A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery.

BACKGROUND: Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries. METHODS: We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the presence of one of these features and the clinically identified need to administer antibiotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics. RESULTS: We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to original strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events. CONCLUSIONS: Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.).

Infection Prevention and Control at Lira University Hospital, Uganda: More Needs to Be Done.

Globally, 5-15% of hospitalized patients acquire infections (often caused by antimicrobial-resistant microbes) due to inadequate infection prevention and control (IPC) measures. We used the World Health Organization's (WHO) 'Infection Prevention and Control Assessment Framework' (IPCAF) tool to assess the IPC compliance at Lira University hospital (LUH), a teaching hospital in Uganda. We also characterized challenges in completing the tool. This was a hospital-based, cross-sectional study conducted in November 2020. The IPC focal person at LUH completed the WHO IPCAF tool. Responses were validated, scored, and interpreted per WHO guidelines. The overall IPC compliance score at LUH was 225/800 (28.5%), implying a basic IPC compliance level. There was no IPC committee, no IPC team, and no budgets. Training was rarely or never conducted. There was no surveillance system and no monitoring/audit of IPC activities. Bed capacity, water, electricity, and disposal of hospital waste were adequate. Disposables and personal protective equipment were not available in appropriate quantities. Major challenges in completing the IPCAF tool were related to the detailed questions requiring repeated consultation with other hospital stakeholders and the long time it took to complete the tool. IPC compliance at LUH was not optimal. The gaps identified need to be addressed urgently.

Staged implementation of a two-tiered hospital-based neonatal care package in a resource-limited setting in Eastern Uganda.

Neonatal mortality remains a major global challenge. Most neonatal deaths occur in low-income countries, but it is estimated that over two-thirds of these deaths could be prevented if achievable interventions are scaled up. To date, initiatives have focused on community and obstetric interventions, and there has been limited simultaneous drive to improve neonatal care in the health facilities where the sick neonates are being referred. Few data exist on the process of implementing of neonatal care packages and their impact. Evidence-based guidelines for neonatal care in health facilities in low-resource settings and direction on how to achieve these standards of neonatal care are therefore urgently needed. We used the WHO-Recommended Quality of Care Framework to build a strategy for quality improvement of neonatal care in a busy government hospital in Eastern Uganda. Twelve key interventions were designed to improve infrastructure, equipment, protocols and training to provide two levels of neonatal care. We implemented this low-cost, hospital-based neonatal care package over an 18-month period. This data-driven analysis paper illustrates how simple changes in practice, provision of basic equipment and protocols, ongoing training and dedicated neonatal staff can reduce neonatal mortality substantially even without specialist equipment. Neonatal mortality decreased from 48% to 40% (P=0.25) after level 1 care was implemented and dropped further to 21% (P<0.01) with level 2 care. In our experience, a dramatic impact on neonatal mortality can be made through modest and cost-effective interventions. We recommend that stakeholders seeking to improve neonatal care in low-resource settings adopt a similar approach.

Spontaneous rupture of bladder in puerperium.

Spontaneous rupture of bladder and extravasation of urine in the peritoneum without evidence of trauma is rare. This condition is an emergency. It presents in a unique way therefore, the diagnosis and treatment is usually delayed. This patient presented with an acute abdominal pain and oliguria. She had delivered normally eight days before re-admission. Investigations were done and an exploratory laparotomy was performed. There was a tear in the fundus of the bladder and the peritoneal cavity contained urine. Peritoneal lavage was done and the bladder was repaired in layers. She was put on continuous bladder drainage for three weeks followed by bladder training. The bladder resumed its normal function. Early diagnosis and appropriate management decreases the morbidity and mortality associated with this condition.