Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

Role of tolterodine in the management of postoperative catheter-related bladder discomfort: Findings in a Nigerian teaching hospital

BACKGROUND

Patient discomfort secondary to an indwelling urethral catheter in the post operative period can be very distressing. These symptoms resemble the overactive bladder (OAB) syndrome. Muscarinic receptor blockers have been successful in the management of OAB. However, information on the use of these drugs in the management of the postoperative catheter-related bladder discomfort (CRBD) in sub-Saharan Africa is still relatively sparse.

OBJECTIVE

To assess the efficacy of preoperative oral tolterodine in the management of CRBD in surgical patients in the immediate postoperative period.

METHODS

This was a double-blind placebo-controlled study consisting of 56 patients in each arm who underwent general anesthesia. Each patient was given oral tolterodine or placebo 1 hour before the induction of anesthesia. The patient was later assessed at the recovery room at intervals after recovery from anesthesia. The presence of CRBD was noted and graded.

RESULTS

The overall incidence of CRBD in both the tolterodine group and the control were 85.7% and 91.1%, respectively. Overall, tolterodine prophylaxis (TP) was associated with an absolute risk reduction (ARR) of 5.4%, relative risk reduction (RRR) of 5.8%, and a number needed to treat (NNT) of 19. The incidence of moderate-to-severe CRBD in the tolterodine and control groups were 10.7% and 78%, respectively, with an ARR of 74.5% with TP.

CONCLUSION

TP does not significantly reduce the incidence of CRBD in the immediate postoperative period but appears to be efficient in the reduction of the severity of postoperative CRBD.

ANAESTHETISTS' ATTITUDES AND PRACTICE OF INFORMED CONSENT IN NIGERIA

BACKGROUND

Informed consent is an integral part of a surgical and anaesthetic procedure, failure to obtain it may result in grave medico-legal implications.

AIM

To determine the attitudes of Nigerian anaesthetists to informed consent.

METHODOLOGY

The study population included physician anaesthetists who attended a continuous medical education programme in November 2015. The target was to cover over 50% of anaesthetists by convenience sampling. The responses to the questions were recorded and descriptive statistics were employed to calculate the various qualitative variables under study.

RESULTS

Fifty-six respondents were analysed, the majority were in the age group 31-40 years (37.5%), consultants were 51.79%, and males constituted 75%. The respondents agreed that the main purposes of informed consent included a need to improve the doctor/patient relationship in 36(64.29%), inform the patient about the desired benefits of the procedure in 32(57.14%), provide the doctor with greater protection against medical litigation in 32(57.14%), and to respect the patient's right of autonomy in 30(53.57%). The general consensus among the respondents was that the anaesthetist should explain to the patient what the procedure entails 40(71.43%), what the procedure aims to achieve and additional procedures that are likely to be necessary to the patient 41(73.21%). It was also agreed that there should be disclosure of all major risks/complications with incidence >1/20 in 29(51.79%) respondents, incidence >1/100 in 20(35.71%), incidence >1/1000, and incidence >1/10000 were 17(30.36%). The respondents who agreed that it is necessary to take consent before performing surgery or anaesthesia on patients and explained the procedure to patients were 48(85.71%).

CONCLUSION

We determined that informed consent was an integral part of a surgical procedure. which helped to improve doctor/patient relationship, respected the patient's right of autonomy and provided the surgeon and anaesthetists with greater protection against medical litigation. It is paramount to disclose all major risk and complications. However, few anaesthetists 19(33.93%) obtain informed consent from their patients before epidural labour analgesia.

EFFICACY OF INTRAVENOUS ESMOLOL VERSUS LIDOCAINE FOR ATTENUATION OF THE PRESSOR RESPONSE IN NIGERIANS

BACKGROUND

Laryngoscopy and tracheal intubation are an integral component of airway management and general anaesthesia. Direct stimulation of the pharynx and larynx by the laryngoscope blade and the insertion of an endotracheal tube elicit a sympathetic nervous system response with a reflex consisting of a transient increase in blood pressure, heart rate, and the occurrence of cardiac dysrhythmias referred to as the 'pressor' response. This may be of major clinical significance in patients with pre-existing systemic hypertension, hypertensive heart disease, coronary artery disease, eclampsia, aneurysmal vascular disease and head injury in whom such a change may culminate in perioperative myocardial ischaemia or infarction, cardiac failure, dysrhythmias, cerebrovascular accidents or secondary brain injury.

AIM

To evaluate and compare the effects of intravenous lidocaine and esmolol on the pressor response as well as determine the occurrence of complications with the use of either agent in a Nigerian population.

METHODOLOGY

Ninety adult ASA I and II patients undergoing elective non-cardiac surgery under general anaesthesia were randomly allocated to one of 3 groups; group E: 2mg.kg ^-1 esmolol, group L: 1.5mg.kg ^-1 lidocaine and group C: 20mls normal saline 3 minutes before laryngoscopy. Induction of anaesthesia was standardized for all patients. Heart Rate, Systolic Blood Pressure, Diastolic Blood Pressure, Mean Arterial Pressure and Rate Pressure Product were recorded at baseline, immediate post, 1, 3, 5 and 10 minutes after intubation.

RESULTS

Mean heart rate increased by 19.1%, 25.7%, and 41.4%, SBP increased 13.3%, 21.6% and 26.9%, MAP by 12.2%, 19.1% and 30.2%, RPP by 28.1%, 45.8% and 78.7% in groups E, L and C respectively post intubation. There were no complications attributable to the use of either agent.

CONCLUSION

Intravenous esmolol 2mg.kg^-1 given prior to laryngoscopy is more effective than intravenous lidocaine 1.5mg.kg^-1 in significantly attenuating the haemodynamic changes associated with pressure response to laryngoscopy and endotracheal intubation in normotensive patients from a Nigerian population.

HEPATITIS B VACCINATION STATUS AND NEEDLE STICK INJURY EXPOSURE AMONG OPERATING ROOM STAFF IN LAGOS, NIGERIA

BACKGROUND

Hepatitis B virus (HBV) is an infective blood-borne pathogen that is a constant threat to operating room staff. The prevalence of Hepatitis B has been reported to range from 4.3% - 68% in Nigeria. The inadequate funding of health care in low income countries impacts negatively on the implementation of effective vaccination programs to protect health care workers including surgical theatre personnel.

AIM

To determine the Hepatitis B vaccination status and the needle stick injury exposure among operating room staff in Lagos, Nigeria.

METHODOLOGY

The multicentre prospective survey was conducted in three public tertiary hospitals and two private hospitals in Lagos utilising a self-administered structured questionnaire that was distributed to operating room staff.

RESULTS

We found that 96.7% (265) of respondents agreed that their job had exposed them to the risk of HBV infection. Over half (55.8%) correctly identified three doses of HBV as adequate to confer immunity against infection. It was observed that 58% (159) of the respondents were fully vaccinated, most of whom were doctors (69.8%, p=0.001) while a total of 173 (63.1%) reported exposure to needle-stick injury with blood in the preceding year.

CONCLUSION

The operating room personnel were knowledgeable about the risk of HBV as an occupational hazard but a large number were not fully vaccinated against HBV infection. There was therefore the need to improve the vaccination coverage and educate identified high-risk operating room staff on appropriate post exposure prophylaxis practices.

Early outcome of combined endoscopic third ventriculostomy and choroid plexus cauterization in childhood hydrocephalus

OBJECT

Although shunts have been the mainstay in treating hydrocephalus over the past 5 decades, the use of endoscopic techniques in addressing this disorder in children offers both the neurosurgeon and the patient a unique opportunity to avoid shunting and its attendant complications. The combination of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) remains uncommon in most centers despite its potential promise. The authors sought to investigate the efficacy of combining ETV and CPC (ETV+CPC) in treating childhood hydrocephalus in Nigeria. Infection and spina bifida contribute a high percentage of the cases of hydrocephalus in Nigeria.

METHODS

Over a 2-year period, all children 0-18 years of age who had endoscopic treatment for hydrocephalus were prospectively evaluated to determine the need for subsequent treatment. Children who had the combination of ETV+CPC were identified as a subcategory and form the basis of this retrospective study.

RESULTS

Twenty-two of 38 endoscopically treated children had undergone the combination of ETV+CPC for hydrocephalus of varied etiology. There was a male preponderance (2.5:1), and 90% of the patients were infants. The overall success rate was 75%, with the best outcome in children with spina bifida. One child required a repeat ETV.

CONCLUSIONS

The combination of ETV+CPC is useful in treating children with hydrocephalus of varied etiology. The complication profile is acceptable, and the overall success rate is comparable to that associated with shunt insertion.

Cortisol and Insulin Levels during Major Gynaecological Operations: The influence of Two Anaesthetic Techniques

BACKGROUND: Metabolic and hormonal changes are noticed within the first few hours after surgical injury. These changes are influenced by the intensity, duration, type of injury, and the anaesthetic techniques.AIM: To investigate the effects of anaesthesia on cortisol, insulin and glucose concentrations during major gynaecological surgeries.METHODS: Forty patients were randomly allotted to receive either balanced general anaesthesia (n=20) or combined spinal epidural anaesthesia extending from T5 to S5 (n=20). Blood samples were collected for cortisol and glucose at preinduction, 1, 3 and 4 hours, and for insulin at preinduction and 24 hours after incision.RESULTS: The mean cortisol concentration was significantly lower 4 hours after incision with combined spinal epidural anaesthesia (19.96 ± 11.32) μg/dl than with balanced general anaesthesia (38.94 ± 10.6) μg/dl, p = 0.018. The mean insulin concentration, 24 hours after incision decreased with combined spinal epidural anaesthesia, but increased with balanced general anaesthesia p = 0.403. The mean glucose concentrations were significantly lower with combined spinal epidural anaesthesia than with balanced general anaesthesia during the 4 hour study period p ≤ 0.05.CONCLUSION: combined spinal epidural anaesthesia extending from T5 to S5 resulted in lower cortisol, insulin and glucose concentrations during major gynaecological surgeries. This may be of benefit in patients scheduled for surgical operations below the umbilicus.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

Background:

To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy.

Materials and Methods:

A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed.

Results:

Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs–12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation.

Conclusion:

One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.

Accreditation of Training Programmes by the West African College of Surgeons

The establishment of surgical training programmes of the West African College of Surgeons started in six teaching hospitals the early 1970s in Nigeria and Ghana; it was championed by College Fellows, surgeons who had returned to the sub-region after having trained in Europe and America. Surgical programmes accreditation, captured in the College's constitution and mission statement, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, clinical services and academic programmes. This pan-regional model adopted by the five Anglophone countries of West Africa has standardized and nurtured surgical training in the disciplines of surgery, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, dental surgery, radiology and anaesthesia. It has also proven to be a useful template in the current drive for the ongoing harmonization of surgical training programmes with Francophone West African as a prelude to an integrated sub-regional accreditation body. This paper details the evolution of surgical programmes accreditation in West Africa, its progress, challenges, opportunities and future trends.

Post operative nausea and vomiting in adult Nigerians

BACKGROUND

This is a prospective study to determine the pattern of postoperative nausea and vomiting in a Nigerian adult population.

METHOD

348 consecutive patients were assessed prospectively for the incidence and risk factors of postoperative nausea and vomiting over a 6-month period. The exclusion criteria included inability to give consent, nausea or vomiting during the period 24 hours before surgery, raised intracranial pressure and patients who received an anti-emetic in the period 48 hours before surgery.

RESULT

Patient's age ranged between 18 and 90 years. There were 213 females (61.2%) and 135 males (38.8%). The incidence of postoperative nausea was 32.2% and vomiting was 20.1%. The major risk factors identified were female gender, body mass index, general anaesthesia-inhalational technique, Ketamine induction, pancuronium, pain and movement of patients from the recovery room to surgical wards (p < 0.05).

CONCLUSION

Nausea and vomiting was identified as a common postoperative complication with multifactoral aetiology. It is recommended that high risk patients should receive prophylactic antiemetics. Regional techniques should also be considered in such patients.

Comparison of suxamethonium and priming with atracurium for rapid sequence orotracheal intubation in a Nigerian adult population

OBJECTIVE

To compare suxamethonium with atracurium using the priming principle, for rapid sequence orotracheal intubation assessing onset time, time to successful laryngoscopy and intubation and quality of intubating conditions.

PATIENTS AND METHODS

A prospective double-blind, randomised study was performed in 90 ASA physical status I and II patients aged between 18 and 64 years undergoing elective surgery requiring endotracheal intubation between October 2002 and June 2003 in a university teaching hospital . All patients were premedicated with 5-10mg oral diazepam and randomly assigned to one of two groups to receive either suxamethonium as a bolus dose (group A) or atracurium (priming with 0.05 mg/kg followed by 0.55 mg/kg after induction of anaesthesia) (group B). In both groups, the trachea was intubated when there was maximal muscle relaxation, determined clinically by jaw muscle relaxation. Muscle paralysis using a PNS, quality of intubating conditions, and occurrence of muscle weakness due to the priming dose of atracurium, time to laryngoscopy and onset time were all noted.

RESULTS

Onset time was 87.1 +/- 25.60s and 135.8 +/- 46.23s in groups A and B respectively (P < 0.05). Group A had a laryngoscopy time of 73.6 +/- 25.22s compared to 107.7 +/- 41.32s in group B (P < 0.05). Intubating conditions were significantly better in group A compared to group B (P < 0.05). The frequency of muscle weakness from the priming dose of atracurium was 6.6%.

CONCLUSION

Atracurium, using the priming principle, is an option in our environment for modified rapid sequence induction when suxamethonium is contraindicated.

An audit of surgical admissions to the intensive care unit of the Lagos University Teaching Hospital (1997 - 2002)

OBJECTIVE

To review the pattern of adult surgical admissions into the Intensive Care Unit (ICU) of Lagos University Teaching Hospital (LUTH).

METHODS

A six-year retrospective review of data of patients above 12 years old admitted to the ICU of LUTH was performed.

RESULTS

290 patients representing 82.6% of the total ICU admissions (351) during the study period were evaluated. 251 (86.6% ) were surgical and 39 (13.4% ) non-surgical. The overall mortality was 40.3% (Surgical - 37.8% , Medical 62.9% ). Emergency admissions accounted for 221 (76.2% ) while electives were 69(33.8% ). The Mean hospital stay (MHS) was 4.8 +/- 0.4 days (Surgical: Medical - 3.9 +/- 0.2:10.1 +/- 2.5). The highest admissions were as a result of trauma (32.1% ) and obstetric complications (9.7% ). Cardiorespiratory monitoring (57.2% ) and respiratory distress (34.1% ) were the main indications for admission. Emergency admission and artificial ventilation contributed significantly to the observed mortality (p < 0.0001)

CONCLUSION

At LUTH, trauma and obstetric complications constituted the major causes for ICU adult surgical admissions.