Evaluating an antimicrobial stewardship programme implemented in an intensive care unit of a large academic hospital, using the RE-AIM framework.

BACKGROUND: The threat of antimicrobial resistance driven by inappropriate and unnecessary use of antimicrobials is a global issue of great concern. Evidence-based approaches to optimising antimicrobial prescribing to improve patient care while reducing the rate of antimicrobial resistance continue to be implemented worldwide. However, the successes or failures of implementation of such approaches are seldom evaluated. OBJECTIVES: To evaluate the impact of an implemented antimicrobial stewardship programme (ASP) in reducing the spread of antimicrobial resistance in the intensive care unit (ICU) of a large academic hospital using the RE-AIM framework. METHODS: A descriptive quasi-experimental study was conducted with adult patients who had been admitted to the ICU of an academic hospital in Johannesburg, South Africa. Data were extracted from patients' records using a structured questionnaire. Descriptive statistics of four RE-AIM dimensions (reach, effectiveness, adoption and implementation) and the overall impact of the implemented antimicrobial stewardship programme were calculated. RESULTS: From the 59 participant records, 21 patients (35.6%) developed hospital-acquired infections and all were prescribed antimicrobials during their stay in the ICU. Twenty-seven pathogens (bacterial species) were isolated from samples acquired from the patients, including Staphylococcus aureus (n=6; 22.2%), Escherichia coli (n=4; 14.8%), Acinetobacter baumannii (n=4; 14.8%) and Streptococcus pnuemoniae (n=3; 11.11%), as well as 10 other bacterial species (37.0%) including Corynebacterium species, Enterococcus faecium, Haemophilus influenzae, Klebsiella species, Clostridium difficile and Salmonella species. Of the 27 pathogens isolated, 19 (70.4 %) were resistant to the prescribed antimicrobials. The overall impact of the ASP implemented in the studied facility was 67.2%. CONCLUSIONS: An ASP requires both thorough implementation and leadership support to have an impact in the reduction of antimicrobial resistance. Lack of leadership support poses a significant challenge to sustainability. There is an urgent need for behavioural change in hospital leadership.

Nurses' communication with patients who are mechanically ventilated in intensive care: the Botswana experience.

BACKGROUND: Communication is an integral part of nursing practice not just only for therapeutic reasons but also for sharing information. Nurses working in intensive care experience challenges when communicating with patients who are mechanically ventilated due to lack of knowledge and skill. These challenges infringe on the patients' rights to receive information and as such they may impact negatively on the patients' outcomes. AIM: This study determined the existing knowledge and skills of intensive care nurses working with mechanically ventilated patients in Botswana. METHODS: A retrospective descriptive and explorative research design with a quantitative approach was used to audit patients' records. This was augmented by further interviewing nurses for their knowledge and skills when communicating with ventilated patients within the two intensive care units in Botswana. The American Association of Critical Nurses Synergy Model was used to guide the study. One hundred and fifty-nine (159) patients' files were audited and 50 nurses chosen by purposive sampling completed a self-administered 42-item questionnaire. Statistical Package for Social Sciences version 10 and Microsoft Excel were used to analyse the data. RESULTS: Assessment of patients' ability to communicate was recorded in more than 90% of files audited. Four per cent (4%) of the respondents only communicated essential information and no other strategies or devices were used to aid communication. CONCLUSION: Communication with ventilated patients can be quite challenging to nurses working in the intensive care unit. There is a need for communication skills training to ensure that all nurses working with mechanically ventilated patients are properly trained, equipped and capable of communicating effectively with the patient. IMPLICATIONS FOR NURSING AND HEALTH POLICY: A greater understanding of communication dynamics with the intensive care unit with patients who are mechanically ventilated is crucial to enable nurses to improve their care and improve patients' comfort. Incorporating communication in the nursing standards would ensure that patients are treated with dignity which would help improve patient outcomes.

One-electron oxidation and reduction of glycosaminoglycan chloramides: a kinetic study.

Hypochlorous acid and its acid-base counterpart, hypochlorite ions, produced under inflammatory conditions, may produce chloramides of glycosaminoglycans, these being significant components of the extracellular matrix (ECM). This may occur through the binding of myeloperoxidase directly to the glycosaminoglycans. The N-Cl group in the chloramides is a potential selective target for both reducing and oxidizing radicals, leading possibly to more efficient and damaging fragmentation of these biopolymers relative to the parent glycosaminoglycans. In this study, the fast reaction techniques of pulse radiolysis and nanosecond laser flash photolysis have been used to generate both oxidizing and reducing radicals to react with the chloramides of hyaluronan (HACl) and heparin (HepCl). The strong reducing formate radicals and hydrated electrons were found to react rapidly with both HACl and HepCl with rate constants of 1-1.7 × 10(8) and 0.7-1.2 × 10(8)M(-1)s(-1) for formate radicals and 2.2 × 10(9) and 7.2 × 10(8)M(-1)s(-1) for hydrated electrons, respectively. The spectral characteristics of the products of these reactions were identical and were consistent with initial attack at the N-Cl groups, followed by elimination of chloride ions to produce nitrogen-centered radicals, which rearrange subsequently and rapidly to produce C-2 radicals on the glucosamine moiety, supporting an earlier EPR study by M.D. Rees et al. (J. Am. Chem. Soc.125: 13719-13733; 2003). The oxidizing hydroxyl radicals also reacted rapidly with HACl and HepCl with rate constants of 2.2 × 10(8) and 1.6 × 10(8)M(-1)s(-1), with no evidence from these data for any degree of selective attack on the N-Cl group relative to the N-H groups and other sites of attack. The carbonate anion radicals were much slower with HACl and HepCl than hydroxyl radicals (1.0 × 10(5) and 8.0 × 10(4)M(-1)s(-1), respectively) but significantly faster than with the parent molecules (3.5 × 10(4) and 5.0 × 10(4)M(-1)s(-1), respectively). These findings suggest that these potential in vivo radicals may react in a site-specific manner with the N-Cl group in the glycosaminoglycan chloramides of the ECM, possibly to produce more efficient fragmentation. This is the first study therefore to conclusively demonstrate that reducing radicals react rapidly with glycosaminoglycan chloramides in a site-specific attack at the N-Cl group, probably to produce a 100% efficient biopolymer fragmentation process. Although less reactive, carbonate radicals, which may be produced in vivo via reactions of peroxynitrite with serum levels of carbon dioxide, also appear to react in a highly site-specific manner at the N-Cl group. It is not yet known if such site-specific attacks by this important in vivo species lead to a more efficient fragmentation of the biopolymers than would be expected for attack by the stronger oxidizing species, the hydroxyl radical. It is clear, however, that the N-Cl group formed under inflammatory conditions in the extracellular matrix does present a more likely target for both reactive oxygen species and reducing species than the N-H groups in the parent glycosaminoglycans.

Reaction of superoxide radicals with glycosaminoglycan chloramides: a kinetic study.

Hypochlorous acid and its acid-base counterpart, hypochlorite ions, produced under inflammatory conditions, may produce chloramides of glycosaminoglycans, perhaps through the binding of myeloperoxidase directly to the glycosaminoglycans. The N-Cl group in the chloramides is a potential target for reducing species such as Cu(I) and superoxide radicals. Laser flash photolysis has been used here to obtain, for the first time, the rate constants for the direct reaction of superoxide radicals with the chloramides of hyaluronan and heparin. The rate constants were in the range 2.2-2.7 × 10(3)M(-1)s(-1). The rate constant for the reaction with the amino acid taurine was found to be much lower, at 3.5-4.0 × 10(2)M(-1)s(-1). This demonstration that superoxide anion radicals react directly with hyaluronan and heparin chloramides may support the mechanism first proposed by M.D. Rees et al. (Biochem. J.381, 175-184, 2004) for an efficient fragmentation of these glycosaminoglycans in the extracellular matrix under inflammatory conditions.

Village chicken flock dynamics and the contribution of chickens to household livelihoods in a smallholder farming area in Zimbabwe.

The development of successful production strategies for poultry rearing depends on an accurate description of village chicken production systems. In Rushinga District of Zimbabwe, participatory rural appraisals (PRAs) followed by checklists and intensive case studies were carried out in three villages. The role of chickens in the livelihoods of households was evaluated. Flock dynamics were monitored monthly for 24 months. Women who were resident on the farm headed 19% of the households. A household comprised 4.8 +/- 2.5 members with arable land of approximately 2.6 ha. In addition to chickens, households grew maize, cotton and sunflower and kept large animals. Flocks ranging from 1 to 50 village chickens per household were reared under a scavenging system of management with suboptimal housing, inadequate feeding and poor health care. The use of ethno-veterinary medicine was common in treating sick chickens. The largest flock sizes were observed in the hot-wet season. Over 90% of an average of 5.4 entries/household per month were from hatched chicks. Mortality claimed an average of 80% of the total exits. Chicken production potential (CPP), which defined the proportion of chickens that could be utilized by a household, averaged 50%. Chicken production efficiency (CPE) was approximately 15% of the CPP. Egg consumption patterns were low and similar across seasons.

Reproduction and lactational performance of cattle in a smallholder dairy system in Zimbabwe.

A study was conducted in two adjacent locations. Nharira (communal) and Lancashire (small-scale commercial) farming areas in Zimbabwe to characterize the breeds and evaluate the reproductive and lactation performance of dairy cattle under smallholder management. The types of cows identified were Friesian, Jersey and Red Dane, and an indigenous Sanga breed called the Mashona and its crossbreds. Both sectors used more exotic and crossbred cows than indigenous cows. The mean monthly weights of the dairy cows were higher in Lancashire than in Nharira and the calving intervals were longer in Nharira than in Lancashire. The mean age at first calving was higher and the mean total lactation yields were greater in Nharira than in Lancashire, but the mean 305-day lactation yields were not significantly different. The mean lactation lengths were longer for the cows from Nharira. It was concluded that the reproductive and lactation performances were low. The calving intervals were extended, probably owing to suboptimal nutrition and heat stress, particularly during the dry season, and to poor management practices, such as delayed mating due to the poor availability of bulls.

Review of the prevalence of malaria in Zimbabwe with specific reference to parasite drug resistance (1984-96).

The response of Plasmodium falciparum malaria to antimalarial drugs, mainly chloroquine, the first-line drug of choice for the treatment of malaria in Zimbabwe is reported here for the period 1984-96. Earlier studies (1982-83) had shown that Zimbabwe was free from drug-resistant falciparum malaria. The first chloroquine-resistant cases of malaria were reported in 1984 in the Zambezi Valley in the north-east of Zimbabwe. Following this report several cases of chloroquine resistance have been reported throughout the malaria-endemic regions of the country thus prompting the Ministry of Health to develop a sustainable national surveillance strategy to monitor, on an annual basis, the spread and extent of P. falciparum resistance to antimalarial drugs available to the National Malaria Control Programme (NMCP). Of all the antimalarial drugs assessed in vivo, only chloroquine and halofantrine have shown resistance, while no resistance in vivo was observed for sulfadoxine-pyrimethamine (Fansidar), quinine and mefloquine. The study shows the need to replace chloroquine with alternative antimalarial drugs in areas where chloroquine resistance is high, and an increase in the drug pool against malaria is also recommended considering that all the alternative antimalarial drugs available to the NMCP have faced resistance in various parts of the world.

Effects of sexual condition and age on carcass characteristics and grading of Sussex cattle in Zimbabwe.

The effects of sexual condition and age at slaughter on carcass characteristics were investigated in Sussex cattle. At three months of age 93 male calves were allocated to three sexual treatments: entire, cryptorchid and castrate. The cattle were weaned at eight months, grazed on range and then placed into feedlots for 90 days prior to slaughter at 15, 18 or 21 months of age. Entire and cryptorchid cattle gained more (P < 0.01) weight and had heavier and learner carcasses than the castrates. Although cattle slaughtered at 15 months of age had better fleshing grades than those slaughtered at 18 or 21 months of age, no animal was down-graded for exhibiting marked secondary sexual characteristics.