Exploring barriers to guideline implementation for prescription of surgical antibiotic prophylaxis in Nigeria.

Background: In Nigeria, the prescription of surgical antibiotic prophylaxis for prevention of surgical site infection tends to be driven by local policy rather than by published guidelines (e.g. WHO and Sanford). Objectives: To triangulate three datasets and understand key barriers to implementation using a behavioural science framework. Methods: Surgeons (N = 94) from three teaching hospitals in Nigeria participated in an online survey and in focus group discussions about barriers to implementation. The theoretical domains framework (TDF) was used to structure question items and interview schedules. A subgroup (N = 20) piloted a gamified decision support app over the course of 6 months and reported barriers at the point of care. Results: Knowledge of guidelines and intention to implement them in practice was high. Key barriers to implementation were related to environmental context and resources and concern over potential consequences of implementing recommendations within the Nigerian context applicable for similar settings in low-to-middle-income countries. Conclusions: The environmental context and limited resource setting of Nigerian hospitals currently presents a significant barrier to implementation of WHO and Sanford guidelines. Research and data collected from the local context must directly inform the writing of future international guidelines to increase rates of implementation.

Reverse gastric tube oesophageal substitution for staged repair of oesophageal atresia and tracheo-oesophageal fistula.

The management of oesophageal atresia and tracheo-oesophageal atresia (OATOF) is very challenging. While in developed countries survival of patients with this condition has improved, the outcome in many developing countries has been poor. Primary repair through a thoracotomy (or video-assisted thoracoscopic surgery where available) is the gold standard treatment of OATOF. However, in our setting where patients typically present late and with minimum support resources such as Neonatal Intensive Care Unit and total parenteral nutrition; staged repair may be the only hope of survival of these patients and this communication highlights the essential steps of this mode of treatment.

Outcome of late presentation of posterior urethral valves in a resource-limited economy: challenges in management.

Delayed presentation of patients with posterior urethral valve with complications like severe urosepsis, uremia, and anemia are seen in our setting. Renal replacement therapy which should have been offered to these patients is not readily available for children in our country. The aim of this study is to determine the pattern of late presentation and outcome of management of posterior urethral valve in a resource-limited setting. A descriptive retrospective study (1997-2009) was conducted. Data including pattern of presentation, duration of symptoms, complications, and outcome of initial management were analyzed. Twenty-one patients were seen. The median age was 3 years (2 days-13 years). The mean duration of symptoms before presentation was 2.6 years. Nineteen patients (91%) presented with urosepsis while 8 patients (36%) presented with significant renal insufficiency. Laboratory findings varied from-mild-to marked elevation in serum creatinine. Radiological findings confirmed the diagnosis of posterior urethral valve. We concluded that late presentation is common in our setting. This is associated with high morbidity and mortality rates. Efforts at improving awareness and early diagnosis among the health team should be made to stem the tide.