Gastrointestinal Tract Colonization Rate of Extended-Spectrum Beta-Lactamase-Producing Gram-Negative Bacteria and Associated Factors Among Orthopaedic Patients in a Tertiary Hospital in Tanzania: Implications for Infection Prevention

Figures & data

Table 1 Socio-Demographic and Clinical Characteristics of Index Orthopaedic Patients

Variable		Number (%)
Sex	Female	87 (32.8)
	Male	178 (67.2)
Residence	Rural	68 (25.7)
	Peri-urban	62 (23.4)
	Urban	135 (50.9)
Education	No formal education	20 (7.6)
	Primary	128 (48.3)
	Secondary	70 (26.4)
	College and above	47 (17.7)
Occupation	Formal employment	46 (17.4)
	Unemployed	86 (32.4)
	Business	47 (17.8)
	Peasant	86 (32.4)
Referral status	Self-referral from home	88 (33.2)
	Referral from other hospital/clinic	177 (66.8)
Type of fracture	Closed	184 (69.4)
	Open	73 (27.6)
	Both closed and open	8 (3.0)
Knowlege on antibiotics	No	99 (37.4)
	Yes	166 (62.6)
Heard about AMR	No	132 (49.8)
	Yes	133 (50.2)
Enough information on AMR	No	225 (84.9)
	Yes	40 (15.1)
Current antibiotic use	No	164 (61.9)
	Yes	101 (38.1)
History of antibiotic use*	No	40 (15.1)
	Yes	225 (84.9)
Self-treatment with antibiotics	No	134 (50.6)
	Yes	131 (49.4)
Domestic/pet animals at home	No	128 (48.3)
	Yes	137 (51.7)
Use of antibiotics in animals	No	171 (64.5)
	Yes	94 (35.5)
Heard of IPC	No	30 (11.3)
	Yes	235 (88.7)
Underlying diseases**	No	242 (91.7)
	Yes	22 (8.3)

Notes: *In the past 3 months; **hypertension (n=9), HIV/AIDS (n=2), other cardiovascular conditions (n=3), diabetes mellitus (n=2), hypertension and diabetes mellitus (n=1), flu (n=1), asthma (n=1), osteomyelitis (n=1), peptic ulcer disease (n=1), and tumour of the leg (n=1).

Abbreviations: AMR, antimicrobial resistance; IPC, infection prevention and control.

Figure 1 ESBL-producing Gram-negative bacteria from the orthopaedic index and neighbouring patients. *Others: Citrobacter spp. (2), Morganella morganii (2), and Pseudomonas aeruginosa (1).

Abbreviations: ESBL, extended-spectrum beta-lactamases; UGNB, unidentified Gram-negative bacteria; spp, species.

Table 2 Antimicrobial Susceptibility Patterns of ESBL-Producing Gram-Negative Bacteria Isolates

Antimicrobial Agent		Escherichia coli *			All Other Gram-Negative Bacteria**
		Resistant, n (%)	Intermediate, n (%)	Sensitive, n (%)	Resistant, n (%)	Intermediate, n (%)	Sensitive, n (%)
Tetracycline	Index	56 (75.7)	4 (5.4)	14 (18.9)	36 (52.9)	5 (7.4)	27 (39.7)
	Neighbour	9 (81.8)	1 (9.1)	1 (9.1)	4 (80.0)	0 (0.0)	1 (20.0)
TMP-SXT	Index	63 (85.1)	1 (1.4)	10 (13.5)	65 (95.6)	1 (1.5)	2 (2.9)
	Neighbour	9 (81.8)	1 (9.1)	1 (9.1)	5 (100.0)	0 (0.0)	0(0.0)
Chloramphenicol	Index	11 (14.9)	0 (0.0)	63 (85.1)	21 (30.9)	2 (2.9)	45 (66.2)
	Neighbour	2 (18.2)	0 (0.0)	9 (81.8)	1 (20.0)	0(0.0)	4 (80.0)
Gentamicin	Index	23 (31.1)	3 (4.0)	48 (64.9)	28 (41.2)	6 (8.8)	34 (50.0)
	Neighbour	2 (18.2)	0 (0.0)	9 (81.8)	1 (20.0)	0(0.0)	4 (80.0)
Ciprofloxacin	Index	38 (51.4)	10 (13.5)	26 (35.1)	29 (42.6)	15 (22.1)	24 (35.3)
	Neighbour	8 (72.7)	0 (0.0)	3 (27.3)	4 (80.0)	0 (0.0)	1 (20.0)
Cefoxitin	Index	12 (16.2)	5 (6.8)	57 (77.0)	24 (35.3)	3 (4.4)	41 (60.3)
	Neighbour	2 (18.2)	1 (9.1)	8 (72.7)	0 (0.0)	0 (0.0)	5 (100.0)
Cefepime	Index	72 (97.2)	1 (1.4)	1 (1.4)	66 (97.1)	2 (2.9)	0 (0.0)
	Neighbour	11 (100.0)	0 (0.0)	0 (0.0)	5 (100.0)	0 (0.0)	0 (0.0)
TZP	Index	8 (10.8)	12 (16.2)	54 (73.0)	8 (11.8)	10 (14.7)	50 (73.5)
	Neighbour	1 (9.1)	3 (27.3)	7 (63.6)	1 (20.0)	0 (0.0)	4 (80.0)
Amikacin	Index	0 (0.0)	2 (2.7)	72 (97.3)	2 (2.9)	0 (0.0)	66 (97.1)
	Neighbour	0 (0.0)	0 (0.0)	11 (100.0)	0 (0.0)	0 (0.0)	5 (100.0)
Meropenem	Index	1 (1.4)	1 (1.4)	72 (97.2)	6 (8.8)	2 (2.9)	60 (88.3)
	Neighbour	0 (0.0)	0 (0.0)	11 (100.0)	0 (0.0)	0 (0.0)	5 (100.0)

Notes: *Index isolates (n=74) and neighbours’ isolates (n=11); **index isolates (n=68) and neighbours’ isolates (n=5).

Abbreviations: TMP-SXT, trimethoprim–sulfamethoxazole; TZP, piperacillin–tazobactam.

Table 3 Factors Associated with Gastrointestinal Tract ESBL Colonization Among Index Orthopaedic Patients

Variable (N)	ESBL Colonization, n, (%)	Univariate Analysis		Multivariate Analysis
		95% CI	p	95% CI	p
Age category (years)
≤18 (90)	38 (42.2)	1
19–59 (152)	76 (50.0)	1.37 (0.81–2.31)	0.242
≥60 (23)	11 (47.8)	1.25 (0.50–3.14)	0.629
Sex
Female (87)	47 (54.0)	1
Male (178)	78 (43.8)	0.66 (0.40–1.11)	0.453
Residence
Rural (68)	33 (48.5)	1
Peri-urban (62)	31 (50.0)	1.06 (0.53–2.11)	0.867
Urban (135)	61 (45.2)	0.87 (0.49–1.57)	0.652
Education
College and above (47)	24 (51.1)	1
Informal (20)	6 (30.0)	0.41 (1.14–1.25)	0.118	0.38 (0.12–1.22)	0.105
Primary (128)	59 (46.1)	0.82 (0.42–1.60)	0.560	0.80 (0.40–1.61)	0.532
Secondary (70)	36 (51.4)	1.01 (0.48–2.12)	0.969	1.02 (0.47–2.21)	0.964
Occupation
Formal occupation (179)	84 (46.9)	1
No formal occupation (86)	41 (47.7)	1.03 (0.62–1.72)	0.909
Domestic animals at home
No (128)	61 (47.7)	1
Yes (137)	64 (46.7)	0.96 (0.59–1.56)	0.878
Referral status
Self-referral from home (88)	36 (40.9)	1
From other hospital/clinic (177)	89 (50.3)	1.46 (0.87–2.45)	0.151	1.44 (0.81–2.56)	0.212
Time to the hospital*
Within 1 day (48)	25 (52.1)	1
Up to 7 days (59)	23 (39.0)	0.59 (0.27–1.27)	0.177	0.53 (0.24–1.16)	0.113
More than 7 days (60)	26 (43.3)	0.81 (0.38–1.72)	0.576	0.92 (0.41–2.09)	0.801
Ward of admission
Ward J5 (115)	59 (51.3)	1
Ward E8 ((150)	66 (44.0)	0.75 (0.46–1.21)	0.238
Type of fracture
Closed (184)	78 (42.4)	1
Open (73)	44 (60.3)	2.06 (1.18–3.58)	0.010	2.08 (1.56–3.75)	0.015
Both (8)	3 (37.5)	0.82 (0.19–3.51)	0.784	0.55 (0.12–2.51)	0.439
History of antibiotic use**
No (40)	15 (37.5)	1
Yes (225)	110 (48.9)	1.59 (0.80–3.18)	0.186	1.97 (0.95–4.11)	0.070
Current use of antibiotic
No (164)	76 (46.3)	1
Yes (101)	49 (48.5)	1.09 (0.66–1.79)	0.731
Knowledge on antibiotics
No (99)	46 (46.5)	1
Yes (166)	79 (47.6)	1.04 (0.63–1.72)	0.859
Heard about AMR
No (132)	60 (45.5)	1
Yes (133)	65 (48.9)	1.14 (0.71–1.86)	0.577
Heard about IPC
Yes (235)	111 (47.2)	1
No (30)	14 (46.7)	0.98 (0.45–2.09)	0.953

Notes: *The duration was missing in 98 patients; **in the past 3 months.

Abbreviations: AMR, antimicrobial resistance; ESBL, extended-spectrum beta-lactamase; IPC, infection prevention and control; CI, confidence interval.

Table 4 Factors Associated with Occurrence of ESBL Bacteria in the Hospital Environment

Variable (N)	ESBL Bacterial Contamination in the Hospital Environment, n, (%)	Univariate Analysis
		95% CI	p
Ward
J5 (33)	10 (30.3)	1
E8 (53)	17 (32.1)	1.09 (0.42–2.78)	0.863
Items sampled
Walking crutches (11)	1 (9.1)	1
Wheelchair (13)	4 (30.8)	4.44 (0.42–47.5)	0.217
Bathroom sinks and door knobs (18)	5 (27.8)	3.85 (0.38–38.36)	0.251
Floor below patient’s bed (22)	11 (50.0)	10.0 (1.09–92.0)	0.042
Bed rails (22)	6 (27.3)	3.75 (0.39–35.9)	0.252
Trends in environmental contamination
Round 1 on 16th January 2020 (29)	12 (41.4)	1
Round 2 on 28th March 2020 (28)	12 (42.9)	1.06 (0.37–3.04)	0.910
Round 3 on 28th May 2020 (29)	3 (10.3)	0.16 (0.04–0.67)	0.012

Abbreviations: ESBL, extended-spectrum beta-lactamase; CI, confidence interval.