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Abegaz FA, dos Santos PT, Mogeni OD, Guarnacci T, Poudyal N, Hong J, Kwon SY, Braae R, Prathan R, Tongkum TL, Kamjumpho W, Chuanchuen R, Marks F, Hendriksen RS, Holm M. Evaluating Quality Management and Diagnostics Microbiology Performance Within an International External Quality Assessment (EQA) Program Serving National One Health Sector Reference Laboratories Across Asia: Experience Amid the Coronavirus Disease 2019 (COVID-19) Pandemic. Clin Infect Dis 2023; 77:S588-S596. [PMID: 38118017 PMCID: PMC10732555 DOI: 10.1093/cid/ciad569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
BACKGROUND Strengthening external quality assessment (EQA) services across the One Health sector supports implementation of effective antimicrobial resistance (AMR) control strategies. Here we describe and compare 2 different approaches for conducting virtual laboratory follow-up assessments within an EQA program to evaluate quality management system (QMS) and procedures for pathogen identification and antimicrobial susceptibility testing (AST). METHODS During the coronavirus disease 2019 (COVID-19) pandemic in 2021 and 2022, 2 laboratory assessment approaches were introduced: virtual-based and survey-based methodologies. The evaluation of 2 underperforming Animal Health laboratories through a virtual-based approach occurred between May and August 2021. This evaluation encompassed the utilization of 3 online meetings and document reviews, performed subsequent to the execution of EQA procedures. Within a distinct group of laboratories, the survey-based assessment was implemented from December 2021 to February 2022, also following EQA procedures. This phase encompassed the dissemination of an online survey to 31 participating laboratories, alongside a sole online consultation meeting involving 4 specific underperforming laboratories. RESULTS The virtual-based assessment post-EQA aimed to identify gaps and areas for improvement in the laboratory's practices for pathogen identification and AST. This approach was, however, time-intensive, and, hence, only 2 laboratories were assessed. In addition, limited interactions in virtual platforms compromised the assessment quality. The survey-based post-EQA assessment enabled evaluation of 31 laboratories. Despite limitations for in-depth analysis of each procedure, gaps in QMS across multiple laboratories were identified and tailored laboratory-specific recommendations were provided. CONCLUSIONS Reliable internet and plans for efficient time management, post-EQA virtual laboratory follow-up assessments are an effective alternative when conducting onsite evaluation is infeasible as observed during the COVID-19 pandemic, although the successful implementation of remediation plans will likely require in person assessments. We advocate application of hybrid approaches (both onsite and virtual) for targeted capacity building of AMR procedures with the ability to implement and oversee the process.
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Affiliation(s)
| | - Patrícia Teixeira dos Santos
- The Technical University of Denmark, National Food Institute, WHO Collaborating Center for Antimicrobial Resistance in Foodborne Pathogens and Genomics and European Union Reference Laboratory for Antimicrobial Resistance, FAO Reference Laboratory for Antimicrobial Resistance, Kgs. Lyngby, Denmark
| | | | | | - Nimesh Poudyal
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jinhui Hong
- International Vaccine Institute, Seoul, Republic of Korea
| | - Soo Young Kwon
- International Vaccine Institute, Seoul, Republic of Korea
| | - Rikke Braae
- The Technical University of Denmark, National Food Institute, WHO Collaborating Center for Antimicrobial Resistance in Foodborne Pathogens and Genomics and European Union Reference Laboratory for Antimicrobial Resistance, FAO Reference Laboratory for Antimicrobial Resistance, Kgs. Lyngby, Denmark
| | - Rangsiya Prathan
- Research Unit for Microbial Food Safety and Antimicrobial Resistance, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Taradon Luang Tongkum
- Research Unit for Microbial Food Safety and Antimicrobial Resistance, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | | | - Rungtip Chuanchuen
- Research Unit for Microbial Food Safety and Antimicrobial Resistance, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Madagascar Institute for Vaccine Research, University of Antananarivo, Antananarivo, Madagascar
| | - Rene S Hendriksen
- The Technical University of Denmark, National Food Institute, WHO Collaborating Center for Antimicrobial Resistance in Foodborne Pathogens and Genomics and European Union Reference Laboratory for Antimicrobial Resistance, FAO Reference Laboratory for Antimicrobial Resistance, Kgs. Lyngby, Denmark
| | - Marianne Holm
- International Vaccine Institute, Seoul, Republic of Korea
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Boakye-Yiadom E, Najjemba R, Thekkur P, Labi AK, Gil-Cuesta J, Asafo-Adjei K, Mensah P, van Boetzelaer E, Jessani NS, Orish VN. Use and Quality of Blood Cultures for the Diagnosis of Bloodstream Infections: A Cross-Sectional Study in the Ho Teaching Hospital, Ghana, 2019-2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6631. [PMID: 37681771 PMCID: PMC10487590 DOI: 10.3390/ijerph20176631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/22/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023]
Abstract
Blood Culture and Drug Susceptibility Testing (CDST) remains vital for the diagnosis and management of bloodstream infections (BSIs). While the Ghana National Standard Treatment Guidelines require CDST to be performed in each case of suspected or clinically diagnosed BSI, these are poorly adhered to in the Ho Teaching Hospital (HTH). This study used secondary medical and laboratory records to describe blood CDST requests by clinicians and the quality of CDST processes for the diagnosis of BSI among patients admitted to HTH from 2019 to 2021. Of 4278 patients, 33% were infants. Pneumonia and neonatal sepsis cases were 40% and 22%, respectively. Only 8% (351/4278) had blood CDST requested. Of 94% (329/351) blood CDST processed and reported, only 7% (22/329) were culture-positive, with likely contaminants being recovered from 16% (52/329) of the specimens. The duration from admission to request was 2 days (IQR: 0-5), and Further qualitative studies must be conducted to understand the reasons for low blood CDST utilisation among clinicians and the patient outcomes. Targeted interventions are required to enhance the utilisation of blood CDST by clinicians and the quality of laboratory processes.
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Affiliation(s)
- Emily Boakye-Yiadom
- Department of Microbiology and Immunology, University of Health and Allied Sciences, Ho PMB 31, Volta Region, Ghana;
- Laboratory Department, Ho Teaching Hospital, Ho P.O. Box MA 374, Volta Region, Ghana; (K.A.-A.); (P.M.)
| | | | - Pruthu Thekkur
- International Union Against Tuberculosis and Lung Disease, 68 Boulevard Saint Michel, 75006 Paris, France;
| | - Appiah-Korang Labi
- Ghana Country Office, World Health Organization, 7 Ameda Street, Roman Ridge, Accra P.O. Box MB 142, Ghana;
| | - Julita Gil-Cuesta
- Luxembourg Operational Research Unit, Operational Centre Brussels, Médecins Sans Frontières, Rue Arbre Benit 46, 1050 Brussels, Belgium;
| | - Karikari Asafo-Adjei
- Laboratory Department, Ho Teaching Hospital, Ho P.O. Box MA 374, Volta Region, Ghana; (K.A.-A.); (P.M.)
| | - Prosper Mensah
- Laboratory Department, Ho Teaching Hospital, Ho P.O. Box MA 374, Volta Region, Ghana; (K.A.-A.); (P.M.)
| | - Elburg van Boetzelaer
- Luxembourg Operational Research Unit, Médecins Sans Frontières, 68 Rue de Gasperich, L-1617 Luxembourg, Luxembourg;
| | - Nasreen S. Jessani
- Centre for Evidence-Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Tygerburg 7505, South Africa;
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
| | - Verner Ndudri Orish
- Department of Microbiology and Immunology, University of Health and Allied Sciences, Ho PMB 31, Volta Region, Ghana;
- Sickle Cell Disease Unit, Department of Internal Medicine, Ho Teaching Hospital, Ho P.O. Box MA 374, Volta Region, Ghana
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3
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Tanasiichuk I, Karaman O, Natrus L. Key success factors for the implementation of quality management systems in developing countries. Afr J Lab Med 2023; 12:2058. [PMID: 36756216 PMCID: PMC9900284 DOI: 10.4102/ajlm.v12i1.2058] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023] Open
Abstract
Background Despite the tremendous progress made in advancing laboratory medicine in low- and middle-income countries (LMICs), inadequate quality management systems (QMSs) remain a problem and barrier to provision of reliable laboratory services in resource-limited settings. Therefore, it is useful to study the experience of medical laboratories in LMICs that have successfully implemented QMS. Aim This review identified key success factors (KSFs) for medical laboratories in LMICs implementing QMS in accordance with the International Organization for Standardization standard 15189 as a pathway to improving laboratory quality. Methods Applying Preferred Reporting Items for Systematic Reviews procedures, we conducted a targeted search of studies from LMICs published between 2012 and 2022 to identify KSFs. Thirty-two out of 952 references retrieved were considered relevant and included in this review. Grounded theory was used to extract key features of the included studies to derive KSFs. Results Ten KSFs for medical laboratories striving to implement QMS were identified and described. These KSFs were integrated to create a model of success for laboratory QMS implementation. The model consists of three underlying factors, namely preparing for change, resource availability, and effective project management, each comprising three separate KSFs. Institutional commitment was identified as the core of the model and is integral to ensuring the quality of laboratory services. Conclusion Laboratories planning to implement a QMS can benefit from understanding the KSFs demonstrated in this study as this would help them to identify the necessary changes to implement and set realistic expectations about the outcomes of QMS implementation.
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Affiliation(s)
- Iryna Tanasiichuk
- Department of Modern Technologies of Medical Diagnostics and Treatment, Institute of Postgraduate Education, Bogomolets National Medical University, Kyiv, Ukraine
| | - Olha Karaman
- Laboratory of Oncoimmunology and Design of Tumor Vaccines, R.E. Kavetsky Institute of Experimental Pathology, Oncology and Radiobiology, National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - Larysa Natrus
- Department of Modern Technologies of Medical Diagnostics and Treatment, Institute of Postgraduate Education, Bogomolets National Medical University, Kyiv, Ukraine
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Costa SP, Carvalho CM. Burden of bacterial bloodstream infections and recent advances for diagnosis. Pathog Dis 2022; 80:6631550. [PMID: 35790126 DOI: 10.1093/femspd/ftac027] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/07/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Bloodstream infections (BSIs) and subsequent organ dysfunction (sepsis and septic shock) are conditions that rank among the top reasons for human mortality and have a great impact on healthcare systems. Their treatment mainly relies on the administration of broad-spectrum antimicrobials since the standard blood culture-based diagnostic methods remain time-consuming for the pathogen's identification. Consequently, the routine use of these antibiotics may lead to downstream antimicrobial resistance and failure in treatment outcomes. Recently, significant advances have been made in improving several methodologies for the identification of pathogens directly in whole blood especially regarding specificity and time to detection. Nevertheless, for the widespread implementation of these novel methods in healthcare facilities, further improvements are still needed concerning the sensitivity and cost-effectiveness to allow a faster and more appropriate antimicrobial therapy. This review is focused on the problem of BSIs and sepsis addressing several aspects like their origin, challenges, and causative agents. Also, it highlights current and emerging diagnostics technologies, discussing their strengths and weaknesses.
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Affiliation(s)
- Susana P Costa
- Centre of Biological Engineering, University of Minho, Campus de Gualtar, 4710-057, Braga, Portugal.,LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.,International Iberian Nanotechnology Laboratory, Av. Mestre José Veiga s/n, 4715-330, Braga, Portugal.,Instituto de Engenharia de Sistemas e Computadores - Microsistemas e Nanotecnologias (INESC MN) and IN - Institute of Nanoscience and Nanotechnology, Rua Alves Redol, 9 1000-029 Lisbon, Portugal
| | - Carla M Carvalho
- International Iberian Nanotechnology Laboratory, Av. Mestre José Veiga s/n, 4715-330, Braga, Portugal
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Chugh TD, Duggal AK, Duggal SD. Patient Safety, Clinical Microbiology, and Collaborative Healthcare. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2022. [DOI: 10.1055/s-0042-1744390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Abstract“Right to health” is a universal right inclusive of a culture of safety. This review aims to highlight how clinical microbiology laboratories can contribute to patient safety. They can bring down medical errors through clinical collaboration and quality control. Timely and accurate inputs from microbiology laboratory help in clinical correlation and aid in safe patient care. Through internet search, using keywords such as “medical errors” and “quality assurance,” global burden of medical errors has been compiled. References have been taken from guidelines and documents of standard national and international agencies, systematic reviews, observational studies, retrospective analyses, meta-analyses, health bulletins and reports, and personal views. Safety in healthcare should lay emphasis on prevention, reporting, analysis, and correction of medical errors. If not recorded, medical errors are regarded as occasional or chance events. Global data show adverse events are as high as 10% among hospitalized patients, and approximately two-thirds of these are reported from low- to middle-income countries (LMICs). This includes errors in laboratories as well. Clinical microbiology can impact patient safety when practiced properly with an aim to detect, control, and prevent infections at the earliest. It is a science that integrates a tripartite relationship between the patient, clinician, and a microbiology specialist. Through collaborative healthcare, all stakeholders benefit by understanding common errors and mitigate them through quality management. However, errors tend to happen despite standardization and streamlining all processes. The aim should be to minimize them, have fair documentation, and learn from mistakes to avoid repetition. Local targets should be set and then extended to meet national and global benchmarks.
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Affiliation(s)
| | - Ashish Kumar Duggal
- Department of Neurology, G. B. Pant Institute of Postgraduate Medical Education and Research, Delhi, India
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Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda. Antibiotics (Basel) 2022; 11:antibiotics11020199. [PMID: 35203802 PMCID: PMC8868487 DOI: 10.3390/antibiotics11020199] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/19/2022] [Accepted: 01/27/2022] [Indexed: 02/04/2023] Open
Abstract
Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.
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7
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Ombelet S, Kpossou G, Kotchare C, Agbobli E, Sogbo F, Massou F, Lagrou K, Barbé B, Affolabi D, Jacobs J. Blood culture surveillance in a secondary care hospital in Benin: epidemiology of bloodstream infection pathogens and antimicrobial resistance. BMC Infect Dis 2022; 22:119. [PMID: 35114948 PMCID: PMC8812239 DOI: 10.1186/s12879-022-07077-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although global surveillance of antimicrobial resistance (AMR) is considered key in the containment of AMR, data from low- and middle-income countries, especially from sub-Saharan Africa, are scarce. This study describes epidemiology of bloodstream infections and antimicrobial resistance rates in a secondary care hospital in Benin. METHODS Blood cultures were sampled, according to predefined indications, in BacT/ALERT FA Plus and PF Plus (bioMérieux, Marcy-l'Etoile, France) blood culture bottles (BCB) in a district hospital (Boko hospital) and to a lesser extent in the University hospital of Parakou. These BCB were incubated for 7 days in a standard incubator and twice daily inspected for visual signs of growth. Isolates retrieved from the BCB were processed locally and later shipped to Belgium for reference identification [matrix-assisted laser desorption/ionization time-of-flight spectrometry (MALDI-TOF)] and antibiotic susceptibility testing (disk diffusion and E-tests). RESULTS From October 2017 to February 2020, 3353 BCB were sampled, corresponding to 3140 blood cultures (212 cultures consisting of > 1 BCB) and 3082 suspected bloodstream infection (BSI) episodes. Most of these cultures (n = 2471; 78.7%) were sampled in children < 15 years of age. Pathogens were recovered from 383 (12.4%) cultures, corresponding to 381 confirmed BSI. 340 of these pathogens were available and confirmed by reference identification. The most common pathogens were Klebsiella pneumoniae (n = 53; 15.6%), Salmonella Typhi (n = 52; 15.3%) and Staphylococcus aureus (n = 46; 13.5%). AMR rates were high among Enterobacterales, with resistance to third-generation cephalosporins in 77.6% of K. pneumoniae isolates (n = 58), 12.8% of Escherichia coli isolates (n = 49) and 70.5% of Enterobacter cloacae isolates (n = 44). Carbapenemase production was detected in 2 Escherichia coli and 2 Enterobacter cloacae isolates, all of which were of the New Delhi metallo-beta lactamase type. Methicillin resistance was present in 22.4% of S. aureus isolates (n = 49). CONCLUSION Blood cultures were successfully implemented in a district hospital in Benin, especially among the pediatric patient population. Unexpectedly high rates of AMR among Gram-negative bacteria against commonly used antibiotics were found, demonstrating the clinical and scientific importance of clinical bacteriology laboratories at this level of care.
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Affiliation(s)
- Sien Ombelet
- Institute of Tropical Medicine, Antwerp, Belgium.
- Department of Microbiology, Immunology & Transplantation, KU Leuven, Leuven, Belgium.
| | | | | | - Esenam Agbobli
- Centre National Hospitalier Universitaire Hubert Koutougou MAGA de Cotonou (CNHU-HKM), Cotonou, Benin
- National Reference Laboratory for Mycobacteria, Cotonou, Benin
| | - Frédéric Sogbo
- Centre National Hospitalier Universitaire Hubert Koutougou MAGA de Cotonou (CNHU-HKM), Cotonou, Benin
- National Reference Laboratory for Mycobacteria, Cotonou, Benin
| | - Faridath Massou
- Centre National Hospitalier Universitaire Hubert Koutougou MAGA de Cotonou (CNHU-HKM), Cotonou, Benin
- National Reference Laboratory for Mycobacteria, Cotonou, Benin
| | - Katrien Lagrou
- Department of Microbiology, Immunology & Transplantation, KU Leuven, Leuven, Belgium
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Dissou Affolabi
- Centre National Hospitalier Universitaire Hubert Koutougou MAGA de Cotonou (CNHU-HKM), Cotonou, Benin
- National Reference Laboratory for Mycobacteria, Cotonou, Benin
| | - Jan Jacobs
- Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology, Immunology & Transplantation, KU Leuven, Leuven, Belgium
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8
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Begg S, Wright A, Small G, Kirby M, Moore S, Koudou B, Kisinza W, Abdoulaye D, Moore J, Malima R, Kija P, Mosha F, Edi C, Bates I. Multi-site comparison of factors influencing progress of African insecticide testing facilities towards an international Quality Management System certification. PLoS One 2021; 16:e0259849. [PMID: 34780512 PMCID: PMC8592480 DOI: 10.1371/journal.pone.0259849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 10/27/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Insecticidal mosquito vector control products are vital components of malaria control programmes. Test facilities are key in assessing the effectiveness of vector control products against local mosquito populations, in environments where they will be used. Data from these test facilities must be of a high quality to be accepted by regulatory authorities, including the WHO Prequalification Team for vector control products. In 2013-4, seven insecticide testing facilities across sub-Saharan Africa, with technical and financial support from Innovative Vector Control Consortium (IVCC), began development and implementation of quality management system compliant with the principles of Good Laboratory Practice (GLP) to improve data quality and reliability. METHODS AND PRINCIPLE FINDINGS We conducted semi-structured interviews, emails, and video-call interviews with individuals at five test facilities engaged in the IVCC-supported programme and working towards or having achieved GLP. We used framework analysis to identify and describe factors affeting progress towards GLP. We found that eight factors were instrumental in progress, and that test facilities had varying levels of control over these factors. They had high control over the training programme, project planning, and senior leadership support; medium control over infrastructure development, staff structure, and procurement; and low control over funding the availability and accessibility of relevant expertise. Collaboration with IVCC and other partners was key to overcoming the challenges associated with low and medium control factors. CONCLUSION For partnership and consortia models of research capacity strengthening, test facilities can use their own internal resources to address identified high-control factors. Project plans should allow additional time for interaction with external agencies to address medium-control factors, and partners with access to expertise and funding should concentrate their efforts on supporting institutions to address low-control factors. In practice, this includes planning for financial sustainability at the outset, and acting to strengthen national and regional training capacity.
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Affiliation(s)
- Sara Begg
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
| | - Alex Wright
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, United Kingdom
| | - Graham Small
- Innovative Vector Control Consortium, Pembroke Place, Liverpool, United Kingdom
| | - Matt Kirby
- London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London, United Kingdom
- KCMUCo-PAMVERC, KCMUCo-PAMVERC Test Facility, Moshi, Tanzania
| | - Sarah Moore
- Ifakara Health Institute, Off Mlabani Passage, Ifakara, Tanzania
| | - Ben Koudou
- Centre Suisse de Recherches Scientifques en Côte D’Ivoire, Route de Dabou, Abidjan, Côte d’Ivoire
| | - William Kisinza
- National Institute of Medical Research, Amani Centre, Amani Medical Research Centre, Muheza, Tanzania
| | - Diabate Abdoulaye
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso, Côte d’Ivoire
| | - Jason Moore
- Ifakara Health Institute, Off Mlabani Passage, Ifakara, Tanzania
| | - Robert Malima
- National Institute of Medical Research, Amani Centre, Amani Medical Research Centre, Muheza, Tanzania
| | - Patrick Kija
- National Institute of Medical Research, Amani Centre, Amani Medical Research Centre, Muheza, Tanzania
| | - Frank Mosha
- KCMUCo-PAMVERC, KCMUCo-PAMVERC Test Facility, Moshi, Tanzania
| | - Constant Edi
- Centre Suisse de Recherches Scientifques en Côte D’Ivoire, Route de Dabou, Abidjan, Côte d’Ivoire
| | - Imelda Bates
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
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von Laer A, N'Guessan MA, Touré FS, Nowak K, Groeschner K, Ignatius R, Friesen J, Tomczyk S, Leendertz FH, Eckmanns T, Akoua-Koffi C. Implementation of Automated Blood Culture With Quality Assurance in a Resource-Limited Setting. Front Med (Lausanne) 2021; 8:627513. [PMID: 34095162 PMCID: PMC8176090 DOI: 10.3389/fmed.2021.627513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/23/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Blood cultures (BC) have a high clinical relevance and are a priority specimen for surveillance of antimicrobial resistance. Manual BC are still most frequently used in resource-limited settings. Data on automated BC performance in Africa are scarce. We implemented automated BC at a surveillance site of the African Network for improved Diagnostics, Epidemiology and Management of Common Infectious Agents (ANDEMIA). Methods: Between June 2017 and January 2018, pairs of automated BC (BacT/ALERT®FA Plus) and manual BC (brain-heart infusion broth) were compared at a University hospital in Bouaké, Côte d'Ivoire. BC were inoculated each with a target blood volume of 10 ml from the same venipuncture. Automated BC were incubated for up to 5 days, manual BC for up to 10 days. Terminal subcultures were performed for manual BC only. The two systems were compared regarding yield, contamination, and turnaround time. For quality assurance, isolates were retested in a German routine microbiological laboratory. Results: BC sampling was increased from on average 24 BC to 63 BC per month. A total of 337 matched pairs of BC were included. Automated BC was positive in 36.5%, manual BC in 24.0% (p-value < 0.01), proportion of contamination was 47.9 and 43.8%, respectively (p-value = 1.0). Turnaround time of positive BC was shortened by 2.5 days with automated compared to manual BC (p < 0.01). Most common detected pathogens in both systems were Klebsiella spp. (26.0%) and Staphylococcus aureus (18.2%). Most contaminants were members of the skin flora. Retesting of 162 isolates was concordant in 79.6% on family level. Conclusions: Implementing automated BC in a resource-limited setting is possible and improves microbiological diagnostic performance. Automated BC increased yield and shortened turnaround times. Regular training and mentorship of clinicians has to be intensified to increase number and quality of BC. Pre-analytical training to improve diagnostic stewardship is essential when implementing a new microbiological method. Retesting highlighted that manual identification and antimicrobial susceptibility testing can be of good quality and sustainable. The implementation of automated tools should be decided individually according to economic considerations, number of samples, stable supply chain of consumables, and technical sustainability.
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Affiliation(s)
- Anja von Laer
- Postgraduate Training for Applied Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.,Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.,European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | | | - Fidèle Sounan Touré
- Laboratoire Central, Centre Hospitalier et Universitaire de Bouaké, Bouaké, Côte d'Ivoire
| | - Kathrin Nowak
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Karin Groeschner
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Ralf Ignatius
- Department of Microbiology, Medical Care Unit Labor 28 GmbH, Berlin, Germany
| | - Johannes Friesen
- Department of Microbiology, Medical Care Unit Labor 28 GmbH, Berlin, Germany
| | - Sara Tomczyk
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Fabian H Leendertz
- Research Group Epidemiology of Highly Pathogenic Microorganisms, Robert Koch Institute, Berlin, Germany
| | - Tim Eckmanns
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - Chantal Akoua-Koffi
- Laboratoire Central, Centre Hospitalier et Universitaire de Bouaké, Bouaké, Côte d'Ivoire
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10
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Orekan J, Barbé B, Oeng S, Ronat JB, Letchford J, Jacobs J, Affolabi D, Hardy L. Culture media for clinical bacteriology in low- and middle-income countries: challenges, best practices for preparation and recommendations for improved access. Clin Microbiol Infect 2021; 27:1400-1408. [PMID: 34015533 DOI: 10.1016/j.cmi.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Culture media are fundamental in clinical microbiology. In laboratories in low- and middle-income countries (LMICs), they are mostly prepared in-house, which is challenging. OBJECTIVES This narrative review describes challenges related to culture media in LMICs, compiles best practices for in-house media preparation, gives recommendations to improve access to quality-assured culture media products in LMICs and formulates outstanding questions for further research. SOURCES Scientific literature was searched using PubMed and predefined MeSH terms. In addition, grey literature was screened, including manufacturer's websites and manuals as well as microbiology textbooks. CONTENT Bacteriology laboratories in LMICs often face challenges at multiple levels: lack of clean water and uninterrupted power supply, high environmental temperatures and humidity, dust, inexperienced and poorly trained staff, and a variable supply of consumables (often of poor quality). To deal with this at a base level, one should be very careful in selecting culture media. It is recommended to look for products supported by the national reference laboratory that are being distributed by an in-country supplier. Correct storage is key, as is appropriate preparation and waste management. Centralized media acquisition has been advocated for LMICs, a role that can be taken up by the national reference laboratories, next to guidance and support of the local laboratories. In addition, there is an important role in tropicalization and customization of culture media formulations for private in vitro diagnostic manufacturers, who are often still unfamiliar with the LMIC market and the plethora of bacteriology products. IMPLICATION The present narrative review will assist clinical microbiology laboratories in LMICs to establish best practices for handling culture media by defining quality, regulatory and research paths.
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Affiliation(s)
- Jeanne Orekan
- Clinical Microbiology, Centre National Hospitalier Universitaire Hubert Koutoukou Maga, Cotonou, Benin
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Sopheap Oeng
- Laboratory Department, Diagnostic Microbiology Development Program, Phnom Penh, Cambodia
| | - Jean-Baptiste Ronat
- Mini-Lab Project, Médecins Sans Frontières, Paris, France; Team ReSIST, INSERM U1184, School of Medicine University Paris-Saclay, France; Bacteriology-Hygiene Unit, Assistance Publique - Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Joanne Letchford
- Laboratory Department, Diagnostic Microbiology Development Program, Phnom Penh, Cambodia
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Dissou Affolabi
- Clinical Microbiology, Centre National Hospitalier Universitaire Hubert Koutoukou Maga, Cotonou, Benin
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Kabugo J, Namutebi J, Mujuni D, Nsawotebba A, Kasule GW, Musisi K, Kigozi E, Nyombi A, Lutaaya P, Kangave F, Joloba ML. Implementation of GeneXpert MTB/Rif proficiency testing program: A Case of the Uganda national tuberculosis reference laboratory/supranational reference laboratory. PLoS One 2021; 16:e0251691. [PMID: 33989348 PMCID: PMC8121318 DOI: 10.1371/journal.pone.0251691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Following the WHO's endorsement of GeneXpert MTB/RIF assay for tuberculosis diagnosis in 2010, Uganda's ministry of health introduced the assay in its laboratory network in 2012. However, assessing the quality of the result produced from this technique is one of its major implementation challenges. To bridge this gap, the National tuberculosis reference laboratory (NTRL) introduced the GeneXpert MTB/RIF proficiency testing (PT) Scheme in 2015. METHODS A descriptive cross-sectional study on the GeneXpert PT scheme in Uganda was conducted between 2015 and 2018. Sets of panels each comprising four 1ml cryovial liquid samples were sent out to enrolled participants at preset testing periods. The laboratories' testing accuracies were assessed by comparing their reported results to the expected and participants' consensus results. Percentage scores were assigned and feedback reports were sent back to laboratories. Follow up of sites with unsatisfactory results was done through "on and off-site support". Concurrently, standardization of standard operating procedures (SOPs) and practices to the requirements of the International Organization for Standardization (ISO) 17043:2010 was pursued. RESULTS Participants gradually increased during the program from 56 in the pilot study to 148 in Round 4 (2018). Continual participation of a particular laboratory yielded an odd of 2.5 [95% confidence interval (CI), 1.22 to 4.34] times greater for achieving a score of above 80% with each new round it participated. The "on and off-site" support supervision documented improved performance of failing laboratories. Records of GeneXpert MTB/RIF PT were used to achieve accreditation to ISO 17043:2010 in 2018. CONCLUSION Continued participation in GeneXpert MTB/RIF PT improves testing accuracy of laboratories. Effective implementation of this scheme requires competent human resources, facility and equipment, functional quality management system, and adherence to ISO 17043:2010.
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Affiliation(s)
- Joel Kabugo
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Joanita Namutebi
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Dennis Mujuni
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Andrew Nsawotebba
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
- Uganda National Health and Laboratory Diagnostic Services, Kampala, Uganda
| | | | - Kenneth Musisi
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Edgar Kigozi
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Abdunoor Nyombi
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Pius Lutaaya
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Fredrick Kangave
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
| | - Moses L. Joloba
- Uganda National Tuberculosis Reference Laboratory, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
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Ronat JB, Natale A, Kesteman T, Andremont A, Elamin W, Hardy L, Kanapathipillai R, Michel J, Langendorf C, Vandenberg O, Naas T, Kouassi F. AMR in low-resource settings: Médecins Sans Frontières bridges surveillance gaps by developing a turnkey solution, the Mini-Lab. Clin Microbiol Infect 2021; 27:1414-1421. [PMID: 33932617 DOI: 10.1016/j.cmi.2021.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/26/2021] [Accepted: 04/13/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND In low- and middle-income countries (LMICs), data related to antimicrobial resistance (AMR) are often inconsistently collected. Humanitarian, private and non-governmental medical organizations (NGOs), working with or in parallel to public medical systems, are sometimes present in these contexts. Yet, what is the role of NGOs in the fight against AMR, and how can they contribute to AMR data collection in contexts where reporting is scarce? How can context-adapted, high-quality clinical bacteriology be implemented in remote, challenging and underserved areas of the world? OBJECTIVES The aim was to provide an overview of AMR data collection challenges in LMICs and describe one initiative, the Mini-Lab project developed by Médecins Sans Frontières (MSF), that attempts to partially address them. SOURCES We conducted a literature review using PubMed and Google scholar databases to identify peer-reviewed research and grey literature from publicly available reports and websites. CONTENT We address the necessity of and difficulties related to obtaining AMR data in LMICs, as well as the role that actors outside of public medical systems can play in the collection of this information. We then describe how the Mini-Lab can provide simplified bacteriological diagnosis and AMR surveillance in challenging settings. IMPLICATIONS NGOs are responsible for a large amount of healthcare provision in some very low-resourced contexts. As a result, they also have a role in AMR control, including bacteriological diagnosis and the collection of AMR-related data. Actors outside the public medical system can actively contribute to implementing and adapting clinical bacteriology in LMICs and can help improve AMR surveillance and data collection.
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Affiliation(s)
- Jean-Baptiste Ronat
- Médecins Sans Frontières, Paris, France; Team ReSIST, INSERM U1184, School of Medicine University Paris-Saclay, France; Bacteriology-Hygiene Unit, Assistance Publique - Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France.
| | | | | | | | - Wael Elamin
- Clinical Microbiology Department, Queen Mary University, London, UK; Clinical Microbiology Department, Elrazi University, Khartoum, Sudan
| | - Liselotte Hardy
- Unit Tropical Bacteriology, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | | | - Olivier Vandenberg
- Center for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles, Brussels, Belgium; Innovation and Business Development Unit, Laboratoire Hospitalier Universitaire de Bruxelles, Brussels, Belgium; Division of Infection and Immunity, University College London, London, UK
| | - Thierry Naas
- Team ReSIST, INSERM U1184, School of Medicine University Paris-Saclay, France; Bacteriology-Hygiene Unit, Assistance Publique - Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
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Daka V, Mubanga M, Mukanga B, Mfune RL, Chileshe M, Machiko A, Mudenda S, Chikwanda E, Mudenda T, Simusika P, Mwale S, Musalula S. Challenges that may impact achieving and maintaining accreditation in clinical laboratories in Zambia during the COVID-19 pandemic. Pan Afr Med J 2021; 38:290. [PMID: 34122717 PMCID: PMC8179981 DOI: 10.11604/pamj.2021.38.290.27836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Affiliation(s)
- Victor Daka
- Public Health Department, School of Medicine, Copperbelt University, Ndola, Zambia.,University of Zambia, School of Veterinary Medicine, Lusaka, Zambia
| | - Mutale Mubanga
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Bright Mukanga
- Public Health Department, School of Medicine, Copperbelt University, Ndola, Zambia
| | - Ruth Lindizyani Mfune
- Public Health Department, School of Medicine, Copperbelt University, Ndola, Zambia.,University of Zambia, School of Veterinary Medicine, Lusaka, Zambia
| | | | - Alfred Machiko
- Public Health Department, School of Medicine, Copperbelt University, Ndola, Zambia
| | - Steward Mudenda
- University of Zambia, School of Veterinary Medicine, Lusaka, Zambia.,University of Zambia, School of Health Sciences, Lusaka, Zambia
| | | | | | - Paul Simusika
- Public Health Department, School of Medicine, Copperbelt University, Ndola, Zambia
| | - Samson Mwale
- Tropical Diseases Research Centre, Ndola, Zambia
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Burke N, Zacharski K, Adley CC, Southern M. A comparison of analytical test methods in dairy processing. Food Control 2021. [DOI: 10.1016/j.foodcont.2020.107637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Ahmad AF, Tahir M, Ige T, Abdullahi I, Usman Y, Suleiman A. Roles and challenges of clinical microbiology laboratories in antimicrobial stewardship in resource-limited countries: A narrative review. JOURNAL OF CLINICAL SCIENCES 2021. [DOI: 10.4103/jcls.jcls_60_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Pezzani MD, Mazzaferri F, Compri M, Galia L, Mutters NT, Kahlmeter G, Zaoutis TE, Schwaber MJ, Rodríguez-Baño J, Harbarth S, Tacconelli E. Linking antimicrobial resistance surveillance to antibiotic policy in healthcare settings: the COMBACTE-Magnet EPI-Net COACH project. J Antimicrob Chemother 2020; 75:ii2-ii19. [PMID: 33280049 PMCID: PMC7719409 DOI: 10.1093/jac/dkaa425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To systematically summarize the evidence on how to collect, analyse and report antimicrobial resistance (AMR) surveillance data to inform antimicrobial stewardship (AMS) teams providing guidance on empirical antibiotic treatment in healthcare settings. METHODS The research group identified 10 key questions about the link between AMR surveillance and AMS using a checklist of 9 elements for good practice in health research priority settings and a modified 3D combined approach matrix, and conducted a systematic review of published original studies and guidelines on the link between AMR surveillance and AMS. RESULTS The questions identified focused on AMS team composition; minimum infrastructure requirements for AMR surveillance; organisms, samples and susceptibility patterns to report; data stratification strategies; reporting frequency; resistance thresholds to drive empirical therapy; surveillance in high-risk hospital units, long-term care, outpatient and veterinary settings; and surveillance data from other countries. Twenty guidelines and seven original studies on the implementation of AMR surveillance as part of an AMS programme were included in the literature review. CONCLUSIONS The evidence summarized in this review provides a useful basis for a more integrated process of developing procedures to report AMR surveillance data to drive AMS interventions. These procedures should be extended to settings outside the acute-care institutions, such as long-term care, outpatient and veterinary. Without proper AMR surveillance, implementation of AMS policies cannot contribute effectively to the fight against MDR pathogens and may even worsen the burden of adverse events from such interventions.
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Affiliation(s)
- Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Fulvia Mazzaferri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Monica Compri
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Nico T Mutters
- Bonn University Hospital, Institute for Hygiene and Public Health, Bonn, Germany
| | - Gunnar Kahlmeter
- Department of Clinical Microbiology, Växjö Central Hospital, Växjö, Sweden
| | - Theoklis E Zaoutis
- Perelman School of Medicine at the University of Pennsylvania, Infectious Diseases Division, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mitchell J Schwaber
- National Centre for Infection Control, Israel Ministry of Health and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jesús Rodríguez-Baño
- Division of Infectious Diseases, Microbiology and Preventive Medicine, Hospital Universitario Virgen Macarena/Department of Medicine, University of Seville/Biomedicine Institute of Seville (IBiS), Seville, Spain
| | - Stephan Harbarth
- Infection Control Program, World Health Organization Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
- Infectious Diseases, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
- German Centre for Infection Research (DZIF), Clinical Research Unit for Healthcare Associated Infections, Tübingen, Germany
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17
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Bediako-Bowan AAA, Kurtzhals JAL, Mølbak K, Labi AK, Owusu E, Newman MJ. High rates of multi-drug resistant gram-negative organisms associated with surgical site infections in a teaching hospital in Ghana. BMC Infect Dis 2020; 20:890. [PMID: 33238903 PMCID: PMC7689982 DOI: 10.1186/s12879-020-05631-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There is limited data to guide the prevention and management of surgical site infections (SSI) in low- and middle-income countries. We prospectively studied aetiological agents associated with SSI and their corresponding antibiotic susceptibility patterns in a tertiary hospital in Ghana. METHODS As part of a cohort study carried out at the surgical department of the Korle Bu Teaching Hospital (KBTH) from July 2017 to April 2019, wound swabs were collected from patients diagnosed with SSI. Isolates cultured from the wound swabs were identified by MALDI TOF and susceptibility testing was conducted according to EUCAST 2020 guidelines. Clinical data were monitored prospectively. RESULTS Of 4577 patients, 438 developed an SSI and 352 microbial isolates were cultured. Isolates were predominantly Gram negative (286, 81%), a pattern seen for all kinds of surgery and all wound classes. The most common species included Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Acinetobacter baumannii. The majority of organisms were multi-drug resistant including 86% of E. coli, 52% of A. baumannii and 86% of K. pneumoniae; and 65% (17/26) of the cefotaxime-resistant K. pneumoniae were extended spectrum β-lactamase producing. One of 139 E. coli, 15 of 49 P. aeruginosa, and 6 of 23 A. baumannii were meropenem resistant, but no clonal pattern was found. There was a 1% (5/428) prevalence of methicillin-resistant S. aureus. CONCLUSIONS The predominance of Gram-negative organisms and the high level of multi-drug resistance indicate a need to re-evaluate antibiotic prophylaxis and treatment protocols in surgical practice in low- and middle-income countries.
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Affiliation(s)
- Antoinette A A Bediako-Bowan
- Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4356, Accra, Ghana.
- Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana.
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark.
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark.
| | - Jørgen A L Kurtzhals
- Centre for Medical Parasitology at Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Kåre Mølbak
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Appiah-Korang Labi
- Centre for Medical Parasitology at Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- Department of Microbiology, Korle-Bu Teaching Hospital, P.O. Box 77, Accra, Ghana
| | - Enid Owusu
- Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Science, University of Ghana, Legon, Accra, Ghana
| | - Mercy J Newman
- Department of Medical Microbiology, University of Ghana Medical School, University of Ghana, Accra, Ghana
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Rohilla R, Bhatia M, Paul M, Omar BJ, Gupta P. Analysis of trends of post-analytical quality indicators in Clinical Bacteriology laboratory: A pilot study from a tertiary care teaching hospital in Uttarakhand, India. Indian J Med Microbiol 2020; 39:196-199. [PMID: 33966862 DOI: 10.1016/j.ijmmb.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
CONTEXT Implementation of quality management system (QMS) which encompasses various quality indicators (QIs), can serve as a stepping stone for continuous improvement & help in achieving globally accepted quality standards in a diagnostic laboratory. AIMS To generate preliminary data on trends of post-analytical QIs in Bacteriology section. SETTINGS AND DESIGN A pilot study was conducted at a tertiary care teaching hospital located in Rishikesh, Uttarakhand. METHODS AND MATERIAL Data of the following four quality indicators pertaining to aerobic culture and sensitivity testing of various clinical samples received in Clinical Bacteriology laboratory was compiled and retrospectively analysed: (i) Rate of reporting errors; (ii) Rate of re-dos; (iii) Percentage of reports correlating with clinical diagnosis; (iv) Percentage of adherence to safety precautions by employees working in diagnostics. STATISTICAL ANALYSIS USED Descriptive statistics like mean and frequency distribution plots. RESULTS The mean reporting error rate was 0.12 per 1000 tests. It was consistently low from July 2018 to May 2019, after which an overall increasing trend was observed. The mean rate of re-dos was 2.79 per 1000 tests. An overall decreasing trend was observed with maximum rates during the months of December 2017 and January 2018. On an average only 7.86% of the reports co-related with clinical diagnosis. Almost 100% adherence to safety precautions was observed with the exception of two instances of needle stick injuries (NSIs). CONCLUSIONS Commitment of laboratory personnel in adopting, maintaining and analysing QMS data will lead to further strengthening of our existing healthcare system.
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Affiliation(s)
- Ranjana Rohilla
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Mohit Bhatia
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Manisha Paul
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Pratima Gupta
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
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Guideline for Urine Culture and Biochemical Identification of Bacterial Urinary Pathogens in Low-Resource Settings. Diagnostics (Basel) 2020; 10:diagnostics10100832. [PMID: 33081114 PMCID: PMC7602787 DOI: 10.3390/diagnostics10100832] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 12/02/2022] Open
Abstract
Medical diagnosis in low-resource settings is confronted by the lack of suitable guidelines, protocols and checklists. Online-accessible procedural documents are difficult to find, might be mistranslated or interpreted and usually do not address the needs of developing countries. Urinalysis, one of the most frequently performed diagnostic examinations worldwide, involves a series of tests aiming to detect particular disorders, such as urinary tract infections, kidney disease and diabetes. In this guideline, we present an alternative approach for clinical laboratories with limited resources to identify common bacterial uropathogens. We propose dividing the identification plan into two levels. The implicated pathogen will first be assigned into a bacterial group, basic identification, against which a suitable panel of antimicrobial agents shall be selected for the antimicrobial susceptibility testing (AST). Characterization of the pathogen to the genus or species level, advanced identification, will then be performed to ensure correct reading of the AST results and determine the epidemiology of clinically significant pathogens. Most of the proposed steps in our guideline are tailored to meet the needs of clinical laboratories in low-resource settings. Such guidelines are needed to strengthen the capacity of regional pathology laboratories and to enhance international initiatives on antimicrobial resistance and health equity.
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Semret M, Abebe W, Kong LY, Alemayehu T, Beyene T, Libman MD, Amogne W, Johannsen ØH, Gebretekle GB, Seifu D, Yansouni CP. Prolonged empirical antibiotic therapy is correlated with bloodstream infections and increased mortality in a tertiary care hospital in Ethiopia: bacteriology testing matters. JAC Antimicrob Resist 2020; 2:dlaa039. [PMID: 34240055 DOI: 10.1093/jacamr/dlaa039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/25/2020] [Accepted: 04/05/2020] [Indexed: 12/31/2022] Open
Abstract
Background Hospital-associated infection (HAI) and antimicrobial resistance (AMR) are major health threats in low- and middle-income countries (LMICs). Because diagnostic capacity is lacking throughout most of Africa, patients are commonly managed with prolonged empirical antibiotic therapy. Our goal was to assess mortality in relation to HAI and empirical therapy in Ethiopia's largest referral hospital. Methods Cohort study of patients with suspected HAI at Tikur Anbessa Specialized Hospital from October 2016 to October 2018. Blood culture testing was performed on an automated platform. Primary outcomes were proportion of patients with bloodstream infection (BSI), antibiotic resistance patterns and 14 day mortality. We also assessed days of therapy (DOT) pre- and post-blood culture testing. Results Of 978 enrolled patients, 777 had blood culture testing; 237 (30%) had a BSI. Enterobacteriaceae were isolated in 49%; 81% of these were cephalosporin resistant and 23% were also carbapenem resistant. Mortality at 14 days was 31% and 21% in those with and without BSI, respectively. Ceftriaxone resistance was strongly correlated with mortality. Patients with BSI had longer DOT pre-blood culture testing compared with those without BSI (median DOT 12 versus 3 days, respectively, P < 0.0001). After testing, DOT were comparable between the two groups (20 versus 18 days, respectively). Conclusions BSI are frequent and fatal among patients with suspected HAI in Ethiopia. Highly resistant blood isolates are alarmingly common. This study provides evidence that investing in systematic blood culture testing in LMICs identifies patients at highest risk of death and that empirical management is frequently inappropriate. Major investments in laboratory development are critical to achieve better outcomes.
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Affiliation(s)
- Makeda Semret
- Department of Medicine and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Workeabeba Abebe
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ling Yuan Kong
- Department of Medicine and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tinsae Alemayehu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Temesgen Beyene
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael D Libman
- Department of Medicine and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | - Daniel Seifu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Cedric P Yansouni
- Department of Medicine and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
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Pierce J, Apisarnthanarak A, Schellack N, Cornistein W, Maani AA, Adnan S, Stevens MP. Global Antimicrobial Stewardship with a Focus on Low- and Middle-Income Countries. Int J Infect Dis 2020; 96:621-629. [PMID: 32505875 PMCID: PMC7271868 DOI: 10.1016/j.ijid.2020.05.126] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Antimicrobial resistance is a global public health crisis. Antimicrobial Stewardship involves adopting systematic measures to optimize antimicrobial use, decrease unnecessary antimicrobial exposure and to decrease the emergence and spread of resistance. Low- and middle-income countries (LMICs) face a disproportionate burden of antimicrobial resistance and also face challenges related to resource availability. Although challenges exist, the World Health Organization has created a practical toolkit for developing Antimicrobial Stewardship Programs (ASPs) that will be summarized in this article.
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Affiliation(s)
- Jacob Pierce
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, 1000 E Marshall St. Richmond, VA, USA, 23298.
| | - Anucha Apisarnthanarak
- Thammasart University Hospital, 8 95 Phahonyothin Rd, Khlong Nueng, Khlong Luang District, Pathum Thani 12120
| | - Natalie Schellack
- Sefako-Makgatho Health Sciences University, School of Pharmacy, Pretoria. Motlegi St, Ga-Rankuwa Zone 1, Ga-Rankuwa, 0208, South Africa
| | - Wanda Cornistein
- Hospital Universitario Austral Av. Juan Domingo Perón 1500, Pilar Centro, Buenos Aires, Argentina
| | - Amal Al Maani
- Directorate General for Disease Surveillance & Control, MOH. P.O Box: 393, PC 100 Muscat, Oman
| | - Syamhanin Adnan
- Hospital Sungai Buloh (Infectious Disease center) Jalan Hospital, 47000 Sungai Buloh, Selangor, Malaysia
| | - Michael P Stevens
- Virginia Commonwealth University School of Medicine, Department of Internal Medicine, Division of Infectious Diseases, 1000 E Marshall St. Richmond, VA, USA, 23298
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22
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Yansouni CP, Seifu D, Libman M, Alemayehu T, Gizaw S, Johansen ØH, Abebe W, Amogne W, Semret M. A Feasible Laboratory-Strengthening Intervention Yielding a Sustainable Clinical Bacteriology Sector to Support Antimicrobial Stewardship in a Large Referral Hospital in Ethiopia. Front Public Health 2020; 8:258. [PMID: 32656174 PMCID: PMC7325602 DOI: 10.3389/fpubh.2020.00258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 05/21/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Access to clinical bacteriology in low resource settings (LRS) is a key bottleneck preventing individual patient management of treatable severe infections, detection of antimicrobial resistance (AMR), and implementation of effective stewardship interventions. We sought to demonstrate the feasibility of a practical bundle of interventions aimed at implementing sustainable clinical bacteriology services at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on cost and intensity of supervision. Methods: Starting in Dec 2015, an intervention based on the CLSI QMS01-A guideline was established, consisting of (i) an initial needs assessment, (ii) development of key standard operating procedures, (iii) adaptation of processes for LRS, (iv) training and supervision of laboratory staff via consultant visits and existing online resources, and (v) implementation of a practical quality systems approach. A guiding principle of the bundle was sustainability of all interventions post implementation. Outcomes and challenges: An initial investment of ~US$ 26,200 for laboratory reagents, and a total of 50 visit-days per year from three Canadian and Norwegian microbiologists were committed. Twelve SOPs, including antimicrobial susceptibility testing, were adapted, and an automated blood culture platform was donated (bioMerieux). In the first 18 months of implementation of the intervention, the average volume of specimens analyzed in the lab went from 15/day to 75/day. The number of blood cultures tested increased from an average of 2/day to over 45/day. Antimicrobial susceptibility testing was introduced and cumulative antibiograms were generated for the institution. Quality control was implemented for all procedures and quality assurance tools implemented included external quality assurance and proficiency testing of six technologists with longitudinal follow-up. The laboratory is on the path toward SLIPTA accreditation by the African Society for Laboratory Medicine. Reagent costs, staff training and retention, and engagement of clinical personnel with the lab proved to be manageable challenges. Key external challenges include in-country supply-chain management issues, lack of competition among distributors, and foreign-currency exchange distortions. Conclusions: Using a relatively low-intensity intervention based on existing training tools and accreditation schemes, we demonstrate that establishment of reasonable-quality clinical bacteriology is not only within reach but also a critical step toward assessing the burden of AMR in settings like this one and implementing effective stewardship strategies.
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Affiliation(s)
- Cedric P. Yansouni
- J.D. MacLean Centre for Tropical Diseases & Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, QC, Canada
| | - Daniel Seifu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael Libman
- J.D. MacLean Centre for Tropical Diseases & Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, QC, Canada
| | - Tinsae Alemayehu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Gizaw
- Microbiology Laboratory, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia
| | | | - Workeabeba Abebe
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Makeda Semret
- J.D. MacLean Centre for Tropical Diseases & Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, QC, Canada
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23
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Kozlakidis Z, Vandenberg O, Stelling J. Editorial: Clinical Microbiology in Low Resource Settings. Front Med (Lausanne) 2020; 7:258. [PMID: 32587861 PMCID: PMC7297910 DOI: 10.3389/fmed.2020.00258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/13/2020] [Indexed: 11/24/2022] Open
Affiliation(s)
- Zisis Kozlakidis
- International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - Olivier Vandenberg
- Innovation and Business Development Unit, LHUB - ULB, Groupement Hospitalier Universitaire de Bruxelles (GHUB), Université Libre de Bruxelles, Brussels, Belgium
- Centre for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Division of Infection and Immunity, Faculty of Medical Sciences, University College London, London, United Kingdom
| | - John Stelling
- Microbiology Laboratory, Women's Hospital, Boston, MA, United States
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24
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Tack B, Phoba MF, Van Puyvelde S, Kalonji LM, Hardy L, Barbé B, Van der Sande MAB, Monsieurs E, Deborggraeve S, Lunguya O, Jacobs J. Salmonella Typhi From Blood Cultures in the Democratic Republic of the Congo: A 10-Year Surveillance. Clin Infect Dis 2020; 68:S130-S137. [PMID: 30845337 PMCID: PMC6405282 DOI: 10.1093/cid/ciy1116] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background This study gives an overview of a decade (2007–2017) of hospital-based Salmonella Typhi bloodstream infection (BSI) surveillance in the Democratic Republic of the Congo (DRC), at 4 main sampling sites. Methods Blood cultures were sampled in hospital-admitted patients with suspected BSI, according to standardized clinical indications. The results of the surveillance period 2015–2017 were compiled with those of previous surveillance periods (2007–2010 and 2011–2014). Whole genome sequencing of isolates with decreased ciprofloxacin susceptibility (DCS) was performed. Results Salmonella Typhi was isolated in 1.4% (531/37 388) and 10.3% (531/5177) of suspected and culture-confirmed BSI episodes, respectively. Salmonella Typhi ranked first among the BSI pathogens in adults (n = 220), but was mostly (n = 301 [56.7%]) isolated from children, of which 72.1% (217/301) and 31.6% (95/301) were <10 years and <5 years old, respectively. Multidrug resistance (MDR), DCS, and combined MDR/DCS were found in 38.3% (n = 180), 24.5% (n = 115), and 11.9% (n = 56) of 470 first isolates, respectively. MDR and DCS rates had increased since 2007, but remained stable during 2015–2017 with no geographical clustering at the province level. Most (91/93 [97.8%]) DCS isolates sequenced belonged to Genotyphi genotype 2.5.1, and gyr S83 was the most frequent DCS mutation (76/93 [81.7%]). Infections occurred perennially, but increased during the rainy season. Conclusions Salmonella Typhi was a frequent cause of BSI in adults and children in DRC, with high rates of antibiotic resistance. Sustainable surveillance and implementation of vaccination are compelling.
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Affiliation(s)
- Bieke Tack
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp.,Department of Microbiology and Immunology, KU Leuven, Belgium
| | - Marie-France Phoba
- Department of Microbiology, National Institute for Biomedical Research.,Department of Microbiology, University Teaching Hospital, Kinshasa, Democratic Republic of the Congo, Antwerp, Belgium
| | - Sandra Van Puyvelde
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.,Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Lisette M Kalonji
- Department of Microbiology, National Institute for Biomedical Research.,Department of Microbiology, University Teaching Hospital, Kinshasa, Democratic Republic of the Congo, Antwerp, Belgium
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp
| | - Marianne A B Van der Sande
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Julius Center for Health Sciences and Primary Care, Global Health Centre, Utrecht University, The Netherlands
| | - Elise Monsieurs
- Royal Museum for Central Africa, Tervuren.,Department of Geography, University of Liège, Belgium
| | - Stijn Deborggraeve
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Octavie Lunguya
- Department of Microbiology, National Institute for Biomedical Research.,Department of Microbiology, University Teaching Hospital, Kinshasa, Democratic Republic of the Congo, Antwerp, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp.,Department of Microbiology and Immunology, KU Leuven, Belgium
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25
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Monteiro T, Wysocka M, Tellez E, Monteiro O, Spencer L, Veiga E, Monteiro S, de Pina C, Gonçalves D, de Pina S, Ludgero-Correia A, Moreno J, Conceição T, Aires-de-Sousa M, de Lencastre H, Gray LJ, Pareek M, Jenkins DR, Beleza S, Oggioni MR, Araujo II. A five-year retrospective study shows increasing rates of antimicrobial drug resistance in Cabo Verde for both Staphylococcus aureus and Escherichia coli. J Glob Antimicrob Resist 2020; 22:483-487. [PMID: 32348903 DOI: 10.1016/j.jgar.2020.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Data on baseline drug resistance important in informing future antimicrobial stewardship programs. So far, no data on the antimicrobial drug resistance of clinical isolates available for the African archipelago of Cabo Verde. METHODS We performed a retrospective analysis over years (2013-17) of the drug susceptibility profiles of clinical isolates in the two main hospitals of Cabo Verde. For Escherichia coli and Staphylococcus aureus, representing 47% and 26% of all clinical isolates, the antimicrobial drug resistance profile was reported for six representative drugs. RESULTS For E. coli we detected an increase in resistance to ampicillin, amoxicillin/clavulanic acid, ceftriaxone, ciprofloxacin and trimethoprim-and for S. aureus to methicillin, erythromycin and trimethoprim-sulfamethoxazole. This increase in both the most commonly isolated bacterial pathogens is alarm as it might compromise empirical treatment in a setting with limited access to laboratory testing. CONCLUSIONS When compared to the published low resistance rates in carriage isolates, the more alarming situation in clinical isolates for S. aureus might encourage antimicrobial stewardship programs to reduce in hospital settings, possibly as part of the Cabo Verdean national plan against antimicrobial drug resistance.
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Affiliation(s)
- Tamar Monteiro
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
| | - Magdalena Wysocka
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK; Department of Molecular Biotechnology and Microbiology, Gdansk University of Technology, Gdansk, Poland
| | - Elena Tellez
- Hospital Agostinho Neto, Ministério da Saúde e Segurança Social, Praia, Santiago, Cabo Verde
| | - Ofelia Monteiro
- Hospital Agostinho Neto, Ministério da Saúde e Segurança Social, Praia, Santiago, Cabo Verde
| | - Luzia Spencer
- Hospital Agostinho Neto, Ministério da Saúde e Segurança Social, Praia, Santiago, Cabo Verde
| | - Elisa Veiga
- Hospital Agostinho Neto, Ministério da Saúde e Segurança Social, Praia, Santiago, Cabo Verde
| | - Sandra Monteiro
- Hospital Baptista de Sousa, Ministério da Saúde e Segurança Social, Mindelo, São Vicente, Cabo Verde
| | - Carine de Pina
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
| | - Deisy Gonçalves
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
| | - Sandrine de Pina
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
| | | | - Joao Moreno
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
| | - Teresa Conceição
- Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica António Xavier (ITQB-NOVA), Universidade Nova de Lisboa, Oeiras, Portugal
| | - Marta Aires-de-Sousa
- Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica António Xavier (ITQB-NOVA), Universidade Nova de Lisboa, Oeiras, Portugal
| | - Herminia de Lencastre
- Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica António Xavier (ITQB-NOVA), Universidade Nova de Lisboa, Oeiras, Portugal; Laboratory of Microbiology & Infectious Diseases, The Rockefeller University, New York, USA
| | - Laura J Gray
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Manish Pareek
- Department of Respiratory Sciences, University of Leicester, Leicester, UK
| | - David R Jenkins
- Department of Clinical Microbiology, University Hospitals of Leicester, NHS Trust, Leicester, UK
| | - Sandra Beleza
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Marco R Oggioni
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK.
| | - Isabel Inês Araujo
- Faculdade de Ciências e Tecnologia, Universidade de Cabo Verde, Praia, Santiago, Cabo Verde
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26
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Gebretekle GB, Haile Mariam D, Abebe Taye W, Mulu Fentie A, Amogne Degu W, Alemayehu T, Beyene T, Libman M, Gedif Fenta T, Yansouni CP, Semret M. Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia. Front Public Health 2020; 8:109. [PMID: 32328474 PMCID: PMC7160317 DOI: 10.3389/fpubh.2020.00109] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/18/2020] [Indexed: 11/15/2022] Open
Abstract
Intense antibiotic consumption in Low- and Middle-Income Countries (LMICs) is fueled by critical gaps in laboratory infrastructure and entrenched syndromic management of infectious syndromes. Few data inform the achievability and impact of antimicrobial stewardship interventions, particularly in Sub-Saharan Africa. Our goal was to demonstrate the feasibility of a pharmacist-led laboratory-supported intervention at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, and report on antimicrobial use and clinical outcomes associated with the intervention. Methods: This was a single-center prospective quasi-experimental study conducted in two phases: (i) an intervention phase (November 2017 to August 2018), during which we implemented weekly audit and immediate (verbal and written) feedback sessions on antibiotic prescriptions of patients admitted in 2 pediatric and 2 adult medicine wards, and (ii) a post-intervention phase (September 2018 to January 2019) during which we audited antibiotic prescriptions but provided no feedback to the treating teams. The intervention was conducted by an AMS team consisting of 4 clinical pharmacists (one trained in AMS) and one ID specialist. Our primary outcome was antimicrobial utilization (measured as days of therapy (DOT) per 1,000 patient-days and duration of antibiotic treatment courses); secondary outcomes were length of hospital stay and in-hospital all-cause mortality. A multivariable logistic regression model was used to explore factors associated with all-cause in-hospital mortality. Results: We collected data on 1,109 individual patients (707 during the intervention and 402 in the post-intervention periods). Ceftriaxone, vancomycin, cefepime, meropenem, and metronidazole were the most commonly prescribed antibiotics; 96% of the recommendations made by the AMS team were accepted. The AMS team recommended to discontinue antibiotic therapy in 54% of cases during the intervention period. Once the intervention ceased, total antimicrobial use increased by 51.6% and mean duration of treatment by 4.1 days/patient. Mean LOS stay as well as crude mortality also increased significantly in the post-intervention phase (LOS: 24.1 days vs. 19.8 days; in hospital death 14.7 vs. 6.9%). The difference in mortality remained significant after adjusting for potential confounders. Conclusions: A pharmacist-led AMS intervention focused on duration of antibiotic treatment was feasible and had good acceptability in our setting. Cessation of audit-feedback activities was associated with immediate and sustained increases in antibiotic consumption reflecting a rapid return to baseline (pre-intervention) prescribing practices, and worse clinical outcomes (increased length of stay and in-hospital mortality). Pharmacist-led audit-feedback activities can effectively reduce antimicrobial consumption and result in better-quality care, but require organizational leadership's commitment for sustainable benefits.
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Affiliation(s)
| | | | | | | | | | - Tinsae Alemayehu
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Temesgen Beyene
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael Libman
- J. D. MacLean Centre for Tropical Diseases and McGill University, Montreal, QC, Canada
| | | | - Cedric P Yansouni
- J. D. MacLean Centre for Tropical Diseases and McGill University, Montreal, QC, Canada
| | - Makeda Semret
- J. D. MacLean Centre for Tropical Diseases and McGill University, Montreal, QC, Canada
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27
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Perovic O, Yahaya AA, Viljoen C, Ndihokubwayo JB, Smith M, Coulibaly SO, De Gouveia L, Oxenford CJ, Cognat S, Ismail H, Frean J. External Quality Assessment of Bacterial Identification and Antimicrobial Susceptibility Testing in African National Public Health Laboratories, 2011-2016. Trop Med Infect Dis 2019; 4:tropicalmed4040144. [PMID: 31847247 PMCID: PMC6958417 DOI: 10.3390/tropicalmed4040144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/22/2022] Open
Abstract
Background: In 2002, the World Health Organization (WHO) launched a regional microbiology external quality assessment (EQA) programme for national public health laboratories in the African region, initially targeting priority epidemic-prone bacterial diseases, and later including other common bacterial pathogens. Objectives: The aim of this study was to analyse the efficacy of an EQA programme as a laboratory quality system evaluation tool. Methods: We analysed the proficiency of laboratories’ performance of bacterial identification and antimicrobial susceptibility testing (AST) for the period 2011–2016. The National Institute for Communicable Diseases of South Africa provided technical coordination following an agreement with WHO, and supplied EQA samples of selected bacterial organisms for microscopy (Gram stain), identification, and antimicrobial susceptibility testing (AST). National public health laboratories, as well as laboratories involved in the Invasive Bacterial Diseases Surveillance Network, were enrolled by the WHO Regional Office for Africa to participate in the EQA programme. We analysed participants’ results of 41 surveys, which included the following organisms sent as challenges: Streptococcus pneumonia, Haemophilus influenzae, Neisseria meningitidis, Salmonella Typhi, Salmonella Enteritidis, Shigella flexneri, Staphylococcus aureus, Streptococcus agalactiae, Streptococcus anginosus, Enterococcus faecium, Serratia marcescens, Acinetobacter baumannii, and Enterobacter cloacae. Results: Eighty-one laboratories from 45 countries participated. Overall, 76% of participants obtained acceptable scores for identification, but a substantial proportion of AST scores were not in the acceptable range. Of 663 assessed AST responses, only 42% had acceptable scores. Conclusion: In the African Region, implementation of diagnostic stewardship in clinical bacteriology is generally suboptimal. This report illustrates that AST is poorly done compared to microscopy and identification. It is critically important to make the case for implementation of quality assurance in AST, as it is the cornerstone of antimicrobial resistance surveillance reporting and implementation of the Global Antimicrobial Resistance Surveillance System.
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Affiliation(s)
- Olga Perovic
- National Institute for Communicable Diseases, Division of National Health Laboratory Service, Johannesburg 2131, South Africa
- Department of Clinical Microbiology, University of Witwatersrand, Johannesburg 2193, South Africa
- Correspondence:
| | - Ali A. Yahaya
- World Health Organization, Regional Office for Africa, Brazzaville 06, Congo; (A.A.Y.); (J.-B.N.); (S.O.C.)
| | - Crystal Viljoen
- Department of Clinical Microbiology, University of Witwatersrand, Johannesburg 2193, South Africa
| | - Jean-Bosco Ndihokubwayo
- World Health Organization, Regional Office for Africa, Brazzaville 06, Congo; (A.A.Y.); (J.-B.N.); (S.O.C.)
| | - Marshagne Smith
- National Institute for Communicable Diseases, Division of National Health Laboratory Service, Johannesburg 2131, South Africa
| | - Sheick O. Coulibaly
- World Health Organization, Regional Office for Africa, Brazzaville 06, Congo; (A.A.Y.); (J.-B.N.); (S.O.C.)
| | - Linda De Gouveia
- National Institute for Communicable Diseases, Division of National Health Laboratory Service, Johannesburg 2131, South Africa
| | | | | | - Husna Ismail
- National Institute for Communicable Diseases, Division of National Health Laboratory Service, Johannesburg 2131, South Africa
| | - John Frean
- National Institute for Communicable Diseases, Division of National Health Laboratory Service, Johannesburg 2131, South Africa
- WITS Research Institute for Malaria, University of Witwatersrand, Johannesburg 2193, South Africa
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28
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Homolka S, Zallet J, Albert H, Witt AK, Kranzer K. Introduction of quality management in a National Reference Laboratory in Germany. PLoS One 2019; 14:e0222925. [PMID: 31613905 PMCID: PMC6793863 DOI: 10.1371/journal.pone.0222925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/10/2019] [Indexed: 11/19/2022] Open
Abstract
Background High quality diagnostic services are crucial for tuberculosis (TB) diagnosis, treatment and control. A strong laboratory quality management system (QMS) is critical to ensuring the quality of testing and results. Recent initiatives to improve TB laboratory quality have focused on low and middle-income countries, but similar issues also apply to high-income countries. Methods and findings Using a multipronged approach reviews of facilities, equipment, processes (purchasing, pre-analytic, analytic and post-analytic), staff, health and safety, documentation, information management and organization based on the ISO 15189 and the twelve quality system essentials were conducted between October 2015 and January 2016 at the National TB Reference Laboratory in Germany. Outcome assessment included proportion of smear positive slides, proportion of contaminated liquid cultures and DNA contamination rates before and after implementation of QMS. The odds ratio for these outcomes was calculated using a before/after comparison. Reviews highlighted deficiencies across all twelve quality system essentials and were addressed in order of priority and urgency. Actions aimed at improving analytical quality, health and safety and information management were prioritised for initial implementation in parallel with each other. The odds ratio for a sample to be tested as microscopically positive increased by 2.08 (95%CI 1.41–3.06) comparing the time before with the time after implementation of quality managed fluorescence microscopy. Liquid culture contamination rates decreased from 23.6- 7.6% in April-July 2016 to <10% in November 2017-March 2018. The proportion of negative controls showing evidence of DNA contamination decreased from 38.2% in 2013 to 8.1% in 2017, the corresponding odds ratio was 0.14 (95%CI 0.07–0.29). Conclusion This study showed marked improvement on quality indicators after implementation of a QMS in a National TB Reference Laboratory. The challenges and lessons learned in this study are valuable not just for high-income settings, but are equally generalizable to other laboratories.
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Affiliation(s)
- Susanne Homolka
- National Reference Laboratory for Mycobacteria, Research Center Borstel, Borstel, Germany
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
- * E-mail:
| | - Julia Zallet
- National Reference Laboratory for Mycobacteria, Research Center Borstel, Borstel, Germany
- Molecular and Experimental Mycobacteriology, Research Center Borstel, Borstel, Germany
| | - Heidi Albert
- Foundation for Innovative New Diagnostics (FIND) South Africa, Cape Town, South Africa
| | - Anne-Kathrin Witt
- National Reference Laboratory for Mycobacteria, Research Center Borstel, Borstel, Germany
| | - Katharina Kranzer
- National Reference Laboratory for Mycobacteria, Research Center Borstel, Borstel, Germany
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, England, United Kingdom
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29
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Jacobs J, Hardy L, Semret M, Lunguya O, Phe T, Affolabi D, Yansouni C, Vandenberg O. Diagnostic Bacteriology in District Hospitals in Sub-Saharan Africa: At the Forefront of the Containment of Antimicrobial Resistance. Front Med (Lausanne) 2019; 6:205. [PMID: 31608280 PMCID: PMC6771306 DOI: 10.3389/fmed.2019.00205] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 09/03/2019] [Indexed: 12/28/2022] Open
Abstract
This review provides an update on the factors fuelling antimicrobial resistance and shows the impact of these factors in low-resource settings. We detail the challenges and barriers to integrating clinical bacteriology in hospitals in low-resource settings, as well as the opportunities provided by the recent capacity building efforts of national laboratory networks focused on vertical single-disease programmes. The programmes for HIV, tuberculosis and malaria have considerably improved laboratory medicine in Sub-Saharan Africa, paving the way for clinical bacteriology. Furthermore, special attention is paid to topics that are less familiar to the general medical community, such as the crucial role of regulatory frameworks for diagnostics and the educational profile required for a productive laboratory workforce in low-resource settings. Traditionally, clinical bacteriology laboratories have been a part of higher levels of care, and, as a result, they were poorly linked to clinical practices and thus underused. By establishing and consolidating clinical bacteriology laboratories at the hospital referral level in low-resource settings, routine patient care data can be collected for surveillance, antibiotic stewardship and infection prevention and control. Together, these activities form a synergistic tripartite effort at the frontline of the emergence and spread of multi-drug resistant bacteria. If challenges related to staff, funding, scale, and the specific nature of clinical bacteriology are prioritized, a major leap forward in the containment of antimicrobial resistance can be achieved. The mobilization of resources coordinated by national laboratory plans and interventions tailored by a good understanding of the hospital microcosm will be crucial to success, and further contributions will be made by market interventions and business models for diagnostic laboratories. The future clinical bacteriology laboratory in a low-resource setting will not be an "entry-level version" of its counterparts in high-resource settings, but a purpose-built, well-conceived, cost-effective and efficient diagnostic facility at the forefront of antimicrobial resistance containment.
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Affiliation(s)
- Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Makeda Semret
- JD MacLean Centre for Tropical Diseases, McGill University, Montreal, QC, Canada
| | - Octavie Lunguya
- Department of Clinical Microbiology, National Institute of Biomedical Research, Kinshasa, Democratic Republic of Congo
- Service of Microbiology, Kinshasa General Hospital, Kinshasa, Democratic Republic of Congo
| | - Thong Phe
- Sihanouk Hospital Center of HOPE, Phnom Penh, Cambodia
| | - Dissou Affolabi
- Clinical Microbiology, Centre National Hospitalier et Universitaire Hubert Koutoukou MAGA, Cotonou, Benin
| | - Cedric Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University, Montreal, QC, Canada
| | - Olivier Vandenberg
- Center for Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Innovation and Business Development Unit, LHUB - ULB, Pôle Hospitalier Universitaire de Bruxelles (PHUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
- Division of Infection and Immunity, Faculty of Medical Sciences, University College London, London, United Kingdom
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30
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Bediako-Bowan AAA, Owusu E, Labi AK, Obeng-Nkrumah N, Sunkwa-Mills G, Bjerrum S, Opintan JA, Bannerman C, Mølbak K, Kurtzhals JAL, Newman MJ. Antibiotic use in surgical units of selected hospitals in Ghana: a multi-centre point prevalence survey. BMC Public Health 2019; 19:797. [PMID: 31226974 PMCID: PMC6588883 DOI: 10.1186/s12889-019-7162-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 06/13/2019] [Indexed: 01/21/2023] Open
Abstract
Background Improper use of antibiotics leads to the emergence of resistant microorganisms as well as drug toxicity, increased healthcare costs, morbidity and mortality. Globally, an estimated 25–68% of hospitalized patients receive suboptimal antibiotic regimes. Information on the extent of this problem in Ghana is currently limited, particularly in surgical units. To strategize for interventions, we estimated the antibiotic use prevalence in surgical departments in a country-wide point prevalence survey (PPS) in Ghana. Methods Between October 2016 and December 2016, we conducted a cross-sectional multi-center country-wide PPS. This involved an audit of in-patients’ records from all units/departments of ten systematically selected hospitals in Ghana. Data were collected with a standardized questionnaire, adopted from the European Centre for Disease Prevention and Control. In this report, we present data on antibiotic use from the surgical units. Results Of 2107 eligible patients included in the PPS, 540 patients were identified in surgical units, of which 70.7% (382/540) received antibiotic therapy. A total of 636 antibiotic prescriptions were issued to these surgical patients; 224 (58.6%) for treatment, including 50 for treatment of hospital-acquired infections, and 144 (37.7%) for prophylaxis (medical and surgical). Median duration of antibiotic therapy prior to the survey was 5 days (interquartile range (IQR): 3-8 days). Surgical prophylaxis was administered for longer than the recommended one day in 107 of 144 (88.4%) patients. The choice of antibiotics was largely similar for community- and hospital-acquired infections as well as for prophylaxis. Only 3.7% of patients had microbiological analysis done on clinical samples. Conclusion We found a high prevalence of antibiotic use, with the choice of antibiotics, in some cases, inconsistent with the country’s treatment guidelines. Antibiotics were administered for long duration including antibiotics for prophylactic purposes and the majority was started without supporting microbiological analysis. Prescription practices that encourage rational use of antibiotics guided by microbiology and enforcement of antibiotic policy guidelines should be the target for future interventions. Electronic supplementary material The online version of this article (10.1186/s12889-019-7162-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoinette A A Bediako-Bowan
- Department of Surgery, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana. .,Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana. .,Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark. .,Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark.
| | - Enid Owusu
- Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Appiah-Korang Labi
- Department of Microbiology, Korle Bu Teaching Hospital, P.O. Box 77, Accra, Ghana.,Department of Clinical Microbiology, Copenhagen University Hospital (Righospitalet), Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Noah Obeng-Nkrumah
- Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Gifty Sunkwa-Mills
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana.,Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Stephanie Bjerrum
- Department of Public Health, Global Health Section, University of Copenhagen, Copenhagen, Denmark
| | - Japheth Awuletey Opintan
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Cynthia Bannerman
- Formerly Institutional Care Division, Ghana Health Service, Accra, Ghana.,Discipline of Community Health, Accra College of Medicine, P. O. Box CT 9828, Cantonments, Accra, Ghana
| | - Kåre Mølbak
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark.,Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Jørgen Anders Lindholm Kurtzhals
- Department of Clinical Microbiology, Copenhagen University Hospital (Righospitalet), Copenhagen, Denmark.,Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Mercy Jemima Newman
- Department of Medical Microbiology, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Accra, Ghana
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Ombelet S, Barbé B, Affolabi D, Ronat JB, Lompo P, Lunguya O, Jacobs J, Hardy L. Best Practices of Blood Cultures in Low- and Middle-Income Countries. Front Med (Lausanne) 2019; 6:131. [PMID: 31275940 PMCID: PMC6591475 DOI: 10.3389/fmed.2019.00131] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/29/2019] [Indexed: 12/25/2022] Open
Abstract
Bloodstream infections (BSI) have a substantial impact on morbidity and mortality worldwide. Despite scarcity of data from many low- and middle-income countries (LMICs), there is increasing awareness of the importance of BSI in these countries. For example, it is estimated that the global mortality of non-typhoidal Salmonella bloodstream infection in children under 5 already exceeds that of malaria. Reliable and accurate diagnosis of these infections is therefore of utmost importance. Blood cultures are the reference method for diagnosis of BSI. LMICs face many challenges when implementing blood cultures, due to financial, logistical, and infrastructure-related constraints. This review aims to provide an overview of the state-of-the-art of sampling and processing of blood cultures, with emphasis on its use in LMICs. Laboratory processing of blood cultures is relatively straightforward and can be done without the need for expensive and complicated equipment. Automates for incubation and growth monitoring have become the standard in high-income countries (HICs), but they are still too expensive and not sufficiently robust for imminent implementation in most LMICs. Therefore, this review focuses on "manual" methods of blood culture, not involving automated equipment. In manual blood cultures, a bottle consisting of a broth medium supporting bacterial growth is incubated in a normal incubator and inspected daily for signs of growth. The collection of blood for blood culture is a crucial step in the process, as the sensitivity of blood cultures depends on the volume sampled; furthermore, contamination of the blood culture (accidental inoculation of environmental and skin bacteria) can be avoided by appropriate antisepsis. In this review, we give recommendations regarding appropriate blood culture sampling and processing in LMICs. We present feasible methods to detect and speed up growth and discuss some challenges in implementing blood cultures in LMICs, such as the biosafety aspects, supply chain and waste management.
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Affiliation(s)
- Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KULeuven, Leuven, Belgium
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Dissou Affolabi
- Centre National Hospitalier Universitaire—Hubert Koutoucou Maga, Cotonou, Benin
| | | | - Palpouguini Lompo
- Clinical Research Unit of Nanoro, Institut de Recherche en Science de la Santé, Nanoro, Burkina Faso
| | - Octavie Lunguya
- National Institute for Biomedical Research, Kinshasa, Democratic Republic of the Congo
- Department of Medical Biology, Cliniques Universitaires, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KULeuven, Leuven, Belgium
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Peeters M, Ombelet S, Chung P, Tsoumanis A, Lim K, Long L, De Smet B, Kham C, Teav S, Vlieghe E, Phe T, Jacobs J. Slow growth of Burkholderia pseudomallei compared to other pathogens in an adapted blood culture system in Phnom Penh, Cambodia. J Med Microbiol 2019; 68:1159-1166. [PMID: 31188093 DOI: 10.1099/jmm.0.001011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Burkholderia pseudomallei is a key pathogen causing bloodstream infections at Sihanouk Hospital Center of Hope, Phnom Penh, Cambodia. Here, visual instead of automated detection of growth of commercial blood culture bottles is done. The present study assessed the performance of this system. METHODOLOGY Blood culture sets, consisting of paired adult aerobic and anaerobic bottles (bioMérieux, FA FAN 259791 and FN FAN 252793) were incubated in a standard incubator for 7 days after reception. Each day, the bottle growth indicator was visually inspected for colour change indicating growth. Blind subculture was performed from the aerobic bottle at day 3. RESULTS From 2010 to 2015, 11 671 sets representing 10 389 suspected bloodstream infection episodes were documented. In 1058 (10.2 %) episodes, pathogens grew; they comprised Escherichia coli (31.7 %), Salmonella Paratyphi A (13.9 %), B. pseudomallei (8.5 %), Staphylococcus aureus (7.8 %) and Klebsiella pneumoniae (7.0 %). Blind subculture yielded 72 (4.1 %) pathogens, mostly (55/72, 76.4 %) B. pseudomallei. Cumulative proportions of growth at day 2 were as follows: E. coli: 85.0 %, Salmonella Paratyphi A: 85.0 %, K. pneumoniae: 76.3 % and S. aureus: 52.2 %; for B. pseudomallei, this was only 4.0 %, which increased to 70.1 % (70/99) at day 4 mainly by detection on blind subculture (55/99). Compared to the anaerobic bottles, aerobic bottles had a higher yield and a shorter time-to-detection, particularly for B. pseudomallei. CONCLUSIONS Visual inspection for growth of commercial blood culture bottles in a low-resource setting provided satisfactory yield and time-to-detection. However, B. pseudomallei grew slowly and was mainly detected by blind subculture. The aerobic bottle outperformed the anaerobic bottle.
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Affiliation(s)
- Marjan Peeters
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Panha Chung
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Achilleas Tsoumanis
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kruy Lim
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Leng Long
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Birgit De Smet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Chun Kham
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Syna Teav
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Erika Vlieghe
- Unit of Internal Medicine and Infectious Diseases, University Hospital Antwerp, Antwerp, Belgium
| | - Thong Phe
- Sihanouk Hospital Centre of HOPE, Phnom Penh, Cambodia
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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Hazim C, Abubeker Ibrahim R, Westercamp M, Belete GA, Amare Kibret B, Kanter T, Yimer G, Adem TS, Stevenson KB, Urrego M, Kale KN, Omondi MW, VanderEnde D, Park BJ, Parsons MMB, Gallagher KM. Establishment of a Sentinel Laboratory-Based Antimicrobial Resistance Surveillance Network in Ethiopia. Health Secur 2019; 16:S30-S36. [PMID: 30480505 DOI: 10.1089/hs.2018.0052] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In 2014, as part of the Global Health Security Agenda, Ethiopia was provided the technical and financial resources needed to prioritize antimicrobial resistance (AMR) in the national public health sphere. Under the direction of a multi-stakeholder working group, AMR surveillance was launched in July 2017 at 4 sentinel sites across the country. The AMR surveillance initiative in Ethiopia represents one of the first systematic efforts to prospectively collect, analyze, and report national-level microbiology results from a network of hospitals and public health laboratories in the country. Baseline readiness assessments were conducted to identify potential challenges to implementation to be addressed through capacity-building efforts. As part of these efforts, the working group leveraged existing resources, initiated laboratory capacity building through mentorship, and established infrastructure and systems for quality assurance, data management, and improved coordination. As a result, AMR surveillance data are being reported and analyzed for use; data from more than 1,700 patients were collected between July 2017 and March 2018. The critical challenges and effective solutions identified through surveillance planning and implementation have provided lessons to help guide successful AMR surveillance in other settings. Ultimately, the surveillance infrastructure, laboratory expertise, and communication frameworks built specifically for AMR surveillance in Ethiopia can be extended for use with other infectious diseases and potential public health emergencies. Thus, building AMR surveillance in Ethiopia has illustrated how laying the foundation for a specific public health initiative can develop capacity for core public health functions with potential benefit.
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Affiliation(s)
- Carmen Hazim
- Carmen Hazim, MPH, is an Epidemiologist, the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Rajiha Abubeker Ibrahim
- Rajiha Abubeker Ibrahim, MSc, is a Researcher, Clinical Bacteriology and Mycology Research Team, the Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Matthew Westercamp
- Matthew Westercamp, PhD, is an Epidemiologist, the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Gebrie Alebachew Belete
- Gebrie Alebachew Belete, MSc, is AMR Coordinator, Bacteriology, Parasitology, and Zoonosis Directorate, the Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Berhanu Amare Kibret
- Berhanu Amare Kibret, MD, MPH, MBA, is Global Health Security-Technical Officer, the Division of Global Health Protection, CDC, Addis Ababa, Ethiopia
| | - Theresa Kanter
- Theresa Kanter, MURP, is Program Deputy, the Division of Global Health Protection, CDC, Addis Ababa, Ethiopia
| | - Getnet Yimer
- Getnet Yimer, PhD, is East Africa Regional Director, Global One Health Initiative, Ohio State University, Addis Ababa, Ethiopia
| | - Thuria Siraj Adem
- Thuria Siraj Adem, MPH, is ASM Local Consultant for Ethiopia, International Affairs, American Society for Microbiology (ASM), Addis Ababa, Ethiopia
| | - Kurt B Stevenson
- Kurt B. Stevenson, MD, is Professor of Medicine and Epidemiology, Department of Internal Medicine, College of Medicine, Ohio State University, Columbus, Ohio
| | - Maritza Urrego
- Maritza Urrego, BBA, CPM, is Program Specialist, International Affairs, ASM, Washington, DC
| | - Kashmira N Kale
- Kashmira N. Kale, MPH, MBA, is PHI/CDC Global Health Fellow, the Division of Global Health Protection, CDC, Addis Ababa, Ethiopia
| | - Michael W Omondi
- Michael W. Omondi, MS, is a Microbiologist, the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Daniel VanderEnde
- Daniel VanderEnde, MD, is Medical Officer, the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Benjamin J Park
- Benjamin J. Park, MD, is Chief, International Infection Control Program, the Division of Healthcare Quality Promotion, US Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Michele M B Parsons
- Michele M. B. Parsons, PhD, is a Microbiologist, Center for Global Health, Division of Global Health Protection, CDC, Atlanta
| | - Kathleen M Gallagher
- Kathleen M. Gallagher, DSc, is Program Director, the Division of Global Health Protection, CDC, Addis Ababa, Ethiopia
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Perovic O, Yahaya AA, Viljoen C, Ndihokubwayo JB, Smith M, Coulibaly SO, de Gouveia L, Oxenford CJ, Cognat S, Frean J. Quality assessment of bacterial identification and antimicrobial susceptibility testing in African national health laboratories, 2011–2016. Afr J Lab Med 2019. [DOI: 10.4102/ajlm.v8i1.762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Defining System Requirements for Simplified Blood Culture to Enable Widespread Use in Resource-Limited Settings. Diagnostics (Basel) 2019; 9:diagnostics9010010. [PMID: 30641976 PMCID: PMC6468589 DOI: 10.3390/diagnostics9010010] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 01/30/2023] Open
Abstract
Bacterial blood stream infections (BSI) are a common cause of mortality and morbidity globally. As the causative agents and the resulting treatment decisions vary, near-patient testing and surveillance tools are necessary to monitor bacterial causes and resistance to antimicrobial agents. The gold standard to identify BSIs is blood culture (BC), a methodology not widely available in resource-limited settings. The aim of the study was to map out a target product profile of a simplified BC system (SBCS) to inform product development efforts. To identify the desired characteristics of a SBCS, we enlisted a small group of specialists working in Africa and Asia. Questions were used to understand challenges and how these constraints inform system requirements. The specialists were infectious disease physicians, public health/clinical microbiologists, clinical researchers, and technology experts with different geographical backgrounds. All suggested that BC should ideally be available at the district hospital level. Many of the same operational challenges, such as limited availability of culture bottles, electricity and internet connectivity, profuse dust, the lack of ambient temperature control, and human capacity constraints were identified across the different regions. BCs, although the accepted gold standard for diagnosis of BSIs, are not widely available outside of reference/research centers in Africa and Asia. To extend the reach of this important tool, it is crucial to engage product developers and academic research partners to develop accessible alternatives.
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Gebretekle GB, Haile Mariam D, Abebe W, Amogne W, Tenna A, Fenta TG, Libman M, Yansouni CP, Semret M. Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia. PLoS One 2018; 13:e0208447. [PMID: 30571688 PMCID: PMC6301706 DOI: 10.1371/journal.pone.0208447] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 11/16/2018] [Indexed: 01/21/2023] Open
Abstract
Background Global action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia. Methods Tikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ2 and fisher exact tests. Qualitative data was analyzed thematically. Findings A total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia. Conclusions This knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.
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Affiliation(s)
| | - Damen Haile Mariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Workeabeba Abebe
- Department of Pediatrics and Child Health, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Wondwossen Amogne
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Admasu Tenna
- Department of Internal Medicine, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Michael Libman
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Cedric P. Yansouni
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
| | - Makeda Semret
- Department of Medicine, Infectious Diseases and Microbiology, and JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Quebec, Canada
- * E-mail:
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Rusanganwa V, Gahutu JB, Nzabahimana I, Ngendakabaniga JMV, Hurtig AK, Evander M. Clinical Referral Laboratories in Rwanda. Am J Clin Pathol 2018; 150:240-245. [PMID: 29931081 PMCID: PMC6067122 DOI: 10.1093/ajcp/aqy047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objectives We investigated the quality system performance in Rwandan referral laboratories to determine their progress toward accreditation. Methods We conducted audits across five laboratories in 2017, using the Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist. Laboratories were scored based on the World Health Organization grading scale (0-5 stars scale) and compared with earlier audits. Results Between 2012 and 2017, only one laboratory progressed (from four to five stars). Four of the five laboratories decreased to one (three laboratories) and zero (one laboratory) stars from four and three stars. Management reviews, evaluation, audits, documents, records, and identification of nonconformities showed a low performance. Conclusions Four of five laboratories are not moving toward accreditation. However, this target is still achievable by energizing responsibilities of stakeholders and monitoring and evaluation. This would be possible because of the ability that laboratories showed in earlier audits, coupled with existing health policy that enables sustainable quality health care in Rwanda.
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Affiliation(s)
- Vincent Rusanganwa
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Clinical Microbiology, Virology, Umeå University, Umeå, Sweden
- Ministry of Health, Kigali, Rwanda
| | - Jean Bosco Gahutu
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | | | - Anna-Karin Hurtig
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Magnus Evander
- Department of Clinical Microbiology, Virology, Umeå University, Umeå, Sweden
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Alabi A, Kazimoto T, Lebughe M, Vubil D, Phaku P, Mandomando I, Kern WV, Abdulla S, Mellmann A, Peitzmann L, Bischoff M, Peters G, Herrmann M, Grobusch MP, Schaumburg F, Rieg S. Management of superficial and deep-seated Staphylococcus aureus skin and soft tissue infections in sub-Saharan Africa: a post hoc analysis of the StaphNet cohort. Infection 2018; 46:395-404. [PMID: 29667040 DOI: 10.1007/s15010-018-1140-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The incidence of Staphylococcus aureus skin and soft tissue infection (SSTI) is high in sub-Saharan Africa. This is fueled by a high prevalence of Panton-Valentine leukocidin (PVL), which can be associated with necrotizing disease. The aim was to describe the clinical presentation and the treatment of SSTI in the African setting and to identify challenges in the management. METHODS Patients (n = 319) were recruited in DR Congo (n = 56, 17.6%), Gabon (n = 89, 27.9%), Mozambique (n = 79, 24.8%) and Tanzania (n = 95, 29.8%) during the prospective observational StaphNet cohort study (2010-2015). A physician recorded the clinical management in standardized questionnaires and stratified the entity of SSTI into superficial (sSSTI) or deep-seated (dSSTI). Selected virulence factors (PVL, β hemolysin) and multilocus sequence types (MLST) were extracted from whole genome sequencing data. RESULTS There were 220/319 (69%) sSSTI and 99/319 (31%) dSSTI. Compared to sSSTI, patients with dSSTI were more often hospitalized (13.2 vs. 23.5%, p = 0.03), HIV-positive (7.6 vs. 15.9%, p = 0.11), and required more often incision and drainage (I&D, 45.5 vs. 76.5%, p = 0.04). The proportion of an adequate antimicrobial therapy increased marginally from day 1 (empirical therapy) to day 3 (definite therapy), for sSSTI (70.7 to 72.4%) and dSSTI (55.4 to 58.9%). PVL was a risk factor for I&D (OR = 1.7, p = 0.02) and associated with MLST clonal complex CC121 (OR = 2.7, p < 0.001). CONCLUSION Appropriate antimicrobial agents and surgical services to perform I&D were available for the majority of patients. Results from susceptibility testing should be considered more efficiently in the selection of antimicrobial therapy.
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Affiliation(s)
- Abraham Alabi
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.,Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany.,German Centre for Infection Research (DZIF), Partner Site Tübingen, Tübingen, Germany
| | | | - Marthe Lebughe
- Institut National de Recherche Bio-Médicale (INRB), Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Delfino Vubil
- Manhiça Health Research Center, Manhiça, Maputo, Mozambique
| | - Patrick Phaku
- Institut National de Recherche Bio-Médicale (INRB), Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Inacio Mandomando
- Manhiça Health Research Center, Manhiça, Maputo, Mozambique.,Instituto Nacional de Saúde, Ministério da Saúde, Maputo, Mozambique
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - Salim Abdulla
- Ifakara Health Institute (IHI), Dar es Salaam, Tanzania
| | | | - Lena Peitzmann
- Institute of Hygiene, University Hospital Münster, Münster, Germany
| | - Markus Bischoff
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg, Germany
| | - Georg Peters
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Mathias Herrmann
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - Martin P Grobusch
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon.,Institut für Tropenmedizin, Eberhard Karls Universität, Tübingen, Germany.,German Centre for Infection Research (DZIF), Partner Site Tübingen, Tübingen, Germany.,Division of Internal Medicine, Department of Infectious Diseases, Center of Tropical Medicine and Travel Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
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Semret M, Ndao M, Jacobs J, Yansouni CP. Point-of-care and point-of-'can': leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics. Clin Microbiol Infect 2018; 24:836-844. [PMID: 29649602 DOI: 10.1016/j.cmi.2018.03.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is an urgent need for integrated diagnosis of febrile syndromes able to account for multiple pathogens and to inform decisions for clinical care and public health. AIMS To reflect on the evolving roles of laboratory-based testing for non-malarial febrile illnesses (NMFIs) in low-resource settings, and to consider how advances in diagnostics, in connectivity and transport, and in implementation of quality systems may substantially enhance the capacity of reference laboratories to bridge the current gap between remote passive surveillance and clinically meaningful integrated fever diagnosis. SOURCES Iterative search of PubMed databases, organizational reports, and expert consultation. CONTENT Implementation of new technologies-such as very broad molecular panels for surveillance and mass spectrometry-may considerably diminish capability gaps in reference laboratories in low-resource settings. Although the need for clinical bacteriology diagnostics is now recognized, the lack of new simple and rapid phenotypic tests for antimicrobial resistance remains a key deficiency. Several initiatives to strengthen diagnostic preparedness for infectious disease outbreaks have highlighted the need for functional tiered laboratory networks. Recently, dramatic headway in connectivity-such as combining automated readers with the image processing and data transmission capabilities of smartphones-now allows for more complex testing and interfacing with distant laboratory information systems while reducing workload and errors. Together with connectivity to transmit and receive results, new approaches to specimen collection and transport-such as the validation of rectal swabs and the use of aerial drones to transport specimens to distant laboratories-now make remote testing feasible. The above innovations also open up the possibility of implementing quality systems through community-level diagnostic stewardship. Finally, strengthened laboratory networks actively support the feasibility of implementing quality-assured point-of-care testing where it is needed. IMPLICATIONS Recent advances offer the present-day possibility of innovations to re-invent the relationship between distant reference laboratories and end-users for integrated diagnosis of NMFIs.
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Affiliation(s)
- M Semret
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - M Ndao
- National Reference Centre for Parasitology, Montreal, Canada
| | - J Jacobs
- Institute of Tropical Medicine, Antwerp, Belgium; KU Leuven, Department of Microbiology and Immunology, Leuven, Belgium
| | - C P Yansouni
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada.
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Pulcini C, Binda F, Lamkang AS, Trett A, Charani E, Goff DA, Harbarth S, Hinrichsen SL, Levy-Hara G, Mendelson M, Nathwani D, Gunturu R, Singh S, Srinivasan A, Thamlikitkul V, Thursky K, Vlieghe E, Wertheim H, Zeng M, Gandra S, Laxminarayan R. Developing core elements and checklist items for global hospital antimicrobial stewardship programmes: a consensus approach. Clin Microbiol Infect 2018; 25:20-25. [PMID: 29625170 DOI: 10.1016/j.cmi.2018.03.033] [Citation(s) in RCA: 115] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/18/2018] [Accepted: 03/22/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES With increasing global interest in hospital antimicrobial stewardship (AMS) programmes, there is a strong demand for core elements of AMS to be clearly defined on the basis of principles of effectiveness and affordability. To date, efforts to identify such core elements have been limited to Europe, Australia, and North America. The aim of this study was to develop a set of core elements and their related checklist items for AMS programmes that should be present in all hospitals worldwide, regardless of resource availability. METHODS A literature review was performed by searching Medline and relevant websites to retrieve a list of core elements and items that could have global relevance. These core elements and items were evaluated by an international group of AMS experts using a structured modified Delphi consensus procedure, using two-phased online in-depth questionnaires. RESULTS The literature review identified seven core elements and their related 29 checklist items from 48 references. Fifteen experts from 13 countries in six continents participated in the consensus procedure. Ultimately, all seven core elements were retained, as well as 28 of the initial checklist items plus one that was newly suggested, all with ≥80% agreement; 20 elements and items were rephrased. CONCLUSIONS This consensus on core elements for hospital AMS programmes is relevant to both high- and low-to-middle-income countries and could facilitate the development of national AMS stewardship guidelines and adoption by healthcare settings worldwide.
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Affiliation(s)
- C Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France.
| | - F Binda
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France; University of Milan, Department of Biomedical and Clinical Sciences «Luigi Sacco», Milan, Italy
| | - A S Lamkang
- Center for Disease Dynamics, Economics & Policy (CDDEP), New Delhi, India
| | - A Trett
- Center for Disease Dynamics, Economics & Policy (CDDEP), New Delhi, India
| | - E Charani
- Imperial College London, Department of Medicine, NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - D A Goff
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - S Harbarth
- Geneva University Hospitals, Infection Control Program and WHO Collaborating Center, Faculty of Medicine, Geneva, Switzerland
| | - S L Hinrichsen
- Universidade Federal de Pernambuco (UFPE), Tropical Diseases Department, Recife, Brazil
| | - G Levy-Hara
- Hospital Carlos G Durand, Unit of Infectious Diseases, Buenos Aires, Argentina
| | - M Mendelson
- Groote Schuur Hospital, University of Cape Town, Department of Medicine, Division of Infectious Diseases & HIV Medicine, Cape Town, South Africa
| | - D Nathwani
- Ninewells Hospital and Medical School, Dundee, UK
| | - R Gunturu
- The Aga Khan University Hospital, Dept. of Pathology, Division of Clinical Microbiology, Nairobi, Kenya
| | - S Singh
- Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - A Srinivasan
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - V Thamlikitkul
- Mahidol University, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - K Thursky
- National Centre for Antimicrobial Stewardship, Royal Melbourne Hospital at the Peter Doherty Institute, Melbourne, Australia
| | - E Vlieghe
- University Hospital Antwerp, Department of General Internal Medicine, Infectious Diseases & Tropical Medicine, Antwerp, Belgium; University of Antwerp, Global Health Institute, Antwerp, Belgium; Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | - H Wertheim
- Radboudumc, Department of Medical Microbiology and Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - M Zeng
- Children's Hospital of Fudan University, Department of Infectious Diseases, Shanghai, China
| | - S Gandra
- Center for Disease Dynamics, Economics & Policy (CDDEP), New Delhi, India
| | - R Laxminarayan
- Center for Disease Dynamics, Economics & Policy (CDDEP), New Delhi, India; Princeton University, Princeton, NJ, USA
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Ombelet S, Ronat JB, Walsh T, Yansouni CP, Cox J, Vlieghe E, Martiny D, Semret M, Vandenberg O, Jacobs J. Clinical bacteriology in low-resource settings: today's solutions. THE LANCET. INFECTIOUS DISEASES 2018. [PMID: 29519767 DOI: 10.1016/s1473-3099(18)30093-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Low-resource settings are disproportionately burdened by infectious diseases and antimicrobial resistance. Good quality clinical bacteriology through a well functioning reference laboratory network is necessary for effective resistance control, but low-resource settings face infrastructural, technical, and behavioural challenges in the implementation of clinical bacteriology. In this Personal View, we explore what constitutes successful implementation of clinical bacteriology in low-resource settings and describe a framework for implementation that is suitable for general referral hospitals in low-income and middle-income countries with a moderate infrastructure. Most microbiological techniques and equipment are not developed for the specific needs of such settings. Pending the arrival of a new generation diagnostics for these settings, we suggest focus on improving, adapting, and implementing conventional, culture-based techniques. Priorities in low-resource settings include harmonised, quality assured, and tropicalised equipment, consumables, and techniques, and rationalised bacterial identification and testing for antimicrobial resistance. Diagnostics should be integrated into clinical care and patient management; clinically relevant specimens must be appropriately selected and prioritised. Open-access training materials and information management tools should be developed. Also important is the need for onsite validation and field adoption of diagnostics in low-resource settings, with considerable shortening of the time between development and implementation of diagnostics. We argue that the implementation of clinical bacteriology in low-resource settings improves patient management, provides valuable surveillance for local antibiotic treatment guidelines and national policies, and supports containment of antimicrobial resistance and the prevention and control of hospital-acquired infections.
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Affiliation(s)
- Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
| | | | | | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada
| | - Janneke Cox
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Erika Vlieghe
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of General Internal Medicine, Infectious and Tropical Diseases, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Delphine Martiny
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium
| | - Makeda Semret
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada; St Mary's Hospital Centre, Montreal, QC, Canada
| | - Olivier Vandenberg
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium; Center for Environmental Health and Occupational Health, Public Health School, Université Libre de Bruxelles, Brussels, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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Cox JA, Vlieghe E, Mendelson M, Wertheim H, Ndegwa L, Villegas MV, Gould I, Levy Hara G. Antibiotic stewardship in low- and middle-income countries: the same but different? Clin Microbiol Infect 2017; 23:812-818. [PMID: 28712667 DOI: 10.1016/j.cmi.2017.07.010] [Citation(s) in RCA: 291] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Antibiotic resistance (ABR) is a quickly worsening problem worldwide, also in low- and middle-income countries (LMICs). Appropriate antibiotic use in humans and animals, i.e. antibiotic stewardship (ABS), is one of the cornerstones of the World Health Organization's global action plan for ABR. Many LMICs are in the process of developing stewardship programs. AIMS We highlight challenges for ABS initiatives in LMICs, give an outline of (inter)national recommendations and demonstrate examples of effective, contextualized stewardship interventions. SOURCES We searched PubMed for articles on ABS interventions in humans in LMICs. Relevant websites and experts were consulted for additional sources. CONTENT Evidence on effective and feasible stewardship interventions in LMICs is limited, and challenges for implementation of interventions are numerous. Nevertheless, several initiatives at the international and local levels in Latin America, Africa and Asia have shown that ABS effective interventions are feasible in LMICs, although contextualization is essential. IMPLICATIONS Specific guidance for setting up antimicrobial stewardship programs in LMICs should be developed. Strategic points might need to be progressively addressed in LMICs, such as (a) ensuring availability of diagnostic testing, (b) providing dedicated education in ABR both for healthcare workers and the general public, (c) creating or strengthening (inter)national agencies towards better regulations and audit on production, distribution and dispensing of drugs, (d) strengthening healthcare facilities, (e) exploring a broader synergism between policy makers, academia, professional bodies and civil society and (f) designing and studying easy and scalable ABS interventions for both hospital and community settings.
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Affiliation(s)
- J A Cox
- Unit of Tropical Laboratory Medicine, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium
| | - E Vlieghe
- Unit of Tropical Laboratory Medicine, Department of Clinical Sciences, Institute of Tropical Medicine, Belgium; Department of General Internal Medicine, Infectious Diseases and Tropical Medicine, University Hospital Antwerp, Antwerp, Belgium.
| | - M Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - H Wertheim
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Viet Nam; Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom; Department of Medical Microbiology, Radboudumc, Nijmegen, The Netherlands
| | - L Ndegwa
- Infection Prevention Network-Kenya (IPNET-Kenya), Nairobi, Kenya
| | - M V Villegas
- Hospital Epidemiology and Bacterial Resistance Area, Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali and Universidad El Bosque, Bogotá, Colombia
| | - I Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - G Levy Hara
- Infectious Diseases Unit, Hospital Carlos G Durand, Buenos Aires, Argentina
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Greub G. Management: from antibiotic stewardship to clinical microbiology. Clin Microbiol Infect 2017. [DOI: 10.1016/j.cmi.2017.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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