Need for standardization and compliance to treatment protocols for COVID-19 within the African Region of the World Health Organization

COVID-19 pandemic changed the face of global health and brought about new issues in global health security and economy. The World Health Organization published guidelines for clinical management of COVID-19 four months after declaration of COVID-19 as a pandemic. Scholarly reviews and studies from member states within WHO AFRO reveals significant deviation from the WHO published protocols on COVID-19. Assessment of national treatment protocols of 30 of 47 WHO AFRO member states showed widespread inappropriate use of antimicrobial agents for patients, which may worsen the global and concerning threat of antimicrobial resistance. There is need for adopting interventions that optimize antimicrobial use in the context of pre- and post-pandemic preparedness to ensure long-term effectiveness and sustainability for antimicrobials. Treatment guidelines are to be adopted or adapted depending on best clinical evidence available. Non-compliance with guidelines might lead to mismanagement of infectious diseases with attendant negative consequences including antimicrobial resistance and misdirection of critical resources and supplies amongst others.

La pandémie de COVID-19 a changé le visage de la santé mondiale et a soulevé de nouveaux problèmes en matière de sécurité sanitaire et d'économie mondiale. L'Organisation mondiale de la santé a publié des lignes directrices pour la gestion clinique du COVID-19 quatre mois après la déclaration du COVID-19 comme pandémie. Les revues scientifiques et les études des États membres de l'OMS AFRO révèlent un écart significatif par rapport aux protocoles publiés par l'OMS sur le COVID-19. L'évaluation des protocoles nationaux de traitement de 30 des 47 États membres de l'OMS AFRO a révélé une utilisation inappropriée et généralisée d'agents antimicrobiens chez les patients, ce qui pourrait aggraver la menace mondiale et préoccupante de résistance aux antimicrobiens. Il est nécessaire d'adopter des interventions qui optimisent l'utilisation des antimicrobiens dans le contexte de la préparation pré et post-pandémique afin de garantir l'efficacité et la durabilité à long terme des antimicrobiens. Les directives thérapeutiques doivent être adoptées ou adaptées en fonction des meilleures preuves cliniques disponibles. Le non-respect des directives pourrait conduire à une mauvaise gestion des maladies infectieuses avec des conséquences négatives qui en découlent, notamment la résistance aux antimicrobiens et une mauvaise orientation des ressources et fournitures essentielles, entre autres.

Clinical neglect of aspergillosis in pulmonary tuberculosis co-infection: a case report of avoidable mortality in a resource-constrained setting

Background: Pulmonary aspergillosis (PA) is common among patients with tuberculosis (TB). With both infections presenting with similar clinical and radiologic features, diagnosis of PA is often made too late or missed completely due to lack of clinical suspicion and poor diagnostic laboratory capacity for mycotic infections prevalent in our settings. We present a case of preventable mortality caused by delayed diagnosis and treatment of PA in a patient with pulmonary TB (PTB). Case presentation: A 13-year-old female was diagnosed and treated for PTB, having received anti-TB regimen for 8 months in a mission hospital from where she was referred due to worsening cough, chest pain and progressive breathlessness. The patient was re-assessed and investigated, with GeneXpert detecting Mycobacterium tuberculosis, susceptible to rifampicin. Diagnosis of pulmonary tuberculosis complicated by right pneumothorax was made indicating an emergency thoracotomy and chest tube insertion and continuation of the first line anti-TB regimen. At about 2 weeks into admission, patients had features of superimposed acute bacterial sepsis with fever becoming high grade, marked neutrophilia with toxic granulation and elevated sepsis biomarker, and this necessitated empiric antibiotic treatment with parenteral meropenem and vancomycin. However, the patient only had mild clinical improvement following which there was progressively worsening respiratory symptoms and massive haemoptysis. Result of sputum fungal study was available on admission day 20 and revealed a growth of Aspergillus flavus. Treatment with intravenous voriconazole was however commenced rather late when the fungal respiratory disease could no longer be remedied. The patient died on admission day 23. Conclusion: Diagnosis of PA in patients with background TB is often made too late to guarantee timely and effective antifungal treatment with negative consequences on patients' outcomes. Improving clinical and laboratory capacities is essential to reducing mortality from PA in healthcare facilities.

Evaluation of nutritional status using body fat, physiological and biochemical parameters in some Nigerian women.

Some nutritional parameters were investigated in 62 healthy Nigerian female subjects of low socio-economic status. The percentage body fat (% BF) and some biochemical parameters, High and Low Density Lipoprotein Cholesterol (HDL-C and LDL-C), Total Plasma Cholesterol (TC), Triglyceride (TG), Uric Acid (UA), Urinary Creatinine (U-Cr), Creatinine in plasma (P-Cr) and Creatinine clearance (Cr-CI), were evaluated. Also determined were the Body Mass Index (BMI), Packed Cell Volume, Systolic and Diastolic Blood Pressure (BP-I, BP-2), various skin-fold measurements and body circumferences. Reference values were then established for these various parameters and the correlation between the various variables determined. When the subjects were stratified into four groups (underweight, normal, overweight, and obese) based on their BMI, significant differences (ANOVA, p < 0.05) were observed in LDL-C, Cr-CI, BP-I, as well as 10 out of the 13 anthropometric parameters. These differences could possibly provide diagnostic/prognostic insight for the four groups and the many important diseases associated with them. The hip circumference, in particular, has such a high correlation with both BMI and % BF that it is being suggested as a substitute for these two important parameters in Nigerian women of low socio-economic background.

Hepatitis B viral markers in surface antigen negative blood donors: the need to look beyond antibody negativity.

BACKGROUND: The presence of Hepatitis B Virus (HBV) in blood that is Hepatitis B Surface Antigen (HBsAg) negative is considered a potential risk for transmission of hepatitis B virus infection. OBJECTIVE: To determine prevalence of antibodies to markers of hepatitis B virus infection in HBsAg negative prospective blood donors. METHODS: A structured questionnaire to assess prospective donor's demographic data and past medical history was administered to 457 consenting HBsAg negative subjects. All the subjects were also negative for antibodies to hepatitis C virus (HCV), human immunodeficiency virus (HIV) and syphilis. Their serum samples were tested for the presence of anti-HBc, anti-HBe, anti-HBs and HBeAg. RESULTS: Of the 457 samples tested, 20 (4.37%), 58 (12.69%), 1 (0.22%), and 1 (0.22%) were positive to anti-HBc, anti-HBs, anti-HBe, and HBeAg antibodies, respectively. Ten (50%) of those who were positive for HBc antibody were also positive to anti-HBe and anti-HBs. Similarly, two (3.4%) donors who were positive for anti-HBs were also positive for HBeAg and anti-HBe. Of the 20 who were anti-HBc positive, seven had tattoo/traditional marks on their body and one had previous history of blood transfusion. CONCLUSION: This study has shown that some potential blood units containing HBV are being transfused to patients unknowingly by screening for HBsAg only. Screening for other markers of hepatitis B virus may increase the rejection rate, but will reduce HBV transmission.

Bacteriologic features and antimicrobial resistance of organisms associated with extracted teeth: findings from a Nigerian university teaching hospital.

BACKGROUND: Empirically prescribed antibiotics are widely employed in the management of odontogenic infections. OBJECTIVE: To characterise the infections associated with extracted teeth and assess effectiveness of the antibiotics prescribed empirically following tooth extraction. METHODS: The study was cross-sectional and consisted of 41 consecutively recruited subjects who required extraction for infections associated with the tooth. Appropriate clinical specimens were collected aseptically from each patient and transported in Stuart's transport medium for processing in the laboratory. Isolation, identification, and susceptibility pattern of anaerobic and facultative organisms were done employing standard bacteriologic techniques. Antimicrobial susceptibility testing was performed by the disc diffusion technique. RESULTS: There were positive cultures for 37 patients. Twenty-eight aerobic (45.9%) bacteria and 32 anaerobic (54.1%) bacteria were isolated, an approximation of two microorganisms per patient. Staphylococcus was the most predominant aerobe (25.0%) whereas Bacteroides fragilis was the most predominant anaerobe (34.2%). All the bacteria isolated showed in vitro resistance to cephalexin, cloxacillin and metronidazole. Eighteen (64.3%) different aerobic bacteria and 13 (40.6%) different anaerobic bacteria were sensitive to ciprofloxacillin and these included staphylococcus and Bacteroides fragilis. Sensitivity pattern for amoxycillin was very poor with 3.6% and 6.3% for aerobes and anaerobes respectively. CONCLUSION: Odontogenic infections from our centre are polymicrobial in nature with anaerobes predominating. High resistance to most of the antibiotics routinely prescribed in our centre is common. Ciprofloxacillin demonstrated the highest sensitivity pattern.

Therapeutic decision in chronic osteomyelitis: sinus track culture versus intraoperative bone culture.

BACKGROUND: The ideal specimen for identification of the etiologic agents in chronic osteomyelitis for best antibiotic decision remains controversial. OBJECTIVE: To assess the concordance of sinus track culture (STC) with that of intraoperative bone culture (IBC) to guide antibiotic therapy in chronic osteomyelitis. METHODS: A prospective comparative study of chronic osteomyelitis patients seen in our centre from January 2004 to December 2006. Specimens from the depths of sinus track and intraoperative bone biopsy were obtained from each patient and subjected to microbiologic examination and their concordance determined. RESULTS: In STCs Staphylococcus aureus has the highest sensitivity (60.5%), specificity (45.0%) and positive predictive value (72.2%). The overall sensitivity (50.9%), specificity (20%) and predictive value (47.5%) of sinus track specimens were very low. Antibiotic decision based on IBC showed 106 patients (82.8%) had resolution of chronic osteomyelitis at mean of 2 years follow-up. CONCLUSION: IBC appears to predict more reliably the complete etiologic organisms than STCs in chronic osteomyelitis.

Asymptomatic bacteriuria in patients with diabetes mellitus in Ile-Ife, South-West, Nigeria.

OBJECTIVES: To investigate the prevalence and associates of asymptomatic bacteriuria (ASB) in a sample of Nigerian diabetic patients. DESIGN: Cross-sectional descriptive and analytic study. SETTING: The Wesley Guild Hospital and Ife State Hospital, both units of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. SUBJECTS: One hundred and thirty five diabetic patients and 57 non-diabetic patients as controls. MAIN OUTCOME MEASURES: Demographic parameters of participants were recorded. Significant bacteriuria was determined for each of the mid-stream urine specimen obtained from all the subjects. Organisms isolated were identified and evaluated for antibiotic susceptibility patterns. RESULTS: There was a significant difference in the prevalence of ASB in the two groups. Prevalence of ASB was 16% and 3.5% in the diabetic patients and control respectively (p=0.03). Demographic parameters except age were not related to the presence of ASB. ASB was found in 54.4% of diabetic patients with poor glycaemia control compared with 2.9% in diabetics with good glycaemia control (p = 0.006). Organisms associated with ASB were Staphylococcus aureus, Klebsiella sp, Escherichia coli and Enterococcus faecalis, however the most predominant was Staphylococcus aureus. These organisms were largely resistant to the common antibiotics tested such as cotrimoxazole and gentamicin but susceptible to nitrofurantoin. CONCLUSIONS: The prevalence of ASB is high in diabetic patients and poor glucose control can be considered a predisposing factor.

The pattern of malaria infection in under-fives in Ile-Ife, Nigeria.

Over 90% of the burden of malaria occurs in sub-Saharan Africa. Children, especially under-fives, are the most vulnerable. In Nigeria, Africa's most populous nation, it accounts for 25 and 30% of infant and childhood deaths, respectively. One hundred and seventy-six children who fulfilled clinical and parasitological criteria for the diagnosis of malaria, 26.4% of all under-fives, who presented to the Seventh Day Adventist Hospital in Ile-Ife during the months of May to September 2005 were studied to identify the factors that were associated with severe malaria in the target population. The proportion of children with severe malaria in the study was 17%, while the case-fatality rate was 3.5%. Of the 17 variables examined, high malaria parasite density, non-use of mosquito-bite preventive measures and poverty remained independently and significantly associated with an increased risk for severe malaria. Progress in stemming the burden of malaria depends on accurate knowledge and understanding of the epidemiology and control of the disease in the affected populations.

Seroprevalence of hepatitis C virus infection in Nigerians with type 2 diabetes mellitus.

BACKGROUND: Several studies have suggested a strong epidemiologic association between Diabetes Mellitus (DM) and Hepatitis C Virus (HCV) infection in some populations. However, the reasons why chronic HCV infection is prevalent in DM remain unknown. Our aims were to determine the prevalence of HCV infection in a population of Nigerian diabetics compared with the general population as well as assess the influence of sex and age on HCV infection in the same diabetic population. DESIGN AND METHODS: A total of 115 diabetic patients were compared with 2,301 blood donors matched by recognized risk factors to acquire HCV infection. Serologic testing for anti HCV was done using a commercial enzyme-linked immunosorbent assay (ELISA) kits. RESULTS: Sixty (60) type 2 diabetic patients were males while fifty-five (55) were females. Their mean age was 55.4 +/- 9 years and mean blood glucose level was 8.5mmol/l. One subject tested positive for HCV infection. The control group consisted of 2,031 adults recruited from the blood donor's clinic. Forty five of them (2.2%) tested positive for HCV. CONCLUSION: Our preliminary results suggest a low sero-prevalence of HCV infection among our patients with type 2 diabetes. Presently, routine screening for HCV infection in persons with diabetes may not be necessary.

Microbial isolates in early swabs of open musculoskeletal injuries.

BACKGROUND: Infections of open musculoskeletal injuries, especially open fractures, continue to pose a challenge to the Orthopaedic and Trauma surgeons. There is a dearth of information on the early bacterial contaminants of these open wounds and their antibiotic sensitivity patterns in our environment. OBJECTIVE: To determine the bacteriology of open wounds of the musculoskeletal system at initial presentation in hospital and their antibiotic susceptibility profile in Ile-Ife, Nigeria. MATERIALS AND METHODS: A prospective study of 86 consecutive patients over an eight-month period (March to October 2002). Eighty-six patients with 96 open wounds of the musculoskeletal system admitted to the Accident and Emergency unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Bacteria were isolated from swabs taken from the depth of the wounds and their antibiotic susceptibility determined. RESULTS: A total of 126 bacterial isolates were recovered from 96 wounds in 86 patients (61 males and 25 females) with mean age of 31.4 years +/- SD. About 73.3% of the wounds were from road traffic accidents and 72.3% of the wounds were severe open fractures (Grades IIIA to C). Staphylococcus aureus constituted 22.2% while coagulase negative Staphylococci (CONS) accounted for 21.4% with Staphylococcus. epidermidis leading the group with 13.5%. Gram negative rods constituted 40.5% of the isolates with Pseudomonas aeruginosa accounting for 11.1%. Antibiotic sensitivity profile revealed that many of the isolates were multiply resistant to the antimicrobials employed but were sensitive to Ofloxacin. CONCLUSION: This study has shown that open wounds of the musculoskeletal system are usually contaminated at presentation with pathogenic organisms. The antibiotic sensitivity pattern of the isolates shows that the quinolones, represented by Ofloxacin, is the most effective antibiotic.

Determination of trace elements status of Nigerians with sickle cell anaemia using INAA and PIXE.

The clinical application of trace elements in the management of Sickle Cell Anaemia (SCA) has not become standard recommended practice despite decades of research. A major reason for this is the ambivalence in published results as to the relative importance of some of these elements in the disease. An attempt has been made in this work to correct some of the various factors that could contribute to such inconsistencies. Results from separate investigations carried out on Nigerian subjects by our group, using both INAA and PIXE methods have been holistically evaluated and compared. Trace and minor elements were determined in wholeblood, erythrocytes, plasma, headhair and nail obtained from SCA patients in steady state and compared with identical samples from normal controls. Twelve elements were determined in blood while 20 and 30 elements were analysed in nail and hair samples respectively from the total 225 subjects. The results indicate a general mild zinc deficiency, more serious for males, in Nigerian SCA patients. It is clear that the elements Na, K, Rb and Br play key roles in maintaining homeostasis in the steady-state SCA patients. Possible gender influence in the utilization of K, Br and Fe in SCA is also suggested.

Campylobacter enteritis in Ilorin, Nigeria.

BACKGROUND: Campylobacterje junilcoli is one of the most commonly identified bacterial causes of acute gastroenteritis worldwide. In Nigeria, it has been reported in the northern part of the country, extensive work has also been done in the south-west leaving behind the middle-belt of the country. OBJECTIVE: To determine the role of Campylobacter jejunilcoli as an agent of diarrhoea in the middle-belt of Nigeria. DESIGN: A prospective case control study. SETTING: University of Ilorin Teaching Hospital (UITH), private hospitals and primary health centers all in Ilorin, Nigeria. SUBJECTS: Three hundred and six children with diarrhoea and 100 without diarrhoea were randomly selected. MAIN OUTCOME MEASURES: Isolation of Campylobacter jejuni/coli from stool samples. Biological characteristics of the isolates. RESULTS: Twenty five (8.2%) of the patients and none of the controls had the organism. Campylobacter jejuni and C. coli were 56% and 44% respectively. All the isolates were susceptible to erythromycin and ciprofloxacin. None of the isolates harboured plasmids. CONCLUSION: C. jejunil coli is an important diarrhoea agent in our geographic environment, further characterisation is desired of these local strains.

Effect of socio-economic status, age and sex on antibody titre profile to Salmonella typhi/paratyphi in Ile-Ife, Nigeria.

BACKGROUND: Typhoid fever remains a great socio-medical problem in many poor and underdeveloped countries, with an estimated 16 million cases and 600,000 deaths occurring each year. Although it has a world wide distribution, typhoid fever is endemic where sanitary controls are inadequate. The distribution of the infection in relation to age and sex has shown that typhoid fever is more prevalent in males than in females with out satisfactory explanation. Also, those in their second and third decades are more susceptible. The aim of the study is to evaluate the effect of socio-economic status, age and sex on antibody titre profile to Salmonella typhi and praratyphi in Ile-Ife, using both healthy individuals with immunological scar to Salmonella typhi/paratyphi and enteric fever patients. METHOD: Healthy volunteers (310) were recruited into the study and clinically diagnosed/culture proven cases (48) were used as control. Widal text was performed on each serum. Slide agglutination was first done, then positive samples were further subjected to tube agglutination for quantitative titration. RESULTS: The relationship between age and antibody titres in both healthy subjects and enteric fever patients is not statistically significant, (P values > 0.05). From the study also, sex and social status do not influence antibody titres to salmonella typhi/paratyphi (P value > 0.05). CONCLUSION: The study has shown that age, sex and social class do not statistically influence antibody titre profile to S. typhi/paratyphi in Ile-Ife, south western Nigeria.

Determination of baseline antibody titre to S. typhi/paratyphi in Ile-Ife, Nigeria.

The aim of the study is to determine the baseline antibody titres to Salmonella typhi/paratyphi in healthy individuals with a view to establishing the significant titre for Widal agglutination test in Ile-Ife, Western Nigeria. Three hundred and ten healthy volunteers were admitted into the study and forty-eight clinically diagnosed and culture positive cases of Enteric fever were used as purposeful controls. Widal test was performed on each serum. Slide agglutination test was first done, then positive samples were further subjected to tube agglutination for quantitative titration. Of the 310 healthy volunteers, 274 (97.2%) had reciprocal antibody titre of < or = 80 to O antigen and 265 (95.0%) had reciprocal antibody titre of < or = 80 to H. antigen of S. typhi. On the other hand, in 48 control cases, 43 (89.6%) had reciprocal antibody titre of > or = 160 to O antigen and 38 (78.2%) had reciprocal titre of > or = 160 to H. antigen. The sensitivity and specificity of the test were 89.9% and 94.2% for O antibody, and 79.2% and 92.3% for H. antibody respectively. The baseline titre to S. typhi/paratyphi for both O & H antibody is 1:80 whilst the significant titre for O & H antibodies is 1:160 and above in Ile-Ife, Nigeria.

Role of Campylobacter jejuni/coli in diarrhoea in Ile-Ife, Nigeria.

BACKGROUND: Campylobacter jejuni/coli are well established causative agents of diarrhoea. In Nigeria, gastroenteritis due to C. jejuni was first reported in northern part of the country in 1981 and the South-Western part in Ile-Ife in 1983. OBJECTIVE: To re-examine the role of C. jejuni as an agent of diarrhoea after more than a decade at Ile-Ife, Nigeria and to determine the biological characteristics of local strains. DESIGN: A prospective case control study. SETTING: Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife, Nigeria. SUBJECTS: Three hundred and three children with diarrhoea and 100 children with other medical conditions other than diarrhoea were randomly selected. MAIN OUTCOME MEASURES: Isolation of C. jejuni/coli from stool samples collected from the patients and controls. Biological characteristics of the isolates. RESULTS: Fifty eight (19.1%) and 6% of the patients and controls, had the organism respectively. Campylobacter coli accounts for 53.3% of isolates. All the isolates were susceptible to erythromycin and there was no evidence of beta-lactamase production. CONCLUSION: Campylobacter jejuni is an important diarrhoea agent in our environment and should be considered strongly in children with diarrhoea. Complete characterization of local, strains is necessary.

Sero-prevalence of HIV antibodies in tuberculosis patients in Ile-Ife, Nigeria.

BACKGROUND: The acquired immunodeficiency syndrome (AIDS) is of major public health concern worldwide more so in sub-Saharan Africa where there is an upsurge in the incidence of the disease. Reports from developed countries have shown that a close link exists between the human immunodeficiency virus (HIV) and pulmonary tuberculosis. No such study has ever been carried out in Ile-Ife, Nigeria. OBJECTIVE: The study was designed to determine the prevalence of HIV infection among randomly selected tuberculosis patients seen in a Nigerian chest clinic using third generation ELISA kits that detect HIV-1 and HIV-2 strains. RESULTS: Of the 79 subjects with confirmed active tuberculosis, 12.7% tested positive for HIV antibodies compared with 2.0% of subjects without tuberculosis designated as the control group--a value that is statistically significant (p < 0.05). Farmers, artisans and students contributed a large proportion of the seropositive sera. Although the seroprevalence rate of 12.7% is low compared with the rates from eastern and southern African countries, this value was threefold higher than 5.2% value reported in metropolitan Lagos--suggesting concern about the spread of HIV in a semi-urban centre such as Ile-Ife. CONCLUSION: This study suggests that a close link exists between active tuberculosis and HIV infection in Ile-Ife, Nigeria which underscores the urgent need to monitor tuberculosis patients as the increase in the rate of new cases may indicate the spread of HIV infection. The study also recommends that an aggressive public awareness programme be undertaken to enlighten communities about the risk of TB/HIV infection.