Methicillin-resistant Staphylococcus aureus (MRSA) in East Africa: red alert or red herring?

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is associated with significant morbidity and mortality and has resultant important economic and societal costs underscoring the need for accurate surveillance. In recent years, prevalence rates reported in East Africa have been inconsistent, sparking controversy and raising concern. METHODS: We described antimicrobial susceptibility patterns of Staphylococcus aureus isolates cultured from patients within the Internal Medicine department of the largest public healthcare facility in East and Central Africa- the Kenyatta National Hospital (KNH) in Nairobi, Kenya. Routine antimicrobial susceptibility data from non-duplicate Staphylococcus aureus isolates cultured between the years 2014-2016 from the medical wards in KNH were reviewed. RESULTS: Antimicrobial susceptibility data from a total of 187 Staphylococcus aureus isolates revealed an overall MRSA prevalence of 53.4%. Isolates remained highly susceptible to linezolid, tigecycline, teicoplanin and vancomycin. CONCLUSIONS: The prevalence of MRSA was found to be much higher than that reported in private tertiary facilities in the same region. Careful interrogation of antimicrobial susceptibility results is important to uproot any red herrings and reserve genuine cause for alarm, as this has a critical bearing on health and economic outcomes for a population.

Understanding and comparing the medical tourism cancer patient with the locally managed patient: A case control study.

INTRODUCTION: Medical tourism is characterized by people seeking treatment abroad for various medical conditions due to varied reasons, many of whom benefit from specialized care for non-communicable diseases. Conversely, there are associated negative effects such as medical complications and weakened health systems. Currently, there is paucity of scientific evidence on patient-related factors influencing seeking treatment benefits abroad. This study sought to compare patient-related factors associated with choice of cancer treatment center locally or abroad, to understand reasons for seeking treatment outside Kenya. MATERIALS AND METHODS: As a case-control study, 254 cancer patients were randomly sampled to compare responses from those who chose to receive initial treatment abroad or in Kenya. The cases were recruited from Ministry of Health while the controls from Kenyatta National Hospital and Texas Cancer Center. Data was analyzed using SPSS Software Version 21. Descriptive statistics, bivariate and multiple logistic regression analysis was carried out. Level of significance was set at 5%. RESULTS: Out of 254 respondents, 174 (69.5%) were treated for cancer in Kenya and 80 (31.5%) in India. We found that cost effectiveness was a significant factor for over 73% of all respondents. The study revealed independent predictors for seeking treatment in India were: monthly income higher than US$ 250; every additional month from when disclosure to patients was done increased likelihood by 1.16 times; physician advice (Odds Ratio(OR) 66; 95% Confidence Interval(CI) 7.9-552.9); friends and family (OR 42; 95% CI 7.07-248.6); and perception of better quality of care (OR 22.5; 95% CI 2.2-230.6). CONCLUSION: Reasons patients with cancer sought treatment in India are multifactorial. Several of these can be addressed to reverse out-ward bound medical tourism and contribute to improving the in-country cancer healthcare. It will require strengthening the health system accordingly and sensitizing the medical fraternity and general public on the same.

Epidemiological and clinical characteristics of patients hospitalised with COVID-19 in Kenya: a multicentre cohort study.

OBJECTIVES: To assess outcomes of patients admitted to hospital with COVID-19 and to determine the predictors of mortality. SETTING: This study was conducted in six facilities, which included both government and privately run secondary and tertiary level facilities in the central and coastal regions of Kenya. PARTICIPANTS: We enrolled 787 reverse transcriptase-PCR-confirmed SARS-CoV2-infected persons. Patients whose records could not be accessed were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was COVID-19-related death. We used Cox proportional hazards regressions to determine factors related to in-hospital mortality. RESULTS: Data from patients with 787 COVID-19 were available. The median age was 43 years (IQR 30-53), with 505 (64%) being men. At admission, 455 (58%) were symptomatic with an additional 63 (9%) developing clinical symptoms during hospitalisation. The most common symptoms were cough (337, 43%), loss of taste or smell (279, 35%) and fever (126, 16%). Comorbidities were reported in 340 (43%), with cardiovascular disease, diabetes and HIV documented in 130 (17%), 116 (15%), 53 (7%), respectively. 90 (11%) were admitted to the Intensive Care Unit (ICU) for a mean of 11 days, 52 (7%) were ventilated with a mean of 10 days, 107 (14%) died. The risk of death increased with age (HR 1.57 (95% CI 1.13 to 2.19)) for persons >60 years compared with those <60 years old; having comorbidities (HR 2.34 (1.68 to 3.25)) and among men (HR 1.76 (1.27 to 2.44)) compared with women. Elevated white cell count and aspartate aminotransferase were associated with higher risk of death. CONCLUSIONS: The risk of death from COVID-19 is high among older patients, those with comorbidities and among men. Clinical parameters including patient clinical signs, haematology and liver function tests were associated with risk of death and may guide stratification of high-risk patients.

Bridging antimicrobial resistance knowledge gaps: The East African perspective on a global problem.

BACKGROUND: There is worldwide concern of rapidly increasing antimicrobial resistance (AMR). However, there is paucity of resistance surveillance data and updated antibiograms in Africa in general. This study was undertaken in Kenyatta National Hospital (KNH) -the largest public tertiary referral centre in East & Central Africa-to help bridge existing AMR knowledge and practice gaps. METHODS: A retrospective review of VITEK 2 (bioMérieux) records capturing antimicrobial susceptibility data for the year 2015 was done and analysed using WHONET and SPSS. RESULTS: Analysis of 624 isolates revealed AMR rates higher than most recent local and international reports. 88% of isolates tested were multi-drug resistant (MDR) whereas 26% were extensively-drug resistant (XDR). E. coli and K. pneumoniae had poor susceptibility to penicillins (8-48%), cephalosporins (16-43%), monobactams (17-29%), fluoroquinolones (22-44%) and trimethoprim-sulfamethoxazole (7%). Pseudomonas aeruginosa and Acinetobacter baumanii were resistant to penicillins and cephalosporins, with reduced susceptibility to carbapenems (70% and 27% respectively). S aureus had poor susceptibility to penicillins (3%) and trimethoprim-sulfamethoxazole (29%) but showed excellent susceptibility to imipenem (90%), vancomycin (97%) and linezolid (99%). CONCLUSIONS: The overwhelming resistance to commonly used antibiotics heralds a clarion call towards strengthening antimicrobial stewardship programmes and regular AMR regional surveillance.

Isolated splenic tuberculosis with subsequent paradoxical deterioration: a case report.

BACKGROUND: Isolated tuberculosis of the spleen has been described occasionally in literature, mostly in immunosuppressed individuals with various risk factors. Sequestration in the spleen makes such Mycobacterium tuberculosis infection difficult to diagnose. This report describes an extremely rare case of isolated splenic tuberculosis in an immunocompetent individual. CASE PRESENTATION: A 26 year old Kenyan male presented with pyrexia of unknown origin, with negative screening tests for bacterial, fungal and parasitic infections. Ziehl-Neelsen staining and GeneXpert tests were negative for M. tuberculosis. Diagnosis of isolated splenic tuberculosis was made on core biopsy of the spleen. The patient initially worsened upon treatment with antituberculous medication attributable to the 'Paradoxical Reaction' phenomenon, before making full recovery. CONCLUSIONS: This case highlights the need to continuously be on the lookout for tuberculosis especially in unusual presentations, including subsequent paradoxical reaction which may be encountered.