Carbapenem-resistant Enterobacteriaceae in patients with bacteraemia at tertiary hospitals in South Africa, 2015 to 2018.

Enhanced surveillance for CREs was established at national sentinel sites in South Africa. We aimed to apply an epidemiological and microbiological approach to characterise CREs and to assess trends in antimicrobial resistance from patients admitted to tertiary academic hospitals. A retrospective analysis was conducted on patients of all ages with CRE bacteraemia admitted at any one of 12 tertiary academic hospitals in four provinces (Gauteng, KwaZulu-Natal, Western Cape and Free State) in South Africa. The study period was from July 2015 to December 2018. A case of CRE bacteraemia was defined as a patient admitted to one of the selected tertiary hospitals where any of the Enterobacteriaceae was isolated from a blood culture, and was resistant to the carbapenems (ertapenem, meropenem, imipenem and/or doripenem) or had a positive result for the Modified Hodge Test (MHT) according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. A positive blood culture result obtained after 21 days of the last blood culture result was regarded as a new case. To distinguish hospital-acquired (HA) from the community-acquired (CA) bacteraemia, the following definitions were applied: the HA CRE bacteraemia was defined as a patient with CRE isolated from blood culture ≥ 72 h of hospital admission or with any prior healthcare contact, within 1 year prior to the current episode or referral from a healthcare facility where the patient was admitted before the current hospital. A case of the CA CRE bacteraemia was defined as a patient with CRE isolated from blood culture < 72 h of hospital admission and with no prior healthcare contact. The majority of carbapenem-resistant Enterobacteriaceae (CRE) (70%) were hospital-acquired (HA) with Klebsiella pneumoniae being the predominant species (78%). In-hospital mortality rate was 38%. The commonest carbapenemase genes were bla-OXA-48 (52%) and bla-NDM (34%). The high mortality rate related to bacteraemia with CRE and the fact that most were hospital-acquired infections highlights the need to control the spread of these drug-resistant bacteria. Replacement with OXA-48 is the striking finding from this surveillance analysis. Infection control and antibiotic stewardship play important roles in decreasing the spread of resistance.

Complications after Dynamic Hip Screw Osteosynthesis of Proximal Femoral Fractures at Army Instructional Hospital-Libreville.

The DHS system is an effective means of open reduction and internal fixation of proximal femur fractures. Postoperative complications are little described and deserve to be studied for better preventive and curative treatment. We report the observations of five (5) patients who presented postoperative complications specific to the DHS system at army instructional Hospital-Libreville. These described complications are related to deterioration of internal fixation leading to callus, nonunion, or infection. Those found are the cut out phenomenon, avascular necrosis of the femoral head, and the fracture of the DHS system. All these complications required surgical revision without functional repercussions at the last follow-up. Complications of internal fixation by the DHS system can be avoided by rigorous asepsis, adequate indications for surgery, and rigorous surgical techniques. Good management can restore hip function.

Fracture-avulsion of tibial tubercle apophyseal in two Cameroonian adolescents.

INTRODUCTION: Avulsion-fractures of the tibial tubercle apophysis are a rare lesion of active adolescent. They are relatively uncommon injuries that occur in the active adolescent. We described cases of tibial tubercle apophysis avulsion-fractures in two Cameroonian adolescents. CASES: We observed 2 cases which occurred in boys after contraction of the quadriceps during sports activity (high jump and football). The lesions were classified as Type IV by Ryu and Debenham (case 1) and type IA by Ogden (Case 2). The treatment was surgical by double screwing (case 1) and orthopedic by plaster knee brace (Case 2). The functional result was excellent without complications. DISCUSSION: Non-displaced fracture of the anterior tibial tubercle I type IA Ogden has good prognosis and responding very well to non-surgical treatment. It should be considered as a separate entity. The other cases of displaced fracture generally require surgery which enables an assessment of often associated lesions. Type IV can required supplemental plate fixation to stabilize the proximal tibia. The prognosis of displaced fractures is poor due to the associated lesions and potential complications. Functional results are excellent despite a few cases of previous pain limiting sports activity. CONCLUSION: Avulsion fractures of the anterior tuberosity in adolescents remain rare in Africa and worldwide. The circumstances of the occurrence are stereotypical. If treated properly, the outcome is usually good.

Microencapsulation in genipin cross-linked gelatine-maltodextrin improves survival of Bifidobacterium adolescentis during exposure to in vitro gastrointestinal conditions.

To improve survival during exposure to adverse conditions, probiotic Bifidobacterium adolescentis 15703T cells were encapsulated in novel mono-core and multi-core phase-separated gelatine-maltodextrin (GMD) microspheres where the gelatine (G) phase was cross-linked with genipin (GP). Microscopy showed that encapsulated cells were exclusively associated with maltodextrin (MD) core(s). Small (average diameter 37 microm) and large (70 microm) GMD and G microspheres were produced by modulating factors (e.g. mixing speed, surfactant, GP and G concentrations) affecting the size, structural stability and phase-separation. In vitro sequential gastro-intestinal (GI) juice challenge experiments revealed increased survival of cells encapsulated in GMD ( approximately 10(6-7) cfu mL(-1)) and G (approximately 10(5) cfu mL(-1)) microspheres as compared to free cells (approximately 10(4) cfu mL(-1)). In GMD microspheres, the bacteria derive energy from MD to survive during exposure to acid and bile salts. In conclusion, the novel food grade GMD microencapsulation formulation was shown to protect probiotic bifidobacteria from adverse conditions.

Volatile compounds profile and sensory evaluation of Beninese condiments produced by inocula of Bacillus subtilis.

BACKGROUND: Three Beninese food condiments (ABS1(24h), IBS2(48h) and SBS3(48h)) were produced by controlled fermentation of African locust beans using inocula of pure cultures of Bacillus subtilis, BS1, BS2 and BS3, respectively. Quantitative and qualitative assessments of the volatile compounds in the condiments produced have been performed using the Likens-Nickerson simultaneous distillation-extraction method and GC-MS analysis, followed by a sensory evaluation in comparison with the spontaneously fermented condiments. RESULTS: A total of 94 volatile compounds have been found including 53 compounds identified in relatively high concentrations and were subdivided into seven main groups with the predominance of four major groups: pyrazines, aldehydes, ketones and alcohols. Compared to the spontaneously fermented condiments, volatile compounds identified in controlled fermented condiments have been found in high number and in concentrations which varied according to the inoculum of B. subtilis used. The condiments produced with starter cultures scored significantly (P < 0.05) higher for odour than the spontaneously fermented condiments. But the overall acceptability (7/10) of the two types of condiments was similar. CONCLUSION: The investigated B. subtilis, BS1, BS2 and BS3 can be considered as potential starter cultures for the fermentation of African locust beans to produce good quality of Beninese food condiments.

The impact of diagnostic methods on the diagnosis of Clostridiodes difficile infection.

BACKGROUND: Clostridiodes difficile is a common cause of healthcare-associated diarrhoea. Laboratory testing for C. difficile infection (CDI) remains an area of confusion, as there is not a single accepted reference standard or a single best test. OBJECTIVES: To analyse the impact of different diagnostic methods on reported CDI rates. In addition, CDI incidence rates at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Johannesburg, South Africa, were determined. METHODS: Results of stool samples submitted for C. difficile testing at CMJAH from 1 January 2014 to 31 August 2017 were reviewed. From January 2014 to July 2016, samples were tested by polymerase chain reaction (PCR) or toxin immunoassay, and from August 2016 to August 2017, algorithm-based testing (glutamate dehydrogenase and toxin immunoassay followed by PCR) was performed. RESULTS: A total of 4 829 samples were submitted. For the first period, toxin immunoassay and PCR showed a positivity rate of 11.4% and 21.1%, respectively, with an overall positivity rate of 18.7% (95% confidence interval (CI) 15.6 - 21.9). For the second period, the positivity rate was 15.9% (95% CI 11.3 - 17.7). This rate included samples that were GDH-positive and either showed toxin production or had a positive Xpert result. The CDI incidence for the two periods was different, with an incidence rate of 8.8 and 6.1 per 10 000 patient-days for the first and second periods, respectively. CONCLUSIONS: The choice of laboratory testing method has a major impact on the diagnosis of CDI, and therefore on reported rates of CDI. Standardisation of laboratory testing and incidence rate reporting is required in order to obtain robust and reliable data.

Analysis and comparison of cumulative antibiograms for the Charlotte Maxeke Johannesburg Academic Hospital adult intensive care and high-care units, 2013 and 2017.

BACKGROUND: Infection is a common complication for patients in intensive care units (ICUs), and increasing antimicrobial resistance (AMR) is a major concern. It is therefore crucial to monitor AMR patterns in order to support clinical decision-making and antimicrobial stewardship strategies. Clinical microbiologists should provide annual cumulative antibiogram reports, which can be used to guide initial empirical antimicrobial therapy for the management of infections. OBJECTIVES: To analyse the cumulative antibiograms for the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) combined adult multidisciplinary ICU and high-care unit (HCU) for 2013 and 2017, compare the antimicrobial susceptibility testing (AST) patterns between the 2 years, and analyse the subset of blood culture isolates. METHODS: A retrospective descriptive analysis was performed of routine bacterial and fungal culture and AST data extracted from the National Health Laboratory Service laboratory information system for the ICU/HCU. Only the first diagnostic isolate of a given species per patient per year was included in the analysis. All analysis and reporting were done in accordance with the applicable Clinical and Laboratory Standards Institute guidelines. RESULTS: Enterobacteriaceae predominated in first-isolate cultures in 2013 (60%) and 2017 (56%). There was an overall decrease in extended-spectrum beta-lactamase-producing Enterobacteriaceae from 2013 (42%) to 2017 (30%) (p=0.013), accompanied by an increase in carbapenem-resistant Enterobacteriaceae from 2013 (4%) to 2017 (11%) (p=0.24). Although the total percentage of Acinetobacter spp. decreased in 2017 (p=0.021), the proportion of extensively drug-resistant isolates doubled to 68% in 2017 (p<0.001). The percentage of methicillin-resistant Staphylococcus aureus decreased significantly from 49% to 14% (p<0.001), along with a significant decrease in vancomycin-resistant enterococci from 17% to 0% (p=0.001). Candida auris increased from 0% in 2013 to 11% in 2017 (p=0.002), and non-albicans Candida spp. predominated (80%) in blood cultures in 2017 (p=0.023). CONCLUSIONS: Appropriate selection of empirical antimicrobial therapy should be guided by the ICU-specific antibiogram. The recommended empirical antimicrobial therapy at the CMJAH ICU/HCU based on the antibiogram analysis would include ertapenem to cover the Enterobacteriaceae. Amikacin is recommended for empirical treatment of suspected pseudomonal infections. Additional empirical antimicrobial therapy for Gram-positive organisms is not routinely advocated, and empirical antifungal therapy with amphotericin B or micafungin is only appropriate in patients at high risk for invasive candidiasis.

Availability and prescription of misoprostol for medical abortion in community pharmacies and associated factors in Accra, Ghana.

OBJECTIVE: To assess misoprostol availability at community pharmacies and determine factors affecting misoprostol prescription for medical abortion. METHODS: A cross-sectional quantitative survey of randomly sampled community pharmacies and their corresponding pharmacists/pharmacy workers was conducted in the city of Accra, Ghana. Structured questionnaires were administered to collect data between May 1 and July 28, 2016. Descriptive statistics (frequencies and proportions) and bivariate and logistic regression analysis were used to analyze the data. RESULTS: Of the 165 community pharmacies surveyed, approximately half (83 [50.3%]) stocked misoprostol. Availability of misoprostol however decreased when moving from first class to third class residential areas. 44 (26.7%) of the respondents had prescribed the drug at some time for medical abortion, but 140 (84.6%) indicated they would not prescribe the drug for medical abortion in future. Factors that significantly predicted misoprostol prescription for medical abortion included sex of the pharmacist/pharmacy worker, demand, and availability of misoprostol. CONCLUSIONS: Demand for misoprostol for medical abortion was found to be high but only half of community pharmacies stocked it, and most pharmacy workers did not wish to prescribe the drug. If community pharmacies are to effectively contribute to expanding access to safe abortion services in Ghana, the disparity between misoprostol provision and demand needs to be addressed.

Development and quality characteristics of shelf-stable soy-agushie: a residual by-product of soymilk production.

A process was developed for the production of a high-protein food ingredient, soy-agushie, from the residual by-product of soymilk production. The product, with a moisture content of about 6%, was evaluated for its quality characteristics and performance in traditional dishes. The protein content was about 26% with similar amino acids content as that of the whole soybean. Lysine remained high in the dehydrated product (6.57 g/16 g N). While over 60% of the original B vitamins content in the beans was extracted with the milk, high proportions of the minerals were found to be retained in the residual by-product. The process adequately reduced the trypsin inhibitor levels in the beans from 25 to 1.5 mg/g. High sensory scores were obtained for recipes developed with soy-agushie in traditional dishes. The scope of utilization of the soy-agushie could be widened to include several traditional foods and bakery products for maximum nutritional benefits.

Attitudes towards smoking restrictions and tobacco advertisement bans in Georgia.

OBJECTIVES: This study aims to provide data on a public level of support for restricting smoking in public places and banning tobacco advertisements. DESIGN: A nationally representative multistage sampling design, with sampling strata defined by region (sampling quotas proportional to size) and substrata defined by urban/rural and mountainous/lowland settlement, within which census enumeration districts were randomly sampled, within which households were randomly sampled, within which a randomly selected respondent was interviewed. SETTING: The country of Georgia, population 4.7 million, located in the Caucasus region of Eurasia. PARTICIPANTS: One household member aged between 13 and 70 was selected as interviewee. In households with more than one age-eligible person, selection was carried out at random. Of 1588 persons selected, 14 refused to participate and interviews were conducted with 915 women and 659 men. OUTCOME MEASURES: Respondents were interviewed about their level of agreement with eight possible smoking restrictions/bans, used to calculate a single dichotomous (agree/do not agree) opinion indicator. The level of agreement with restrictions was analysed in bivariate and multivariate analyses by age, gender, education, income and tobacco use status. RESULTS: Overall, 84.9% of respondents indicated support for smoking restrictions and tobacco advertisement bans. In all demographic segments, including tobacco users, the majority of respondents indicated agreement with restrictions, ranging from a low of 51% in the 13-25 age group to a high of 98% in the 56-70 age group. Logistic regression with all demographic variables entered showed that agreement with restrictions was higher with age, and was significantly higher among never smokers as compared to daily smokers. CONCLUSIONS: Georgian public opinion is normatively supportive of more stringent tobacco-control measures in the form of smoking restrictions and tobacco advertisement bans.

NDM-1 has arrived: first report of a carbapenem resistance mechanism in South Africa.

The New Delhi Metallo-ß-lactamase (NDM) resistance mechanism in Enterobacteriaceae threatens to render serious Gram-negative infections untreatable. The NDM-1 enzyme hydrolyses all available penicillin, cephalosporin and carbapenem antibiotics, and is commonly accompanied by additional resistance mechanisms to multiple antibiotic classes. Initially identified as a significant healthcare risk on the Indian sub-continent, it has rapidly become a global problem, posing significant diagnostic and management challenges. Here we report the first laboratory-confirmed case of NDM-1 in South Africa.