Antibiotic use in surgical units of selected hospitals in Ghana: a multi-centre point prevalence survey

Background

Improper use of antibiotics leads to the emergence of resistant microorganisms as well as drug toxicity, increased healthcare costs, morbidity and mortality. Globally, an estimated 25–68% of hospitalized patients receive suboptimal antibiotic regimes. Information on the extent of this problem in Ghana is currently limited, particularly in surgical units. To strategize for interventions, we estimated the antibiotic use prevalence in surgical departments in a country-wide point prevalence survey (PPS) in Ghana.

Methods

Between October 2016 and December 2016, we conducted a cross-sectional multi-center country-wide PPS. This involved an audit of in-patients’ records from all units/departments of ten systematically selected hospitals in Ghana. Data were collected with a standardized questionnaire, adopted from the European Centre for Disease Prevention and Control. In this report, we present data on antibiotic use from the surgical units.

Results

Of 2107 eligible patients included in the PPS, 540 patients were identified in surgical units, of which 70.7% (382/540) received antibiotic therapy. A total of 636 antibiotic prescriptions were issued to these surgical patients; 224 (58.6%) for treatment, including 50 for treatment of hospital-acquired infections, and 144 (37.7%) for prophylaxis (medical and surgical). Median duration of antibiotic therapy prior to the survey was 5 days (interquartile range (IQR): 3-8 days). Surgical prophylaxis was administered for longer than the recommended one day in 107 of 144 (88.4%) patients. The choice of antibiotics was largely similar for community- and hospital-acquired infections as well as for prophylaxis. Only 3.7% of patients had microbiological analysis done on clinical samples.

Conclusion

We found a high prevalence of antibiotic use, with the choice of antibiotics, in some cases, inconsistent with the country’s treatment guidelines. Antibiotics were administered for long duration including antibiotics for prophylactic purposes and the majority was started without supporting microbiological analysis. Prescription practices that encourage rational use of antibiotics guided by microbiology and enforcement of antibiotic policy guidelines should be the target for future interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7162-x) contains supplementary material, which is available to authorized users.

Patient safety situational analysis in Ghana

Objectives

The objective of the study was to assess the patient safety situation in Ghana. Specifically, the study aimed at assessing the WHO’s 12 action areas of patient safety.

Design

This was a descriptive cross-sectional survey. Data collection methods included interviews and observation using WHO adapted questionnaire.

Setting

The setting was mainly 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana.

Participants

Respondents were purposively selected based on their position in the health facilities and the type of information required. Main Outcome Measure(s): The main outcome measures were the WHO’s 12 action areas of patient safety.

Results

The median bed capacity of the hospitals assessed was 93 (min = 60, max = 1812). The country’s highest score (94%) was in the action area of knowledge and learning in patient safety where all (16, 100%) sampled facilities had systems in place for recording adverse events, specific protocols for patient care, etc. Five (5) of the 12 action areas (i.e. national patient policy, hospital acquired infections, surgical safety, patient safety partnerships and patient safety funding) had scores lower than the mean score (66%).

Conclusion

The key strength identified in the patient safety situational analysis of Ghana was knowledge and learning in patient safety while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding, respectively.

Accelerating newborn survival in Ghana through a low-dose, high-frequency health worker training approach: a cluster randomized trial

BACKGROUND

Newborn deaths comprise nearly half of under-5 deaths in Ghana, despite the fact that skilled birth attendants (SBAs) are present at 68% of births, which implies that evidence-based care during labor, birth and the immediate postnatal period may be deficient. We assessed the effect of a low-dose, high-frequency (LDHF) training approach on long-term evidence-based skill retention among SBAs and impact on adverse birth outcomes.

METHODS

From 2014 to 2017, we conducted a cluster-randomized trial in 40 hospitals in Ghana. Eligible hospitals were stratified by region and randomly assigned to one of four implementation waves. We assessed the relative risks (RRs) of institutional intrapartum stillbirths and 24-h newborn mortality in months 1-6 and 7-12 of implementation as compared to the historical control period, and in post-intervention facilities compared to pre-intervention facilities during the same period. All SBAs providing labor and delivery care were invited to enroll; their knowledge and skills were assessed pre- and post-training, and 1 year later.

RESULTS

Adjusting for region and health facility type, the RR of 24-h newborn mortality in the 40 enrolled hospitals was 0·41 (95% CI 0·32-0·51; p < 0.001) in months 1-6 and 0·30 (95% CI 0·21-0·43; p < 0·001) in months 7-12 compared to baseline. The adjusted RR of intrapartum stillbirth was 0·64 (95% CI 0·53-0·77; p < 0·001) in months 1-6 and 0·48 (95% CI 0·36-0·63; p < 0·001) in months 7-12 compared to baseline. Four hundred three SBAs consented and enrolled. After 1 year, 200 SBAs assessed had 28% (95% CI 25-32; p < 0·001) and 31% (95% CI 27-36; p < 0·001) higher scores than baseline on low-dose 1 and 2 content skills, respectively.

CONCLUSIONS

This training approach results in a sustained decrease in facility-based newborn mortality and intrapartum stillbirths, and retained knowledge and skills among SBAs after a year. We recommend use of this approach for future maternal and newborn health in-service training and programs.

TRIAL REGISTRATION

Retrospectively registered on 25 September 2017 at Clinical Trials, identifier NCT03290924 .

Rheumatic fever and rheumatic heart disease among children presenting to two referral hospitals in Harare, Zimbabwe

BACKGROUND

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) remain significant causes of morbidity and mortality in resource-limited settings. In Zimbabwe ARF/RHD characteristics have not been systematically documented.

OBJECTIVES

To document cases of ARF/RHD among children presenting at referral hospitals in Harare, Zimbabwe, determine their clinical and echocardiographic characteristics, and identify opportunities for improving care.

METHODS

A cross-sectional survey was carried out in which consecutive children aged 1 - 12 years presenting with ARF/RHD according to the 2002/3 World Health Organization modified Jones criteria were enrolled.

RESULTS

Out of 2 601 admissions and 1 026 outpatient visits over 10 months, 50 children were recruited, including 31 inpatients with ARF/RHD and 19 outpatients with chronic RHD. Among inpatients, 9 had ARF only, 7 recurrent ARF with RHD, and 15 RHD only. The commonest valve lesions were mitral regurgitation (26/31) and aortic regurgitation (11/31). The commonest reason for admission was cardiac failure (22/31). The proportion of ARF/RHD cases among inpatients aged 1 - 12 years was 11.9/1 000. Of the 22 with RHD, 14 (63.6%) presented de novo and 1 had bacterial endocarditis. Among the outpatients, 15 had cardiac failure while echocardiographic findings included mitral regurgitation (18/19) and aortic regurgitation (5/19). At presentation, 18/26 known cases were on oral penicillin prophylaxis and 7 on injectable penicillin. Of those on secondary prophylaxis, 68.0% reported taking it regularly.

CONCLUSION

ARF/RHD remains a major problem and cause of hospital admissions in Harare, Zimbabwe. Children often present late with established RHD and cardiac failure. With the majority on oral penicillin, secondary prophylaxis was suboptimal in a resource-limited setting unable to offer valve replacement surgery.

Evidence-based training and mentorship combined with enhanced outcomes surveillance to address the leading causes of neonatal mortality at the district hospital level in Ghana

OBJECTIVE

To evaluate the impact of a district hospital intervention focused on enhancing healthcare provider capacity to address leading causes of neonatal death: birth asphyxia, infection and prematurity.

METHODS

The neonatal quality improvement initiative was launched at two intervention referral district hospitals in Ghana. Local Health and Demographic Surveillance Systems were enlisted to enhance recording of neonatal and infant deaths in the community and at the facility. After baseline site assessments, a team of local paediatric experts conducted three clinical trainings on-site at each intervention hospital. Assessments were conducted to evaluate participant knowledge before and after participation in training modules. Monthly mentorship visits provided additional training to support the adoption of essential early neonatal care practices.

RESULTS

In the first year of implementation, the initiative provided focused clinical training to 278 participants. A comparison of pre- and post-training test results demonstrates significant improvement in provider knowledge (73% vs. 89% correct, P < 0.001), with even greater improvement among trainees receiving recurrent refresher training (86% vs. 94% correct, P < 0.001). Participant feedback following training revealed enthusiasm about the programme and improved confidence.

CONCLUSIONS

Locally led initiatives that invest directly in healthcare provider education and health systems strengthening represent a promising avenue for reducing neonatal morbidity and mortality. The NQI initiative demonstrates the positive impact of a district hospital intervention that combines on-site training, mentorship and enhanced demographic surveillance.

Cor pulmonale in children with human immunodeficiency virus infection

A cross-sectional echocardiographic study of 50 black Zimbabwean children with clinical human immunodeficiency virus (HIV) infection was carried out. The median age was 9 months. Seventy per cent had chronic cough, 60% respiratory distress and 40% cyanosis. Sixty per cent had pericardial effusion and 48% right ventricular hypertrophy (RVH) and dilation. However, the clinical diagnosis of heart failure was difficult as most of these children (80%) had hepatomegaly. These findings suggest that respiratory disease plays a role in the causation of RVH in these children. As cardiac causes of RVH were absent, this was presumed to be due to cor pulmonale. HIV-infected children presenting with respiratory distress may have clinically unapparent cor pulmonale. Early and appropriate management may by beneficial.

The effects of hospitalization for bed rest on duration of gestation, fetal growth and neonatal morbidity in triplet pregnancy

Nineteen women attending a special multiple pregnancy antenatal clinic with a triplet pregnancy were randomly allocated to either bed rest in hospital from 24 weeks gestation onwards until delivery, or to continue conventional outpatient management. Conclusions are limited by the trial size, but the study suggests that routine hospitalization for bed rest decreases the incidence of preterm delivery and light-for-gestational age infants and reduces the need for intensive neonatal care. Although still compatible with change variation, the observations, if confirmed in a larger randomized study, would have considerable implications for clinical practice. The policy needs further evaluation in a large multicentered collaborative study.

The effects of hospitalization for rest on fetal growth, neonatal morbidity and length of gestation in twin pregnancy

OBJECTIVE

To test whether a policy of hospitalization for bed rest, from 28-30 weeks gestation until delivery, lengthens the duration of gestation, improves fetal growth and decreases neonatal morbidity in twin pregnancy.

DESIGN

A randomized controlled trial.

SETTING

Harare Maternity Hospital, Zimbabwe.

SUBJECTS

118 women with an uncomplicated twin pregnancy between 28 and 30 weeks gestation.

INTERVENTION

Hospitalization for bed rest. Encouraged to rest in bed as much as possible, although voluntary ambulation was allowed.

MAIN OUTCOME MEASURES

Gestational age at delivery and number of infants delivered preterm (less than 37 weeks); birthweight and number of small-for-gestational age (SGA) infants; neonatal morbidity was assessed by number of infants requiring admission to the neonatal unit and the length of stay.

RESULTS

There was no effect on duration of gestation or the occurrence of preterm delivery. Mean birthweight was greater in the hospitalized group (t = -2.28, df 234, P = 0.02) and there were fewer SGA infants (OR 0.57, 95% CI 0.33-0.96). No differences were found in neonatal morbidity.

CONCLUSIONS

Hospitalization for bed rest does not prolong pregnancy but can improve fetal growth, although this was not reflected in improved neonatal morbidity. Whether twin fetal growth can be enhanced similarly in other populations should be investigated.

Preterm labour in twin pregnancies: can it be prevented by hospital admission?

Women attending a twin pregnancy antenatal clinic underwent cervical palpation to calculate a cervical score by subtracting dilatation from length. Those with a score of -2 or less at or before 34 weeks are at especially high risk of preterm labour. A total of 139 such women were randomly allocated either to receive bed-rest in hospital or to continue conventional outpatient management. No beneficial effect of bed-rest could be identified in prolonging twin pregnancy or improving fetal outcome.

Preterm labor in twin pregnancies: prediction by cervical assessment

Patients attending a twin pregnancy antenatal clinic underwent cervical palpation at each visit to calculate a cervical score by subtracting dilatation from length. Prediction of the onset of labor by cervical assessment was studied in 223 already parous women with twin pregnancies who ultimately labored spontaneously. The lower the score, the shorter was the mean time until delivery, although there existed a subgroup of patients who had ripe cervices for several weeks before the onset of labor. The cervical score itself appeared to give better prediction of labor than did changes in the score. Cervical assessment identified a group of twin pregnancies at especially high risk of preterm labor, in that 76% of patients with a score of -2 or less at or before 34 weeks delivered preterm. There was no evidence that labor was precipitated by vaginal examination, although this requires further study.

Tape measurement of symphysis-fundal height in twin pregnancies

We hypothesized that tape measurement of symphysis-fundal height could be useful in detecting multiple pregnancies, and in such cases in predicting preterm labour and identifying small-for-gestational-age (SGA) fetuses. Although mean fundal height is substantially greater in twin than singleton pregnancies, the value of the technique to detect multiple pregnancies may be limited because combined birth-weight is less and the frequency of SGA fetuses is greater in undiagnosed than in diagnosed twin pregnancies. We found no evidence that the measured fundal height is greater in pregnancies going on to preterm delivery, and we suggest that the commonly accepted theory that the high rate of preterm labour in twin pregnancies results simply from uterine overdistension be reappraised. Nevertheless, fundal height measurement was of value in identifying pregnancies in which both babies were SGA and is therefore recommended as a simple, inexpensive and non-invasive technique.

Fluctuating jaundice and intestinal bleeding in a 6-year-old girl with fascioliasis

A six-year-old girl presented with fever, haematemesis, melaena, fluctuating jaundice, tender hepatomegaly, palpable gall bladder and eosinophilia. At laparotomy a liver fluke was removed from the common bile duct. Despite treatment with praziquantel and metronidazole she succumbed to severe gastrointestinal bleeding.

Prophylaxis of postoperative epididymitis. Vasectomy or vas ligation?

Preoperative vasectomy for the prevention of postoperative epididymitis in 103 cases is compared to preoperative vas ligation in 132 cases performed by the same surgical team. Both methods showed good results. However, vas ligation is easier to perform and seems to have less complications. The vas ligation procedure is discussed.