Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis.

BACKGROUND: Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA. METHODS: The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript. RESULTS: Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials. CONCLUSIONS: Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

Bacterial profile and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa: a systematic review and meta-analysis.

The number of diabetic foot ulcer patients is substantially increasing, with the rapidly rising burden of diabetic mellitus in sub-Saharan Africa. The data on the regional prevalence of diabetic foot ulcer infecting bacteria and their antimicrobial resistance patterns is crucial for its proper management. This systematic review and meta-analysis determined the pooled prevalence of bacterial profiles and antimicrobial resistance patterns of infected diabetic foot ulcers in sub-Saharan Africa. A comprehensive search of the literature was performed on CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Critical appraisal was done using the Joanna Briggs Institute's tool for prevalence studies. A pooled statistical meta-analysis was conducted using STATA Version 17.0. The I2 statistics and Egger's test were used to assess the heterogeneity and publication bias. The pooled prevalence and the corresponding 95% confidence interval of bacterial profiles and their antimicrobial resistance patterns were estimated using a random effect model. Eleven studies with a total of 1174 study participants and 1701 bacteria isolates were included. The pooled prevalence of the most common bacterial isolates obtained from DFU were S. aureus (34.34%), E. coli (21.16%), and P. aeruginosa (20.98%). The highest pooled resistance pattern of S. aureus was towards Gentamicin (57.96%) and Ciprofloxacin (52.45%). E.coli and K. Pneumoniae showed more than a 50% resistance rate for the most common antibiotics tested. Both gram-positive and gram-negative bacteria were associated with diabetic foot ulcers in sub-Saharan Africa. Our findings are important for planning treatment with the appropriate antibiotics in the region. The high antimicrobial resistance prevalence rate indicates the need for context-specific effective strategies aimed at infection prevention and evidence-based alternative therapies.

Testing the Impact of Phone Texting Reminders for Children's Immunization Appointments in Rural Cameroon: Protocol for a Nonrandomized Controlled Trial.

BACKGROUND: Globally, over 20 million children are unvaccinated and over 25 million missed their follow-up doses during the COVID-19 pandemic; thus, they face vaccine-preventable diseases and unnecessary deaths. This is especially the case for those with HIV or living in vulnerable settings. Using cell phones to send reminders to parents has been shown to improve vaccination rates. OBJECTIVE: We aim to determine whether implementation of an automated SMS reminder will improve child vaccination rates in a turbulent, semiurban/semirural setting in a low-income country. METHODS: This will be a nonrandomized controlled trial that will be conducted at Azire Integrated Health Centre, Bamenda, Cameroon. RESULTS: A total of 200 parents per study group (aged over 18 years) who are registered at the clinic at least one month prior to the study will be recruited. The intervention group will receive 2 reminders: 1 week and 2 days prior to the scheduled vaccination. For those who miss their appointments, a reminder will be sent 1 week after their missed appointment. The control group will receive the regular care provided at the clinic. Baseline information, clinical visit data, and vaccination records will be collected for both groups. Descriptive statistics will be used to summarize baseline characteristics between and within clusters and groups. The Fisher exact test will be used to compare parent-child units who return for follow-up visits (as a percentage) and children vaccinated as scheduled (as a percentage) between the study groups. Finally, we will compare how many members of both study groups return for 1 follow-up visit using Kaplan-Meier survival analysis. CONCLUSIONS: Due to limited effective child vaccination interventions in unstable settings, this study will be of high importance for suggesting a holistic approach to improve child vaccination and public health. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47018.

Prevalence of Group B Streptococcus maternal colonization, serotype distribution, and antimicrobial resistance in Sub-Saharan Africa: A systematic review and meta-analysis.

OBJECTIVE: Group B Streptococcus (GBS)-associated maternal, perinatal, and neonatal mortality and morbidity disproportionately affects Sub-Saharan Africa (SSA). This systematic review and meta-analysis aimed to address the estimated prevalence, antimicrobial susceptibility, and serotype distribution of GBS isolates in SSA. METHODS: This study was done according to PRISMA guidelines. MEDLINE/PubMed, CINAHL (EBSCO), Embase, SCOPUS, Web of Sciences databases, and Google Scholar were used to retrieve both published and unpublished articles. STATA software version 17 was used for data analysis. Forest plots using the random-effect model were used to present the findings. Heterogeneity was assessed using Cochrane chi-square (I2) statistics, while the Egger intercept was used to assess publication bias. RESULTS: Fifty-eight studies that fulfilled the eligibility criteria were included for meta-analysis. The pooled prevalence of maternal rectovaginal colonization and vertical transmission of GBS were 16.06, 95% CI [13.94, 18.30] and 43.31%, 95% CI [30.75, 56.32], respectively. The highest pooled proportion of antibiotic resistance to GBS was observed in gentamicin (45.58%, 95% CI [4.12%, 91.23]), followed by erythromycin, (25.11%, 95% CI [16.70, 34.49]). The lowest antibiotic resistance was observed in vancomycin (3.84%, 95% CI [0.48, 9.22]). Our findings indicate that serotypes Ia/Ib/II/ III/and V cover almost 88.6% of serotypes in SSA. CONCLUSIONS: The estimated high prevalence and resistance to different antibiotic classes observed in GBS isolates from SSA suggests the need for implementation of effective intervention efforts.

Individual and Social Level Factors Influencing Repeated Pregnancy among Unmarried Adolescent Mothers in Katavi Region-Tanzania: A Qualitative Study.

Adolescents' pregnancy rates are still high in Tanzania, despite the efforts made by the national campaign. Within two years after the first pregnancy, adolescent mothers are more at risk of repeat conception. Repeated pregnancies are associated with increased maternal and perinatal outcomes. Katavi is a leading region in the country, with 45% adolescent pregnancy. Studies are scarce on factors influencing repeated pregnancy among unmarried adolescent mothers in the region. Therefore, this study explored the individual and social level factors influencing repeated pregnancy among unmarried adolescent mothers in the Katavi Region. An exploratory qualitative study, using key informant interviews (KIIs) was adopted for 16 participants. The study participants were unmarried adolescent mothers, aged 15-19 years, who were purposively sampled. Thematic analysis was used to analyze qualitative data. QSR Nvivo version 14 was used to analyze these data. The study established the individual factors influencing repeated pregnancy, which were inadequate sexuality knowledge, individually perceived barriers to contraceptive use, and the guarantee for marriage. Furthermore, the social factors identified were the power of decision-making, peer pressure, and the parent-child relationship. Inadequate education on sexuality is observed as a crucial factor influencing repeated pregnancy. Parents as primary educators should be encouraged to talk with their children, especially adolescent girls about sexual education.

Uptake of cervical cancer screening and its predictors among women of reproductive age in Gomma district, South West Ethiopia: a community-based cross-sectional study.

BACKGROUND: Cervical cancer is a public health challenge despite the available free screening service in Ethiopia. Early screening for cervical cancer significantly improves the chances of successful treatment of pre-cancers and cancers among women of reproductive age. Therefore, this study aimed to assess the uptake of screening and identify the factors among women of reproductive age. METHODS: A community-based cross-sectional study was conducted in Gomma Woreda, Jimma Zone, Ethiopia, from 1st to the 30th of August, 2019. The total sample size was 422. A systematic random sampling technique was employed. Data were collected using a structured questionnaire, entered in epidata, and exported and analyzed using SPSS version 20.0 software packages. Descriptive, bivariate and multivariable logistic regression analyses with 95% CI for odds ratio (OR) were performed to declare a significant predictors. RESULT: A total of 382 study participants were involved with a response rate of 90.5%. The mean age of the study participants was 26.45 ± 4.76 SD. One hundred forty-eight (38.7%) of participants had been screened for CC. Marital status (AOR = 10.74, 95%, CI = 5.02-22.96), residence (AOR = 4.45, 95%, CI = 2.85-6.96), educational status (AOR = 1.95, 95% CI = 1.12-3.49), government employee (AOR = 2.61, 95%, CI = 1.33-5.15), birth experience (AOR = 8.92, 95% CI = 4.28-19.19), giving birth at health center and government hospitals (AOR = 10.31, 95% CI = 4.99-21.62; AOR = 5.54, 95% CI = 2.25-13.61); distance from health facility (AOR = 4.41, 95% CI = 2.53-9.41), health workers encouragement (AOR = 3.23, 95% CI = 1.57-6.63), awareness on cervical cancer (AOR = 0.37, 95% CI = 0.19-0.72), awareness about CC screening (AOR = 4.52, 95%, CI = 2.71-7.55) and number of health facility visit per year (AOR = 3.63, 95%, CI = 1.86-6.93) were the predictors for the uptake of cervical cancer screening. CONCLUSION: The uptake of cervical cancer screening was low. Marital status, residence, occupation, perceived distance from screening health facility, health workers encouragement, number of health facility visits, birth experience, place of birth, and knowledge about cervical cancer screening were the predictors. There is a need to conduct further studies on continuous social and behavioral change communication.

Prevalence and antimicrobial susceptibility level of typhoid fever in Ethiopia: A systematic review and meta-analysis.

Typhoid fever continues to be a health challenge in low-and middle-income countries where access to clean water and sanitation infrastructure is scarce. The non-confirmatory diagnostic method continues to hinder effective diagnosis and treatment, ensuring in a high antimicrobial resistance. This systematic review and meta-analysis aimed to estimate the pooled prevalence and antimicrobial susceptibility level of typhoid fever in Ethiopia. The review was designed based on the condition-context-population review approach. Fifteen eligible articles were identified from PubMed, Google Scholar, and Science Direct databases. Risk of bias and quality of studies were assessed using the Joanna Briggs Institute's appraisal criteria. Heterogeneity was assessed using Cochran's Q test and I2 statistics. The review protocol was registered in PROSPERO (registration number CRD42021224478). The estimated pooled prevalence of typhoid fever from blood and stool culture diagnosis was 3% (95% CI: 2%-4%, p < 0.01) (I2  = 82.25) and Widal test examination 33% (95% CI: 22%-44%) (I2  = 99.14). The sub-group analyses identified a lower detection of typhoid fever of 2% (95% CI: 1%-3%) among febrile patients compared to typhoid suspected cases of 6% (95% CI: 2%-9%). The stool culture test identified was twofold higher, value of 4% (95% CI: 2%-7%) salmonella S. Typhi infection than blood culture test of 2% (95% CI: 1%-4%). The antimicrobial susceptibility of salmonella S. Typhi for antibiotics was 94%, 80% and 65% for ceftriaxone, ciprofloxacin, and gentamycin respectively. Low susceptibility of salmonella S. Typhi isolates against nalidixic acid 22% (95% CI: 2%-46%) and chloramphenicol 11% (95% CI: 2%-20%) were observed. The diagnosis of typhoid fever was under or overestimated depending on the diagnostic modality. The Widal test which identified as nonreliable has long been used in Ethiopia for the diagnosis of salmonella S. Typhi causing high diagnosis uncertainties. Antimicrobial susceptibility of salmonella S. Typhi was low for most nationally recommended antibiotics. Ethiopian Food and Drug Authority must strengthen its continued monitoring and enhanced national antimicrobial surveillance system using the best available state-of-the-art technology and or tools to inform the rising resistance of salmonella S. Typhi towards the prescription of standard antibiotics. Finally, it is crucial to develop an evidence-based clinical decision-making support system for the diagnosis, empiric treatment and prevention of antimicrobial resistance.

Prevalence of antimicrobial resistance and its clinical implications in Ethiopia: a systematic review.

BACKGROUND: Antimicrobial resistance is one of the major public health challenges in Ethiopia. However, there is no comprehensive summary of existing AMR data in the country. AIM: To determine the prevalence of antimicrobial resistance and its clinical implications in Ethiopia. METHODS: A systematic literature search was performed on the PubMed/Medline database. Original studies on antimicrobial resistance conducted in Ethiopia between 1st January 2009 and 31st July 2019 were included. The outcome measure was the number of isolates resistant to antimicrobial agents in terms of specific pathogens, and disease condition. Data was calculated as total number of resistant isolates relative to the total number of isolates per specific pathogen and medication. RESULTS: A total of 48,021 study participants enrolled from 131 original studies were included resulting in 15,845 isolates tested for antimicrobial resistance. The most common clinical sample sources were urine (28%), ear, nose, and throat discharge collectively (27%), and blood (21%). All the studies were cross-sectional and 83% were conducted in hospital settings. Among Gram-positive bacteria, the reported level of resistance to vancomycin ranged from 8% (Enterococcus species) to 20% (S. aureus). E. coli, K. pneumoniae and P. aeruginosa were the most common Gram-negative pathogens resistant to key antimicrobial agents described in the national standard treatment guideline and were associated with diverse clinical conditions: urinary tract infections, diarrhea, surgical site infections, pneumonia, ocular infections, and middle ear infections. CONCLUSION: Overall, there is a high prevalence of antimicrobial resistance in Ethiopia. Empirical treatment of bacterial infections needs to be guided by up-to-date national guidelines considering local antimicrobial susceptibility patterns. Equipping diagnostic laboratories with culture and drug susceptibility testing facilities, and establishing a strong antimicrobial stewardship program should be high priorities.

Tuberculosis Treatment Outcome and Predictors in Africa: A Systematic Review and Meta-Analysis.

This review aimed to summarize and estimate the TB treatment success rate and factors associated with unsuccessful TB treatment outcomes in Africa. Potentially eligible primary studies were retrieved from PubMed and Google Scholar. The risk of bias and quality of studies was assessed using The Joanna Briggs Institute's (JBI) appraisal criteria, while heterogeneity across studies was assessed using Cochran's Q test and I2 statistic. Publication bias was checked using the funnel plot and egger's test. The protocol was registered in PROSPERO, numbered CRD42019136986. A total of 26 eligible studies were considered. The overall pooled estimate of TB treatment success rate was found to be 79.0% (95% CI: 76-82%), ranging from 53% (95% CI: 47-58%) in Nigeria to 92% (95% CI: 90-93%) in Ethiopia. The majority of unsuccessful outcomes were attributed to 48% (95% CI: 40-57%) death and 47% (95% CI: 39-55%) of defaulter rate. HIV co-infection and retreatment were significantly associated with an increased risk of unsuccessful treatment outcomes compared to HIV negative and newly diagnosed TB patients with RR of 1.53 (95% CI: 1.36-1.71) and 1.48 (95% CI: 1.14-1.94), respectively. TB treatment success rate was 79% below the WHO defined threshold of 85% with significant variation across countries. Countries need to explore contextual underlining factors and more effort is required in providing TB preventive treatment, improve case screening and linkage for TB treatment among HIV high-risk groups and use confirmatory TB diagnostic modality. Countries in Africa need to strengthen counseling and follow-up, socio-economic support for patients at high risk of loss to follow-up and poor treatment success is also crucial for successful TB control programs.

Male partners' participation in birth preparedness and complication readiness in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Maternal and neonatal health outcomes remain a challenge in low- and middle-income countries (LMICs) despite priority given to involving male partners in birth preparedness and complication readiness (BPCR). Men in LMICs often determine women's access to and affordability of health services. This systematic review and meta-analysis determined the pooled magnitude of male partner's participation in birth preparedness and complication readiness in LMICs. METHODS: Literature published in English language from 2004 to 2019 was retrieved from Google Scholar, PubMed, CINAHL, Scopus, and EMBASE databases. The Joanna Briggs Institute's critical appraisal tool for prevalence and incidence studies were used. A pooled statistical meta-analysis was conducted using STATA Version 14.0. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis was carried out to validate publication bias and heterogeneity. The random effect model was used to estimate the summary prevalence and the corresponding 95% confidence interval (CI) of birth preparedness and complication readiness. The review protocol has been registered in PROSPERO number CRD42019140752. The PRISMA flow chart was used to show the number of articles identified, included, and excluded with justifications described. RESULTS: Thirty-seven studies with a total of 17, 148 participants were included. The pooled results showed that 42.4% of male partners participated in BPCR. Among the study participants, 54% reported having saved money for delivery, whereas 44% identified skilled birth attendants. 45.8% of male partners arranged transportation and 57.2% of study participants identified health facility as a place of birth. Only 16.1% of the male partners identified potential blood donors. CONCLUSIONS: A low proportion of male partners were identified to have participated in BPCR in LMICs. This calls countries in low- and middle-income setting for action to review their health care policies, to remove the barriers and promote facilitators to male partner's involvement in BPCR. Health systems in LMICs must design and innovate scalable strategies to improve male partner's arrangements for a potential blood donor and transportation for complications that could arise during delivery or postpartum haemorrhage.

Comorbidity of Geo-Helminthes among Malaria Outpatients of the Health Facilities in Ethiopia: Systematic Review and Meta-Analysis.

BACKGROUND: Coinfection of malaria and intestinal helminths affects one third of the global population, largely among communities with severe poverty. The spread of these parasitic infections overlays in several epidemiological locations and the host shows different outcomes. This systematic review and meta-analysis determine the pooled prevalence of malaria and intestinal helminthiases coinfections among malaria suspected patients in Ethiopia. METHODS: Primary studies published in English language were retrieved using appropriate search terms on Google Scholar, PubMed/MEDLINE, CINHAL, Scopus, and Embase. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was used for critical appraisal of studies. A pooled statistical meta-analysis was conducted using STATA Version 14.0 software. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test, respectively. Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The Random effects model was used to estimate the summary prevalence of comorbidity of malaria and soil transmitted helminthiases and the corresponding 95% confidence intervals (CI). The review protocol has registered in PROSPERO number CRD42019144803. RESULTS: We identified ten studies (n = 6633 participants) in this study. The overall pooled result showed 13% of the ambulatory patients infected by malaria and intestinal helminths concurrently in Ethiopia. The pooled prevalence of Plasmodium falciparum and Plasmodium vivax, and mixed infections were 12, 30, and 6%, respectively. The most common intestinal helminth parasites detected were Hookworm, Ascaris lumbricoides, and Tirchuris trichiura. CONCLUSIONS: The comorbidity of malaria and intestinal helminths causes lower hemoglobin level leading to maternal anemia, preterm delivery, and still birth in pregnant women and lactating mother. School-aged children and neonates coinfected by plasmodium species and soil transmitted helminths develop cognitive impairment, protein energy malnutrition, low birth weight, small for gestational age, and gross motor delay. The Ministry of Health of Ethiopia and its international partners working on malaria elimination programs should give more emphasis to the effect of the interface of malaria and soil transmitted helminths, which calls for an integrated disease control and prevention.