2.2. Study Setting

Ghana is classified as a low middle-income country (LMIC) in West Africa with a total population of approximately 30.8 million. Accra is the capital city located at the coastal belt and has a total population of approximately 5 million [17]. Health care in Ghana is mainly provided by public sector facilities but with significant contribution from private sector facilities including laboratories. The public healthcare system consists of tertiary care hospitals, district (secondary) hospitals and primary health care facilities [18]. According to the law, patients need prescriptions from a medical doctor to get antibiotics [15]. However, it is possible to get antibiotics without prescriptions from private pharmacies. The Ghana Standard Treatment Guidelines (2017) suggest the following antibiotics for the treatment of UTIs: ciprofloxacin, cefuroxime and amoxicillin/clavulanic acid for uncomplicated infections; and gentamicin and ceftriaxone for complicated infections [19].

MDS Lancet Laboratories Gh. LTD is a private medical laboratory with 29 locations dotted throughout 10 of the 16 administrative regions of Ghana. The laboratory processes approximately 148,500 samples per month and receives more than 50,000 urine (routine examination and cultures) samples per year. All testing and information management processes are conducted under strict quality control mechanisms as defined in the laboratory’s standard operating procedures. The laboratory holds ISO 15189 2012 certification. The headquarters/main laboratory is located in Accra. The microbiology department where this research was carried out has standard quality assurance mechanisms in place at the pre-analytical, analytical and post-analytical stages.

The urine samples for this study originated from patients diagnosed with suspected UTIs in health care facilities (hospitals and clinics) in both the public and private sectors. Urine samples are usually transported by the patients or their relatives in sterile urine containers. All microbiology samples from the different branches that are meant for culture are transported to the microbiology laboratory in Accra within 24 h for processing using temperature-controlled, sample-transportation bags.

All urine samples received in the laboratory are registered and plated on cysteine lactose electrolyte deficient (CLED) agar, McConkey’s agar, blood agar and antimicrobial plates [20]. The first three media are used to determine the presence of microorganisms in the sample, while the latter is used to determine the presence of antibiotics in the urine and provides information on the use of antibiotics prior to sample collection. After 24 h of incubation, cultures are assessed and positive samples are further processed for identification of the specific microorganisms by performing indole and oxidase and other biochemical tests as well as the Analytical Profile Index (API) or Microscan [21]. Antimicrobial susceptibility testing is performed using the Kirby–Bauer disc diffusion method on Mueller–Hinton agar [22]. Zones of inhibition are interpreted using the Clinical and Laboratory Standards Institute (CLSI) guidelines [23].