Bacterial isolates and antibiotic susceptibility among women with abnormal vaginal discharge attending the gynecology clinic at a tertiary hospital in southwestern Uganda: a cross-sectional study.

BACKGROUND: Abnormal vaginal discharge is a common complaint among women of reproductive age, affecting about one- third of all women. In resource-limited settings where access to laboratory services is limited, treatment is usually syndromic. This approach may result in ineffective treatment, with high recurrence rates and a potential of developing antibiotic resistance. This study aimed to determine the bacterial isolates and antibiotic susceptibility among women with an abnormal vaginal discharge attending the gynecology clinic at a tertiary hospital in Southwestern Uganda. METHODS: We conducted a hospital based cross-sectional study among 361 women aged 15-49 years, presenting with abnormal vaginal discharge at the gynecology clinic of Mbarara Regional Referral Hospital from December 2020 to June 2021. Demographic characteristics were collected using a structured questionnaire. We collected cervical and vaginal sterile swabs and subjected them to wet preparation and gram stain. The specimens were cultured for bacterial isolates. Susceptibility testing was performed on samples with bacterial isolates using the Kirby-Bauer disc diffusion method, on the commonly prescribed antibiotics in this setting. We summarized and described the bacterial isolates and antibiotic susceptibility patterns as frequencies and percentages. RESULTS: We enrolled 361 women with abnormal vaginal discharge. Bacteria were isolated in 29.6% (107/361) of the women, and the commonest isolates included; Staphylococcus aureus 48.6% (52/107), Klebsiella pneumoniae 29.9% (32/107) and Enterococcus faecalis 15% (16/107). Yeast cells were found in 17.7% (64/361) of the women with abnormal vaginal discharge. Cefuroxime (90.7%) and Ciprofloxacin (81.3%) had a high level of sensitivity while high levels of resistance were observed for Doxycycline (86.0%) and Azithromycin (67.0%). CONCLUSION: The common bacterial isolates were Staphylococcus aureus, Klebsiella pneumoniae and Enterococcus faecalis. The isolated bacteria were most sensitive to Cefuroxime and Ciprofloxacin but resistant to Doxycycline and Azithromycin. There is need for routine culture and susceptibility testing of women with abnormal vaginal discharge so as to guide treatment, minimize inappropriate antibiotic use and consequently reduce antibiotic resistance.

Advanced abdominal ectopic pregnancy and the role of antenatal ultrasound scan in its diagnosis and management.

Abdominal pregnancy is a very rare form of ectopic gestation in which implantation occurs in the peritoneal cavity. It accounts for about 1% of all ectopic pregnancies and is associated with a higher risk of morbidity and mortality due to complications such as preeclampsia, placenta abruption, and oligohydromnios, which necessitate pregnancy termination before term, and the risk of massive hemorrhage associated with abnormal placentation. We present a case of advanced abdominal ectopic pregnancy, diagnosed in the second trimester and complicated by anhydramnios. An abdominal ultrasound scan showed a nongravid uterus and a single live extrauterine fetus within the abdominal cavity, with no surrounding liquor at 23 weeks and 3 days average gestational age. Mother was consented and an emergency laparatomy performed. A premature baby was delivered but died in Neonatal Intensive Care Unit (NICU) after 4 hours due to severe acute respiratory distress syndrome. Mother had good postoperative recovery. Advanced abdominal ectopic pregnancy though very rare, is associated with complications that lead to early termination. Ultrasound scan is a reliable tool for the diagnosis of abdominal pregnancy in settings with limited access to Magnetic Resonance Imaging (MRI). It should be recommended to all mothers at their earliest antenatal care (ANC) visit to help determine the site of pregnancy and guide further intervention.

Unusual presentation of Pott disease and diagnostic challenges in a resource-limited setting: a case report.

BACKGROUND: Pott disease is rare and responsible for only 1%-2% of all tuberculosis cases. It poses diagnostic challenges in resource-limited settings due to unusual presentation and limited investigative capacity, resulting in debilitating sequelae if diagnosed late. CASE PRESENTATION: We present a case of severe Pott disease of the lumbar spine, with a large paravertebral abscess tracking down to the gluteal region in a 27-year-old Black African Ugandan woman living with human immunodeficiency virus, whose main complaint was right lower abdominal pain. She was initially misdiagnosed from the peripheral clinics as a case of lumbago and later with a psoas abscess. The diagnosis of severe Pott disease was established at the regional referral hospital following an abdominal computed tomography scan, and the patient was appropriately initiated on anti-tuberculosis drugs. However, only abscess drainage and provision of a lumbar corset were possible, with no neurosurgical intervention done on the spine due to financial constraints. Clinical review at 2, 6, and 12 months revealed improvement. CONCLUSIONS: Pott disease may present with non-specific symptoms such as abdominal pain resulting from pressure effects of an expansile cold abscess. This, coupled with limited diagnostic capacity in resource-limited settings; results in significant morbidity and possible mortality. Hence, there is need to train clinicians to increase their index of suspicion and equip health units with basic radiological equipment, such as x-ray, for timely detection and subsequent management of Pott disease.

Prevalence and factors associated with severe anaemia post-caesarean section at a tertiary Hospital in Southwestern Uganda.

BACKGROUND: Severe anaemia after caesarean section adversely affects the woman and the new-born. While prenatal anaemia is extensively studied, the literature on post-caesarean section anaemia is limited and characteristics of women at the highest risk of developing severe anaemia after caesarean section are unknown. This study aimed to determine the prevalence and factors associated with severe anaemia on day three post caesarean section. METHODS: On the third day after caesarean section, women were consecutively enrolled in a cross-sectional study at Mbarara Regional Referral Hospital (MRRH). Women who got transfused peripartum were excluded. For every woman, we measured haemoglobin (Hb) concentration and collected data on sociodemographic, obstetric, and medical characteristics. The primary outcome was severe anaemia after caesarean section, defined as Hb < 7 g/dl. We used logistic regression analysis to determine factors associated with severe anaemia after caesarean section. P-value < 0.05 was considered statistically significant. RESULTS: From December 2019 to March 2020, 427 of 431 screened women were enrolled in the study. Their mean age was 26.05 (SD ± 5.84) years. Three hundred thirteen (73.3%) had attended at least four antenatal care visits. The prevalence of severe anaemia post-caesarean section was 6.79%. Foetus with macrosomia (aOR 7.9 95%CI: 2.18-28.85, p <  0.01) and having mild or moderate anaemia pre-caesarean section (aOR:9.6, 95%CI: 3.91-23.77, p <  0.01) were the factors associated with severe anaemia after caesarean section. CONCLUSION: Severe anaemia in women post-caesarean section is relatively uncommon at our institution. It is associated with preoperative anaemia and macrosomic birth. Women with a low preoperative Hb concentration and those whose foetus have macrosomia could be targeted for haemoglobin optimisation before and during caesarean section.

Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting.

INTRODUCTION: Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs. METHODS: POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated. RESULTS: Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32-4.32) to 4.68 (95% CI, 4.35-5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2-83.0) and 98.5 (95% CI, 93.3-99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged. CONCLUSIONS: Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs.

Frequency of HIV status disclosure, associated factors and outcomes among HIV positive pregnant women at Mbarara Regional Referral Hospital, southwestern Uganda.

INTRODUCTION: Positive HIV results disclosure plays a significant role in the successful prevention and care of HIV infected patients. It provides significant social and health benefits to the individual and the community. Non-disclosure is one of the contextual factors driving the HIV epidemic in Uganda. Study objectives: to determine the frequency of HIV disclosure, associated factors and disclosure outcomes among HIV positive pregnant women at Mbarara Hospital, southwestern Uganda. METHODS: A cross-sectional study using quantitative and qualitative methods among a group of HIV positive pregnant women attending antenatal clinic was done and consecutive sampling conducted. RESULTS: The total participant recruitment was 103, of which 88 (85.4%) had disclosed their serostatus with 57% disclosure to their partners. About 80% had disclosed within less than 2 months of testing HIV positive. Reasons for disclosure included their partners having disclosed to them (27.3%), caring partners (27.3%) and encouragement by health workers (25.0%). Following disclosure, 74%) were comforted and 6.8% were verbally abused. Reasons for non-disclosure were fear of abandonment (33.3%), being beaten (33.3%) and loss of financial and emotional support (13.3%). The factors associated with disclosure were age 26-35 years (OR 3.9, 95% CI 1.03-15.16), primary education (OR 3.53, 95%CI 1.10-11.307) and urban dwelling (OR 4.22, 95% CI 1.27-14.01). CONCLUSION: Participants disclosed mainly to their partners and were comforted and many of them were encouraged by the health workers. There is need to optimize disclosure merits to enable increased participation in treatment and support programs.

Rapid, remote education for point-of-care ultrasound among non-physician emergency care providers in a resource limited setting

Introduction : Access to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as "task-shifting" where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs.Methods:POCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated.Results:Over the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32­4.32) to 4.68 (95% CI, 4.35­5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2­83.0) and 98.5 (95% CI, 93.3­99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged.Conclusions : Remotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs

Prevalence and Factors Associated with Hydatidiform Mole among Patients Undergoing Uterine Evacuation at Mbarara Regional Referral Hospital.

OBJECTIVE: We sought to determine the prevalence of and factors associated with hydatidiform molar gestations amongst patients undergoing uterine evacuation at Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda. METHODS: This was a cross-sectional study carried out from November 2016 to February 2017. All patients admitted for uterine evacuation for nonviable pregnancy were included. The study registered 181 patients. Data were collected on sociodemographics, medical conditions, obstetrics, and gynecological factors. The evacuated tissue received a full gross and histopathologic examination. Cases of pathologically suspected complete hydatidiform mole were confirmed by p57 immunohistochemistry. Data were analyzed using STATA 13. RESULTS: The prevalence of hydatidiform mole was 6.1% (11/181). All detected moles were complete hydatidiform moles, and there were no diagnosed partial hydatidiform moles. Clinical diagnosis of molar pregnancy was suspected in 13 patients, but only 69.2% (9/13) were confirmed as molar pregnancies histologically. Two cases were clinically unsuspected. Factors that had a significant relationship with complete hydatidiform mole included maternal age of 35 years and above (aOR 13.5; CI: 1.46-125.31; p=0.00), gestational age beyond the first trimester at the time of uterine evacuation (aOR 6.2; CI: 1.07-36.14; p=0.04), and history of previous abortion (aOR 4.3; CI: 1.00-18.57; p=0.05). CONCLUSION: The prevalence of complete hydatidiform mole was high at 6.1%. Associated risk factors included advanced maternal age (35 years and above), history of previous abortions, and gestational age beyond the first trimester at the time of evacuations. RECOMMENDATIONS: We recommend putting in place capacity to do routine histopathological examination of all products of conception especially those at high risk for a molar gestation either by clinical suspicion or by risk factors including advanced maternal age, advanced gestational age, and history of previous abortion because of high prevalence of complete mole.