Antibiotic Guidelines for Critically Ill Patients in Nigeria.

BACKGROUND: It is well documented that inappropriate use of antimicrobials is the major driver of antimicrobial resistance. To combat this, antibiotic stewardship has been demonstrated to reduce antibiotic usage, decrease the prevalence of resistance, lead to significant economic gains and better patients' outcomes. In Nigeria, antimicrobial guidelines for critically ill patients in intensive care units (ICUs), with infections are scarce. We set out to develop antimicrobial guidelines for this category of patients. METHODS: A committee of 12 experts, consisting of Clinical Microbiologists, Intensivists, Infectious Disease Physicians, Surgeons, and Anesthesiologists, collaborated to develop guidelines for managing infections in critically ill patients in Nigerian ICUs. The guidelines were based on evidence from published data and local prospective antibiograms from three ICUs in Lagos, Nigeria. The committee considered the availability of appropriate antimicrobial drugs in hospital formularies. Proposed recommendations were approved by consensus agreement among committee members. RESULTS: Candida albicans and Pseudomonas aeruginosa were the most common microorganisms isolated from the 3 ICUs, followed by Klebsiella pneumoniae, Acinetobacter baumannii, and Escherichia coli. Targeted therapy is recognized as the best approach in patient management. Based on various antibiograms and publications from different hospitals across the country, amikacin is recommended as the most effective empiric antibiotic against Enterobacterales and A. baumannii, while colistin and polymixin B showed high efficacy against all bacteria. Amoxicillin-clavulanate or ceftriaxone was recommended as the first-choice drug for community-acquired (CA) CA-pneumonia while piperacillin-tazobactam + amikacin was recommended as first choice for the treatment of healthcare-associated (HA) HA-pneumonia. For ventilatorassociated pneumonia (VAP), the consensus for the drug of first choice was agreed as meropenem. Amoxycillin-clavulanate +clindamycin was the consensus choice for CAskin and soft tissue infection (SSIS) and piperacillin-tazobactam + metronidazole ±vancomycin for HA-SSIS. Ceftriaxone-tazobactam or piperacillin-tazobactam + gentamicin was consensus for CA-blood stream infections (BSI) with first choice+regimen for HA-BSI being meropenem/piperacillin-tazobactam +amikacin +fluconazole. For community-acquired urinary tract infection (UTI), first choice antibiotic was ciprofloxacin or ceftriaxone with a catheter-associated UTI (CAUTI) regimen of first choice being meropenem + fluconazole. CONCLUSION: Data from a multicenter three ICU surveillance and antibiograms and publications from different hospitals in the country was used to produce this evidence-based Nigerian-specific antimicrobial treatment guidelines of critically ill patients in ICUs by a group of experts from different specialties in Nigeria. The implementation of this guideline will facilitate learning, continuous improvement of stewardship activities and provide a baseline for updating of guidelines to reflect evolving antibiotic needs.

CONTEXTE: Il est bien établi que l'utilisation inappropriée des antimicrobiens est le principal moteur de la résistance aux antimicrobiens. Pour lutter contre ce phénomène, il a été démontré que la bonne gestion des antibiotiques permettait de réduire l'utilisation des antibiotiques, de diminuer la prévalence de la résistance, de réaliser des gains économiques significatifs et d'améliorer les résultats pour les patients. Au Nigéria, les directives antimicrobiennes pour les patients gravement malades dans les unités de soins intensifs (USI), souffrant d'infections, sont rares. Nous avons entrepris d'élaborer des lignes directrices sur les antimicrobiens pour cette catégorie de patients. MÉTHODES UTILISÉES: Un comité de 12 experts, composé de microbiologistes cliniques, d'intensivistes, de médecins spécialistes des maladies infectieuses, de chirurgiens et d'anesthésistes, a collaboré à l'élaboration de lignes directrices pour la prise en charge des infections chez les patients gravement malades dans les unités de soins intensifs nigérianes. Les lignes directrices sont basées sur des données publiées et des antibiogrammes prospectifs locaux provenant de trois unités de soins intensifs de Lagos, au Nigeria. Le comité a pris en compte la disponibilité des médicaments antimicrobiens appropriés dans les formulaires des hôpitaux. Les recommandations proposées ont été approuvées par consensus entre les membres du comité. RÉSULTATS: Candida albicans et Pseudomonas aeruginosa étaient les microorganismes les plus fréquemment isolés dans les trois unités de soins intensifs, suivis par Klebsiella pneumoniae, Acinetobacter baumannii et Escherichia coli. La thérapie ciblée est reconnue comme la meilleure approche pour la prise en charge des patients. Sur la base de divers antibiogrammes et publications provenant de différents hôpitaux du pays, l'amikacine est recommandée comme l'antibiotique empirique le plus efficace contre les entérobactéries et A. baumannii, tandis que la colistine et la polymixine B se sont révélées très efficaces contre toutes les bactéries. L'amoxicilline-clavulanate ou la ceftriaxone ont été recommandées comme médicaments de premier choix pour les pneumonies communautaires, tandis que la pipéracilline-tazobactam + amikacine ont été recommandées comme médicaments de premier choix pour le traitement des pneumonies associées aux soins. Pour les pneumonies acquises sous ventilation mécanique (PAV), le consensus sur le médicament de premier choix est le méropénem. L'amoxycilline-clavulanate +clindamycine était le choix consensuel pour les infections de la peau et des tissus mous et la pipéracilline-tazobactam + métronidazole ±vancomycine pour les infections de la peau et des tissus mous. HA-SSIS. Ceftriaxone-tazobactam ou pipéracilline-tazobactam + gentamicine a fait l'objet d'un consensus pour les infections de la circulation sanguine de l'AC (BSI), le premier choix de régime pour les HA-BSI étant le méropénem/pipéracilline-tazobactam +amikacine +fluconazole. Pour les infections urinaires communautaires, l'antibiotique de premier choix était la ciprofloxacine ou la ceftriaxone, le régime de premier choix pour les infections urinaires associées à un cathéter étant le meropenem +fluconazole. CONCLUSION: Les données issues d'une surveillance multicentrique de trois unités de soins intensifs, d'antibiogrammes et de publications de différents hôpitaux du pays ont été utilisées par un groupe d'experts de différentes spécialités nigérianes pour élaborer ces lignes directrices sur le traitement antimicrobien des patients gravement malades dans les unités de soins intensifs, fondées sur des données probantes et spécifiques au Nigeria. La mise en œuvre de ces lignes directrices facilitera l'apprentissage, l'amélioration continue des activités de gestion et fournira une base de référence pour la mise à jour des lignes directrices afin de refléter l'évolution des besoins en antibiotiques. Mots clés: Antimicrobiens, Résistance aux antimicrobiens, Gestion des antibiotiques, Lignes directrices, Soins intensifs, Unité de soins intensifs, Infections associées aux soins de santé.

Challenges of caregivers and needs of children with parents in a Nigerian prison.

Background: Separation of a parent from the family as a result of incarceration has both short-term and long-term effects on the family, even after release from prison. This study is a report of factors and challenges of the family left to adapt to the changed circumstances of separation from parent(s) who are incarcerated. Methods: This was a cross sectional study carried out on 89 caregivers of children whose parents are incarcerated at the Agodi prison, Ibadan who gave informed and written consent to interview their families. Results: Most caregivers had little or no formal education (69.7%) and 67.4% are into petty trading or subsistence farming. A majority of the caregivers reported the need of schooling (85.4%), provision of food (84.3%) and medical care (71.9%) as major challenges, only 25% received any form of support to meet these needs. Twenty-nine (32.6%) respondents reported receiving financial support to provide for the child's feeding. Some caregivers 21 (23.6%), obtained loans to cope with the financial needs of the children while only 3 (3.4%) received support from family or other non-governmental organisations. Conclusion: The caregivers of children of prison inmates face significant challenges in meeting the needs of feeding, health and schooling. Support structures and policies to address these gaps are required.

Co-existing sickle cell anaemia and inflammatory bowel disease: case report and review of the literature.

Sickle cell anaemia (SCA) is a chronic haemolytic anaemia associated with vaso-occlusive painful crises which may affect several systems including the gastro-intestinal system, resulting in abdominal pain. The concurrence of inflammatory bowel disease and haemoglobinopathy is rare. No previously reported concurrent cases of both SCA and ulcerative colitis (UC) in sub-Saharan Africa were found in the literature. A 16-year-old girl with concurrent SCA and UC is presented. She was admitted to University College Hospital, Ibadan with a 1-year history of recurrent peri-umbilical pain and bloody stools. These symptoms were mainly attributed to SCA at the referring hospital, and she was managed for chronic tropical diarrhoea without a remarkable clinical response. This case illustrates the concurrent presentation of SCA and ulcerative colitis which led to the missed and delayed diagnosis of ulcerative colitis.

Fulminant hepatitis B virus (HBV) infection in an infant following mother-to-child transmission of an e-minus HBV mutant: Time to relook at HBV prophylaxis in South African infants.

The prevalence of hepatitis B virus (HBV) infection in pregnant women is high in South Africa (SA), yet prophylaxis to prevent mother-to-child transmission (MTCT) falls short of international recommendations. We describe a 10-week-old infant who developed fulminant hepatic failure following MTCT. The mother was hepatitis e-antibody positive and had a viral load of only 760 IU/mL. Genetic analysis of virus from mother and infant showed that both had the G1896A mutation in the preC/C gene, which truncates hepatitis e antigen (HBeAg) during translation, causing an HBeAg-negative phenotype. HBeAg attenuates antiviral immune responses, and its absence was probably responsible for the infant's fulminant hepatitis, due to an uncontrolled immune attack on infected liver cells. Pregnant women are not tested for HBV infection in SA and MTCT rates are unknown. Addition of a birth dose of vaccine, HBV screening of pregnant women and antiviral prophylaxis to positive mothers should be prioritised.

BURDEN OF CYTOPAENIAS AMONG HIV POSITIVE PREGNANT WOMEN AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN.

INTRODUCTION: Few studies have examined cytopaenia among HIV positive pregnant women. OBJECTIVES: To assess burden of cytopaenia among HIV positive pregnant women. METHODOLOGY: This cross-sectional study of women on HAART ≤6months, defined anemia as hematocrit <33%, leucopenia as total white blood cell count <3,000 cells/mm3 and thrombocytopenia as absolute platelet count <100,000 cells/mm3. Univariate and bivariate analyses were performed. RESULTS: Over 8 years, of 1,197 women, the mean age was 29.02(±5.4) years and mean gestational age 25.9(±8.1) weeks. Prevalence of anaemia was 76.8%, leucopaenia 6.9% and thrombocytopenia 4.7%. The mean haematocrit was 28.5%(±4.5); median white blood count 5,500/mm3 ; median platelet count 200,000/mm3 and median CD4 323 cells/mm3. Mean haematocrit was highest (29.7%±5.3) in women in the first trimester but lowest (28.4% ±4.6) in women in second trimester (p=0.04). Compared with earlier trimesters, women in the third trimester had higher median white blood count (5,600 cells/mm3), higher neutrophil (61.0% ±11.2) but lower lymphocytes (28.3%± 9.2) (p=0.18; 0.00, 0.00). Median absolute platelet count was highest (206,000 cells/mm3) in the first trimester but lowest (195,000 cells/mm3) in third trimester (0.04). Women with lower CD4 had higher prevalence of cytopaenias. CONCLUSION: Cytopaenias are not uncommon in this population especially with lower CD4.

HCV co-infection is associated with metabolic abnormalities among HAART naive HIV-infected persons.

OBJECTIVES: To determine the metabolic abnormalities among Hepatitis C Virus (HCV) co infected HAART naïve HIV infected persons within the adult ARV clinic of the University College Hospital/University of Ibadan, Ibadan, Nigeria Methods: This was a retrospective study involving the review of clinical records of newly recruited HIV-infected persons in the adult antiretroviral (ARV) clinic over a 12 month period (January - December 2006). Baseline results for fasting plasma glucose (FPG) and fasting lipid profile were retrieved. RESULTS: Out of the 1,260 HIV infected persons seen during the study period, HCV co-infection was found in 75 (6%) persons. The median values for total cholesterol, LDL-cholesterol and HDL-cholesterol were lower in the HCV co-infected persons. HIV-HCV co-infection was associated with a 0.31 mmol/L depression in Total Cholesterol (TC). The median FPG concentration was significantly higher in HIV-HCV co-infected than HIV only infected persons (5.33mmol/L vs. 5.00mmol/L, p = 0.047). However, regression analysis showed there was no relationship between the HIV-HCV co infected state and fasting glucose levels. CONCLUSION: HIV-HCV co-infection may be associated with a predictable decline in plasma cholesterol, but FPG may not be sufficient to demonstrate insulin resistance in these persons.

Paediatric endocrine disorders at the university college hospital, ibadan: 2002 - 2009.

BACKGROUND: Until recently, most published research focus more on infectious diseases and malnutrition giving the impression that endocrine disorders are uncommon. Reports on endocrine disorders in children in developing countries are few compared to developed countries reflecting the different level of prevalence in the different geographical locations and or level of awareness and availability of facilities for proper diagnosis. OBJECTIVE: This study aims at defining the burden of paediatric endocrine disorders in Ibadan. SUBJECTS/METHODS: A review of records of children who presented at University College Hospital, Ibadan with paediatric endocrine disorders from 2002 to 2009 was carried out. RESULTS: During the eight-year period, a total of 110 children presented with various endocrine disorders but only 94 had complete data for this study. There were 47(50%) males and 37(39.4%) females, and in 10(10.6%) of them, had genital ambiguity at presentation. Patients' ages ranged from 2 weeks to 15 years with a median of 3 years. Many (35%) patients were malnourished with weight less than 80% of the expected weight for age and only 9% were overweight. Yearly distribution of cases showed a steady increase in number of cases from 2005. Rickets and metabolic disorders constituted 56.4% of patients; Diabetes mellitus was diagnosed in 12.8%, adrenal disoders in 10.6%, pubertal disorders in 5.3% and growth disorders in 4.3% of the patients. Thyroid disorders were present in 6.4%, obesity in 3.2% while the least common disorder was Diabetes insipidus (1%). About 58% of the children had parents in the low socioeconomic status and the management of the cases were severely hampered by lack of funds. About 60.6% of these patients were lost to follow up, during the period. CONCLUSIONS: Paediatric endocrine disorders are associated with a high incidence of malnutrition. Most patients presented with rickets which is a preventable condition.

Paediatric Endocrine Disorders at the University College Hospital; Ibadan: 2002 - 2009

Background: Until recently; most published research focus more on infectious diseases and malnutrition giving the impression that endocrine disorders are uncommon. Reports on endocrine disorders in children in developing countries are few compared to developed countries reflecting the different level of prevalence in the different geographical locations and or level of awareness and availability of facilities for proper diagnosis. Objective: This study aims at defining the burden of paediatric endocrine disorders in Ibadan. Subjects/Methods: A review of records of children who presented at University College Hospital; Ibadan with paediatric endocrine disorders from 2002 to 2009 was carried out. Results: During the eight-year period; a total of 110 children presented with various endocrine disorders but only 94 had complete data for this study. There were 47(50) males and 37(39.4) females; and in 10(10.6) of them; had genital ambiguity at presentation. Patients' ages ranged from 2 weeks to 15 years with a median of 3 years. Many (35) patients were malnourished with weight less than 80 of the expected weight for age and only 9 were overweight. Yearly distribution of cases showed a steady increase in number of cases from 2005. Rickets and metabolic disorders constituted 56.4 of patients; Diabetes mellitus was diagnosed in 12.8; adrenal disoders in 10.6; pubertal disorders in 5.3 and growth disorders in 4.3 of the patients. Thyroid disorders were present in 6.4; obesity in 3.2 while the least common disorder was Diabetes insipidus (1). About 58 of the children had parents in the low socioeconomic status and the management of the cases were severely hampered by lack of funds. About 60.6 of these patients were lost to follow up; during the period. Conclusions: Paediatric endocrine disorders are associated with a high incidence of malnutrition. Most patients presented with rickets which is a preventable condition

Knowledge and Views of Paediatricians about Pulse Oximetry: a Nationwide Online Survey in Nigeria

Pulse oximetry is a non-invasive method of measuring oxygen saturation in clinical settings. This study was carried out to determine the level of knowledge and competencies relating to pulse oximetry and the ability to interpret the information.We conducted a nationwide, multi-centre, and questionnaire-based online survey between January and June 2010. A 32-item questionnaire relating to the use of pulse oximetry in children was answered by 224 in-training and 157 qualified paediatricians (median duration of practice 6 years) working in 24 states in Nigeria. Knowledge of pulse oximetry was evaluated on a scale of 0­100%. Data were analysed using Chisquare and t-test statistics at 5% level of significance.The overall mean test score was 36.6±20.8% (range0­76.5%). The mean knowledge score among intraining and qualified paediatricians was 35.4±19.1%and38.3±23.1%,respectively(p>0.05). Only 16.3% of the respondents answered all three questions correctly relating to the relationship between oxygen saturationand partial pressure of oxygen. Pertaining to the accuracy of pulse oximeters, 3.9% of the respondents answered all 14 questions correctly. On indications for use of pulse oximetry, 29% correctly answered all nine questions. Only 18% of respondents correctly answered the seven questions on interpretation of pulse oximeter reading. Some 73% of respondents believed that training in the use of pulse oximetry was inadequate.A significant proportion of the paediatricians were untrained in pulse oximetry, lacked knowledge of basic principles, and made serious errors in interpretation of readings from pulse oximeters. We suggest that medical schools and residency training programmes place more emphasis on teaching the principles and uses of pulse oximetry