emerging Infections Surveillance (GEIS) Branch (funding year 2018, ProMIS ID P0028_18_N3_2.1). Data availability The data supporting the findings of this study are available within the paper and its Supplementary Information. The raw data however, are available from the corresponding author upon reasonable request and are located in controlled access storage. Declarations Institutional review board statement Ethical approval was obtained from the Noguchi Memorial Institute Institutional Review Board (Ethical code number: 054/11–12, Date of approval: 03/02/2012), 37-Military Hospital Institutional Review Board (Ethical code number: 085/2017, Date of approval: 21/03/2017), and the Naval Medical Research Centre Institutional Review Board (Ethical code number: NAMRU3.2012.0007; Date of approval: 15/05/2018) in compliance with all applicable U.S. federal regulations governing the protection of human subjects. Conflict of interest The authors declare no conflict of interest. Commander Andrew Letizia and Lieutenant Commander Sanders are U.S. military service members, while Dr. Naiki Attram is an employee of the U.S. Government. This work was prepared as part of their official duties. Title 17, U.S.C., § 105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., § 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. The funders had no role in the study design, in the collection, analyses, or interpretation of data, in writing the manuscript, or in the decision to publish the results. Received: 14 September 2023 / Accepted: 1 December 2023 References 1. W.H.O., Global action plan on antimicrobial resistance. 2015. 2. Laxminarayan. RDLH. Challenges of drug resistance in the developing world: short communication. British Medical Journal. 2012. 3. Martin J, Leah FM, Doré K, Buxton JA, Pollari F, Henry B, Middleton D, Ahmed R, Jamieson F, Ciebin B, McEwen SA, Wilson JB. Multi-provincial Salmonella Typhimurium Case-Control Study Steering Committee. Increased burden of Illness associated with antimicrobial-resistant Salmonella enterica serotype typhimurium Infections. J Infect Dis. 2004;189(3). 4. O’Neill J. Tackling drug-resistant infections globally: Final report and recommen- dations. 2016. 5. Tadesse BT, Ongarello AEA, Havumaki S, Wijegoonewardena J, González M IJ, Dittrich S. Antimicrobial resistance in Africa: a systematic review. BMC Infect Dis. 2010;17. 6. Stije J, Leopold FL, Tarekegn H, Schultsz C. Antimicrobial drug resistance among clinically relevant bacterial isolates in sub-saharan Africa: a systematic review. Jounals of Antimicrobials and Chemotherapy. 2014;69. 7. Okeke IN, Laxminarayan R, Bhutta ZA, Duse AG, Jenkins P, O’Brien TF, Pablos- Mendez A. Antimicrobial resistance in developing countries. Part I: recent trends and current status. The Lancet Infectious Diseases. 2005;5. 8. Donkor GY, Dontoh E, Owusu-Ofori A. A cross-sectional study on the prevalence of antibiotic use prior to laboratory tests at two Ghanaian hospitals. PLoS ONE. 2019;14(1). 9. W.H.O., Antimicrobial resistance: global report on surveillance 2014. 10. Unemo M, Lahra MM, Cole M, Galarza P, Ndowa F, Martin I, Dillon J-AR, Ramon-Pardo P, Bolan G, Wi T. World Health Organization Global Gonococ- cal Antimicrobial Surveillance Program (WHO GASP): review of new data and evidence to inform international collaborative actions and research efforts. Sex Health. 2019;16(5). 11. England PH. Update on investigation of UK case of Neisseria gonorrhoeae with high-level resistance to azithromycin and resistance to ceftriaxone acquired abroad, in Health Protection Report. 2018. https://doi.org/10.1186/s13756-023-01351-8 https://doi.org/10.1186/s13756-023-01351-8 Page 7 of 7Attram et al. Antimicrobial Resistance & Infection Control (2023) 12:146 12. Eyre DW, Lord SND, Regisford-Reimmer E, Chau N, Barker K, Morgan L, Newn- ham M, Golparian R, Unemo D, Crook M, Peto DW, Hughes TE, Cole G, Fifer MJ, Edwards HA, Andersson MI. Gonorrhoea treatment failure caused by a Neis- seria gonorrhoeae strain with combined ceftriaxone and high-level azithromycin resistance, England, February 2018 Euro Surveillance. 2018;23. 13. Fifer H, Jones NU, Alexander L, Hughes S, Golparian GD, Unemo M. Failure of dual antimicrobial therapy in treatment of Gonorrhea. N Engl J Med. 2016;374(25):2504–6. 14. Poncin T, Fouere S, Braille A, Camelena F, Agsous M, Bebear C, Kumanski S, Lot F, Mercier-Delarue S, Ngangro NN, Salmona M, Schnepf N, Timsit J, Unemo M, Bercot B. Multidrug-resistant Neisseria gonorrhoeae failing treatment with ceftri- axone and doxycycline in France, November 2017. Euro Surveill. 2018;23(21). 15. Ministry of Health GNDPG. Standard Treatment Guidelines (STG) and Essential Medicines List 7th ed. Ghana: Ministry of Health; 2017: p. p 442–447. 16. Attram N, Agbodzi B, Dela H, Behene E, Nyarko EO, Kyei NNA, Larbi JA, Law- son BWL, Addo KK, Newman MJ, Duplessis CA, Adams N, Unemo M, Letizia AG. Antimicrobial resistance (AMR) and molecular characterization of Neisseria gonorrhoeae in Ghana, 2012–2015. PLoS ONE. 2019;14(10). 17. Dela H, Behene AN, Kumordjie E, Addo S, Nyarko KK, Kyei EO, Carroll NNA, Kwakye JNA, Duplessis C, Adams CA, Garges N, Letizia E. A.G., Risk factors asso- ciated with gonorrhea and chlamydia transmission in selected health facilities in Ghana. BMC Infect Disease. 2019;16(1). 18. Mensah BN, Agyemeng IB, Afriyie DK, Amponsah SK. Self-medication practice in Akuse, a rural setting in Ghana. Nigerian Postgrad Med J. 2019;26(3):189–94. 19. Berkley JA, Mwangi LBS, Williams I, Bauni T E., Mwarumba S. Bacteremia among children admitted to a rural hospital in Kenya. N Engl J Med. 2005;352(1):39–47. 20. Unemo M, Shafer WM. Antimicrobial resistance in Neisseria gonorrhoeae in the 21st century: past, evolution, and future Clin Microbiol Rev. 2014;27(3):587– 613. https://doi.org/10.1128/CMR.00010-14. PMID: 24982323; PMCID: PMC4135894. 21. World Health Organization. (2016). WHO guidelines for the treatment of Neisseria gonorrhoeae. World Health Organization. https://iris.who.int/ handle/10665/246114. 22. https://fdaghana.gov.gh/wp-content/uploads/2017/06/NEW-DRUG-CLASSI- FICATION-LIST.pdf. 23. Yevutsey SK, Buabeng KO, Aikins M, Anto BP, Biritwum RB, Frimodt-Møller N, Gyansa-Lutterodt M. Situational analysis of antibiotic use and resistance in Ghana: policy and regulation. BMC Public Health. 2017;17(1):896. 24. Mayhew S, Nzambi K, Pépin J, Adjei S. Pharmacists’ role in managing sexually transmitted Infections: policy issues and options for Ghana. Health Policy Plann. 2001;16:152–60. 25. Sakeena MHF, Bennett AA, McLachlan AJ. Non-prescription sales of antimi- crobial agents at community pharmacies in developing countries: a systematic review. Int J Antimicrob Agents, 2018. 52(6). Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. https://doi.org/10.1128/CMR.00010-14 https://iris.who.int/handle/10665/246114 https://iris.who.int/handle/10665/246114 http://fdaghana.gov.gh/wp-content/uploads/2017/06/NEW-DRUG-CLASSIFICATION-LIST.pdf http://fdaghana.gov.gh/wp-content/uploads/2017/06/NEW-DRUG-CLASSIFICATION-LIST.pdf Antimicrobial use of patients with sexually transmitted infection symptoms prior to presentation at five health facilities in Southern Ghana Abstract Background Methods Results Discussion Conclusion References