Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda.

INTRODUCTION: In low-income and middle-income countries, there is a high demand for surgical care, although many individuals lack access due to its affordability, availability, and accessibility. Costs are an important metric in healthcare and can influence healthcare access and outcomes. The aim of this study was to determine the financial impact of infections in acute care surgery patients and factors associated with inability to pay the hospital bill at a Rwandan referral hospital. MATERIALS AND METHODS: This was a prospective observational study of acute care surgery patients at a tertiary referral hospital in Rwanda with infections. Data were collected on demographics, clinical features, hospital charges, and expenses. Factors associated with inability to pay the hospital bill were analyzed using Chi-squared and Wilcoxon rank sum tests. RESULTS: Over 14 mo, 191 acute care surgery patients with infections were enrolled. Most (n = 174, 91%) patients had health insurance. Median total hospital charges were 414.24 United States Dollars (interquartile range [IQR]: 268.20, 797.48) and median patient charges were 41.53 USD (IQR: 17.15, 103.09). At discharge, 53 (28%) patients were unable to pay their hospital bill. On a univariate analysis actors associated with inability to pay the bill included transportation via ambulance, occupation as a farmer, diagnosis, complications, surgical site infection, and length of hospital stay. On a multivariable analysis, intestinal obstruction (adjusted odds ratio 4.56, 95% confidence interval 1.16, 17.95, P value 0.030) and length of hospital stay more than 7 d (adjusted odds ratio 2.95, 95% confidence interval 1.04, 8.34, P value 0.042) were associated with inability to pay the final hospital bill. CONCLUSIONS: Although there is broad availability of health insurance in Rwanda, hospital charges and other expenses remain a financial burden for many patients seeking surgical care. Further innovative efforts are needed to mitigate expenses and minimize financial risk.

Community- and Hospital-Acquired Infections in Surgical patients at a Tertiary Referral Hospital in Rwanda.

BACKGROUND: Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasing in globally. The aim of this study was to compare community-acquired infections (CAIs) and hospital-acquired infections (HAIs) and determine the rate of third-generation cephalosporin resistance and ESBL-PE at a tertiary referral hospital in Rwanda. METHODS: This was a cross-sectional study of Rwandan acute care surgery patients with infection. Samples were processed for culture and susceptibility patterns using Kirby-Bauer disk diffusion method. Third-generation cephalosporin resistance and ESBL-PE were compared in patients with CAI versus HAI. RESULTS: Over 14 months, 220 samples were collected from 191 patients: 116 (62%) patients had CAI, 59 (32%) had HAI, and 12 (6%) had both CAI and HAI. Most (n = 178, 94%) patients were started on antibiotics with third-generation cephalosporins (ceftriaxone n = 109, 57%; cefotaxime n = 52, 27%) and metronidazole (n = 155, 81%) commonly given. Commonly isolated organisms included Escherichia coli (n = 62, 42%), Staphylococcus aureus (n = 27, 18%), and Klebsiella spp. (n = 22, 15%). Overall, 67 of 113 isolates tested had resistance to third-generation cephalosporins, with higher resistance seen in HAI compared with CAI (74% vs 46%, p value = 0.002). Overall, 47 of 89 (53%) isolates were ESBL-PE with higher rates in HAI compared with CAI (73% vs 38%, p value = 0.001). CONCLUSIONS: There is broad and prolonged use of third-generation cephalosporins despite high resistance rates. ESBL-PE are high in Rwandan surgical patients with higher rates in HAI compared with CAIs. Infection prevention practices and antibiotic stewardship are critical to reduce infection rates with resistant organisms in a low-resource setting.

Development of an acute care surgery service in Rwanda.

BACKGROUND: Acute care surgery (ACS) encompasses trauma, critical care, and emergency general surgery. Due to high volumes of emergency surgery, an ACS service was developed at a referral hospital in Rwanda. The aim of this study was to evaluate the epidemiology of ACS and understand the impact of an ACS service on patient outcomes. METHODS: This is a retrospective observational study of ACS patients before and after introduction of an ACS service. χ2 test and Wilcoxon rank-sum test were used to describe the epidemiology and compare outcomes before (pre-ACS)) and after (post-ACS) implementation of the ACS service. RESULTS: Data were available for 120 patients before ACS and 102 patients after ACS. Diagnoses included: intestinal obstruction (n=80, 36%), trauma (n=38, 17%), appendicitis (n=31, 14%), and soft tissue infection (n=17, 8%) with no difference between groups. The most common operation was midline laparotomy (n=138, 62%) with no difference between groups (p=0.910). High American Society of Anesthesiologists (ASA) score (ASA ≥3) (11% vs. 40%, p<0.001) was more common after ACS. There was no difference in intensive care unit admission (8% vs. 8%, p=0.894), unplanned reoperation (22% vs. 13%, p=0.082), or mortality (10% vs. 11%, p=0.848). The median length of hospital stay was longer (11 days vs. 7 days, p<0.001) before ACS. CONCLUSIONS: An ACS service can be implemented in a low-resource setting. In Rwanda, ACS patients are young with few comorbidities, but high rates of mortality and morbidity. In spite of more patients who are critically ill in the post-ACS period, implementation of an ACS service resulted in decreased length of hospital stay with no difference in morbidity and mortality. LEVEL OF EVIDENCE: Prognostic and epidemiologic study type, level III.