Background: Infectious diseases and the rapid emergence of multidrug-resistant pathogens continue to pose a threat to global health. The development of antimicrobial-resistant organisms is an alarming issue caused by inappropriate use of antibiotic agents. It is estimated that death from antimicrobial resistant pathogens could increase >10-fold to ~10 million deaths annually by 2050 if action is not taken. “It is essential to have reliable data on how medicines are used in order to identify areas to develop targeted interventions” (WHO 2011). Investigating antimicrobial use in hospitals is the first step in evaluating the underlying causes of AMR. In Sierra Leone, no other study related to antibiotic prescribing patterns in hospital setting has been undertaken. Objective: To investigate antibiotic prescription patterns using the WHO hospital antimicrobial use indicator tool at the Kingharman Hospital for 1 month. Methods: Data were collected from patient charts for 1 month, January 1–31, 2019. A data extraction tool was used to capture information on patient demographics, diagnosis, and antibiotics prescription details regarding dosage, duration, and frequency of administration. The tool adopted 6 selected indicators from the WHO antimicrobial use manual to measure the extent of antibiotic use in hospital and performance among prescribers. Results: Of the 189 charts reviewed, 175 included antibiotic prescriptions. The percentage of prescriptions involving antibiotics was 92.5%. The average number of drugs prescribed was 2, with an average duration of 5.2 days. Moreover, 50.5% of antibiotics prescribed were generic, and 96.6% were from the Ministry of Health and Sanitation Essential Medicine List (EML). The most commonly used antibiotics were ciprofloxacin (38.8%), followed by ceftriaxone (23.0%), amoxicillin (16.8%), metronidazole (8.5%), and others(12.7%). Typhoid accounted for 34.8% of broad-spectrum antibiotics, UTI accounted for 17.7%, malaria accounted for 12.5%, 25.5% were unspecified, and 9.5% were for unclear diagnoses. Typically, combinations of fluroquinolones and cephalosporins were used to treat typhoid and UTIs. Conclusions: This cross-sectional study represents a broad picture of antibiotic prescribing patterns at the King Harman Hospital. There was no strict adherence to the WHO recommended prescribing guidelines. These findings also indicate the degree of irrational and inappropriate prescribing of broad-spectrum antibiotics. This study highlights the need for a comprehensive assessment of antimicrobial use to gain a better understanding of national antibiotic use and to guide interventions to reducing AMR.Funding: NoneDisclosures: NoneIf I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.DisagreeChristiana Kallon
Background: Surgical site infections (SSIs) are among the most common healthcare-associated infections (HAIs) in low- and middle-income countries (LMICs). SSI surveillance can be challenging and resource-intensive to implement in LMICs. To support feasible LMIC SSI surveillance, we piloted a multisite SSI surveillance protocol using simplified case definitions and methodology in Sierra Leone. Methods: A standardized evaluation tool was used to assess SSI surveillance knowledge, capacity, and attitudes at 5 proposed facilities. We used simplified case definitions restricted to objective, observable criteria (eg, wound purulence or intentional reopening) without considering the depth of infection. Surveillance was limited to post-cesarean delivery patients to control variability of patient-level infection risk and to decrease data collection requirements. Phone-based patient interviews at 30-days facilitated postdischarge case finding. Surveillance activities utilized existing clinical staff without monetary incentives. The Ministry of Health provided training and support for data management and analysis. Results: Three facilities were selected for initial implementation. At all facilities, administration and surgical staff described most, or all, infections as “preventable” and all considered SSIs an “important problem” at their facility. However, capacity assessments revealed limited staff availability to support surveillance activities, limited experience in systematic data collection, nonstandardized patient records as the basis for data collection, lack of unique and consistent patient identifiers to link patient encounters, and no quality-assured microbiology services. To limit system demands and to maximize usefulness, our surveillance data collection elements were built into a newly developed clinical surgical safety checklist that was designed to support surgeons’ clinical decision making. Following implementation and 2 months of SSI surveillance activities, 77% (392 of 509) of post-cesarean delivery patients had a checklist completed within the surveillance system. Only 145 of 392 patients (37%) under surveillance were contacted for final 30-day phone interview. Combined SSI rate for the initial 2-months of data collection in Sierra Leone was 8% (32 of 392) with 31% (10 of 32) identified through postdischarge case finding. Discussion: The surveillance strategy piloted in Sierra Leone represents a departure from established HAI strategies in the use of simplified case definitions and implementation methods that prioritize current feasibility in a resource-limited setting. However, our pilot implementation results suggest that even these simplified SSI surveillance methods may lack sustainability without additional resources, especially in postdischarge case finding. However, even limited phone-based patient interviews identified a substantial number of infections in this population. Although it was not addressed in this pilot study, feasible laboratory capacity building to support HAI surveillance efforts and promote appropriate treatment should be explored.Funding: NoneDisclosures: None
Background: Antibiotic resistance (AMR) is a safety concern for patients in Sierra Leone. AMR can occur in communities and as well in the process of receiving treatments in healthcare settings, and it can pose a major threat to patient safety. Healthcare-associated infections and AMR result in longer duration of illness, longer treatment, higher mortality, increased costs, and increased burden to health facilities. Objective: The purpose of this study was to generate more reliable estimates of the risk factors for the prevalence of HAI and to investigate patterns of antibiotic prescriptions done. Methods: The survey was conducted in 6 regional hospitals in Sierra Leone (Kono, Kambia, BO, Makeni, Moyamba, and Kenema) from June 16 to July 10 2019. The survey targeted inpatients in the pediatric, maternity, medical, and surgical wards. A structured questionnaire adopted from the WHO PPS form was used to collect information from patient medical charts and care notes. Results: Data were collected from 156 patients, of whom 140 patients were on antibiotics, 100 were women, and 40 were men. Patients on 1 antibiotic regimen accounted for 8.6% (n = 12) and 91.4% (n = 128) on a regimen of 2 or 3 antibiotics. Only 5 patients (3.6%) were on oral antibiotics and 135 (96.4%) were on IV antibiotics. In the maternity ward, 28 of 40 patients (70%) had had a caesarian section and were on 2 or more antibiotics; 18 patients with caesarian sections (64.3%) developed complications and continued on an antibiotic regimen for >1 week. The remaining 12 patients (30%) in the maternity ward were admitted for anemia and hypertension (ie, preeclampsia), and these patients were on 1 antibiotic regimen for which they had no clinical indication. Conclusions: The survey results show that every patient admitted to the hospital was covered with antibiotics with or without indications; no laboratory investigations were performed before antibiotics were initiated. These findings further reveal a large number of patients who were exposed to intravenous cannulation, which predisposes catheter-associated bloodstream infections. The survey results justify the need for an antibiotic stewardship program to guide use of antibiotics.Funding: NoneDisclosures: NoneIf I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.DisagreeChristiana Kallon
Background: Surgical site infections (SSIs) are associated with increased healthcare costs, antibiotic resistance, morbidity, and mortality. In low- and middle-income countries (LMICs), SSIs account for most healthcare-acquired infections (HAIs). In Africa, up to 20% of women who undergo a caesarean section develop a wound infection. Surveillance has been shown to be an essential component in the overall strategy to reduce SSIs. Methods: Surgical site infection surveillance is being implemented in 16 health facilities in Sierra Leone, with at least 1 from each of the 5 US Census regions: Eastern, Western, Northern, Northwestern, and Southern. These health facilities were selected based on the availability of a dedicated infection prevention and control (IPC) focal person. Women were observed for 30 days after caesarean section. A standardized surgical safety and surveillance checklist including case definitions and observable criteria (eg, purulent drainage, wound abscess, or intentional reopening) was used. Clinical staff were trained to collect data and to conduct in-person and phone interviews with patients on days 3, 7, and 30 after caesarean section. Results: From March 2021 to July 2021, a total of 2,529 women had caesarean sections in 15 health facilities; most occurred in the Northern region (785 of 2,529). Among these 2,529 women, 1,522 (60%) had an SSI surveillance checklist started, and of those 1,522, 632 (42%) had a completed checklist. Health facilities in most of the rural regions, (Eastern, Northwestern, and Southern) had no completed checklists. The overall SSI rate for the 15 health facilities was 3% (70 of 2,529). The Southern region had the highest SSI rate at 50% (35 of 70), but the Western region did not report any SSIs. Of the 70 cases, 49 (70%) were identified through active inpatient surveillance and 21 (30%) were identified through postdischarge surveillance. Conclusions: One of the priorities of Sierra Leone’s National IPC Action Plan is to establish HAI surveillance. Surgical site surveillance is an essential component of HAI surveillance and leads to timely identification so infections can be treated quickly. This study was limited by inadequate data collection and patients lost to follow-up after discharge. However, this study illustrates that surveillance leads to the diagnosis of most SSI cases after caesarean section while patients are still hospitalized. Simple yet effective SSI surveillance can be conducted in LMICs to identify and ultimately treat SSI after caesarean section. More support is needed in rural and smaller facilities for better implementation of SSI surveillance in Sierra Leone.Funding: NoneDisclosures: None
Background: Improved infection prevention and control (IPC) reduces healthcare-associated infections (HAIs). Following the Ebola virus disease (EVD) outbreak in West Africa (2014–2016), Sierra Leone made substantial investments in strengthening IPC in health facilities. The WHO identified 8 core components of IPC and developed an accompanying assessment framework (IPCAF) to monitor IPC capacity and progress. The IPCAF reflects the 8 WHO core components of IPC. The core component constitute a consistent universal outline that supports guidance to healthcare decision makers and service providers at national and international levels. We conducted an in-depth assessment of IPC practices in Sierra Leone using the IPCAF tool. Methods: This assessment was conducted in in July 2019 over a 2-week period. Data were collected through interview with IPC focal persons as well as observations and corroboration of document and immediate feedback on findings given to facilities through brief exit meetings. All areas of the facility were assessed (ie, all wards, operation theatres, laboratories maternity units, sterile service departments, waste management units, etc). The main objective was to identify the gaps and challenges faced by health facilities. Each component was scored based on the responses and observations, with the scores ranging from zero to 100 and the maximum score was 800. The IPCAF allocated hospitals to 4 different “IPC levels”: inadequate, basic, intermediate, and advanced. Results: Moreover, 13 hospitals were assessed, including 12 primary level hospitals and 1 secondary level hospital. The median score was 367. 5 (IQR, 110), which corresponds to a basic level of IPC. Primary-level hospitals scored higher (median, 373; IQR, 112.5) compared to secondary-level hospitals (median, 280; IQR, 0). The lowest score was in healthcare-associated infection surveillance (median, 0; IQR, 5), and the highest score was in the built environment, availability of materials, and equipment to support IPC (median, 62.5; IQR, 22.5). Conclusions: The assessment provides a baseline of the status of IPC in Sierra Leone in the post-EVD period using the IPCAF tool. These results can be used to guide healthcare facilities and policy makers in developing strategies for IPC quality improvement projects to improve low-performing healthcare facilities. Significant gaps were observed in key IPC areas, especially in secondary-level health facilities. There is need to establish national surveillance for healthcare-associated infections, to institutionalize monitoring of IPC practices, and to ensure an appropriate staffing–workload ratio in health facilities.Funding: NoneDisclosures:If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the Funding: company. DisagreeAnna MarutaIf I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.DisagreeChristiana Kallon
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