Incidence and predictors of infection in patients undergoing primary isolated coronary artery bypass grafting: a report from a tertiary care hospital in a developing country.

AIM: Infection following coronary artery bypass grafting (CABG) is a leading cause of morbidity, mortality, and increased length of hospital stay. Many studies have investigated the predictive value of known risk factors for infection in patients following CABG and conclusions have been variable and may reveal regional or institution-specific influence. The purpose of this prospective study was to determine the pre- and peri-operative risk factors for infection in patients undergoing coronary artery bypass surgery in a developing country. METHODS: A prospective study was undertaken to collect data on 12 reported risk factors for all patients undergoing CABG during a five-year period at The Aga Khan University Hospital, Pakistan. The relationship of these risk factors to infection following CABG was evaluated. RESULTS: Out of 767 consecutive patients admitted for CABG, a total of 73 (9.51%) developed 92 infections following surgery. Sternal Surgical Site Infection (SSI) developed in 30 patients (3.91%), of which 29 (96.7%) were superficial and 1 (3.33%) was deep. There were 37 leg wound infections at the site of conduit harvest, and 2 cases of infection at the intra-aortic balloon pump. There were 12 cases of sepsis and 11 urinary tract infections. There were 26 cases (35.6%) of leukocytosis and 17 patients (23.3%) showed elevated erythrocyte sedimentation rate (ESR). Staphylococcus aureus was the most frequently isolated pathogen (39.7%). Bacteremia data was not collected. Of the total cases of infection following CABG, 59 required prolonged hospitalization or readmission. Univariate analysis was performed using a p-value of <0.2 as the inclusion criteria for further analysis using logistic regression. Multivariate analysis with adjusted Relative Risk (RR) showed that diabetes (P=0.002, RR=2.3, 95% CI=1.4-4.0), obesity (P=0.036, RR=2.2, 95% CI=1.0-4.4), use of an intra-aortic balloon pump (P=0.001, RR=3.6, 95% CI=1.7-7.7), female gender (P=0.004, RR=2.5, 95% CI=0.2-0.8) and prolonged mechanical ventilation (P=<0.0001, RR=6.7, 95% CI=2.8-15.5) were independent predictors of infection in the study population. CONCLUSION: This study suggests that diabetes, obesity, use of an intra-aortic balloon pump and female gender are independent predictors of infection in patients undergoing CABG. Early and strict diabetic control and pre-operative weight reduction may reduce the incidence of infection following CABG. Contamination of these patients may occur before, during and after the operation and efforts to curb such contamination must be intensive. Further prospective studies need to be undertaken to identify and establish these and other risk factors for infection in the region and elsewhere.

Managing hypertension in rural Uganda: Realities and strategies 10 years of experience at a district hospital chronic disease clinic.

The literature on the global burden of noncommunicable diseases (NCDs) contrasts a spiraling epidemic centered in low-income countries with low levels of awareness, risk factor control, infrastructure, personnel and funding. There are few data-based reports of broad and interconnected strategies to address these challenges where they hit hardest. Kisoro district in Southwest Uganda is rural, remote, over-populated and poor, the majority of its population working as subsistence farmers. This paper describes the 10-year experience of a tri-partite collaboration between Kisoro District Hospital, a New York teaching hospital, and a US-based NGO delivering hypertension services to the district. Using data from patient and pharmacy registers and a random sample of charts reviewed manually, we describe both common and often-overlooked barriers to quality care (clinic overcrowding, drug stockouts, provider shortages, visit non-adherence, and uninformative medical records) and strategies adopted to address these barriers (locally-adapted treatment guidelines, patient-clinic-pharmacy cost sharing, appointment systems, workforce development, patient-provider continuity initiatives, and ongoing data monitoring). We find that: 1) although following CVD risk-based treatment guidelines could safely allocate scarce medications to the highest-risk patients first, national guidelines emphasizing treatment at blood pressures over 140/90 mmHg ignore the reality of "stockouts" and conflict with this goal; 2) often-overlooked barriers to quality care such as poor quality medical records, clinic disorganization and local employment practices are surmountable; 3) cost-sharing initiatives partially fill the gap during stockouts of government supplied medications, but still may be insufficient for the poorest patients; 4) frequent prolonged lapses in care may be the norm for most known hypertensives in rural SSA, and 5) ongoing data monitoring can identify local barriers to quality care and provide the impetus to ameliorate them. We anticipate that our 10-year experience adapting to the complex challenges of hypertension management and a granular description of the solutions we devised will be of benefit to others managing chronic disease in similar rural African communities.