Characterisation of colistin resistance in Gram-negative microbiota of pregnant women and neonates in Nigeria.

A mobile colistin resistance gene mcr was first reported in 2016 in China and has since been found with increasing prevalence across South-East Asia. Here we survey the presence of mcr genes in 4907 rectal swabs from mothers and neonates from three hospital sites across Nigeria; a country with limited availability or history of colistin use clinically. Forty mother and seven neonatal swabs carried mcr genes in a range of bacterial species: 46 Enterobacter spp. and single isolates of; Shigella, E. coli and Klebsiella quasipneumoniae. Ninety percent of the genes were mcr-10 (n = 45) we also found mcr-1 (n = 3) and mcr-9 (n = 1). While the prevalence during this collection (2015-2016) was low, the widespread diversity of mcr-gene type and range of bacterial species in this sentinel population sampling is concerning. It suggests that agricultural colistin use was likely encouraging sustainment of mcr-positive isolates in the community and implementation of medical colistin use will rapidly select and expand resistant isolates.

Antibiotic resistance genes in the gut microbiota of mothers and linked neonates with or without sepsis from low- and middle-income countries.

Early development of the microbiome has been shown to affect general health and physical development of the infant and, although some studies have been undertaken in high-income countries, there are few studies from low- and middle-income countries. As part of the BARNARDS study, we examined the rectal microbiota of 2,931 neonates (term used up to 60 d) with clinical signs of sepsis and of 15,217 mothers screening for blaCTX-M-15, blaNDM, blaKPC and blaOXA-48-like genes, which were detected in 56.1%, 18.5%, 0% and 4.1% of neonates' rectal swabs and 47.1%, 4.6%, 0% and 1.6% of mothers' rectal swabs, respectively. Carbapenemase-positive bacteria were identified by MALDI-TOF MS and showed a high diversity of bacterial species (57 distinct species/genera) which exhibited resistance to most of the antibiotics tested. Escherichia coli, Klebsiella pneumoniae and Enterobacter cloacae/E. cloacae complex, the most commonly found isolates, were subjected to whole-genome sequencing analysis and revealed close relationships between isolates from different samples, suggesting transmission of bacteria between neonates, and between neonates and mothers. Associations between the carriage of antimicrobial resistance genes (ARGs) and healthcare/environmental factors were identified, and the presence of ARGs was a predictor of neonatal sepsis and adverse birth outcomes.

Determination of neonatal case-specific fatality rates in a tertiary health institution in North Central Nigeria.

BACKGROUND: The current neonatal mortality rate in Nigeria (37/1000) is among the highest in the world and the major causes have consistently been reported as sepsis, perinatal asphyxia and prematurity. However, case-specific fatality which defines the risk of dying from these and other neonatal morbidities is rarely emphasized. Determination of case-specific fatality rates (CSFR) may inform a change in our current approach to neonatal care interventions which may eventually bring about the much-needed reduction in our neonatal mortality rate. Our aim was to determine the case-specific fatality rates for the common causes of mortality among hospitalized neonates at the National Hospital Abuja (NHA). METHODS: Relevant demographic and clinical data on all neonates admitted into the NICU at the NHA over a period of 13 months (January 2017 to February 2018) were extracted from the Neonatal Registry database and analyzed using appropriate statistical methods with the SPSS version 20 software. The case-specific fatality rates were computed for the predominant morbidities in addition to determination of the neonatal mortality rates and associated risk factors. RESULTS AND CONCLUSION: A total of 730 neonates were admitted, out of which 391 (53.6%) were females, 396 (54.5%) were inborn and 396 (54.2%) were term. The three most prevalent morbidities were prematurity 272(37.2%), neonatal Jaundice 208(28.4%) and perinatal asphyxia 91(12.5%) while the most common causes of mortality were prematurity 47/113(41.6%), congenital malformations 27/113(23.9%) and perinatal asphyxia 26/113(23%). Congenital malformations had the highest case-specific fatality 27/83(32.5%) followed by Perinatal Asphyxia 26/91(28.6%) and prematurity 47/272(20.7%). The mortality pattern differed between inborn and out born babies. Implications of these case-specific fatality rates for targeted interventions are discussed.

Blood pressure pattern and the relationship with body mass index among apparently healthy secondaryschool students in Sokoto metropolis, Nigeria

Background. Childhood obesity may result in the premature onset of cardiovascular risk factors, particularly hypertension, hence the need for proper screening. However, blood pressure (BP) is measured only once in most studies in Nigeria, probably because of difficulties in returning to the study areas for repeat measurement.Objective. To determine the BP pattern and assess its relationship with body mass index (BMI) in apparently healthy secondary-school students aged 10 - 18 years in Sokoto metropolis, Nigeria.Methods. This study was descriptive and cross-sectional, and carried out between 13 October 2014 and 30 January 2015. In total, 800students from 6 schools were selected through multistage sampling. BP was measured on three separate days according to the National High Blood Pressure Education Program charts. BMI was categorised according to the Centers for Disease Control charts. The relationship of BP level with BMI was determined.Results. There were 424 (53.0%) males and 376 (47.0%) females, with a ratio of approximately 1:1. BP increased with age. The mean systolic and diastolic BP was significantly higher in females than males (systolic 113.1 mmHg v. 110.5 mmHg, and diastolic 69.0 mmHg v. 66.5 mmHg, respectively; p=0.01). Females had a higher mean BMI than males (18.7 kg/m2 v. 17.9 kg/m2, respectively; p<0.01). BP increased as the BMI percentile increased (p<0.001). The prevalence rates of hypertension were 6.1%, 3.5% and 3.1% at the first, second and third screenings, respectively, while the corresponding prevalence rates of prehypertension were 14.3%, 8.4% and 7.1%. The prevalence of obesity and overweight was 0.3% and 5.9%, respectively.Conclusion. The prevalence rate of prehypertension and hypertension reduced with subsequent measurements, and the prevalence rates of overweight and obesity were low. However, higher BP levels were associated with higher BMI, supporting its predictive significance for elevated BP

Macrosomic births in abuja: A case-control study of predisposing factors and early neonatal outcome.

BACKGROUND: Although research has shown that having a macrosomic fetus could be predictive of a negative pregnancy outcome, the factors that control its incidence and the outcome of delivery management have been less well characterized in Africa. The aim of this study was to identify specific predispositions and the factors that influence the early neonatal outcome of macrosomic infants in Abuja. METHODS: Data from 120 mother and macrosomic (weighing ≥4000 g) newborn pairs, and an equal number of mother and normal weight (2500-3999 g) matched controls, delivered over a 5-month period at three large hospitals in Abuja, Nigeria, were analyzed. Chi-square and logistic regression analyses were performed for various predisposing factors and neonatal outcomes of macrosomic births. RESULTS: The incidence of macrosomia was 77 per 1000 births. Independent predictors of macrosomia were parental high social class (P = 0.000), gestational weight gain of ≥15 kg (P = 0.000), and previous history of macrosomia (P = 0.002). The most frequent route of delivery was emergency cesarean section accounting for 51 (42%) births. Macrosomia was significantly associated with higher rates of birth injuries (P = 0.030), perinatal asphyxia (P = 0.015), admissions into the special care newborn unit (P = 0.000), and hypoglycemia (P = 0.000). Although the difference in the early neonatal mortality rates between the macrosomic group (2.5%) and the control group (0.8%) was not statistically significant, nearly 70% of deaths in the macrosomic group were associated with severe perinatal asphyxia. CONCLUSION: Our findings highlight the need for improved anticipatory care of the macrosomic fetus at delivery, in Africa.

Group B streptococcal colonization and transmission dynamics in pregnant women and their newborns in Nigeria: implications for prevention strategies.

OBJECTIVES: Because few studies have been conducted on group B Streptococcus (GBS) in Nigeria, we sought to estimate GBS colonization and transmission frequencies for 500 women and their newborns and identify risk factors for both outcomes. METHODS: GBS strains were characterized for antibiotic susceptibilities, capsule (cps) genotype, pilus island profile and multilocus sequence type (ST). RESULTS: In all, 171 (34.2%) mothers and 95 (19.0%) of their newborns were colonized with GBS; the vertical transmission rate was 48.5%. One newborn developed early-onset disease, yielding an incidence of 2.0 cases per 1000 live births (95% CI 0.50-7.30). Rectal maternal colonization (OR 26.6; 95% CI 13.69-51.58) and prolonged rupture of membranes (OR 4.2; 95% CI 1.03-17.17) were associated with neonatal colonization, whereas prolonged membrane rupture (OR 3.4; 95% CI 1.04-11.39) and young maternal age (OR 2.0; 95% CI 1.22-3.39) were associated with maternal colonization. Women reporting four or more intrapartum vaginal examinations (OR 6.1; 95% CI 3.41-10.93) and douching (OR 3.7; 95% CI 2.26-6.11) were also more likely to be colonized. Twelve STs were identified among 35 mother-baby pairs with evidence of transmission; strains of cpsV ST-19 (n = 9; 25.7%) and cpsIII ST-182 (n = 7; 20.0%) predominated. CONCLUSIONS: These data demonstrate high rates of colonization and transmission in a population that does not use antibiotics to prevent neonatal infections, a strategy that should be considered in the future.

Posttransfusion haematocrit equilibration: timing posttransfusion haematocrit check in neonates at the national hospital, abuja, Nigeria.

Anaemia is a common morbidity in the NICU and often requires transfusion of packed red blood cells. Haematocrit equilibration following red cell transfusion occurs over time ultimately resulting in a stable packed cell volume (PCV). Knowledge of this equilibration process is pertinent in the accurate timing of posttransfusion (PT) PCV. We conducted a prospective study to determine an appropriate timing for PT PCV estimation on 47 stable anaemic babies at the Neonatal Unit of National Hospital, Abuja. Values of PCV were determined before transfusion and at 1, 6, 12, 24, and 48 hours posttransfusion. Forty of the recruited neonates and young infants were analyzed. Their gestational age range was 26 to 40 weeks. 1-hour PT PCV (48.5% ± 5.5%) was similar to the 6-hour PT PCV (47.8% ± 5.6%) P = 0.516, but both were significantly different from the 12-hour (46.8% ± 5.9%), 24-hour (45.9 ± 5.8%), and 48-hour (45.4% ± 6.2%) PT PCVs. The 12-hour PT PCV was similar to the 24-hour and 48-hour PT PCVs (P = 0.237 and 0.063, resp.). We concluded that, in stable nonhaemorrhaging and nonhaemolysing young infants, the estimated timing of haematocrit equilibration and, consequently, posttransfusion PCV is 12 hours after red blood cell transfusion.

ABO (H) secretor status of sickle cell disease patients in Zaria, Kaduna State, Nigeria.

Certain individuals secrete ABO blood group antigens in body fluids and secretions while others do not. In this study, the presence of water soluble agglutinogens in body fluids such as blood, saliva and urine of 64 sickle cell disease patients and 75 AA genotype subjects who served as control were taken and tested by hem-agglutination inhibition method. Data obtained was expressed in percentages. Results revealed that 84.4% sickle cell patients were secretors while 15.6% were non secretors. Amongst the control, 97.3% were secretors while 3.1% were non secretors. 81.2% SS and 3.2% SS+F patients were secretors while 15.6% SS were non secretors, 68% AA were secretors and 29.3% AS were secretors while 2.7% AA were non secretors. The result showed that a non secretor is more likely to be an SS than a secretor and Secretor status is influenced by hemoglobin genotype.

A ten year review of maternal mortality in Sokoto, northern Nigeria.

OBJECTIVE: To determine the institutional maternal mortality ratio, risk factors, causes and to suggest ways of preventing or reducing the maternal deaths. SUBJECTS & METHODS: A descriptive study based on hospital case records of all maternal deaths at the Usmanu Danfodiyo University Teaching Hospital, Sokoto, between January 1990 and December 1999. RESULTS: There were 197 maternal deaths and 9,158 live births during the study period. The maternal mortality ratio was 2,151/100,000 live births. Mean age at death was 27 years. Risk factors included nulliparity, poverty; illiteracy and lack of prenatal care. Main causes of death were ruptured uterus, eclampsia, infection and haemorrhage. CONCLUSION: The maternal mortality ratio is high. Most of the deaths could have been prevented by prenatal care and prompt treatment of the obstetric emergencies. Unless somebody, somewhere, is prepared to cater for the poor at times of dire need, the maternal death toll will remain high.

Medical treatment of ectopic pregnancy using parental methotrexate.

Between January and December 1999, we were able to diagnose five cases of unruptured ectopic pregnancy, using a transabdominal convex sector transducer. All the five patients presented with lower abdominal pains but were in stable clinical state. They were treated with two doses of 50mg methotrexate intravenously, 48 hours apart. Four of the patients had clinical, immunological, and sonographic evidence of resolution. The only failure was in the patient whose gestation sac was 4.8cm in its maximal diameter. She eventually had laparotomy and salpingectomy.

Undiagnosed breech in Zaria, Nigeria.

There is no certainty about the best way of dealing with a breech presentation first diagnosed in labour. In our unit, the decision to allow a trial of vaginal delivery rested on the clinical assessment of the size of the baby and the maternal pelvis, and the progress of labour. We compared the outcome of 32 cases where a breech presentation was first diagnosed in labour with 65 women where the malpresentation was diagnosed antenatally where a full assessment including ultrasound and radiological pelvimetry could be made. There was no significant difference in the mode of delivery and fetal outcome. We continue to favour careful case selection for vaginal delivery even where the breech is first diagnosed in labour.

Uterine rupture in Sokoto, Northern Nigeria--are we winning?

All cases of uterine rupture that were managed at the Usmanu Danfodiyo University Teaching Hospital Sokoto from January, 1995 to December, 1997 were reviewed and the findings compared with those of a previous study from the same institution, 10 years ago. Out of 3,106 deliveries within the study period there were 42 cases of ruptured uterus, giving an incidence of 1 in 74 deliveries which is similar to an incidence of 1 in 72 deliveries, a decade ago. Virtually all (41 cases) were illiterate and 93% had no antenatal care. Cephalopelvic disproportion, malpresentation and previous uterine scar were common associated factors as in the previous study. Maternal mortality of 38% and fetal mortality of 98% did not differ significantly from the previous report. The significant changes over the last 10 years were the reduction in the number of booked patients with uterine rupture from 44 to 3 cases (P < 0.05) and the reduction in the number of rupture following obstetric trauma from 32 to just 1 case (P < 0.05). Because illiteracy and poverty are at the root cause, we have now decided to take our research findings directly to the community and religious leaders, hoping that in another 10 years we might see more positive changes.

Magnesium sulphate for treatment of eclampsia: the Nigerian experience.

The preliminary result of an ongoing study in 4 major hospitals across Nigeria on the use of magnesium sulphate (MgSO4) as an anticonvulsant in the management of eclampsia is presented. All the 21 obstetric patients with eclampsia (recruited so far) were treated with MgSO4 as the only anticonvulsant. All the patients responded well to the treatment regime in terms of control of fit, and remained conscious thereafter. There was no incidence of severe adverse reactions to the drug. The mean number of convulsions in the patients treated was 4. The observed side effects were nausea, vomiting and dizziness in 3 patients and there were 3 perinatal deaths. The findings so far on maternal and fetal outcomes support the routine administration of MgSO4 as the drug of choice for the control of convulsion in women with eclampsia.

Gestation age at antenatal clinic booking in Sokoto, northern Nigeria.

Between January 1995 and December 1996, a cross-sectional study was undertaken to determine the gestational age at which women book for antenatal care. The average gestational age at first antenatal attendance for the 2.304 women in the survey group was 23.5 +/- 6.0 weeks. The difference between the gestational age at first attendance for the literate subgroup (24.2 +/- 6.1 weeks) was not statistically significant (P > 0.05) The gestational age at booking among the grand multiparous women was significantly higher than that of the primigravidae (25.30 +/- 5.9 versus 23.1 +/- 6.1 weeks; P < 0.05). In 71% of cases there was no specific reason for electing the time for antenatal booking. Health education, with emphasis on the benefits of booking in the first trimester of pregnancy, is advocated. Service providers should also develop a referral system for those pregnant women relocating to new stations.

Community education to encourage use of emergency obstetric services, Kebbi State, Nigeria. The Sokoto PMM Team.

PRELIMINARY STUDIES: Focus group discussions and a mini-survey in Kebbi State, Nigeria, revealed poor knowledge of obstetric complications, lack of confidence in health services, and cultural barriers to seeking care. INTERVENTIONS: After upgrading services in emergency obstetric facilities, the team began community education to encourage utilization. Messages focused on recognition and need for prompt treatment of complications, and addressed men's role as decision-makers. Beginning in 1992, messages were disseminated through weekly meetings with community opinion leaders, video shows, posters and handbills. RESULTS: A post-intervention mini-survey showed knowledge gains of over 30% among women and men. The increase was greatest (59% increase among women and 55% among men) on the need for prompt care for women with obstetric complications. However, utilization of emergency obstetric services did not increase. At Maiyama Maternity Center, referrals declined from 18 in 1992 to four in 1995. At Jega Health Center, referrals remained relatively stable at 20-30/year, but the number of women with major obstetric complications treated declined from 234 in 1992 to 136 in 1995. At Birnin Kebbi Specialist Hospital, the referral center, the number of women with complications treated declined from 200 in 1990 to 152 in 1995. COSTS: The cost of community education was approximately US $9500, of which 15% was contributed by the community. CONCLUSIONS: Increased awareness of the signs of obstetric complications and the need for prompt treatment among community women and men did not result in greater utilization of emergency obstetric services at the facilities studied.

Predicting conception and safe delivery of a macrosomic baby.

Clinical data obtained prospectively from 98 neonates, 49 normal weight controls, and retrospectively from their mothers had revealed a low incidence of neonatal macrosomia and some important predictive indices of conception and safe delivery of such babies. All the macrosomic infants were singletons and above 37 weeks gestation. The incidence of macrosomia was 26 per 1,000 live births. Increasing maternal age (up to 28 years) parity (up to three) and height were positively correlated with the conception and safe delivery of a macrosomic baby. A maternal height of less than 1.64m was found to be associated with a higher risk of unsafe spontaneous vaginal delivery of a large infant. It is suggested that even in the developing countries all efforts should be made to confirm a diagnosis of foetal macrosomia before the onset of labour so that the mother can be properly assessed for the most appropriate method of delivery.

Antimalarial drug response of Plasmodium falciparum from Zaria, Nigeria.

The sensitivity of Zaria strains of Plasmodium falciparum to chloroquine, mefloquine, quinine and sulphadoxine/pyrimethamine was investigated 5 years after the appearance of in vivo/in vitro chloroquine resistance in urban Zaria. Infections in 36/43 children (83.7%) treated with chloroquine were sensitive while those in 7 (16.3%) were resistant. 8/13 isolates cultured (61.5%) were sensitive in vitro to chloroquine and 5 (38.5%) were resistant. Of the cultured isolates, 13/13 (100%), 12/13 (92.3%) and 5/7 (71.4%) showed mefloquine, quinine and sulphadoxine/pyrimethamine sensitivity, respectively. The results confirmed chloroquine and sulphadoxine/pyrimethamine resistance in urban Zaria and revealed emerging quinine resistance. Resistance to chloroquine and sulphadoxine/pyrimethamine is at RI level and chloroquine should continue to be the first-line drug for the treatment and prevention of P. falciparum infection in the Zaria area of northern Nigeria. We suggest that, while quinine serves as second-line drug, mefloquine should be reserved for infections resistant to chloroquine, quinine and sulphadoxine/pyrimethamine.