Point prevalence of evidence-based antimicrobial use among hospitalized patients in sub-Saharan Africa: a systematic review and meta-analysis.

Excessive and improper use of antibiotics causes antimicrobial resistance which is a major threat to global health security. Hospitals in sub-Saharan Africa (SSA) has the highest prevalence of antibiotic use. This systematic review and meta-analysis aimed to determine the pooled point prevalence (PPP) of evidence-based antimicrobial use among hospitalized patients in SSA. Literature was retrieved from CINAHL, EMBASE, Google Scholar, PubMed, Scopus, and Web of Science databases. Meta-analysis was conducted using STATA version 17. Forest plots using the random-effect model were used to present the findings. The heterogeneity and publication bias were assessed using the I2 statistics and Egger's test. The protocol was registered in PROSPERO with code CRD42023404075. The review was conducted according to PRISMA guidelines. A total of 26, 272 study participants reported by twenty-eight studies published from 10 countries in SSA were included. The pooled point prevalence of antimicrobial use in SSA were 64%. The pooled estimate of hospital wards with the highest antibiotic use were intensive care unit (89%). The pooled prevalence of the most common clinical indication for antibiotic use were community acquired infection (41%). The pooled point prevalence of antimicrobial use among hospitalized patients were higher in SSA. Higher use of antibiotics was recorded in intensive care units. Community acquired infection were most common clinical case among hospitalized patients. Health systems in SSA must design innovative digital health interventions to optimize clinicians adhere to evidence-based prescribing guidelines and improve antimicrobial stewardship.

Outcome of Induction and Associated Factors among Term and Post-Term Mothers Managed at Jimma University Specialized Hospital: A Two Years' Retrospective Analysis.

BACKGROUND: Induction of labor using oxytocin is a routine procedure in obstetrics used for vaginal delivery of gravid uterus. The purpose of this study was to analyze outcome of induction with oxytocin and associated factors among mothers who delivered at term and post-term in Jimma University Specialized Hospital, Southwest Ethiopia. METHODS: A facility based cross-sectional study was conducted on records of 280 laboring mothers who delivered at term and post-term after induction with oxytocin from September 1(st), 2009 to August 31(st), 2011. The data were extracted using checklist and analyzed using SPSS windows version 16.0. The level of significance to declare relationship between the dependent and independent variables was set at p< 0.05. RESULTS: Mean maximum oxytocin levels used until vaginal delivery and at time of diagnosis of failed induction were 55.0 ± 29.8 and 89.7± 11.6 miu/min respectively. Mean time elapsed from initiation of induction with oxytocin to vaginal delivery and till diagnosis of failed induction were 6:10 ± 3:09 and 9:57± 2:01 hours respectively. Failed induction was diagnosed in 21.4% of the mothers. Primigravidity, unfavorable and intermediate Bishop Scores determined at admission were found to be predictors of failed induction. CONCLUSION: High rate of failed induction and high level of oxytocin use were found. Preparation of the cervix before commencing induction in primigravid women is recommended to improve success of induction with the current protocol.

Risk factors for tuberculosis after highly active antiretroviral treatment (HAART) initiation among HIV patients: A systematic review.

BACKGROUND: Tuberculosis is one of the most frequent causes of death among adults despite being nearly 100% curable in the developing world. The lifetime risk of tuberculosis in immune competent persons is 5% to 10%, but in HIV positive individuals, there is a 5% to 15% annual risk of developing active tuberculosis disease and there appears to be little research addressing HIV and tuberculosis co-infection. OBJECTIVE: To synthesise the best available evidence on risk factors for developing tuberculosis after highly active antiretroviral treatment initiation among HIV patients INCLUSION CRITERIA: HIV patients who had initiated highly active antiretroviral treatment and were above 15 years of age.Risk factors for developing active tuberculosis among HIV patients after initiation of highly active antiretroviral treatment.Analytical epidemiological study designs were included in the review.The studies considered in this review included socio-demographic and clinical variables as risk factors for developing tuberculosis after HAART initiation such as, but not limited to: baseline CD4 count, HAART type, WHO clinical stage of HIV, previous history of TB and gender. SEARCH STRATEGY: English language articles published between January 1997 and December 2011 were searched using a comprehensive search strategy. ASSESSMENT OF METHODOLOGICAL QUALITY: Conducted, using the Joanna Briggs Institute critical appraisal tools. DATA EXTRACTION: Carried out, using the Joanna Briggs Institute data extraction tool. DATA SYNTHESIS: Meta- analysis was conducted using random effects model with Rev Man 5 software. RESULTS: Five cohort studies were included in the review. The risk of developing active tuberculosis after initiating highly active antiretroviral treatment was found to be 2.14 times higher in subjects with a baseline CD4+ cell count ≥ 200 than their counterparts with a 95% CI from 1.52 to 3.02 and this effect was statistically significant, p<0.0001. The overall effect of gender on development of post highly active antiretroviral treatment tuberculosis was found to be not significant, p=0.64. The meta analysis for prior TB history as a risk factor favoured those who didn't have prior tuberculosis history to have 1.24 times higher risk than their counter parts even if it is not found to be statistically significant, p=0.56. There was no difference identified in the risk of developing post highly active antiretroviral treatment tuberculosis among patients taking protease inhibitor based treatment regimens and those taking non nucleoside reverse transcriptase inhibitor based treatment regimen. The last variable considered as a risk factor for post highly active antiretroviral treatment tuberculosis was the WHO's clinical stages for HIV and the risk was found to be 1.77 times higher among those who were at stage 1 or 2 during enrolment than their counterparts but this risk is not statistically significant, p=0.44. CONCLUSIONS: Having no prior tuberculosis history, female gender and WHO clinical stage of HIV at enrolment were found to be a risk but their relation with post highly active antiretroviral treatment tuberculosis was not statistically significant. The meta-analysis also did not identify any difference among the groups taking protease inhibiter based and non nucleoside reverse transcriptase inhibiters (NNRTI) based treatments in relation to post highly active antiretroviral treatment tuberculosis. But, the analysis revealed that there exists a statistically significant risk for developing post highly active antiretroviral treatment tuberculosis among individuals having a baseline CD4+ cell count ≥ 200 being found to be at higher risk.Unlike other HIV-associated opportunistic infections, tuberculosis may occur at relatively high CD4+ cell counts. Patients with no prior tuberculosis history and at WHO clinical stage 1 or 2 of HIV may also be at risk of developing post-HAART TB and need to be investigated thoroughly.Further longitudinal studies covering all other possible risk factors such as genetic and behavioral factors need to be carried out to produce comprehensive data.

Khat as a risk factor for hypertension: A systematic review.

BACKGROUND: Studies suggest possible newer risk factors for hypertension including Khat chewing, a plant which grows wild in countries bordering the Red Sea and along the east coast of Africa and the Arabian Peninsula. OBJECTIVES: The objective was to synthesise the best available evidence on the epidemiological association between Khat chewing as exposure (potential risk factor) and hypertension. INCLUSION CRITERIA: Subjects aged 16 years old or older regardless of gender and ethnicity, country of residence, Khat dose, frequency, duration of chewing or other characteristics of Khat exposure and co-presence of other known risk factors for hypertension.The focus of interest of this review was the epidemiological association between Khat chewing as exposure (potential risk factor) and hypertension as an outcome.Observational analytical studies (cohort studies, case-control studies and cross-sectional studies) were considered for inclusion. SEARCH STRATEGY: Three staged search strategy was used to identify all relevant published and grey literature in English language from 1988 to 2011. Databases searched were PubMed, CINAHL, PopLine, LILACS, MedNar and Embase. METHODOLOGICAL QUALITY: All papers selected for inclusion in the review were subjected to a rigorous, independent appraisal by the two reviewers prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute. DATA COLLECTION AND SYNTHESIS: Due to poor internet service in our setting we were unable to use the Joanna Briggs Institute -software for data extraction and synthesis as approved in the protocol. Quantitative papers were pooled in statistical meta-analysis using the Review Manager Software. Odds ratios and their 95% confidence intervals were calculated for analysis. RESULTS: Two studies from Ethiopia and one from Saudi Arabia were identified. In the study done by Getahun et al. 44 of the chewers (n=324) and 34 of the non chewers (n=319) were found to have hypertension. Analysis of this study showed no statistically significant association between Khat chewing and hypertension (OR=1.29, 95% CI =0.80-2.08). In the second study done by Mossie, 29 of the chewers (n=277) and 73 of the non chewers (n=621) were found to have hypertension and there was no statistically significant association between Khat chewing and hypertension (OR=0.88, 95% CI =0.56-1.38). Seventy seven of the chewers (n=568) and 160 of the non chewers (n=1207) were found to have hypertension) in the third study done by Ibrahim, similarly there was no statistically significant association between Khat chewing and prevalence of hypertension (OR=1.03, 95% CI =0.77-1.37 in this study.On meta analysis, a total of 3321 subjects were involved. Of the Khat chewers (1174), 150 were found to have hypertension. On contrary, 267 of non chewers (2147) were found to have hypertension. Finding of the analysis showed no statistically significant association between Khat chewing and hypertension (Odds ratio=1.04, 95% Confidence Interval= 0.84, 1.29). The studies were homogenous, Heterogeneity test: Chi = 1.35, df = 2, (P = 0.51). The test for overall effect also showed no statistical significance at conventional levels (P>0.05). CONCLUSIONS: We did not find sufficient evidence to conclude that Khat as epidemiologic risk factor for hypertension.The present systematic review did not identify a statistically significant association of Khat chewing as epidemiologic risk factor for hypertension. IMPLICATIONS FOR RESEARCH: This review identifies the need for further studies on Khat as an epidemiologic risk factor for hypertension considering further aspects of chewing, like dose-response, duration of chewing and co-existence of other co-morbid factors of hypertension.

Determinants of non-compliance with Antiretroviral Therapy among adults living with HIV/AIDS: A Systematic Review.

BACKGROUND: Non-compliance with Antiretroviral Therapy is a major public health concern and further challenged by interaction of various social and clinical obstacles. So; near perfect pill taking is desirable in order to maximise its benefits. OBJECTIVES: To systematically search, appraise and synthesise the best available evidence on determinants of non-compliance with Antiretroviral Therapy among adults living with HIV/AIDS and provide direction to future how to increase compliance with Antiretroviral Therapy. INCLUSION CRITERIA: The systematic review considered studies with 18 years and above year old adults living with HIV/AIDS.Determinants of non-compliance with Antiretroviral Therapy among adults living with HIV/AIDS.Quantitative study designs were considered for inclusion.Socio-economic, Health service, Psychosocial and behavioural and Clinical related outcomes. SEARCH STRATEGY: English language articles published between January1997 and December 2011 were sought across major databases. METHODOLOGICAL QUALITY: Methodological quality was assessed using Joanna Briggs Institute Meta Analysis of Statistical Assessment and Review Instrument critical appraisal tools. DATA COLLECTION: Data were extracted from papers included in the review by using a standardized data extraction tool. DATA SYNTHESIS: Meta- analysis was conducted using fixed and random effects model with mantel Haenszel method using Revman5 software. Heterogeneity between the studies was assessed using χ test at a p-value of <0.05. Summary statistics were expressed as adjusted odds ratio or adjusted risk ratio with 95% confidence intervals at a p-value of <0.05. RESULTS: Nine studies (seven cross-sectional, one cohort study and one case-control study) were included in the review. Results from meta analysis showed that white race adults living with HIV/AIDS were 1.38 times more likely to non-comply with Antiretroviral Therapy when compared with black adults living with HIV/ AIDS (Adjusted Relative Risk=1.38; 95%CI=1.21, 1.58, p value<0.00001). Non-depressed adults living with HIV/AIDS were 1.77 times more likely to non-comply with Antiretroviral Therapy when compared with depressed adults living with HIV/AIDS (Adjusted Odds ratio =1.77; 95%CI=1.17, 2.69, p value=0.007). Substance non-user adults living with HIV/ AIDS were 2.04 times more likely to non-comply with Antiretroviral Therapy when compared with substance user adults living with HIV/ AIDS (Adjusted Relative Risk =2.04; 95%CI=1.51, 2.74, p value=<0.00001). Adults living with HIV/ AIDS with baseline CD4 count ≥200cells/ml were 1.8 times more likely to non-comply with Antiretroviral Therapy when compared with adults livings with HIV/ AIDS with baseline CD4 count ≥200cells/ml (Adjusted Odds ratio=1.84; 95%CI=1.08, 3.15, p value=0.03). CONCLUSION: We found the base line CD4 count ≥200cells/ml, not being depressed; not using substances and being white in race were associated with non-compliance with Antiretroviral Therapy.Behavioural change via counselling should be encouraged as a way to increase compliance. Reminders to take mediations regularly, on time, offering encouragement to keep going, helping to keep clinic appointments and providing emotional support for adults living with HIV/AIDS is important.Further research utilizing more robust experimental methods would help to further explore the findings of this review.

Educating leaders in hospital management: a new model in Sub-Saharan Africa.

QUALITY ISSUE: The vast majority of health system capacity-building efforts have focused on enhancing medical and public health skills; less attention has been directed at developing hospital managers despite their central role in improving the functioning and quality of health-care systems. Initial ASSESSMENT AND CHOICE OF INTERVENTION: Initial assessment of hospital management systems demonstrated weak functioning in several management areas. In response, we developed with the Ethiopian Ministry of Health (MoH) a novel Master of Hospital Administration (MHA) program, reflecting a collaborative effort of the MoH, the Clinton HIV/AIDS Initiative, Jimma University and Yale University. The MHA is a 2-year executive style educational program to develop a new cadre of hospital leaders, comprising 5% classroom learning and 85% executive practice. IMPLEMENTATION: The MHA has been implemented with 55 hospital leaders in the position of chief executive officer within the MoH, with courses taught in collaboration by faculty of the North and the South universities. EVALUATION AND LESSONS LEARNED: The program has enrolled two cohorts of hospital leaders and is working in more than half of the government hospitals in Ethiopia. Lessons learned include the need to: (i) balance education in applied, technical skills with more abstract thinking and problem solving, (ii) recognize the interplay between management education and policy reform, (iii) remain flexible as policy changes have direct impact on the project, (iv) be realistic about resource constraints in low-income settings, particularly information technology limitations, and (v) manage the transfer of knowledge for longer term sustainability.