Point-of-care and point-of-‘can’: leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics

Semret, Makeda; Ndao, Momar; Jacobs, Jan; Yansouni, Cédric P.

doi:10.1016/j.cmi.2018.03.044

Cited by 21 publications

(13 citation statements)

References 74 publications

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“…Implementing systematic microbiological testing and focusing educational efforts on appropriate use of diagnostic tests for infections constitutes a major paradigm shift for LMICs, but certainly deserves to be a core objective in stewardship efforts in these settings. Recent developments such as WHO’s Essential Diagnostics List (to complement the long-standing Essential Medicines list) [34], and a growing literature on building bacteriology capacity in LRS are encouraging steps in that direction [32, 35, 36].…”

Section: Discussionmentioning

confidence: 99%

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

et al. 2018

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BackgroundGlobal action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia.MethodsTikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ2 and fisher exact tests. Qualitative data was analyzed thematically.FindingsA total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia.ConclusionsThis knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.

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Section: Discussionmentioning

confidence: 99%

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

et al. 2018

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“…Adequate microbiology capacity is vital not only for the identification and targeted treatment of individual patients’ infection but also to inform local empiric therapeutic choices and pharmaceutical purchasing. One strategy to expand access to high-quality diagnostics is the development of regional reference laboratory networks [ 78 , 79 ]. Additionally, as rapid diagnostic testing becomes more available and affordable, this may play a more important role in the initial management of sepsis.…”

Section: Practical Steps To Reduce the Global Burden Of Sepsismentioning

confidence: 99%

The global burden of sepsis: barriers and potential solutions

et al. 2018

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Sepsis is a major contributor to the global burden of disease. The majority of sepsis cases and deaths are estimated to occur in low and middle-income countries. Barriers to reducing the global burden of sepsis include difficulty quantifying attributable morbidity and mortality, low awareness, poverty and health inequity, and under-resourced and low-resilience public health and acute health care delivery systems. Important differences in the populations at risk, infecting pathogens, and clinical capacity to manage sepsis in high and low-resource settings necessitate context-specific approaches to this significant problem. We review these challenges and propose strategies to overcome them. These strategies include strengthening health systems, accurately identifying and quantifying sepsis cases, conducting inclusive research, establishing data-driven and context-specific management guidelines, promoting creative clinical interventions, and advocacy.

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“…This practice is not advised, because the origin and quality of the culture media are difficult to track down and useful additives, such as the ones described in Table 3, will not be present in the broth, compromising performance. An alternative to the commercially available bottles is to support local production of blood culture media by reference laboratories, from where they can be dispersed to smaller hospitals (2, 285). An exemplary initiative is the laboratory logistic and educational support provided by the Diagnostic Microbiology Development Program in Cambodia (1) 5 .…”

Section: Challengesmentioning

confidence: 99%

Best Practices of Blood Cultures in Low- and Middle-Income Countries

et al. 2019

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Bloodstream infections (BSI) have a substantial impact on morbidity and mortality worldwide. Despite scarcity of data from many low- and middle-income countries (LMICs), there is increasing awareness of the importance of BSI in these countries. For example, it is estimated that the global mortality of non-typhoidal Salmonella bloodstream infection in children under 5 already exceeds that of malaria. Reliable and accurate diagnosis of these infections is therefore of utmost importance. Blood cultures are the reference method for diagnosis of BSI. LMICs face many challenges when implementing blood cultures, due to financial, logistical, and infrastructure-related constraints. This review aims to provide an overview of the state-of-the-art of sampling and processing of blood cultures, with emphasis on its use in LMICs. Laboratory processing of blood cultures is relatively straightforward and can be done without the need for expensive and complicated equipment. Automates for incubation and growth monitoring have become the standard in high-income countries (HICs), but they are still too expensive and not sufficiently robust for imminent implementation in most LMICs. Therefore, this review focuses on “manual” methods of blood culture, not involving automated equipment. In manual blood cultures, a bottle consisting of a broth medium supporting bacterial growth is incubated in a normal incubator and inspected daily for signs of growth. The collection of blood for blood culture is a crucial step in the process, as the sensitivity of blood cultures depends on the volume sampled; furthermore, contamination of the blood culture (accidental inoculation of environmental and skin bacteria) can be avoided by appropriate antisepsis. In this review, we give recommendations regarding appropriate blood culture sampling and processing in LMICs. We present feasible methods to detect and speed up growth and discuss some challenges in implementing blood cultures in LMICs, such as the biosafety aspects, supply chain and waste management.

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Point-of-care and point-of-‘can’: leveraging reference-laboratory capacity for integrated diagnosis of fever syndromes in the tropics

Abstract: Recent advances offer the present-day possibility of innovations to re-invent the relationship between distant reference laboratories and end-users for integrated diagnosis of NMFIs.

Cited by 21 publications

References 74 publications

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

The global burden of sepsis: barriers and potential solutions

Best Practices of Blood Cultures in Low- and Middle-Income Countries

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