High Levels of Antibiotic Resistance Patterns in Two Referral Hospitals during the Post-Ebola Era in Free-Town, Sierra Leone: 2017–2019
, Francis Moses 1,2, Alexandre Delamou 3,4, Katrina Hann 5, Engy Ali 6, Freddy Eric Kitutu 7, Juliet Sanyu Namugambe 8, Doris Harding 1, Veerle Hermans 6, Kudakwashe Takarinda 9, Pruthu Thekkur 9 and Isatta Wurie 2
Round 1
Reviewer 1 Report
Despite the limitations, clearly identified by the authors, the paper is very interesting
Author Response
Response to Reviewer 1
Thank you very much for reviewing this paper and your useful comments and suggestions. We have revised the manuscript in line with your suggestions. We have provided a point-by-point response to your comments and suggestions using bold font and bullets.
Reviewer comments
Despite the limitations, clearly identified by the authors, the paper is very interesting
Response #1: We Thank the reviewer for these encouraging comments
Reviewer 2 Report
Estimated Authors,
I've read with great interest your paper entitled "High Levels of Antibiotic Resistance Patterns in Two Referral Hospitals during the Post-Ebola Era in Free-town, Sierra Leone". This study is, in my opinion, of particular interest as it deals the significant issue of potential surge of AMR after an epidemic wave. In other words, the consequences of the Ebola epidemic may anticipate those of the COVID-19 Pandemic in the specific settings of AMR.
Focusing on the paper:
- to begin with, a significat caveat: scattered across the text, several words are broken down as they were deliberately written so to fit the row separation (e.g. sur-veillance Row44, alt-hough row45, out-break row50, and so on); please fix them.
- introduction is appropriately informative
- methods fit the aims of the paper
- results are properly written, but following amendments are, in my opinion, required:
- Figure 1: in order to be fully informative, the graph should report % values of positive bacterial isolates either instead of crude data or with crude data
- please report whether the a) number of requests for AMR analyses b) occurrence of AMR was chronologically associated with the surge in ebola epidemic
- are some informations on the eventual prognosis of the patients available?
- please report the number (even in approximative figures) of total patients treated by the assessed centers during the timeframe you analyzed
- please report, if possible, the rationale behind the requests for AMR analysis. In other words: was there (in the referral centers representing the source of the sample) any guideline identifying the specimens requiring to be analyzed ?
Author Response
Response to Reviewer 2
Thank you very much for reviewing this paper and your useful comments and suggestions. We have revised the manuscript in line with your suggestions. We have provided a point-by-point response to your comments and suggestions using bold font and bullets.
Reviewer comments
Estimated Authors, I've read with great interest your paper entitled "High Levels of Antibiotic Resistance Patterns in Two Referral Hospitals during the Post-Ebola Era in Free-town, Sierra Leone". This study is, in my opinion, of particular interest as it deals the significant issue of potential surge of AMR after an epidemic wave. In other words, the consequences of the Ebola epidemic may anticipate those of the COVID-19 Pandemic in the specific settings of AMR. Focusing on the paper:
Response: We Thank the reviewer for these encouraging comments.
Reviewer comment #1:to begin with, a significant caveat: scattered across the text, several words are broken down as they were deliberately written so to fit the row separation (e.g. surveillance Row44, although row45, out-break row50, and so on); please fix them.
Response #1: We have adjusted the manuscript based on this comment.
Reviewer comment #2:
- introduction is appropriately informative
- methods fit the aims of the paper
Response #2: We Thank the reviewer for these encouraging comments.
Reviewer comment #3: results are properly written, but following amendments are, in my opinion, required:
- Figure 1: in order to be fully informative, the graph should report % values of positive bacterial isolates either instead of crude data or with crude data
- please report whether the a) number of requests for AMR analyses b) occurrence of AMR was chronologically associated with the surge in Ebola epidemic
- are some information’s on the eventual prognosis of the patients available?
- please report the number (even in approximative figures) of total patients treated by the assessed centres during the timeframe you analyzed
- please report, if possible, the rationale behind the requests for AMR analysis. In other words: was there (in the referral centres representing the source of the sample) any guideline identifying the specimens requiring to be analyzed?
Response #3:
- We understand the comments of the reviewer. However, this study only analysed samples with positive bacteria growth. (see lines 119 – 120) This will be difficult for the graph to be reported in %.
- a) Data on the number of requests were not available; b) our study period (2017-2019) does not coincide with the period of the Ebola epidemic (2014-2016).
- Patient outcome data were not available, and, therefore, not included in the study.
- Patient volume data were not available.
- Please find more explanations on where sample requests came from in the section on study setting (2.2). (see lines 83 – 88 highlighted)
Reviewer 3 Report
This is an important paper. The topic is highly relevant and we definitely do not know enough about antibiotic resistance patterns in Africa. I also find that the micro-biological analysis and the findings are well done. I strongly support this paper. However, the public health side is really weak and requires much more effort.
- Post-Ebola Era: I expected that the title would indicate that the antibiotic resistance has something to do with Ebola. It seems that you just refer to a certain time as Ebola does not play a role anymore. I think this is misleading the reader. You should either write several paragraphs on the relation between the Ebola-epidemic and antibiotic resistance ot leave any reference to Ebola, in particular in the title.
- The discussion and the conclusions are not much more than repetition of what you found. I the discussion I would expect that you discuss the literature: what do others find? How has it developed? What are the reasons? what does all that have to do with Ebola? What can we do?
Author Response
Response to Reviewer 3
Thank you very much for reviewing this paper and your useful comments and suggestions. We have revised the manuscript in line with your suggestions. We have provided a point-by-point response to your comments and suggestions using bold font and bullets.
Reviewer comment #1: This is an important paper. The topic is highly relevant, and we definitely do not know enough about antibiotic resistance patterns in Africa. I also find that the micro-biological analysis and the findings are well done. I strongly support this paper. However, the public health side is really weak and requires much more effort.
Response #1: We Thank the reviewer for these encouraging comments.
Reviewer comment #2: Post-Ebola Era: I expected that the title would indicate that the antibiotic resistance has something to do with Ebola. It seems that you just refer to a certain time as Ebola does not play a role anymore. I think this is misleading the reader. You should either write several paragraphs on the relation between the Ebola-epidemic and antibiotic resistance or leave any reference to Ebola, in particular in the title.
Response #2: We understand the comments of the reviewer. During the Ebola outbreak, there were debates on the use or overuse of antibiotics. And the risk of antimicrobial resistance in our setting is existing. Therefore, the post-Ebola period is important to understand the implications of this paper given that the systems strengthening occurred as a result of the outbreak response, leading to lab capacity as such is described in your paper. (see lines 54 – 84 highlighted)
Reviewer comment #3: The discussion and the conclusions are not much more than repetition of what you found. I the discussion I would expect that you discuss the literature: what do others find? How has it developed? What are the reasons? what does all that have to do with Ebola? What can we do?
Response #3: We understand the comments of the reviewer. We know that there is limited information, which is why it is difficult to compare these results to other studies and hence the need for national laboratory system strengthening. (see lines 71 – 73 highlighted)
Round 2
Reviewer 3 Report
I do not see that the authors have responded to my comments #2 and #3. I have hardly seen a review with so little changes given that my comments were clearly indicating shortcomings of the paper.
Author Response
Response to Reviewer 3
Thank you very much for reviewing this paper and your useful comments and suggestions. We have revised the manuscript in line with your suggestions. We have provided a point-by-point response to your comments and suggestions using bold font and bullets.
Reviewer comment #1: This is an important paper. The topic is highly relevant, and we definitely do not know enough about antibiotic resistance patterns in Africa. I also find that the micro-biological analysis and the findings are well done. I strongly support this paper. However, the public health side is really weak and requires much more effort.
Response #1: Thank you for this comment. We have added further clarification on the public health relevance of this study. Please find inputs (see lines 77-78 and 215-220)
Reviewer comment #2: Post-Ebola Era: I expected that the title would indicate that the antibiotic resistance has something to do with Ebola. It seems that you just refer to a certain time as Ebola does not play a role anymore. I think this is misleading the reader. You should either write several paragraphs on the relation between the Ebola-epidemic and antibiotic resistance or leave any reference to Ebola, in particular in the title.
Response #2: Please find changes (see line 1-4)
Reviewer comment #3: The discussion and the conclusions are not much more than repetition of what you found. I the discussion I would expect that you discuss the literature: what do others find? How has it developed? What are the reasons? what does all that have to do with Ebola? What can we do?
Response #3: We understand the comments of the reviewer and have added further detail based on this point.. (see lines 194-207)
Author Response File: 
Author Response.docx
