Quality of Data Recording and Antimicrobial Use in a Municipal Veterinary Clinic in Ghana

The recording of antimicrobial use data is critical for the development of interventions for the containment of antimicrobial resistance. This cross-sectional study assessed whether dissemination activities and recommendations made after an operational research (OR) study in 2021 resulted in better data recording and improved the use of antimicrobials in a rural veterinary clinic. Routinely collected data from treatment record books were compared between 2013 and 2019 (pre-OR) and from July 2021 to April 2023 (post-OR). The most common animals presenting for care in the the pre - and post OR periods were dogs (369 and 206, respectively). Overall, antimicrobial use in animals increased from 53% to 77% between the two periods. Tetracycline was the most commonly used antimicrobial (99%) during the pre-OR period, while Penicillin-Streptomycin was the most commonly used antimicrobial (65%) during the post-OR period. All animals that received care at the clinic were documented in the register during both periods. Whereas the diagnosis was documented in 269 (90%) animals in the post-OR period compared to 242 (47%) in the pre-OR period, the routes and dosages were not adequately recorded during the both periods. Therefore, the quality of data recording was still deficient despite the dissemination and the recommendations made to some key stakeholders. Recommendations are made for a standardized antimicrobial reporting tool, refresher training, and continuous supervisory visits to the clinic.

Quality of Reporting of Adverse Drug Reactions to Antimicrobials Improved Following Operational Research: A before-and-after Study in Sierra Leone (2017-2023)

Background: The quality of pharmacovigilance data is important for guiding medicine safety and clinical practice. In baseline and follow-up studies after introducing interventions to improve the quality of reporting of Individual Case Safety Reports (ICSRs) in Sierra Leone, we compared (a) timeliness and completeness of reporting and (b) patient outcomes classified as 'recovering'. Methods: Baseline (January 2017-December 2021) and follow-up (June 2022-April 2023) studies of ICSRs in the national pharmacovigilance database. Interventions introduced following recommendations from the baseline study included: updating standard operating procedures and guidelines, setting performance targets follow-up of patient outcomes, and training. Results: There were 566 ICSRs in the baseline study and 59 in the follow-up study. Timelines (reporting < 30 days) improved by five-fold (10% at baseline to 47% in follow-up). For the completeness of variables in ICSRs (desired threshold ≥ 90%),this was 44% at baseline and increased to 80% in the follow-up study. 'Recovering' outcomes reduced from 36% (baseline study) to 3% (follow-up study, p < 0.001). Conclusions: Significant improvements in timeliness, completeness, and validation of ICSRs were observed following operational research in Sierra Leone. While enhancing pharmacovigilance and patient safety, this study highlights the important synergistic role operational research can play in improving monitoring and evaluation systems.

Have Hand Hygiene Practices in Two Tertiary Care Hospitals, Freetown, Sierra Leone, Improved in 2023 following Operational Research in 2021?

In 2021, an operational research study in two tertiary hospitals in Freetown showed poor hand hygiene compliance. Recommended actions were taken to improve the situation. Between February-April 2023, a cross-sectional study was conducted in the same two hospitals using the World Health Organization hand hygiene tool to assess and compare hand hygiene compliance with that observed between June-August 2021. In Connaught hospital, overall hand hygiene compliance improved from 51% to 60% (p < 0.001), and this applied to both handwash actions with soap and water and alcohol-based hand rub. Significant improvements were found in all hospital departments and amongst all healthcare worker cadres. In 34 Military Hospital (34MH), overall hand hygiene compliance decreased from 40% to 32% (p < 0.001), with significant decreases observed in all departments and amongst nurses and nursing students. The improvements in Connaught Hospital were probably because of more hand hygiene reminders, better handwash infrastructure and more frequent supervision assessments, compared with 34MH where interventions were less well applied, possibly due to the extensive hospital reconstruction at the time. In conclusion, recommendations from operational research in 2021 contributed towards the improved distribution of hand hygiene reminders, better handwash infrastructure and frequent supervision assessments, which possibly led to improved hand hygiene compliance in one of the two hospitals. These actions need to be strengthened, scaled-up and guided by ongoing operational research to promote good hand hygiene practices elsewhere in the country.

Use and Quality of Blood Cultures for the Diagnosis of Bloodstream Infections: A Cross-Sectional Study in the Ho Teaching Hospital, Ghana, 2019-2021

Blood Culture and Drug Susceptibility Testing (CDST) remains vital for the diagnosis and management of bloodstream infections (BSIs). While the Ghana National Standard Treatment Guidelines require CDST to be performed in each case of suspected or clinically diagnosed BSI, these are poorly adhered to in the Ho Teaching Hospital (HTH). This study used secondary medical and laboratory records to describe blood CDST requests by clinicians and the quality of CDST processes for the diagnosis of BSI among patients admitted to HTH from 2019 to 2021. Of 4278 patients, 33% were infants. Pneumonia and neonatal sepsis cases were 40% and 22%, respectively. Only 8% (351/4278) had blood CDST requested. Of 94% (329/351) blood CDST processed and reported, only 7% (22/329) were culture-positive, with likely contaminants being recovered from 16% (52/329) of the specimens. The duration from admission to request was 2 days (IQR: 0-5), and Further qualitative studies must be conducted to understand the reasons for low blood CDST utilisation among clinicians and the patient outcomes. Targeted interventions are required to enhance the utilisation of blood CDST by clinicians and the quality of laboratory processes.

Surgical Antibiotic Prophylaxis Administration Improved after introducing Dedicated Guidelines: A Before-and-After Study from Dhulikhel Hospital in Nepal (2019-2023)

(1) Background: Surgical antibiotic prophylaxis (SAP) is important for reducing surgical site infections. The development of a dedicated hospital SAP guideline in the Dhulikhel Hospital was a recommendation from a baseline study on SAP compliance. Compliance with this new guideline was enhanced through the establishment of a hospital committee, the establishment of an antibiotic stewardship program and the funding and training of healthcare professionals. Using the baseline and a follow-up study after introducing dedicated hospital SAP guidelines, we compared: (a) overall compliance with the SAP guidelines and (b) the proportion of eligible and non-eligible patients who received initial and redosing of SAP; (2) Methods: A before-and-after cohort study was conducted to compare SAP compliance between a baseline study (July 2019-December 2019) and a follow-up study (January 2023-April 2023); (3) Results: A total of 874 patients were in the baseline study and 751 in the follow-up study. Overall SAP compliance increased from 75% (baseline) to 85% in the follow-up study (p < 0.001). Over 90% of those eligible for the initial dose of SAP received it in both studies. Inappropriate use for those not eligible for an initial dose was reduced from 50% to 38% (p = 0.04). For those eligible for redosing, this increased from 14% to 22% but was not statistically significant (p = 0.272); (4) Conclusions: Although there is room for improvement, introduction of dedicated SAP guidelines was associated with improved overall SAP compliance. This study highlights the role of operational research in triggering favorable interventions in hospital clinical care.

Quality of Electronic TB Register Data Compared with Paper-Based Records in the Kyrgyz Republic

This study evaluated the effectiveness of an electronic system for managing individuals with drug-sensitive pulmonary tuberculosis in the Kyrgyz Republic. This cohort study used programmatic data. The study included people registered on the paper-based system in 2019 and 302 people registered on both the electronic and the paper-based systems between June 2021 and May 2022. The data from the 302 individuals were used to assess the completeness of each form of record and the concordance of the electronic record with the paper-based system. This study showed that for most variables, the completeness and concordance were 85.3-93.0% and were lowest for nonmandatory fields such as medication side effects (26.8% vs. 13.6%). No significant difference was observed in the time taken from symptom onset to diagnosis and treatment initiation between the two systems. However, the electronic system had a significantly higher percentage of subjects who initiated treatment on the day of diagnosis (80.3% vs. 57.1%). The proportion with successful outcomes was similar in both groups, but the electronic system had a significantly lower proportion of individuals with outcomes that were not evaluated or recorded (4.8% vs. 14.3%, p < 0.001). This study highlights the potential advantages and gaps associated with implementing an electronic TB register system for improving records.

Improvement in the Surveillance System for Livestock Diseases and Antimicrobial Use Following Operational Research Studies in Sierra Leone January-March 2023

In Sierra Leone, two operational research (OR) studies in 2019 and 2021 showed deficiencies in the data being captured by the Integrated Animal Disease Surveillance and Reporting (IADSR) system. This third OR study was conducted in 2023 to assess whether the second OR study's results and recommendations were disseminated with the key stakeholders, the uptake of the recommendations, improvements in data capture in the IADSR system, and to describe the data on livestock disease and antimicrobial use. In 2022, on seven occasions, the authors of the second OR study disseminated the study's findings. Of the four recommendations, the one on improving laboratory infrastructure for confirmation of animal disease was not implemented. The district animal health weekly surveillance reports received through the IADSR system were sustained at 88% between the second (2021) and third (2023) studies. In both studies, the proportion of sick animals receiving antibiotics (25%) remained the same, but the use of "critically important antimicrobials for veterinary use" declined from 77% (in 2021) to 69% (in 2023). The IADSR system has improved considerably in providing information on animal health and antibiotic use, and sequential OR studies have played a key role in its improvement.

Has Data Quality of an Antimicrobial Resistance Surveillance System in a Province of Nepal Improved between 2019 and 2022?

An operational research study was conducted in 2019 to assess the quality of data submitted by antimicrobial resistance (AMR) surveillance sites in the Bagmati Province of Nepal to the National Public Health Laboratory for Global Antimicrobial Resistance and Use Surveillance System (GLASS). Measures were implemented to enhance the quality of AMR surveillance by strengthening capacity, improving infrastructure, implementing data sharing guidelines, and supervision. The current study examined reports submitted by surveillance sites in the same province in 2022 to assess whether the data quality had improved since 2019. The availability of infrastructure at the sites was assessed. Of the nine surveillance sites in the province, seven submitted reports in 2022 versus five in 2019. Completeness in reporting improved significantly from 19% in 2019 to 100% in 2022 (p < 0.001). Timely reports were received from two sites in 2019 and only one site in 2022. Specimen-pathogen consistency in accordance with the GLASS guidelines for urine, feces, and genital swab specimens improved, with ≥90% consistency at all sites. Overall, the pathogen-antibacterial consistency improved significantly for each GLASS priority pathogen. The study highlights the importance of dedicated infrastructure and institutional arrangements for AMR surveillance. Similar assessments covering all provinces of the country can provide a more complete country-wide picture.

The Trend, Characteristics and Treatment Outcomes in Patients with Tuberculosis Undergoing Thoracic Surgery in the Kyrgyz Republic between 2017 and 2021

Surgery has played an important role in managing complicated tuberculosis in former Soviet Union countries, including the Kyrgyz Republic. However, published information is limited. This study aimed to document the trend, characteristics and outcomes of tuberculosis patients who underwent thoracic surgery, using routinely collected data. Between 2017 and 2021, 4-7% of tuberculosis patients in the Kyrgyz Republic underwent thoracic surgery in two centres in Bishkek and Osh. In 2021, case records were retrieved in 264 (78%) of 340 patients undergoing thoracic surgery in the country. The most common indications for surgery were pleural exudate/empyema in 127 (44%) and tuberculoma in 83 (32%). Most patients (73%) underwent surgery within 30 days of starting TB treatment. Two-thirds of patients underwent radical surgery, and surgical outcomes were excellent in 99% of patients with one death. Post-operatively, 63 (23%) patients had no TB detected by the histology, with the two most common specified conditions being lung cancer and pulmonary hydatid disease. TB treatment was stopped in these patients. Of the 201 patients with confirmed TB after surgery, TB-treatment success was documented in 163 (81%), died/failure/lost to follow-up in 10 (5%) and not evaluated in 28 (14%). This study shows that thoracic surgery is feasible, safe and effective in the routine programme setting. Recommendations are made to strengthen referral and monitoring systems.

Assessing Changes in Surgical Site Infections and Antibiotic Use among Caesarean Section and Herniorrhaphy Patients at a Regional Hospital in Sierra Leone Following Operational Research in 2021

Surgical site infections (SSIs) are a major public health threat to the success of surgery. This study assessed changes in SSIs and use of antibiotics among caesarean section (CS) and herniorrhaphy patients at a regional hospital in Sierra Leone following operational research. This was a comparative before and after study using routine hospital data. The study included all the CS and herniorrhaphy patients who underwent surgery between two time periods. Of the seven recommendations made in the first study, only one concerning improving the hospital's records and information system was fully implemented. Three were partially implemented and three were not implemented. The study population in both studies showed similar socio-demographic characteristics. The use of postoperative antibiotics for herniorrhaphy in both studies remained the same, although a significant increase was found for both pre- and postoperative antibiotic use in the CS patients, 589/596 (98.8%) in 2023 and 417/599 (69.6%) in 2021 (p < 0.001). However, a significant decrease was observed in the overall incidence of SSIs, 22/777 (2.8%) in 2023 and 46/681 (6.7%) in 2021 (p < 0.001), and the incidence of SSIs among the CS patients, 15/596 (2.5%) in 2023 and 45/599 (7.5%) in 2021 (p < 0.001). The second study highlights the potential value of timely assessment of the implementation of recommendations following operational research.

Improvement in Infection Prevention and Control Performance Following Operational Research in Sierra Leone: A Before (2021) and After (2023) Study

INTRODUCTION

Infection prevention and control (IPC) is crucial to limit health care-associated infections and antimicrobial resistance. An operational research study conducted in Sierra Leone in 2021 reported sub-optimal IPC performance and provided actionable recommendations for improvement.

METHODS

This was a before-and-after study involving the national IPC unit and all twelve district-level secondary public hospitals. IPC performance in 2021 (before) and in 2023 (after) was assessed using standardized World Health Organization checklists. IPC performance was graded as: inadequate (0-25%), basic (25.1-50%), intermediate (50.1-75%), and advanced (75.1-100%).

RESULTS

The overall IPC performance in the national IPC unit moved from intermediate (58%) to advanced (78%), with improvements in all six core components. Four out of six components achieved advanced levels when compared to the 2021 levels. The median score for hospitals moved from basic (50%) to intermediate (59%), with improvements in six of eight components. Three of four gaps identified in 2021 at the national IPC unit and four of seven at hospitals had been addressed by 2023.

CONCLUSIONS

The study highlights the role of operational research in informing actions that improved IPC performance. There is a need to embed operational research as part of the routine monitoring of IPC programs.

Triple Priority: TB/HIV Co-Infection and Treatment Outcomes among Key Populations in The Kyrgyz Republic: A National Cohort Study (2018-2022)

Background: Improving tuberculosis (TB) care in key populations is an operational research priority in the Kyrgyz Republic. Here, we describe the characteristics of TB/HIV co-infected individuals, their affiliations with key country-wide population groups, and their TB treatment outcomes. Methods: This was a cohort study using national programmatic data (2018-2022). The key population groups included people with increased exposure to TB, limited access to TB services, and increased risk of acquiring TB. Results: Among 693 individuals with TB/HIV co-infection, the majority (58%) of individuals were from two regions of the Kyrgyz Republic (Chui and Bishkek). Eighty-four percent (84%) individuals had one or more affiliations to eight key population groups, with 49% of the individuals affiliated to ≥2 groups and 92% of the individuals were on both antiretroviral treatment and cotrimoxazole preventive therapy. Overall, 406 (59%) of the individuals had successful outcomes and 287 (41%) of the individuals had unsuccessful outcomes. Unsuccessful outcomes increased from 36% (n-39) with TB/HIV alone to 47% (n-86) with affiliations to ≥3 key population groups (P-0.03). Unsuccessful outcomes were associated with co-morbidities (diabetes mellitus and hepatitis B/C), migration, alcohol use, and extrapulmonary TB. Conclusions: For a long time, people with TB/HIV co-infection have been recognized as a "double priority". Affiliation to key populations accentuates their status to "triple priority". We advocate for increased attention and equity towards these populations.

Managing Comorbidities, Determinants and Disability at Start and End of TB Treatment under Routine Program Conditions in China

Many patients with tuberculosis (TB) have comorbidities, risk determinants and disability that co-exist at diagnosis, during and after TB treatment. We conducted an observational cohort study in 11 health facilities in China to assess under routine program conditions (i) the burden of these problems at the start and end of TB treatment and (ii) whether referral mechanisms for further care were functional. There were 603 patients registered with drug-susceptible TB who started TB treatment: 84% were symptomatic, 14% had diabetes, 14% had high blood pressure, 19% smoked cigarettes, 10% drank excess alcohol and in 45% the 6 min walking test (6MWT) was abnormal. Five patients were identified with mental health disorders. There were 586 (97%) patients who successfully completed TB treatment six months later. Of these, 18% were still symptomatic, 12% had diabetes (the remainder with diabetes failed to complete treatment), 5% had high blood pressure, 5% smoked cigarettes, 1% drank excess alcohol and 25% had an abnormal 6MWT. Referral mechanisms for the care of comorbidities and determinants worked well except for mental health and pulmonary rehabilitation for disability. There is need for more programmatic-related studies in other countries to build the evidence base for care of TB-related conditions and disability.

"Together against Tuberculosis": Cascade of Care of Patients Referred by the Private Health Care Providers in the Kyrgyz Republic

Until 2021, in the Kyrgyz Republic, tuberculosis (TB) was diagnosed and treated only in the public sector. With funding support of the STOP-TB partnership, the private providers in four regions of the country and Bishkek city were mapped, trained and incentivized to screen for and identify presumptive TB patients and refer them to the public facilities for diagnosis and treatment. In this study, we describe the cascade of care of such patients. This was a cohort study involving secondary analysis of routine data. Of 79,352 patients screened during February 2021-March 2022, 2511 (3%) had presumptive TB, of whom 903 (36%) were not tested for TB [pre-diagnostic loss to follow-up]. A total of 323 (13%) patients were diagnosed with TB, of whom, 42 (13%) were not started on treatment [pre-treatment loss to follow-up]. Among 257 patients eligible for outcome assessment, 197 (77%) had treatment success, 29 (11%) were lost-to-follow-up, 13 (5%) died, 4 (2%) had treatment failure and 14 (5%) were not evaluated. While this donor-funded, pioneering initiative was successful in engaging the private sector, we recommend that the national TB programme scales up the initiative nationally with dedicated budgets, activities and plans to monitor progress. Qualitative research is urgently needed to understand the reasons for the gaps in the care cascade.

Audit of Clinical Care Received by COVID-19 Patients Treated at a Tertiary Care Hospital of Nepal in 2021

Like the world over, Nepal was also hard hit by the second wave of COVID-19. We audited the clinical care provided to COVID-19 patients admitted from April to June 2021 in a tertiary care hospital of Nepal. This was a cohort study using routinely collected hospital data. There were 620 patients, and most (458, 74%) had severe illness. The majority (600, 97%) of the patients were eligible for admission as per national guidelines. Laboratory tests helping to predict the outcome of COVID-19, such as D-dimer and C-reactive protein, were missing in about 25% of patients. Nearly all (>95%) patients with severe disease received corticosteroids, anticoagulants and oxygen. The use of remdesivir was low (22%). About 70% of the patients received antibiotics. Hospital exit outcomes of most (>95%) patients with mild and moderate illness were favorable (alive and discharged). Among patients with severe illness, about 25% died and 4% were critically ill, needing further referral. This is the first study from Nepal to audit and document COVID-19 clinical care provision in a tertiary care hospital, thus filling the evidence gap in this area from resource-limited settings. Adherence to admission guidelines was excellent. Laboratory testing, access to essential drugs and data management needs to be improved.

Pattern of Antimicrobial Susceptibility and Antimicrobial Treatment of Neonates Admitted with Suspected Sepsis in a Teaching Hospital in Ghana, 2021

Neonatal sepsis is a life-threatening emergency, and empirical antimicrobial prescription is common. In this cross-sectional study of neonates admitted with suspected sepsis in a teaching hospital in Ghana from January-December 2021, we described antimicrobial prescription patterns, compliance with national standard treatment guidelines (STG), blood culture testing, antimicrobial resistance patterns and treatment outcomes. Of the 549 neonates admitted with suspected sepsis, 283 (52%) were males. Overall, 529 (96%) received empirical antimicrobials. Most neonates (n = 407, 76.9%) were treated empirically with cefuroxime + gentamicin, while cefotaxime was started as a modified treatment in the majority of neonates (46/68, 67.6%). Only one prescription complied with national STGs. Samples of 257 (47%) neonates underwent blood culture testing, of which 70 (27%) were positive. Isolates were predominantly Gram-positive bacteria, with coagulase-negative Staphylococcus and Staphylococcus aureus accounting for 79% of the isolates. Isolates showed high resistance to most penicillins, while resistance to aminoglycosides and quinolones was relatively low. The majority of neonates (n = 497, 90.5%) were discharged after successfully completing treatment, while 50 (9%) neonates died during treatment. Strengthening of antimicrobial stewardship programmes, periodic review of STGs and increased uptake of culture and sensitivity testing are needed to improve management of sepsis.

What Is in the Salad? Escherichia coli and Antibiotic Resistance in Lettuce Irrigated with Various Water Sources in Ghana

INTRODUCTION

Safety of the environment in which vegetables are grown, marketed and consumed is paramount as most are eaten raw. Irrigation sources include open drains and streams, which are often contaminated with human and animal waste due to poor sanitation infrastructure. In irrigated vegetable farms using such sources in Ghana, we assessed Escherichia coli counts, antibiotic resistance patterns and resistant genes on irrigated lettuce.

METHODS

A cross-sectional study was conducted between January-May 2022, involving five major vegetable farms in Ghana.

RESULTS

Escherichia coli was found in all 25 composite lettuce samples analyzed. Counts expressed in CFU/g ranged from 186 to 3000, with the highest counts found in lettuce irrigated from open drains (1670) and tap water using hose pipes (3000). Among all bacterial isolates, resistance ranged between 49% and 70% for the Watch group of antibiotics, 59% for the Reserved group and 82% were multidrug-resistant. Of 125 isolates, 60 (48%) were extended-spectrum beta-lactamase-producing, of which five (8%) had the blaTEM-resistant gene.

CONCLUSIONS

Lettuce was contaminated with Escherichia coli with high levels of antibiotic resistance. We call on the Ghana Ministry of Food and Agriculture, Food and Drugs Authority and other stakeholders to support farmers to implement measures for improving vegetable safety.

Antibiotic-Resistant Bacteria in Drinking Water from the Greater Accra Region, Ghana: A Cross-Sectional Study, December 2021-March 2022

With safely managed water accessible to only 19% of the population in Ghana, the majority of its residents are at risk of drinking contaminated water. Furthermore, this water could be a potential vehicle for the transmission of antimicrobial-resistant bacteria. This study assessed the presence of bacteria and the antibiotic resistance profile of Escherichia coli and Pseudomonas aeruginosa in drinking-water sources using membrane filtration and Kirby-Bauer disc diffusion methods. A total of 524 water samples were analyzed for total coliforms, total heterotrophic bacteria, E. coli and P. aeruginosa. Samples included sachets, bottled water, tap water, borehole and well water. Most of the sachet and bottled water samples were within the limits of Ghana's standards for safe drinking water for the parameters tested. Over 50% of tap and borehole water was also free of E. coli and P. aeruginosa. Overall, of 115 E. coli isolates from tap and ground water samples, most were resistant to cefuroxime (88.7%), trimethoprim-sulfamethoxazole (62.6%) and amoxicillin-clavulanate (52.2%). P. aeruginosa isolates were most resistant to aztreonam (48%). Multidrug resistance was predominantly seen among E. coli isolates (58%). Evidence from this study calls for routine antimicrobial resistance surveillance in drinking water across the country and additional treatment of water sources at household levels.

Adherence to Prescribing Indicators at a District Hospital in Ghana: Do We Match WHO Standards?

(1) Background: Rational use of medicines (RUM) and their assessment are important to ensure optimal use of resources and patient care in hospitals. These assessments are essential to identifying practice gaps for quality improvement. (2) Methods: Assessment of adherence to WHO/International Network for Rational Use of Drugs core prescribing indicators among outpatients in 2021 was conducted at the University Hospital of the Kwame Nkrumah University of Science and Technology in the Ashanti Region of Ghana. We reviewed electronic medical records (EMR) of 110,280 patient encounters in the year which resulted in 336,087 medicines prescribed. (3) Results: The average number of medicines prescribed per encounter was three, with generics being prescribed in 76% of prescriptions. Injections were prescribed in 7% of encounters while 90% of medicines were from Ghana's Essential Medicines List, 2017. (4) Conclusions: With the exception of patient encounters with injections, none of the prescribing indicators assessed in this study met WHO optimum levels, providing targets for quality improvement in RUM. Implementing prescribing guides and policies, regular audits and feedback as well as continuous professional development training may help to improve prescribing practices in the hospital.

Appropriateness of Antibiotic Prescribing for Acute Conjunctivitis: A Cross-Sectional Study at a Specialist Eye Hospital in Ghana, 2021

Most presentations of conjunctivitis are acute. Studies show that uncomplicated cases resolve within 14 days without medication. However, antibiotic prescription remains standard practice. With antimicrobial resistance becoming a public health concern, we undertook this study to assess antibiotic prescription patterns in managing acute conjunctivitis in an eye hospital in Ghana. We recorded 3708 conjunctivitis cases; 201 were entered as acute conjunctivitis in the electronic medical records (January to December 2021). Of these, 44% were males, 56% were females, 39% were under 5 years, 21% were children and adolescents (5-17 years) and 40% were adults (≥18 years). A total of 111 (55.2%) patients received antibiotics, of which 71.2% were appropriately prescribed. The use of antibiotics was more frequent in children under 17 years compared to adults (p < 0.0001). Of the prescribed antibiotics, 44% belonged to the AWaRe "Access" category (Gentamycin, Tetracycline ointment), while 56% received antibiotics in the "Watch" category (Ciprofloxacin, Tobramycin). Although most of the antibiotic prescribing were appropriate, the preponderance of use of the Watch category warrants stewardship to encompass topical antibiotics. The rational use of topical antibiotics in managing acute conjunctivitis will help prevent antimicrobial resistance, ensure effective health care delivery, and contain costs for patients and the health system.

Moving towards the end of the neglected in Ethiopia

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Distribution of snake species and snakebites in hotspots of Ethiopia

INTRODUCTION

In Sub-Saharan Africa, snakebites are a public health problem. In Ethiopia, clinical cases have been described, but little information exists on snakebites burden and its geographical distribution. The aim of this study was to document the spatial distribution of venomous snakes and snakebites in Ethiopia.

METHODOLOGY

In a cross-sectional observational study, venomous snakes were collected during snake catching activities in six Ethiopian hotspot areas between April 2015 and September 2020. Species and habitat were described. In the hotspot areas, routine health information data on reported snakebites was collected in 78 districts and subsequently used to map annual incidence per district.

RESULTS

A total of 333 snakes were collected and 14 species were identified. The most prevalent species were Bitis arietans, Bitis arietanus somalica, Echis pyramidum, known as vipers, and Naja pallida, known as cobra. The highest number of snakes (75) was observed in the Northwest and Eastern parts of Ethiopia, mostly in cultivation and man-made farm land, wooded and moist dry savanna. In each hotspot a wide variety of species was observed, although composition was different. The highest snakebite incidence overlapped with the high snakes densities in Northwest Ethiopia. The snakebite annual average incidence at district level was very heterogeneous and ranged from < 15 cases/100,000 inhabitants (44% of the districts) to 309.2 cases/100,000 inhabitants.

CONCLUSIONS

Snake diversity and distribution, linked to high incidence of snakebites in the hotspots, suggests a close interconnection between human, animal and environmental systems and could inform the need for antivenoms per geographical locality.

Ivermectin mass drug administration for onchocerciasis elimination: can it reduce the prevalence of scabies in Ethiopia?

INTRODUCTION

While ivermectin mass drug administration (MDA) has been implemented since long for onchocerciasis elimination, there is doubt whether this would also be effective for scabies control. If effective, this would allow integration of both programs. We compared scabies prevalence in districts implementing ivermectin MDA for the onchocerciasis elimination program and those not implementing the intervention in Amhara region, Ethiopia.

METHODOLOGY

We conducted a cross-sectional study comparing the scabies prevalence in 14 districts implementing ivermectin MDA for onchocerciasis elimination program between 2013-2018 and in 28 districts without this intervention in Amhara region Ethiopia. We used 2018 scabies survey data to determine scabies prevalence. All individuals screened for scabies during the survey were included. We collected data on risk factors from the districts database and annual reports. Multivariate linear regression analysis was used to account for potential confounding factors.

RESULTS

We included data on 4,319,064 subjects across 42 districts. Except the differences in temperature and population density, districts in both groups were comparable. A total of 371,780 scabies cases were detected in the 2018 survey. The median scabies prevalence was 6% (IQR 2.6-11.9) in the intervention districts and 5.2% (1.8-10.4) in the control districts (p-value 0.77). In adjusted analysis, the difference remained statistically non-significant (coefficient 0.37 (95% confidence interval (-0.93-1.67); p-value 0.554).

CONCLUSIONS

The implementation of ivermectin MDA for onchocerciasis control was not associated with reduced scabies prevalence. Consequently, standard scabies MDA should be deployed for scabies control.

Mycetoma patients in Ethiopia: case series from Boru Meda Hospital

INTRODUCTION

Mycetoma is a chronic infection that can affect the skin, subcutaneous tissue, and bone. Although Ethiopia is in the so-called mycetoma belt, very little has been published about the disease in Ethiopia. There are no data about mycetoma in Ethiopia yet. Here, we present the first detailed description of mycetoma patients in Ethiopia.

CASES PRESENTATION

Seven cases of clinically diagnosed mycetoma from Boru Meda Hospital are described. All patients presented with swelling of the foot, although sinuses and grains were identified for only one patient. Patients presented late with a median lesion duration of five years, and most had previously tried modern or traditional treatment. Differentiation between lesions of bacterial or fungal origin was not possible in our hospital, and therefore all patients were started on combined treatments of antifungals and antibiotics.

CONCLUSIONS

We confirm that mycetoma is present in Ethiopia, although there is no formal reporting system. Well-designed systematic studies are warranted to determine the exact burden of mycetoma in Ethiopia. A national strategy for mycetoma disease control should be designed with a focus on reporting, diagnosis, and management.

Clinical pattern and treatment outcome of Cutaneous Leishmaniasis in two hospitals in Bahir Dar, Ethiopia (2017-2021)

INTRODUCTION

Cutaneous Leishmaniasis (CL) in Ethiopia is caused by a unique species, L. aethiopica. In Ethiopia, there are limited studies that provide detailed clinical descriptions of CL, treatment options, and treatment outcomes.

METHODOLOGY

We conducted a descriptive study based on routinely collected data in medical files from two hospitals in Bahir Dar, Ethiopia, from 2017 to 2021. Three months following the end of therapy, we retrieved sociodemographic and clinical data, as well as data on the treatment outcome.

RESULTS

Between March 2017 and June 2021, 94 patients were diagnosed with CL at the two hospitals. Of those, 46 (48.9%) of individuals had localized CL, 36 (38.3%) mucocutaneous leishmaniasis (MCL), and 12 (12.8%) diffuse CL. Sixty-five (69.1%) of the participants were men. The most prevalent morphologic appearances were plaque (n = 42, 46.2%), nodule (n = 38, 41.8%), infiltrative (n = 34, 36.2%), crusted (n = 32, 34%), and ulcerated (n = 24, 25.5%). Scarred, volcanic, and patchy lesions were also documented. Systemic pentavalent antimonials were the most common treatment (n = 55, 58.5%), curing 21/38 (55%) of the patients. Pentavalent antimonials were also given intralesionally to seventeen patients (18.1%), with 15/16 (94%) of them being cured. Overall, 61% (40/66) of patients with documented treatment outcomes were cured.

CONCLUSIONS

As CL in Ethiopia has a wide array of clinical presentations, clinicians should be suspicious of patients from endemic areas who present with dermatologic manifestations. Physicians can employ local treatment as a first line before resorting to systemic therapy.

Snakebite case management: a cohort study in Northwest Ethiopia, 2012-2020

INTRODUCTION

Timely and appropriate management of snakebites in the tropics is a lifesaver. Many snakebite patients are being bitten in remote rural areas and do not manage to get in due time to healthcare facilities. This study assessed the clinical features and the risk factors associated with treatment outcomes of snakebite patients admitted at two hospitals in the Northwest of Ethiopia.

METHODOLOGY

In a retrospective cohort study, routinely collected data from 250 patients' medical charts at University of Gondar Hospital and Metema Hospital, between September 2012 and August 2020, were reviewed.

RESULTS

The median age of the snakebite cases was 24 years (95% CI = 22-26), with 80.8% male patients. At admission 148/250 patients presented in Clinical stage 1 or 2 (local symptoms only) and 73.7% presented more than 12 hours after the bite, 80.2% received antibiotics and 79.0% antivenom. The median duration of hospitalization was 3 days (95% CI = 3-4); 72% of the patients recovered and were discharged, 10.8% died and 0.5% underwent an amputation. On logistic regression analysis, residence in rural areas (AOR = 2.52, 95 % CI = 1.2-5.3), sign of bacterial superinfection on the bite site (AOR = 4.69. 95% CI = 1.4-15.4), clinical stage 3 or 4 with systemic symptoms or toxic signs at admission (AOR = 4.84, 95% CI = 1.3-18.0) and no treatment with antivenoms (AOR = 6.65, 95% CI = 1.6-27.7) were associated with bad outcome (death, amputation and/or referred/ went against medical advice).

CONCLUSIONS

Timely presentation at early clinical stage, appropriate clinical management and availability of antivenoms are cornerstones to reduce snakebite morbidity and mortality.

Surveillance of WHO Priority Gram-Negative Pathogenic Bacteria in Effluents from Two Seafood Processing Facilities in Tema, Ghana, 2021 and 2022: A Descriptive Study

Antimicrobial resistant (AMR) bacteria in effluents from seafood processing facilities can contribute to the spread of AMR in the natural environment. In this study conducted in Tema, Ghana, a total of 38 effluent samples from two seafood processing facilities were collected during 2021 and 2022, as part of a pilot surveillance project to ascertain the bacterial load, bacterial species and their resistance to 15 antibiotics belonging to the WHO AWaRe group of antibiotics. The bacterial load in the effluent samples ranged from 13-1800 most probable number (MPN)/100 mL. We identified the following bacterial species: E. coli in 31 (82%) samples, K. pneumoniae in 15 (39%) samples, Proteus spp. in 6 (16%) samples, P. aeruginosa in 2 (5%) samples and A. baumannii in 2 (5%) samples. The highest levels of antibiotic resistance (100%) were recorded for ampicillin and cefuroxime among Enterobacteriaceae. The WHO priority pathogens-E. coli (resistant to cefotaxime, ceftazidime and carbapenem) and K.pneumoniae (resistant to ceftriaxone)-were found in 5 (13%) effluent samples. These findings highlight the need for enhanced surveillance to identify the source of AMR and multi-drug resistant bacteria and an adoption of best practices to eliminate these bacteria in the ecosystem of the seafood processing facilities.

Antimicrobial, Multi-Drug and Colistin Resistance in Enterobacteriaceae in Healthy Pigs in the Greater Accra Region of Ghana, 2022: A Cross-Sectional Study

There is little published information on antimicrobial resistance (AMR) in animals in Ghana. We determined the prevalence and factors associated with AMR, multi-drug resistance (MDR-resistance to ≥3 antimicrobial classes) and colistin resistance in Enterobacteriaceae in healthy pigs in Accra, Ghana. Rectal swabs obtained from the pigs on 20 farms from January to March 2022, were examined for Escherichia coli, Enterobacter spp. and Klebsiella pneumoniae. AMR was determined using standard microbiological techniques and the mcr-1 gene detected through molecular analysis. Enterobacteriaceae were isolated from 197 of 200 pigs: these comprised 195 E. coli isolates, 38 Enterobacter spp. and 3 K. pneumoniae, either singly or combined. Over 60% of E. coli were resistant to tetracycline, with 27% and 34% being resistant to amoxicillin/clavulanic acid and ampicillin, respectively; 23% of E. coli and 5% of Enterobacter spp. exhibited MDR phenotypes. Phenotypic colistin resistance was found in 8% of E. coli and Enterobacter spp., with the mcr-1 gene detected in half. Our study findings should be incorporated into on-going AMR, MDR and colistin resistance surveillance programs in Ghana. We further advocate for tailored-specific education for pig farmers on animal antimicrobial use and for strengthened regulatory policy on antimicrobial usage and monitoring in the animal production industry.

High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study

BACKGROUND

Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance.

METHODS

Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year.

RESULTS

The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions.

CONCLUSIONS

Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.

Trends in Influenza Infections in Three States of India from 2015-2021: Has There Been a Change during COVID-19 Pandemic?

The COVID-19 pandemic and public health response to the pandemic has caused huge setbacks in the management of other infectious diseases. In the present study, we aimed to (i) assess the trends in numbers of samples from patients with influenza-like illness and severe acute respiratory syndrome tested for influenza and the number and proportion of cases detected from 2015−2021 and (ii) examine if there were changes during the COVID-19 period (2020−2021) compared to the pre-COVID-19 period (2015−2019) in three states of India. The median (IQR) number of samples tested per month during the pre-COVID-19 period was 653 (395−1245), compared to 27 (11−98) during the COVID-19 period (p value < 0.001). The median (IQR) number of influenza cases detected per month during the pre-COVID-19 period was 190 (113−372), compared to 29 (27−30) during the COVID-19 period (p value < 0.001). Interrupted time series analysis (adjusting for seasonality and testing charges) confirmed a significant reduction in the total number of samples tested and influenza cases detected during the COVID-19 period. However, there was no change in the influenza positivity rate between pre-COVID-19 (29%) and COVID-19 (30%) period. These findings suggest that COVID-19-related disruptions, poor health-seeking behavior, and overburdened health systems might have led to a reduction in reported influenza cases rather than a true reduction in disease transmission.

Compliance with Medication amongst Persons with Diabetes Mellitus during the COVID-19 Pandemic, Kerala, India: A Cross Sectional Study

Compliance with medication in persons with diabetes mellitus (DM) has been a challenge during the COVID-19 pandemic, leading to poor glycemic control and higher risk of complications. In the state of Kerala, India, 20−25% of adults have DM. Our cross-sectional study aimed to assess medication compliance and factors associated with poor compliance in DM persons attending selected primary care government facilities in Kerala during the COVID-19 pandemic. Persons registered with DM for >6 months were consecutively interviewed between August and September 2021. Poor compliance was defined as answering “No” to one or more of three questions related to access and intake of medication two weeks prior to and the day before the interview. Factors independently associated with poor compliance were assessed using adjusted prevalence ratios (aPr) and 95% confidence intervals. Of the 560 DM persons included, 209 (37%) exhibited poor compliance. Factors associated with poor compliance were age 19−45 years (aPr 1.4, 1.1−1.9); inability to be blood glucose tested during the COVID-19 pandemic (aPr 3.6, 2.9−4.3); not having COVID-19 (aPr 1.4, 1.0−1.9); and being double vaccinated against COVID-19 (aPr 1.4, 1.1−2.0). Focused attention must be paid to these groups to improve medication compliance and prevent DM complications and severe COVID-19-related disease.

COVID-19 Amongst Travelers at Points of Entry in Nepal: Screening, Testing, Diagnosis and Isolation Practices

WHO recommends surveillance for COVID-19 among travelers at Points of Entry (POE) to countries. At 13 selected POE at the Nepal-India border, between March 2021 and July 2021, we describe the screening, testing, diagnosis and isolation practices of COVID-19 amongst travelers. Those who stayed in India or elsewhere for > one day and those who did not have a negative RT-PCR result within the last 72 h of travel were tested for COVID-19 with rapid antigen diagnostic tests. Daily surveillance reports maintained at POE were used for analysis. Of 337,338 travelers screened, 69,886 (21%) were tested and 3907 (6%) were diagnosed with COVID-19. The proportions tested averaged 15% during April-May when screened numbers were high and increased to 35% in July when screened numbers had decreased. The proportions diagnosed positive peaked at 10% in April-May, but decreased to below 1% in June and July. Testing coverage varied from 0−99% in the different POE. Most COVID-19 cases were Nepalese, male, <60 years of age, migrant workers and presented with fever. Of COVID-19 cases, 32% had home-based isolation, 64% underwent community-based isolation and the remainder either went to hospital or returned to India. In conclusion, about one fifth of travelers overall were tested, with coverage varying considerably over time and among different POE. Strengthening surveillance processes at POE is needed.

Achieving Minimum Standards for Infection Prevention and Control in Sierra Leone: Urgent Need for a Quantum Leap in Progress in the COVID-19 Era!

INTRODUCTION

Good Infection prevention and control (IPC) is vital for tackling antimicrobial resistance and limiting health care-associated infections. We compared IPC performance before (2019) and during the COVID-19 (2021) era at the national IPC unit and all regional (4) and district hospitals (8) in Sierra Leone.

METHODS

Cross-sectional assessments using standardized World Health Organizations IPC checklists. IPC performance scores were graded as inadequate = 0-25%, basic = 25.1-50%, intermediate = 50.1-75%, and advanced = 75.1-100%.

RESULTS

Overall performance improved from 'basic' to 'intermediate' at the national IPC unit (41% in 2019 to 58% in 2021) and at regional hospitals (37% in 2019 to 54% in 2021) but remained 'basic' at district hospitals (37% in 2019 to 50% in 2021). Priority gaps at the national IPC unit included lack of: a dedicated IPC budget, monitoring the effectiveness of IPC trainings and health care-associated infection surveillance. Gaps at hospitals included no assessment of hospital staffing needs, inadequate infrastructure for IPC and lack of a well-defined monitoring plan with clear goals, targets and activities.

CONCLUSION

Although there is encouraging progress in IPC performance, it is slower than desired in light of the COVID-19 pandemic. There is urgent need to mobilize political will, leadership and resources and make a quantum leap forward.

Bacterial Isolates and Antibiotic Resistance of Escherichia coli Isolated from Fresh Poultry Excreta Used for Vegetable Farming in Freetown, Sierra Leone

The transfer of antibiotic resistance from animals to humans is of concern in recent times. One potential source of such transfer is the untreated poultry excreta used as manure in farming. We aim to identify bacterial isolates and antibiotic susceptibility patterns of Escherichia coli in poultry excreta in Sierra Leone. This was a cross-sectional study of fresh poultry excreta samples collected from four commercial poultry sites in Freetown, Sierra Leone, from June−September 2021. Bacterial isolates were tested against eight antibiotics using established standards. Of 100 samples, 93 showed Escherichia coli (93%): of those, eight isolates also had Salmonella (8%). E. coli was 100% resistant to all three ‘Watch’ drugs (erythromycin, cefoxitin and streptomycin) and tetracycline. E. coli was least resistant to ampicillin (12%), followed by chloramphenicol (35%). The prevalence of multidrug resistance was 95.6%. Multiple antibiotic resistance index ranged from 0.5−0.7 (optimal < 0.2), indicating high prior exposure to antibiotics in these poultries. Such high levels of resistance in E. coli isolated from poultry excreta could pose a serious threat to humans. We recommend (i) routine surveillance to monitor antibiotic resistance in poultry excreta, (ii) using poultry excreta as manure only after treatment and (iii) restricting the use of antibiotics as prophylactics and growth promoters in poultry feeds.

Culture Requests and Multi-Drug Resistance among Suspected Urinary Tract Infections in Two Tertiary Hospitals in Freetown, Sierra Leone (2017-21): A Cross-Sectional Study

In sub-Saharan Africa, there is limited information about the use of microbiology laboratory services in patients with suspected urinary tract infections (UTIs). This cross-sectional study assessed the requests for urine culture in patients with suspected UTI in two tertiary (maternal and paediatric) hospitals—Freetown and Sierra Leone, during May 2017–May 2021—and determined antimicrobial resistance (AMR) patterns among bacterial isolates. One laboratory served the two hospitals, with its electronic database used to extract information. Overall, there were 980 patients, of whom 168 (17%) had cultures requested and performed. Of these, 75 (45%) were culture positive. During 2017–2019, there were 930 patients, of whom 156 (17%) had cultures performed. During 2020–2021, when services were disrupted by the COVID-19 pandemic, there were 50 patients, of whom 12 (24%) had cultures performed. The four commonest isolates were Escherichia coli (36), Klebsiella pneumoniae (10), Staphylococcus aureus (9), and Pseudomonas spp. (6). There were high levels of AMR, especially for trimethoprim-sulfamethoxazole (47%), nalidixic acid (44%), nitrofurantoin (32%) and cefotaxime (36%). Overall, 41 (55%) bacterial isolates showed multidrug resistance, especially E. coli (58%), Pseudomonas spp. (50%), and S. aureus (44%). These findings support the need for better utilization of clinical microbiology services to guide antibiotic stewardship and monitoring of trends in resistance patterns.

Incidence of Surgical Site Infection and Use of Antibiotics among Patients Who Underwent Caesarean Section and Herniorrhaphy at a Regional Referral Hospital, Sierra Leone

Surgical site infections (SSIs) are common postoperative complications. Surgical antibiotic prophylaxis (SAP) can prevent the occurrence of SSIs if administered appropriately. We carried out a retrospective cohort study to determine the incidence of SSIs and assess whether SAP were administered according to WHO guidelines for Caesarean section (CS) and herniorrhaphy patients in Bo regional government hospital from November 2019 to October 2020. The analysis included 681 patients (599 CSs and 82 herniorrhaphies). Overall, the SSI rate was 6.7% among all patients, and 7.5% and 1.2% among CS patients and herniorrhaphy patients, respectively. SAP was administered preoperatively in 85% of CS and 70% of herniorrhaphy patients. Postoperative antibiotics were prescribed to 85% of CS and 100% of herniorrhaphy patients. Ampicillin, metronidazole, and amoxicillin were the most commonly used antibiotics. The relatively low rate of SSIs observed in this study is probably due to improved infection prevention and control (IPC) measures following the Ebola outbreak and the current COVID-19 pandemic. A good compliance rate with WHO guidelines for preoperative SAP was observed. However, there was a high use of postoperative antibiotics, which is not in line with WHO guidelines. Recommendations were made to ensure the appropriate administration of SAP and reduce unnecessary use of antibiotics.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

Inconsistent Country-Wide Reporting of Adverse Drug Reactions to Antimicrobials in Sierra Leone (2017-2021): A Wake-Up Call to Improve Reporting

Background: Monitoring of adverse drug reactions (ADRs) to antimicrobials is important, as they can cause life-threatening illness, permanent disabilities, and death. We assessed country-wide ADR reporting on antimicrobials and their outcomes. Methods: A cross-sectional study was conducted using individual case safety reports (ICSRs) entered into the national pharmacovigilance database (VigiFlow) during 2017−2021. Results: Of 566 ICSRs, inconsistent reporting was seen, with the highest reporting in 2017 and 2019 (mass drug campaigns for deworming), zero reporting in 2018 (reasons unknown), and only a handful in 2020 and 2021 (since COVID-19). Of 566 ICSRs, 90% were for antiparasitics (actively reported during mass campaigns), while the rest (passive reporting from health facilities) included 8% antibiotics, 7% antivirals, and 0.2% antifungals. In total, 90% of the reports took >30 days to be entered (median = 165; range 2−420 days), while 44% had <75% of all variables filled in (desired target = 100%). There were 10 serious ADRs, 18 drug withdrawals, and 60% of ADRs affected the gastrointestinal system. The patient outcomes (N-566) were: recovered (59.5%), recovering (35.5%), not recovered (1.4%), death (0.2%), and unknown (3.4%). There was no final ascertainment of ‘recovering’ outcomes. Conclusions: ADR reporting is inconsistent, with delays and incomplete data. This is a wake-up call for introducing active reporting and setting performance targets.

Hand Hygiene Compliance at Two Tertiary Hospitals in Freetown, Sierra Leone, in 2021: A Cross-Sectional Study

Hand hygiene actions are essential to reduce healthcare-associated infections and the development of antimicrobial resistance. In this cross-sectional study at two tertiary hospitals, Freetown, Sierra Leone, we observed hand hygiene compliance (defined as using handwash with soap and water or alcohol-based hand rub (ABHR) amongst healthcare workers between June and August 2021. Using the WHO Hand Hygiene tool, observations were made in relation to the type of opportunity, different wards and types of healthcare worker. Overall, 10,461 opportunities for hand hygiene were observed, of which 5086 (49%) resulted in hand hygiene actions. ABHR was used more often than handwash (26% versus 23%, p < 0.001). Overall, compliance was significantly better: after being with a patient/doing a procedure than before (78% after body fluid exposure risk compared with 24% before touching a patient—p < 0.001); in Paediatric (61%) compared with Medical wards (46%)—p < 0.001; and amongst nurses (52%) compared with doctors (44%)—p < 0.001. Similar patterns of compliance were observed within each hospital. In summary, hand hygiene compliance was sub-optimal, especially before being with a patient or before clean/aseptic procedures. Improvement is needed through locally adapted training, hand hygiene reminders in wards and outpatient departments, uninterrupted provision of ABHR and innovative ways to change behaviour.

Operational Research to Inform Programmatic Approaches to the Management of Tuberculosis in Uzbekistan

Globally, an estimated 10 million people fell ill with tuberculosis (TB) in 2019, a number that has been declining very slowly in recent years [...].

High multidrug resistance in urinary tract infections in a tertiary hospital, Kathmandu, Nepal

SETTING:

Tribhuvan University Teaching Tertiary Care Hospital, Kathmandu, Nepal, May–October 2019.

OBJECTIVE:

1) To describe the bacteriological profile, 2) to identify the antimicrobial resistance (AMR) pattern, and 3) to find the demographic characteristics associated with the presence of bacterial growth and multidrug resistance (MDR) in adult urine samples undergoing culture and drug susceptibility testing.

DESIGN:

This was a hospital-based, cross-sectional study using routine laboratory records.

RESULTS:

Among 11,776 urine samples, 16% (1,865/11,776) were culture-positive, predominantly caused by Escherichia coli (1,159/1,865; 62%). We found a high prevalence of resistance to at least one antibiotic (1,573/1,865; 84%) and MDR (1,000/1,865; 54%). Resistance to commonly used antibiotics for urinary tract infections (UTIs) such as ceftazidime, levofloxacin, cefepime and ampicillin was high. Patients aged ⩾60 years (adjusted prevalence ratio [aPR] 1.6, 95% CI 1.4–1.7) were more likely to have culture positivity. Patients with age ⩾45 years (45–59 years: aPR 1.5, 95% CI 1.3–1.7; ⩾60 years: aPR 1.4, 95% CI 1.2–1.6), male sex (aPR 1.3, 95% CI 1.2–1.5) and from inpatient settings (aPR 1.4, 95% CI 1.2–1.7) had significantly higher prevalence of MDR.

CONCLUSION:

Urine samples from a tertiary hospital showed high prevalence of E. coli and MDR to routinely used antibiotics, especially among inpatients. Regular surveillance and application of updated antibiograms are crucial to monitor the AMR situation in Nepal.

Incidence of healthcare-associated infections with invasive devices and surgical procedures in Nepal

SETTING

Dhulikhel Hospital, Kathmandu University Hospital, Kathmandu, Nepal.

OBJECTIVES

1) To report the incidence of health-care-associated infections (HAIs), 2) to compare demographic, clinical characteristics and hospital outcomes in those with and without HAIs; and 3) to verify bacterial types in HAI and community-acquired infections (CAIs) among inpatients with invasive devices and/or surgical procedures.

DESIGN

This was a cohort study using secondary data (December 2017 to April 2018).

RESULTS

Of 1,310 inpatients, 908 (69.3%) had surgical procedures, 125 (9.5%) had invasive devices and 277 (21.1%) both. Sixty-six developed HAIs (incidence = 5/100 patient admissions, 95% CI 3.9-6.3). Individuals with HAIs had a 5.5-fold higher risk of longer hospital stays (⩾7 days) and a 6.9-fold risk of being in intensive care compared to the surgical ward. Unfavourable hospital exit outcomes were higher in those with HAIs (4.5%) than in those without (0.9%, P = 0.02). The most common HAI bacteria (n = 70) were Escherichia coli (44.3%), Enterococcus spp. (22.9%) and Klebsiella spp. (11.4%). Of 98 CAIs with 41 isolates, E. coli (36.6%), Staphylococcus aureus (22.0%) and methicillin-resistant S. aureus (14.6%) were common.

CONCLUSION

We found relatively low incidence of HAIs, which reflects good infection prevention and control standards. This study serves as a baseline for future monitoring and action.

Annual consumption of parenteral antibiotics in a tertiary hospital of Nepal, 2017-2019: a cross-sectional study

SETTING

Patan Hospital, a tertiary care hospital in Lalitpur District, Nepal.

OBJECTIVES

To describe the annual parenteral antibiotic consumption in 1) defined daily dose (DDD) and DDD per 100 admissions; 2) calculate DDD per 100 admissions and proportions by pharmacological subgroup, chemical subgroup and AWaRe categories; and 3) describe patient expenditure on parenteral antibiotics as a proportion of the total patient expenditure on drugs and consumables between 2017 and 2019.

DESIGN

This was a cross-sectional study.

RESULTS

Total DDD of parenteral antibiotics increased by 23% from 39,639.7 in 2017 to 48,947.7 in 2019. DDD per 100 admissions increased by 10% from 172.1 in 2017 to 190.2 in 2019. Other beta-lactam antibacterials comprised the most frequently consumed pharmacological subgroup. The chemical substance most often consumed was ceftriaxone, with an increasing trend in the consumption of vancomycin and meropenem. Parenteral antibiotics in 'Watch' category were the most consumed over the study period, with a decreasing trend in 'Access' and increasing trend in 'Reserve' categories.

CONCLUSION

We aimed to understand the consumption of parenteral antibiotics at a tertiary care hospital and found that Watch antibiotics comprised the bulk of antibiotic consumption. Overconsumption of antibiotics from the 'Watch' and 'Reserve' categories can promote antimicrobial resistance; recommendations were therefore made for their rational use.

High drug resistance among Gram-negative bacteria in sputum samples from an intensive care unit in Nepal

SETTING

Tribhuvan University Teaching Hospital, Kathmandu, Nepal.

OBJECTIVES

1) To report the number and proportion of Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas (PABS) species among intensive care unit (ICU) patients with sputum culture; and 2) to assess antimicrobial resistance patterns, demographic and clinical characteristics associated with resistance to at least one antibiotic and ICU discharge outcomes among those patients with PABS species admitted to hospital between 14 April 2018 and 13 April 2019.

DESIGN

This was a hospital-based, cross-sectional study using secondary data.

RESULTS

Of 166 who underwent sputum culture, 104 (63%) had bacterial growth, of which, 67 (64%) showed PABS species. Of the positive cultures, Pseudomonas, Acinetobacter, Burkholderia and Stenotrophomonas were present in respectively 32 (30.7%), 31 (29.8%), 1 (1%) and 3 (2.8%). Pseudomonas showed a high level of resistance to levofloxacin (61%), cefepime (50%) and amikacin (50%). Acinetobacter was largely resistant to cefepime (95%), imipenem (92%) and levofloxacin (86%). Of the 67 with PABS infection, 32 (48%) died.

CONCLUSION

The study showed a high prevalence of Pseudomonas and Acinetobacter and the emergence of Stenotrophomonas in sputum culture samples of ICU patients. This highlights the need for monitoring PABS and associated resistance patterns to reduce mortality in ICU patients.

Antibiotic resistance in patients with chronic ear discharge awaiting surgery in Nepal

SETTING

Biratnagar Eye Hospital, Biratnagar, Nepal, which offers ear surgery for chronic suppurative otitis media (CSOM).

OBJECTIVE

In patients with CSOM awaiting surgery, to determine the 1) sociodemographic characteristics 2) bacterial isolates and their antibiotic resistance patterns and 3) characteristics of those refused surgery, including antibiotic resistance.

DESIGN

A cohort study using hospital data, January 2018-January 2020.

RESULTS

Of 117 patients with CSOM and awaiting surgery, 64% were in the 18-35 years age group, and 79% were cross-border from India. Of 118 bacterial isolates, 80% had Pseudomonas aeruginosa and 16% had Staphylococcus aureus. All isolates showed multidrug resistance to nine of the 12 antibiotics tested. The lowest antibiotic resistance in P. aeruginosa was for vancomycin (29%) and moxifloxacin (36%), and for S. aureus, this was vancomycin (9%) and amikacin (17%). Fourteen (12%) patients underwent surgery: myringoplasty (n = 7, 50%), cortical mastoidectomy with tympanostomy (n = 4, 29%) and modified radical mastoidectomy (n = 3, 21%). Those infected with P. aeruginosa and with resistance to over six antibiotics were significantly more likely to be refused for surgery.

CONCLUSION

Patients awaiting ear surgery were predominantly infected with multidrug-resistant P. aeruginosa and were consequently refused surgery. This study can help inform efforts for improving surgical uptake and introducing cross-border antimicrobial resistance surveillance.

Short and long-term outcomes of video observed treatment in tuberculosis patients, the Republic of Moldova

INTRODUCTION

The Republic of Moldova is among the 18 high priority countries for tuberculosis (TB) in Europe. This study compared adherence and short and long-term TB treatment outcomes for TB patients who experienced asynchronous Video Observed Treatment (aVOT) during three months of outpatient treatment versus Directly Observed Treatment (DOT) in operational conditions in 2016-2017 in Chisinau.

METHODOLOGY

We used secondary data from the 2016-2017 Randomized Clinical Trial (RCT) that piloted the aVOT Strategy in Chisinau and data from the national TB register. Relative risk was selected as a measure of association in analysis of treatment strategies (aVOT and DOT under operational conditions) and short and long-term treatment outcomes.

RESULTS

From 647 TB patients included in the study, 169 followed the treatment strategy in the RCT (83 in aVOT and 86 in DOT) and 478 were on DOT in operational conditions. Those in aVOT were more likely to have favourable short-term outcome than patients with DOT in operational conditions (RR 0.07; p < 0.001). TB recurrence as an indicator for the long-term outcome, was observed in group with DOT in operational conditions (40 cases, p = 0.006).

CONCLUSIONS

This study demonstrated that the aVOT treatment strategy was associated with better adherence and both short and long-term TB treatment favourable outcomes. aVOT as a new patient-centred approach supporting TB patients on improving treatment adherence and outcomes might be recommended as an alternative to DOT strategy in the Republic of Moldova.

9-12 months short treatment for patients with MDR-TB increases treatment success in Kyrgyzstan

INTRODUCTION

MDR/RR-TB is a growing problem in Kyrgyzstan. In 2005, the country introduced standard or individualized treatment for 20-24 months. Because of poor treatment outcomes, in 2017 a short treatment with strict eligibility criteria was introduced. The aim of this study was to compare characteristics and treatment outcomes of MDR/RR-TB patients receiving short (9-12 months) treatment in 2017 with those receiving standard or individualized (20-24 months) treatment in 2016/2017.

METHODOLOGY

A comparative cohort study using routine programmatic data. Characteristics, sputum culture conversion and treatment outcomes were compared between those on short treatment with those on standard/individualized treatment using the chi-square test, crude and adjusted risk ratios (RR and aRR).

RESULTS

The study included 274, 82 and 132 patients on standard, individualized and short treatment, respectively. There were more females, fewer migrants/homeless and unemployed and more new TB patients on short treatment compared with the other two groups. A favorable outcome (cure and treatment completed) was significantly higher in short treatment patients (83%) compared with those on standard (50%) or individualized (59%) treatment (p < 0.001). There was higher 1-month sputum culture conversion with short treatment (35%) compared with the other two groups (19% and 24%, p < 0.05). Short treatment (aRR 1.6, 1.4-1.8), female gender (aRR 1.2, 1.1-1.4), not being homeless (aRR 12.9, 4.5-17.3) and having new TB (aRR 1.3, 1.0-1.5) were independently associated with a favorable outcome.

CONCLUSIONS

The treatment success was higher in selected MDR-TB patients given short treatment in Kyrgyzstan: this regimen should be scaled-up to all MDR-TB patients.

Mental health interventions for rifampicin-resistant tuberculosis patients with alcohol use disorders, Zhytomyr, Ukraine

INTRODUCTION

Despite concerted efforts, Ukraine is challenged by increasing rates of multidrug and rifampicin-resistant tuberculosis (MDR/RR-TB) comorbid with alcohol use disorder (AUD). This study describes a cohort of RR-TB patients with high alcohol consumption treated in MSF Zhytomyr Project, Ukraine.

METHODOLOGY

We used programmatic data for 73 RR-TB patients screened with the AUD Identification Test March-July 2019 and followed-up for culture conversion/TB treatment outcome till 31 January 2020. We described socio-demographic, behavioral, and clinical characteristics, the level of depressive symptoms, and TB treatment outcomes in three groups: 1) patients with AUD who received mental health interventions (MHI); 2) patients with AUD who did not receive MHI; 3) patients with no AUD. We also found three potential contributors to declining to receive MHI.

RESULTS

Main characteristics of the study groups did not differ substantially. Those receiving MHI (mean: nine sessions) were rated for alcohol consumption as 'hazardous' (41%), 'harmful' (43%) and 'dependence' (36%) and had higher depression scores versus the second (p=0.009) and third (p=0.095) groups at baseline. Depressive symptoms declined at 9-month follow-up for all patients. Culture conversion was seen at 77%, 73%, and 83% for each group respectively. We also found three reasons for declining from MHI.

CONCLUSIONS

We detected little differences across the groups. However, our study cohort demonstrated substantially higher adherence rates, culture conversion and reduction of depressive symptoms than reported globally. We recommend further research on the effectiveness of MHI in changing the drinking habits, quality of life and/or TB treatment outcomes of patients with AUD.

A five-year audit of gaps in HIV testing and associations with TB treatment outcomes in Armenia, 2015-2019

INTRODUCTION

Poor human immunodeficiency virus (HIV) testing practices and underreporting of HIV-related data in TB information systems remain barriers to effective care for TB-HIV co-infected patients. HIV testing and recording practices in national TB program have not been formally evaluated in Armenia. This study aimed to assess the recording completeness of HIV testing and HIV status in the national TB program electronic database, and to determine trend in HIV testing and the association between HIV testing and treatment outcomes for all TB patients registered in Armenia (2015-2019).

METHODOLOGY

A cohort study of TB patients using routine programmatic data from the national TB program of Armenia.

RESULTS

From 2015 to 2019, the electronic database was completed for HIV testing and HIV status by 48.1% and 97.5%, respectively. Of all registered TB patients 93.6% were tested for HIV. Of a total 4,674 patients, 1,085 (23.2%) had unsuccessful outcomes. Patients with HIV status "not tested" and "not recorded" compared to HIV "negatives" had 1.76 (95%CI 1.42-2.11) and 1.6 (95%CI 1.20-2.06) times higher risk of unsuccessful outcomes, respectively. Lost to follow-up was the most frequent unsuccessful outcome in HIV status "not tested" group.

CONCLUSIONS

An analysis of nationwide data revealed incompleteness of the national TB electronic database for HIV data. Patients with HIV status "not tested" and "not recorded" had higher risk of unsuccessful TB treatment outcomes. Upgrade of the electronic database with information on key indicators of TB-HIV services will facilitate improved monitoring and reporting.

Breaking the paradigm: Optimized Case Finding multiplies tuberculosis detection among key populations in Ukraine

INTRODUCTION

In 2018, there were 3 million "missed" tuberculosis (TB) cases globally, much of which was disproportionally concentrated among key populations. To enhance TB case-finding, an Optimized Case Finding (OCF) strategy involving all contacts within the social network of an index TB case was introduced in five regions of Ukraine. We assessed TB detection and linkage to TB treatment using OCF in key populations.

METHODOLOGY

A cohort study using routine program data (July 2018 - March 2020). OCF empowers the index TB case to identify and refer up to eight close contacts within his/her social network for TB investigations.

RESULTS

Of 726 index TB cases in key populations, 6,998 close contacts were referred for TB investigations and 275 were diagnosed with TB (183 drug-sensitive and 92 drug-resistant TB). The TB case detection rate was 3,930/100,000 and the Numbers Needed to Investigate to detect one TB case was 25. TB was most frequent among people who inject drugs and homeless groups. Compared to TB detection using routine household case finding within the general population (1,090/100,000), OCF was 3.6-fold more effective and when compared to passive case finding in the general population (60/100,000), OCF was 66 times more effective. 99% (273) of TB patients were linked to care and initiated TB treatment.

CONCLUSIONS

The OCF strategy among key populations is very effective in identifying TB cases and involving them for treatment through the recruitment of the contacts from the risk social networks. We advocate to scale-up this case finding strategy in Ukraine and beyond.