Prevalence of hospital acquired enterococci infections in two primary-care hospitals in Osogbo, Southwestern Nigeria

Enterococci are opportunistic bacteria that become pathogenic when they colonize niches where they are not normally found. Of recent, they have become major cause of nosocomial infections, especially of the bloodstream, urinary tract and surgical sites. The aim of this study is to determine the point‐prevalence rate of human enterococci infections among hospitalized patients in Osogbo, Nigeria. The study was conducted between January and June 2009 in two primary‐care hospitals in Osogbo and involved a total of 118 patients who developed clinical evidence of infection at least 48 hours after hospital admission. Appropriate clinical samples were collected from the patients after an informed consent and cultured for isolation/biochemical identification of Enterococcus species at the Bacteriology Laboratory of Ladoke Akintola University of Technology, Osogbo using standard microbiological methods. There were 525 hospital admissions within the time frame of the study of which 118 (22.5%) developed hospital acquired infection (HAI); 58 (49.2%) of which cultured positive for bacterial pathogens. Enterococci were isolated from infective focus in 7 patients, giving a prevalence rate of hospital‐acquired enterococci infection of 5.9%. Two species of Enterococcus were identified; Enterococcus faecalis from urinary tract infection (UTI) and surgical site infection (SSI) of 6 (85.7%) patients and Enterococcus faecium from UTI in 1 (14.3%) patient. Other bacteria recovered from other infective foci were Klebsiella spp 31.0%, Pseudomonas spp 20.7%, Staphylococcus aureus 17.2%, Escherichia coli 12.1%, Staphylococcus epidermidis 3.4%, Streptococcus pneumoniae 1.7% and Serratia spp 1.7%. All the enterococci isolates were multiply antibiotic resistant, and 42.9% were vancomycin‐resistant enterococci (VRE) with the VRE strains showing resistance to wider range of antibiotics than the vancomycin‐sensitive strains. Other Gram‐positive and Gram negative bacterial isolates also demonstrated multiple resistance to all commonly available antibiotics in this community except E. coli and Pseudomonas spp which were relatively sensitive to ciprofloxacin and ceftazidime. This limited study demonstrated a high prevalence rate of multiple antibiotic resistant enterococci infections among hospitalized patients in this environment. There is need for systematic surveillance of hospitals for enterococci infections; prudent use and rational prescription of antibiotics and stringent measures to reduce the prevalence rate by health education on infection control measures such asisolation, cleaning, disinfection and sterilization.Keywords: Nosocomial, Prevalence, Enterococcus, Vancomycin‐Resistance, Primary Car

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

PENICILLIN–RESISTANT STREPTOCOCCUS PNEUMONIAE – A REVIEW

Since the first report in 1967, the incidence of Penicillin Resistant Streptococcus pneumoniae (Pneumococcus) has risen steadily worldwide, and now complicates diagnostic and treatment strategies for infections due to this organism. More worrisome is the fact that in areas where Penicillin Resistant Streptococcus pneumoniae (PRSP) has become established, resistance to other antimicrobial agents such as cephalosporins, sulphonamides and macrolides is also common. This development has a grave implication for therapy of life threatening pneumococcal infections like meningitis and septicaemia, with the extended spectrum cephalosporins, such as ceftriaxone and cefotaxime, and the newer macrolides, azithromycin and clarithromycin. The mechanism of resistance to &beta;-lactam antibiotics is decreased binding of drug to the bacteria cell wall brought about by genetic transformation in bacterial chromosome. Recently, using molecular techniques that can index overall relatedness of the drug resistant pneumococcal isolates, it has been possible to establish clonal dissemination of drug resistant pneumococci across continents, with acquisition of additional drug resistance determinants as a result of “local” antibiotic selective pressures. This is a review of literature on the epidemiology, mechanism of resistance, laboratory identification, treatment, prevention and control of Penicillin Resistant Pneumococci (PRP), with emphasis on the problems of identification and reporting in developing countries. Key Words: penicillin, Streptococcus pneumoniae, resistant, extended spectrum cephalosporins. African Journal Of Clinical And Experimental Microbiology Jan 2004 Vol.5 No.1 78-10

Review Article: Recent Advances in the Laboratory Diagnosis of Malaria

Malaria is a global health problem with about 2-4 billion people at risk, about 200-300 million cases occurring annually resulting in about 1 million deaths, 90% of which occur in the sub-Saharan Africa. Prompt and accurate diagnosis is the key to effective disease management, one of the main interventions of the Global Malaria Control Strategy. The “gold standard” test for the diagnosis of malaria, blood film microscopy, has in recent times come under some criticism. Apart from being cumbersome and time consuming, the reliability of the test depends on the competence of the microscopist and the test is not sensitive when parasitaemia is less than 100 parasites/µL of blood, a situation usually seen in non-immune subjects. Several new innovative malaria diagnostic tests called Rapid Diagnostic Tests (RDT) have been developed to circumvent these limitations. The application of these new techniques in clinical laboratories is limited by cost, variable sensitivities, spill-over antigenaemia and false positive reactions in some cases. Although the polymerase chain reaction (PCR) assays for malaria diagnosis is extremely sensitive and specific, and has been suggested to replace blood film microscopy as the “gold standard”, the long time, high cost and technical expertise required is limiting the usefulness of these techniques, especially in Africa. This communication provides information on the available malaria diagnostics and the recent advances in the laboratory diagnosis of malaria. Key words: Recent advances, malaria diagnostics Afr. J. Clin. Exper. Microbiol. 2005; 6(2): 113-12