1
|
Klinger A, Mueller A, Sutherland T, Mpirimbanyi C, Nziyomaze E, Niyomugabo JP, Niyonsenga Z, Rickard J, Talmor DS, Riviello E. Predicting mortality in adults with suspected infection in a Rwandan hospital: an evaluation of the adapted MEWS, qSOFA and UVA scores. BMJ Open 2021; 11:e040361. [PMID: 33568365 PMCID: PMC7878147 DOI: 10.1136/bmjopen-2020-040361] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RATIONALE Mortality prediction scores are increasingly being evaluated in low and middle income countries (LMICs) for research comparisons, quality improvement and clinical decision-making. The modified early warning score (MEWS), quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA), and Universal Vital Assessment (UVA) score use variables that are feasible to obtain, and have demonstrated potential to predict mortality in LMIC cohorts. OBJECTIVE To determine the predictive capacity of adapted MEWS, qSOFA and UVA in a Rwandan hospital. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES We prospectively collected data on all adult patients admitted to a tertiary hospital in Rwanda with suspected infection over 7 months. We calculated an adapted MEWS, qSOFA and UVA score for each participant. The predictive capacity of each score was assessed including sensitivity, specificity, positive and negative predictive value, OR, area under the receiver operating curve (AUROC) and performance by underlying risk quartile. RESULTS We screened 19 178 patient days, and enrolled 647 unique patients. Median age was 35 years, and in-hospital mortality was 18.1%. The proportion of data missing for each variable ranged from 0% to 11.7%. The sensitivities and specificities of the scores were: adapted MEWS >4, 50.4% and 74.9%, respectively; qSOFA >2, 24.8% and 90.4%, respectively; and UVA >4, 28.2% and 91.1%, respectively. The scores as continuous variables demonstrated the following AUROCs: adapted MEWS 0.69 (95% CI 0.64 to 0.74), qSOFA 0.65 (95% CI 0.60 to 0.70), and UVA 0.71 (95% CI 0.66 to 0.76); there was no statistically significant difference between the discriminative capacities of the scores. CONCLUSION Three scores demonstrated a modest ability to predict mortality in a prospective study of inpatients with suspected infection at a Rwandan tertiary hospital. Careful consideration must be given to their adequacy before using them in research comparisons, quality improvement or clinical decision-making.
Collapse
Affiliation(s)
- Amanda Klinger
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ariel Mueller
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Tori Sutherland
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christophe Mpirimbanyi
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Elie Nziyomaze
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jean-Paul Niyomugabo
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Zack Niyonsenga
- University of Rwanda College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jennifer Rickard
- Department of Surgery, Kigali University Teaching Hospital, Kigali, Rwanda
- Division of Critical Care/Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Daniel S Talmor
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Elisabeth Riviello
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Sutherland T, Mpirimbanyi C, Nziyomaze E, Niyomugabo JP, Niyonsenga Z, Muvunyi CM, Mueller A, Bebell LM, Nkubana T, Musoni E, Talmor D, Rickard J, Riviello ED. Widespread antimicrobial resistance among bacterial infections in a Rwandan referral hospital. PLoS One 2019; 14:e0221121. [PMID: 31443107 PMCID: PMC6707788 DOI: 10.1371/journal.pone.0221121] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/30/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Resistance among bacterial infections is increasingly well-documented in high-income countries; however, relatively little is known about bacterial antimicrobial resistance in low-income countries, where the burden of infections is high. METHODS We prospectively screened all adult inpatients at a referral hospital in Rwanda for suspected infection for seven months. Blood, urine, wound and sputum samples were cultured and tested for antibiotic susceptibility. We examined factors associated with resistance and compared hospital outcomes for participants with and without resistant isolates. RESULTS We screened 19,178 patient-days, and enrolled 647 unique participants with suspected infection. We obtained 942 culture specimens, of which 357 were culture-positive specimens. Of these positive specimens, 155 (43.4%) were wound, 83 (23.2%) urine, 64 (17.9%) blood, and 55 (15.4%) sputum. Gram-negative bacteria comprised 323 (88.7%) of all isolates. Of 241 Gram-negative isolates tested for ceftriaxone, 183 (75.9%) were resistant. Of 92 Gram-negative isolates tested for the extended spectrum beta-lactamase (ESBL) positive phenotype, 66 (71.7%) were ESBL positive phenotype. Transfer from another facility, recent surgery or antibiotic exposure, and hospital-acquired infection were each associated with resistance. Mortality was 19.6% for all enrolled participants. CONCLUSIONS This is the first published prospective hospital-wide antibiogram of multiple specimen types from East Africa with ESBL testing. Our study suggests that low-resource settings with limited and inconsistent access to the full range of antibiotic classes may bear the highest burden of resistant infections. Hospital-acquired infections and recent antibiotic exposure are associated with a high proportion of resistant infections. Efforts to slow the development of resistance and supply effective antibiotics are urgently needed.
Collapse
Affiliation(s)
- Tori Sutherland
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Christophe Mpirimbanyi
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Elie Nziyomaze
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Jean-Paul Niyomugabo
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Zack Niyonsenga
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Claude Mambo Muvunyi
- Department of Clinical Biology, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Lisa M. Bebell
- Division of Infectious Diseases, Massachusetts General Hospital, MGH Global Health, and Harvard Medical School, Boston, United States of America
| | - Theoneste Nkubana
- Department of Pathology, Kigali University Teaching Hospital, Kigali, Rwanda
| | - Emile Musoni
- Department of Clinical Biology, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center (BIDMC), Harvard Medical School, Boston, United States of America
| | - Jennifer Rickard
- Department of Surgery, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, Kigali, Rwanda
- Department of Surgery, University of Minnesota, Minneapolis, United States of America
| | - Elisabeth D. Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States of America
| |
Collapse
|