In the developing countries under review, there are limited data from large surveillance studies on antimicrobial resistance. In addition few short clinical studies document the susceptibility pattern of common pathogens from human and animals. This may partly be due to the lack of microbiological facilities in many health facilities in developing countries . Our findings emphasize the need for coordinated efforts to improve the diagnosis of infectious diseases in developing countries coupled with surveillance of antimicrobial resistance in these countries. Together with the increased effort by WHO to control malaria transmission, other potential causes of fever should be taken into consideration; and appropriate antibiotic treatment will reduce morbidity and mortality resulting from other causes of fever.
Despite few studies blood stream and urinary tract infections have been found to be common in these countries as demonstrated in this review and it should be noted that the endemicity of HIV has changed their epidemiology in Africa. Apart from Salmonella spp; multi-drug Escherichia coli and Klebsiella pneumoniae were found to be common causes of blood stream infections and UTI. Increased trend of these isolates to become resistant to ampicillin, gentamicin and third generations’ cephalosporins was noted; this could be due to overuse of these drugs in the community and hospitals, in all countries reviewed no clear antibiotic policy was found.
ESBL has been found to be a threat, especially as a cause of nosocomial infections. Prevalence as high as 50% have been observed among Klebsiella pneumoniae from inpatients in these countries. The occurrence of the Escherichia coli clone ST 131 in Tanzania confirms that resistant clones can spread from one part of the world to another . Low mean resistance rates to meropenem were observed in these countries; this could be explained by the fact that this drug is expensive and not available in the market. There is an urgent need of antibiotic policy in these countries because in countries where carbapenems have been misused, such as India or Pakistan, outbreaks of carbapenems resistant Escherichia coli and Klebsiella pneumoniae have been experienced . Recently, the emergence of NDM-1 plasmid mediated carbapenems resistance has been noted, spreading from India to Europe, USA and Africa. Joint efforts are needed to control the spread of NDM-1.
In this review few studies were found to address enteric pathogens, it was noted that Shigella spp were more resistance than Salmonella spp; an increase trend of multi--drug resistant Shigella spp in DRC was noted. Similarly most of diarrheagenic Escherichia coli were resistant to commonly used antibiotics (ampicillin, co-trimoxazole, tetracycline and erythromycin). This could be due to self prescription of these antibiotics for the treatment of diarrhea episodes as evidenced by increased resistance of Vibrio cholerae strains between outbreaks in Zambia and Tanzania. In all countries under review, many patients buy antibiotics from private pharmacies and drug shops for self-medication before seeking medical professional care [80–82]. In addition Campylobacter spp were found to be resistant to ciprofloxacin, cefuroxime and erythromycin. This situation needs to be further investigated with standardize microbiological method so that the real magnitude can be established or confirmed.
In addition, MRSA appears to be an emerging problem; the problem might be underestimated because not all laboratories in these countries are performing MRSA identification. However Staphylococcus aureus has been the major cause of SSI, as documented in few studies from these countries. The increase trend of MRSA as noted in Tanzania; necessitate the coordinated surveillance to determine the evolution of these strains in Africa. MRSA isolates have been isolated from animals and we need, therefore, to compare the genotypes between animals and humans, as evidenced by the diversity of MRSA genotypes in Tanzania and Zambia [68–70].
Few laboratories are routinely conducting testing for ESBL and MRSA detection. This observation stresses the need for governmental and non- governmental organizations to provide sustainable support to improve laboratory capacity in developing countries. This should go hand in hand with the establishment of a quality assurance system to ensure quality microbiological results from all laboratories. As noted in Tanzania, there is an increased resistance trend to ceftriaxone and ceftazidime among isolates causing nosocomial infections. Improving diagnostic facilities and research capacity to determine the evolution of ESBL and MRSA clones in Africa is no longer an option but is mandatory, especially when the treatment of ESBL producing isolates and MRSA becomes too expensive for countries like DRC, Mozambique, Tanzania and Zambia.
Unauthorized use of antibiotics seems to be common, both in medical and veterinary settings. While we have found no evidence linking antimicrobial resistance in human cases with the use of similar antibiotics in animals, there is a need for a coordinated one health based surveillance of the antimicrobial resistance in humans and animals. It appears also relevant to follow the recommendations of the Joint FAO-OIE-WHO on non-human antimicrobial usage.