Sepsis: emerging pathogens and antimicrobial resistance in Ethiopian referral hospitals

Genomic characterizations of Klebsiella variicola: emerging pathogens identified from sepsis patients in Ethiopian referral hospitals

Healthcare in low- and middle-income countries is becoming problematic due to the emergence of multidrug-resistant bacteria causing serious morbidity and mortality. Klebsiella variicola carrying multiple antimicrobial resistance (AMR) genes were found significantly among sepsis patients in a study done between October 2019 and September 2020 at four Ethiopian hospitals located in the central (Tikur Anbessa and Yekatit 12), southern (Hawassa), and northern (Dessie) parts. Among 1416 sepsis patients, 74 K. variicola isolates were identified using MALDI-TOF, most of them at Dessie (n = 44) and Hawassa (n = 28) hospitals. Whole genome sequencing showed that K. variicola strains identified at Dessie Hospital displayed phylogenetic clonality, carried an IncM1 plasmid and the majority were ST3924. Many K. variicola identified at Hawassa Hospital were clonally clustered and the majority belonged to novel STs and carried IncFIB(K) and IncFII(K) plasmids concurrently. Fifty K. variicola carried ESBL genes while 2 isolates harboured AmpC. Other frequently found genes were aac(3)-lla, blaCTX-M-15, blaTEM-1B, blaLEN2, blaOXA-1, blaSCO-1, catB3, dfrA14, QnrB1, aac(6')-lb-cr and sul2. Virulence genes detected at both sites were mrk operons for biofilm formation and siderophore ABC transporter operons for iron uptake. Capsular alleles varied, with wzi 269 at Dessie and wzi 582 at Hawassa. The isolation of multidrug-resistant K. variicola as an emerging sepsis pathogen calls for strong infection prevention strategies and antimicrobial stewardship supported by advanced bacterial identification techniques.

Prevalence of phenotypic drug resistance profiles and multi-drug-resistant Pseudomonas and Acinetobacter species recovered from clinical specimens in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Antimicrobial-resistant Pseudomonas and Acinetobacter species are emerging as serious public health risks, both globally and in resource-limited countries such as Ethiopia. These microorganisms cause serious, life-threatening infections and are becoming increasingly resistant to commonly prescribed antibiotics. The high prevalence and resistance patterns of these bacteria need immediate action to inform treatment guidelines, increase infection control measure, and develop effective public health policies. This systematic review and meta-analysis aimed to assess the prevalence of phenotypic drug resistance profiles and multi-drug-resistant Pseudomonas and Acinetobacter species recovered from clinical specimens in Ethiopia.

METHODS

This systematic review and meta-analysis, which followed PRISMA principles, analyzed data from PubMed, Scopus, and Google Scholar to determine the prevalence and antibiotic resistance trends of Pseudomonas and Acinetobacter species in Ethiopia. Eligible studies were extracted by using Microsoft Excel and exported to STATA version 17 for analysis. The pooled prevalence was estimated using a random-effects model, and heterogeneity was examined using the I2 statistic. Publication bias was investigated using funnel plot analysis and Egger's test, and sensitivity analysis was used to assess the impact of individual studies on the total pooled findings.

RESULT

Of the 1,375 studies identified, 187 were eligible for qualitative analysis, leading to the inclusion of 65 studies in the meta-analysis. This analysis encompassed a total of 1,264 isolates, with 364 identified as Pseudomonas and Acinetobacter species. The systematic review revealed a pooled prevalence of 19.12% (95% CI: 14.86-23.38) for Pseudomonas species and 12.46% (95% CI: 5.82-19.10) for Acinetobacter species. The combined prevalence of both pathogens was 25.31 (95% CI: 18.61-32.00) with substantial heterogeneity (I2 = 93.6%, p < 0.001). across the studies. Pseudomonas exhibited high resistance rates to amoxicillin-clavulanic Acid (83.73%) and tetracycline (89.15%), while Acinetobacter showed 87.21% resistance to tetracycline and 79.72% to ceftriaxone. The overall pooled prevalence of MDR Pseudomonas species was 72.73% (95% CI: 67.02-78.44), and for Acinetobacter species, it reached 84.69% (95% CI: 78.78-90.59), respectively. Moreover, the pooled prevalence of MDR for both species isolated from clinical samples in Ethiopia was 74.79% (95% CI: 70.14-79.43), with significant heterogeneity (I2 = 99.7%, p < 0.001) across the studies.

CONCLUSION

The pooled prevalence of Pseudomonas and Acinetobacter species and their antibiotic resistance were alarmingly high in clinical samples in Ethiopia. These findings highlight the crucial need for more antimicrobial surveillance, stronger stewardship programs, and targeted research to combat the growing threat of resistance. Strategic public health policies are required to decrease these pathogens.

Antimicrobial resistance pattern of Acinetobacter baumannii clinical isolate in Ethiopia. A systematic review and meta-analysis

BACKGROUND

Antimicrobial resistance (AMR) is a growing global health threat. Acinetobacter baumannii (A. baumannii) emerged as one of the most concerning critical priority pathogens due to its ability to develop resistance to multiple antimicrobial agents. In Ethiopia, the public health impact of AMR is increasingly significant, with A. baumannii responsible for a variety of infections. Although A. baumannii causes a range of infections in Ethiopian patients, the drug resistance status of the clinical isolates has not been thoroughly assessed. Therefore, this systematic review and meta-analysis aimed to determine the country-wide AMR of A. baumannii.

METHODS

This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted a search of articles on PubMed, Web of Science, Science Direct, Scopes electronic databases, Google Scholar search engine, and institutional repositories/libraries for studies published between 2015 and 2024. Eligible studies on A. baumannii-related infections and AMR in Ethiopia were assessed for quality using the Joanna Briggs Institute (JBI) criteria. Data on study characteristics were extracted, and statistical analyses, including heterogeneity (Invers of variance), publication bias (Eggers test), and subgroup analyses, were performed using STATA 17.0. A random effect model was used to compute the pooled prevalence of AMR.

RESULTS

This systematic review and meta-analysis of 26 Ethiopian studies (26,539 participants) found an A. baumannii prevalence of 3.99% (95% CI: 3.01-4.98%) and 9.13% of all bacterial infections (95% CI: 6.73-11.54%). The most common infections were surgical site infections, urinary tract infections, pneumonia, and sepsis. Pooled resistance to antibiotics varied, with amikacin showing the lowest resistance (20.27%) (95% CI: 11.51-29.03) and cefotaxime the highest (83.18) (95% CI: 71.87-94.48). A pooled multi-drug resistant (MDR) A. baumannii was found in 88.22% (95% CI: 82.28-94.15) of isolates, with regional and infection-type variations, particularly in higher prevalence in Oromia and Amhara regions and sepsis cases.

CONCLUSION

This systematic review underscores the alarming rise of antimicrobial resistance in A. baumannii, particularly against carbapenems. The findings highlight a high prevalence of MDR A. baumannii and widespread extended-spectrum beta-lactamase production, with notable regional variations in resistance patterns. These high resistance rates reinforce A. baumannii as a critical global health threat, necessitating urgent interventions such as enhanced antimicrobial stewardship programs, improved infection control measures, and the development of alternative treatment strategies. Healthcare professionals, policymakers, and researchers must collaborate to mitigate the clinical and public health impact of this pathogen.

PROTOCOL REGISTRATION

This systematic review and meta-analysis was registered on PROSPERO (Registration ID: CRD42024623927).

A Case of Lelliottia amnigena-Induced Acute Calculous Cholecystitis and a Literature Review

Atypical presentations can confuse the clinical picture, especially in patients with comorbidities. Particularly, rare pathogens, such as Lelliottia amnigena, can cause infections in immunocompromised patients or, sometimes, present as epidemic infections. We present a case of a female patient with a history of cryptogenic cirrhosis and poorly controlled diabetes, who developed acute calculous cholecystitis with positive bile cultures for L. amnigena, a rare, Gram-negative facultative anaerobic bacillus, usually associated with water sources and immunocompromised hosts. The patient also had positive titers for acute hepatitis A. This case is the first to our knowledge that reports L. amnigena-induced acute cholecystitis, along with concomitant acute hepatitis A positive serology. We aim to emphasize the importance of a broad differential diagnosis in such patients, early identification of rare pathogens, and the role of comprehensive clinical judgment in guiding treatment decisions.

Bacterial etiology and antimicrobial resistance in bloodstream infections at the University of Gondar Comprehensive Specialized Hospital: a cross-sectional study

Background

Bacterial bloodstream infections are a major global health concern, particularly in resource-limited settings including Ethiopia. There is a lack of updated and comprehensive data that integrates microbiological data and clinical findings. Therefore, this study aimed to characterize bacterial profiles, antimicrobial susceptibility, and associated factors in patients suspected of bloodstream infections at the University of Gondar Comprehensive Specialized Hospital.

Methods

A cross-sectional study analyzed electronic records from January 2019 to December 2021. Sociodemographic, clinical, and blood culture data were analyzed. Descriptive statistics and binary logistic regression were employed to identify factors associated with bloodstream infections. Descriptive statistics such as frequency and percentage were computed. Furthermore, a binary and multivariable logistic regression model was fitted to determine the relationship between BSI and associated factors. Variables with p-values of <0.05 from the multivariable logistic regression were used to show the presence of statistically significant associations.

Results

A total of 4,727 patients' records were included in the study. Among these, 14.8% (701/4,727) were bacterial bloodstream infections, with Gram-negative bacteria accounting for 63.5% (445/701) of cases. The most common bacteria were Klebsiella pneumoniae (29.0%), Staphylococcus aureus (23.5%), and Escherichia coli (8.4%). The study revealed a high resistance level to several antibiotics, with approximately 60.9% of the isolates demonstrating multidrug resistance. Klebsiella oxytoca, Klebsiella pneumoniae, and Escherichia coli exhibited high levels of multidrug resistance. The study identified emergency OPD [AOR = 3.2; (95% CI: 1.50-6.74)], oncology ward [AOR = 3.0; (95% CI: 1.21-7.17)], and surgical ward [AOR = 3.3; (95% CI: 1.27-8.43)] as factors associated with increased susceptibility to bloodstream infections.

Conclusion

The overall prevalence of bacterial isolates was high with concerning levels of multi-drug resistance. The study identified significant associations between bloodstream infections with age groups and presentation in specific clinical settings, such as the emergency OPD, oncology ward, and surgical ward. Strict regulation of antibiotic stewardship and the implementation of effective infection control programs should be enforced.

Caspase-11 and NLRP3 exacerbate systemic Klebsiella infection through reducing mitochondrial ROS production

Introduction

Klebsiella pneumoniae is a Gram-negative bacterium and the third most commonly isolated microorganism in blood cultures from septic patients. Despite extensive research, the mechanisms underlying K. pneumoniae-induced sepsis and its pathogenesis remain unclear. Acute respiratory failure is a leading cause of mortality in systemic K. pneumoniae infections, highlighting the need to better understand the host immune response and bacterial clearance mechanisms.

Method

To investigate the impact of K. pneumoniae infection on organ function and immune response, we utilized a systemic infection model through intraperitoneal injection in mice. Bacterial loads in key organs were quantified, and lung injury was assessed. Survival analysis was performed in wild-type (WT) and gene deficient mice. Mitochondrial damage and reactive oxygen species (ROS) production, as well as cytokine levels were measured in macrophages isolated from these mice to evaluate their contribution to bacterial clearance capacity.

Results

Our findings demonstrate that K. pneumoniae systemic infection results in severe lung injury and significant bacterial accumulation in multiple organs, with the highest burden in the lungs. Deficiency of caspase-11 or NLRP3 led to prolonged survival, a reduction in pulmonary bacterial load, increased blood oxygen levels, and decreased IL-6 levels in the lungs compared to WT controls. Furthermore, caspase-11- and NLRP3-deficient macrophages exhibited elevated mitochondrial ROS production in response to K. pneumoniae, which correlated with more effective bacterial clearance.

Discussion

These results suggest that caspase-11 and NLRP3 contribute to K. pneumoniae-induced sepsis by impairing mitochondrial function and reducing ROS production in macrophages, thereby compromising bacterial clearance. The observed reduction in lung injury and increased survival in caspase-11- and NLRP3-deficient mice indicate that targeting these pathways may offer potential therapeutic strategies to improve host defense against systemic K. pneumoniae infection.

Risk factors associated with mortality and pathogen characteristics of bloodstream infection-induced severe sepsis in the pediatric intensive care unit: a retrospective cohort study

Background

Bloodstream infection (BSI)-induced severe sepsis is a common cause of mortality, frequently resulting in septic shock and multiple organ dysfunction syndrome (MODS). This study aimed to analyze mortality risk factors and summarize pathogen characteristics associated with BSI-induced severe sepsis in the pediatric intensive care unit (PICU).

Methods

This retrospective study was conducted at a tertiary pediatric hospital between January 2015 and December 2023, encompassing children with BSI-induced severe sepsis in the PICU. Clinical characteristics, laboratory parameters, pathogen characteristics, and drug resistance profiles of the patients were collected. Clinical and laboratory indicators along with pathogen characteristics were summarized. Logistic regression analysis was employed to identify independent risk factors associated with 28-day mortality.

Results

A total of 192 patients with bloodstream infection (BSI)-induced severe sepsis were identified, with a 28-day in-hospital mortality rate of 36.98% (71/192). The incidence of septic shock (42.1% vs. 69%, P < 0.001) and AKI (14% vs. 31%, P = 0.005) was significantly lower in the survival group compared to the non-survival group. In multivariate analysis, independent risk factors for 28-day mortality were the pediatric sequential organ failure assessment (pSOFA) score (OR 1.176; 95% CI: 1.046-1.321, p = 0.007) and the P/F value (OR 0.994; 95% CI: 0.991-0.997, P < 0.001). Double organism growth was detected in 8 cultures, and a total of 200 pathogenic bacteria were isolated from all blood cultures. Of these, 110 strains (55.0%) were Gram-negative bacteria, 88 strains (44.0%) were gram-positive bacteria, and 2 strains (1.0%) were Candida albicans. The most commonly isolated pathogens were Staphylococcus aureus, Coagulase-negative Staphylococcus, and Escherichia coli. The detection rate of carbapenem resistance (CR) in Acinetobacter baumannii (66.7%) was higher than that in Pseudomonas aeruginosa (15.4%). The detection rates of extended-spectrum cephalosporin resistance (ECR) and fluoroquinolone resistance (FQR) in Escherichia coli (E. coli) were higher than those in Klebsiella pneumoniae.

Conclusion

In the PICU, higher mortality was observed in children with BSI-induced severe sepsis who presented with elevated pSOFA scores and low P/F values. Acinetobacter baumannii exhibited the highest levels of CR and FQR, while Escherichia coli demonstrated the highest level of ECR.

Geographical mapping and temporal trends of Acinetobacter baumannii carbapenem resistance: A comprehensive meta-analysis

BACKGROUND

Carbapenem-resistant Acinetobacter baumannii (CRAB) is of critical concern in healthcare settings, leading to limited treatment options. In this study, we conducted a comprehensive meta-analysis to assess the prevalence of CRAB by examining temporal, geographic, and bias-related variations.

METHODS

We systematically searched prominent databases, including Scopus, PubMed, Web of Science, and EMBASE. Quality assessment was performed using the JBI checklist. Subgroup analyses were performed based on the COVID-19 timeframes, years, countries, continents, and bias levels, antimicrobial susceptivity test method and guidelines.

RESULTS

Our comprehensive meta-analysis, which included 795 studies across 80 countries from 1995 to 2023, revealed a surge in carbapenem resistance among A. baumannii, imipenem (76.1%), meropenem (73.5%), doripenem (73.0%), ertapenem (83.7%), and carbapenems (74.3%). Temporally, 2020-2023 witnessed significant peaks, particularly in carbapenems (81.0%) and meropenem (80.7%), as confirmed by meta-regression, indicating a steady upward trend.

CONCLUSION

This meta-analysis revealed an alarmingly high resistance rate to CRAB as a global challenge, emphasizing the urgent need for tailored interventions. Transparency, standardized methodologies, and collaboration are crucial for the accurate assessment and maintenance of carbapenem efficacy.

Overall status of carbapenem resistance among clinical isolates of Acinetobacter baumannii: a systematic review and meta-analysis

BACKGROUND

Resistance to carbapenems, the first-line treatment for infections caused by Acinetobacter baumannii, is increasing throughout the world. The aim of the present study was to determine the global status of resistance to carbapenems in clinical isolates of this pathogen, worldwide.

METHODS

Electronic databases were searched using the appropriate keywords, including: 'Acinetobacter' 'baumannii', 'Acinetobacter baumannii' and 'A. baumannii', 'resistance', 'antibiotic resistance', 'antibiotic susceptibility', 'antimicrobial resistance', 'antimicrobial susceptibility', 'carbapenem', 'carbapenems', 'imipenem', 'meropenem' and 'doripenem'. Finally, following some exclusions, 177 studies from various countries were included in this study. The data were then subjected to a meta-analysis.

RESULTS

The average resistance rate of A. baumannii to imipenem, meropenem and doripenem was 44.7%, 59.4% and 72.7%, respectively. A high level of heterogeneity (I2 > 50%, P value < 0.05) was detected in the studies representing resistance to imipenem, meropenem and doripenem in A. baumannii isolates. Begg's and Egger's tests did not indicate publication bias (P value > 0.05).

CONCLUSIONS

The findings of the current study indicate that the overall resistance to carbapenems in clinical isolates of A. baumannii is relatively high and prevalent throughout the world. Moreover, time trend analysis showed that the resistance has increased from the year 2000 to 2023. This emphasizes the importance of conducting routine antimicrobial susceptibility testing before selecting a course of treatment, as well as monitoring and controlling antibiotic resistance patterns in A. baumannii strains, and seeking novel treatment options to lessen the emergence and spread of resistant strains and to reduce the treatment failure.

Progress on implementing the WHO-GLASS recommendations on priority pathogen-antibiotic sensitivity testing in Africa: A scoping review

Introduction

The World Health Organization global antimicrobial resistance surveillance system (GLASS) was rolled out in 2015 to guide antimicrobial resistance (AMR) surveillance. However, its implementation in Africa has not been fully evaluated. We conducted a scoping review to establish the progress of implementing the WHO 2015 GLASS manual in Africa.

Methods

We used MeSH terms to comprehensively search electronic databases (MEDLINE and Embase) for articles from Africa published in English between January 2016 and December 2023. The Arksey and O'Malley's methodological framework for scoping reviews was employed. Data were collected on compliance with WHO GLASS recommendations for AMR surveillance-priority samples, pathogens, and pathogen-antibiotic combinations and analysed using Microsoft Excel.

Results

Overall, 13,185 articles were identified. 7,409 were duplicates, and 5,141 articles were excluded based on titles and abstracts. 609 full-text articles were reviewed, and 147 were selected for data extraction. Of the 147 selected articles, 78.9% had been published between 2020 and 2023; 57.8% were from Eastern Africa. 93.9% of articles were on cross-sectional studies. 96.6% included only one priority sample type; blood (n=56), urine (n=64), and stool (n=22). Of the 60 articles that focused on blood as a priority sample type, 71.7%, 68.3%, 68.3%, 36.7%, 30%, and 10% reported recovery of Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Salmonella species and Streptococcus pneumoniae, respectively. Salmonella and Shigella species were reported to have been recovered from 91.3% and 73.9% of the 23 articles that focused on stool. E. coli and K. pneumoniae recoveries were also reported from 94.2% and 68.1% of the 69 articles that focused on urine. No article in this review reported having tested all the recommended WHO GLASS pathogen-antibiotic combinations for specific pathogens.

Conclusion

Progress has been made in implementing the GLASS recommendations in Africa, but adoption varies across countries limiting standardisation and comparability of data.

Enhancing acute inflammatory and sepsis treatment: superiority of membrane receptor blockade

Conditions such as acute pancreatitis, ulcerative colitis, delayed graft function and infections caused by a variety of microorganisms, including gram-positive and gram-negative organisms, increase the risk of sepsis and therefore mortality. Immune dysfunction is a characterization of sepsis, so timely and effective treatment strategies are needed. The conventional approaches, such as antibiotic-based treatments, face challenges such as antibiotic resistance, and cytokine-based treatments have shown limited efficacy. To address these limitations, a novel approach focusing on membrane receptors, the initiators of the inflammatory cascade, is proposed. Membrane receptors such as Toll-like receptors, interleukin-1 receptor, endothelial protein C receptor, μ-opioid receptor, triggering receptor expressed on myeloid cells 1, and G-protein coupled receptors play pivotal roles in the inflammatory response, offering opportunities for rapid regulation. Various membrane receptor blockade strategies have demonstrated efficacy in both preclinical and clinical studies. These membrane receptor blockades act as early stage inflammation modulators, providing faster responses compared to conventional therapies. Importantly, these blockers exhibit immunomodulatory capabilities without inducing complete immunosuppression. Finally, this review underscores the critical need for early intervention in acute inflammatory and infectious diseases, particularly those posing a risk of progressing to sepsis. And, exploring membrane receptor blockade as an adjunctive treatment for acute inflammatory and infectious diseases presents a promising avenue. These novel approaches, when combined with antibiotics, have the potential to enhance patient outcomes, particularly in conditions prone to sepsis, while minimizing risks associated with antibiotic resistance and immune suppression.

Isolation and Antimicrobial Resistance Patterns of Bacterial Pathogens from Community-Acquired Pneumonia at Adama Hospital Medical College, Adama, Ethiopia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality worldwide. It also contributes significantly to hospital admissions, particularly in low-income countries such as Ethiopia, where it accounts for major public health problems. This could be attributed to the increasing prevalence of antibiotic-resistant pathogens in CAP patients. This study aimed to identify and assess the antibiotic resistance patterns of bacterial isolates from CAP patients at the Adama Hospital Medical College in Adama City, Ethiopia. A cross-sectional study was conducted from November 10, 2022, to November 30, 2023. Demographic, clinical data, and sputum samples were collected from patients with CAP (n = 369). Sputum samples were subjected to standard microbiological procedures, including culture, Gram staining, and a panel of different biochemical tests for the identification of pathogenic bacterial isolates. The Kirby-Bauer disc diffusion method was used for drug susceptibility testing. Descriptive statistics were computed by using SPSS (version 26). Of the 369 patients with CAP, bacterial pathogens were identified in 31.7% (n = 117, 95% CI: 27.0%-36.7%). The most common isolates were Moraxella catarrhalis (n = 15; 12.8%), Staphylococcus aureus (n = 15; 12.8%), Klebsiella pneumoniae (n = 12; 10.3%), Escherichia coli (n = 11; 9.4%), Pseudomonas aeruginosa (n = 11; 9.4%), Enterobacter species (n = 11; 9.4%), and Citrobacter species (n = 11; 9.4%). Among the identified isolates, resistance rates were high in Enterobacteriaceae, followed by Gram-positive bacteria, and non-Enterobacteriaceae. Overall, 68 (58.1%) of the identified bacterial isolates were multidrug resistant (MDR), with K. pneumoniae accounting for the highest proportion of multidrug resistant isolates (91.7%), while P. aeruginosa accounted for the lowest proportion (9.1%) of MDR isolates. This study revealed a high prevalence (31.7%) of bacterial pathogens in CAP patients and higher (58.1%) MDR bacterial pathogens. Therefore, regular surveillance and monitoring systems are warranted for assessing predominant pathogens and antibiotic resistance patterns.

Extended tests for evaluating post-traumatic brain injury deficits in resource-limited settings: methods and pilot study data

Introduction

Traumatic brain injury (TBI) is one of the leading causes of all injury-related deaths and disabilities in the world, especially in low to middle-income countries (LMICs) which also suffer from lower levels of funding for all levels of the health care system for patients suffering from TBI. These patients do not generally get comprehensive diagnostic workup, monitoring, or treatment, and return to work too quickly, often with undiagnosed post-traumatic deficits which in turn can lead to subsequent incidents of physical harm.

Methods

Here, we share methods and results from our research project to establish innovative, simple, and scientifically based practices that dramatically leverage technology and validated testing strategies to identify post-TBI deficits quickly and accurately, to circumvent economic realities on the ground in LMICs. We utilized paper tests such as the Montreal cognitive assessment (MoCA), line-bisection, and Bell's test. Furthermore, we combined modifications of neuroscience computer tasks to aid in assessing peripheral vision, memory, and analytical accuracies. Data from seventy-one subjects (51 patients and 20 controls, 15 females and 56 males) from 4 hospitals in Ethiopia are presented. The traumatic brain injury group consists of 17 mild, 28 moderate, and 8 severe patients (based on the initial Glasgow Comma Score). Controls are age and education-matched subjects (no known history of TBI, brain lesions, or spatial neglect symptoms).

Results

We found these neurophysiological methods can: 1) be implemented in LMICs and 2) test impairments caused by TBI, which generally affect brain processing speed, memory, and both executive and cognitive controls.

Discussion

The main findings indicate that these examinations can identify several deficits, especially the MoCA test. These tests show great promise to assist in the evaluation of TBI patients and support the establishment of dedicated rehabilitation centers. Our next steps will be expansion of the cohort size and application of the tests to other settings.

Prevalence of meropenem-resistant Pseudomonas Aeruginosa in Ethiopia: a systematic review and meta‑analysis

INTRODUCTION

Antimicrobial resistance (AMR) is a pressing global health concern, particularly pronounced in low-resource settings. In Ethiopia, the escalating prevalence of carbapenem-resistant Pseudomonas aeruginosa (P. aeruginosa) poses a substantial threat to public health.

METHODS

A comprehensive search of databases, including PubMed, Scopus, Embase, Hinari, and Google Scholar, identified relevant studies. Inclusion criteria encompassed observational studies reporting the prevalence of meropenem-resistant P. aeruginosa in Ethiopia. Quality assessment utilized JBI checklists. A random-effects meta-analysis pooled data on study characteristics and prevalence estimates, with subsequent subgroup and sensitivity analyses. Publication bias was assessed graphically and statistically.

RESULTS

Out of 433 studies, nineteen, comprising a total sample of 11,131, met inclusion criteria. The pooled prevalence of meropenem-resistant P. aeruginosa was 15% (95% CI: 10-21%). Significant heterogeneity (I2 = 83.6%) was observed, with the number of P. aeruginosa isolates identified as the primary source of heterogeneity (p = 0.127). Subgroup analysis by infection source revealed a higher prevalence in hospital-acquired infections (28%, 95% CI: 10, 46) compared to community settings (6%, 95% CI: 2, 11). Geographic based subgroup analysis indicated the highest prevalence in the Amhara region (23%, 95% CI: 8, 38), followed by Addis Ababa (21%, 95% CI: 11, 32), and lower prevalence in the Oromia region (7%, 95% CI: 4, 19). Wound samples exhibited the highest resistance (25%, 95% CI: 25, 78), while sputum samples showed the lowest prevalence. Publication bias, identified through funnel plot examination and Egger's regression test (p < 0.001), execution of trim and fill analysis resulted in an adjusted pooled prevalence of (3.7%, 95% CI: 2.3, 9.6).

CONCLUSION

The noteworthy prevalence of meropenem resistance among P. aeruginosa isolates in Ethiopia, particularly in healthcare settings, underscores the urgency of implementing strict infection control practices and antibiotic stewardship. Further research is imperative to address and mitigate the challenges posed by antimicrobial resistance in the country.

Genomic islands and their role in fitness traits of two key sepsis-causing bacterial pathogens

To survive and establish a niche for themselves, bacteria constantly evolve. Toward that, they not only insert point mutations and promote illegitimate recombinations within their genomes but also insert pieces of 'foreign' deoxyribonucleic acid, which are commonly referred to as 'genomic islands' (GEIs). The GEIs come in several forms, structures and types, often providing a fitness advantage to the harboring bacterium. In pathogenic bacteria, some GEIs may enhance virulence, thus altering disease burden, morbidity and mortality. Hence, delineating (i) the GEIs framework, (ii) their encoded functions, (iii) the triggers that help them move, (iv) the mechanisms they exploit to move among bacteria and (v) identification of their natural reservoirs will aid in superior tackling of several bacterial diseases, including sepsis. Given the vast array of comparative genomics data, in this short review, we provide an overview of the GEIs, their types and the compositions therein, especially highlighting GEIs harbored by two important pathogens, viz. Acinetobacter baumannii and Klebsiella pneumoniae, which prominently trigger sepsis in low- and middle-income countries. Our efforts help shed some light on the challenges these pathogens pose when equipped with GEIs. We hope that this review will provoke intense research into understanding GEIs, the cues that drive their mobility across bacteria and the ways and means to prevent their transfer, especially across pathogenic bacteria.

Knowledge and Associated Factors Towards Sepsis Management Among Nurses Working in the Emergency Department of Public Hospitals in Addis Ababa

Background

Sepsis is a major cause of mortality worldwide and an important public health problem. The quality of patient care is negatively impacted when nurses lack adequate knowledge regarding the management of sepsis. On the other hand, little is known regarding Ethiopian nurses' knowledge of sepsis management.

Objective

To assess the level of knowledge and the associated factors towards sepsis management among nurses working in emergency departments in public hospitals in Addis Ababa, Ethiopia.

Method

From March 18 to April 18, 2022, a health facility-based cross-sectional study was conducted. A simple sampling technique (lottery method) was used to select the hospitals. The data was analyzed using SPSS version 25. The study employed logistic regression analysis to examine the association between the independent variables and the level of knowledge. Variables were significantly associated with a level of knowledge if they had a p-value of less than 0.05 and a 95% confidence interval.

Result

Of the 127 participants, more than half (56.7%) had poor knowledge. Nurses' knowledge of managing sepsis was significantly associated with not having regular training, a low level of education, and working experience of less than five years. The findings of the multivariable regression analysis revealed that the following variables were associated with a nurse's knowledge of sepsis management: low level of education (AOR = 3.2 (95% CI, 1.16-8.77), lack of training adjusted odd ratio (AOR = 2.5 (95% CI, 1.07-5.93), and less than five years of work experience (AOR = 3.6 (95% CI, 1. 29-9.830).

Conclusion

The majority of nurses had inadequate knowledge of managing sepsis. On the other hand, the majority of nurses had a favourable attitude toward sepsis management. Lack of prior training, a low level of education, and less than five years of work experience were all significantly associated with nurses' poor knowledge regarding sepsis management. This study recommends that hospital managers should provide on-the-job and long-term training for nurses working in the emergency department to enhance the level of nurses' knowledge towards sepsis management at their institutions.

Lelliottia amnigena recovered from the lung of a harbour porpoise, and comparative analyses with Lelliottia spp

Strain M1325/93/1 (herein referred to by our laboratory identifier, GFKo1) of Lelliottia amnigena was isolated from the lung of a harbour porpoise in 1993. The genome sequence and antimicrobial resistance profile (genomic, phenotypic) of the strain were generated, with the genomic data compared with those from closely related bacteria. We demonstrate that the recently described chromosomally encoded AmpC β-lactamase bla LAQ is a core gene of L. amnigena , and suggest that new variants of this class of lactamase are encoded by other members of the genus Lelliottia . Although presence of bla LAQ is ubiquitous across the currently sequenced members of L. amnigena , we highlight that strain GFKo1 is sensitive to ampicillin and cephalosporins. These data suggest that bla LAQ may act as a useful genetic marker for identification of L. amnigena strains, but its presence may not correlate with expected phenotypic resistances. Further studies are required to determine the regulatory mechanisms of bla LAQ in L. amnigena .

Two Novel Plant-Growth-Promoting Lelliottia amnigena Isolates from Euphorbia prostrata Aiton Enhance the Overall Productivity of Wheat and Tomato

Euphorbiaceae is a highly diverse family of plants ranging from trees to ground-dwelling minute plants. Many of these have multi-faceted attributes like ornamental, medicinal, industrial, and food-relevant values. In addition, they have been regarded as keystone resources for investigating plant-specific resilience mechanisms that grant them the dexterity to withstand harsh climates. In the present study, we isolated two co-culturable bacterial endophytes, EP1-AS and EP1-BM, from the stem internodal segments of the prostate spurge, Euphorbia prostrata, a plant member of the succulent family Euphorbiaceae. We characterized them using morphological, biochemical, and molecular techniques which revealed them as novel strains of Enterobacteriaceae, Lelliotia amnigena. Both the isolates significantly were qualified during the assaying of their plant growth promotion potentials. BM formed fast-growing swarms while AS showed growth as rounded colonies over nutrient agar. We validated the PGP effects of AS and BM isolates through in vitro and ex vitro seed-priming treatments with wheat and tomato, both of which resulted in significantly enhanced seed germination and morphometric and physiological plant growth profiles. In extended field trials, both AS and BM could remarkably also exhibit productive yields in wheat grain and tomato fruit harvests. This is probably the first-ever study in the context of PGPB endophytes in Euphorbia prostrata. We discuss our results in the context of promising agribiotechnology translations of the endophyte community associated with the otherwise neglected ground-dwelling spurges of Euphorbiaceae.

Lelliottia amnigena and Pseudomonas putida Coinfection Associated with a Critical SARS-CoV-2 Infection: A Case Report

Lelliottia amnigena is a Gram-negative facultative anaerobic bacillus identified from water sources and later from food (onions, cream, unpasteurized milk, and Spanish pork sausages), which, under certain circumstances, can cause infections in humans, especially in immunocompromised patients. Few cases of human infections have been reported in the literature, such as endophthalmitis, urinary tract infection, pyonephrosis, and sepsis. We describe the case of a 69-year-old Caucasian male patient who lives in an urban environment and presents himself to the emergency department with chills, fever, myalgias, marked physical asthenia, dry cough, dyspnea, symptoms for which he is tested and confirmed with SARS-CoV-2 infection using real-time reverse transcriptase-polymerase chain reaction (RT-PCR) from nasal and pharyngeal swabs, after being admitted the same day (25 May 2023) to the Infectious Diseases Clinic from the County Clinical Emergency Hospital Sibiu, Romania. At the time of admission, a pulmonary computerized tomography (CT) scan was performed, which revealed a severity score of 10 out of 25. In the second week of the disease, the patient presents with hemoptysis, from which bacteriological examinations are carried out, and Pseudomonas putida and Lelliottia amnigena are identified. The evolution was slowly favorable under antiviral treatment, corticotherapy, antibiotic therapy (in the absence of the identified etiology, initially meropenem was administered in association with linezolid, and then ceftazidime-avibactam), voriconazole, anakinra, salbutamol inhaler, inhalation corticosteroids, with slow reduction in oxygen requirement, the patient continued oxygen therapy at home after discharge with a flow rate of 5 L/minute. During the third harvesting of sputum samples, P. putida was isolated along with L. amnigena, both strains of low-virulence species, and maintained susceptibility to antibiotics. In the context of an immunosuppressed patient with previous pulmonary surgery for actinomycosis, chronic obstructive pulmonary disease, and bronchiectasis, all these conditions are favorable for biofilm formation. L. amnigena remains a pathogen rarely isolated in human pathology, but we should pay more attention, especially in the immunosuppressed patient, where it can be responsible for an extremely serious clinical picture.

Prevalence of Multidrug-Resistant Pathogens Causing Neonatal Early and Late Onset Sepsis, a Retrospective Study from the Tertiary Referral Children's Hospital

Introduction

Sepsis is the most severe infectious disease with the highest mortality rate, particularly among neonates admitted to the neonatal intensive care unit (NICU). This study retrospectively analyzed the epidemiology, antibiotic resistance profiles, and prevalence of multidrug-resistant (MDR) bacteria isolated from blood or cerebrospinal fluid (CSF) cultures in order to evaluate the appropriateness of initial empirical therapy for neonatal sepsis.

Methods

A retrospective study was conducted in the NICU from January 1, 2015, to December 31, 2022. Microbiological data from patients admitted to the NICU were anonymously extracted from the Laboratory of Microbiology database. Neonatal sepsis was classified into two types: early-onset sepsis (EOS), which occurs within the first 72 hours of life, and late-onset sepsis (LOS) for those begins later.

Results

A total of 679 bacterial strains, 543 from blood and 136 from CSF, were detected in 631 neonates. Among these, 378 isolates (55.67%) were Gram-positive bacteria, and 301 isolates (44.33%) were Gram-negative bacteria. The most frequently isolated pathogens were Coagulase-negative staphylococci (CoNS) (36.52%), followed by Klebsiella pneumoniae (20.47%) and Escherichia coli (13.84%). In EOS, 121 strains were found, CoNS represented the majority (33.88%), followed by Klebsiella pneumoniae (23.97%) and Escherichia coli (8.26%). Early-onset septicemia exhibited 67 (55.37%) MDR bacteria. In LOS, 558 strains were isolated, CoNS represented the majority of pathogens (37.10%), followed by Klebsiella pneumoniae (19.71%) and Escherichia coli (15.05%). Late-onset septicemia showed 332 (59.50%) MDR bacteria. High rates of MDR were found in CoNS (76.21%), carbapenem-resistant Klebsiella pneumoniae (66.91%), and MRSA (33.33%).

Conclusion

The study revealed an alarming prevalence of MDR strains isolated from neonatal sepsis, emphasizing the necessity of finding effective prevention and treatment measures. Colistin can be used for MDR Gram-negative bacteria, while vancomycin and teicoplanin can be considered treatment therapies for staphylococcal infections.

Antibacterial Properties of Ethacridine Lactate and Sulfmethoxazole Loaded Functionalized Graphene Oxide Nanocomposites

The emergence of drug-resistant bacterial strains that reduce the effectiveness of antimicrobial agents has become a major ongoing health concern in recent years. It is therefore necessary to find new antibacterials with broad-spectrum activity against both Gram-positive and Gram-negative bacteria, and/or to use nanotechnology to boost the potency of already available medications. In this research, we examined the antibacterial efficacy of sulfamethoxazole and ethacridine lactate loaded two-dimensional glucosamine functionalized graphene-based nanocarriers against a range of bacterial isolates. Graphene oxide was first functionalized with glucosamine, which as a carbohydrate moiety can render hydrophilic and biocompatible characters to the GO surface, and subsequently loaded with ethacridine lactate and sulfamethoxazole. The resulting nanoformulations had distinct, controllable physiochemical properties. By analyzing the formulation using Fourier Transform Infrared Spectroscopy (FTIR), X-ray diffraction (PXRD), a thermogravimetric analysis (TGA), zetasizer, and a morphological analysis using Scanning Electron Microscopy and Atomic Force Microscopy, researchers were able to confirm the synthesis of nanocarriers. Both nanoformulations were tested against Gram-negative bacteria, including Escherichia coli K1, Serratia marcescens, Pseudomonas aeruginosa, Salmonella enterica, as well as Gram-positive bacteria, including Bacillus cereus, Streptococcus pyogenes, and Streptococcus pneumoniae. Importantly, ethacridine lactate and its nanoformulations exhibited significant antibacterial properties against all bacteria tested in this study. When tested for minimum inhibitory concentration (MIC), the results were remarkable and revealed that ethacridine lactate presented MIC₉₀ at 9.7 µg/mL against S. enteric, and MIC₉₀ at 6.2 µg/mL against B. cereus. Notably, ethacridine lactate and its nanoformulations showed limited toxicity effects against human cells using lactate dehydrogenase assays. Overall, the results revealed that ethacridine lactate and its nanoformulations possess antibacterial activities against various Gram-negative and Gram-positive bacteria and that nanotechnology can be employed for the targeted delivery of effective drugs without harming the host tissue.

Multicenter Surveillance of Antimicrobial Resistance among Gram-Negative Bacteria Isolated from Bloodstream Infections in Ghana

BACKGROUND

Antimicrobial resistance (AMR) in Gram-negative bacteria-causing bloodstream infections (BSIs), such as Klebsiella pneumoniae and non-typhoidal Salmonella (NTS), is a major public health concern. Nonetheless, AMR surveillance remains scarce in sub-Saharan Africa, where BSI treatment is largely empirical. The aim of the study was to determine the distribution and AMR patterns of BSI-causing NTS, K. pneumoniae, and other Gram-negative bacteria in Ghana.

METHODS

A cross-sectional study was conducted between April and December 2021 at eleven sentinel health facilities across Ghana as part of a pilot study on the feasibility and implementation of the human sector AMR surveillance harmonized protocol in sub-Saharan Africa. Gram-negative bacteria recovered from blood specimens of febrile patients were identified using MALDI-TOF and evaluated for antimicrobial resistance using the BD Phoenix M50 analyzer and Kirby-Bauer disc diffusion. The Department of Medical Microbiology at the University of Ghana served as the reference laboratory.

RESULTS

Out of 334 Gram-negative blood isolates, there were 18 (5.4%) NTS, 85 (25.5%) K. pneumoniae, 88 (26.4%) Escherichia coli, 40 (12.0%) Acinetobacter baumannii, 25 (7.5%) Pseudomonas aeruginosa, and 77 (23.1%) other Gram-negative bacteria. As a composite, the isolates displayed high resistance to the antibiotics tested-amoxicillin (89.3%), tetracycline (76.1%), trimethoprim-sulfamethoxazole (71.5%), and chloramphenicol (59.7%). Resistance to third-generation cephalosporins [ceftriaxone (73.7%), cefotaxime (77.8%), and ceftazidime (56.3%)] and fluoroquinolones [ciprofloxacin (55.3%)] was also high; 88% of the isolates were multidrug resistant, and the rate of extended-spectrum beta-lactamase (ESBL) production was 44.6%. Antibiotic resistance in K. pneumoniae followed the pattern of all Gram-negative isolates. Antibiotic resistance was lower in NTS blood isolates, ranging between 16.7-38.9% resistance to the tested antibiotics. Resistance rates of 38.9%, 22.2%, and 27.8% were found for cefotaxime, ceftriaxone, and ceftazidime, respectively, and 27.8% and 23.8% for ciprofloxacin and azithromycin, respectively, which are used in the treatment of invasive NTS. The prevalence of multidrug resistance in NTS isolates was 38.9%.

CONCLUSIONS

Multicenter AMR surveillance of Gram-negative blood isolates from febrile patients was well-received in Ghana, and the implementation of a harmonized protocol was feasible. High resistance and multidrug resistance to first- or second-choice antibiotics, including penicillins, third-generation cephalosporins, and fluoroquinolones, were found, implying that these antibiotics might have limited effectiveness in BSI treatment in the country. Continuation of AMR surveillance in Gram-negative blood isolates is essential for a better understanding of the extent of AMR in these pathogens and to guide clinical practice and policymaking.

Clinical Profile of Patients Presenting With Sepsis to the Emergency Department of a Tertiary Care Hospital in Wardha During the COVID Pandemic (June 2020-June 2021)

Background

Sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Septic shock, multi-organ dysfunction, and death occur in severe cases with reduced blood flow to vital organs. Sepsis contributes to 15-20% of all global deaths. Through this study, we intend to evaluate the clinical profile and study the common blood investigatory panels along with organisms causing sepsis in patients presenting with sepsis in the emergency department during the COVID pandemic. In addition, the study was also done to estimate the prevalence of sepsis and compare patients having sepsis with serum lactate, sepsis with Systemic Inflammatory Response Syndrome (SIRS) criteria, and sepsis with quick Sepsis Related Organ Failure Assessment (qSOFA) score.

Method

Observational retrospective study to evaluate patients presenting with sepsis diagnosed by the Third International Consensus Definitions for Sepsis and Septic Shock” criteria presenting to the emergency department of Acharya Vinoba Bhave Rural Hospital (AVBRH) affiliated to Jawaharlal Nehru Medical College (JNMC), Wardha during COVID pandemic (June 2020-June 2021).

Results

The majority of the patients presented with fever (42%), and very few presented with altered mental status (8%). Seventy-four percent of the study population did not show any bacterial growth on blood culture, but out of the remaining 26%, blood culture, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pnemoniae were the significant microbes. Amongst qSOFA, SIRS criteria, and serum lactate as a screening tool for sepsis, SIRS is the most sensitive for screening sepsis patients.

Conclusion

Staphylococcus aureus, Pseudomonas aerugenosa, and Klebsiella pneumoniae were the major contributors in the development of sepsis in COVID-19-associated infection. The presence of raised leukocyte counts and serum lactate should alarm clinicians of possible sources of infection. The timely initiation, rapid de-escalation of empirical antibiotics, and strict compliance with infection control practices should be accomplished to reduce the occurrence of multidrug resistance organisms.

Analysis of Anti-Infective Treatment of 9 Neonates with Raoultella ornithinolytica Sepsis

Raoul ornithine-releasing bacteria widely exist in water, plants, and soil, and colonize the digestive tract and upper respiratory tract of the human body. They are aerobic, unpowered, and capsular opportunistic pathogens. The infectivity of this bacterium is still uncertain, but the possibility of nosocomial infection has been mentioned in the literature. Studies have pointed out that the bacterium should be diagnosed in time and sensitive antibiotics should be used early. Once complicated with sepsis, it can cause multiple organ failure with a poor prognosis. In this study, we retrospectively analyzed the clinical data of nine cases of neonatal L. ornithine septicemia, to explore the clinical characteristics of neonatal L. ornithine septicemia and anti-infection therapy.