Opportunities and challenges for improving antimicrobial stewardship in low and middle income countries ; lessons learnt from the maternal sepsis intervention in Western Uganda

This paper presents findings from an action-research intervention designed to identify ways of improving antimicrobial stewardship in a Ugandan Regional Referral Hospital. Building on an existing health partnership and extensive action-research on maternal health, it focused on maternal sepsis. Sepsis is one of the main causes of maternal mortality in Uganda and Surgical Site Infection, a major contributing factor. Post-natal wards also consume the largest volume of antibiotics. The findings from the Maternal Sepsis Intervention demonstrate the potential for remarkable changes in health worker behaviour through multi-disciplinary engagement. Nurses and midwives create the connective tissue linking pharmacy, laboratory scientists and junior doctors to support an evidence-based response to prescribing. These multi-disciplinary ‘huddles’ form a necessary, but insufficient, grounding for active clinical pharmacy. The impact on antimicrobial stewardship and maternal mortality and morbidity is ultimately limited by very poor and inconsistent access to antibiotics and supplies. Insufficient and predictable stock-outs undermine behaviour change frustrating health workers’ ability to exercise their knowledge and skill for the benefit of their patients. This escalates healthcare costs and contributes to Anti-Microbial Resistance

Antibiotic Resistance Profiles and Population Structure of Healthcare-associated and Community-associated Staphylococcus aureus isolated in Fort Portal, Western Uganda

Antimicrobials currently hold infectious pathogens at bay, but with cases of resistance ever increasing, those same pathogens have the potential to reverse decades of medical progress, creating one of the biggest threats to global health, food security and development in the world today. The impact of antimicrobial resistance (AMR) is of particular concern for low-income countries which already suffer from a high burden of infectious bacterial diseases in both humans and animals, with cost constraints preventing the widespread application of newer, more expensive agents. Tackling AMR is particularly challenging in settings such as Fort Portal Regional Referral Hospital (FPRRH), Western Uganda, where specific knowledge of local AMR epidemiology is required to inform evidence-based improvement of antibiotic stewardship measures in the local area.This study focused on the evaluation of Staphylococcus aureus, a commensal bacterium carried by roughly 30% of the human population commonly in the nasopharynx and/or on skin. S. aureus also acts as a major human pathogen frequently associated with nosocomial infections where the skin has been broken, for example from a wound or surgical procedure. The three core aims of this study involved the evaluation of clinical and community associated S. aureus resistance profiles; evaluation of the population diversity of clinically associated S. aureus; and the elucidation of key resistance associated genes through the whole genome sequencing (WGS) of 41 clinical isolates.A population structure for the 41 sequenced isolates was inferred by comparing their core genomes. Twenty isolates formed a tight cluster corresponding to multilocus sequence typing (MLST) clonal complex (CC) 152, a CC found to be particularly prevalent in northern Africa. In agreement with other studies, the occurrence of Panton-Valentine leukocidin toxin-encoding genes was significantly higher among CC152 strains than non-CC152 strains. However, it was also observed that the coagulase gene was over-represented in this CC, further defining the virulence strategy of this important pathogen.Initial analysis of antimicrobial susceptibility testing (AST) data of S. aureus isolated from both clinical infections at FPRRH and the hand swabs of people in the local community revealed 64% (45/70) and 83% (104/125) of isolates were resistant to one or more antibiotic and 26% (18/70) and 49% (61/125) were multidrug resistant (MDR) respectively. Methicillin-resistant S. aureus (MRSA) was isolated at rates of 38% (8/21) and 22% (27/125) for the clinical and community associated isolates respectively.WGS of the 41 clinical S. aureus isolates revealed resistance phenotypes were largely explained by the presence of antibiotic resistance genes. Although all isolates were susceptible to clindamycin, a 24% carriage of erm genes suggests potential for rapid development of resistance. The frequency of genes associated with methicillin, chloramphenicol and ciprofloxacin resistance were significantly lower amongst CC152 strains than non-CC152 strains; thus, in keeping with previous work, it was found that CC152 was almost exclusively methicillin-sensitive S. aureus (MSSA). By generating detailed information about the epidemiology of circulating S. aureus and their antibiotic susceptibility, this study has provided, for the first time, data on which evidence-based infection and AMR interventions at FPRRH can be based, including the procurement and prescription of antibiotics. Furthermore, this study was able to build and promote international collaborations between Salford University, FPRRH, Ugandan Infectious Diseases Institute and Makerere University for the effective transfer of knowledge and completion of advanced research

A questionnaire study of the negative outcomes for UK health professional volunteers in low and middle income countries

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. INTRODUCTION: Past research has reported considerable benefits of international health professional volunteering for British healthcare professionals; however, there are also some negative outcomes reported. Negative outcomes reportedly happen on a personal, professional and organisational level. However, there is little evidence of the frequency they might occur. METHODS: We aimed to understand what the negative outcomes of health professional volunteering in low-income and middle-income countries were, and how frequently they occurred, in an opportunistic sample of UK health professionals. We used a questionnaire developed using potential negative outcomes reported in the peer-reviewed papers. We conducted secondary analysis on cross-sectional questionnaire data from 222 healthcare professionals. RESULTS: This research provides an indication of the frequency that negative outcomes might occur. Post hoc analyses revealed that some outcomes were experienced by the majority of health professional volunteers, for example, lack of formal recognition (131/169, 78%) and financial cost (92/169, 68%). While others happened less, for example, a reliance on agency or locum work (12/169, 7%) and loss of pension (31/169, 18%). CONCLUSION: The outcomes reported in this research quantify some of the concerns that have been raised in previous literature. Negative outcomes might be associated with certain features of volunteering and further research is needed to prospectively compare different features. Organisers of volunteering opportunities should be aware of the potential negative outcomes and engage with the research into negative outcomes to generate and apply findings about minimising potential negative outcomes, carefully balancing these against the needs of the host country

Anti-microbial resistance in global perspective

This open access book provides an accessible introduction to the mechanics of international development and global health text for policy-makers and students across a wide range of disciplines. Antimicrobial resistance is a major threat to the well-being of patients and health systems the world over. In fragile health systems so challenged, on a day-today basis, by the overwhelming burden of both infectious and non-communicable disease, it is easy to overlook the impacts of AMR. The Maternal Sepsis Intervention, focusing on a primary cause of maternal death in Uganda, demonstrates the systemic nature of AMR and the gains that can be made through improved Infection Prevention Control and direct engagement of laboratory testing in antibiotic prescribing

Lactate dehydrogenase is not a useful marker for relapse in patients on surveillance for stage I germ cell tumours

As part of surveillance protocols for stage I germ cell tumours, many centres routinely measure human chorionic gonadotrophin (HCG), alpha feto-protein (AFP) as well as lactate dehydrogenase (LDH). In conjunction with regular imaging and clinical examination, does routine measurement of LDH add anything to our relapse/pick up rate? Records of 494 patients at Mount Vernon Hospital who relapsed on surveillance between 1985 and 2005 were examined. Of the 494 patients who relapsed, 125 had raised LDH at the time of relapse. 112 of these had a concurrent rise in either AFP, HCG or both, 11 had their disease detected on CT before the rise in LDH, one had a clinically palpable para-aortic mass and the final patient complained of back pain and his retroperitoneal disease was thus discovered on imaging. Routine measurement of LDH in patients on surveillance for stage I germ cell tumours does not add to the early detection of relapse

Work restructuring and changing craft identity: the Tale of the Disaffected Weavers (or what happens when the rug is pulled from under your feet)

This article explores the changes in worker identity that can occur during manufacturing restructuring – specifically those linked to the declining status of craft work – through an in-depth case study of Weaveco, a UK carpet manufacturer. An analysis of changes in the labour process is followed by employee reactions centred on the demise of the traditional craft identity of male carpet weavers. The voices of the weavers dramatize the tensions involved in reconstructing their masculine identity, and we consider the implications this has for understanding gendered work relations

Antibiotic resistance profiles and population structure of disease-associated Staphylococcus aureus infecting patients in Fort Portal Regional Referral Hospital, Western Uganda

Tackling antimicrobial resistance (AMR) is particularly challenging in low-resource settings such as Fort Portal Regional Referral Hospital (FPRRH) in Western Uganda. Specific knowledge of local AMR epidemiology is required to inform evidence-based improvement of antibiotic stewardship measures in the hospital. To address this, we combined existing antimicrobial susceptibility testing (AST) from FPRRH, with whole genome sequencing (WGS) of 41 Staphylococcus aureus isolates (2017–2019). AST revealed 73 % (30 of 41) of isolates were resistant to one or more antibiotics and 29 % (12 of 41) were multi-drug resistant (MDR). Resistance phenotypes were largely explained by the presence of antibiotic resistance genes in WGS data. Five isolates were methicillin-resistant S. aureus (MRSA) and MDR. Although all isolates were susceptible to clindamycin, a 24 % carriage of erm genes suggests potential for rapid development of resistance. We inferred a population structure for the S. aureus isolates by comparing their core genomes. Twenty isolates formed a tight cluster corresponding to multilocus sequence typing clonal complex (CC) 152, a CC found to be particularly prevalent in northern Africa. The frequency of genes associated with methicillin, chloramphenicol and ciprofloxacin resistance were significantly lower among CC152 strains than non-CC152 strains; thus, in keeping with previous work, we find that CC152 is almost exclusively methicillin-sensitive S. aureus (MSSA). Also, in agreement with other studies, we observed that the occurrence of Panton–Valentine leukocidin toxin-encoding genes was significantly higher among CC152 strains than non-CC152 strains. However, we also observed that the coagulase gene was over-represented in this CC, further defining the virulence strategy of this important pathogen. By generating detailed information about the epidemiology of circulating S. aureus and their antibiotic susceptibility, our study has provided, for the first time, data on which evidence-based infection and AMR interventions at FPRRH can be based

A consideration of the challenges involved in supervising international masters students

This paper explores the challenges facing supervisors of international postgraduate students at the dissertation stage of the masters programme. The central problems of time pressure, language difficulties, a lack of critical analysis and a prevalence of personal problems among international students are discussed. This paper makes recommendations for the improvement of language and critical thinking skills, and questions the future policy of language requirements at HE for international Masters students

Dual career couples in academia, international mobility and dual career services in Europe

The number of dual career couples in academia is growing due to the increasing proportion of women with a doctoral degree and the greater propensity of women to choose another academic as their partner. At the same time, international mobility is required for career advancement in academia creating challenges for dual career couples where both partners pursue careers. This paper has two objectives: a) to raise the increasingly important issue of dual career couples in academia and the gendered effect that the pressure for mobility has on career advancement and work-life interference, and b) to present examples of recently established dual career services of higher education institutions in Germany, Denmark and Switzerland, responding to the needs of the growing population of dual career couples. Due to long established practices of dual career services in the US, the European examples will be compared with US practices. This paper raises the significance of considering dual career couples in institutional policies that aim for an internationally excellent and diversified academic workforce. It will appraise dual career services according to whether they reinforce or address gender inequalities and provide recommendations to HEIs interested in developing services and programmes for dual career couples

Echoes of time. The mobility of Brazilian researchers and students in Portugal

A investigação que apresentamos, de caráter exploratório, recaiu sobre histórias biográficas de brasileiros que escolhem Portugal para prosseguir formação e ou investigação. Procura-se encontrar na sua experiência elos de ligação explicativos sobre as motivações e os processos que os trazem para Portugal, assim como as expetativas e os projetos que comportam para os seus futuros e que incluem, ou não, este país. Temos em conta, especialmente, a forma como essa narrativa transporta sentidos identitários decorrentes das formas de relacionamento intercultural e político entre Portugal e Brasil e formas de cooperação implícitas, assim como mapas representacionais acerca dos lugares de eleição para desenvolvimento de carreiras científicas e académicas. A nossa pesquisa incide sobre as informações recolhidas através de um inquérito por questionário e entrevistas realizadas junto de estudantes e bolseiros brasileiros em Portugal.We present an exploratory study that investigated biographical stories of Brazilians who choose to continue their education or develop research in Portugal. We sought to find in their experiences explanatory links connecting the motivations and processes that bring them to Portugal, as well as the expectations and projects that they hold for the future, which may include, or not, this country. We take into account, particularly, the way this narrative carries senses of identity arising from the forms of intercultural and political relationship between Portugal and Brazil, as well as implicit forms of cooperation and representations about the places chosen for the development of scientific and academic careers. Our research draws on information collected through a survey based on questionnaires and interviews with Brazilian students and scholarship holders in Portugal.(undefined