Assessment of treatment strategies in acute bacterial meningitis in Ethiopia

Background – Management of patients with suspected bacterial meningitis needs swift clinical decision making and early antibiotic initiation. However, the care of such patients in resource limited settings is challenging due to patients’ late presentation, limited diagnostic facilities and lack of evidence based treatment guidelines. Objective – To investigate the current strategies in the management of bacterial meningitis and to assess its discharge outcomes at teaching hospitals in Ethiopia Methods – Retrospective and prospective study designs were used. In the retrospective study, data was collected at four teaching hospitals in Ethiopia from patients who were treated as a case of bacterial meningitis from December 31, 2011 to April 30, 2015. The prospective study was conducted at Jimma University Hospital from March 1, 2013 to December 31, 2015. Descriptive analyses were done for most of baseline characteristics. Bivariate and multivariable analyses were also done to identify factors associated with unfavorable outcomes. Result – (i) Retrospective study: 425 patients of age 14 years and older were included in this study. Lumbar puncture was done for only 236 (55.5%) of cases. Only 96 (22.6%) of them had cerebrospinal fluid (CSF) abnormalities compatible with bacterial meningitis. A causative bacterium was identified in only 14 of the cases. Overall, 86 patients (20.2%) died while in the hospital. (ii) Prospective study: 127 adults (≥18 years) participated in this study; 109 (85.8%) had their CSF analysed. However, only 90 (70.9%) of them had findings suggestive of bacterial meningitis and causative bacteria were isolated in only 26 (20.5%). The over all in hospital mortality was 22.8% (29 deaths). Depressed level of consciousness, focal neurologic deficits and concomitant pneumonia on presentation were associated with increased in hospital death. Adjunctive dexamethasone treatment was used in 50.4% and 33.1% in retrospective and prospective studies, respectively, and was associated with unfavorable discharge outcome. Conclusion – Outcome in patients treated for bacterial meningitis in Ethiopia was found to be poor. Moreover, most of them did not receive proper diagnostic workup and alternative diagnoses were overlooked as a result. Adjunctive dexamethasone treatment was associated with unfavorable outcome at discharge. Thus, management of patients with suspected bacterial meningitis should be supported by laboratory tests and treatment should be tailored to evidences from the settings and current evidence-based recommendations

Assessment of treatment strategies in acute bacterial meningitis in Ethiopia

Background – Management of patients with suspected bacterial meningitis needs swift clinical decision making and early antibiotic initiation. However, the care of such patients in resource limited settings is challenging due to patients’ late presentation, limited diagnostic facilities and lack of evidence based treatment guidelines. Objective – To investigate the current strategies in the management of bacterial meningitis and to assess its discharge outcomes at teaching hospitals in Ethiopia Methods – Retrospective and prospective study designs were used. In the retrospective study, data was collected at four teaching hospitals in Ethiopia from patients who were treated as a case of bacterial meningitis from December 31, 2011 to April 30, 2015. The prospective study was conducted at Jimma University Hospital from March 1, 2013 to December 31, 2015. Descriptive analyses were done for most of baseline characteristics. Bivariate and multivariable analyses were also done to identify factors associated with unfavorable outcomes. Result – (i) Retrospective study: 425 patients of age 14 years and older were included in this study. Lumbar puncture was done for only 236 (55.5%) of cases. Only 96 (22.6%) of them had cerebrospinal fluid (CSF) abnormalities compatible with bacterial meningitis. A causative bacterium was identified in only 14 of the cases. Overall, 86 patients (20.2%) died while in the hospital. (ii) Prospective study: 127 adults (≥18 years) participated in this study; 109 (85.8%) had their CSF analysed. However, only 90 (70.9%) of them had findings suggestive of bacterial meningitis and causative bacteria were isolated in only 26 (20.5%). The over all in hospital mortality was 22.8% (29 deaths). Depressed level of consciousness, focal neurologic deficits and concomitant pneumonia on presentation were associated with increased in hospital death. Adjunctive dexamethasone treatment was used in 50.4% and 33.1% in retrospective and prospective studies, respectively, and was associated with unfavorable discharge outcome. Conclusion – Outcome in patients treated for bacterial meningitis in Ethiopia was found to be poor. Moreover, most of them did not receive proper diagnostic workup and alternative diagnoses were overlooked as a result. Adjunctive dexamethasone treatment was associated with unfavorable outcome at discharge. Thus, management of patients with suspected bacterial meningitis should be supported by laboratory tests and treatment should be tailored to evidences from the settings and current evidence-based recommendations

Pancytopenia of Unknown Cause in Adult Patients Admitted to a Tertiary Hospital in Ethiopia: Case series

BACKGROUND: Over the past few years, we have witnessed a dramatic increase in the number of patients presenting with severe pancytopenia to Jimma University Hospital. We now present sociodemographic and clinical characteristics of adult patients admitted with pancytopenia of unknown cause to Jimma University Hospital during the period of March 2015 to June 2016. Complete blood count and other diagnostic tests were done for all patients to uncover underlying causes.RESULT: Out of 65 cases admitted with pancytopenia during the specified period, 40 were excluded for various reasons. The rest 25 patients were included in this review. The mean age was 32.1 years (SD=14.9); 14 were younger than 30 years of age. The mean hemoglobin level, white cell count and platelet count were 48.6 g/L (SD=1.9), 1,918 /μL (SD=879.8) and 36,200 /μL (SD=26,131) respectively. The major presenting symptoms were generalized malaise and fever. No geographic or seasonal clustering of the caseswas seen.CONCLUSION: The number of cases with pancytopenia of unidentified cause seen at the hospital over the specified period is alarmingly high and deserves great attention. The hematologic alteration in most of the patients was found to be severe with poor clinical outcome. This calls for large scale community based investigation to uncover the root cause of the problem.KEYWORDS: Aplastic anemia, Pancytopenia, Ethiopia, Jimm

Exploratory analysis of time from HIV diagnosis to ART start, factors and effect on survival: A longitudinal follow up study at seven teaching hospitals in Ethiopia

Background: the HIV care in Ethiopia has reached 79% coverage. The timeliness of the care provided at the different levels in the course of the disease starting from knowing HIV positive status to ART initiation is not well known. This study intends to explore the timing of the care seeking, the care provision and associated factors.Methods: This is a longitudinal follow-up study at seven university hospitals. Patients enrolled in HIV care from September 2005 to December 2013 and aged ≥14 years were studied. Different times in the cascade of HIV care were examined including the duration from date HIV diagnosed to enrollment in HIV care, duration from enrollment to eligibility for ART and time from eligibility to initiation of ART. Ordinal logistic regression was used to investigate their determinants while the effect of these periods on survival of patients was determined using cox-proportional hazards regression.Results: 4159 clients were studied. Time to enrollment after HIV test decreased from 39 days in 2005 to 1 day after 2008. It took longer if baseline CD4 was higher, and eligibility for ART was assessed late. Young adults, lower baseline CD4, HIV diagnosis<2008, late enrollment, and early eligibility assessment were associated with early ART initiation. Male gender, advanced disease stage and lower baseline CD4 were consistent risk factors for mortality.Conclusion and recommendation: Time to enrollment and duration of ART eligibility assessment as well as ART initiation time after eligibility is improving. Further study is required to identify why mortality is slightly increasing after 2010.Key words: HIV, HIV testing, enrollment, eligibility, antiretroviral therapy, mortality, Ethiopia

Magnitude of Antiretroviral Drug toxicity in adult HIV patients in Ethiopia: A cohort study at seven teaching hospitals

Background: The introduction of antiretroviral therapy (ART) has resulted in significant mortality reduction and improvement in the quality of life. However, this has come at a cost of increased drug toxicity. The objective of this study was to assess the patterns and predictors of ART toxicity in adult HIV patients in Ethiopia.Methods: This is a prospective cohort study conducted at seven teaching hospitals between September 2009 and December 2013 involving 3921 HIV patients on ART. Adverse drug reactions (ADR) due to ART were identified based on clinical assessment and/or laboratory parameters. Multivariable random effects Poisson regression analysis was used to identify factors independently associated with toxicity.Result: ADR due to ART drugs was reported in 867 (22.1 %) of the participants; 374 (9.5%) had severe forms. About 87% of reported toxicities were limited to three organ systems – the skin, nervous system and blood. The overall incidence of ADR was 9 per 100 person years. About a third of toxicities occurred during the first six months after ART initiation with the incidence rate of 22.4 per 100 person years. Concomitant anti-tuberculosis treatment was the strongest independent predictor of toxicity.Conclusion: ADR was found to be highly prevalent in HIV patients on ART at tertiary hospitals in Ethiopia. Most of these conditions occurred early after ART initiation and in those with concomitant anti-tuberculosis treatment. Thus, routine monitoring of patients on ART should be strengthened with particular emphasis in the first 6 months. Strategies should also be devised to replace older and more toxic agents with newer and safer drugs available.Key words: HIV, ART, adverse drug reaction, incidence rate, ACM, Ethiopi

Predictors of Mortality among Adult People Living with HIV and Its Implications for Appointment Spacing Model Approach Care

BACKGROUND፡ Ethiopia has been motivated to achieve a goal of “appointment spacing model approach care.” However, little has been documented on the predictor of mortality and challenges of sustainable HIV care. Therefore, the aim of this study was to determine predictors of mortality among adult people living with HIV/AIDS on antiretroviral therapy (ART).METHODS: A retrospective cohort study was conducted on 676 adult people living with HIV who enrolled to ART clinic from September 01, 2012 - August 30, 2016. Multivariable Cox Regression analysis was done where adjusted hazard ratio (AHR)with corresponding 95% confidence interval (CI) at P value ≤ 0.05 cut of point was used to identify predictors of mortality.RESULTS: The total person-time contributed was 28,209 personmonths with an overall mortality incidence rate of 11 per 1000 person-months observation. The cumulative mortality incidence among females over the study period was 16.8% (64/382). Severe undernourishment and moderate malnutrition at baseline, younger age, female sex, single, divorced, illiterate, lack of disclosure, advanced WHO clinical stage, seeking treatment outside catchment area, rural residence and immunological failure were found to be independent predictors of mortality.CONCLUSIONS: Poor nutritional status at baseline, advanced stage of HIV disease, occurrence of treatment failure, female sex, substance abuse, lack of social support, immunological failure, clinical failure, and younger age, low level of education and poor physical access to healthcare facility were found to be important predictors of mortality. Intervening, those factors as routine and part of the appointment spacing model care can improve survival of PLWHA

Outcome of patients with acute bacterial meningitis in a teaching hospital in Ethiopia: A prospective study

Background: The mortality and neurologic sequelae associated with acute bacterial meningitis (ABM) remain high despite advances in medical care. The main aim of this study was to evaluate short-term outcome in patients treated as bacterial meningitis at a teaching hospital in Ethiopia to identify factors that could be focused on to improve outcome in this setting. Methods: A hospital based longitudinal study was conducted at Jimma University Hospital in southwest Ethiopia from March 1, 2013 to December 31, 2015. Participants of this study were patients of age 18 years and older who were treated as confirmed or possible cases of ABM. Patients were followed throughout their hospital stay for change in their clinical course and predefined end points. A multivariable analysis was done to identify factors associated with unfavorable outcomes. Result: 90 patients admitted with diagnosis of acute bacterial meningitis were included in the study;cerebrospinal fluid was analysed for 85 (94.4%) of them. Causative bacteria were isolated in 26 (28.9%) patients only;most of these isolates (84.6%) were either Streptococcus pneumoniae or Neisseria meningitidis. Patients managed as cases of ABM at the hospital suffered from a high rate of unfavorable outcome (36.7%) and an overall mortality rate of 22.2%. Impaired level of consciousness (AOR = 0.766, 95% CI = 0.589-0.995), dexamethasone therapy (AOR = 4.676, 95% CI = 1.12-19.50) and fever persisting after two days of admission (AOR = 24.226, 95% CI = 5.24-111.96) were found to be independently associated with unfavorable outcome. Conclusion: Outcome in patients treated for ABM at the hospital was found to be poor. Impaired mentation, treatment with adjunctive dexamethasone and persistent fever were found to be associated with poor outcome. Thus, development of clinical guidelines for treatment of ABM that suit the local context is essential to improve patient management and outcome

Adjunctive dexamethasone therapy in unconfirmed bacterial meningitis in resource limited settings: is it a risk worth taking?

Background: Bacterial meningitis is associated with significant morbidity and mortality despite advances in medical care. The main objective of this study was to assess the association of adjunctive dexamethasone treatment with discharge outcome of patients treated as bacterial meningitis in low income setting. Methods: A retrospective study was conducted at four teaching hospitals across Ethiopia. Patients of age 14 years and older treated as cases of bacterial meningitis between January 1, 2011 and April 30, 2015 were included in this study. Information regarding sociodemographic data, clinical presentations, laboratory data, treatments given and status at hospital discharge were retrieved from patients' medical records using a structured questionnaire. Predefined outcome variables at discharge were analysed using descriptive statistics. Multivariable logistic regression was used to identify factors independently associated with poor outcome. Results: A total of 425 patients treated with the presumptive clinical diagnosis of bacterial meningitis were included in this study (lumbar puncture done in 56 %;only 19 % had CSF findings compatible with bacterial meningitis, and only 3 % had proven etiology). The overall in hospital mortality rate was 20.2 %. Impaired consciousness, aspiration pneumonia, and cranial nerve palsy at admission were independently associated with increased mortality. Adjuvant dexamethasone, which was used in 50.4 % of patients, was associated with increased in-hospital mortality (AOR = 3.38;95 % CI 1.87-6.12, p < 0.001) and low Glasgow outcome scale (GOS) at discharge (AOR = 4.46 (95 % CI 1.98-10.08). This association between dexamethasone and unfavorable outcome was found to be more pronounced in suspected but unproven cases and in those without CSF alterations compatible with bacterial meningitis. Conclusion: Most patients treated for suspected bacterial meningitis did not receive proper diagnostic workup. Adjuvant dexamethasone use in clinically suspected but unproven cases of bacterial meningitis was associated with an increased mortality and poor discharge GOS. These findings show that there are potential deleterious effects in unconfirmed cases in this setting. Physicians practising under such circumstances should thus abide with the current recommendation and defer the use of adjuvant corticosteroid in suspected cases of bacterial meningitis

The cost of suspected and confirmed bacterial meningitis cases treated at Jimma University Medical Center, Ethiopia

BACKGROUND: Infections of the central nervous system (CNS) such as meningitis or encephalitis can be caused by myriad of microorganisms and may be life-threatening. In Ethiopia, it is an important cause of premature death and disability, being the 9th most common cause of years of life lost and loss of disability adjusted life years. The objective of this study was to estimate the cost of suspected and confirmed bacterial meningitis among inpatient managed patients at JUMC.METHODS: A facility-based cross-sectional study was conducted from July 28 to September 12, 2018. A semi-structured questionnaire was used in this study. Checklists were used to collect the types of laboratory tests performed and prescribed medications. This cost of illness study was conducted from the patient perspectives. We employed a micro-costing bottom-up approach to estimate the direct cost of meningitis. The humancapital approach was used for estimating wages lost.RESULT: Among total patients admitted and treated in JUMC, higher proportions (69.8%) were suspected bacterial meningitis but have been treated as confirmed cases. Total median costs for both suspected and confirmed bacterial meningitis patients were estimated to be ETB 98,812.32 (US $3,593.2; IQR 1,303.0 to 5,734.0). Total median direct cost was ETB 79,248.02 (US$2,881.75; IQR 890.7 to 3,576.7). Moreover, 45.3% of the patients reported that they were either admitted or given medication at JUMC or nearby health facility before their current admissions.CONCLUSION: These findings indicate that most cases of bacterial meningitis were treated only empirically, and the cost of the treatment was high, especially for resource-limited countries like Ethiopia. To minimize the burden of meningitis and avoid unnecessary hospitalizations, the availability of diagnostic techniques is vitally important

Clinical Profile of Neonates Admitted with Sepsis to Neonatal Intensive Care Unit of Jimma Medical Center, A Tertiary Hospital in Ethiopia

BACKGROUND፡ Globally, over 3 million newborn die each year, one million of these attributed to infections. The objective of this study was to determine the etiologies and clinical characteristics of sepsis in neonates admitted to intensive care unit of a tertiary hospital in Ethiopia.METHODS: A longitudinal hospital based cohort study was conducted from April 1 to October 31, 2018 at the neonatal intensive care unit of Jimma Medical Center, southwest Ethiopia. Diagnosis of sepsis was established using the World Health Organization’s case definition. Structured questionnaires and case specific recording formats were used to capture the relevant data. Venous blood and cerebrospinal fluid from neonates suspected to have sepsis were collected.RESULTS: Out of 304 neonates enrolled in the study, 195 (64.1%) had clinical evidence for sepsis, majority (84.1%;164/195) of them having early onset neonatal sepsis. The three most frequent presenting signs and symptoms were fast breathing (64.6%; 122/195), fever (48.1%; 91/195) and altered feeding (39.0%; 76/195). Etiologic agents were detected from the blood culture of 61.2% (115/195) neonates. Bacterial pathogens contributed for 94.8% (109/115); the rest being fungal etiologies. Coagulase negative staphylococci (25.7%; 28/109), Staphylococcus aureus (22.1%; 24/109) and Klebsiella species (16.5%; 18/109) were the most commonly isolated bacteria.CONCLUSION: Majority of the neonates had early onset neonatal sepsis. The major etiologies isolated in our study markedly deviate from the usual organisms causing neonatal sepsis. Multicentre study and continuous surveillance are essential to tackle the current challenge to reduce neonatal mortality due to sepsis in Ethiopia