Journal Article > ResearchFull Text
Confl Health. 2024 August 5; Volume 21; 114.; DOI:10.1186/s12978-024-01835-9
Pasquier E, Owolabi OO, Powell B, Fetters T, Ngbale R, et al.
Confl Health. 2024 August 5; Volume 21; 114.; DOI:10.1186/s12978-024-01835-9
BACKGROUND
Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals’ PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.
RESULTS
Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSIONS
Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Journal Article > ResearchFull Text
Bull World Health Organ. 2024 June 1; Volume 102 (Issue 06); 389-399.; DOI:10.2471/BLT.23.291235
Al Kady C, Moussally K, Chreif W, Farra A, Caluwaerts S, et al.
Bull World Health Organ. 2024 June 1; Volume 102 (Issue 06); 389-399.; DOI:10.2471/BLT.23.291235
English
Français
Español
عَرَبِيّ
中文
Русский
OBJECTIVE
To determine whether adding urine culture to urinary tract infection diagnosis in pregnant women from refugee camps in Lebanon reduced unnecessary antibiotic use.
METHODS
We conducted a prospective, cross-sectional study between April and June 2022 involving pregnant women attending a Médecins Sans Frontières sexual reproductive health clinic in south Beirut. Women with two positive urine dipstick tests (i.e. a suspected urinary tract infection) provided urine samples for culture. Bacterial identification and antimicrobial sensitivity testing were conducted following European Committee on Antimicrobial Susceptibility Testing guidelines. We compared the characteristics of women with positive and negative urine culture findings and we calculated the proportion of antibiotics overprescribed or inappropriately used. We also estimated the cost of adding urine culture to the diagnostic algorithm.
FINDINGS
The study included 449 pregnant women with suspected urinary tract infections: 18.0% (81/449) had positive urine culture findings. If antibiotics were administered following urine dipstick results alone, 368 women would have received antibiotics unnecessarily: an overprescription rate of 82% (368/449). If administration was based on urine culture findings plus urinary tract infection symptoms, 144 of 368 women with negative urine culture findings would have received antibiotics unnecessarily: an overprescription rate of 39.1% (144/368). The additional cost of urine culture was 0.48 euros per woman.
CONCLUSION
A high proportion of pregnant women with suspected urinary tract infections from refugee camps unnecessarily received antibiotics. Including urine culture in diagnosis, which is affordable in Lebanon, would greatly reduce antibiotic overprescription. Similar approaches could be adopted in other regions where microbiology laboratories are accessible.
To determine whether adding urine culture to urinary tract infection diagnosis in pregnant women from refugee camps in Lebanon reduced unnecessary antibiotic use.
METHODS
We conducted a prospective, cross-sectional study between April and June 2022 involving pregnant women attending a Médecins Sans Frontières sexual reproductive health clinic in south Beirut. Women with two positive urine dipstick tests (i.e. a suspected urinary tract infection) provided urine samples for culture. Bacterial identification and antimicrobial sensitivity testing were conducted following European Committee on Antimicrobial Susceptibility Testing guidelines. We compared the characteristics of women with positive and negative urine culture findings and we calculated the proportion of antibiotics overprescribed or inappropriately used. We also estimated the cost of adding urine culture to the diagnostic algorithm.
FINDINGS
The study included 449 pregnant women with suspected urinary tract infections: 18.0% (81/449) had positive urine culture findings. If antibiotics were administered following urine dipstick results alone, 368 women would have received antibiotics unnecessarily: an overprescription rate of 82% (368/449). If administration was based on urine culture findings plus urinary tract infection symptoms, 144 of 368 women with negative urine culture findings would have received antibiotics unnecessarily: an overprescription rate of 39.1% (144/368). The additional cost of urine culture was 0.48 euros per woman.
CONCLUSION
A high proportion of pregnant women with suspected urinary tract infections from refugee camps unnecessarily received antibiotics. Including urine culture in diagnosis, which is affordable in Lebanon, would greatly reduce antibiotic overprescription. Similar approaches could be adopted in other regions where microbiology laboratories are accessible.
Journal Article > ResearchFull Text
Glob Health Action. 2024 April 25; Volume 17 (Issue 1); 2336708.; DOI:10.1080/16549716.2024.2336708
Reinholdz H, Agardh A, Verputten M, Byenda J, Frielingsdorf H
Glob Health Action. 2024 April 25; Volume 17 (Issue 1); 2336708.; DOI:10.1080/16549716.2024.2336708
BACKGROUND
Sexual violence is widespread in war-torn North Kivu province in the Democratic Republic of the Congo (DRC). Timely access to care is crucial for the healing and wellbeing of survivors of sexual violence, but is problematic due to a variety of barriers. Through a better understanding of care-seeking behaviours and factors influencing timely access to care, programmes can be adapted to overcome some of the barriers faced by survivors of sexual violence.
OBJECTIVE
The aim of this study was to describe demographics, care-seeking patterns and factors influencing timely care-seeking by survivors of sexual violence.
METHODS
Retrospective file-based data analysis of sexual violence survivors accessing care within two Médecins Sans Frontières (MSF) programmes supporting the Ministry of Health, in North Kivu, DRC, 2014-2018.
RESULTS
Most survivors (66%) sought care at specialised sexual violence clinics and a majority of the survivors were self-referred (51%). Most survivors seeking care (70%) did so within 3 days. Male survivors accessing care were significantly more likely to seek care within 3 days compared to females. All age groups under 50 years old were more likely to seek care within 3 days compared to those aged 50 years and older. Being referred by the community, a family member, mobile clinic or authorities was significantly associated with less probability of seeking care within 3 days compared to being self-referred.
CONCLUSION
Access to timely health care for survivors of sexual violence in North Kivu, DRC, is challenging and varies between different groups of survivors. Providers responding to survivors of sexual violence need to adapt models of care and awareness raising strategies to ensure that programmes are developed to enable timely access to care for all survivors. More research is needed to further understand the barriers and enablers to access timely care for different groups of survivors.
Sexual violence is widespread in war-torn North Kivu province in the Democratic Republic of the Congo (DRC). Timely access to care is crucial for the healing and wellbeing of survivors of sexual violence, but is problematic due to a variety of barriers. Through a better understanding of care-seeking behaviours and factors influencing timely access to care, programmes can be adapted to overcome some of the barriers faced by survivors of sexual violence.
OBJECTIVE
The aim of this study was to describe demographics, care-seeking patterns and factors influencing timely care-seeking by survivors of sexual violence.
METHODS
Retrospective file-based data analysis of sexual violence survivors accessing care within two Médecins Sans Frontières (MSF) programmes supporting the Ministry of Health, in North Kivu, DRC, 2014-2018.
RESULTS
Most survivors (66%) sought care at specialised sexual violence clinics and a majority of the survivors were self-referred (51%). Most survivors seeking care (70%) did so within 3 days. Male survivors accessing care were significantly more likely to seek care within 3 days compared to females. All age groups under 50 years old were more likely to seek care within 3 days compared to those aged 50 years and older. Being referred by the community, a family member, mobile clinic or authorities was significantly associated with less probability of seeking care within 3 days compared to being self-referred.
CONCLUSION
Access to timely health care for survivors of sexual violence in North Kivu, DRC, is challenging and varies between different groups of survivors. Providers responding to survivors of sexual violence need to adapt models of care and awareness raising strategies to ensure that programmes are developed to enable timely access to care for all survivors. More research is needed to further understand the barriers and enablers to access timely care for different groups of survivors.
Journal Article > ResearchFull Text
Public Health Action. 2024 March 1; Volume 14 (Issue 1); 14-19.; DOI:10.5588/pha.23.0022
Tsorou C, Williams A, van den Boogaard W, Staderini N, Repetto E, et al.
Public Health Action. 2024 March 1; Volume 14 (Issue 1); 14-19.; DOI:10.5588/pha.23.0022
SETTING
Sexually transmitted infections (STIs) can impact individuals of any demographic. The most common pathogens causing STIs are Chlamydia trachomatis, Neisseria gonorrhea and Trichomonas vaginalis; these can be treated with specific antibiotics.
OBJECTIVE
To compare the GeneXpert CT/NG test-and-treat algorithm to the syndromic approach algorithm and their impact on antibiotic prescription for gonorrhoea and chlamydia STIs.
DESIGN
A retrospective observational study on women aged ≥18 years who accessed the Médecins Sans Frontières Day Care Centre in Athens with complaints related to urogenital infections between January 2021 and March 2022. Women with abnormal vaginal discharge, excluding clinically diagnosed candidiasis, were eligible for Xpert CT/NG testing.
RESULTS
Of the 450 women who accessed care, 84 were eligible for Xpert CT/NG testing, and only one was positive for chlamydia, therefore resulting in saving 81 doses of ceftriaxone and azithromycin, and 19 doses of metronidazole. The cost of Xpert CT/NG testing, including treatment was €4,606.37, while full antibiotic treatment would have costed €536.76.
CONCLUSION
The overall cost of the Xpert CT/NG test-and-treat algorithm was higher than the syndromic approach. However, quality of care should be weighed against the potential benefits of testing and syndromic treatment to determine the best option for each patient; we therefore advocate for decreasing the costs.
Sexually transmitted infections (STIs) can impact individuals of any demographic. The most common pathogens causing STIs are Chlamydia trachomatis, Neisseria gonorrhea and Trichomonas vaginalis; these can be treated with specific antibiotics.
OBJECTIVE
To compare the GeneXpert CT/NG test-and-treat algorithm to the syndromic approach algorithm and their impact on antibiotic prescription for gonorrhoea and chlamydia STIs.
DESIGN
A retrospective observational study on women aged ≥18 years who accessed the Médecins Sans Frontières Day Care Centre in Athens with complaints related to urogenital infections between January 2021 and March 2022. Women with abnormal vaginal discharge, excluding clinically diagnosed candidiasis, were eligible for Xpert CT/NG testing.
RESULTS
Of the 450 women who accessed care, 84 were eligible for Xpert CT/NG testing, and only one was positive for chlamydia, therefore resulting in saving 81 doses of ceftriaxone and azithromycin, and 19 doses of metronidazole. The cost of Xpert CT/NG testing, including treatment was €4,606.37, while full antibiotic treatment would have costed €536.76.
CONCLUSION
The overall cost of the Xpert CT/NG test-and-treat algorithm was higher than the syndromic approach. However, quality of care should be weighed against the potential benefits of testing and syndromic treatment to determine the best option for each patient; we therefore advocate for decreasing the costs.
Technical Report > Evidence Brief
MSF (Médecins Sans Frontières)
2023 October 24
Between 2018 and 2022, teams from Médecins Sans Frontières (MSF) in the Central African Republic (CAR) took care of over 19,500 survivors of sexual violence across the country.
During the same period, the United Nations sexual and reproductive health agency (UNFPA) documented 14,907 other cases of sexual violence in CAR reported by other humanitarian organisations working in the country, or by state structures.
This report outlines the public health emergency that sexual violence has become in CAR, with recommendations to address the crisis.
Tongolo (“star” in local language Sango), a holistic project opened by MSF at the end of 2017 in the capital, Bangui, accounted for 66% of the cases seen by MSF. The project provides medical treatment and mental health support, as well as guidance to pursue legal action and obtain protection, such as emergency shelter or socio-economic support.
MSF teams also took care of patients for sexual violence at a dozen other locations, in nearly every corner of the Central African Republic. Numerous gaps were noted at different levels in terms of assistance for the survivors as well as huge challenges for them to access care.
During the same period, the United Nations sexual and reproductive health agency (UNFPA) documented 14,907 other cases of sexual violence in CAR reported by other humanitarian organisations working in the country, or by state structures.
This report outlines the public health emergency that sexual violence has become in CAR, with recommendations to address the crisis.
Tongolo (“star” in local language Sango), a holistic project opened by MSF at the end of 2017 in the capital, Bangui, accounted for 66% of the cases seen by MSF. The project provides medical treatment and mental health support, as well as guidance to pursue legal action and obtain protection, such as emergency shelter or socio-economic support.
MSF teams also took care of patients for sexual violence at a dozen other locations, in nearly every corner of the Central African Republic. Numerous gaps were noted at different levels in terms of assistance for the survivors as well as huge challenges for them to access care.
Journal Article > ResearchFull Text
Res Sq. 2023 July 17; DOI:10.21203/rs.3.rs-3153198/v1
Pasquier E, Owolabi OO, Powell B, Fetters T, Ngbale RN, et al.
Res Sq. 2023 July 17; DOI:10.21203/rs.3.rs-3153198/v1
BACKGROUND
Abortion-related complications remain a main cause of maternal mortality. Post-abortion care (PAC) provision in humanitarian settings suffers from limited accessibility, poor quality, and lack of research on how to address these challenges. We proposed a comprehensive conceptual framework for measuring the quality of PAC and applied it using data from the AMoCo (Abortion-related Morbidity and mortality in fragile or Conflict-affected settings) study in two hospitals supported by Médecins Sans Frontières (MSF) in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We adapted the WHO Maternal and Newborn Health quality-of-care framework to measure PAC inputs, process (provision and experience of care) and outcomes. We analyzed data from 4 study components: an assessment of the two hospitals’ PAC signal functions, a survey of the knowledge, attitudes, practices, and behavior of 140 and 84 clinicians providing PAC, a prospective review of the medical records of 520 and 548 women presenting for abortion complications, of whom 360 and 362 hospitalized women participated in an interview survey in the Nigerian and CAR hospitals, respectively.
RESULTS
Inputs – Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26.5 in the CAR hospital.
Provision of care – In both hospitals, less than 2.5% were treated with dilatation and sharp curettage, a non-recommended technology when receiving instrumental uterine evacuation. Over 80% received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients without indication. All (99%) of discharged women in CAR received contraceptive counselling but only 39% in Nigeria.
Experience of care – Women reported generally good experience of respect and preservation of dignity. But only 49% in Nigeria and 59% in CAR said they were given explanations about their care and 15% felt capable of asking questions during treatment in both hospitals.
Outcomes – The risk of healthcare-related abortion-near-miss (happening =24h after presentation) was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSION
Our proposed framework enabled comprehensive measurement of the quality of PAC in two MSF-supported hospitals in humanitarian settings. Its application identified that hospitals provided good clinical care resulting in a low risk of healthcare-related abortion-near-miss. However, hospitals need to improve provider-patient communication and would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Abortion-related complications remain a main cause of maternal mortality. Post-abortion care (PAC) provision in humanitarian settings suffers from limited accessibility, poor quality, and lack of research on how to address these challenges. We proposed a comprehensive conceptual framework for measuring the quality of PAC and applied it using data from the AMoCo (Abortion-related Morbidity and mortality in fragile or Conflict-affected settings) study in two hospitals supported by Médecins Sans Frontières (MSF) in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS
We adapted the WHO Maternal and Newborn Health quality-of-care framework to measure PAC inputs, process (provision and experience of care) and outcomes. We analyzed data from 4 study components: an assessment of the two hospitals’ PAC signal functions, a survey of the knowledge, attitudes, practices, and behavior of 140 and 84 clinicians providing PAC, a prospective review of the medical records of 520 and 548 women presenting for abortion complications, of whom 360 and 362 hospitalized women participated in an interview survey in the Nigerian and CAR hospitals, respectively.
RESULTS
Inputs – Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26.5 in the CAR hospital.
Provision of care – In both hospitals, less than 2.5% were treated with dilatation and sharp curettage, a non-recommended technology when receiving instrumental uterine evacuation. Over 80% received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients without indication. All (99%) of discharged women in CAR received contraceptive counselling but only 39% in Nigeria.
Experience of care – Women reported generally good experience of respect and preservation of dignity. But only 49% in Nigeria and 59% in CAR said they were given explanations about their care and 15% felt capable of asking questions during treatment in both hospitals.
Outcomes – The risk of healthcare-related abortion-near-miss (happening =24h after presentation) was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSION
Our proposed framework enabled comprehensive measurement of the quality of PAC in two MSF-supported hospitals in humanitarian settings. Its application identified that hospitals provided good clinical care resulting in a low risk of healthcare-related abortion-near-miss. However, hospitals need to improve provider-patient communication and would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
Journal Article > ResearchFull Text
IJID Reg. 2023 July 13; Volume 8; 111-117.; DOI:10.1016/j.ijregi.2023.07.004
Mhlanga L, Welte A, Grebe E, Ohler L, Van Cutsem G, et al.
IJID Reg. 2023 July 13; Volume 8; 111-117.; DOI:10.1016/j.ijregi.2023.07.004
OBJECTIVE
We estimated changes in the HIV incidence from 2013 to 2018 in Eshowe/Mbongolwane, KwaZulu Natal, South Africa where Médecins Sans Frontières is engaged in providing HIV testing and care since 2011.
METHODS
Using data from two cross-sectional household-based surveys conducted in 2013 and 2018, with consenting participants aged 15-59 years, we applied the incidence estimation frameworks of Mahiane et al and Kassanjee et al.
RESULTS
In total 5599 (62.4% women) and 3276 (65.9% women) individuals were included in 2013 and 2018 respectively. We found a mean incidence in women 20-29 years of 2.71 cases per 100 person-years (95% CI: 1.23; 4.19) in 2013 and 0.4 cases per 100 person-years (95% CI: 0.0; 1.5) in 2018. The incidence in men 20-29 years was 1.91 cases per 100 person years (95% CI: 0.87; 2.93) in 2013 and 0.53 cases per 100 person-years (95% CI: 0.0; 1.4) s in 2018. The incidence decline among women aged 15-19 was -0.34 cases per 100 person-years (95% CI: -1.31;0.64).
CONCLUSIONS
The lack of evidence of incidence decline among adolescent girls is noteworthy and disconcerting our findings suggest that large scale surveys should seriously consider focusing their resources on the core group of women aged 15-19.
We estimated changes in the HIV incidence from 2013 to 2018 in Eshowe/Mbongolwane, KwaZulu Natal, South Africa where Médecins Sans Frontières is engaged in providing HIV testing and care since 2011.
METHODS
Using data from two cross-sectional household-based surveys conducted in 2013 and 2018, with consenting participants aged 15-59 years, we applied the incidence estimation frameworks of Mahiane et al and Kassanjee et al.
RESULTS
In total 5599 (62.4% women) and 3276 (65.9% women) individuals were included in 2013 and 2018 respectively. We found a mean incidence in women 20-29 years of 2.71 cases per 100 person-years (95% CI: 1.23; 4.19) in 2013 and 0.4 cases per 100 person-years (95% CI: 0.0; 1.5) in 2018. The incidence in men 20-29 years was 1.91 cases per 100 person years (95% CI: 0.87; 2.93) in 2013 and 0.53 cases per 100 person-years (95% CI: 0.0; 1.4) s in 2018. The incidence decline among women aged 15-19 was -0.34 cases per 100 person-years (95% CI: -1.31;0.64).
CONCLUSIONS
The lack of evidence of incidence decline among adolescent girls is noteworthy and disconcerting our findings suggest that large scale surveys should seriously consider focusing their resources on the core group of women aged 15-19.
Conference Material > Video
Mukooza E
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/bg0s-y318
Conference Material > Video
Al Kady C
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/6cdv-9f90
Conference Material > Abstract
Al Kady C, Moussally K, Caluwaerts S, Chreif W, Dibiasi J, et al.
MSF Scientific Day International 2023. 2023 June 7; DOI:10.57740/73jr-dg45
INTRODUCTION
Inappropriate use of antibiotics is widespread, and one of the main drivers for antimicrobial resistance (AMR). In pregnant women with suspected urinary tract infection (UTI), studies have suggested antibiotic over-use in up to 96%; use may be particularly high in settings with limited diagnostic resources and where reliant on symptomatic approaches. In south Beirut, specifically within camps where refugees settle and living conditions are poor, MSF has been operational since 2014 as the main provider of free primary healthcare services as well as sexual and reproductive health (SRH) care. Current MSF protocols operational in this setting recommend the use of urine dipsticks for UTI screening in pregnant women, followed by empirical antibiotic treatment for those with a positive result (positive for nitrites and/or leucocytes).
METHODS
In 2021, around 6,300 (24%) of the total 26,300 antenatal care (ANC) consultations conducted had a suspected UTI, based on urine dipstick results, and all those suspected with UTI were prescribed antibiotics. A prospective study was conducted between April and July 2022, to determine if adding urine
culture, following positive urine dipstick, to the protocol would reduce the use of unnecessary antibiotics. We used descriptive statistics to describe the population and compare positive and negative urine cultures. We calculated the proportion of patients receiving appropriate or inappropriate antibiotics.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the ethics committee of the Lebanese American University.
RESULTS
A total of 449 pregnant women with suspected UTI were included in this study; all received urine culture. 81 (18%) were culture-positive. Under usual practice, 368 women (82%) would have been overprescribed antibiotics, based solely on urine dipstick results. 197 (44%) of the cohort were symptomatic, and were given empirical antibiotic treatment, with cefixime administered to 42 (21%) women and fosfomycin to 155 (79%). Escherichia coli (79%) was the most common bacterial species isolated, followed by Proteus (11%). In addition, among the 81 positive cultures, 4 (5%) were found resistant to fosfomycin and 39 (48%) to cefixim
CONCLUSION
These study findings reinforce concern around potential over prescription of unnecessary antibiotics in such populations, which could contribute to a potential rise in AMR. In addition, resistance to cefixime, one of the recommended antibiotics to treat UTI’s, is relatively high in this community. In contexts where urine culture is feasible, not costly, accessible, and results rapidly available, particularly with large cohorts of patients, urine culture should be the main method used to diagnose UTI; treatment should be based on microbiology/antibiotic sensitivity results.
CONFLICTS OF INTEREST
None declared.
Inappropriate use of antibiotics is widespread, and one of the main drivers for antimicrobial resistance (AMR). In pregnant women with suspected urinary tract infection (UTI), studies have suggested antibiotic over-use in up to 96%; use may be particularly high in settings with limited diagnostic resources and where reliant on symptomatic approaches. In south Beirut, specifically within camps where refugees settle and living conditions are poor, MSF has been operational since 2014 as the main provider of free primary healthcare services as well as sexual and reproductive health (SRH) care. Current MSF protocols operational in this setting recommend the use of urine dipsticks for UTI screening in pregnant women, followed by empirical antibiotic treatment for those with a positive result (positive for nitrites and/or leucocytes).
METHODS
In 2021, around 6,300 (24%) of the total 26,300 antenatal care (ANC) consultations conducted had a suspected UTI, based on urine dipstick results, and all those suspected with UTI were prescribed antibiotics. A prospective study was conducted between April and July 2022, to determine if adding urine
culture, following positive urine dipstick, to the protocol would reduce the use of unnecessary antibiotics. We used descriptive statistics to describe the population and compare positive and negative urine cultures. We calculated the proportion of patients receiving appropriate or inappropriate antibiotics.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the ethics committee of the Lebanese American University.
RESULTS
A total of 449 pregnant women with suspected UTI were included in this study; all received urine culture. 81 (18%) were culture-positive. Under usual practice, 368 women (82%) would have been overprescribed antibiotics, based solely on urine dipstick results. 197 (44%) of the cohort were symptomatic, and were given empirical antibiotic treatment, with cefixime administered to 42 (21%) women and fosfomycin to 155 (79%). Escherichia coli (79%) was the most common bacterial species isolated, followed by Proteus (11%). In addition, among the 81 positive cultures, 4 (5%) were found resistant to fosfomycin and 39 (48%) to cefixim
CONCLUSION
These study findings reinforce concern around potential over prescription of unnecessary antibiotics in such populations, which could contribute to a potential rise in AMR. In addition, resistance to cefixime, one of the recommended antibiotics to treat UTI’s, is relatively high in this community. In contexts where urine culture is feasible, not costly, accessible, and results rapidly available, particularly with large cohorts of patients, urine culture should be the main method used to diagnose UTI; treatment should be based on microbiology/antibiotic sensitivity results.
CONFLICTS OF INTEREST
None declared.