Nosocomial infections in neonatal intensive care units: Cost-effective control strategies in resource-limited countries

Background: Nosocomial infections or hospital-acquired infectionsconstitute a global health problem. They lead to significant morbidity and mortality in both developed and resource-limited countries. The neonatal intensive care unit (NICU) is a suitable environment for disseminating these infections; underscoring the need for preventive intervention measures.Objectives: This review aims to highlight the global burden of nosocomialinfections in neonatal intensive care units (NICUs), to discuss their epidemiology and clinical spectrum, as well as the costeffective control strategies in resource-limited settings.Sources: Sources of information were from Google searches andPubMed- linked articles using the key words- nosocomial infections,neonatal intensive care unit, control. Related articles from hard copiesof medical literature and journals were also gathered.Results: Although paucity of data exists on the incidence of nosocomialinfections in NICUs in developing countries, reports from developedcountries indicate a range of 6% to 25%. Much higher figures were noted in some developing countries. Several risk factors for nosocomial infections were identified but varied in different NICUs surveyed. Effective control strategies have been recommended but hand washing or hand hygiene appears universally applicable in both developed and resource-limitedcountries. Economic analyses of these strategies in developed countrieshave established their costeffectiveness while the adaptability of hand hygiene program to resource-limited settings has been demonstrated in a World Health Organization pilot study in sub- Saharan Africa.Conclusion: Hand washing or hand hygiene by health-care personnelremains the most important evidence-based and cost-effective controlstrategy for the spread of nosocomial infections in NICUs in resource-limited countries.Key words: nosocomial infections; neonatal intensive care unit;control

Chronic kidney disease in children as seen in a tertiary hospital in Enugu, South-East, Nigeria

Background: The prevalence of chronic kidney disease (CKD) in children has been reported to be rising locally and globally. There is a dearth of data and inadequate facilities for the management of CKD in children in most of the developing countries like Nigeria.Objectives: The objective of this study is to ascertain the prevalence of CKD among children seen at University of Nigeria Teaching Hospital (UNTH), Enugu, South‑East Nigeria and also to determine the stage of CKD at presentation, possible etiology, treatment options offered and the outcome.Materials and Methods: A retrospective review of pediatric ward admissions in UNTH over a 5 year period (July, 2007 to June, 2012) was done. Information, including the age at presentation, symptoms, level of renal function, management and outcome, were obtained from the medical case notes.Results: There were 3002 pediatric admissions within the period of review, of which 98 (3.3%) had CKD, giving incidence of 3.0 new cases per million‑child population per year and the prevalence of 14.9 per million children population. Majority (54.1%) of those with CKD were over 10 years of age. Edema, oliguria and hypertension were the most frequent clinical features. The most common etiology was glomerular disease (63.6%) and 44.9% presented in CKD stage 4 and 5. Renal replacement therapy (RRT) was offered to 25 (25.5%) of the patients; 6 (24%) of whom had hemodialysis and 3 (12%) had acute peritoneal dialysis while 16 (64%) were managed conservatively. None of the patients had chronic or adequate dialysis. The overall outcome showed that 8 (8.2%) died while on admission, 15 (15.3%) left against medical advice (discharge against medical advice) because of financial constraints and could not access the therapy, 25 (25.5%) were discharged on conservative management and lost to follow‑up while another 50 (51.0%) were discharged and still on follow‑up.Conclusion: CKD in children poses myriad of challenges in management in our setting with late presentation of patients and limited resources being prominent. The majority of patients could not access and sustain RRT and the outcome continues to be daunting.Key words: Children, chronic kidney disease, Enugu, Nigeria, prevalenc

Epidemic History and Evolutionary Dynamics of Hepatitis B Virus Infection in Two Remote Communities in Rural Nigeria

BACKGROUND: In Nigeria, hepatitis B virus (HBV) infection has reached hyperendemic levels and its nature and origin have been described as a puzzle. In this study, we investigated the molecular epidemiology and epidemic history of HBV infection in two semi-isolated rural communities in North/Central Nigeria. It was expected that only a few, if any, HBV strains could have been introduced and effectively transmitted among these residents, reflecting limited contacts of these communities with the general population in the country. METHODS AND FINDINGS: Despite remoteness and isolation, approximately 11% of the entire population in these communities was HBV-DNA seropositive. Analyses of the S-gene sequences obtained from 55 HBV-seropositive individuals showed the circulation of 37 distinct HBV variants. These HBV isolates belong predominantly to genotype E (HBV/E) (n=53, 96.4%), with only 2 classified as sub-genotype A3 (HBV/A3). Phylogenetic analysis showed extensive intermixing between HBV/E variants identified in these communities and different countries in Africa. Quasispecies analysis of 22 HBV/E strains using end-point limiting-dilution real-time PCR, sequencing and median joining networks showed extensive intra-host heterogeneity and inter-host variant sharing. To investigate events that resulted in such remarkable HBV/E diversity, HBV full-size genome sequences were obtained from 47 HBV/E infected persons and P gene was subjected to Bayesian coalescent analysis. The time to the most recent common ancestor (tMRCA) for these HBV/E variants was estimated to be year 1952 (95% highest posterior density (95% HPD): 1927-1970). Using additional HBV/E sequences from other African countries, the tMRCA was estimated to be year 1948 (95% HPD: 1924-1966), indicating that HBV/E in these remote communities has a similar time of origin with multiple HBV/E variants broadly circulating in West/Central Africa. Phylogenetic analysis and statistical neutrality tests suggested rapid HBV/E population expansion. Additionally, skyline plot analysis showed an increase in the size of the HBV/E-infected population over the last approximately 30-40 years. CONCLUSIONS: Our data suggest a massive introduction and relatively recent HBV/E expansion in the human population in Africa. Collectively, these data show a significant shift in the HBV/E epidemic dynamics in Africa over the last century

The role of novel biomarkers in childhood idiopathic nephrotic syndrome: a narrative review of published evidence

Samuel N Uwaezuoke Department of Pediatrics, Pediatric Nephrology Firm, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria Abstract: Two histological subtypes of idiopathic nephrotic syndrome are commonly recognized in children, namely minimal change nephropathy and focal segmental glomerulosclerosis. Children with minimal change nephropathy (the majority of whom are steroid-sensitive) and focal segmental glomerulosclerosis (the majority of whom are steroid-resistant) require early identification in order to ensure appropriate therapeutic intervention and better outcome. Although renal biopsy and histology remain the ideal diagnostic steps to identify these histological subtypes, reports indicate that serum and urinary biomarkers are now being utilized in the investigation of childhood idiopathic nephrotic syndrome. This paper aims to review the diagnostic and prognostic utility of novel biomarkers in childhood idiopathic nephrotic syndrome and to highlight their role in differentiating steroid-sensitive nephrotic syndrome (SRNS) from steroid-resistant nephrotic syndrome (SSNS). Using the terms “idiopathic nephrotic syndrome,” “children,” and “biomarkers” the PubMed database was searched for relevant studies related to the topic. Biomarkers such as adiponectin, neopterin, β2-microglobulin, and N-acetyl-β-D glucosaminidase were reported as diagnostic markers. In addition to neopterin and N-acetyl-β-D glucosaminidase, urine vitamin D-binding protein and α1β-glycoprotein were shown to differentiate SRNS from SSNS while N-acetyl-β-D glucosaminidase and β2-microglobulin could predict steroid responsiveness and renal outcome in SRNS. Although progress has been made in demonstrating the diagnostic and prognostic utility of these biomarkers, their limited availability in most laboratories has precluded a complete paradigm shift from the conventional renal biopsy. Nevertheless, further longitudinal studies are required to establish their usefulness as noninvasive predictors of disease response to immunosuppressive therapy. Keywords: biomarkers, idiopathic nephrotic syndrome, children, investigatio

Prevention of Diabetic Nephropathy in Children and Adolescents: How Effective are the Current Strategies?

This paper aims to review the risk factors for diabetic nephropathy (DN) and the effectiveness of the current strategies for its prevention. Type 1 diabetes mellitus (T1DM) is the predominant form of diabetes in children and adolescents, but the prevalence of Type 2 diabetes mellitus (T2DM) in these age groups is currently increasing worldwide. One of the major challenges of T1DM is the development of DN among other microvascular complications. DN evolves over a long period of time starting from microalbuminuria and progressing to end stage renal failure. While microalbuminuria in children is reversible and may not evolve to end-stage renal failure, macroalbuminuria inevitably progresses to end-stage renal failure irrespective of any known treatment. Several modifiable and non-modifiable risk factors are well documented in the literature but addressing a few are critical in the prevention of DN. For instance, tight glycemic control and intensive control of hypertension have significant impact on prevention and progression of DN. From several studies, tight glycemic control has been shown to decrease the risk of microvascular disease in both T1DM and T2DM. Thus, poor glycemic control is critical in the etiology of DN. While tight glycemic control in patients with T1DM reduces the incidence of microalbuminuria and the progression from microalbuminuria to macroalbuminuria, there is overwhelming evidence to show that antihypertensive treatment with angiotensin converting enzyme (ACE) inhibitors is important in both preventing and treating microalbuminuria, and thus preventing progression to overt DN. Dietary protein restriction is also an adjunct strategy in retarding the progression of DN. Other novel therapeutic strategies have been recently tried and found potentially effective. Research is ongoing to establish the clinical efficacy and usefulness of some of these new agents in futur

The prevalence of urinary tract infection in children with severe acute malnutrition: a narrative review

Samuel N Uwaezuoke Department of Pediatrics, Pediatric Nephrology Firm, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria Abstract: This article aims to review the current evidence which shows that the prevalence of urinary tract infection (UTI) has been increasing in children with severe acute malnutrition (SAM). UTI remains one of the most common causes of febrile illness in pediatric practice. Most studies conducted among hospitalized children with complicated SAM have reported high prevalence rates of UTI. Clearly, the knowledge of baseline risk of UTI can help clinicians to make informed diagnostic and therapeutic decisions in these children. From the global reports reviewed in this article, UTI prevalence rates range from as low as 6% to as high as 37% in developing countries, while the most common bacterial isolates from urine cultures are Gram-negative coliform organisms such as Escherichia coli and Klebsiella species. These findings form the basis for the current diagnostic and therapeutic guidelines for clinicians managing children with complicated SAM. With the reported high prevalence of UTI among these children and concerns over antibiotic resistance, more extensive data are required using standardized microbiological methods. Thus, the assessment of the performance of urine dipsticks and microscopy against the gold standard urine culture is an important step toward strengthening the evidence for the therapeutic guidelines for UTI in children with SAM. Keywords: protein energy malnutrition, bacterial infection, urinary tract, therapeutic guideline

The role of novel biomarkers in predicting diabetic nephropathy: a review

Samuel N Uwaezuoke Pediatric Nephrology Firm, Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria Abstract: Diabetic nephropathy (DN) is one of the microvascular complications of the kidney arising commonly from type 1 diabetes mellitus (T1DM), and occasionally from type 2 diabetes mellitus (T2DM). Microalbuminuria serves as an early indicator of DN risk and a predictor of its progression as well as cardiovascular disease risk in both T1DM and T2DM. Although microalbuminuria remains the gold standard for early detection of DN, it is not a sufficiently accurate predictor of DN risk due to some limitations. Thus, there is a paradigm shift to novel biomarkers which would help to predict DN risk early enough and possibly prevent the occurrence of end-stage kidney disease. These new biomarkers have been broadly classified into glomerular biomarkers, tubular biomarkers, biomarkers of inflammation, biomarkers of oxidative stress, and miscellaneous biomarkers which also include podocyte biomarkers, some of which are also considered as tubular and glomerular biomarkers. Although they are potentially useful for the evaluation of DN, current data still preclude the routine clinical use of majority of them. However, their validation using high-quality and large longitudinal studies is of paramount importance, as well as the subsequent development of a biomarker panel which can reliably predict and evaluate this renal microvascular disease. This paper aims to review the predictive role of these biomarkers in the evaluation of DN. Keywords: type 1 diabetes mellitus, renal microvascular complication, microalbuminuria, end-stage kidney disease, biomarker pane

Nocturnal enuresis in school‑aged children with sickle‑cell anemia: Any relationship with hyposthenuria?

Background: Reports show that children with sickle‑cell anemia (SCA) have a tendency for nocturnal enuresis when compared with their counterparts with normal hemoglobin. Although nocturnal enuresis in SCA has been attributed to several factors including tubular and even bladder dysfunction, its relationship with hyposthenuria has been questioned in some studies.Aim: The study aims to determine the relationship of hyposthenuria with nocturnal enuresis seen in school‑aged children with SCA.Subjects and Methods: A cross‑sectional study of seventy school‑aged children with SCA, who met the study criteria and seventy age‑ and gender‑matched controls was conducted at the Sickle‑cell Clinic, University of Nigeria Teaching Hospital in Enugu, Southeast Nigeria. The diagnosis of enuresis among the subjects and controls was based on the Diagnostic and Statistical Manual of Mental Disorders‑IV criteria while urine specific gravity (USG) was determined on dipstick urinalysis. The frequencies of categorical variables were compared using Chi‑square test or Fisher exact test as appropriate and the means of continuous variables with Student’s t‑test. The level of statistical significance was taken as P < 0.05.Results: The prevalence of hyposthenuria was 4.5% and 8.3% among enuretic and nonenuretic subjects respectively, 6.7% and 10.9% among enuretic and nonenuretic controls and 4.5% and 6.7% among enuretic subjects and controls, respectively. The differences were not statistically significant. The mean ± standard deviation USG was significantly higher in the subjects than in the controls (1.02 ± 0.01 vs. 1.01 ± 0.01, P = 0.013) and enuretic subjects than enuretic controls (1.02 ± 0.01 vs. 1.01 ± 0.01, P = 0.007). The prevalence of nocturnal enuresis was significantly higher in male subjects compared to female subjects (odds ratio [OR] [95% confidence interval (95% CI)] =8.14 (2.12, 31.24), χ2 = 12.21, P < 0.001) and male controls (χ2 = 5.57, P = 0.018). Enuretic subjects had a significantly higher prevalence of parental history of childhood enuresis (OR [95% CI] =10.39 [2.45, 44.05], P < 0.002) than the enuretic controls. The relationship between the enuretic subjects and controls with respect to age of attainment of urinary control, family size, socioeconomic class, and sibling history of enuresis were not statistically significant.Conclusions: Nocturnal enuresis in children with SCA may not be related to hyposthenuria. However, male gender and parental history of childhood enuresis are significant risk factors.Key words: Hyposthenuria, nocturnal enuresis, sickle‑cell anemi

Prognostic scores and biomarkers for pediatric community-acquired pneumonia: how far have we come?

Samuel N Uwaezuoke,1 Adaeze C Ayuk2 1Pediatric Nephrology Firm, 2Pediatric Pulmonology Firm, Department of Pediatrics, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria Abstract: This article aimed to review the current prognostic and diagnostic tools used for community-acquired pneumonia (CAP) and highlight those potentially applicable in children with CAP. Several scoring systems have been developed to predict CAP mortality risk and serve as guides for admission into the intensive care unit. Over the years, clinicians have adopted these tools for improving site-of-care decisions because of high mortality rates in the extremes of age. The major scoring systems designed for geriatric patients include the Pneumonia Severity Index and the confusion, uremia, respiratory rate, blood pressure, age >65 years (CURB-65) rule, as well as better predictors of intensive care unit admission, such as the systolic blood pressure, multilobar chest radiography involvement, albumin level, respiratory rate, tachycardia, confusion, oxygenation and arterial pH (SMART-COP) score, the Infectious Diseases Society of America/American Thoracic Society guidelines, the criteria developed by España et al as well as the systolic blood pressure, oxygenation, age and respiratory rate (SOAR) criteria. Only the modified predisposition, insult, response and organ dysfunction (PIRO) score has so far been applied to children with CAP. Because none of the tools is without its limitations, there has been a paradigm shift to incorporate biomarkers because they are reliable diagnostic tools and good predictors of disease severity and outcome, irrespective of age group. Despite the initial preponderance of reports on their utility in geriatric CAP, much progress has now been made in demonstrating their usefulness in pediatric CAP. Keywords: community-acquired pneumonia, children, scoring systems, biomarkers&nbsp

Steady state, Gender comparison of haemoglobin concentration and vital signs of children with Sickle Cell anaemia in Crises and Steady State at- tending UNTH Ituku-Ozalla Enugu, Nigeria

Abstract Sickle Cell anaemia (SCA) is a genetic haematological disorder characterized by red blood cells that assume an abnormal, rigid, sickle shape. The current steady state haemoglobin concentration among children with sickle cell anaemia attending University of Nigeria Teaching Hospital since relocation to the present new site four years ago are not known necessitating the study. Objectives: To determine the steady state, gender comparison of haemoglobin concentration and vital signs among children with Sickle Cell anaemia in Crises and Steady State attending UNTH Ituku-0zalla Enugu. This is a prospective observational study involving 50 children with SCA in steady state, 50 in crisis and 50 with normal haemoglobin AA genotype carried out between June 2009 and October 2009. The steady state haemoglobin concentration among children with sickle cell anaemia in this environment was 7.2±1.2g/dl. The mean haemoglobin concentration among the group of subjects showed a significant gender difference (p=0.016). Females in both crises and steady state had fairly high haemoglobin concentration when compared to their male counterparts. The mean temperature, pulse and respiratory rate of sickle cell anaemia subjects in crises were 37.2±1.03oC, 101.15±19.73/mins and 34.0±3.36/mins respectively while the values for steady state and control were lower and statistically significant. The mean haemoglobin concentration of subjects in g/dl (crises 6.8+1.7 and steady state 7.2+1.2) was significantly lower than (10.8+1.2) obtained in the controls. Females with SCA had fairly high haemoglobin concentration when compared to the male counterparts