Assessment of antimicrobial resistance laboratory-based surveillance capacity of hospitals in Zambia: findings and implications for system strengthening

BACKGROUND

A well-established antimicrobial resistance (AMR) laboratory-based surveillance (LBS) is of utmost importance in a country like Zambia which bears a significant proportion of the world's communicable disease burden. This study assessed the capacity of laboratories in selected hospitals to conduct AMR surveillance in Zambia.

METHODS

This cross-sectional exploratory study was conducted among eight purposively selected hospitals in Zambia between August 2023 and December 2023. Data were collected using the self-scoring Laboratory Assessment of Antibiotic Resistance Testing Capacity (LAARC) tool.

FINDINGS

Of the assessed facilities, none had full capacity to conduct AMR surveillance with varying capacities ranging from moderate (63% (5/8)) to low (38% (3/8)). Some of the barriers of AMR-LBS were the lack of an electronic laboratory information system (63% (5/8)) and the lack of locally generated antibiograms (75% (6/8)). Quality control for antimicrobial susceptibility testing (AST), pathogen identification and media preparation had the lowest overall score among all of the facilities with a score of 14%, 20% and 44%, respectively. The highest overall scores were in specimen processing (79%), data management (78%), specimen collection, transport and management (71%), and safety (70%). Most facilities had standard operating procedures in place but lacked specimen-specific standard operating procedures.

CONCLUSION

The absence of laboratories with full capacity to conduct AMR surveillance hinders efforts to combat AMR and further complicates the treatment outcomes of infectious diseases. Establishing and strengthening LBS systems are essential in quantifying the burden of AMR and supporting the development of local antibiograms and treatment guidelines.

Assessing Spectrum of Fractures in Elderly; Perspective on Tertiary Care Hospital of Nepal

Background There is an increasing life expectancy and a surging elderly population in the last few decades, leading to a higher incidence of fractures in the elderly. The health care of the elderly in Nepal is below par and there are no studies done to evaluate the spectrum of fractures in the elderly. Objective To evaluate the demographical and epidemiological aspects of fractures in the elderly (≥ 65 years) presenting to a tertiary care hospital in Nepal in a 15 years' timeline. Method This study was a retrospective epidemiological study conducted in the Department of Orthopedics, Dhulikhel Hospital, Kathmandu University Hospital (DH, KUH), Nepal. The patients of age ≥ 65 years having traumatic injuries, admitted in the orthopedics ward from 2006 January to 2020 December were included. Patient demographics, site of injury, fracture incidence, mechanism of injury, hospital stay duration, and mode of treatment (surgical/ conservative) were evaluated. Result Of the 787 patients with an average age of 73.65 ± 7.5 years, 54% were females. Peritrochanteric fracture was the most common fracture (29.4%) followed by spine (18.3%). The most common mechanism of injury was fall on the labeled ground (38.6%). The incidence of fragility fractures (peri-trochanteric, proximal humerus, spine, and distal radius) was increasing with age. Conclusion Females, peritrochantric fractures, and trivial trauma are the most common occurrences for fractures in elderly. The incidence of fragility fractures is increasing with age but the overall incidence of fractures compared to other studies is low. Higher incidences of road traffic accidents (RTA) and compound fractures among the elderly are serious public health concerns that highlight the importance of primary preventive measures.

Neurological Outcome of Early versus Late Surgery Following Cervical Spinal Cord Injury

Background There are numerous retrospective studies and a few prospective studies to determine the neurologic outcome after early versus late surgical treatment for cervical spinal cord injury. Objective To compare the neurological outcome between early (within 72 hours after injury) and delayed (≥ 72 hours after injury) surgery in patients with cervical spinal injury. Method This is a retrospective analysis of the neurological outcome of early versus late surgery following cervical spinal cord trauma. Patients meeting appropriate inclusion criteria were divided into an early or a late surgical treatment group. The neurologic outcomes and other complications were recorded up to six months of follow-up. Result Overall, there was a significant difference in neurological status at presentation and at follow-up (p < 0.001). However, there was no statistically significant difference between the early versus late surgery groups (p-value 0.261) in terms of neurological outcome. Complications were found to be higher among those undergoing posterior surgical approach (OR = 23.75; 95% CI 2.65, 212.98) than those with anterior or combined approach (p=0.005). However, multivariate analysis of these variables failed to show any statistically significant difference between the two groups. Conclusion The timing of surgery does not alter the neurological outcomes and the development of complications significantly. The American Spinal Cord Injury Association (ASIA) status at the time of presentation is found to be the single most important factor correlating with the neurological outcome.

Osteosynthesis of Neck of Femur Fracture below 65 years of Age: does timing of surgery influence osteonecrosis, nonunion and functional outcome?

Background Influence of timing of injury surgery interval in outcome of osteosynthesis of neck of femur has always been a matter of debate. Patients in our set up have been surgically treated for neck of femur fracture with wide range of injury surgery interval which could have resulted in varied functional outcome and radiological outcome. Objective To evaluate the difference in functional outcome, femoral head osteonecrosis and non-union in fracture neck of femur fixed within and after twenty-four hours. Method All patients, who had undergone osteosynthesis for the neck of femur fractures via open or closed technique from 2010 to 2018 were analyzed retrospectively. The cases were examined and evaluated in terms of injury surgery interval, fracture union, functional status using Modified Harris Hip Score, complications like femoral head osteonecrosis and non-union. Result Fifty patients with an average injury surgery interval of 34±28 hours were evaluated. Twenty three (46%) cases were included in early surgery group (< 24 hours) and 27 (54%) patients were included in delayed (> 24 hours) surgery group. Incidence of femoral head osteonecrosis was reported in two (4%) cases, both being in delayed fixation group (p=0.49). Non-union was reported in four (8%) patients, one in early fixation group and three in delayed fixation group (p=0.61). The average Modified Harris Hip Score in early fixation group was 87 and in delayed fixation group was 84 (p=0.1). Forty two (84%) cases had a good quality of reduction and eight (16%) had a poor reduction. Non-union and functional outcome significantly differed between the good and poor reduction group (p=0.001 and 0.004 respectively). Conclusion There is no significant difference in the functional and radiological outcome of cases operated before and after 24 hours for osteosynthesis of neck of femur fractures in patients 16 to 65 years age group. However, poor reduction is significantly associated with the increased rate of non-union and poor functional outcome.

Outcome of Achilles Tendon Repair using Four Strand Cross Locked Cruciate Repair Technique

Background Four strand cross locked cruciate tendon repair technique for Achilles tendon rupture has shown promising result. Objective To evaluate the outcome of all acute traumatic Achilles tendon rupture case treated by a novel repair technique of four strand cross locked cruciate. Method A total of 40 cases of acute traumatic Achilles tendon rupture from 2011 to 2018 treated by four strand cross locked cruciate repair technique were retrospectively evaluated using Achilles Tendon Total Rupture Score. Result Average age of patient was 29.45 years. Male preponderance was seen. Most of the patient (97.5%) had complete rupture of Achilles tendon. Most of the patient (92.5%) had open injury. The average length of hospitalization was 7 days. All the patients recovered to the level of physical activity previous to the tendon lesion. The achilles tendon total rupture score significantly improved from 6 month post op period to 12 months (p=0.02) and 2 years post op period (p=0.038). Conclusion The optimum method of suturing technique for acute traumatic rupture of Achilles tendon remains controversial. The four strand cross locked cruciate repair technique provides a stable and reliable construct for the Achilles tendon repair. The technique requires further investigation with direct comparison with other mostly used techniques like Krackow and Gift box suture technique.

Coxsackie B Virus Infection as a rare cause of Acute Renal Failure and Hepatitis

We report a 37 year female patient, admitted with complains of fever, jaundice and myalgia of seven days. There was no history of trauma, drug abuse, seizure or vigorous exercise nor history of renal and musculoskeletal disease. Here we have discussed the clinical features, biochemical derangements, diagnosis of coxsackie B virus, multi organ involvement and need of urgent hemodialysis for appropriate management of the case.

Tuberculosis Caused by Mycobacterium orygis in Dairy Cattle and Captured Monkeys in Bangladesh: a New Scenario of Tuberculosis in South Asia

Mycobacterium orygis, commonly known as the oryx bacillus and a newly proposed Mycobacterium tuberculosis complex subspecies, was isolated from 18 cattle in a dairy farm and two captured rhesus monkeys in a zoo in Bangladesh. All the infected animals had tuberculosis lesions in their lungs, suggesting transmission and infection with M. orygis by an airborne route. The 20 isolates were analysed using a range of conventional and molecular typing methods, and RD-deletion typing and sequencing of selected genes confirmed the isolates as M. orygis. Multiple-locus variable-number tandem repeat analysis (MLVA) allowed the isolates to be divided into three clusters based on the relatedness of their MLVA profiles. The two monkey isolates shared the same MLVA pattern with 15 of the cattle isolates, whereas the remaining three cattle isolates had different patterns, even though the latter animals had been kept in the same dairy farm. The diversity observed among isolates may suggest the bacteria have been established in this area for a long period. This study along with other recent findings that report the detection of M. orygis from animals as well as humans originating from South Asia potentially indicate endemic distribution of M. orygis in South Asia.

Health system through the eyes of a doctor from rural Nepal

Its almost 30 years of declaration of Alma-Ata for primary healthcare policy the health system in Nepal still facing shortage of trained medical doctors and health professionals reaching remote and rural part of the country to provide quality health services. There are number of issues such as financial or non-financial incentives, professional advancements, educational opportunities and workplace environment. Healthcare delivery system in Nepal is failing to meet the healthcare need of the general public and needs discussion and revision. However, despite of so many challenges more doctors are willing to work in the remote and rural Nepal. The government has to come out with effective planning and policy regarding health system and human resource for health. In this context, an attempt has been made for a analytical perspective from a medical doctor point of view to highlight some of the pertinent local and policy related issues to improve Health System in Nepal.

Hysterectomy: an analysis of perioperative and post operative complication

OBJECTIVE

To document peri operative and post operative complication observed after hysterectomy, regardless of route on the operator.

MATERIAL AND METHODS

A hospital based prospective study was carried out in department of obstetrics and gynaecology, KMCTH Sinamangal for six months. The study was carried out in patients undergoing hysterectomy who were followed from the time of admission to the time of discharge and two weeks thereafter. And followings were noted--Indication; route of hysterectomy, intraoperative and postoperative morbidities during hospital stay and after two weeks of discharge was noted.

RESULT

Total number of hysterectomy carried out was 50. 31 (62%) were Total abdominal hysterectomy, and 19 (38%) were vaginal hysterectomy. Indication for total abdominal hysterectomy were fibroid uterus 12 (24%), DUB 8 (16%), CIN 4 (8%), chronic cervicitis 1 (2%). II U-V prolapse with previous LSCS 1 (2%), endometriosis 1 (2%). Prophylactic for Ca breast 1 (2%), Postmenopausal bleeding 1 (2%). All cases of vaginal hysterectomy were performed for 2nd degree U-V prolapse. Intra operative complication during surgery were two cases of haemorrhage (4%) each in both total abdominal hysterectomy and vaginal hysterectomy. There was one case of bladder injury during abdominal hysterectomy. Postoperative complication noted were febrile morbidity 1 (2%) in abdominal hysterectomy. Urinary tract infection remains the single most common febrile morbidity. There was one case of secondary haemorrhage in both type of hysterectomy. One was managed conservatively and other required laparotomy. There were three (6%) cases of wound infection in abdominal hysterectomy of two which were sanguineous discharge and one was frank pus which required secondary suture.