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Antibiotic Use in Pediatric Care in Ghana: A Call to Action for Stewardship in This Population
Get PDFBackground/Objectives: Antibiotic use is common among hospitalized pediatric patients. However, inappropriate use, including excessive use of Watch antibiotics, can contribute to antimicrobial resistance, adverse events, and increased healthcare costs. Consequently, there is a need to continually assess their usage among this vulnerable population. This was the objective behind this study. Methods: The medical records of all pediatric patients (under 12 years) admitted and treated with antibiotics at a Ghanaian Teaching Hospital between January 2022 and March 2022 were extracted from the hospital’s electronic database. The prevalence and appropriateness of antibiotic use were based on antibiotic choices compared with current guidelines. Influencing factors were also assessed. Results: Of the 410 admitted patients, 319 (77.80%) received at least one antibiotic. The majority (68.65%; n = 219/319) were between 0 and 2 years, and males (54.55%; n = 174/319). Ceftriaxone was the most commonly prescribed antibiotic (20.69%; n = 66/319), and most of the systemic antibiotics used belonged to the WHO Access and Watch groups, including a combination of Access and Watch groups (42.90%; n = 136/319). Neonatal sepsis (24.14%; n = 77/319) and pneumonia (14.42%; n = 46/319) were the most common diagnoses treated with antibiotics. Antibiotic appropriateness was 42.32% (n = 135/319). Multivariate analysis revealed ceftriaxone prescriptions (aOR = 0.12; CI = 0.02–0.95; p-value = 0.044) and surgical prophylaxis (aOR = 0.07; CI = 0.01–0.42; p-value = 0.004) were associated with reduced antibiotic appropriateness, while a pneumonia diagnosis appreciably increased this (aOR = 15.38; CI = 3.30–71.62; p-value < 0.001). Conclusions: There was high and suboptimal usage of antibiotics among hospitalized pediatric patients in this leading hospital. Antibiotic appropriateness was influenced by antibiotic type, diagnosis, and surgical prophylaxis. Targeted interventions, including education, are needed to improve antibiotic utilization in this setting in Ghana and, subsequently, in ambulatory care
The social determinants of tuberculosis: a case-control study characterising pathways to equitable intervention in Peru
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Despite being key components of global tuberculosis policy, poverty reduction and social protection interventions have been inconsistently implemented. We aimed to characterise how poverty and interrelated personal risk factors increase tuberculosis risk in Peru to inform the design of locally appropriate, person-centred, equity-oriented interventions.
Methods
We undertook a case-control study among people aged 15 years and over in 32 communities in Peru between 2016 and 2019. Cases (n = 2337) were people diagnosed with any form of tuberculosis. Controls (n = 981) were people living in randomly selected households in the same communities. We derived measures of household poverty from three dimensions (physical, human, and financial capital) and investigated the associations between these; personal risk factors more specifically linked to health (e.g. smoking); and tuberculosis. We used logistic regression to calculate adjusted odds ratios (aOR), 95% confidence intervals (95% CI), and population attributable fractions (PAF). A directed acyclic graph was used to inform the analytical approach.
Results
Household poverty was strongly associated with tuberculosis (aOR = 3.1; 95% CI: 2.3–4.2 for people from the ‘poorer’ versus ‘less poor’ half of households). There was a non-linear social gradient across deciles of household poverty, with odds of tuberculosis increasing exponentially as poverty deepened (aOR = 12.6; 95% CI: 6.8–23.2 for the ‘poorest’ decile versus the ‘least poor’ decile). Overall, tuberculosis burden could be halved by reducing poverty in the ‘poorer’ half of households to the level of the ‘less poor’ half (PAF = 47%; 95% CI: 40–54). For key personal risk factors, we estimated PAF for alcohol excess (PAF = 12.3%, 95% CI: 7.2–17.2); underweight (PAF = 10.3%, 95% CI: 8.7–11.8); smoking (PAF = 8.8%, 95% CI: 3.8–13.5); HIV (PAF = 5.7%, 95% CI: 4.6–6.7); and diabetes (PAF = 4.6%, 95% CI: 3.3–6.0). We also identified other important risk factors including previous tuberculosis (PAF = 14.8%, 95% CI: 11.6–17.9); incarceration (PAF = 9.5%, 95% CI: 6.8–12.1); and lower social capital (PAF = 4.1%, 95% CI: 2.6–5.6). Most personal risk factors, particularly education and substance misuse, tuberculosis exposures (e.g. incarceration and homelessness), and undernutrition, exhibited a social gradient across quintiles of household poverty and were more prevalent in people living in poorer households (Cochran-Armitage test for linear trend P < 0.001 for variables showing these social gradients).
Conclusions
Interventions addressing multidimensional household poverty and interrelated personal risk factors could substantially reduce tuberculosis burden. Our results provide an evidence base for designing person-centred, equity-oriented interventions; and support more effective implementation of poverty reduction and social protection within the global tuberculosis response
Barriers to Compliance with National Guidelines Among Children Hospitalized with Community-Acquired Pneumonia in Vietnam and the Implications
No full textBackground: Community-acquired pneumonia (CAP) is the leading cause of death in infants aged 1–59 months. Concurrent with this, there is a need to prescribe antibiotics wisely in Vietnam due to concerns with rising antimicrobial resistance (AMR). Consequently, an urgent need has arisen to treat patients according to agreed guidelines. The aim of this study was to investigate the current management of infants under five years old with CAP in Vietnam as well as identify possible obstacles to adhering to national guidelines. Methods: A mixed-method approach was used incorporating both quantitative and qualitative data analysis in a leading hospital in Vietnam, which influences others. Data from 108 pediatric patient records were collected and analyzed. Subsequently, in-depth interviews were conducted with pediatric doctors treating these patients to ascertain possible reasons for non-adherence to guidelines. Results: The mean age of children diagnosed with CAP was 27.94 ± 12.99 months, with 82.4% having non-severe CAP, and 41.7% of children had previously used antibiotics before hospitalization. The median length of hospital stay was 7 days. All children were prescribed antibiotics, 91.4% of children received these initially intravenously, with third-generation cephalosporins being the most (91.7%) commonly prescribed. Cefoperazone/sulbactam was the most frequently prescribed (48.2%) antibiotic. However, on 96.1% of occasions cefoperazone/sulbactam was given at higher doses than the label instructions. Overall, 73.3% of antibiotics prescribed were “Watch” antibiotics. In addition, the proportion of initial antibiotic regimens that were consistent with current national guidelines was only 4.63%. Conclusions: There were considerable concerns with low adherence rates to current guidelines alongside high rates of prescribing of injectable third-generation cephalosporins due to various internal and external barriers. Antimicrobial stewardship programs with updated national guidelines are urgently needed in Vietnamese hospitals to treat CAP in children as part of ongoing measures to reduce increasing AMR rates. Such activities should also help improve antibiotic use in the community following improved education of trainee ambulatory care physicians regarding appropriate management of children with CAP
Antibody-Fab and -Fc features promote Mycobacterium tuberculosis restriction
Get PDFMycobacterium tuberculosis, the causative agent of tuberculosis (TB), a leading cause of death by an infectious disease globally, has no efficacious vaccine. Antibodies are implicated in M. tuberculosis control, but the mechanisms of action remain poorly understood. We assembled a library of monoclonal antibodies (mAb) and screened for M. tuberculosis-restrictive activity in mice, identifying protective antibodies targeting diverse antigens. To dissect the mechanism of mAb-mediated M. tuberculosis restriction, we optimized a protective lipoarabinomannan-specific mAb, generating Fc variants. In vivo analysis of these Fc variants revealed a role for Fc-effector function in M. tuberculosis restriction. Restrictive Fc variants altered distribution of M. tuberculosis across innate immune cells. Single-cell transcriptomics highlighted distinctly activated pathways within innate immune cell subpopulations, identifying early activation of neutrophils as a key signature of mAb-mediated M. tuberculosis restriction. Therefore, antibody-mediated restriction of M. tuberculosis is associated with reorganization of the tissue-level immune response to infection and depends on the collaboration of antibody Fab and Fc
The Burden of Neonatal Invasive Candidiasis in Low- and Middle-income Countries: A Systematic Review and Meta-analysis
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Invasive Candida infection remains a significant threat to neonates worldwide. Most evidence on neonatal invasive candidiasis (NIC) comes from high-income countries, leaving the burden and characteristics of NIC in low- and middle-income countries (LMICs) poorly described. This study aimed to investigate the incidence, case-fatality rates (CFR), epidemiology, and etiology of NIC in LMICs.
Methods
We conducted a systematic literature review and meta-analyses of all eligible studies in 17 databases published from inception until April 2022 focusing on microbiologically confirmed NIC in LMICs.
Findings
A total of 257 articles were included, with 10 994 NIC cases from 27 LMICs. The overall incidence rate was 2.6% (95% confidence interval [CI], 2.2–3.0). Regional disparities were evident, with South-East Asia reporting the highest incidence rate (6.3%; 95% CI, 3.2–10.3). The mean gestational age and birth weight were 31.4 weeks (standard deviation, 3.3) and 1530 g (standard deviation, 644.6), respectively. Among 10 087 included isolates, the predominant species was C albicans (39.0%), followed by C parapsilosis (24.8%), with marked differences in species distribution across World Health Organization regions. Fluconazole was the most commonly used agent for NIC treatment (55.4%; 1567/2826). Overall, 24.8% (1128/6613) of isolates with available data were resistant to fluconazole. The pooled estimated CFR was 18.7% (95% CI, 15.5–22.1).
Conclusions
A higher NIC incidence rate and CFR in LMICs is noted compared to high-income countries, although infected babies were less premature with a higher birth weight. The proportion of fluconazole-resistant isolates was high. Prevention and treatment strategies for NIC need to be targeted to LMIC settings
Long term outcomes following embolisation of bronchial and non-bronchial systemic arteries for the management of haemoptysis – a 20-year experience
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Bronchial artery embolisation (BAE) is considered the most effective non-surgical technique for management of moderate-massive haemoptysis. Associated risks include neurological compromise such as stroke and spinal cord ischaemia. We aim to evaluate post-procedural outcomes and complication rates.
Materials and methods
A single-centre retrospective observational study was conducted for BAE cases performed between January 2002-June 2022 in a London teaching hospital. Data was collected from electronic medical records and Picture Archiving Communications System (PACS). Primary outcomes were measured, and statistical analysis was performed to identify risk factors for haemoptysis recurrence.
Results
One hundred eleven patients underwent 141 procedures with technical success achieved in 87.8% and clinical success in 84.8%. The most common causes of haemoptysis were aspergilloma (24.8%), bronchiectasis (19.1%) and malignancy (11.3%). Haemoptysis recurrence occurred in 65 cases (46%) with 20 patients undergoing repeat embolisation. Aspergillosis, cystic fibrosis, and non-tuberculous pneumonia were identified as risk factors for recurrent haemoptysis (p < 0.005). Pre-procedure MDCTA did not improve technical success. The rate of stroke in the cohort was 6.4% (9 cases), which is more so than quoted in the literature. Four of these patients presented with apical cavitations secondary to infection (aspergilloma or bacterial pneumonia).
Conclusions
BAE is an effective endovascular treatment in patients with massive and recurrent haemoptysis. However, there is a well-documented risk of recurrent symptoms and early mortality, particularly in the setting of aspergilloma, cystic fibrosis and non-tuberculous pneumonia. The risk of stroke should not be underestimated. Patients should be counselled appropriately during informed consent prior to embarking on BAE
A Randomized Double‐Blind, Placebo‐Controlled Trial of Artesunate and Curcumin in Patients With Crohn's Disease: A Pilot Study
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Less than half of all patients with Crohn's disease remain in remission with long‐term use of azathioprine. Our aim was to assess the efficacy of Artesunate and Curcumin in maintaining remission in patients with Crohn's disease, who had ongoing evidence of disease activity despite taking azathioprine.
Methods
Patients with Crohn's disease being treated with azathioprine for at least 3 months but still had mild to moderate Crohn's disease (CDAI 150–450) were included. Patients were randomized into four blocks of 10 patients each in a 2 × 2 factorial design to receive artesunate 200 mg PO daily for 2 weeks and/or curcumin 200 mg PO daily for 3 months or placebo. Harvey–Bradshaw Index, CDAI, and fecal calprotectin were measured at baseline, 1 week, 1 month, 3 months, and 6 months.
Results
Forty patients were recruited and randomized into the study. Both Artesunate and Curcumin were well tolerated with no adverse effects. The Harvey–Bradshaw Index statistically differed across the treatment groups at 6 months (p = 0.047), there were no significant group differences in the post hoc pairwise analysis. The differences in CDAI from baseline to 6 months were statistically significant in Artesunate + Curcumin (p = 0.0098) and Curcumin + Placebo (p = 0.0431) groups. Similarly, statistically significant differences were observed between Baseline and 6 months for the Harvey–Bradshaw Index in the Artesunate + Curcumin (p = 0.0070) and Curcumin + Placebo (p = 0.0138) groups.
Conclusion
A combination of artesunate and curcumin in patients with ongoing inflammatory activity appears to be effective as measured by CDAI and Harvey–Bradshaw Index
Atrial fibrillation burden in clinical practice, research, and technology development: a clinical consensus statement of the European Society of Cardiology Council on Stroke and the European Heart Rhythm Association.
Get PDFAtrial fibrillation (AF) is one of the most common cardiac diseases and a complicating comorbidity for multiple associated diseases. Many clinical decisions regarding AF are currently based on the binary recognition of AF being present or absent with the categorical appraisal of AF as continued or intermittent. Assessment of AF in clinical trials is largely limited to the time to (first) detection of an AF episode. Substantial evidence shows, however, that the quantitative characteristic of intermittent AF has a relevant impact on symptoms, onset, and progression of AF and AF-related outcomes, including mortality. Atrial fibrillation burden is increasingly recognized as a suitable quantitative measure of intermittent AF that provides an estimate of risk attributable to AF, the efficacy of antiarrhythmic treatment, and the need for oral anticoagulation. However, the diversity of assessment methods and the lack of a consistent definition of AF burden prevent a wider clinical applicability and validation of actionable thresholds of AF burden. To facilitate progress in this field, the AF burden Consensus Group, an international and multidisciplinary collaboration, proposes a unified definition of AF burden. Based on current evidence and using a modified Delphi technique, consensus statements were attained on the four main areas describing AF burden: Defining the characteristics of AF burden, the recording principles, the clinical relevance in major clinical conditions, and implementation as an outcome in the clinic and in clinical trials. According to this consensus, AF burden is defined as the proportion of time spent in AF expressed as a percentage of the recording time, undertaken during a specified monitoring duration. A pivotal requirement for validity and comparability of AF burden assessment is a continuous or near-continuous duration of monitoring that needs to be reported together with the AF burden assessment. This proposed unified definition of AF burden applies independent of comorbidities and outcomes. However, the disease-specific actionable thresholds of AF burden need to be defined according to the targeted clinical outcomes in specific populations. The duration of the longest episode of uninterrupted AF expressed as a time duration should also be reported when appropriate. A unified definition of AF burden will allow for comparability of clinical study data to expand evidence and to establish actionable thresholds of AF burden in various clinical conditions. This proposed definition of AF burden will support risk evaluation and clinical treatment decisions in AF-related disease. It will further promote the development of clinical trials studying the clinical relevance of intermittent AF. A unified approach on AF burden will finally inform the technology development of heart rhythm monitoring towards validated technology to meet clinical needs
Dronedarone provides effective early rhythm control: post-hoc analysis of the ATHENA trial using EAST-AFNET 4 criteria
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This post-hoc analysis of the ATHENA trial assessed whether dronedarone (400 mg twice daily) improved cardiovascular outcomes compared with placebo in patients with early atrial fibrillation/atrial flutter (AF) and cardiovascular comorbidities, based on EAST-AFNET 4 inclusion criteria and outcomes.
Methods and results
The co-primary outcomes were (i) a composite of cardiovascular death, stroke, or hospitalisation due to worsening of heart failure (HF) or acute coronary syndrome (ACS) and (ii) nights spent in hospital per year. Sinus rhythm (SR) at 12 months was a secondary outcome. The primary safety outcome was a composite of death, stroke, or pre-specified serious adverse events of special interest (AESIs) related to rhythm control therapy. 1810 patients with early AF were identified. Patients receiving dronedarone had fewer deaths from cardiovascular causes, strokes, or hospitalisations due to worsening of HF or ACS compared with patients receiving placebo [dronedarone (n = 924), 87 patients with ≥1 event; placebo (n = 886), 117 patients with ≥1 event; hazard ratio 0.71; 95% confidence interval 0.54–0.94; P = 0.014]. Number of nights spent in hospital did not differ between treatment groups. More patients receiving dronedarone (69.2%) were in SR at 12 months compared with placebo (60.8%). Primary safety events comprising death, stroke, or pre-specified serious AESIs related to rhythm control therapy were not different (dronedarone vs. placebo: 60 vs. 71 patients with ≥1 event).
Conclusion
These data support the use of dronedarone for early rhythm control therapy in selected patients with early AF.
Trial registration
ATHENA: ClinicalTrials.gov identifier NCT00174785. EAST-AFNET 4: ClinicalTrials.gov identifier NCT01288352
A retrospective clinical evaluation of the quality of antibiotic use in treating ear, nose and throat infections in ambulatory care setting of a teaching hospital in Ghana: findings and implications
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Ear, nose and throat (ENT) infections are often associated with high levels of morbidity and mortality. Antibiotic overuse and misuse for most ENT infections have been reported, caused by a lack of expertise or uncertainties to distinguish between infection types. This study sought to determine the level of appropriateness of antibiotics for ENT infections and its associated factors in ambulatory care in a teaching hospital in Ghana to guide future policies given rising resistance rates.
Methods
A retrospective cross-sectional study design was undertaken to audit the quality of antibiotic use in Ho Teaching Hospital, a leading teaching hospital in Ghana, between January 2022 to December 2022. A checklist was designed to extract patient socio-demographic and clinical information from electronic medical records. The main study outcome was the appropriate choice of antibiotics principally in accordance to the Ghana standard treatment guidelines. Descriptive, bivariate and multivariate analyses were performed on the data collected using STATA version 14.
Results
The electronic medical records of a total of 3,279 patients were extracted. The majority (57.88%, n = 1898) of patients were females, median (inter-quartile range) age was 25 [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42] years. Ear infections were the commonest (66.24%, n = 2172) diagnosed ENT infection, followed by throat infections (15.74%, n = 516). The most prescribed antibiotic was oral amoxicillin-clavulanic acid together with a topical neomycin-steroid combination (28.00%, n = 918), followed by amoxicillin-clavulanic acid alone (18.69%, n = 613). The appropriate choice of antibiotic for all ENT infections in accordance with treatment guidelines was 60.11%. Inappropriate use of antibiotics was high when more than one antibiotic and World Health Organisation (WHO) ‘Watch’ group antibiotics were prescribed and ear infections compared to the nose and throat infections were treated.
Conclusion
The appropriateness of antibiotic use for ENT infections in this hospital was suboptimal. It was predicted by the type of infection, the number of antibiotics prescribed and the WHO AWaRe group. Antimicrobial stewardship interventions such as clinical audit with feedback and clinician education must be enhanced to among other things identify antibiotic use gaps to help reduce unnecessary use of antibiotics for ENT infections
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