Assessing Changes in Bacterial Load and Antibiotic Resistance in the Legon Sewage Treatment Plant between 2018 and 2023 in Accra, Ghana.

Wastewater treatment plants are efficient in reducing bacterial loads but are also considered potential drivers of environmental antimicrobial resistance (AMR). In this study, we determined the effect of increased influent wastewater volume (from 40% to 66%) in the Legon sewage treatment plant (STP) on the removal of E. coli from sewage, along with changes in AMR profiles. This before and after study compared E. coli loads and AMR patterns in influent and effluent samples from a published baseline study (January-June 2018) with a follow-up study (March-May 2023). Extended-spectrum beta-lactamase (ESBL) E. coli were measured pre- and post-sewage treatment during the follow-up study. The follow-up study showed 7.4% and 24% ESBL E. coli proportions in influent and effluent, respectively. In both studies, the STP was 99% efficient in reducing E. coli loads in effluents, with no significant difference (p = 0.42) between the two periods. More E. coli resistance to antimicrobials was seen in effluents in the follow-up study versus the baseline study. The increased influent capacity did not reduce the efficiency of the STP in removing E. coli from influent wastewater but was associated with increased AMR patterns in effluent water. Further studies are required to determine whether these changes have significant effects on human health.

Antibiotic-Resistant Bacteria in Drinking Water from the Greater Accra Region, Ghana: A Cross-Sectional Study, December 2021-March 2022.

With safely managed water accessible to only 19% of the population in Ghana, the majority of its residents are at risk of drinking contaminated water. Furthermore, this water could be a potential vehicle for the transmission of antimicrobial-resistant bacteria. This study assessed the presence of bacteria and the antibiotic resistance profile of Escherichia coli and Pseudomonas aeruginosa in drinking-water sources using membrane filtration and Kirby-Bauer disc diffusion methods. A total of 524 water samples were analyzed for total coliforms, total heterotrophic bacteria, E. coli and P. aeruginosa. Samples included sachets, bottled water, tap water, borehole and well water. Most of the sachet and bottled water samples were within the limits of Ghana's standards for safe drinking water for the parameters tested. Over 50% of tap and borehole water was also free of E. coli and P. aeruginosa. Overall, of 115 E. coli isolates from tap and ground water samples, most were resistant to cefuroxime (88.7%), trimethoprim-sulfamethoxazole (62.6%) and amoxicillin-clavulanate (52.2%). P. aeruginosa isolates were most resistant to aztreonam (48%). Multidrug resistance was predominantly seen among E. coli isolates (58%). Evidence from this study calls for routine antimicrobial resistance surveillance in drinking water across the country and additional treatment of water sources at household levels.

What Is in the Salad? Escherichia coli and Antibiotic Resistance in Lettuce Irrigated with Various Water Sources in Ghana.

INTRODUCTION: Safety of the environment in which vegetables are grown, marketed and consumed is paramount as most are eaten raw. Irrigation sources include open drains and streams, which are often contaminated with human and animal waste due to poor sanitation infrastructure. In irrigated vegetable farms using such sources in Ghana, we assessed Escherichia coli counts, antibiotic resistance patterns and resistant genes on irrigated lettuce. METHODS: A cross-sectional study was conducted between January-May 2022, involving five major vegetable farms in Ghana. RESULTS: Escherichia coli was found in all 25 composite lettuce samples analyzed. Counts expressed in CFU/g ranged from 186 to 3000, with the highest counts found in lettuce irrigated from open drains (1670) and tap water using hose pipes (3000). Among all bacterial isolates, resistance ranged between 49% and 70% for the Watch group of antibiotics, 59% for the Reserved group and 82% were multidrug-resistant. Of 125 isolates, 60 (48%) were extended-spectrum beta-lactamase-producing, of which five (8%) had the blaTEM-resistant gene. CONCLUSIONS: Lettuce was contaminated with Escherichia coli with high levels of antibiotic resistance. We call on the Ghana Ministry of Food and Agriculture, Food and Drugs Authority and other stakeholders to support farmers to implement measures for improving vegetable safety.

Appropriateness of Antibiotic Prescribing for Acute Conjunctivitis: A Cross-Sectional Study at a Specialist Eye Hospital in Ghana, 2021.

Most presentations of conjunctivitis are acute. Studies show that uncomplicated cases resolve within 14 days without medication. However, antibiotic prescription remains standard practice. With antimicrobial resistance becoming a public health concern, we undertook this study to assess antibiotic prescription patterns in managing acute conjunctivitis in an eye hospital in Ghana. We recorded 3708 conjunctivitis cases; 201 were entered as acute conjunctivitis in the electronic medical records (January to December 2021). Of these, 44% were males, 56% were females, 39% were under 5 years, 21% were children and adolescents (5-17 years) and 40% were adults (≥18 years). A total of 111 (55.2%) patients received antibiotics, of which 71.2% were appropriately prescribed. The use of antibiotics was more frequent in children under 17 years compared to adults (p < 0.0001). Of the prescribed antibiotics, 44% belonged to the AWaRe "Access" category (Gentamycin, Tetracycline ointment), while 56% received antibiotics in the "Watch" category (Ciprofloxacin, Tobramycin). Although most of the antibiotic prescribing were appropriate, the preponderance of use of the Watch category warrants stewardship to encompass topical antibiotics. The rational use of topical antibiotics in managing acute conjunctivitis will help prevent antimicrobial resistance, ensure effective health care delivery, and contain costs for patients and the health system.

Quantitative assessment of exposure to fecal contamination in urban environment across nine cities in low-income and lower-middle-income countries and a city in the United States.

BACKGROUND: During 2014 to 2019, the SaniPath Exposure Assessment Tool, a standardized set of methods to evaluate risk of exposure to fecal contamination in the urban environment through multiple exposure pathways, was deployed in 45 neighborhoods in ten cities, including Accra and Kumasi, Ghana; Vellore, India; Maputo, Mozambique; Siem Reap, Cambodia; Atlanta, United States; Dhaka, Bangladesh; Lusaka, Zambia; Kampala, Uganda; Dakar, Senegal. OBJECTIVE: Assess and compare risk of exposure to fecal contamination via multiple pathways in ten cities. METHODS: In total, 4053 environmental samples, 4586 household surveys, 128 community surveys, and 124 school surveys were collected. E. coli concentrations were measured in environmental samples as an indicator of fecal contamination magnitude. Bayesian methods were used to estimate the distributions of fecal contamination concentration and contact frequency. Exposure to fecal contamination was estimated by the Monte Carlo method. The contamination levels of ten environmental compartments, frequency of contact with those compartments for adults and children, and estimated exposure to fecal contamination through any of the surveyed environmental pathways were compared across cities and neighborhoods. RESULTS: Distribution of fecal contamination in the environment and human contact behavior varied by city. Universally, food pathways were the most common dominant route of exposure to fecal contamination across cities in low-income and lower-middle-income countries. Risks of fecal exposure via water pathways, such as open drains, flood water, and municipal drinking water, were site-specific and often limited to smaller geographic areas (i.e., neighborhoods) instead of larger areas (i.e., cities). CONCLUSIONS: Knowledge of the relative contribution to fecal exposure from multiple pathways, and the environmental contamination level and frequency of contact for those "dominant pathways" could provide guidance for Water, Sanitation, and Hygiene (WASH) programming and investments and enable local governments and municipalities to improve intervention strategies to reduce the risk of exposure to fecal contamination.

Extended Spectrum Beta-Lactamase Escherichia coli in River Waters Collected from Two Cities in Ghana, 2018-2020.

Infections by Extended-Spectrum Beta-Lactamase producing Escherichia coli (ESBL-Ec) are on the increase in Ghana, but the level of environmental contamination with this organism, which may contribute to growing Antimicrobial Resistance (AMR), is unknown. Using the WHO OneHealth Tricycle Protocol, we investigated the contamination of E. coli (Ec) and ESBL-Ec in two rivers in Ghana (Odaw in Accra and Okurudu in Kasoa) that receive effluents from human and animal wastewater hotspots over a 12-month period. Concentrations of Ec, ESBL-Ec and percent ESBL-Ec/Ec were determined per 100 mL sample. Of 96 samples, 94 (98%) were positive for ESBL-Ec. concentrations per 100 mL (MCs100) of ESBL-Ec and %ESBL-Ec from both rivers were 4.2 × 104 (IQR, 3.1 × 103-2.3 × 105) and 2.79 (IQR, 0.96-6.03), respectively. MCs100 were significantly lower in upstream waters: 1.8 × 104 (IQR, 9.0 × 103-3.9 × 104) as compared to downstream waters: 1.9 × 106 (IQR, 3.7 × 105-5.4 × 106). Both human and animal wastewater effluents contributed to the increased contamination downstream. This study revealed high levels of ESBL-Ec in rivers flowing through two cities in Ghana. There is a need to manage the sources of contamination as they may contribute to the acquisition and spread of ESBL-Ec in humans and animals, thereby contributing to AMR.

Reduced Bacterial Counts from a Sewage Treatment Plant but Increased Counts and Antibiotic Resistance in the Recipient Stream in Accra, Ghana-A Cross-Sectional Study.

Wastewater treatment plants receive sewage containing high concentrations of bacteria and antibiotics. We assessed bacterial counts and their antibiotic resistance patterns in water from (a) influents and effluents of the Legon sewage treatment plant (STP) in Accra, Ghana and (b) upstream, outfall, and downstream in the recipient Onyasia stream. We conducted a cross-sectional study of quality-controlled water testing (January-June 2018). In STP effluents, mean bacterial counts (colony-forming units/100 mL) had reduced E. coli (99.9% reduction; 102,266,667 to 710), A. hydrophila (98.8%; 376,333 to 9603), and P. aeruginosa (99.5%; 5,666,667 to 1550). Antibiotic resistance was significantly reduced for tetracycline, ciprofloxacin, cefuroxime, and ceftazidime and increased for gentamicin, amoxicillin/clavulanate, and imipenem. The highest levels were for amoxicillin/clavulanate (50-97%) and aztreonam (33%). Bacterial counts increased by 98.8% downstream compared to the sewage outfall and were predominated by E. coli, implying intense fecal contamination from other sources. There was a progressive increase in antibiotic resistance from upstream, to outfall, to downstream. The highest resistance was for amoxicillin/clavulanate (80-83%), cefuroxime (47-73%), aztreonam (53%), and ciprofloxacin (40%). The STP is efficient in reducing bacterial counts and thus reducing environmental contamination. The recipient stream is contaminated with antibiotic-resistant bacteria listed as critically important for human use, which needs addressing.

Variation in E. coli concentrations in open drains across neighborhoods in Accra, Ghana: The influence of onsite sanitation coverage and interconnectedness of urban environments.

Alongside efforts to improve safe management of feces along the entire sanitation chain, including after the toilet, global sanitation efforts are focusing on universal access 'basic' services: onsite facilities that safely contain excreta away from human contact. Although fecal sludge management is improving in urban areas, open drains remain a common fate for feces in these often densely-populated neighborhoods in low-income countries. To-date, it is unclear to what extent complete coverage of onsite sanitation reduces fecal contamination in the urban environment and how fecal contamination varies within urban drains across neighborhoods by sanitation status within a city. We assessed how neighborhood levels of environmental fecal contamination (via spatially-representative sampling of open drains for E. coli) varied across four neighborhoods with varying income, type and coverage of household sanitation facilities, and population density in Accra, Ghana. Neighborhoods with very high sanitation coverage (≥89%) still had high (>4 log10 CFU/100 mL) E. coli concentrations in drains. Between-neighborhood variation in E. coli levels among the high coverage neighborhoods was significant: drain concentrations in neighborhoods with 93% and 89% coverage (4.7 (95% CI: 4.5, 4.9) & 4.9 (95% CI: 4.5, 5.3) log10 CFU/100 mL, respectively) were higher than in the neighborhood with 97% coverage (4.1 log10 CFU/100 mL, 95% CI: 3.8, 4.4 log10 CFU/100 mL). Compared with the highest coverage neighborhood, the neighborhood with lowest coverage (48%) also had higher E. coli concentrations (5.6 log10 CFU/100 mL, 95% CI: 5.3, 5.9 log10 CFU/100 mL). Although fecal contamination in open drains appeared lower in neighborhoods with higher onsite sanitation coverage (and vice versa), other factors (e.g. fecal sludge management, animals, population density) may affect drain concentrations. These results underscore that neighborhood-level onsite sanitation improvements alone may not sufficiently reduce fecal hazards to public health from open drains. These findings supporting the need for integrated, city-level fecal sludge management alongside multifaceted interventions to reduce fecal contamination levels and human exposure.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana.

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.