Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs. Subjects and Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis. Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.

Cervical traction: a simple step ahead in the prevention of postpartum hemorrhage

Background: Postpartum hemorrhage is the most common preventable cause of maternal mortality in developing countries. The present study aimed to examine the impact of cervical traction technique in reducing the amount of postpartum blood loss and rate of PPH.Methods: This was a case-control, pilot study conducted in a tertiary hospital between June 2017 to June 2018. A total of 200 singletons, low-risk pregnant females, undergoing normal vaginal delivery, were enrolled in this study. Subjects showing a high risk for PPH were excluded. Patients were randomized as case group (n=100) and control group (n=100). The case group received sustained traction for 90 seconds to anterior and posterior lip of the cervix with active management of the third stage of labor, whereas the control group received routine active management of the third stage of labor. All subjects were followed up for 6 hours post-delivery. The amount of blood loss, hematocrit and hemoglobin post-delivery were compared between both groups.Results: The mean blood loss (ml), decrease in hemoglobin (g/L) and decrease in hematocrit post-delivery in cases were significantly low compared to controls (207±37.6 versus 340±49, P<0.01), (0.78±0.2 versus 1.4±0.3, P=0.03) and (1.7±0.2 versus 3.5±0.2, P<0.01). PPH occurred in 7 of 200 (3.5%) patients. The difference in the number of PPH was not significant (5/100; 5% versus 2/100; 2% P=0.2). There were no complications reported due to cervical traction.Conclusions: Cervical traction is a simple and safe maneuver to reduce the amount of postpartum blood loss. Larger RCT is recommended to investigate the reduction in PPH rate.

Sonographic assessment of fetal head deflexion using occiput: spine angle measured during first stage of labour and its role in predicting the mode of delivery among nulliparous women

Background: The attitude of the fetal head during labour significantly influences the progress and outcome of delivery and is mainly diagnosed by vaginal examination during labour. The aim of the study was to quantify the extent of deflexion of the fetal head by measuring the fetal occiput spine angle (OSA) through transabdominal ultrasonography in the first stage of labour and to determine whether the fetal OSA can predict the mode of delivery.Methods: We conducted a prospective observational study on 145 nulliparous uncomplicated singleton pregnant women without occiput-posterior position of the fetus during active labour. The OSA was measured as the angle between the two tangential lines to the occipital bone and the vertebral body of the first cervical spine, during active labour and monitored until delivery. Intra- and interobserver reproducibility of the OSA measurement and the correlation between the OSA and mode of delivery were also evaluated.Results: For the study population, the mean value of the OSA measured in the active phase of the first stage was 124.2±11.5⁰. The OSA measurement showed excellent intraobserver agreement (r = 0.82; 95% confidence interval [95% CI] 0.70-0.80) and fair-to-good interobserver agreement (r = 0.62; 95% CI 0.51-0.71).  The mean OSA was significantly less for the group of patients who required conversion to cesarean section due to labour arrest (n=32) as compared to those who had vaginal delivery (n=113) (116.25±9.2⁰ versus 126.53±11.1⁰, P<0.01). An OSA of ≥121° was associated with vaginal delivery in 80.5% (91/113) of women, whereas 87.5% (28/32) of the women who delivered by cesarean section had an OSA <121⁰.Conclusions: Measurement of the OSA, by sonography is feasible, reproducible and an objective tool to assess the degree of fetal head deflexion during labour and to predict the mode of delivery.

Successful post-cardiopulmonary resuscitation urokinase therapy for massive perioperative pulmonary embolism - a case report.

We report a case of hip arthroplasty done under epidural and general anaesthesia. The patient had two episodes of acute massive pulmonary embolism perioperatively. He received cardiopulmonary resuscitation for the cardiovascular collapse that ensued and was administered a single dose of urokinase inspite of having relative (major) contraindications to the same.

Carcinoid crisis during a partial hepatic resection; lack of essential drugs: a cause for concern in the tropics.

We report a patient of carcinoid syndrome with hepatic metastasis (primary lesion in the ileum) who was posted for a right hepatic lobe resection and excision of the primary lesion. The patient developed carcinoid crisis with excessive blood loss due to vasodilation and severe hypotension during surgery. This case highlights the lack of essential drugs in the management of an intraoperative carcinoid crisis in this part of the world.

Laryngeal changes following long-term stenting with polyvinyl chloride tubes.

BACKGROUND. To treat tracheal stenosis and permit wound healing to occur an inert stent is required which resists the contraction process and prevents re-stenosis. The newer stents of polyvinyl chloride are not readily available in India and endotracheal tubes are used in many centres. In our centre polyvinyl chloride tubes are used nasotracheally for prolonged periods. We prospectively studied the pattern of laryngeal changes that occur because of prolonged nasotracheal stenting with polyvinyl chloride tubes. METHODS. The incidence and pattern of laryngeal changes due to stents was prospectively studied at the time of removal of stents, using an operating microscope. Twenty-nine patients underwent tracheal reconstructive surgery for tracheal stenosis (post-intubation or post-tracheostomy) and tracheal injuries. RESULTS. Twelve different lesions were noted and their pattern was related to the period of stenting. Fibrosis, fibrous band formation and webs were noted after four weeks. A high incidence of laryngeal changes was seen in all age groups with an overall incidence of 79% (males 79%; females 88%; adults 82%, children 75%). The mean (SD) duration of stenting was 50 (33) days. Patients with laryngeal changes had a significantly (p < 0.05) longer duration of stenting [56 (34) days] compared to those without any lesion [29 (15) days]. CONCLUSIONS. After four weeks of stenting the severity and incidence of laryngeal changes increase. We recommend restriction of the use of polyvinyl chloride stents to less than four weeks to prevent permanent laryngeal damage.

A profile of nutritional practices and its cost in an intensive care in India.

In a retrospective study fifty patients admitted to a combined medical and surgical intensive care unit were surveyed to see the pattern of nutritional support. The routine practices of initial assessment and monitoring of the nutritional state, ordering and technique of feeding, routes of administration and complications were noted over a 3 week period. This gives an idea of the pattern of care and problems associated with nutritional support of the critically ill in this part of the world. The average cost of parenteral nutrition for three weeks was approximately Rs. 25,960 ($865 approx.) per patient.

Diazepam induced delirium.

In Ophthalmic practice diazepam is often used a a premedicant. We report a case where administration of diazepam led to a state of acute delirium because of which surgery had to be postponed. The possible mechanisms for this reaction and the treatment is discussed. This side effect of diazepam should be kept in mind while dealing with delirium in the geriatric age group.