Evidence for Bartonella quintana in Lice Collected from the Clothes of Ethiopian Homeless Individuals.

Human lice, Pediculus humanus, can transmit various pathogens, including Bartonella quintana, Borrelia recurrentis, and Rickettsia prowazekii. Xenosurveillance is an epidemiological approach to assessing human infection risks performed by screening vectors of infectious disease agents. In the proof-of-principle study reported herein, the DNA of 23 human lice was collected from the clothes of 30 homeless Ethiopian individuals. These samples were assessed using 16S rRNA gene-specific pan-eubacterial PCR for screening, followed by Bartonella genus 16S-23S internal transcribed spacer (ITS) sequence-specific PCR, Bartonella genus gltA gene-specific PCR, and 16S rRNA gene PCR with specificity for relapsing-fever-associated Borrelia spp. with subsequent sequencing of the amplicons. In one sample, the pan-eubacterial 16S rRNA gene-specific screening PCR, the Bartonella genus 16S-23S ITS sequence-specific PCR, and the Bartonella genus gltA gene-specific PCR allowed for the sequencing of B. quintana-specific amplicons. In two additional samples, Bartonella genus gltA gene-specific PCR also provided sequences showing 100% sequence identity with B. quintana. In total, 3/23 (13.0%) of the assessed lice were found to be positive for B. quintana. Correlating clinical data were not available; however, the assessment confirmed the presence of B. quintana in the local louse population and thus an associated infection pressure. Larger-sized cross-sectional studies seem advisable to more reliably quantify the infection risk of lice-infested local individuals. The need for prevention by providing opportunities to maintain standard hygiene for Ethiopian homeless individuals is stressed by the reported findings, especially in light of the ongoing migration of refugees.

Disseminated Cryptococcosis Is a Common Finding among Human Immunodeficiency Virus-Infected Patients with Suspected Sepsis and Is Associated with Higher Mortality Rates.

Cryptococcosis is the leading cause of death among people with HIV in Sub-Saharan Africa. The lack of optimum diagnoses and medications significantly impair the management of the disease. We investigated the burden of cryptococcosis and related mortality among people with HIV and suspected sepsis in Ethiopia. We conducted a prospective study at (1) Adama Hospital Medical College and (2) Asella Referral and Teaching Hospital from September 2019 to November 2020. We enrolled adult, HIV-infected patients presenting with suspected sepsis and assessed their 28-day survival rates. We performed blood cultures and cryptococcal antigen (CrAg) testing. In total, 82 participants were enrolled with a median age of 35 years, and 61% were female. Overall, eleven (13%) had positive CrAg tests, of which five grew Cryptococcus in blood cultures. Despite high-dose fluconazole (1200 mg/d) monotherapy being given to those with positive CrAg tests, the 28-day mortality was 64% (7/11), with mortality being significantly higher than among the CrAg-negative patients (9% (6/71); p < 0.001). Cryptococcosis was the leading cause of mortality among HIV-infected sepsis patients in this Ethiopian cohort. The CrAg screening of HIV-infected patients attending an emergency department can minimize the number of missed cryptococcosis cases irrespective of the CD4 T cell count and viral load. These findings warrant the need for a bundle approach for the diagnosis of HIV-infected persons presenting with sepsis in low- and middle-income countries.

Access to the World Health Organization-recommended essential diagnostics for invasive fungal infections in critical care and cancer patients in Africa: A diagnostic survey.

BACKGROUND: Invasive fungal infections (IFIs) contribute to significant morbidity and mortality among patients with haemato-oncological conditions, seriously ill hospitalised patients and those in intensive care (ICU). We surveyed for the World Health Organization-recommended essential diagnostic tests for IFIs in these risk groups in Africa. METHODS: The Global Action For Fungal Infections (GAFFI) evaluated the different levels of access to both diagnostics for IFIs for populations in Africa, with the aim of building a comparative dataset and a publicly available interactive map. Data was collected through a validated questionnaire administered to a country leader in relevant topics (i.e., HIV, laboratory coordination) and/or Ministry of Health representatives and followed up with 2 rounds of validation by video calls, and later confirmation by email of findings. RESULTS: Initial data was collected from 48 African countries covering 99.65 % of the population. Conventional diagnostics such as blood cultures, direct microscopy and histopathology were often used for diagnosis of IFIs in more than half of the facilities. Bronchoscopy was rarely done or not done in 20 countries (population 649 million). In over 40 African countries (population >850 million), Aspergillus antigen testing was never performed in either the public or private sectors. Computed tomography (CT) imaging is routinely used in 27 (56 %) of countries in the public sector and 21 44 %) in the private sector. However, magnetic resonance imaging remains relatively uncommon in most African countries. CONCLUSIONS: There are critical gaps in the availability of essential diagnostics for IFIs in Africa, particularly Aspergillus antigen testing and modern medical imaging modalities. Early diagnosis and commencement of targeted therapy of IFIs are critical for optimal outcomes from complex cancer therapies.

Risk-adjusted active tuberculosis case finding strategy in central Ethiopia.

Background: The World Health Organization recommends active case finding for tuberculosis (TB). Our study evaluated the targeted screening of household contacts (HHCs) of patients with contagious pulmonary tuberculosis (PTB) in Central Ethiopia. Methods: The HHCs of patients with microbiologically confirmed PTB were screened for TB symptoms and risk factors for TB transmission. Symptomatic HHCs were subjected to secondary investigation. Antimicrobial resistance was investigated among study participants. Results: Overall, 112 index patients with TB were included, and 289 HHCs from 89 households were screened. Multidrug-resistant-TB was detected in 2.7% (n=3) of index patients. The routine public health system process did not identify any TB suspects among HHCs. In total, 23.9% (n=69) of HHCs reported ≥1 TB symptom and PTB was confirmed in 2.1% (n=6). Reporting >1 TB symptom (relative risk [RR] 29.4, 95% CI 3.5-245.5, P<0.001) and night sweats (RR 27.1, 95% CI 3.2-226.6, P<0.001) were associated with the greatest relative risk. Regular alcohol consumption was identified as an individual risk factor for TB among HHCs (P=0.022). Conclusion: The MDR-TB rate among our patients was higher than recently reported for Ethiopia. Enhanced contact tracing using a risk-adjusted approach seems feasible and increases the case detection rate among HHCs of confirmed TB cases.

The implementation of the Kinyoun staining technique in a resource-limited setting is feasible and reveals a high prevalence of intestinal cryptosporidiosis in patients with HIV.

OBJECTIVES: In resource-limited settings, intestinal Cryptosporidial or coccidian infections are common causes of chronic diarrhea but usually remain undiagnosed by routine stool investigation. Here, the addition of the Kinyoun staining technique after stool concentration was evaluated as an easy and inexpensive method for diagnosis of intestinal parasitic infection in patients with HIV. METHODS: This cross-sectional study investigated patients with HIV with diarrhea and randomly selected patients with HIV without diarrhea as controls. Stool samples were examined by wet mount microscopy and Kinyoun staining after stool concentration. Clinical, sociodemographic, and behavioral data were collected. Statistical analysis was performed using chi-squared test and multivariate regression analysis. RESULTS: In total, 163 participants were included (62.0% female, mean age 38.2 [SD ± 10.7] years). Diarrhea was present in 52.1% (85/163). The prevalence of intestinal parasites was 18.4% (30/163). Cryptosporidial infections were more frequent among patients with diarrhea (12.9% [11/85] vs 1.3% [1/78], P = 0.005) and in patients with CD4+ cell count <200 cells/µl (25.9% [7/27] vs 3.7% [5/136], P = 0.001). Risk factors for intestinal parasitic infections were diarrhea and the habit of regularly eating uncooked food. Kinyoun staining was necessary for the detection of cryptosporidiosis. CONCLUSION: In our cohort, the prevalence of intestinal parasitic infection was high, especially after additional use of Kinyoun staining for detection of Cryptosporidia or intestinal coccidia. Considering its clinical relevance, particularly in individuals at risk, the implementation of this technique should be considered in resource-limited settings.

Prevalence and characterization of antimicrobial resistance among gram-negative bacteria isolated from febrile hospitalized patients in central Ethiopia.

BACKGROUND: Infectious diseases are among the leading causes of death in many low-income countries, such as Ethiopia. Without reliable local data concerning causative pathogens and antimicrobial resistance, empiric treatment is suboptimal. The objective of this study was to characterize gram-negative bacteria (GNB) as pathogens and their resistance pattern in hospitalized patients with infections in central Ethiopia. METHODS: Patients ≥ 1 year of age with fever admitted to the Asella Referral and Teaching Hospital from April 2016 to June 2018 were included. Blood and other appropriate clinical specimens were collected and cultured on appropriate media. Antibiotic susceptibility testing (AST) was performed using the Kirby-Bauer method and VITEK® 2. Species identification and detection of resistance genes were conducted using MALDI-ToF MS (VITEK® MS) and PCR, respectively. RESULTS: Among the 684 study participants, 54.2% were male, and the median age was 22.0 (IQR: 14-35) years. Blood cultures were positive in 5.4% (n = 37) of cases. Among other clinical samples, 60.6% (20/33), 20.8% (5/24), and 37.5% (3/8) of swabs/pus, urine and other body fluid cultures, respectively, were positive. Among 66 pathogenic isolates, 57.6% (n = 38) were GNB, 39.4% (n = 26) were gram-positive, and 3.0% (n = 2) were Candida species. Among the isolated GNB, 42.1% (16/38) were Escherichia coli, 23.7% (9/38) Klebsiella pneumoniae and 10.5% (4/38) Pseudomonas aeruginosa. In total, 27/38 gram-negative isolates were available for further analysis. Resistance rates were as follows: ampicillin/sulbactam, 92.6% (n = 25); cefotaxime, 88.9% (n = 24); ceftazidime, 74.1% (n = 20); cefepime, 74.1% (n = 20); gentamicin, 55.6% (n = 15); piperacillin/tazobactam, 48.1% (n = 13); meropenem, 7.4% (n = 2); and amikacin, 3.7% (n = 1). The blaNDM-1 gene was detected in one K. pneumoniae and one Acinetobacter baumannii isolate, which carried an additional blaOXA-51 gene. The ESBL enzymes were detected in 81.5% (n = 22) of isolates as follows: TEM, 77.2% (n = 17); CTX-M-1 group, 68.2% (n = 15); SHV group, 27.3% (n = 6); and CTX-M-9 group, 9.1% (n = 2). Based on the in vitro antimicrobial susceptibility results, empiric treatment initiated in 13 of 18 (72.2%) patients was likely ineffective. CONCLUSION: We report a high prevalence of ESBL-producing bacteria (81.5%) and carbapenem resistance (7.4%), with more than half of GNB carrying two or more ESBL enzymes resulting in suboptimal empiric antibiotic therapy. These findings indicate a need for local and national antimicrobial resistance surveillance and the strengthening of antimicrobial stewardship programs.

Characterization of HIV-1 drug resistance among patients with failure of second-line combined antiretroviral therapy in central Ethiopia.

BACKGROUND: As a consequence of the improved availability of combined antiretroviral therapy (cART) in resource-limited countries, an emergence of HIV drug resistance (HIVDR) has been observed. We assessed the prevalence and spectrum of HIVDR in patients with failure of second-line cART at two HIV clinics in central Ethiopia. METHODS: HIV drug resistance was analysed in HIV-1-infected patients with virological failure of second-line cART using the geno2pheno application. RESULTS: Among 714 patients receiving second-line cART, 44 (6.2%) fulfilled the criteria for treatment failure and 37 were eligible for study inclusion. Median age was 42 years [interquartile range (IQR): 20-45] and 62.2% were male. At initiation of first-line cART, 23 (62.2%) were WHO stage III, mean CD4 cell count was 170.6 (range: 16-496) cells/µL and median (IQR) HIV-1 viral load was 30 220 (7963-82 598) copies/mL. Most common second-line cART regimens at the time of failure were tenofovir disoproxil fumarate (TDF)-lamivudine (3TC)-ritonavir-boosted atazanavir (ATV/r) (19/37, 51.4%) and zidovudine (ZDV)-3TC-ATV/r (9/37, 24.3%). Genotypic HIV-1 resistance testing was successful in 35 (94.6%) participants. We found at least one resistance mutation in 80% of patients and 40% carried a protease inhibitor (PI)-associated mutation. Most common mutations were M184V (57.1%), Y188C (25.7%), M46I/L (25.7%) and V82A/M (25.7%). High-level resistance against the PI ATV (10/35, 28.6%) and lopinavir (LPV) (5/35, 14.3%) was reported. As expected, no resistance mutations conferring integrase inhibitor resistance were detected. CONCLUSIONS: We found a high prevalence of resistance mutations, also against PIs (40%), as the national standard second-line cART components. Resistance testing before switching to second- or third-line cART is warranted.

Tick species from cattle in the Adama Region of Ethiopia and pathogens detected.

Ticks will diminish productivity among farm animals and transmit zoonotic diseases. We conducted a study to identify tick species infesting slaughter bulls from Adama City and to screen them for tick-borne pathogens. In 2016, 291 ticks were collected from 37 bulls in Adama, which were ready for slaughter. Ticks were identified morphologically. Total genomic DNA was extracted from ticks and used to test for Rickettsia spp. with real-time PCR. Species identification was done by phylogenetic analysis using sequencing that targeted the 23S-5S intergenic spacer region and ompA genes. Four tick species from two genera, Amblyomma and Rhipicephalus, were identified. Amblyomma cohaerens was the dominant species (n = 241, 82.8%), followed by Amblyomma variegatum (n = 22, 7.5%), Rhipicephalus pulchellus (n = 19, 6.5%), and Rhipicephalus decoloratus (n = 9, 3.0%). Among all ticks, 32 (11%) were positive for Rickettsia spp. and 15 (5.2%) of these were identified as R. africae comprising at least two genetic clades, occurring in A. variegatum (n = 10) and A. cohaerens (n = 5). The remainder of Rickettsia-positive samples could not be amplified due to low DNA yield. Furthermore, another 15 (5.2%) samples carried other pathogenic bacteria: Ehrlichia ruminantium (n = 9; 3.1%) in A. cohaerens, Ehrlichia sp. (n = 3; 1%) in Rh. pulchellus and A. cohaerens, Anaplasma sp. (n = 1; 0.5%) in A. cohaerens, and Neoehrlichia mikurensis (n = 2; 0.7%) in A. cohaerens. All ticks were negative for Bartonella spp., Babesia spp., Theileria spp., and Hepatozoon spp. We reported for the first time E. ruminatium, N. mikurensis, Ehrlichia sp., and Anaplasma sp. in A. cohaerens. Medically and veterinarily important pathogens were mostly detected from A. variegatum and A. cohaerens. These data are relevant for a One-health approach for monitoring and prevention of tick-borne disease transmission.

Clinical and microbiological characterization of sepsis and evaluation of sepsis scores.

BACKGROUND: Despite the necessity of early recognition for an optimal outcome, sepsis often remains unrecognized. Available tools for early recognition are rarely evaluated in low- and middle-income countries. In this study, we analyzed the spectrum, treatment and outcome of sepsis at an Ethiopian tertiary hospital and evaluated recommended sepsis scores. METHODS: Patients with an infection and ≥2 SIRS criteria were screened for sepsis by SOFA scoring. From septic patients, socioeconomic and clinical data as well as blood cultures were collected and they were followed until discharge or death; 28-day mortality was determined. RESULTS: In 170 patients with sepsis, the overall mortality rate was 29.4%. The recognition rate by treating physicians after initial clinical assessment was low (12.4%). Increased risk of mortality was significantly associated with level of SOFA and qSOFA score, Gram-negative bacteremia (in comparison to Gram-positive bacteremia; 42.9 versus 16.7%), and antimicrobial regimen including ceftriaxone (35.7% versus 19.2%) or metronidazole (43.8% versus 25.0%), but not with an increased respiratory rate (≥22/min) or decreased systolic blood pressure (≤100mmHg). In Gram-negative isolates, extended antimicrobial resistance with expression of extended-spectrum beta-lactamase and carbapenemase genes was common. Among adult patients, sensitivity and specificity of qSOFA score for detection of sepsis were 54.3% and 66.7%, respectively. CONCLUSION: Sepsis is commonly unrecognized and associated with high mortality, showing the need for reliable and easy-applicable tools to support early recognition. The established sepsis scores were either of limited applicability (SOFA) or, as in the case of qSOFA, were significantly impaired in their sensitivity and specificity, demonstrating the need for further evaluation and adaptation to local settings. Regional factors like malaria endemicity and HIV prevalence might influence the performance of different scores. Ineffective empirical treatment due to antimicrobial resistance is common and associated with mortality. Local antimicrobial resistance statistics are needed for guidance of calculated antimicrobial therapy to support reduction of sepsis mortality.

Variation of vital signs with potential to influence the performance of qSOFA scoring in the Ethiopian general population at different altitudes of residency: A multisite cross-sectional study.

INTRODUCTION: The physiological range of different vital signs is dependent on various environmental and individual factors. There is a strong interdependent relationship between vital signs and health conditions. Deviations of the physiological range are commonly used for risk assessment in clinical scores, e.g. respiratory rate (RR) and systolic blood pressure (BPsys) in patients with infections within the quick sequential organ failure assessment (qSOFA) score. A limited number of studies have evaluated the performance of such scores in resource-limited health care settings, showing inconsistent results with mostly poor discriminative power. Divergent standard values of vital parameters in different populations, e.g. could influence the accuracy of various clinical scores. METHODS: This multisite cross-sectional observational study was performed among Ethiopians residing at various altitudes in the cities of Asella (2400m above sea level (a.s.l.)), Adama (1600m a.s.l.), and Semara (400m a.s.l.). Volunteers from the local general population were asked to complete a brief questionnaire and have vital signs measured. Individuals reporting acute or chronic illness were excluded. RESULTS: A positive qSOFA score (i.e. ≥2), indicating severe illness in patients with infection, was common among the studied population (n = 612). The proportion of participants with a positive qSOFA score was significantly higher in Asella (28.1%; 55/196), compared with Adama, (8.3%; 19/230; p<0.001) and Semara (15.1%; 28/186; p = 0.005). Concerning the parameters comprised in qSOFA, the thresholds for RR (≥22/min) were reached in 60.7%, 34.8%, and 38.2%, and for BPsys (≤100 mmHg) in 48.5%, 27.8%, and 36.0% in participants from Asella, Adama, and Semara, respectively. DISCUSSION: The high positivity rate of qSOFA score in the studied population without signs of acute infection may be explained by variations of the physiological range of different vital signs, possibly related to the altitude of residence. Adaptation of existing scores using local standard values could be helpful for reliable risk assessment.

Carriage of ESBL-producing Gram-negative bacteria by flies captured in a hospital and its suburban surroundings in Ethiopia.

BACKGROUND: Local data from the Asella Teaching and Referral Hospital in the town of Asella, Ethiopia reveal a high prevalence of extended-spectrum ß-lactamase- (ESBL) producing Gram-negative bacteria (GNB) in clinical isolates. To investigate a possible route of transmission, we determined the proportions ESBL-producing GNB in isolates from flies caught in the hospital and in the town of Asella. METHODS: Flies were collected in August 2019 from the neonatal intensive care unit (NICU), the orthopedic ward, the hospital's waste disposal area, and from a butchery situated 1.5 km from the hospital. After trapping, the flies were macerated and suspended in sterile normal saline. The suspensions were inoculated on MacConkey agar and incubated overnight. Species identification and antimicrobial susceptibility testing were performed using Vitek®-MS and VITEK® 2. RESULTS: In total, 103 bacterial isolates were obtained from 85 flies (NICU: 11 isolates from 20 flies, orthopedic ward: 10 isolates from 12 flies, waste disposal area: 37 isolates from 26 flies, butchery: 45 isolates from 27 flies). The proportions of ESBL-producing bacteria among isolates obtained from flies collected in the hospital compound were significantly higher (82%, 90%, and 57% in NICU, orthopedic ward and waste disposal area, respectively) compared to flies collected outside of the hospital compound (2% (@1/45) in the butchery) (p ≤ 0.001). The proportion of ESBL was 67% (6/9) among Raoultella spp. 67% (4/6) among Kluyvera spp., 56% (5/9) among Enterobacter spp., 50% (5/10) among E. coli, and 44% (8/18) among Klebsiella spp.. Of the 40 ESBL-genes detected, 85% were CTX-M-like, 83% TEM-like, 23% SHV-like, and 2% CTX-M-2-like. ESBL-producing bacteria showed higher rates of resistance against ciprofloxacin (66% vs. 5%), gentamicin (68% vs. 3%), piperacillin-tazobactam (78% vs. 5%), and trimethoprim-sulfamethoxazole (88% vs. 16%), compared to non-ESBL-producing bacteria. CONCLUSION: A high proportion of ESBL was identified in isolates from flies caught in the hospital compound compared with isolates of flies collected at a distance of 1.5 km from the hospital. Flies can be potential vectors for transmission of multidrug-resistant (MDR) bacteria within hospitals. Further studies are needed to determine the source of MDR colonization in flies and possible impact of MDR for nosocomial infections.

CTX-M-9 group ESBL-producing Raoultella planticola nosocomial infection: first report from sub-Saharan Africa.

BACKGROUND: Raoultella are Gram-negative rod-shaped aerobic bacteria which grow in water and soil. They mostly cause nosocomial infections associated with surgical procedures. This case study is the first report of a Raoultella infection in Africa. Case presentation We report a case of a surgical site infection (SSI) caused by Raoultella planticola which developed after caesarean section (CS) and surgery for secondary small bowel obstruction. The patient became febrile with neutrophilia (19,157/µL) 4 days after laparotomy and started to develop clinical signs of a SSI on the 8th day after laparotomy. The patient continued to be febrile and became critically ill despite empirical treatment with ceftriaxone and vancomycin. Raoultella species with extended antimicrobial resistance (AMR) carrying the CTX-M-9 ß-lactamase was isolated from the wound discharge. Considering the antimicrobial susceptibility test, ceftriaxone was replaced by ceftazidime. The patient recovered and could be discharged on day 29 after CS. CONCLUSIONS: Raoultella planticola was isolated from an infected surgical site after repeated abdominal surgery. Due to the infection the patient's stay in the hospital was prolonged for a total of 4 weeks. It is noted that patients undergoing surgical and prolonged inpatient treatment are at risk for infections caused by Raoultella. The development of a SSI caused by Raoultella planticola with extended AMR has to be assumed to be a consequence of ineffective antibiotic utilization. The presented case advices that rare bacteria as Raoultella should be considered as potential cause of nosocomial SSI with challenging treatment due to high levels of AMR.

Outbreak of Louse-Borne Relapsing Fever among Urban Dwellers in Arsi Zone, Central Ethiopia, from July to November 2016.

We report epidemiological and clinical aspects of an outbreak of louse-borne relapsing fever (LBRF) in Asella in Arsi Zone, central Ethiopia, from July to November 2016. A total of 63 LBRF cases were reported. The overall case fatality rate was 13% among treated patients. In this article, the first-line epidemiological assessment, individual prevention and control measures, and public health investigations and interventions in relation to this outbreak are described. Treatment recommendations for resource-limited settings are discussed by review of the latest literature.

Implementation of the WHO multimodal Hand Hygiene Improvement Strategy in a University Hospital in Central Ethiopia.

BACKGROUND: The burden of health-care associated infections in low-income countries is high. Adequate hand hygiene is considered the most effective measure to reduce the transmission of nosocomial pathogens. We aimed to assess compliance with hand hygiene and perception and knowledge about hand hygiene before and after the implementation of a multimodal hand hygiene campaign designed by the World Health Organization. METHODS: The study was carried out at Asella Teaching Hospital, a university hospital and referral centre for a population of about 3.5 million in Arsi Zone, Central Ethiopia. Compliance with hand hygiene during routine patient care was measured by direct observation before and starting from six weeks after the intervention, which consisted of a four day workshop accompanied by training sessions and the provision of locally produced alcohol-based handrub and posters emphasizing the importance of hand hygiene. A second follow up was conducted three months after handing over project responsibility to the Ethiopian partners. Health-care workers' perception and knowledge about hand hygiene were assessed before and after the intervention. RESULTS: At baseline, first, and second follow up we observed a total of 2888, 2865, and 2244 hand hygiene opportunities, respectively. Compliance with hand hygiene was 1.4% at baseline and increased to 11.7% and 13.1% in the first and second follow up, respectively (p < 0.001). The increase in compliance with hand hygiene was consistent across professional categories and all participating wards and was independently associated with the intervention (adjusted odds ratio, 9.18; 95% confidence interval 6.61-12.76; p < 0.001). After the training, locally produced alcohol-based handrub was used in 98.4% of all hand hygiene actions. The median hand hygiene knowledge score overall was 13 (interquartile range 11-15) at baseline and increased to 17 (15-18) after training (p < 0.001). Health-care workers' perception surveys revealed high appreciation of the different strategy components. CONCLUSION: Promotion of hand hygiene is feasible and sustainable in a resource-constrained setting using a multimodal improvement strategy. However, absolute compliance remained low. Strong and long-term commitment by hospital management and health-care workers may be needed for further improvement.