Healthcare-associated infections including neonatal bloodstream infections in a leading tertiary hospital in Botswana

The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis

Background

Hospital-acquired infections (HAI) are a leading cause of morbidity and mortality globally. These infections are diverse, but the majority are lower respiratory tract infection (LRTI), surgical site infection (SSI), bloodstream infection (BSI), and urinary tract infection (UTI). For most sub-Saharan African countries, studies revealing the burden and impact of HAI are scarce, and few systematic reviews and meta-analysis have been attempted. We sought to fill this gap by reporting recent trends in HAI in sub-Saharan Africa (SSA) with attention to key patient populations, geographic variation, and associated mortality.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of six electronic databases (Web of Science, Pubmed, APA PsycInfo, CINAHL, Embase, and the Cochrane Library) to identify studies assessing the prevalence of HAI in SSA countries. Studies published between 01 January 2014 and 31 December 2023 were included. We applied no language or publication restrictions. Record screening and data extractions were independently conducted by teams of two or more reviewers. Using the R software (version 4.3.1) meta and metafor packages, we calculated the pooled prevalence estimates from random-effect meta-analysis, and further explored sources of heterogeneity through subgroup analyses and meta-regression. This study is registered with PROSPERO, CRD42023433271.

Findings

Forty-one relevant studies were identified for analysis, consisting of 15 from West Africa (n = 2107), 12 from Southern Africa (n = 2963), 11 from East Africa (n = 2142), and 3 from Central Africa (n = 124). A total of 59.4% of the patient population were associated with paediatric admissions. The pooled prevalence of HAI was estimated at 12.9% (95% CI: 8.9-17.4; n = 7336; number of included estimates [k] = 41, p < 0.001). By subregions, the pooled current prevalence of HAI in the West Africa, Southern Africa, East Africa and Central Africa were estimated at 15.5% (95% CI: 8.3-24.4; n = 2107; k = 15), 6.5% (95% CI: 3.3-10.7; n = 2963; k = 12), 19.7% (95% CI: 10.8-30.5; n = 2142; k = 11) and 10.3% (95% CI: 1.1-27.0; n = 124; k = 3) of the patient populations respectively. We estimated mortality resulting from HAI in SSA at 22.2% (95% CI: 14.2-31.4; n = 1118; k = 9).

Interpretation

Our estimates reveal a high burden of HAI in SSA with significant heterogeneity between regions. Variations in HAI distribution highlight the need for infection prevention and surveillance strategies specifically tailored to enhance prevention and management with special focus on West and East Africa, as part of the broader global control effort.

Funding

No funding was received for this study.

Multidrug-Resistant Organism Infections of Inpatients in a Hospital in Eastern China from 2015 to 2021

Background

The prevalence of multidrug-resistant organisms (MDRO) is gradually increasing in the global scope, causing serious burden to patients and society, which is an important public health problem.

Objective

To analyze the distribution and trend of MDROs and provide a reference for hospital infection control.

Methods

Collected data on MDROs infections among inpatients in a Grade III Level A hospital in Suzhou from 2015 to 2021, including drug-resistant bacteria strains and specimen sources, etc. Mantel-Haenszel χ² test was used to evaluate the trend of infection rates over the years and SPSS version 26.0 was used for statistics analysis.

Results

The hospital infection rate showed an overall downward trend across the seven-year period, ranging from 1.53% to 2.10%. According to the analysis of change of drug-resistant bacteria strains, the highest infection rate was carbapenem-resistant Acinetobacter baumannii (CRABA) (63.74%), followed by methicillin-resistant Staphylococcus aureus (MRSA) (46.37%), carbapenem-resistant Pseudomonas aeruginosa (CRPAE) (24.87%), carbapenem-resistant Enterobacteriaceae (CRE) (13.14%) and vancomycin-resistant Enterococcus (VRE) (0.42%). The results of Mantel-Haenszel χ² test showed that there was a linear relationship between the detection rate of CRE and CRPAE and the time (P<0.001), but the correlation was not strong (R = 0.136; R = 0.139). The overall detection rate of the five pathogens also increased (P<0.001). The majority of the specimens, mainly from sputum, airway secretions, and midstream urine, had a detection rate of over 70%.

Conclusion

Our data showed that the detection rate of MDROs generally increased from 2015 to 2021, although the hospital infection rate displayed a declining trend. Among the detection rate MDROs, the highest was CRABA, and the lowest was VRE. It is necessary to enhance the prevention, control, and management of MDROs infections in the clinical practice.

Review and analysis of the overlapping threats of carbapenem and polymyxin resistant E. coli and Klebsiella in Africa

BACKGROUND

Carbapenem-resistant Enterobacterales are among the most serious antimicrobial resistance (AMR) threats. Emerging resistance to polymyxins raises the specter of untreatable infections. These resistant organisms have spread globally but, as indicated in WHO reports, the surveillance needed to identify and track them is insufficient, particularly in less resourced countries. This study employs comprehensive search strategies with data extraction, meta-analysis and mapping to help address gaps in the understanding of the risks of carbapenem and polymyxin resistance in the nations of Africa.

METHODS

Three comprehensive Boolean searches were constructed and utilized to query scientific and medical databases as well as grey literature sources through the end of 2019. Search results were screened to exclude irrelevant results and remaining studies were examined for relevant information regarding carbapenem and/or polymyxin(s) susceptibility and/or resistance amongst E. coli and Klebsiella isolates from humans. Such data and study characteristics were extracted and coded, and the resulting data was analyzed and geographically mapped.

RESULTS

Our analysis yielded 1341 reports documenting carbapenem resistance in 40 of 54 nations. Resistance among E. coli was estimated as high (> 5%) in 3, moderate (1-5%) in 8 and low (< 1%) in 14 nations with at least 100 representative isolates from 2010 to 2019, while present in 9 others with insufficient isolates to support estimates. Carbapenem resistance was generally higher among Klebsiella: high in 10 nations, moderate in 6, low in 6, and present in 11 with insufficient isolates for estimates. While much less information was available concerning polymyxins, we found 341 reports from 33 of 54 nations, documenting resistance in 23. Resistance among E. coli was high in 2 nations, moderate in 1 and low in 6, while present in 10 with insufficient isolates for estimates. Among Klebsiella, resistance was low in 8 nations and present in 8 with insufficient isolates for estimates. The most widespread associated genotypes were, for carbapenems, blaOXA-48, blaNDM-1 and blaOXA-181 and, for polymyxins, mcr-1, mgrB, and phoPQ/pmrAB. Overlapping carbapenem and polymyxin resistance was documented in 23 nations.

CONCLUSIONS

While numerous data gaps remain, these data show that significant carbapenem resistance is widespread in Africa and polymyxin resistance is also widely distributed, indicating the need to support robust AMR surveillance, antimicrobial stewardship and infection control in a manner that also addresses broader animal and environmental health dimensions.

Antimicrobial Management of Skin and Soft Tissue Infections among Surgical Wards in South Africa: Findings and Implications

Skin and soft tissue infections (SSTIs) are one of the most common infectious diseases requiring antibiotics. However, complications of SSTIs may lead to the overprescribing of antibiotics and to subsequent antibiotic resistance. Consequently, monitoring the prescribing alignment with the current recommendations from the South African Standard Treatment Guidelines (STG) is necessary in order to improve future care. This study involved reviewing pertinent patients with SSTIs who were prescribed antimicrobials in the surgical ward of a leading South African tertiary public hospital from April to June 2021 using an adapted data collection tool. Sixty-seven patient files were reviewed. Among the patients with SSTIs, hypertension and chronic osteomyelitis were the most frequent co-morbidities at 22.4% and 13.4%, respectively. The most diagnosed SSTIs were surgical site infections (35.1%), wound site infections (23%), and major abscesses (16.2%). Blood cultures were performed on 40.3% of patients, with Staphylococcus aureus (32.7%) and Enterococcus spp. (21.2%) being the most cultured pathogens. Cefazolin was prescribed empirically for 46.3% of patients for their SSTIs. In addition, SSTIs were treated with gentamycin, ciprofloxacin, and rifampicin at 17.5%, 11.3%, and 8.8%, respectively, with treatment fully complying with STG recommendations in 55.2% of cases. Overall, the most common cause of SSTIs was Staphylococcus aureus, and empiric treatment is recommended as the initial management. Subsequently, culture sensitivities should be performed to enhance adherence to STGs and to improve future care.

Understanding of Final Year Medical, Pharmacy and Nursing Students in Pakistan towards Antibiotic Use, Antimicrobial Resistance and Stewardship: Findings and Implications

Antimicrobial resistance (AMR) is a leading public health threat, which is exacerbated by the high and inappropriate use of antibiotics. Consequently, there is a need to evaluate knowledge regarding antibiotic use, AMR and the readiness to implement antimicrobial stewardship programs (ASPs) among final year medical, pharmacy and nursing students in Pakistan. This reflects the high and increasing rates of AMR in the country, and students as future healthcare professionals (HCPs). A cross-sectional study was conducted among 1251 final year students from 23 public and private educational institutions in Punjab. The majority of the surveyed participants possessed good knowledge of antibiotic use, AMR and the potential causes of AMR. The most common sources of the information on antibiotics were smartphones (69.9%), peers (35.9%) and medical textbooks (30.6%). However, most surveyed participants were not fully prepared to participate in ASPs. They knew, though, how to reduce AMR by educating HCPs about appropriate prescribing, implementing ASPs and improving laboratory facilities. There was a significant association between antibiotic knowledge and causes of AMR with sex, family income and student type (p < 0.05). Being a student at a public sector university (OR = 4.809; CI = 3.261−7.094; p < 0.001) and age (OR = 0.524, CI = 0.327−0.842; p < 0.008) were among the key factors impacting students’ training on ASPs. Educational curricula must be improved to include more information about appropriate antibiotic use and ASPs, along with sufficient training, workshops and clinical rotations in the final year, to fully equip students by graduation.

Healthcare-associated infections in Africa: a systematic review and meta-analysis of point prevalence studies

BACKGROUND

There is limited data to describe the point-prevalence of healthcare-associated infections (HAIs) among patients at a regional level in Africa. This study estimated the pooled prevalence of HAIs and described the distribution of HAIs as well as the pathogens identified from African studies.

METHODS

PubMed, Scopus and Google Scholar databases were searched to find point-prevalence studies of HAIs in Africa. Studies conducted in Humans that reported the prevalence of HAIs among hospitalized patients and published in English language from January 2010 to March 2022 were selected. Longitudinal studies of HAIs and unpublished studies were excluded. The reference list of the selected studies was checked to find additional studies. A meta-analysis was conducted using RevMan 5.4 and the pooled prevalence of HAIs was determined using a random effect model.

RESULTS

Of the 6094 articles identified from the databases, fifteen eligible articles were selected. The studies were conducted in the North, South, East and West African regions with Tunisia (n = 4) and South Africa (n = 2) having the highest number of studies. Most of the studies (n = 12, 80.0%) had good quality. The pooled prevalence of HAIs was 12.76% (95% confidence interval [CI] 10.30-15.23) with a high degree of heterogeneity (I² = 90.0%). The prevalence of HAIs varied between wards with the highest rate found in the ICU (25.2%-100%), followed by neonatal ICU/ward (7.0%-53.6%) and paediatric medical ward (2.7%-33.0%). Surgical site infection was the most common HAIs and accounted for 41.6% of all HAIs (95% CI 23.55-59.80), followed by bloodstream infection (17.07%, 95% CI 11.80-22.33) and respiratory tract infections/pneumonia (17.04%, 95% CI 13.21-20.87). Recent hospitalization (adjusted odds ratio [AOR]: 4.17, 95% CI 1.85-9.41), presence of peripheral vascular catheter (AOR: 2.87, 95% CI 1.54-5.36) and having diabetes mellitus (AOR: 2.46, 95% CI 1.45-4.17) were the strongest predictors of HAIs in Africa. Only 37.9% of HAIs had documented positive microbiological culture result with gram negative bacteria including Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa, Acinetobacter baumannii and Citrobacter been the most common microorganisms and accounted for 40%-100% of the pathogens.

CONCLUSIONS

The pooled point-prevalence of HAIs in Africa is more than two times higher than the rate reported in developed countries. The prevalence varied between the countries and was highest in the ICU and neonatal ICU/ward. Surgical site infection and bloodstream infection were the most common HAIs reported in African studies. Recent hospitalization, presence of peripheral vascular catheter and having diabetes mellitus were the strongest predictors of HAIs in African studies. Most of the HAIs are preventable with appropriate infection control measures and antimicrobial stewardship. Additional studies are needed especially in the Central African region. Future studies should be designed using standardized protocol and standardized definition to reduce heterogeneity among the studies.

A web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital in the Kingdom of Eswatini and the implications

OBJECTIVES

Currently there is limited knowledge regarding antimicrobial utilization patterns among public hospitals in Eswatini. This is a concern given rising resistance rates among African countries. This study aimed to address this by determining antimicrobial utilization patterns using a point prevalence survey (PPS) methodology at Raleigh Fitkin Memorial (RFM) Hospital. The findings would be used to identify potential interventions to improve future antimicrobial utilization.

METHOD

A PPS was conducted using a web-based application (App). Antimicrobials were categorized according to the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) classification. Each ward in the hospital was surveyed in one day using patient files. All patients in the ward, admitted by 08h30 on the day of the survey, were included. Ethical clearance was granted by the university and at country level.

RESULTS

Overall, 68 patient files in 12 wards were surveyed, with 88.2% (60/68) receiving at least one antimicrobial. The most widely prescribed antimicrobials were amoxicillin (24.3%), and ceftriaxone IV (21.6%), mostly from the Access group (69.9%), and zero from the Reserve group. In the past 90 days prior to admission, most patients (60.3%; 41/68) were not receiving any antimicrobials. Of concern was that antimicrobial use was empirical for all patients (100%) with mostly parenteral administration (88.3%; 91/103). In addition, the majority of surgical prophylaxis patients (80%; 12/15) were given an extended course post surgery. There was also no documented switch or stop dates, or patient culture and drug sensitivity results.

CONCLUSION

Antimicrobial utilization is high at RFM hospital. Identified targets for quality improvement programs include encouraging earlier switching to oral antimicrobials, reducing extended use for surgical prophylaxis and encouraging greater sensitivity testing and documentation stop dates. The development of the App appreciably reduced data collection times and analysis, and would be recommended for use in other public hospitals.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

Characterizing the bioburden of ESBL-producing organisms in a neonatal unit using chromogenic culture media: a feasible and efficient environmental sampling method

INTRODUCTION

Infections due to extended spectrum beta-lactamase producing organisms (ESBL) have emerged as the leading cause of sepsis among hospitalized neonates in Botswana and much of sub-Saharan Africa and south Asia. Yet, ESBL reservoirs and transmission dynamics within the neonatal intensive care unit (NICU) environment are not well-understood. This study aimed to assess the efficiency and feasibility of a chromogenic-culture-media-based environmental sampling approach to characterize the ESBL bioburden within a NICU.

METHODS

A series of four point-prevalence surveys were conducted at a 36-bed NICU at a public tertiary referral hospital in Botswana from January-June 2021. Samples were collected on 4 occasions under semi-sterile technique using 1) flocked swabs & templates (flat surfaces); 2) sterile syringe & tubing (water aspiration); and 3) structured swabbing techniques (hands & equipment). Swabs were transported in physiological saline-containing tubes, vortexed, and 10 µL was inoculated onto chromogenic-agar that was selective and differential for ESBL (CHROMagar™ ESBL, Paris, France), and streaking plates to isolate individual colonies. Bacterial colonies were quantified and phenotypically characterized using biochemical identification tests.

RESULTS

In total, 567 samples were collected, 248 (44%) of which grew ESBL. Dense and consistent ESBL contamination was detected in and around sinks and certain high-touch surfaces, while transient contamination was demonstrated on medical equipment, caregivers/healthcare worker hands, insects, and feeding stations (including formula powder). Results were available within 24-72 h of collection. To collect, plate, and analyse 50 samples, we estimated a total expenditure of $269.40 USD for materials and 13.5 cumulative work hours among all personnel.

CONCLUSIONS

Using basic environmental sampling and laboratory techniques aided by chromogenic culture media, we identified ESBL reservoirs (sinks) and plausible transmission vehicles (medical equipment, infant formula, hands of caregivers/healthcare workers, & insects) in this NICU environment. This strategy was a simple and cost-efficient method to assess ESBL bioburden and may be feasible for use in other settings to support ongoing infection control assessments and outbreak investigations.

Bacterial and fungal profile, drug resistance pattern and associated factors of isolates recovered from blood samples of patients referred to Ethiopian Public Health Institute: cross-sectional study

Background

Blood stream infections are serious infections that usually induce prolongation of hospital stay, morbidity and mortality in several countries including Ethiopia. The aim of this study was to determine bacterial and fungal profile, their drug resistance patterns, and risk factors associated with blood stream infections.

Methods

A cross sectional study design was conducted from February 23 to June 23, 2020 at Ethiopian public health. A structured questionnaire was used to collect data on socio-demographic factors and clinical conditions. Blood specimens were analyzed using standard microbiological techniques. Antimicrobial susceptibility tests were performed using Kirby–Bauer disc diffusion technique and Vitek compact 2. Simple and multiple logistic regressions were used to assess the potential risk factors.

Results

A total of 175 pathogens isolated from 346 blood specimens. Of these, 60% Gram-negative bacteria, 30.86% Gram-positive bacteria and 9.14% fungal isolates were identified. Burkholderia cepacia and Coagulase negative staphylococcus were the predominant pathogen among Gram-negative and Gram-positive bacteria respectively. Among fungus, Candida krusei (56.25%) was the most predominant isolate. The highest proportions of antibacterial resistance were observed among 3rd generation cephalosporin and penicillin. Most fungal isolates expressed resistance to fluconazole. Sex (P = 0.007), age (P < 0.001) and use of invasive medical devices (P = 0.003) were identified as risk factors for bacterial blood stream infections.

Conclusion

The study showed high prevalence of blood stream infection was due to B. cepacia and non-C. albicans spp. This finding alarming ongoing investigation of blood stream infection is important for recognizing future potential preventive strategies including environmental hygiene and management of comorbid medical diseases to reduce the problem.

Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

Background

There are limited data on healthcare-associated infections (HAI) from African countries like Malawi.

Aim

We undertook a point prevalence survey of HAI and antimicrobial use in the surgery department of Queen Elizabeth Central Hospital (QECH) in Malawi and ascertained the associated risk factors for HAI.

Methods

A cross-sectional point prevalence survey (PPS) was carried out in the surgery department of QECH. The European Centre for Disease Prevention and Control PPS protocol version 5.3 was adapted to our setting and used as a data collection tool.

Findings

105 patients were included in the analysis; median age was 34 (IQR: 24-47) years and 55.2% patients were male. Point prevalence of HAI was 11.4% (n=12/105) (95% CI: 6.0%-19.1%), including four surgical site infections, four urinary tract infections, three bloodstream infections and one bone/joint infection. We identified the following risk factors for HAI; length-of-stay between 8 and 14 days (OR=14.4, 95% CI: 1.65-124.7, p=0.0143), presence of indwelling urinary catheter (OR=8.3, 95% CI: 2.24-30.70, p=0.003) and history of surgery in the past 30 days (OR=5.11, 95% CI: 1.46-17.83, p=0.011). 29/105 patients (27.6%) were prescribed antimicrobials, most commonly the 3rd-generation cephalosporin, ceftriaxone (n=15).

Conclusion

The prevalence rates of HAI and antimicrobial use in surgery wards at QECH are relatively high. Hospital infection prevention and control measures need to be strengthened to reduce the burden of HAI at QECH.

Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction

Antimicrobial resistance (AMR) is a growing problem worldwide, including South Africa, where an AMR National Strategy Framework was implemented to instigate antimicrobial stewardship programmes (ASPs) and improve antimicrobial prescribing across sectors. To address the need to assess progress, a sequential mixed methodology with an explanatory research design was employed. In Phase 1, a self-administered questionnaire was completed by healthcare professionals (HCPs) from 26 public sector healthcare facilities across South Africa to assess compliance with the Framework. The results were explored in Phase 2 through 10 focus group discussions and two in-depth interviews, including 83 participants. Emerging themes indicated that public healthcare facilities across South Africa are facing many challenges, especially at entry level primary healthcare (PHC) facilities, where antimicrobial stewardship activities and ASPs are not yet fully implemented. Improved diagnostics and surveillance data are a major shortcoming at these facilities. Continuous education for HCPs is deficient, especially for the majority of prescribers at PHC level and health campaigns are nearly non-existent. Involvement and visibility of management at certain facilities is a serious shortfall. Consequently, it is important to call attention to the challenges faced with improving antimicrobial prescribing across countries and address these to reduce AMR, especially in PHC facilities, being the first point of access to healthcare for the vast majority of patients in developing countries.

Profiles of microorganisms isolated from neonates' blood cultures, incubators, cradles, ventilators, washbasins, and health-workers of Libreville University Hospital Neonatal Service: focus on infection prevention and control measures

Background

Nosocomial infection outbreaks in neonatal services are a serious healthcare concern in both developed and developing countries, but few studies have been conducted in sub-Saharan Africa.

Objective

This study explored the etiology of septicemia in neonates and associated patterns of antimicrobial susceptibility in Gabon.

Methods

We analyzed cultures from neonates’ blood and swabs from medical personnel and equipment located in the neonatology service.

Results

Sixty-eight microorganisms were isolated from the medical personnel and equipment; 46 microorganisms were isolated from neonates’ blood culture. Klebsiella pneumoniae spp pneumoniae was the most common bacteria found in both (30.6% and 26.9%, respectively). All Klebsiella pneumoniae spp pneumonia isolates were resistant to amoxicillin with clavulanic acid, gentamycin resistance ranged from 93% to 100%, and cephalosporin resistance ranged from 33.3% to 47%.

Conclusions:

Awareness of the etiology, prevalence, and outcome of nosocomial infection is the first and most important step to appropriate interventions.

Strategies to Improve Antimicrobial Utilization with a Special Focus on Developing Countries

Antimicrobial resistance (AMR) is a high priority across countries as it increases morbidity, mortality and costs. Concerns with AMR have resulted in multiple initiatives internationally, nationally and regionally to enhance appropriate antibiotic utilization across sectors to reduce AMR, with the overuse of antibiotics exacerbated by the COVID-19 pandemic. Effectively tackling AMR is crucial for all countries. Principally a narrative review of ongoing activities across sectors was undertaken to improve antimicrobial use and address issues with vaccines including COVID-19. Point prevalence surveys have been successful in hospitals to identify areas for quality improvement programs, principally centering on antimicrobial stewardship programs. These include reducing prolonged antibiotic use to prevent surgical site infections. Multiple activities centering on education have been successful in reducing inappropriate prescribing and dispensing of antimicrobials in ambulatory care for essentially viral infections such as acute respiratory infections. It is imperative to develop new quality indicators for ambulatory care given current concerns, and instigate programs with clear public health messaging to reduce misinformation, essential for pandemics. Regular access to effective treatments is needed to reduce resistance to treatments for HIV, malaria and tuberculosis. Key stakeholder groups can instigate multiple initiatives to reduce AMR. These need to be followed up.

Neonatal sepsis in a tertiary unit in South Africa

BACKGROUND

Antimicrobial resistance (AMR) has emerged as a global threat to healthcare resulting in an increase in morbidity and mortality. Neonatal sepsis is ranked as the third highest cause of neonatal demise globally, in which AMR accounted for 31.0% of deaths. AMR in neonates has been poorly characterised in Durban, South Africa. Thus, the resultant effect of AMR on empiric regimens for neonatal sepsis is uncertain in this setting. Therefore, this study analysed the aetiology and antimicrobial susceptibility patterns of bloodstream infections within the neonatal intensive care unit at a tertiary hospital in Durban, with the aim of establishing an effective empiric regimen for the unit.

METHODS

A retrospective data review on positive blood cultures from the neonatal intensive care unit at Inkosi Albert Luthuli Central Hospital was conducted. Three time periods were analysed: 2014, 2016 and 2018. Culture data from neonates aged 0-30 days were included and repeat cultures were de-duplicated. The frequency of common organisms and their antimicrobial susceptibilities were analysed. Fischer's exact test was used for subgroup analysis. Poisson and logistic regressions were used to assess significant trends in organisms and antimicrobial susceptibilities over time.

RESULTS

Late-onset sepsis (86.8%) predominated over early-onset sepsis (13.2%). A preponderance of gram-positive organisms (68.7%) over gram-negatives (26.8%) and fungi (4.5%) was detected. Common pathogens included coagulase-negative staphylococci (53.5%), Klebsiella pneumoniae (11.6%), enterococci (9.3%), and Acinetobacter baumannii (7.7%). Despite the small contribution of fungi to the microbial profile, fluconazole-resistant Candida parapsilosis predominated within that group. High rates of resistance to first- and second-line antibiotics were also noted among gram-positive and gram-negative organisms. Multidrug resistant organisms included extended-spectrum beta-lactamase (ESBL) K. pneumoniae (7.6%) and extensively-drug resistant A. baumannii (7.0%). However, a statistically significant decrease in ESBL-producing organisms was documented during the entire study period (p = 0.005).

CONCLUSIONS

It was determined that first-line antimicrobials, advocated by the World Health Organization for treatment of neonatal sepsis, proved ineffective in this unit due to high levels of AMR. Therefore, this study advises that meropenem with or without vancomycin provides optimal empiric cover. Amphotericin B is advocated for empiric antifungal therapy. Ongoing surveillance is necessary.

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications

BACKGROUND

There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

METHODS

Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

RESULTS

There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

CONCLUSION

There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.

Clinical Outcome and Predictors of Intestinal Obstruction Surgery in Ethiopia: A Cross-Sectional Study

Background

Despite the advancement in the healthcare system, the impact of surgical interventions on public health systems will continue to grow. But predicting the outcome is challenging. Concerns related to unexpected outcomes and delays in the diagnosis of postoperative complications are the major issue. Intestinal obstruction is a common life-threatening surgical condition followed by fatal and nonfatal postoperative complications. This study was aimed at assessing results after surgery for intestinal obstruction in a hospital of Ethiopia. Methodology. An institutional-based cross-sectional study was conducted among 254 postoperative patients admitted with intestinal obstruction from January 1, 2014, to December 31, 2017. Data were coded and entered into EpiData 4.2.0.0 software and exported to the Statistical Package for the Social Sciences version 22 for analysis. A binary logistic regression model was used for analysis. All variables with a p value < 0.25 during bivariable analysis were considered for multivariable logistic regression analysis.

Results

The magnitude of poor surgical outcome of intestinal obstruction was 21.3% for patients enrolled into this investigation. The age group of ≥55 years (adjusted odds ratio (AOR) = 2.9, 95% CI: 1.03, 8.4), duration of illness of ≥24 hrs (AOR = 3.1, 95% CI: 1.03, 9.4), preoperative diagnosis of a gangrenous large bowel (AOR = 3.6, 95% CI: 1.3, 9.8), and a gangrenous small bowel (AOR = 4.2, 95% CI: 1.3, 13.7) were significantly associated with poor surgical outcome.

Conclusions

The magnitude of poor surgical outcome was high. Age, late presentation of illness, and gangrenous bowel obstructions were significantly associated with poor outcomes. So, concern should be given in early detection and follow-up of patients who came late and older patients.

Healthcare-associated infection and its determinants in Ethiopia: A systematic review and meta-analysis

Background

Healthcare-associated infection is a global threat in healthcare which increases the emergence of multiple drug-resistant microbial infections. Hence, continuous surveillance data is required before or after patient discharge from health institutions though such data is scarce in developing countries. Similarly, ongoing infection surveillance data are not available in Ethiopia. However, various primary studies conducted in the country showed different magnitude and determinants of healthcare-associated infection from 1983 to 2017. Therefore, this systematic review and meta-analysis aimed to estimate the national pooled prevalence and determinants of healthcare-associated infection in Ethiopia.

Methods

We searched PubMed, Science Direct, Google Scholar, and grey literature deposited at Addis Ababa University online repository. The quality of studies was checked using Joanna Brigg’s Institute quality assessment scale. Then, the funnel plot and Egger’s regression test were used to assess publication bias. The pooled prevalence of healthcare-associated infection was estimated using a weighted-inverse random-effects model meta-analysis. Finally, the subgroup analysis was done to resolve the cause of statistical heterogeneity.

Results

A total of 19 studies that satisfy the quality assessment criteria were considered in the final meta-analysis. The pooled prevalence of healthcare-associated infection in Ethiopia as estimated from 18 studies was 16.96% (95% CI: 14.10%-19.82%). In the subgroup analysis, the highest prevalence of healthcare-associated infection was in the intensive care unit 25.8% (95% CI: 3.55%-40.06%) followed by pediatrics ward 24.16% (95% CI: 12.76%-35.57%), surgical ward 23.78% (95% CI: 18.87%-29.69%) and obstetrics ward 22.25% (95% CI: 19.71%-24.80%). The pooled effect of two or more studies in this meta-analysis also showed that patients who had surgical procedures (AOR = 3.37; 95% CI: 1.85–4.89) and underlying non-communicable disease (AOR = 2.81; 95% CI: 1.39–4.22) were at increased risk of healthcare-associated infection.

Conclusions

The nationwide prevalence of healthcare-associated infection has remained a problem of public health importance in Ethiopia. The highest prevalence was observed in intensive care units followed by the pediatric ward, surgical ward and obstetrics ward. Thus, policymakers and program officers should give due emphasis on healthcare-associated infection preventive strategies at all levels. Essentially, the existing infection prevention and control practices in Ethiopia should be strengthened with special emphasis for patients admitted to intensive care units. Moreover, patients who had surgical procedures and underlying non-communicable diseases should be given more due attention.

The burden of healthcare-associated infection in Ethiopia: a systematic review and meta-analysis

Background

Different primary studies in Ethiopia showed the burden of nosocomial infection across geographical setting and variant period. However, the national level of burden and types of healthcare-associated infections were unknown. Hence, this systematic review and meta-analysis estimated the overall nationwide burden and types of healthcare-associated infections in Ethiopia.

Methods

We searched PubMed, Science Direct, Google Scholar, African Journal Online, and Addis Ababa University repository by date April 7, 2020. To assess publication bias, Egger’s test regression analysis was applied. Weight-inverse random-effect model meta-analysis was used. Subgroup analysis was conducted based on ward type, study region, study design, sample size and diagnostic method, ward type, and study participants.

Results

A total of 18 studies with 13,821 patients participated in the overall prevalence estimation. The pooled prevalence of healthcare-associated infection was 16.96% (95% CI 14.10–19.82). Specifically, surgical site infection (39.66%), urinary tract infection (27.69%), bloodstream infection (19.9%), dual infections (SSI and UTI) (14.01%), and respiratory tract (13.51%) were the commonest types of healthcare-associated infection. In subgroup analysis, the highest overall prevalence was observed as surgical, gynecology, and obstetrics ward (22.42%).

Conclusions

The national prevalence of healthcare-associated infection remains high. The most common type of HCAI was surgical site infection, followed by urinary tract infection, bloodstream infection, SSI and UTI, and respiratory tract infection. The overall prevalence was highest in surgical, gynecology, and obstetrics ward. Hence, infection prevention and control should be a priority agenda in healthcare with due emphasis for surgical patients.

Prevalence of healthcare-associated infections and antimicrobial use among inpatients in a tertiary hospital in Fiji: a point prevalence survey

Background

Healthcare-associated infections (HAIs) and antimicrobial use (AMU) are important drivers of antimicrobial resistance, yet there is minimal data from the Pacific region. We sought to determine the point prevalence of HAIs and AMU at Fiji’s largest hospital, the Colonial War Memorial Hospital (CWMH) in Suva. A secondary aim was to evaluate the performance of European Centre for Diseases Prevention and Control (ECDC) HAI criteria in a resource-limited setting.

Methods

We conducted a point prevalence survey of HAIs and AMU at CWMH in October 2019. Survey methodology was adapted from the ECDC protocol. To evaluate the suitability of ECDC HAI criteria in our setting, we augmented the survey to identify patients with a clinician diagnosis of a HAI where diagnostic testing criteria were not met. We also assessed infection prevention and control (IPC) infrastructure on each ward.

Results

We surveyed 343 patients, with median (interquartile range) age 30 years (16–53), predominantly admitted under obstetrics/gynaecology (94, 27.4%) or paediatrics (83, 24.2%). Thirty patients had one or more HAIs, a point prevalence of 8.7% (95% CI 6.0% to 12.3%). The most common HAIs were surgical site infections (n = 13), skin and soft tissue infections (7) and neonatal clinical sepsis (6). Two additional patients were identified with physician-diagnosed HAIs that failed to meet ECDC criteria due to insufficient investigations. 206 (60.1%) patients were receiving at least one antimicrobial. Of the 325 antimicrobial prescriptions, the most common agents were ampicillin (58/325, 17.8%), cloxacillin (55/325, 16.9%) and metronidazole (53/325, 16.3%). Use of broad-spectrum agents such as piperacillin/tazobactam (n = 6) and meropenem (1) was low. The majority of prescriptions for surgical prophylaxis were for more than 1 day (45/76, 59.2%). Although the number of handwashing basins throughout the hospital exceeded World Health Organization recommendations, availability of alcohol-based handrub was limited and most concentrated within high-risk wards.

Conclusions

The prevalence of HAIs in Fiji was similar to neighbouring high-income countries, but may have been reduced by the high proportion of paediatric and obstetrics patients, or by lower rates of inpatient investigations. AMU was very high, with duration of surgical prophylaxis an important target for future antimicrobial stewardship initiatives.

Antibiotic resistance and sensitivity pattern of Metallo-β-Lactamase Producing Gram-Negative Bacilli in ventilator-associated pneumonia in the intensive care unit of a public medical school hospital in Bangladesh

BACKGROUND

Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICU), accounting for 25% of all ICU infections. Antimicrobial resistance is increasing and becoming a significant health problem worldwide, increasing hospital length of stay, mortality and costs. Identifying antibiotic resistance patterns in VAP is important as this can cause outbreaks in ICUs. To date, there have been limited studies assessing this in Bangladesh. Consequently, the primary objective of this research was to study the species of bacterial growth and to determine the antibiotic resistance patterns of Metallo-β-Lactamase (MBL) producing gram-negative bacilli among ICU patients with VAP in a public medical school hospital, Bangladesh. In addition, identify the factors associated with a positive culture to provide future guidance.

METHOD

Cross-sectional study performed in the Chattogram Medical College Hospital, Bangladesh. Mueller Hinton agar plates were used for antibiotic sensitivity testing by the Kirby-Buer disc diffusion test.

RESULTS

Among 105 clinically suspected VAP cases, qualitative cultures were positive in 95 (90%) of them. The most common bacteria identified were Acinetobacter spp. (43.2%), Klebsiella spp. (20%) and Pseudomonas spp. (18.9%). A positive culture was not associated with patients' age or gender. Among 41 isolated Acinetobacter spp., 38 (92.7%) were resistant to gentamicin followed by 36 (87.8%) to ceftriaxone. Among 24 isolated Klebsiella spp., 22 (83.3%) were resistant to ceftriaxone. Among 18 isolated Pseudomonas spp., 16 (88.8%) were resistant to ciprofloxacin, and 13 (72.2%) were resistant to ceftriaxone. Among nine isolated E. coli, all were resistant to ceftriaxone and ciprofloxacin. All four Proteus spp. (100%) isolated were resistant to ciprofloxacin. Additionally, phenotype MBL producing was 65.22% and genotype was 45.65% among imipenem resistant pathogens. Imipenem resistant pathogens were sensitive to amoxyclav, amikacin¸ azithromycin, ceftazidime, ceftriaxone, colistin and gentamycin.

CONCLUSION

A positive culture was detected in 90% of VAP patients, but it was not associated with the patients' age and gender. The most common bacteria identified were Acinetobacter spp., Klebsiella spp. and Pseudomonas spp., where the majority of these were resistant to ceftriaxone. The results are being used to provide future guidance on the empiric management of VAP in this hospital.

Compliance with South Africa's Antimicrobial Resistance National Strategy Framework: are we there yet?

Antimicrobial resistance (AMR) is a growing problem worldwide. South Africa has recently released its Antimicrobial Resistance National Strategy Framework (referred to as the Framework) to instigate antimicrobial stewardship programmes (ASPs). Consequently, there is a need to assess compliance with the Framework.

METHODS

Descriptive study design, collecting quantitative data, among pre-selected public healthcare facilities. One healthcare professional from each participating facility, involved in ASPs, was invited to participate.

RESULTS

Overall 26 facilities from 8 provinces participated. Average compliance to the Framework was 59.5% for the 26 facilities, with 38.0% for community health centres, 66.9% for referral hospitals and 73.5% for national central hospitals. For 7 facilities compliance was <50% while 5 facilities were >80% compliant.

CONCLUSION

Although some facilities complied well with the Framework, overall compliance was sub-optimal. With the introduction of universal healthcare in South Africa, coupled with growing AMR rates, ongoing initiatives to actively implement the Framework should be targeted at non-compliant facilities.

Point prevalence surveys of antimicrobial use: a systematic review and the implications

Introduction: In view of increasing concerns with antimicrobial resistance (AMR), the World Health Organization (WHO) instituted a Global Action Plan (GAP) to address this. Area covered: One of the strategies to achieve the goals of GAP is to conduct regular surveillance of antimicrobial use through point prevalence surveys (PPS). In this review, PubMed, EBSCO, Proquest, Cinahl, and Scopus were searched for PPS of antimicrobial use published in English between January 2000 and December 2019. After systematic database screening of 2,893 articles, 60 PPS met the inclusion criteria and consequently were incorporated in this systematic review. Expert opinion: This review highlighted that most of the PPS were conducted in upper-middle and high-income countries. Prevalence of antimicrobial use was significantly higher in non-European hospitals compared with European hospitals. The domination of third-generation cephalosporin and fluoroquinolones use across all the regions suggests substantial use of broad-spectrum antimicrobials across countries. Among all identified regions around the world, India was the region where the highest use of antimicrobials was observed. Although PPS is a useful tool to assess the pattern of antimicrobial use and provides a robust baseline; however, a standardized surveillance method is needed. In order to optimize antimicrobial use, more efforts are required to improve antimicrobial use.

Antimicrobial utilization research and activities in Botswana, the past, present and the future

A number of activities are ongoing to reduce AMR in Botswana by improving antimicrobial utilization across all sectors. However, there is a need to share experiences. With the objective of sharing these, the second one day symposium was held in the University of Botswana in October 2018 involving both private and public hospitals. In Lenmed Bokamoso hospital, ESKAPE organisms were associated with 50-90% of clinical infections; however, there was no correlation between healthcare associated infections (HAIs) and admission swab positivity with ESKAPE or ESBL isolates. Hang times, the time between a prescription and IV administration, were also discussed. At Nyangabwe Hospital, the prevalence of HAIs was 13.54%, 48.9% were laboratory confirmed of which 8.5% were blood stream infections (BSIs). The prevalence of different bacteria causing neonatal BSIs was also investigated. At Princess Marina Hospital, positive cultures were seen in 22.4% of blood cultures with contaminants comprising the majority. Several activities are ongoing in Botswana across sectors as a result of the findings and will be periodically reported to further improve antibiotic utilization.