Antibiotic use among surgical inpatients at a tertiary health facility: a case for a standardized protocol for presumptive antimicrobial therapy in the developing world

Background

Indiscriminate antimicrobial use is one of the greatest contributors to antimicrobial resistance. A low level of asepsis in hospitals and inadequate laboratory support have been adduced as reasons for indiscriminate use of antimicrobials among surgical patients. At present, there are no guidelines for presumptive antibiotic use in Nigeria and sub-Saharan Africa.

Aim

Surgical inpatients at the study hospital were surveyed to determine the level of antimicrobial use and degree of compliance with prescription quality indicators.

Methods

A cross-sectional survey was conducted among all surgical inpatients in May 2019 using a standardized tool developed by the University of Antwerp to assess the point prevalence of antimicrobials. Inpatients who were admitted from 08:00 h on the day of the survey were included. Data on patients' demographics, indication for antimicrobial use, reason for antimicrobial use, stop/review date, adherence to guidelines and laboratory use were collected. The prevalence of antimicrobial use in the surgical department was estimated.

Results

Eighty-two inpatients were included in the survey. Of these, 97.6% were receiving at least one antimicrobial agent. Only 5.4% of the prescriptions were targeted, and 37.6% of prescriptions were for empirical treatment of infections. Approximately half (50.7%) of the patients were receiving presumptive antibiotics, and 6% were receiving prophylactic antibiotics. In total, 58.7% of prescriptions were administered parenterally, and 98.2% of patients had documentation of a stop/review date. Metronidazole (P=32.3%, T=29.2%), ceftriaxone (P=28.4%, T=19.8%) and ciprofloxacin (P=14.2%, T=14.6%) were the most common antimicrobials used.

Conclusions

There is a high rate of antimicrobial use among surgical inpatients, and the rate of indiscriminate antimicrobial prescribing among these patients needs to be reduced. This can be achieved by developing antimicrobial guidelines for presumptive antimicrobial therapy.

EFFECT OF TRIMETHOPRIM-SULFAMETHOXAZOLE PROPHYLAXIS ON FEACAL CARRIAGE RATES OF RESISTANT ISOLATES OF Escherichia Coli IN HIV-INFECTED ADULT PATIENTS IN LAGOS

Background:

Methods:

Results:

Conclusions:

EFFECT OF TRIMETHOPRIM-SULFAMETHOXAZOLE PROPHYLAXIS ON FEACAL CARRIAGE RATES OF RESISTANT ISOLATES OF ESCHERICHIA COLI IN HIV-INFECTED ADULT PATIENTS IN LAGOS

BACKGROUND

The daily use of Trimethoprim-Sulfamethoxazole (TMP-SMX) prophylaxis reduces morbidity and mortality among patients infected with human immunodeficiency virus (HIV) but its impact on increasing antimicrobial resistance rates has been of public health concern, globally. This study investigated the effect of daily TMP-SMX prophylaxis on feacal carriage rates of resistant isolates of Escherichia coli in HIV-infected adult patients in Lagos.

METHODS

A total of 550 HIV-infected patients with CD4-cell counts of less than 350 cells/mm³ who were eligible for TMP-SMX prophylaxis and attending Lagos University Teaching Hospital, Lagos, Nigeria, were recruited for this study. Stool/rectal swab samples were aseptically collected from the patients and processed using standard methods for culture and sensitivity.

RESULTS

There was a baseline Trimethoprim-Sulfamethoxazole resistance rate of 54% which increased to 77.9% in first 3 months, rising to 96.1% by 6 months and all isolates were resistant by the 9th month. There was also evidence of cross-resistance to other antibiotics with significance in association with TMP-SMX resistance (p<0.0001). The Escherichia coli isolates showed a progressive increase in resistance to the tested antibiotics over the 12-month period. The resistance was in the following order: Ampicillin (74% to 82.6% in the first 3 months; 98.3% by the 6th month and 99.4% by the 9th month; all isolates were resistant by the 12th month), Augmentin (32.5% to 47.7% in first 3 months; 76.1% by the 6th month; 86.3% by the 9th month; all isolates were resistant by 12 months), Ceftriaxone (2.0% to 10.8% in first 3 months; 20.6% by the 6th month; 24.2% by the 9th month; 54.3% by the 12 months).

CONCLUSIONS

The carriage rate of feacal E. coli resistant to TMP-SMX is common before TMP-SMX prophylaxis. Initiation of TMP-SMX leads to further increase in resistance to TMP-SMX and cross-resistance to other antimicrobials.

EFFECT OF TRIMETHOPRIM-SULFAMETHOXAZOLE PROPHYLAXIS ON FAECAL CARRIAGE RATES OF RESISTANT ISOLATES OF ESCHERICHIA COLI IN HIV-INFECTED ADULT PATIENTS IN LAGOS

Background:

The daily use of Trimethoprim-Sulfamethoxazole (TMP-SMX) prophylaxis reduces morbidity and mortality among patients infected with Human Immunodeficiency Virus (HIV) but its impact on increasing antimicrobial resistance rates has been of public concern globally. This study investigated the effect of daily TMP-SMX prophylaxis on faecal carriage rates of resistant isolates of Escherichia coli in HIV-infected adult patients in Lagos.

Methods:

A total of 550 HIV-infected patients with CD4-cell count of less than 350 cell/mm³ and were eligible for TMP-SMX prophylaxis attending Lagos University Teaching Hospital, Lagos, Nigeria, were recruited. Stool/rectal swab samples were aseptically collected from the patients and processed using standard methods for culture and sensitivity.

Results:

There was a baseline Trimethoprim-Sulfamethoxazole resistance rate of 54% which increased to 77.9% in first 3 months, rising to 96.1% by 6 months and all isolates were resistant by the 9th month. There was also evidence of cross-resistance to other antibiotics with significant association with TMP-SMX resistance (p<0.0001). The Escherichia coli isolates showed a progressive increase in resistance to the tested antibiotics over the 12-month period. The resistance was in the following order: Ampicillin (74% to 82.6% in the first 3 months; 98.3% by the 6th month and 99.4% by the 9th month; all isolates were resistant by the 12th month). Augmentin (32.5% to 47.7% in first 3 months; 76.1% by the 6th month; 86.3% by the 9th month; all isolates were resistant by 12 months). Ceftriaxone (2.0% to 10.8% in first 3 months; 20.6% by the 6th month; 24.2% by the 9th month; 54.3% by the 12 months).

Conclusion:

The carriage rate of faecal E. coli resistant to TMP-SMX is common before TMP-SMX prophylaxis. Initiation of TMP-SMX leads to further increase in resistance to TMP-SMX and cross-resistance to other antimicrobials.

Phenotypic determination of carbapenemase producing enterobacteriaceae isolates from clinical specimens at a tertiary hospital in Lagos, Nigeria

AIMS AND OBJECTIVES

Carbapenemase production among clinical isolates of Enterobacteriaceae has been widely reported with prevalence rates ranging from between 2.8% and 53.6%. The aim of this study was to assess the prevalence of carbapenemase production among clinical isolates of Enterobacteriaceae from a Tertiary Hospital in Lagos, Nigeria, and to characterize the type of carbapenemase produced.

MATERIALS AND METHODS

Carbapenemase production was detected phenotypically using a commercially available combination disc test (Rosco Diagnostica carbapenemase detection Neo-Sensitab) containing inhibitors to the various carbapenemase classes. The Neo-Sensitabs were used for Enterobacteriaceae isolates that were resistant after the initial antibiotic susceptibility testing with meropenem (10 μg).

RESULTS

A total of 177 Enterobacteriaceae isolates were investigated and 27 (15.2%) were carbapenem-resistant. From the 27 carbapenem non-susceptible isolates, 22 (12.4%) were carbapenemase producers while 5 (2.8%) exhibited carbapenem resistance due to extended spectrum beta-lactamase production. Of the 22 isolates that were positive for carbapenemase production, 15 (8.5%) were metallo beta-lactamase (MBL) producers, 6 (3.4%) produced oxacillinase-48 while 1 (0.5%) produced both MBL and Klebsiella pneumoniae carbapenemase. Hence, the overall prevalence of carbapenemase-producing Enterobacteriaceae in this study was 12.4%.

CONCLUSION

Carbapenemase-producing Enterobacteriaceae was indeed prevalent in our institution. The combination disc test was a cost effective and suitable method for the initial detection of carbapenemase-producing Enterobacteriaceae within the clinical setting especially when molecular detection methods are not available.

Incidence of postoperative eye infections in a private eye hospital in Lagos, Nigeria

BACKGROUND

There is a dearth of information on postoperative eye infections in Nigeria and most hospitals do not have an infection control program in place.

OBJECTIVE

This study was done to investigate the incidence of post-operative eye infections, their potential sources and the preparedness of the hospital to prevent such infections.

METHODS

A microbiological survey of all eye surgical procedures between March 2004 and May 2005 was performed. Relevant samples were taken and cultured pre, intra and post operatively as required. Definitions of infections were based on the Centers for Disease Control (CDC) Criteria. In the eye clinic, and operation theatre, infection control procedures and practices were audited using a pre-designed questionnaire.

RESULTS

There were 2 cases of post operative eye infections (with Haemophilus influenzae and Corynebacterium species) during the one year of survey of 339 performed surgeries. S. aureus, Coagulase negative staphylococcus (CNS), and Enterobacter spp were cultured from the aqueous humour, as well as pre and post operative conjunctivae swabs of three other patients. Eighty four (24.8%) other patients were colonized post operatively with CNS (32), S. aureus (28), Klebsiella pneumoniae (8), E. coli (5), Corynebacterium species (3), Pseudomonas aeruginosa (1) Proteus mirabilis (4), Enterobacter species alone (1) and in association with CNS on 2 occasions. Seventy eight percent of patients had contact with staff who consistently haboured Staphylococcus species in their nares. Four patients (0.11%) were exposed to surgeons whose hands were contaminated and one eye (0.003%) to contaminated antiseptic solution. Facilities for hand washing and protective clothing were adequate but staffs were observed to perform an inadequate hands scrubbing. Most items were heat sterilized. Cleaning facilities were adequate and the environment was clean. The choice of antiseptic was correct, but that of disinfectant was considered incorrect. The ophthalmic equipments except the eye occluder were appropriately disinfected. Staffs were not protected when handling linen. Infected linens were separated from soiled linens only in the theatre. They were not bagged, and were hand sluiced. The only type of waste that was properly handled was sharps. All waste types were stored together prior to final disposal away from the public.

CONCLUSION

The incidence of post-operative infection was 1.69% and their sources were the patients' normal flora. Other potential sources of post-operative eye infections identified included nares of hospital staff, hands of surgeon and hospital disinfectants. Areas of deficiencies in infection control practices, which require proper infection control policies, include hand scrubbing practices, disinfection, linen management and waste handling.

Aetiology of bacteraemia among adult AIDS patients attending Lagos University Teaching Hospital (LUTH), Lagos, Nigeria

BACKGROUND

Bacteraemia is a relatively common event in HIV-infected patients, especially in late infection. Studies in Africa have shown that more than 23% of AIDS patients have bacteraemia but there is paucity of data from Nigeria.

METHODS

Blood samples from 67 consecutive patients with AIDS attending the Lagos University Teaching Hospital between April and August 2000 were cultured. Temperature, ESR, Full blood count, and where possible CD4 counts were obtained. Socio-demographic details were also recorded. Thirty apparently healthy people were randomly selected from a low-risk population to act as non-AIDS controls. The Oxoid Signal Blood Culture System was used to investigate bacteraemia. Antibiotic sensitivity tests were carried out on all isolates.

RESULTS

Twenty-two (33%) of the 67 AIDS patients were culture positive. Non-typhoidal Salmonella spp (45.5%), coagulase-negative staphylococci (22.7%) and Staphylococcus aureus (18.2%) were most commonly isolated. One isolate each of Klebsiella pneumoniae, Pseudomonas aeruginosa and Bacillus spp were identified. All bacteraemic patients had temperatures above 38 degrees C and white blood cell counts ranged between 2,700-13,500/mm(3). There was a high rate of antibiotic resistance particularly to chloramphenicol, tetracyclines, cotrimoxazole and beta-lactam antibiotics. However, most isolates were still susceptible to gentamicin and the fluoroquinolones. There was no significant difference in the socio-demographics of the bacteraemic AIDS and non-bacteraemic AIDS patients.

CONCLUSION

Salmonella spp. were the most common aetiological agent of bacteraemia among AIDS patients seen at the Lagos University Teaching Hospital (LUTH), Nigeria. A high temperature was a pointer to the presence of bactaeraemia while total white blood cell counts were not useful. It is recommended that blood culture should be done for AIDS patients with elevated temperature irrespective of the total white blood cell count.

Correlating antibiotic consumption with antimicrobial resistance of uropathogens in a university teaching hospital in Lagos, Nigeria

OBJECTIVE

This study was carried out to correlate the antibiotic consumption rates with the antibiotic resistance rates of uropathogens in Lagos University Teaching Hospital.

METHODOLOGY

Urine specimens obtained over 18 months (between January 2005 and June 2006) were processed for microscopy culture and sensitivity, and records of antibiotics dispensed during the same periods were reviewed. Significant bacteriuria was performed by the standard loop method. Isolation and identification of organisms was by standard laboratory methods. The antibiotic consumption calculator of Monnet (ABC calc version 3) was used to classify the antibiotics into ATC classes and to calculate the numbers of daily defined doses. The 6-monthly antibiotic resistance and consumption rates were compared using Pearson's correlation coefficient. For analysis, the period of study was divided into three.

RESULTS

Except for co-trimoxazole the rates of consumption of all antibiotics were higher in the second period than the first period of the study and highest in the 3rd period for ciprofloxacin, and ceftazidime. This correlated with an increase in the rates of resistance for some antibiotics during the 2nd and 3rd periods. While a steady increase in consumption of ciprofloxacin correlated with a steady increase in the resistance rates from the 1st to the 3rd periods, a steady increase in consumption of ceftazidime was associated with an increased resistance rate from the 2nd to 3rd periods.

CONCLUSION

Increased consumption of the antibiotics tested, most noticeably, ciprofloxacin and ceftazidime correlated with increased resistance rates. There is need for urgent interventions like formulation of antibiotic policies and education of staff on the appropriate use of antibiotics to reduce the development of resistance.

Bacterial flora of commonly used soaps in three hospitals in Nigeria

OBJECTIVES

To obtain general information on soap use and soap bacterial flora, and to assess the risk of transmission of organisms from contaminated soap to patients.

DESIGN

Descriptive study.

SETTING

Three hospitals in an urban area of Lagos, Nigeria. A teaching (761 bed) hospital, a general hospital (a 51 bed secondary healthcare facility) and a private hospital (a 30 bed private community with a surgical specialty).

RESULTS

Bar soaps were much more commonly used than liquid soaps. Out of the thirty six bar soaps and their receptacles studied, 19 (52.8%) were found wet, nine (25%) dry, five (13.9%) very dry, and three (8.3%) in a pool of water. A total of 39% soaps and 75% of receptacles were contaminated. Thirty three percent of the dry soaps and 68.4% of the wet soaps were contaminated. None of the very dry soaps and all in a pool of water were contaminated. The bacteria isolated from soaps included Pseudomonas aeruginosa (89.5%) and Klebsiella pneumoniae (10.5%), while Pseudomonas aeruginosa (70.6%), Klebsiella pneumoniae (14.7%), Staphylococcus aureus (11.8%) and Serratia marcescens (2.9%) were isolated from the receptacles. The antibiogram showed that the Pseudomonas aeruginosa isolated from the soaps and their containers (sinks) were distinct from those obtained from colonised or infected wounds. The soap contamination rates correlated with the conditions in which the soaps were kept.

CONCLUSION

The type of soap containers in particular, played a vital role in keeping the soap dry or wet. In all the hospitals studied, the policies on soap use, if any, were not in agreement with the recommended guidelines. The healthcare workers need to be re-educated on these guidelines.

Contamination levels of in-use disinfectants in a teaching hospital in Lagos, Nigeria

In-use testing of the disinfectants; Hibitane (5% w/v Chlorhexidinegluconate), Hibiscrub (4% w/v Chlorhexidinegluconate), Savlon (3% w/v Chlorhexidine/Cetrimide), hydrogen peroxide (6% w/v hydrogen peroxide with stabilizer) and a common household bleach Jik (3.5% w/v sodium hypochlorite), was carried out over a two-month period at a university teaching hospital in Nigeria. Contamination levels were high with 82 (63.1%) of the 130 in-use disinfectants contaminated. However, a few of the stock solutions remained sterile. One hundred and thirty-four isolates were obtained of which 120 (91%) were gram-negative with Pseudomonas species being the commonest, constituting 67.2% of all the isolates. Gram-positive organisms made up the remaining 12 (9.0%) isolates. All the Pseudomonas spp. were resistant to gentamicin, ceftazidime, nalidixic acid and perfloxacin. Contributory factors for the high contamination levels were dilution of disinfectants with tap water, inadequate care of stock solution bottles and long storage of the diluted disinfectants in the wards.