BACKGROUND
The history of conflicts in the Middle East has resulted in a high burden of complications from conflict-related wounds like posttraumatic osteomyelitis (PTO). This is particularly challenging to manage in settings like Mosul, Iraq and Gaza, Palestine, where healthcare systems are weakened. In nonconflict settings, PTO caused by Pseudomonas aeruginosa (PAPTO) can lead to >20% of treatment failures. We aim to describe the clinical characteristics, outcomes, and management, in PAPTO patients admitted to Médecins Sans Frontières (MSF) facilities in Mosul and Gaza between 1 April 2018 and 31 January 2022.
METHODS
We conducted a retrospective cohort study on patients with PAPTO diagnosed with culture of intraoperative bone biopsy, using routinely collected data.
RESULTS
Among 66 PAPTO episodes from 61 enrolled patients, 37.9% had a multidrug-resistant Pseudomonas aeruginosa, with higher antibiotic resistance in Gaza. Polymicrobial infections were prevalent (74.2%), mainly involving Staphylococcus aureus (74.1%), being predominantly methicillin-resistant (95.0%). Overall, 81.7% received appropriate antibiotic treatment, with monotherapy used in 60.6% of episodes and a median treatment duration of 45.5 days. Recurrence was observed in 24.6% of episodes within a median of 195 days (interquartile range, 64-440 days). No significant differences were found in recurrence rates based on the type of antibiotic treatment (mono- or dual therapy) or episode (mono- or polymicrobial).
CONCLUSIONS
Management of PAPTO in the conflict-affected, low-resource settings of Mosul and Gaza achieved a recurrence rate aligned with global reports through appropriate and targeted antibiotic use, primarily in monotherapy, provided over a mean treatment duration of 45.5 days.
OBJECTIVE
The primary objectives of this study were to assess the usefulness of C-reactive protein (CRP) and procalcitonin (PCT) in the diagnosis of bacterial co-infections in coronavirus disease 2019 (COVID-19) and if their incorporation in antimicrobial stewardship (AMS) programs is safe and useful, stratified by severity of disease as level of care, intensive care unit (ICU) or non-ICU. Our secondary objectives were to identify cut-off values for antibiotic decision-making and identify reported results from low- and middle-income countries (LMICs).
DESDIGN
A scoping review of published literature, adhering to the PRISMA statement for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. The last search was performed in January 2024.
RESULTS
Fifty-nine studies were included in this scoping review: 20 studies reporting predictive values and/or sensitivity/specificity results for PCT, 8 reporting clear objectives on AMS, and 3 studies from LMICs.
CONCLUSION
In the context of non-ICU hospitalized COVID-19 patients in high-income countries, a PCT value below 0.25 mg/L can be a useful tool to rule out bacterial co-infection. The wide range of reported negative predictive values suggests that PCT should be interpreted in the context of other clinical findings. Our results do not support the use of CRP in the same manner as PCT. There is a clear need for more studies in LMICs.
BACKGROUND
Drug-resistant TB (DR-TB) remains a major public health threat. In 2022, Uzbekistan reported 2,117 cases of DR-TB, with 69% tested for fluoroquinolone resistance. Limited information is available on the prevalence of resistance to bedaquiline, linezolid, and fluoroquinolone, which are key components of the all-oral treatment regimen for rifampicin-resistant TB in Uzbekistan.
METHODS
A retrospective study was conducted using extensive programmatic data from 2019 to 2023 in Uzbekistan. We assessed second-line drug-resistant TB (SLDR-TB) rates using phenotypic drug susceptibility testing (pDST). Demographic and clinical characteristics associated with SLDR-TB were analysed using multivariable logistic regression models based on the Allen-Cady approach.
RESULTS
In total, 2,405 patients with TB who had undergone pDST were included (median age 40 years, 47% female). The overall SLDR-TB resistance rate was 24% (95% CI 22-26). Prevalence of resistance to bedaquiline, linezolid, moxifloxacin, levofloxacin, and amikacin were respectively 3.1%, 0.8%, 15%, 13%, and 12%. Risk factors for SLDR-TB were resistance to rifampicin and/or isoniazid, exposure to clofazimine, retreatment status, contact with drug-susceptible TB case or DR-TB case, and diabetes.
CONCLUSIONS
The high prevalence of SLDR-TB is of major concern, emphasising the need for baseline pDST in RR-TB treatment. Identified risk factors can aid early detection of at-risk individuals and inform clinical practice.
INTRODUCTION
Both high- and low-income countries reported increased antibiotic consumption among COVID-19 patients during the first months of the pandemic. To date, however, no studies have examined changes in antibiotic consumption during the COVID-19 pandemic within humanitarian emergency contexts.
METHODS
Data was collected by Médecins Sans Frontières (MSF) for the years 2018-2021 across the following humanitarian settings: Afghanistan (Lashkar Gah), Bangladesh (Kutupalong), the Democratic Republic of Congo (Mweso and Baraka), and South Sudan (Bentiu). Inpatient and outpatient antibiotic consumption was calculated as Daily Defined Dose (DDD) per 1000 inhabitants per day, as per the World Health Organisation's (WHO) Collaborating Centre for Drug Statistics Methodology. Interrupted time series (ITS) analysis, using an autoregressive integrated moving average (ARIMA) model was used to analyse retrospective monthly antibiotic consumption. The impact of COVID-19 pandemic was evaluated as total antibiotic consumption and according to WHO Access, Watch, Reserve (AWaRe) group classifications within each humanitarian setting.
RESULTS
The COVID-19 pandemic had no statistically significant impact on total antibiotic consumption in South Sudan (Bentiu) and Bangladesh (Kutupalong). Similarly, the pandemic had no impact on total antibiotic consumption in DR Congo (Baraka), despite an initial 0.27% (estimate=.274, p-value=0.006) increase in March 2020 driven by Access group antibiotics. Meanwhile, total antibiotic consumption in DR Congo (Mweso) and Afghanistan (Lashkar Gah) declined by 0.74% (estimate = -.744, p = 0.003) and 0.26% (estimate = -.26, p < 0.001), respectively with the COVID-19 pandemic.
CONCLUSION
Further studies are required to investigate what may have contributed to these results.
BACKGROUND
Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs.
METHODS
Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days.
RESULTS
Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan.
CONCLUSIONS
This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.
BACKGROUND
Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini.
METHODS
Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo.
RESULTS
Four themes emerged that reflected participants’ experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones.
CONCLUSIONS
vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.
The Médecins Sans Frontières Tertiary Orthopaedic Care center in Mosul, Iraq, provides reconstructive surgery, microbiological analysis, integrated infection prevention and control, and antibiotic stewardship services. Between May 2018 and February 2020, we recorded soft tissue and/or bone infections caused by gram-negative extensively drug-resistant (XDR) bacteria in 4.9% (13/266) of the admitted patients. The XDR bacteria identified among 12 patients in this case series were extended-spectrum β-lactamase–producing Klebsiella pneumoniae (n = 5, 41.7%) with intermediate sensitivity or resistance to imipenem and/or meropenem, Acinetobacter spp (n = 3, 25.0%; 2 Acinetobacter baumannii strains) resistant to imipenem and/or meropenem, Pseudomonas aeruginosa (n = 2, 16.7%) resistant to imipenem and meropenem, and extended-spectrum β-lactamase–producing Proteus mirabilis (n = 2, 16.7%) resistant to meropenem. Most XDR isolates were sensitive only to colistin or polymyxin B, neither of which is available in Iraq. Therefore, the only treatment option was multiple rounds of surgical debridement and wound care. The infection was deemed cured before discharge in 7 patients (58.3%). Meanwhile, 4 patients (33.3%) were discharged with unhealed wounds, and outpatient follow-up was planned. One patient died in the intensive care unit of a referral hospital after developing septicemia postsurgery. XDR bacteria pose substantial health risks in Iraq. Thus, improving antimicrobial stewardship and accessibility to essential antibiotics is critical to address this issue.
Background
Isoniazid (INH, H) resistance is the most common drug-resistant TB pattern, with treatment success rates lower than those in drug-susceptible TB. The WHO recommends a 6-month regimen of rifampicin (RIF, R), ethambutol (EMB, E), pyrazinamide (PZA, Z), and levofloxacin (Lfx) (6REZLfx) for INH-resistant, RIF-susceptible TB (HRRS-TB). Uzbekistan has a high burden of TB (62/100,000 population) and multidrug-resistant TB (12/100,000 population).
Methods
We conducted a retrospective, descriptive study of microbiologically confirmed HRRS-TB using routinely collected programmatic data from 2009 to 2020.
Results
We included 854 HRRS-TB cases. Treatment success was 80.2% overall. For REZLfx, the treatment success rate was 92.0% over a short treatment duration, with no amplifications to RIF or second-line anti-TB drug resistance. We documented 46 regimens with REZLfx plus linezolid (success 87.0%) and 539 regimens using kanamycin or capreomycin (success 76.6%). We identified 37 treatment failures (4.3%), 30 deaths (3.5%), 25 resistance amplifications (2.9%), including eight to RIF (0.9%), and 99 lost to follow-up (LTFU) cases (11.6%). Unsuccessful outcomes were more common with older age, diabetes, chest X-ray cavities, smear positivity, smear-positive persistence, and male sex. LTFU was more common with injection-containing regimens.
Conclusions
REZLfx is a safe and effective first-line treatment for INH-resistant, RIF-susceptible TB. Treatment success was lower and LTFU was higher for injection-containing regimens.