How Well Are Hand Hygiene Practices and Promotion Implemented in Sierra Leone? A Cross-Sectional Study in 13 Public Hospitals

Infection prevention and control in conflict-affected areas in northeast Syria: A cross-sectional study

Objectives

In northeastern Syria (NES), the adherence of health care facilities to infection prevention and control (IPC) standards remains underexplored. This study evaluates the IPC performance of various health facilities against World Health Organization (WHO) benchmarks using the IPC Assessment Framework (IPCAF) and the Hand Hygiene Self-Assessment Framework (HHSAF).

Methods

We conducted a cross-sectional survey of 33 health care facilities, including primary (PHC), secondary (SHC), and tertiary health care centres (THC). Data were collected via on-site evaluations using the IPCAF and HHSAF tools.

Results

A significant 91% of facilities did not meet half of the WHO IPC minimum requirements. Specifically, 57% of PHCs met 26-50% of the standards, while none exceeded 75%. Among SHCs, 71% met 26-50% of the standards, while 44% of THCs fell within this range. Notably, 81.8% of facilities were classified as 'inadequate' per the IPCAF, with none achieving 'intermediate' or 'advanced' levels. The HHSAF results were similarly concerning, with 34.4% deemed 'inadequate' and 65.6% at the 'basic' level. A weak positive correlation (0.137) was found between IPCAF and HHSAF scores.

Conclusions

NES health care facilities demonstrate substantial deficiencies in IPC compliance, with critical gaps in IPC programmes, health care-associated infection surveillance, and training. Urgent interventions are required to enhance IPC practices, leveraging local strengths and fostering international collaborations to improve patient safety and health care quality in the region.

Evaluating the tolerability and acceptability of a locally produced alcohol-based handrub and hand hygiene behaviour among health workers in Sierra Leone: a longitudinal hospital-based intervention study

BACKGROUND

Alcohol-based handrub (ABHR) is the gold standard for hand hygiene (HH) and is a cornerstone of infection prevention and control (IPC) strategies. However, several factors influence the efficient use of ABHR by health workers. This study evaluated the tolerability and acceptability of a locally produced ABHR product and HH behaviour among health workers.

METHODS

A longitudinal hospital-based intervention study was conducted in accordance with the WHO's standardized protocol for evaluating ABHR tolerability and acceptability (Method 1). Sixty health workers across 4 hospitals in Sierra Leone were observed over a 30-day period at three separate visits (days 1, 3-5, and 30) by trained observers. The outcomes of interest included skin tolerability and product acceptabilityevaluated using subjective and objective measures.

RESULTS

Objective and subjective evaluations demonstrated strong skin tolerability and high acceptability with the product. At all three visits, the skin tolerability score assessed by trained observers was < 2 in ≥ 97% of participants, exceeding the WHO benchmark score (BMS = < 2 in ≥ 75%). Participants' self-evaluations of overall skin integrity were 97% (visit 2) and 98% (visit 3) for scores > 4 (BMS = > 4 in ≥ 75%). The primary acceptability criteria increased up to 95% (colour) and 88% (smell) at visit 3 (BMS = > 4 in ≥ 50%). Despite high acceptability, the product's drying effect remained low at 52% and 58% during visits 2 and 3, respectively (BMS = > 4 in ≥ 75%). There were positive HH behaviours (n = 53, 88%), with more than half (n = 38, 63%) of them exhibiting HH at almost every HH moment. The mean ABHR was notably high (76.1 ml, SD ± 35), especially among nurses (mean = 80.1 ml) and doctors (mean = 74.0 ml).

CONCLUSION

The WHO-formulated, locally produced ABHR was well tolerated and accepted by health workers. These findings support the continuous utilization of evidence-based, cost-effective hand hygiene interventions in resource-limited settings. High handrub consumption and frequent HH practices were noticeable HH behaviours. Further research is recommended to optimize product formulations for skin dryness and investigate the association between ABHR consumption and hand hygiene compliance.

High incidence of catheter-associated urinary tract infections and related antibiotic resistance in two hospitals of different geographic regions of Sierra Leone: a prospective cohort study

OBJECTIVE

Catheter-associated urinary tract infections (CAUTI) are common worldwide, but due to limited resources, its actual burden in low-income countries is unknown. Currently, there are gaps in knowledge about CAUTI due to lack of surveillance activities in Sierra Leone. In this prospective cohort study, we aimed to determine the incidence of CAUTI and associated antibiotic resistance in two tertiary hospitals in different regions of Sierra Leone.

RESULTS

The mean age of the 459 recruited patients was 48.8 years. The majority were females (236, 51.3%). Amongst the 196 (42.6%) catheterized patients, 29 (14.8%) developed CAUTI. Bacterial growth was reported in 32 (84%) patients. Escherichia coli (14, 23.7%), Klebsiella pneumoniae (10, 17.0%), and Klebsiella oxytoca (8, 13.6%) were the most common isolates. Most isolates were ESBL-producing Enterobacteriaceae (33, 56%) and WHO Priority 1 (Critical) pathogens (38, 71%). Resistance of K. pneumoniae, K. oxytoca, E. coli, and Proteus mirabilis was higher with the third-generation cephalosporins and penicillins but lower with carbapenems, piperacillin-tazobactam and amikacin. To reduce the high incidence of CAUTI and multi-drug resistance organisms, urgent action is needed to strengthen the microbiology diagnostic services and develop and implement catheter bundles that provide clear guidance for catheter insertion, care and removal.

Hand Hygiene Practices and Promotion in Public Hospitals in Western Sierra Leone: Changes Following Operational Research in 2021

Hand hygiene is the most important intervention for preventing healthcare-associated infections and can reduce preventable morbidity and mortality. We described the changes in hand hygiene practices and promotion in 13 public hospitals (six secondary and seven tertiary) in the Western Area of Sierra Leone following the implementation of recommendations from an operational research study. This was a "before and after" observational study involving two routine cross-sectional assessments using the WHO hand hygiene self-assessment framework (HHSAF) tool. The overall mean HHSAF score changed from 273 in May 2021 to 278 in April 2023; it decreased from 278 to 250 for secondary hospitals but increased from 263 to 303 for tertiary hospitals. The overall mean HHSAF score and that of the tertiary hospitals remained at the "intermediate" level, while secondary hospitals declined from "intermediate" to "basic" level. The mean score increased for the "system change" and "institutional safety climate" domains, decreased for "training and education" and "reminders in the workplace" domains, and remained the same for the "evaluation and feedback" domain. Limited resources for hand hygiene promotion, lack of budgetary support, and formalized patient engagement programs are the persistent gaps that should be addressed to improve hand hygiene practices and promotion.

Antibiotic use and consumption in Freetown, Sierra Leone: A baseline report of prescription stewardship in outpatient clinics of three tertiary hospitals

Objective

As there are no country-representative data on bacterial sensitivities to guide antimicrobial stewardship (AMS) interventions, an AMS programme was established in the outpatient clinics of three tertiary hospitals in Freetown, Sierra Leone.

Methods

The study employed a cross-sectional design to collect antibiotic prescribing data from 370 pregnant women and lactating mothers, 314 children and 229 regular patients in the outpatient clinics of the Princess Christian Maternity Hospital (PCMH), Ola During Children's Hospital and Connaught Hospital (CH), respectively, in April 2022. All data were analysed using Stata Version 16.

Results

Of 913 patients, most were female (n=635, 69.5%), treated at PCMH (n=370, 40.5%) and had a bacterial infection (n=661, 72.4%). The indication for prescribing antibiotics was inappropriate in 252 (27.6%) patients. Of the 1236 prescriptions, 393 (31.8%) were made at CH. The duration of antibiotic use was not stated in 230 (18.6%) prescriptions. Overall antibiotic consumption was 55.3 defined daily doses per 1000 outpatient-days.

Conclusion

Gaps in antibiotic prescriptions were identified in the outpatient clinics of three national referral hospitals in Sierra Leone. In order to combat antimicrobial resistance, AMS interventions are needed to reduce the prescription of antibiotics for inappropriate indications or without specified duration.

Establishing an Antimicrobial Stewardship Program in Sierra Leone: A Report of the Experience of a Low-Income Country in West Africa

Antimicrobial Resistance (AMR) is a growing global health challenge that threatens to undo gains in human and animal health. Prevention and control of AMR requires functional antimicrobial stewardship (AMS) program, which is complex and often difficult to implement in low- and middle-income countries. We aimed to describe the processes of establishing and implementing an AMS program at Connaught Hospital in Sierra Leone. The project involved the setting up of an AMS program, capacity building and performing a global point prevalence survey (GPPS) at Sierra Leone’s national referral hospital. Connaught Hospital established a multidisciplinary AMS subcommittee in 2021 to provide AMS services such as awareness campaigns, education and training and review of guidelines. We performed a GPPS on 175 patients, of whom more than half (98, 56.0%) were prescribed an antibiotic: 63 (69.2%) in the surgical wards and 53 (51.2%) in the medical wards. Ceftriaxone (60, 34.3%) and metronidazole (53, 30.3%) were the most common antibiotics prescribed to patients. In conclusion, it is feasible to establish and implement an AMS program in low-income countries, where most hospitalized patients were prescribed an antibiotic.

High levels of surgical antibiotic prophylaxis: Implications for hospital-based antibiotic stewardship in Sierra Leone

Objective

Despite the impact of inappropriate prescribing on antibiotic resistance, data on surgical antibiotic prophylaxis in sub-Saharan Africa are limited. In this study, we evaluated antibiotic use and consumption in surgical prophylaxis in 4 hospitals located in 2 geographic regions of Sierra Leone.

Methods

We used a prospective cohort design to collect data from surgical patients aged 18 years or older between February and October 2021. Data were analyzed using Stata version 16 software.

Results

Of the 753 surgical patients, 439 (58.3%) were females, and 723 (96%) had received at least 1 dose of antibiotics. Only 410 (54.4%) patients had indications for surgical antibiotic prophylaxis consistent with local guidelines. Factors associated with preoperative antibiotic prophylaxis were the type of surgery, wound class, and consistency of surgical antibiotic prophylaxis with local guidelines. Postoperatively, type of surgery, wound class, and consistency of antibiotic use with local guidelines were important factors associated with antibiotic use. Of the 2,482 doses administered, 1,410 (56.8%) were given postoperatively. Preoperative and intraoperative antibiotic use was reported in 645 (26%) and 427 (17.2%) cases, respectively. The most commonly used antibiotic was ceftriaxone 949 (38.2%) with a consumption of 41.6 defined daily doses (DDD) per 100 bed days. Overall, antibiotic consumption was 117.9 DDD per 100 bed days. The Access antibiotics had 72.7 DDD per 100 bed days (61.7%).

Conclusions

We report a high rate of antibiotic consumption for surgical prophylaxis, most of which was not based on local guidelines. To address this growing threat, urgent action is needed to reduce irrational antibiotic prescribing for surgical prophylaxis.

The burden of surgical site infections and related antibiotic resistance in two geographic regions of Sierra Leone: a prospective study

Despite the prolongation of hospitalization, increase in morbidity, mortality and cost of care associated with both surgical site infections (SSIs) and antibiotic resistance, there are limited data on SSIs and antibiotic resistance to guide prevention strategies in Sierra Leone. This study assessed the burden of SSIs and related antibiotic resistance in the 34 Military Hospital (MH) and Makeni Government Hospital (MGH) located in two geographic regions of Sierra Leone using a prospective study design to collect data from adults aged 18 years or older. Of the 417 patients, 233 (55.9%) were enrolled in MGH. Most were women 294 (70.5%). The incidence rate of SSI was 5.5 per 1000 patient-days, and the cumulative incidence of SSI was 8.2%. Common bacteria isolated in MH were Escherichia coli (6,33.3%) and Pseudomonas aeruginosa (3,16.7%) and in MGH were P. aeruginosa (3,42.9%) and Proteus mirabilis (2,28.9%). Of the gram-negative bacteria, 40% were Extended-spectrum beta-lactamase-producing Enterobacteriaceae, 33% were Carbapenem-resistant P. aeruginosa and 10% were carbapenem-resistant Enterobacteriaceae. Although the incidence of SSIs in our study is lower than previously reported, the rate of antibiotic resistance reported in this study is high. Urgent action is needed to invest in the microbiology infrastructure to support SSI surveillance and prevention strategies.