Chukwu et al.

Antimicrobial Resistance & Infection Control (2022) 11:134

https://doi.org/10.1186/s13756-022-01171-2

RESEARCH Open Access

High prevalence of resistance

to third‑generation cephalosporins detected
among clinical isolates from sentinel healthcare
facilities in Lagos, Nigeria
Emelda E. Chukwu1*, Oluwatoyin B. Awoderu1, Christian A. Enwuru1, Ebelechukwu E. Afocha1,
Rahman G. Lawal1, Rahaman A. Ahmed2, Ishola Olanrewaju1, Chika K. Onwuamah2, Rosemary A. Audu1,2 and
Folasade T. Ogunsola1,3

Abstract
Background: Antimicrobial resistance (AMR) in bacterial pathogens is a worldwide concern that demands immedi-
ate attention. Most information on AMR originates from high-income countries and little is known about the burden
in Africa, particularly Nigeria. Using four sentinel sites (General hospitals) in Lagos State, this study sought to estimate
the burden of AMR.
Methods: This is a hospital-based surveillance using secondary health care centres. Four sites were randomly
selected and included in the study. Clinical isolates were collected over a period of 6 months for each site from
August 2020 to March 2021. All isolates were characterised and analysed for resistance to 15 antibiotics using the
Kirby-Baur method. Multiplex PCR assay was used for the detection of Extended spectrum beta lactamase genes. Data
analysis was done using SPSS version 27.0.
Results: Four hundred and ninety-nine (499) patients consented and participated in this study, consisting of 412
(82.6%) females and 87 (17.4%) males. The mean age ± SD of the participants was 33.9 ± 13.8 with a range of 1–89
years. The majority (90.8%) of the participants were outpatients. Two hundred and thirty-two (232) isolates were
obtained from 219 samples, comprising of 120 (51.7%) Gram positive and 112 (48.3%) Gram negative organisms. Key
bacterial pathogens isolated from this study included Staphylococcus aureus (22.8%), Escherichia coli (16.4%), Staphylo-
coccus spp. (15.9%), Enterococcus spp. (7.3%) and Klebsiella pneumoniae (6.5%). There was high prevalence of multi-
drug resistance (79.3%) among the isolates with 73.6% of Staphylococcus aureus phenotypically resistant to methicillin
and 70% possessed the MecA gene. 76.5% of Enterococcus spp. isolated were Vancomycin resistant. Overall, resistance
to Cephalosporins was most frequently/commonly observed (Cefotaxime 87.5%).
Conclusion: A high incidence of AMR was identified in clinical bacteria isolates from selected general hospitals in
Lagos State, highlighting the necessity for the implementation of national action plans to limit the prevalence of AMR.
Surveillance via collection of isolates has a lot of promise, especially in resource-limited environments.

*Correspondence: emeldachukwu123@gmail.com
1
Antimicrobial Resistance Research group, Nigerian Institute of Medical
Research, Yaba, Lagos State, Nigeria
Full list of author information is available at the end of the article

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Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 2 of 11

Keywords: Antibiotics, Antimicrobial resistance, MecA, Clinical isolates, Resistance genes, ESBL genes, Staphylococcus
aureus, Nigeria

Introduction et al. [11] conducted a systematic review of AMR in

Antimicrobial resistance (AMR) in bacterial pathogens has Sub-Saharan Africa, highlighting the limitations of cur-
been established as a worldwide threat requiring urgent rent data and revealing a significant incidence of AMR
attention. Africa, with its high infectious disease burden, to routinely used antibiotics in clinical bacterial isolates.
is hampered by paucity of data on the burden of AMR. The As a result, more effort needs to be made in a stepwise
role of antibiotics in the treatment of infectious illnesses approach towards the implementation of a surveillance
cannot be overemphasized. However, the prevalence of plan. Appropriate data pertaining to the epidemiology
infectious diseases associated with cases of multidrug- of AMR can be obtained via phenotypic and genotypic
resistant (MDR) bacteria have been steadily rising [1]. detection of AMR strains of public health importance.
AMR has reached epidemic magnitudes, increasing Surveillance data can help influence clinical therapy deci-
public health concerns because there are few novel anti- sions and policy, and strategy formulation for AMR con-
biotics in development, especially for Gram-negative trol. As a preliminary step toward monitoring trends of
bacteria [2]. Therapeutic options for infections due to AMR development and spread in Lagos, this study pro-
bacteria have become increasingly limited. Poor regula- vides information on the prevalence of AMR in bacterial
tion of over-the-counter purchase of antibiotics remains clinical isolates in Lagos State.
an issue in Nigeria, more so in Lagos state with the num-
ber of patent and proprietary medication shops projected Methods
to be 1374 per 100,000 population in each local govern- Study design
ment area [3]. Many of these drug vendors and commu- This is a hospital-based survey which was piloted in
nity pharmacies purchase and stock, controlled drugs selected General hospitals (secondary health care cen-
including antibiotics that are outside their licensing and tres) in Lagos to assess the prevalence of AMR and ESBL
supply them over-the-counter without regulations [4]. production in bacteria strains from clinical samples. The
The incidence of extended spectrum beta-lactamase sentinel sites were randomly selected because their com-
(ESBL) producing pathogenic bacteria is increasing in bined catchment area covered most of the Lagos popu-
Nigeria. In research carried out in 2010 in Kano, North- lation and they also had appropriate/basic laboratory
western Nigeria to test for ESBL production among facilities and personnel for the detection of the bacteria
Enterobacteriaceae isolates, an ESBL prevalence of 9.25% pathogens of interest which was ensured using a check-
was identified [5]. Similarly, a study in 2010 conducted at list (Additional file 1). All bacterial isolates from clinical
a tertiary health institution in Ogun State, Southwestern specimens in selected general hospitals were included.
Nigeria, to determine ESBL prevalence in Escherichia Only participants who gave their consent to provide
coli and Klebsiella species, reported an ESBL prevalence clinical and laboratory data were enrolled for the study.
of 2.5% for Escherichia coli and 5% for Klebsiella pneu- Structured questionnaires were used to obtain demo-
moniae [6]. A higher prevalence was reported in 2016 by graphic information as well as predictors for assessing
Mohammed et al. [7] with an ESBL prevalence of 23.8% the relative risk of AMR.
for Escherichia coli and 30.0% for Klebsiella species in a
teaching hospital in North-eastern Nigeria. In a recent The study location/site
study, Akinyemi et al. [8] identified a significantly higher The study was carried out in Lagos State. The metropolis
incidence of 69.8% among Klebsiella pneumoniae iso- of Lagos is a low-lying and densely populated coastal area
lated from clinical samples from four medical centres in in the southwestern part of Nigeria. The study sites were
Lagos State. The problem of AMR can be exacerbated mapped based on the three senatorial districts in Lagos
by misconceptions on the use of antibiotics leading to state (Lagos East, Lagos west and Lagos central). Strati-
overuse and misuse. A recent survey revealed that many fied random sampling method was used to select two
Nigerians believe that catarrh, cold and flu, and measles, secondary health care facilities from each district giving a
are conditions requiring antibiotics [9]. total of six General Hospitals. However, two of the facili-
To combat AMR, the first step proposed in the WHO’s ties pulled out due to some logistical constraints which
Global Action Plan (GAP) is to conduct a baseline evalu- prevented them from meeting the requirements for the
ation of AMR prevalence in all countries [10]. Leopold study. The four sites used for this study included Lagos
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 3 of 11

Fig. 1 Schematic representation of Study design

Island Maternity Hospital (LIMH), Mushin General Hos- questionnaire administration, appropriate sample collec-
pital (MGH), Randle General Hospital (RGH) and Sho- tion, cultivation and isolation methods.
molu General Hospital (SGH), see Fig. 1.
Sample collection/ initial cultivation and isolation
Recruitment and training of personnel at the collection Routine, clinical sample specimens including sputum,
centres urine, stool and swabs from wounds, vagina, cervix, ear,
Two medical laboratory scientists (microbiology spe- eye and throat were collected at the sentinel sites (Gen-
cialty) working at the Microbiology department of the eral Hospitals). All individuals who presented at the four
hospital laboratory and the Head of the Department participating centers during the study period and gave
were selected from each center for a training workshop their consent to participate were included in the study.
prior to commencing the study. Study tools and pro- The samples were collected over a period of 6 months
cedures were harmonized, and they were trained on for each site from August 2020 to March 2021. All four
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 4 of 11

Table 1 List of primers used for the study

Target Primer Product size (BP) References

mecA F: AAA​ATC​GAT​GGT​AAA​GGT​TGGC​ 532 [14]

R: AGT​TCT​GCA​GTA​CCG​GAT​T TGC​
TEM F: TCG​CCG​CAT​ACA​C TA​T TC​TCA​AGA​ATGAC​ 422 [13]
R: CAG​CAA​TAA​ACC​AGC​CAG​CCG​GAA​G
SHV F: TGT​ATT​ATCTC(C/T) CTG​T TA​GCC(A/G) CCCTG​ 739 [13]
R: GCT​C TG​C TT​TGT​TAT​TCG​GGC​CAA​GC
CTX-M F: ATG​TGC​AGY​ACC​AGT​AAR​GTKATGGC​ 590 [13]
R: GGT​RAA​RTA​RGT​SACC​AGA​AYC​AGC​GG
VEB F: GAT​GGT​GTT​TGG​TCG​CAT​ATC​GCA​AC 391 [13]
R: CAT​CGC​TGT​TGG​GGT​TGC​CCA​ATT​T T

centers completed 6 months of sample collection from (1.25/23.75 µg). All the antibiotics were obtained from
their commencement date. Specimens were analysed Oxoid laboratories (OXOID). Diameters of the zones
following the routine protocol for bacteria isolation. of inhibition for individual antibacterial agents were
Pure growth colonies were presumptively identified and translated into susceptible, intermediate, and resistant
stored. All bacteria strains were placed on agar slants and categories, according to the CLSI criteria [12]. Multi-
transferred to the Microbiology department of the Nige- drug resistant microorganisms were defined as resist-
rian Institute of Medical Research where further micro- ant to at least three classes of antibacterial [12]. Isolates
biological and molecular analysis were carried out. with zones of inhibition ≤ 27 mm for cefotaxime and
≤ 22 mm for ceftazidime were selected as potential ESBL
Collection, characterization and storage of isolates producers.
Isolates were characterized using routine biochemical
methods. The identity was subsequently confirmed using Preparation of DNA template for polymerase chain
BD BioMic V3 biochemical rating Identification system:
DNA extraction was undertaken using the Quick-DNA™
reaction
—BioMic V3 is a semi-automated bacteriological iden-
tification system (Becton Dickinson, USA). Identified Miniprep plus kit (Inqaba Biotec West Africa Ltd) to
isolates were stored in duplicates at − 20 °C using 20% extract and purify the bacteria genomic DNA according
Glycerol-Brain heart infusion (BHI) broth and skimmed to manufacturer’s instructions. DNA concentrations and
milk until required for further processing. purity was determined using Nanodrop Spectrophotom-
eter ND-1000 (USA) and read at 280 nm and extracted
Detection of strains of MRSA by cefoxitin disc diffusion DNA was stored at − 20 °C.
method
Susceptibility of Staphylococcus aureus isolates to cefoxi- Genotyping of ESBL producing strains
tin (30 µg) was determined by modified Kirby-Bauer disc Genotyping of ESBL producing strains for beta-lacta-
diffusion method following Clinical Laboratory Standard mase genes TEM, SHV, CTX-M and VEB was performed
Institute (CLSI) guidelines [12] to screen for methicillin as described by Trung et al. [13]. The multiplex PCR was
resistance. All strains of Staphylococcus aureus were also optimized according to the following experimental con-
screened for MecA gene. ditions: Thermal cycling comprised initial denaturation
at 95 °C for 4 min, 35 cycles of 94 °C for 25 s, 58 °C for
Antimicrobial drug susceptibility testing 45 s and 72 °C for one minute [13].
Antibiotic susceptibility testing was performed using
the disk diffusion method (Kirby Bauer) according to the Detection of MecA Gene by Polymerase Chain Reaction
CLSI criteria on Mueller-Hinton agar plates (OXOID). (PCR).
The antibiotics used in this study included vancomycin The extracted DNA from Staphylococcus aureus was
(30 µg), penicillin G (10iU), amoxicillin- clavulanic acid subjected to PCR for detection of MecA gene using the
(20/10 µg), ofloxacin (5 µg), meropenem (10 µg), cefoxi- primer supplied by Inqaba biotec (see Table 1). Cycling
tin (30 µg), ceftazidime (30 µg), cefotaxime (30 µg), cip- parameter consists of initial denaturation at 94 °C for
rofloxacin (5 µg), gentamicin (10 µg), erythromycin 30 min, denaturation at 94 °C for 30 s, primer annealing
(15 µg), tetracycline (30 µg), chloramphenicol (30 µg), at 55 °C for 30 s, extension at ­72oC for 1 min and final
linezolid (30 µg) and trimethoprim sulfamethoxazole
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 5 of 11

Table 2 Socio-demographics of participants were outpatients. Two hundred and thirty-two (232) iso-
Variable Number (%)
lates were obtained from 219 samples comprising of 120
(51.7%) Gram positive and 112 (48.3%) Gram negative
Gender bacteria (Table 2). Key bacteria pathogens isolated from
Female 412 (82.6) this study include Staphylococcus aureus (22.8%), Staphy-
Male 87 (17.4) lococcus spp (15.9%), Escherichia coli (16.4%), Entero-
Total 499 (100) coccus spp (7.3%) and Klebsiella pneumoniae (6.5%) see
Patient status Table 3. The highest number of isolates was obtained
In-patient 45 (9) from MGH indicating a higher infection rate in this
Out-patient 453 (90.8) region (Table 4), however there was no significant differ-
Missing 1 (0.2) ence in the distribution of multi-drug resistant bacteria
Age category Mean age ± SD = 33.86 ± 13.8 (1–89 years) across the four centres ­(X2 = 5.47, p = 0.49).
0–20 56 (11.2) There was high prevalence of multi-drug resistance
21–40 326 (65.3) (79.3%) among the isolates with E. coli, S. aureus and
41–60 85 (17) K. pneumoniae showing 84.2%, 83% and 86.7% resist-
60 and above 27 (5.4) ance respectively (Table 3). Although the majority of the
Missing 5 (1) participants were within the age range of 21–40 years
Healthcare facility (Table 2), there was no significant difference in the dis-
LIMH 140 (28.1) tribution of multi-drug resistant bacteria across the age
MGH 143 (28.7)
RGH 125 (25.1)
SGH 91 (18.2)
Table 3 Distribution of Multi-drug resistance (MDR) across the
bacterial species. The WHO priority pathogens are highlighted in
Specimen type
bold
Urine 269 (53.9)
High Vaginal Swab 161 (32.3) Bacterial specie No Isolated Frequency of
MDR
Wound swab 17 (3.4) Number (%
Stool 12 (2.4) of species
Semen 11 (2.2) identified)
Sputum 10 (2) Staphylococcus aureus 53 44 (83)
Endocervical swab 9 (1.8) Escherichia coli 38 32 (84.2)
Ear swab 4 (0.8) Staphylococcus spp 39 23 (58.9)
Urethral swab 4 (0.8) Klebsiella pneumoniae 15 13 (86.7)
Throat swab I (0.2) Citrobacter koseri 12 10 (83.3)
Abdominal abscess 1 (0.2) Enterobacter aerogenes 12 7 (58.3)
Total 499 (100) Enterococcus spp 17 16 (94.1)
Gram reaction N = 232 Streptococcus spp 11 11 (100)
Gram positive 120 (51.7) Klebsiella spp 8 8 (100)
Gram negative 112 (48.3) Citrobacter freundii 4 3 (75)
Total 232 Enterobacter cloacae 4 1 (100)
Acinectobacter baumannii 3 2 (66.7)
Pseudomonas aeruginosa 3 3 (100)
extension at 72 °C for 10 min. For quality control, Escher- Burkholderia cepacian 2 2 (100)
ichia coli ATCC 25,922, S. aureus ATCC 25,923, S. aureus Proteus mirabilis 2 1 (50)
ATCC 29,213 (MecA negative), and S. aureus ATCC Pseudomonas oryzihabitans 2 2 (100)
700,699 (MecA positive) were used. Salmonella spp 2 1 (50)
Chromobacterium violaceum 1 1 (100)
Result Cronobacter sakazaki 1 1 (100)
Four hundred and ninety-nine (499) patients consented Micrococcus luteus 1 1 (100)
and participated in this study consisting of 412 (82.6%) Pluralibacter gergoviae 1 1 (100)
females and 87 (17.4%) males (Table 2). The mean Stenotrophomonas xanthoma 1 1 (100)
age ± SD of participants was 33.9 ± 13.8 with a range Total 232 184 (79.3)
of 1–89 years. The majority (90.8%) of the participants Bold signifies WHO priority pathogens
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 6 of 11

Table 4 Distribution of isolates across the centres

Sentinel centres No of patients with request for No of patients who consented and No of isolates MDR prevalence (%)
culture within the study period participated in the study obtained X2 = 5.47
P = 0.49

LIMH 402 140 (34.8%) 36 (25.7%) 29 (80.6)

MGH 302 143(47.4%) 113 (79%) 88 (77.6)
RGH 330 125 (37.8%) 38 (30.4%) 29 (76.3)
SGH 691 91 (13.2%) 45 (49.5%) 38 (84.4)
Total 1725 499 232 (46.5%) 184 (79.3)

Fig. 2 Distribution of Multi-drug resistance across the age categories

categories ­(X2 = 3.92, p = 0.69)—see Fig. 2. A few of the Discussion

participants (6.9%) reported exposure to domestic ani- Infections caused by multi-drug resistant bacteria
mals with the majority being exposed to dogs (43.8%) are on the rise leading to treatment failure, prolonged
and poultry (25.0%). Participants who were exposed to hospital stay, and death [11]. We report the results of
domestic animals were more likely to have multi-drug a laboratory survey of AMR in four sentinel sites (gen-
resistant infections ­(X2 = 7.963, p = 0.019). In general, eral hospitals) in Lagos State. General hospitals (GH)
resistance to Cephalosporins was highest (Figs. 3 and 4) in Lagos State are secondary public healthcare centres
while 76.5% of Enterococcus spp isolated were resistant which are slightly more equipped than the primary
to vancomycin. The majority (73.6%) of Staphylococcus health centres but have fewer facilities than the teach-
aureus were phenotypically resistant to methicillin and ing hospitals (Tertiary). These hospitals are commu-
70% possessed the MecA gene (Fig. 5). nity-based entities that admit all types of medical and
surgical cases but concentrate on patients with acute
ESBL genotyping using ­blaCTX−M, ­blaTEM, ­blaSHV and ­blaVEB illnesses needing relatively short-term care. There was
Out of 57 Gram negative isolates subjected to ESBL gen- a female preponderance in the study participants which
otyping (37 E.coli and 20 Klebsilella spp), 46 (80.7%) had was partly due to the fact that one of the facilities
at least one ESBL gene. Of these, 38(66.7%) had ­blaTEM , (LIMH) was specifically a mother-and-child hospital.
3 (5.3%) had only b­ laSHV while 5(8.8%) had both b­ laTEM That notwithstanding, more women consented to par-
and ­blaSHV genes. Eleven (19.3%) were negative to all the ticipate in the study than males. This female prepon-
ESBL genes tested (Fig. 6). None of the isolates exhibited derance has also been reported in a laboratory-based
­blaCTX−M or ­blaVEB ESBL genes. surveillance of AMR in Ghana [15].
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 7 of 11

Fig. 3 Resistance profile of Gram-positive bacteria isolates

Fig. 4 Resistance profile of Gram-Negative bacteria isolates

The facilities being general hospitals, had limited bed- during that period. Although the highest number of iso-
space, hence the lower number of in-patient (9%) com- lates were obtained from MGH showing a higher rate of
pared to out-patient (90.8%) participants. Also, the infection in this region, there was no significant differ-
COVID-19 pandemic and partial lock down during the ence in the distribution of multi-drug resistant bacteria
study period may have affected the number of in-patients across the four centres (p = 0.49).
as people were generally weary of going to hospitals
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 8 of 11

the need for a one health approach towards understand-

ing the true burden of MDR pathogens, especially in low-
and-middle income countries.
The present study showed high prevalence of resistance
to third-generation cephalosporins across both Gram-
positive and Gram-negative bacteria isolated. Increasing
trend of resistance to third generation cephalosporins
have been reported by previous studies in Nigeria [23,
24]. This may likely indicate an overuse of these group of
antibiotics. A point prevalence of survey to determine the
rate of antibiotic prescription in four tertiary hospitals
in Nigeria, reported that about 50% of prescriptions in
these hospitals lacked clear therapeutic indications and
third generation cephalosporins was fingered as the most
prescribed antibiotics [25]. Third-generation cephalo-
sporins are broad-spectrum antibiotics that are useful in
the treatment of variety of clinical infections. Therefore,
high levels of resistance to these antimicrobials are wor-
risome. Also, antibiotics of last resort, such as linezolid, a
WHO reserve antibiotic [26] for the treatment of infec-
tion caused by multi-drug resistant Gram-positive bacte-
Fig. 5 Agarose gel containing representative amplicon for the
detection of MecA genes. Lane M, DNA ladder, Lane1 is a negative
ria, showed a concerning susceptibility profile with 33%
control, lane 2 is a positive control while Lane 3 to 30 contains resistance (Fig. 3). The high prevalence of MDR (79.3%)
representative band for MecA gene at 532 bp recorded in this study has also been reported elsewhere
in Iraq with 75% and 87.5% MDR phenotypes for K.
pneumoniae and E. coli isolates respectively [27]. This is
Gram-positive and gram-negative bacteria were iden- a huge concern for clinical epidemiology and infectious
tified in the current study, consistent with other surveil- diseases management.
lance studies [15–17]. Although some opinions have Methicillin resistant Staphylococcus aureus (MRSA) is
suggested the focus on WHO priority specimen and emerging as one of the major pathogens of public health
pathogens in surveillance, there are contrary opinion concern. Methicillin resistance in Staphylococcus aureus
to this [18, 19]. This study considered all clinical speci- confers resistance to the entire classes of -lactams includ-
mens received for culture at the sentinel sites during the ing cephalosporins and carbapenems and has a higher
study period, and therefore, captured both priority and risk of development of resistance to the quinolones, ami-
non-priority pathogens which may be contributing to noglycosides, and macrolides [28, 29]. The high preva-
AMR through transfer of antibiotic resistance genes. The lence of MRSA (73.6%) recorded in this study is a source
most prevalent pathogens isolated in the current study of major concern and this trend has also been reported
included Escherichia coli and Staphylococcus aureus in previous studies [30]. However, Adhikari et al. [31]
with K. pneumoniae, E. coli and S. aureus and showing reported a lower prevalence (35.5%) in S. aureus isolated
the highest prevalence of multi-drug resistance, in 86.7%, from wound/pus of patients attending a tertiary care hos-
84.2% and 83% of clinical isolates respectively. These pital in Kathmandu, Nepal. The MecA gene was not pre-
findings are similar to the report of surveillance studies sent in some of the strains of MRSA screened by cefoxitin
conducted elsewhere in Ghana [15], Europe [20], and disc diffusion method, but CLSI guidelines stipulates that
Southwestern Nigeria [21]. Exposure to domestic ani- S. aureus isolates should be regarded as MRSA if they
mals was a significant risk factor for multi-drug resistant are found resistant to either cefoxitin or oxacillin or both
infection in this study. The abuse of antibiotics in the care regardless of the presence or absence of MecA gene [32].
of domestic / companion animals including dogs, poultry The use of multiplex PCR to screen for ­ blaCTX− M,
and fish has been recognized as a major driver of AMR. ­blaTEM, ­blaSHV and ­blaVEB ESBL genes in Escherichia coli
Iramiot et al. [22] reported high prevalence of multi-drug and Klebsiella spps from this study showed high preva-
resistance among organisms from both human (93%) and lence (80.7%) of ESBL genes with 66.7% having ­blaTEM
animal (83%) rectal swabs in Southwestern Uganda and gene. This is contrary to global picture in which the most
suggested a high likelihood of transmission of multi-drug common type of ESBL is reported to be CTX-M-type
resistance between humans and animals. This reiterates ESBLs when compared to SHV and TEM ESBLs [33].
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 9 of 11

Fig. 6 Agarose gel showing amplicon for ­blaTEM, and b­ laSHV ESBL genes with 422 bp and 739 bp band size respectively. Figure 6A lane 4 &13 and
Fig. 6B lane 5 shows bands for ­blaTEM, ­blaSHV genes

Our study did not record any CTX-M genes among the the potential to provide a more realistic picture of the
tested isolates. High prevalence of b ­ laTEM has also been burden of AMR in the locality.
reported by Pishtiwan and Khadija [27] among ESBL-
producing Klebsiella pneumoniae (81%) and Escherichia Limitations
coli (64.7%) isolated from thalassemia patients in Erbil, Some facilities had various challenges such as the break-
Iraq. Similarly, Ghorbani-Dalini et al. [34], reported a down of the autoclave and incubators plus stock outs
higher prevalence of ­blaTEM gene (83.33%) and concluded which led to interruption in sample collection and pro-
that the ­blaTEM gene for ESBLs-producing E. coli was cessing. Also, COVID-19 pandemic and its attendant
widespread in Iran. issues including partial to total lockdown drastically
ESBL production in certain bacteria strains can pre- reduced the number of people presenting at the centres
cipitate resistance to other classes of antibiotics (amino- for microbiological tests during the study period.
glycosides, quinolones, and sulfonamides) complicating Some participants declined consent to participate cit-
treatment strategies [35]. Multi-drug resistant ESBL pro- ing concerns that their samples were being used for
ducing bacteria was found to be generally high in this COVID-19 research. Although efforts were made to edu-
study. The higher prevalence of b ­ laTEM recorded in this cate the patients properly on the objectives of the study,
study buttresses the need for periodic monitoring of a lot of people declined participation, and this greatly
resistance patterns and resistance genes of bacterial path- affected the uptake of study especially at the SGH site.
ogens in a geographical area for adequate control and Furthermore, the sites did not process specialized sam-
surveillance of antibiotic resistance. ples such as blood culture and cerebrospinal fluid (CSF)
The high level of antibiotic resistance recorded in this during the study period. It may either be that these tests
study has dire implication for empirical treatment. There are not routinely requested for, or they lacked adequate
is urgent need for development of suitable surveillance facilities for processing them. The study however, ana-
tools, especially for monitoring AMR to ensure periodic lysed routine samples collected at the designated cen-
review/update of empirical treatment guideline. The tres and had no influence on the examination requested
strength of this surveillance model is that unlike the sen- or the sample type. There was a female preponderance
tinel model with teaching hospitals proposed by Moham- in the study which was partly due to the fact that one of
med et al. [36] and currently being conducted by the the centres was a “mother and child” hospital (LIMH).
Nigerian Center for Disease Control (NCDC), this model However, the perception of general hospitals, as more of
uses General hospitals which are usually the first point maternity centres may have also contributed to the higher
of call for citizens seeking healthcare and has the ability number of females than males. Additionally, females are
to include the grass root population. The high number of more likely to give their consent and participate in health
out-patients (90.8%) in this study invariably provides an studies than males who may perceive it as time wasting.
insight on the community prevalence of AMR. Further-
more, teaching hospitals in Nigeria are referral centres Conclusion
where majority of the cases are chronic and have under- Based on our findings in this pilot study, there was a high
gone initial treatment at the referring centres with little prevalence of AMR in clinical bacteria isolates from gen-
or no success. As a result, survey of general hospitals has eral hospitals in Lagos State stressing the need for urgent
Chukwu et al. Antimicrobial Resistance & Infection Control (2022) 11:134 Page 10 of 11

implementation of national action plans to tackle AMR. Data availability

All data generated or analysed during this study are included in this published
It is clear that laboratory-based AMR surveillance by article [and its supplementary information files] Original data set are available
isolate collection can yield reliable data on the resistant from the corresponding author upon reasonable request.
profile and possible trend in the emergence and spread
of resistance. Sentinel protocols involving the collection Declarations
of isolates may have the common drawback of producing
Ethics approval and consent to participate
a smaller dataset, but it has the advantage of high repro- Ethical clearance was obtained from Nigerian Institute of Medical Research
ducibility since all isolates are tested under the same Institutional Review Board (IRB/19/022). Also, social permission to conduct this
conditions using standardized methods and antibiotic study was obtained from Lagos State Ministry of Health (LSMH/2695/II/141)
and Lagos State Health Service commission (SHSC/2222/VOL.1/49). All partici-
panels. This is crucial in a resource poor setting where pants willingly signed an informed consent form before demographic infor-
healthcare centres have limited facilities for monitor- mation was obtained from them using a questionnaire. Information obtained
ing AMR and further ensures uniformity of data gener- from the patients were treated as confidential. Unique identifiers were used to
identify the samples and data management protocols were followed.
ated for ease of comparability. We recommend that this
approach be standardized and escalated for investigating Consent for publication
and monitoring of AMR in other states with the aim to Not applicable.
ascertain the burden of AMR in Nigeria. Competing interests
The authors declare that they have no competing interests.

Abbreviations Author details

AMR: Antimicrobial resistance; ESBL: Extended spectrum beta-lactamase; CLSI: 1
Antimicrobial Resistance Research group, Nigerian Institute of Medical
Clinical Laboratory Standard Institute; DNA: Deoxyribonucleic acid; NIMR: Research, Yaba, Lagos State, Nigeria. 2 Center for Human Virology and Genom-
Nigerian Institute of Medical Research; SPSS: Statistical package for social ics, Microbiology Department, Nigerian Institute of Medical Research, Yaba,
sciences; GAP: Global action plan; NAP: National action plan; MDR: Multidrug Lagos State, Nigeria. 3 Department of Medical Microbiology and Parasitology,
resistance; LIMH: Lagos Island Maternity Hospital; MGH: Mushin General Hospi- College of Medicine, University of Lagos, Idi‑Araba, Nigeria.
tal; RGH: Randle General Hospital; SGH: Shomolu General Hospital.
Received: 9 May 2022 Accepted: 17 October 2022
Supplementary Information
The online version contains supplementary material available at https://​doi.​
org/​10.​1186/​s13756-​022-​01171-2.
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