ABSTRACT
Antimicrobial resistance is a major threat to human health that is predicted to impact most heavily on sub-Saharan Africa, however there is a lack of clinical outcome data from drug-resistant infections in this setting. There are reasons to expect the COVID-19 pandemic to have both positive and negative impacts on AMR in Africa. We have recruited a series of prospective longitudinal cohorts from Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi and the surrounding communities in the Southern Region of Malawi. The data from these cohorts has been used to describe the aetiology of febrile illness, the burden of antimicrobial resistance in this setting and the distribution of extended spectrum beta-lactamase producing bacteria in humans, animals and the environment. Amongst a cohort of patients presenting to QECH unwell with febrile illness, 67% were living with human immunodeficiency virus (HIV). We identified a diagnosis in 145 of 225 (64%) participants, most commonly tuberculosis (TB;34%) followed by invasive bacterial infections (17%), arboviral infections (13%), and malaria (9%). In a second cohort with drug resistant infection, resistance to third-generation cephalosporins was associated with an increased probability of in-hospital mortality (hazard ratio [HR] 1.44, 95% CI 1.02-2.04), longer hospital stays (1.5 days, 1.0-2.0) and decreased probability of discharge alive (HR 0.31, 0.22-0.45). In the community cohorts, a paucity of environmental health infrastructure and materials for safe sanitation was identified across all sites and ESBL-Enterobacterales were isolated from 41.8% of human stool, 29.8% of animal stool and 66.2% of river water samples and was associated with the wet season, living in urban areas, advanced age and in household-animal interactions. Life threatening febrile illness is common in Blantyre however, diagnostics are few, however the COVID-19 pandemic has led to rapid expansion of diagnostic capacity. We are, however frequently treating the wrong bugs with ceftriaxone, further there was significant expansion of azithromycin demand and usage during the pandemic. Current management of sepsis has not been optimised and ceftriaxone use is promoting carriage of ESBL bacteria out of the hospital and ESBL E. coli and K. pneumoniae are ubiquitous in the community, where environmental hygiene infrastructure and community antimicrobial stewardship are critically lacking.Copyright © 2023
ABSTRACT
SESSION TITLE: Critical Thinking SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: We describe a case of severe thrombocytopenia due to reaction with an electron-beam sterilized polysulfone (PS) membrane in a patient with a previous diagnosis of reported chronic immune thrombocytopenic purpura (ITP). This phenomenon has been previously described but is rarely reported. Electron-beam (e-beam) sterilized PS membranes are classically more biocompatible than cellulose-based membranes but adverse reactions may occur as demonstrated in our case. CASE PRESENTATION: An 84-year-old woman with ESRD on hemodialysis (HD) and reported chronic ITP refractory to glucocorticoids with severe thrombocytopenia at baseline presented for evaluation of chest pain. She was incidentally found to have severe thrombocytopenia and treated with high dose glucocorticoids with minimal improvement in her thrombocytopenia and transitioned to chronic glucocorticoid taper. She had a severe chronic thrombocytopenia despite glucocorticoids which was suspected to be chronic ITP and diagnosed after initiation of outpatient HD. HD was held the first few days of her admission. She was found to have multifocal pneumonia due to SARS-CoV-2 infection. She developed progressive hypoxemic respiratory failure requiring intubation with sepsis treated with vancomycin & piperacillin-tazobactam. BAL revealed ESBL Escherichia coli & transitioned to ertapenem. She developed recurrent thrombocytopenia following HD and her PLT would improve between HD sessions. Evaluation of usual culprits of thrombocytopenia was unrevealing. Reaction to the PS membrane was suspected and a cellulose-based dialyzer membrane was used instead for subsequent sessions of HD with recovery of the platelet counts to normal. The remainder of her course was significant for tracheostomy with ventilator dependence and surrogate pursued compassionate care. DISCUSSION: We describe an interesting case of severe thrombocytopenia due to PS membrane reaction which was previously labeled as chronic ITP. Usual culprits such as pseudothrombocytopenia, HIT, HIV, HCV, hypersplenism, alcohol use, nutritional deficiencies, and rheumatologic disease were excluded. Synthetic membranes like PS-membranes are traditionally regarded as more biocompatible but filter reactions are described [1]. It is hypothesized that e-beam radiation may affect dialyzer membrane integrity or structure, or produce intermediary products which may cause platelet activation, aggregation, and adsorption, and therefore thrombocytopenia [2]. There is a high prevalence of thrombocytopenia among critically ill patients undergoing HD [3]. CONCLUSIONS: Thrombocytopenia due to PS dialyzer membrane is a rarely reported phenomenon and may be underrecognized in critically ill patients. This entity should be considered in the differential diagnosis of patients undergoing HD who develop thrombocytopenia. Early recognition may reduce incidence of bleeding and need for blood products in these patients. Reference #1: Golli-Bennour EE, Kouidhi B, Dey M et al. Cytotoxic effects exerted by polyarylsulfone dialyser membranes depend on different sterilization processes. Int Urol Nephrol 2011;43: 483–490. Reference #2: Batalini F, Aleixo GF, Maoz A, Sarosiek S. Haemodialysis-associated thrombocytopenia: interactions among the immune system, membranes and sterilisation methods. BMJ Case Rep. 2019 Sep 4;12(9):e229594. doi: 10.1136/bcr-2019-229594. PMID: 31488440;PMCID: PMC6731774. Reference #3: Griffin BR, Jovanovich A, You Z, Palevsky P, Faubel S, Jalal D. Effects of Baseline Thrombocytopenia and Platelet Decrease Following Renal Replacement Therapy Initiation in Patients With Severe Acute Kidney Injury. Crit Care Med. 2019;47(4):e325-e331. doi:10.1097/CCM.0000000000003598 DISCLOSURES: No relevant relationships by Adefemi Adeyemo No relevant relationships by Zachary Chandler No relevant relationships by Bijal Patel No relevant relationships by Vandana Seeram