National health insurance scheme improves access and optimization of antimicrobial use in the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

BACKGROUND: Nigeria instituted the National Health Insurance Scheme (NHIS) for universal health coverage. This study compared the NHIS and out-of-pocket (OOP) antibiotic prescribing with the World Health Organization (WHO) optimal values. METHODS: A total of 2190 prescription forms from the NHIS and OOP were included in this study conducted at Obafemi Awolowo University Teaching Hospitals Complex, Nigeria from January 2021 to December 2022 and analysed using WHO drug prescribing guidelines. RESULTS: The average number of drugs per encounter was higher in the NHIS prescribing (χ2=58.956, p=0.00) than in OOP prescribing. The percentage of encounters with an antibiotic prescribed is higher in NHIS prescribing (χ2=46.034, p=0.000) than in OOP prescribing. The percentage of parenteral antibiotic prescribing is higher in OOP prescribing (χ2=25.413, p=0.000) than in NHIS prescribing. The percentage of antibiotic prescribed from the National Essential Medicine List is higher in NHIS prescribing (χ2=8.227, p=0.000) as well as the antibiotics prescribed from the Access category of the WHO Access, Watch and Reserve (AWaRe) Classification of antibiotics (χ2=23.946, p=0.000) when compared with OOP prescribing. CONCLUSIONS: Prescribing indicators show better performances with NHIS antibiotic prescribing and are closer to the WHO-recommended optimal values than in OPP prescribing. Hence NHIS prescribing can be an easy target for hospital antibiotic stewardship intervention for optimal antibiotic prescribing.

Clinical and bacteriological profiles of neonatal sepsis in a tertiary hospital, south-western Nigeria.

Introduction: Antibiotic-resistant bacteria complicate treatment options in neonatal sepsis, especially in developing countries. This study determined the epidemiology and bacteriological characteristics of neonatal sepsis at a tertiary hospital, in southwest Nigeria. Methods: This was a cross-sectional study from December 2017 to April 2019 among admitted babies with clinical neonatal sepsis. Blood culture was performed by semi-automated system, sepsis biomarker assay (serum procalcitonin) by a semi-quantitative kit while proforma was used to capture clinico-demographic data. Bacterial identification, antibiotic susceptibility patterns, determination of genetic elements mediating resistance, were performed by standard methods and polymerase chain reaction protocols, respectively. Quantitative data were expressed as frequencies, mean; bivariate and multivariate analyses were performed by Chi-square or Fishers' exact test and logistic regression. Results: Of the 192 cases of neonatal sepsis enrolled, 42.7% (82/192) were blood culture positive. Factors associated with blood culture positivity included respiratory rate ≥60 bpm (60/82; p<0.03), lethargy/unconsciousness (59/82; FE=7.76; p<0.001), grunting respiration (54/82; p=0.04), meconium passage before birth (17/82; p=0.03) and prolonged rupture of membranes ≥24 hours (50/82; FE=6.90; p=0.01). On the other hand, mortality in the neonates was associated with elevated serum procalcitonin assay (>0.5 ng/mL) χ2=13.58; p=0.03] and Gram-negative bacteremia (χ2=24.64; p<0.001). The most common bacterial isolates were Staphylococcus aureus (42/82), coagulase-negative Staphylococcus spp. (17/82), Enterobacter spp. (8/82), and Acinetobacter spp. (6/82). Methicillin resistance was present in 85.7% (36/42) of Staphylococcus aureus and 52.9% (9/17) of coagulase-negative Staphylococcus, while extended-spectrum beta-lactamase (ESBL) and AmpC enzymes were present in (21.1%; 4/19) of the Gram-negative bacilli. Conclusions: Almost half of the cases of clinically diagnosed neonatal sepsis have bacterial etiologic confirmation of sepsis. Gram-negative bacteremia and high serum procalcitonin predict mortality in neonatal sepsis. There was high resistance to common antibiotics for the treatment of neonatal sepsis in our settings.

Lest we forget: Odunbaku Oguntona Sapara William (1895-1935) beyond the demystification of deity.

Oguntola Odunbaku Sapara Williams (born Alexander Johnson Williams, 1861-1935) was a Fellow of the Royal Institute of Public Health. This paper attempts to highlight the effort of an African doctor to fight disease outbreaks during the African colonial era. His uninterrupted 32 years career as a colonial medical officer in one of the British colonies in West Africa, provided superintendence for the eradication of smallpox as a result of this, he was credited with the demystification of metaphysical involvement in the smallpox epidemic and thus eradication of smallpox in the Lagos colony. He also provided leadership for the control of bubonic plague, and tuberculosis epidemics and pioneered initiatives to reduce maternal and infant mortality by vaccination, enactment of public health law, environmental sanitation, and health education in Southwest Nigeria.

Rectal carriage of extended-spectrum ß-lactamase-producing Enterobacteriales among neonates admitted into a special care baby unit, southwest Nigeria.

BACKGROUND: The intestinal microbiota of neonates can be colonised by extended-spectrum ß-lactamase-producing Enterobacteriales (ESBL-PE) with the risks of subsequent infections. The antimicrobial resistance profile of the gut flora of neonates is not well defined in Nigeria. This study determined the burden of rectal carriage of ESBL-PE among neonates. METHODS: We conducted a prospective longitudinal study among neonates admitted into a tertiary hospital from September 2019 to November 2019. Stools were sampled at admission and weekly until exit and processed by standard laboratory methods including polymerase chain reaction to identify ESBL genes. The ESBL-PE colonisation period prevalence at admission and acquisition rate were determined. RESULTS: The period prevalence of the ESBL-PE colonisation and acquisition rate were 46.5% (59/127) and 34.6% (36/104), respectively. Prolonged rupture of the amniotic membrane (PROM; >24 h; p=0.004, odds ratio [OR] 0.297), number of neonates on admission in the same room (p<0.001, OR 0.053) and presence of an ESBL-PE colonisers (p=0.004, OR 0.272) were independent risk factors for ESBL-PE rectal colonisation. ESBL-PE colonisation did not correlate with mortality (Fisher's exact test 1.342, p=0.196). CONCLUSIONS: The rate of ESBL-PE neonatal rectal colonisation is high in our settings and this underscores the need for a review of neonatal admission protocols, embracing of antibiotic stewardship in the management of PROM, resistance surveillance and implementation of infection prevention and control in the neonatal unit.

Rectal Colonization and Nosocomial Transmission of Carbapenem-Resistant Acinetobacter baumannii in an Intensive Care Unit, Southwest Nigeria.

Background: Acinetobacter baumannii are of major human health importance because they cause life-threatening nosocomial infections and often are highly resistant to antimicrobials. Specific multidrug-resistant A. baumannii lineages are implicated in hospital outbreaks globally. We retrospectively investigated a suspected outbreak of carbapenem-resistant A. baumannii (CRAB) colonizing patients in an intensive care unit (ICU) of a tertiary hospital in Southwest Nigeria where genomic surveillance of Acinetobacter has hitherto not been conducted. Methods: A prospective observational study was conducted among all patients admitted to the ICU between August 2017 and June 2018. Acinetobacter species were isolated from rectal swabs and verified phenotypically with the Biomerieux Vitek 2 system. Whole genome sequencing (WGS) was performed on the Illumina platform to characterize isolates from a suspected outbreak during the study period. Phylogenetic analysis, multilocus sequence typing, and antimicrobial resistance gene prediction were carried out in silico. Results: Acinetobacter isolates belonging to the A. baumannii complex were recovered from 20 (18.5%) ICU patients. Single nucleotide polymorphism (SNP) analysis and epidemiological information revealed a putative outbreak clone comprising seven CRAB strains belonging to the globally disseminated international clone (IC) 2. These isolates had ≤2 SNP differences, identical antimicrobial resistance and virulence genes, and were all ST1114/1841. Conclusion: We report a carbapenem-resistant IC2 A. baumannii clone causing an outbreak in an ICU in Nigeria. The study findings underscore the need to strengthen the capacity to detect A. baumannii in human clinical samples in Nigeria and assess which interventions can effectively mitigate CRAB transmission in Nigerian hospital settings.

Clones and Clusters of Antimicrobial-Resistant Klebsiella From Southwestern Nigeria.

BACKGROUND: Klebsiella pneumoniae is a World Health Organization high-priority antibiotic-resistant pathogen. However, little is known about Klebsiella lineages circulating in Nigeria. METHODS: We performed whole-genome sequencing (WGS) of 141 Klebsiella isolated between 2016 and 2018 from clinical specimens at 3 antimicrobial-resistance (AMR) sentinel surveillance tertiary hospitals in southwestern Nigeria. We conducted in silico multilocus sequence typing; AMR gene, virulence gene, plasmid, and K and O loci profiling; as well as phylogenetic analyses, using publicly available tools and Nextflow pipelines. RESULTS: Phylogenetic analysis revealed that the majority of the 134 K. pneumoniae and 5 K. quasipneumoniae isolates from Nigeria characterized are closely related to globally disseminated multidrug-resistant clones. Of the 39 K. pneumoniae sequence types (STs) identified, the most common were ST307 (15%), ST5241 (12%), ST15 (~9%), and ST25 (~6%). ST5241, 1 of 10 novel STs detected, is a single locus variant of ST636 carrying dfrA14, tetD, qnrS, and oqxAB resistance genes. The extended-spectrum ß-lactamase (ESBL) gene blaCTX_M-15 was seen in 72% of K. pneumoniae genomes, while 8% encoded a carbapenemase. No isolate carried a combination of carbapenemase-producing genes. Four likely outbreak clusters from 1 facility, within STs 17, 25, 307, and 5241, were ESBL but not carbapenemase-bearing clones. CONCLUSIONS: This study uncovered known and novel K. pneumoniae lineages circulating in 3 hospitals in Southwest Nigeria that include multidrug-resistant ESBL producers. Carbapenemase-producing isolates remain uncommon. WGS retrospectively identified outbreak clusters, pointing to the value of genomic approaches in AMR surveillance for improving infection prevention and control in Nigerian hospitals.

Healthcare-associated infections and compliance of hand hygiene among healthcare workers in a tertiary health facility, southwest Nigeria.

INTRODUCTION: Healthcare-associated infections (HAIs) are threats in healthcare settings contributing to increased morbidity, mortality and antimicrobial resistance worldwide. Hand hygiene (HH) is the simplest and most important single intervention to reduce HAIs. AIMS/OBJECTIVES: This study sought to determine rates of HAIs as well as compliance of HH among healthcare workers (HCWs) in Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC). METHODS: A cross-sectional study was conducted among 227 HCWs (59 doctors, 129 nurses and 39 ward attendants) selected by multistage sampling across 10 hospital wards. Electronic interviewer-administered questionnaire, HH compliance checklist and point prevalence of HAI were done using World Health Organization and Centers for Disease Control and Prevention toolkits, respectively. RESULTS: Only 20.33% (n = 12) of doctors, 3.88% (n = 5) of nurses and 2.56% (n = 1) of ward attendants had good knowledge of HH (χ2 = 22.22, P value = 0.01). Among doctors, 11.86% (n = 7), 6.98% (n = 9) of nurses and 2.56% (n = 1) of ward attendants had positive perception towards HH (χ2 = 7.87, P value = 0.25). Of the 174 opportunities for HH observed, compliance rates were 42.37%, 55.81% and 68.97% among doctors, nurses and ward attendants, respectively. Point prevalence of HAI was 16.38%. DISCUSSION: Good knowledge and positive perception about HH were uncommon among doctors, nurses and ward attendants. However, ward attendants had the highest compliance to HH. There was a high prevalence of HAIs in this institution.

A systematic review of healthcare-associated infections in Africa: An antimicrobial resistance perspective.

BACKGROUND: Healthcare-associated infection (HCAI) is a global health challenge, not only as an issue of patient safety but also as a major driver of antimicrobial resistance (AMR). It is a major cause of morbidity and mortality with economic consequences. OBJECTIVE: This review provides an update on the occurrence of HCAI, as well as the contribution of emerging AMR on healthcare delivery in Africa. METHODS: We searched PubMed, Cochrane database, African Journals Online and Google Scholar for relevant articles on HCAI in Africa between 2010 and 2017. Preferred reporting items of systematic reviews and meta-analyses guidelines were followed for selection. Thirty-five eligible articles were considered for the qualitative synthesis. RESULTS: Of the 35 eligible articles, more than half (n = 21, 60%) were from East Africa. Klebsiella spp., Staphylococcus aureus, Escherichia coli and Pseudomonas spp. were the common pathogens reported in bloodstream infection, (catheter-associated) urinary tract infection, surgical site infection and healthcare-associated pneumonia. Among these various subtypes of HCAI, methicillin-resistant S. aureus (3.9% - 56.8%) and extended-spectrum beta-lactamase producing Gram-negative bacilli (1.9% - 53.0%) were the most reported antimicrobial resistant pathogens. CONCLUSION: This review shows a paucity of HCAI surveillance in Africa and an emergence of AMR priority pathogens. Hence, there is a need for a coordinated national and regional surveillance of both HCAI and AMR in Africa.

Cylindrocarpon lichenicola keratomycosis in Nigeria: the challenge of limited access to effective antimicrobials.

INTRODUCTION: We report a rare cause of keratitis, due to Cylindrocarpon lichenicola, in a farmer with keratomycosis. Despite the acknowledged virulence of this fungus, a suitable antifungal for its management was not accessible. CASE PRESENTATION: A 67-year-old farmer presented with a two-week history of pain, mucopurulent discharge, redness and a corneal ulcer with a visual acuity of hand movement in the right eye. With a working diagnosis of infective keratitis, corneal scrapings were taken under a slit lamp biomicroscope for microbiological testing. Direct lactophenol cotton blue mounts revealed septate fungal hyphae, while fungal culture on Sabouraud dextrose agar at room temperature grew woolly mould phenotypically consistent with C. lichenicola. MANAGEMENT AND OUTCOME: The patient was started on hourly topical natamycin (5%), ciprofloxacin (0.3%), two-hourly instillation of tobramycin (0.3%) and atropine (1%) twice daily for three months following the isolation of the fungus. The eye healed with a corneal scar and no improvements in visual acuity. DISCUSSION: This infection was difficult to manage due to the inaccessibility of a suitable antifungal, namely, voriconazole in our setting. Hence, there is a need for prompt identification and early institution of suitable antifungals in any patient with suspected keratomycosis.