Roll out of a successful antimicrobial stewardship programme in Lagos University Teaching Hospital Nigeria using the Global-Point Prevalence Survey

Background: Antimicrobial resistance (AMR) has become a public health emergency with increasing rates and spread globally. Antimicrobial stewardship (AMS) has been advocated to reduce the burden of antimicrobial resistance, promote rational and appropriate use of antibiotics and improve clinical outcomes. Education and training are one of the AMS interventions to improve antimicrobial use. We present the roll out of a successful AMS programme with education and training using the Global-PPS as data collection tool to measure AMS interventions and impact.Methodology: This was a cross sectional study on the implementation of an AMS programme at the Lagos University Teaching Hospital. Global PPS was conducted in 2015 to collect baseline data which was used to identify targets for quality improvement in AMS and was repeated in 2017 and 2018 to measure impact of AMS interventions. AMS interventions included education, feedback of Global-PPS result and writing of the hospitalwide antibiotic policy based on the baseline data.Results: Out of the 746 inpatients surveyed, 476 (68.3%) had received at least one antimicrobial on the days of Global-PPS. The antimicrobial prescribing rates reduced significantly over the three time periods. In 2015, 82.5% were placed on antimicrobials, 65.5% in 2017 and 51.1% in 2018 (p<0.00001). The documentation of indication for treatment significantly improved from 53.4% in 2015 to 97.2% in 2018 (p<0.0001). Stop review date also significantly improved from 28.7% to 70.2% in 2018 (p<0.00001). Surgical prophylaxis for more than 24 hours reduced significantly from 93.3% in 2015 to 65.7% in 2018 (p=0.002) even though the prevalence was still high. The three most commonly administered antimicrobial groups were third generation cephalosporins, imidazole derivatives and quinolones. The most commonly prescribed antibiotics for surgical prophylaxis were ceftriaxone and metronidazole in 2015 and ceftriaxone in 2017.Conclusion: The use of education and training as AMS intervention in a limited resource setting clearly made impact on antimicrobial prescribing patterns in the hospital. Global-PPS is useful to set quality improvement targets and for monitoring, evaluation and surveillance of an AMS programme. Keywords: Antibiotic, Stewardship, Resistance, Education, Global-PP

Prune Belly Syndrome in Nigeria – A report of two cases and review of literature

Background: Prune belly Syndrome is a rare congenital disorder made up of a myriad of anomalies with a typical triad of absence of  anterior abdominal wall muscles, urinary tract anomalies and bi-lateral cryptorchidism. Incidence is stated to be 1 in 30,000- 40,000 live births. The syndrome classically occurs in males. It is a cause of great morbidity with chronic renal failure and End stage renal disease (ESRD) occurring in 25-30% of patients and mortality of about 60%. Our neonatal unit managed 2 cases of this rare syndrome within a one month period. Objective: This report aimed to highlight the presentation, investigation and management of the cases and discuss the aetio- pathogenesis, management strategies, and prognostic factors of the condition. Case report: We report two term male neonates who presented in the first 24 hrs of life with laxity of abdominal wall muscles,  cryptorchidism and varied urinary tract abnormalities which included bilateral hydronephrosis (with multiple communicating cysts),hydroureter, severe vesicoureteric reflux and bladder outlet obstruction. Treatment was with urinary drainage and prophylactic antibiotics. One of them developed UTI and renal failure which ultimately led to demise, while the other discharged against medical advice. Conclusion: Prune belly syndrome often has a poor prognosis with high mortality. Though management is controversial and often  involves complex surgical intervention not readily available in resource-poor settings such as ours, early and coordinated multidisciplinary management with adequate patient education would improve survival and quality of life. Keywords: Congenital disorder, Nigeria, Prune belly syndrome

Outcome of twin and higher order multiple pregnancies: A comparative study

ERRATUM     The article was previously published in the Nigerian Quarterly Journal of Hospital Medicine (NQJHM), 2014, vol 24(3): 196-198 with a few errors, which has now been rectified in the current publication NQJHM, 2014 vol 24(4):Background: The prevalence of higher order multiple (HOM) pregnancies (pregnancies with 3 or more fetuses) has been on the increase worldwide and these pregnancies have a high risk of morbidity and mortality for both the mother and the babiesObjective: To compare the outcome of twin and higher order multiple pregnancies (HOM) in Lagos, Nigeria.Methods: The hospital records of all multiple pregnancies and the babies delivered at a tertiary centre in Lagos from January 2008 to December 2012 were reviewed retrospectively. The mode of delivery, gestational age, pregnancy and neonatal outcome of the babies were recorded. The pregnancy and neonatal outcomes of twin and HOM pregnancies and the babies were comparedResults: There were 328 twin and 32 HOM pregnancies out of 9799 deliveries during the period giving a prevalence of 3.35% and 0.33% for twins and HOM pregnancies respectively. Higher order multiple pregnancies were more likely to end as preterm deliveries (97.0% vs 59.3%, p=0.000), be delivered by caesarean section (95.9% vs 64.2%, p=0.000) and at a lower gestational age (32.5+2.8weeks vs 34.9+3.7weeks, p=0.000) compared to the twin gestations. The babies from the HOM pregnancies were also significantly smaller than the twins at birth, (1806+ 571g versus 2214 + 720g, p=0.000).The perinatal mortality rate was 165 and 131 per thousand births for HOM and twins respectively (p=0.369). Overall mortality was significantly higher for HOM pregnancies (28.8%vs 19.4%, p=0.026) but when the babies were analyzed based on their gestational ages and birth weight there was no significant difference in mortality.Conclusion: The occurrence of preterm delivery appears to be common with HOM pregnancies. However, the mortality in the two groups with comparable gestational ages and birth weights are similar.Keywords: Comparison, outcome, twins, higher order multiple pregnancie

Outcome of twin and higher order multiple pregnancies: A comparative study.

Background: The prevalence of higher order multiple pregnancies has been on the increase worldwide.Objective: To compare the outcome of twin and higher order multiple pregnancies (HOM) in Lagos, Nigeria.Methods: The hospital records of all multiple pregnancies and the babies delivered at a tertiary centre in Lagos from January 2008 to December 2012 were reviewed retrospectively. The mode of delivery, gestational age, pregnancy and neonatal outcome of the babies were recorded. The pregnancy and neonatal outcomes of twin and HOM pregnancies and the babies was comparedResults: There were 328 twin and 32 HOM pregnancies out of 9799 deliveries during the period giving a prevalence of 3.35% and 0.33% for twins and HOM pregnancies respectively. Higher order multiple pregnancies were more likely to end as preterm deliveries (97.0% vs 59.3%, p=0.000), be delivered by caesarean section (95.9% vs 64.2%, p=0.000) and at a lower gestational age (32.5+2.8weeks vs 34.9+3.7weeks, p=0.000) compared to the twin gestations. The babies from the HOM pregnancies were also significantly smaller than the twins at birth, (1806+ 571g versus 2214 + 720g, p=0.000). The perinatal mortality rate was 165 and 131 per thousand births for HOM and twins respectively (p=0.369). Overall mortality was significantly higher for HOM pregnancies (28.8%vs 19.4%, p=0.026) but when the babies were analyzed based on their gestational ages and birth weight there was no significant difference in mortality.Conclusion: The occurrence of preterm delivery appears to be common with HOM pregnancies. However, the mortality in the two groups with comparable gestational ages and birth weights are similar.Keywords: comparison, outcome, twins, higher order multiple pregnancie

Clinical and haematological features of newborns of mothers with hypertensive disorders in pregnancy in Lagos, Nigeria

Background: Newborns of mothers with hypertensive disorders in pregnancy have an increased risk of preterm delivery, low birth weight, perinatalasphyxia and haematological derangements such as polycythaemia, thrombocytopenia and neutropenia. These morbidities are associated with  uteroplacental insufficiency. The haematological derangements however have not been studied in detail in African neonates. Objective: To determine the clinical and haematological features of newborns of hypertensive mothers Methods: Cross-sectional study involving 250 newborns; 125 newborns each of hypertensive mothers (cases), and normotensive mothers (controls). The babies were examined following delivery, their clinical data were recorded, and umbilical cord blood samples were analysed for haematological indices. Results: Preterm deliveries were significantly higher amongst infants of hypertensive mothers (31.2%)compared with controls (12.0%);p = 0.000.  Similarly, the birth weight, length and head circumference of the cases were significantly lower than the controls; p = 0.008, 0.003 and 0.004 respectively. Low fifth minute APGAR scores occurred more frequently in cases (8.0%) than controls (0.8%), p=0.010; whilst the mean haematocrit  was also significantly higher in cases than the controls, p = 0.013. The median absolute neutrophil count and platelet count were significantly lower in cases than controls; p=0.023 and 0.047 respectively. Thrombocytopenia was identified in 40.0% of the cases compared to 27.2% of the controls, p =  0.041 Conclusion: The present study has shown that newborns of hypertensive mothers have an increased risk of neonatal morbidities such as preterm birth, LBW and thrombocytopenia compared to the newborns of mothers with normal blood pressure in pregnancy, hence close attention needs to be paid to them with emphasis on their haematological system. Key words: newborn, pregnancy, hypertension, hypertensive disorders, haematological, clinical&nbsp

Congenital hepatic angiomyolipoma in a term neonate: Presentation of a rare case and review of the literature

Angiomyolipoma (AML) of the liver is a rare benign, mesenchymal neoplasm that is composed of an admixture of blood vessels, smooth muscles, and variable adipose tissue. Hepatic AML poses a differential diagnostic challenge with other liver tumours. Awareness of the diverse morphological spectrum in liver biopsy is necessary to avoid misdiagnosis. Hepatic AML has an extremely low risk of malignant transformation. Hepatic AML is usually under recognized by clinicians and is seldom included in differential diagnosis of focal liver lesions. This disease is rare in neonates. We report a rare case of congenital hepatic AML in a term male Nigerian neonate who until histology report was being managed for probable hepatoblastoma. To the best of our knowledge, this is the first report of hepatic angiomyolipoma in a neonate in Africa. This report is to create awareness for congenital hepatic AML and tendency for its misdiagnosis in neonates. Keywords: Congenital; Hepatic angiomyolipoma; Neonate Key Messages: Occurrence of hepatic angiomy olipoma is rare in the neonatal period and the diagnosis poses a challenge with other liver tumours. Histology is essential to confirming the diagnosis and providing appropriate treatment