Importance
Surgical site infection (SSI) complicates 2-5% of surgeries in the United States. Severity of SSI ranges from superficial skin infection to life-threatening conditions such as severe sepsis, and SSIs are responsible for increased morbidity, mortality, and economic burden associated with surgery. Staphylococcus aureus (S. aureus) is a commonly-isolated organism for SSI, and methicillin-resistant S. aureus SSI incidence is increasing globally.

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A systematic review of risk factors associated with surgical site infections among surgical patients.

A review of the published and unpublished literature on bacterial resistance in human and animals was performed. Sixty-eight articles/reports from the Democratic Republic of Congo (DRC), Mozambique, Tanzania and Zambia were reviewed. The majority of these articles were from Tanzania. There is an increasing trend in the incidence of antibiotic resistance; of major concern is the increase in multidrug- resistant Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Vibrio cholera, non-typhoid Salmonella and other pathogens responsible for nosocomial infections. The increase in methicillin- resistant Staphylococcus aureus and extended-spectrum beta-lactamase (ESBL) producers in the countries under review confirms the spread of these clones worldwide. Clinical microbiology services in these countries need to be strengthened in order to allow a coordinated surveillance for antimicrobial resistance and provide data for local treatment guidelines and for national policies to control antimicrobial resistance. While the present study does not provide conclusive evidence to associate the increasing trend in antibiotic resistance in humans with the use of antibiotics in animals, either as feed additives or veterinary prescription, we strongly recommend a one-health approach of systematic surveillance across the public and animal health sectors, as well as the adherence to the FAO (Food and Agriculture Organization)-OIE (World Organization of animal Health) –WHO(World Health Organization) recommendations for non-human antimicrobial usage.

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Antimicrobial resistance in human and animal pathogens in Zambia, Democratic Republic of Congo, Mozambique and Tanzania: an urgent need of a sustainable surveillance system

Background: Klebsiella pneumoniae strains expressing ESBLs are a predominant cause of hospital acquired infections. Here we describe the molecular epidemiology of these isolates in a tertiary hospital in Tanzania, as potential pathogens for neonatal infections. Methods: Between April 2009 and March 2010 all Klebsiella pneumoniae isolates with phenotypic expression Extended Spectrum Beta Lactamase (ESBL) were collected and characterized. Identification was done using in house biochemical tests in case of ambiguous results confirmation was done using API 20E. Susceptibility testing was determined using the disc diffusion method followed by specific PCR and sequencing to determine ESBL genes. Phylogenetic analysis, Pulse field gel electrophoresis (PFGE) and Multi-Locus sequence typing (MLST) to PFGE clusters representative isolates were performed to determine clones of the isolates. Conjugation and hybridization were performed to determine the location of blaCTX-M-15 gene. Results: A total of 92 non- repetitive ESBL producing K. pneumoniae representing 50.3% of Klebsiella pneumoniae isolates were characterized. These isolates were from blood 61 (66%), wound swab 13 (14%), urine 12 (13%) and pus 6 (7%) were analyzed. Most blood culture strains originated from neonatal unit 39/61(64%) and 22 (36%) of the blood culture isolates were from neonatal ICU. All isolates were resistant to gentamicin and 54% were resistant to ciprofloxacin. Using a similarity index of 80%, the isolates were assigned to thirteen clusters based on PFGE patterns and contained sub-clusters with identical strains indicating clonal outbreaks. Cluster X5, X7 and X8, and X9 were grouped into ST48, ST14 and ST348 respectively. Based on gyrA PCR- RFLP phylogenetic analysis all isolates were grouped as KpI. The predominant ESBL allele detected was blaCTX-M-15 which was found in 76% of isolates, followed by blaTEM-104 (19%), blaSHV-11 (3.2%) and blaTEM-176 (2%). The blaCTX-M-15 gene was located in multiple conjugative IncF plasmids ranging from 25 kb-485 kb in size. Conclusion: The high prevalence of blaCTX-M-15 observed among ESBL producing K. pneumoniae in Tanzania, is possibly due to the spread of a common IncFII 145 kb plasmid and of certain clones such as ST14 and ST48. Furthermore the 485 kb plasmid detected is the largest plasmid reported to carry blaCTX-M-15 todate.

http://geb.uni-giessen.de/geb/volltexte/2013/10418/pdf/1471_2334_13_466.pdf

Predominance of Klebsiella pneumoniae ST14 carrying CTX-M-15 causing neonatal sepsis in Tanzania

Background: Surgical site infection (SSI) is the second most common infectious complication after urinary tract infection following a delivery by caesarean section (CS). At Bugando Medical Centre there has no study documenting the epidemiology of SSI after CS despite the large number of CSs performed and the relatively common occurrence of SSIs. Methods: This was a prospective cohort study involving pregnant women who underwent a CS between October 2011 and February 2012 at Bugando Medical Centre. A total of 345 pregnant women were enrolled. Preoperative, intraoperative and postoperative data were collected using a standardized questionnaire. Wound specimens were collected and processed as per standard operative procedures; and susceptibility testing was carried out using a disc diffusion technique. Data was analyzed using STATA version 11. Results: The overall cumulative incidence of SSI was 10.9% with an incidence rate of 37.5 per 10,000 people/day (95% CI, 26.8-52.4). The median time from CS to the development of SSI was 7 days (interquartile range [IQR] = 6–9 days). Six independent risk factors for post caesarean SSI as identified in this study by multivariate analysis are: hypertensive disorders of pregnancy (HR: 2.5; 95% CI, 1.1-5.6; P= 0.021), severe anaemia (HR: 3.8; 95% CI, 1.2-12.4, P= 0.028), surgical wound class III (HR: 2.4; 95% CI, 1.1-5.0; P= 0.021), multiple vaginal examinations (HR: 2.5; 95% CI, 1.2-5.1; P= 0.011), prolonged duration of operation (HR: 2.6; 95% CI, 1.2-5.5; P= 0.015) and an operation performed by an intern or junior doctor (HR: 4.0; 95% CI, 1.7-9.2; P= 0.001). Staphylococcus aureus was the most common organism (27.3%), followed by Klebsiella pneumoniae (22.7%). Patients with a SSI had a longer average hospital stay than those without a SSI (12.7 ± 6.9 vs. 4 ± 1.7; P < 0.0001) and the case fatality rate among patients with a SSI was 2.9%. Conclusion: SSIs are common among women undergoing CSs at Bugando Medical Centre. SSIs were commonly associated with multiple factors. Strategies to control these factors are urgently needed to control SSIs post CS at Bugando Medical Centre and other centres in developing countries.

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Incidence and predictors of surgical site infections following caesarean sections at Bugando Medical Centre, Mwanza, Tanzania.

Surgical site infections (SSIs) are difficult to treat and are associated with substantially longer hospital stay, higher treatment cost, morbidity and mortality, particularly when the etiological agent is multidrug-resistant (MDR). To address the limited data in Uganda on SSIs, we present the spectrum of bacteria isolated from hospitalized patients, the magnitude and impact of MDR bacterial isolates among patients with SSIs. A descriptive cross sectional study was conducted from September 2011 through April 2012 involving 314 patients with SSIs in the obstetrics & gynecology, general surgery and orthopedic wards at Mulago National Hospital in Kampala, Uganda. Wound swabs were taken and processed using standard microbiological methods. Clinico-demographic characteristics of patients were obtained using structured questionnaires and patients’ files. Of the 314 enrolled patients with SSIs (mean age 29.7 ±13.14 years), 239 (76.1%) were female. More than half of the patients were from obstetrics and gynecology (62.1%, 195/314). Of 314 wound swabs taken, 68.8% (216/314) were culture positive aerobically, yielding 304 bacterial isolates; of which 23.7% (72/304) were Escherichia coli and 21.1% (64/304) were Staphylococcus aureus. More than three quarters of Enterobacteriaceae were found to be extended spectrum beta lactamase (ESBL) producers and 37.5% of S. aureus were Methicillin resistant S. aureus (MRSA). MDR occurred in 78.3% (238/304) of the isolates; these were more among Gram-negative bacteria (78.6%, 187/238) compared to Gram-positive bacteria (21.4%, 51/238), (p-value < 0.0001, χ2 = 49.219). Amikacin and imepenem for ESBL-producing Enterobacteriacea and vancomycin for MRSA showed excellent performance except that they remain expensive drugs in Uganda. Most SSIs at Mulago National Hospital are due to MDR bacteria. Isolation of MRSA and ESBL-producing Enterobacteriaceae in higher proportions than previously reported calls for laboratory guided SSIs- therapy and strengthening of infection control surveillance in this setting.

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Antimicrobial resistance in hospitalized surgical patients: a silently emerging public health concern in Uganda

Background
Surgical site infection (SSI) continues to be a major source of morbidity and mortality in developing countries despite recent advances in aseptic techniques. There is no baseline information regarding SSI in our setting therefore it was necessary to conduct this study to establish the prevalence, pattern and predictors of surgical site infection at Bugando Medical Centre Mwanza (BMC), Tanzania.

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Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania

Background: Vascular endothelial growth factor VEGF families have been implicated in prognosis and clinicopathological outcomes in patients with gastric cancer. This review aims to assess the relationship of clinicopathological and prognostic outcomes of patients with gastric cancer, present with overexpression of VEGF families in gastric cancer tissues. Methods: Full-published studies regarding clinicopathological and prognostic outcomes of patients with gastric cancer present with overexpression VEGF families sought through PubMed, MEDLINE, EMBASE and HINARI. The exclusion criteria for the reviewed literature were as follows. (1) The studies involved neoadjuvant or preoperative chemotherapy, chemoradiotherapy and target therapy. (2) Non-English articles. (3) The patients had multiple tumors. (4) The data sample was not reliable (5). The studies analyze the expression of VEGF in blood serum. STATA SE v. 13.1 (STATA_ Corporation, Texas, USA) has been used to analyze data. Statistical significant p-value was taken to be P<0.05 and two sided alpha of 5% implemented to determine confidence intervals and p-values. The outcomes of interest were clinicopathological and prognostic outcomes. Results: In this review, 96 studies identified and left twelve eligible literatures to assess the clinicopathological and prognostic outcomes of VEGF expression in patients with gastric cancer. VEGF-A expression was found to be significantly associated with the size of the tumor (P=0.028), increase the risk of positive lymph nodes (P=0.002) and lymphovascular invasion (P=0.001). Also, it was found to be associated with poor prognosis for overall survival and disease-free survival in patients with gastric cancer. Studies have shown patients with high expression of VEGF-C protein had significantly poorer prognoses than a group with low VEGF-C expression. Also, expression of VEGF-C was evaluated, and it showed a substantial relation to TNM staging, vascular, and lymphatic invasion (P<0.01). The expression of VEGF-D in gastric cancer tissue correlated significantly with the size of the tumor, invasion to lymphatic and venous tissues and distant metastasis, all these contribute to the TNM stage, and it is useful in the evaluation of prognosis of gastric cancer patients regarding progression-free survival and overall survival. Conclusion: This systematic review demonstrated that VEGF protein, especially VEGF-A, C and D overexpression in gastric cancer, all associated with poor prognosis and clinicopathological outcomes. We recommend that VEGF be a prognostic and predictive marker, and measured in all resected gastric cancer tissues to predict prognosis and clinicopathological outcomes of patients with gastric cancer.

Brian Mawalla

Papers

Predictors of surgical site infections among patients undergoing major surgery at Bugando Medical Centre in Northwestern Tanzania

Clinicopathological and Prognostic Outcomes of VEGF Expression in Resected Gastric Cancer Tissues. A Systematic Review