'Prospective audit with intervention and feedback' as a core antimicrobial stewardship strategy in the paediatrics department of a Nigerian tertiary hospital.

Introduction: Inappropriate use of antibiotics for childhood illnesses, especially for non-bacterial infections, contributes to the development of antimicrobial resistance (AMR). Globally, implementation of antimicrobial stewardship programme (ASP) in all healthcare institutions is a strategic intervention to improve the appropriate use of antibiotics, reduce antimicrobial consumption and tackle AMR. The aim of this study was to evaluate the effect of prospective audit with intervention and feedback as an antimicrobial stewardship strategy on antimicrobial use, evaluate prescribers' response to recommendations and determine the rate of AMR in the Paediatrics Department of the Lagos University Teaching Hospital, Nigeria. Materials and Methods: This was an implementation study of the paediatrics Antimicrobial Stewardship Programme (ASP) over a period of 6 months. It was initiated with a point prevalence survey (PPS) to describe the antimicrobial prescribing patterns and followed by prospective audit with interventions and feedback using an antimicrobial checklist and the existing antimicrobial guidelines in the Paediatrics Department. Results: The antibiotic prescribing prevalence was high (79.9%) at baseline PPS with 139 patients on admission, of which 111 (79.9%) were treated with 202 antibiotic therapies. Over the 6 months of study, 582 patients on 1146 antimicrobial therapies were audited. Compliance with departmental guidelines was 58.1% of the total 1146 prescriptions audited (n = 666), making the antimicrobial prescription inappropriate in 41.9% (n = 480) of therapies. The most recommended intervention for inappropriateness was 'change antibiotics' 48.8% (n = 234), followed by 'stop antibiotics' 26% (n = 125), 'reduce the number of antibiotics' 19.6% (n = 194) and 'de-escalate' 2.4% (n = 11). Agreement with ASP interventions occurred in 193 (40.2%) cases, and the least agreed intervention was 'stop antibiotics' (n = 40, 32%). However, there was a steady increase in compliance rates with ASP interventions over the 6 months of period study, which was statically significant (χ2: 30.005; P = 0.001). Conclusion: ASP prospective audit with intervention and feedback was of significant benefit in improving compliance with antimicrobial guidelines, thereby improving antimicrobial therapy in the Paediatrics Department of LUTH, Nigeria.

Prevalence of and risk factors for hepatitis B and C viral co-infections in HIV infected children in Lagos, Nigeria.

INTRODUCTION: The study was carried out to determine the prevalence of and risk factors for hepatitis B and C viral co-infections in HIV infected children in Lagos. METHOD: A cross-sectional study conducted to determine the prevalence and risk factors for hepatitis B and C viral co-infection in children aged 2 months to 13 years. There were 187 HIV infected and 187 HIV naïve age, sex-matched controls. Blood samples of participants were assayed for the serologic markers [HBsAg, anti-HBc, and anti-HCV)] of HBV and HCV viral infections using the Enzyme-Linked Immunosorbent assay (ELISA) method. RESULT: The prevalence of HBV infection using HBsAg was 5.3% and 4.8% (p = 0.814), among HIV-infected and HIV naïve children respectively, while using anti-HBc the prevalence was 7.0% and 7.5% (p = 0.842) among HIV- infected and HIV naïve children respectively. The prevalence of HCV infection among HIV- infected and HIV naive children were equal to 0.5% (p = 1.000). There was also no significant association with the identifiable risk factors (sharing of a toothbrush, sharing of needles, incision marks/tattoo, hepatitis B immunization status, history of blood transfusion, previous surgical operation, sexual exposure/abuse, history of jaundice, and genital circumcision) and the HBV and or HCV status among both groups of children. History of sexual exposure/abuse and history of jaundice were however found to be predictors of the presence of HBsAg among HIV infected children only, using a binary logistic regression model. CONCLUSION: The prevalence of HBV and or HCV infection among HIV-infected children is similar to the prevalence among HIV naïve children, suggesting that HIV-infected children are not more predisposed to viral hepatitis than healthy children. Also, there was no significant difference in the prevalence of HBV infection irrespective of the use of HBsAg or anti-HBc.

Human immunodeficiency virus status in malnourished children seen at Lagos.

INTRODUCTION: Human immunodeficiency virus and protein energy malnutrition are still prevalent in Nigeria and the occurrence of the two conditions together confers a poor prognosis. The aim of this study was to determine the current categories of malnutrition amongst under-5 children in Lagos, document their HIV status and determine any peculiarities in the clinical features, haematological and some biochemical profile in these children. METHODS: The study was a cross-sectional study conducted at the Paediatric departments of the Lagos University Teaching Hospital and the Massey Street Children's Hospital, both in Lagos, over a 6-month period. All the subjects had anthropometry, HIV testing, full blood count and serum proteins done. The factors associated with HIV status were determined with the logistic regression analysis. RESULTS: Two hundred and fourteen (214) malnourished children ≤5 years, including 25 (11.7%) with HIV were recruited in the study. Among the study participants, 150 (70.1%) and 54 (29.9%) had moderate and severe malnutrition, respectively. Fever, cough and diarrhea were the most common symptoms in the study participants. The haematological indices were comparable in the two groups, the serum globulin levels though higher in the HIV infected group was not statistically significantly different from the non-infected group.(p = 0.66). None of the factors explored on multivariate analysis was able to predict the occurrence of the infection in this cohort. CONCLUSION: Malnourished children remain a high risk group for HIV infection and the prevalence of the infection obtained in this group of children is still unacceptably high. Discriminatory features between malnutrition and HIV remains difficult. The presence of hyperglobulinaemia on laboratory analysis in a malnourished child may heighten the suspicion of possible underlying associated HIV infection. Screening of malnourished children for HIV infection and further longitudinal studies on malnourished children with HIV is advocated.

Neonatal burns in Lagos, South-Western Nigeria: Epidemiology and outcome of management.

BACKGROUND: Burns in the neonate are rare and result mostly from iatrogenic sources in developed countries. The socioeconomic settings of developing countries are different from those in the developed countries. A review of the epidemiology and management of burns in the neonates in Lagos, Nigeria is presented. METHODS: The case notes of burns in patients less than 29 days-old from 2004 to 2008 in 4 tertiary health institutions in Lagos were retrieved from the Medical Records Department; necessary data were extracted and analyzed. RESULTS: There were 21 neonates with burns within the study period. The incidence of neonatal burns ranged between 0.5 and 2.5%/year. The mean age was 16.38 ± 1.84 days and the mean BSA of 26.00 ± 5.53%. The etiology of burns was thermal in 19(90.5%) and chemical in 2(9.5%). Hypokalemia was common at early stages of their treatment. Burns were sustained at home in 90.5% of the cases. The mortality rate was 43.5%. Inhalation and thermal injuries were associated with most of the deaths. CONCLUSION: Domestic incidents from flames are the commonest causes of neonatal burns in the study environment. These are associated with prolonged morbidity and high mortality rate. Health education, highlighting methods of prevention should be undertaken in the community. Well equipped burn centers should be established to treat burns in all age groups.

Relationship between Painful Crisis and Serum Zinc Level in Children with Sickle Cell Anaemia.

Sickle cell anaemia (SCA) is associated with zinc deficiency; zinc supplementation may ameliorate some of its clinical manifestations including the relief of painful crisis. Subjects and Methods. Serum zinc levels were determined in 71 children with SCA and painful crisis and in equal numbers in steady state. Seventy-one children with AA genotype acted as controls. Qualitative assessment of zinc content of 24-hour dietary recall and the last meal consumed before blood was drawn was taken. Serum zinc was determined using atomic absorption spectrophotometer. Haemoglobin concentration and packed cell volume (PCV) were determined using standard methods. Results. The mean serum zinc concentration in the study was less than international reference range. The controls had significantly higher serum zinc concentrations than the SCA group (42.7 ± 13.6 versus 32.3 ± 14.0 µg/dL, P < .000); this difference was due to the significantly lower values of serum zinc in SCA with painful crisis compared with the remaining two groups F = 30.9, P<.000. There was a positive correlation between serum zinc and haemoglobin concentration only in the control group (r = 0.4; P = .001). Conclusion. The serum zinc levels in this study were low. Painful crisis in SCA may exert greater demand for zinc utilization in children with SCA thereby resulting in lower serum levels.

T-lymphocyte subsets in apparently healthy nigerian children.

Population studies showed that there are differences in T-lymphocytes subpopulation of normal children in different regions, and reference values in an area might be different from another. This study compared the values in our population with CDC and WHO reference values. Blood samples from 279 healthy, HIV-negative children <12 years of age were analysed for complete blood count, CD3+, CD4+, CD8+ counts and percentages. Except for CD8%, mean values for all parameters measured significantly decreased with age. CD4+ counts were higher in females than males, P < .05. Using the WHO criteria, 15.9% of subjects had low total lymphocyte count and 20.6% had low CD4 count. Children <3 years had median CD4% lower than WHO normal values. Our median CD4+ counts correlated with CDC values. Values used by WHO in infants are higher than ours. We suggest that our children be assessed using CDC reference values which correlate with ours.

Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria.

The success of antiretroviral therapy (ART) depends on a high level of adherence to a life-long regimen of antiretroviral drugs (ARVs). Since the scale-up of access to ARVs in Nigeria, few studies have determined the level of adherence of ART among children. This study was undertaken to determine the level of ART adherence among paediatric patients at an outpatient clinic, the reasons for non-adherence, and the factors associated with adherence, according to caregivers' reports. Out of a total of 212 children, 183 (86%) were adherent in the three days preceding the interview, while 29 (14%) were not adherent. Drug exhaustion at home (16 children), followed by 'child slept through' (7 children) and 'caregiver away' were the most common reasons for a child having missed one or more ARV doses. Independent factors for adherence were male gender (odds ratio [OR] = 2.85; 95% confidence interval [CI]: 1.17-6.92) and attendance at last scheduled clinic appointment (OR = 4.76; 95% CI: 1.73-13.04). The caregiver's highest educational attainment, distance travelled to the clinic, use of medication reminders, formulation of ARVs, duration of HAART usage, age of the child and orphan status were not significantly associated with adherence to drug treatment. The overall level of adherence was high and similar to the rate reported prior to free access to ART services in Nigeria. Among child patients on HAART, there is a need to identify factors affecting clinic attendance and drug exhaustion at home.