Transitioning to Automated Microbiologic Era: Blood Culture Isolates in Children and Adults in Federal Teaching Hospital in Gombe, North East Nigeria 2016-2020

Introduction: Automated blood culture systems for incubation and growth monitoring have become the standard in high-income countries (HICs), but are still relatively expensive and not universally available for implementation in most low- and middle-income countries (LMIC). We aimed to report blood culture isolates using Automated technique in children and adults admitted into the Federal Teaching Hospital Gombe from 2016 to 2020. Materials and Methods: Blood Culture Isolates in children (0 - 18 years) and adults (>19 yrs) by Bactec 9050 Automated culture system from 2016-2020 were retrieved from the medical and laboratory register. Information analyzed included, age, sex, month, and year and culture growth and reported antibiotic sensitivity. A Bactec Blood culture tests is $20 in this facility. In Nigeria, the minimum monthly wage is $70 (Official currency exchange rate is N423/US Dollar). Results: Of the 1713 blood cultures performed, children 0 - 18 years were 1322 (77.2%) and adult (19 years above) (22.8%). Overall positivity was 733 (42.2%) with males 385 (52.5%). Of the 1322 Blood cultures (BC) in children 615 (46.5%) were positive for isolates and adults 118 (30.2)%. Blood culture positivity decreased with increasing age with newborns 251 (34.5%) and adults > 65 years 18 (2.5%). Staphylococcus aureus constituted 61.3% of all isolates and was the leading isolates in all age groups;Alkaligenes (9.1%);Citrobacter 8.1%, Klebsiella 6.7%;Pseudomonas 6.1%;E. coli 2.7%;Enterococcus 2%;Proteus 1%. Of the Antimicrobial resistance priority isolates E. coli susceptibility ranged from 71% to Gentamycin and 100% to Cefixime;Klebsiella from 25% sensitivity to Amikacin to 78% each to chloramphenicol and ciprofloxacin;Salmonella was 100% sensitive to chloramphenicol, ciprofloxacin and cefuroxime. Klebsiella was 100% sensitive to Cefoxitin;Proteus sensitivity ranged from 35% to ampicillin and 100% to ciprofloxacin and cefuroxime. Staph aureus sensitivity was 35% to cefoxitin, 70% to amoxicillin/clavulanate and 70% to cefuroxime. Conclusion: Blood culture yield by Automated method was high. Staph aureus was the predominant pathogen and bacterial yield reduced with increasing age. Antibiotic sensitivity was variably reduced against gram negative bacteria.

Bacterial Blood Isolates in Children: Conventional vs. Bactec Automated Blood Culture System in a Tertiary Health Centre in Gombe, North East Nigeria

Background/Aim: Blood culture is critical in the diagnosis and treatment of blood stream infections (BSIs) especially in children. BSIs are among the most common cause of morbidity/mortality and blood culture has remained the gold standard for diagnosis. We sought to compare Blood Culture Isolates (BCI) from conventional and Bactec automated blood culture system (ABCS) among paediatric patients at the Federal Teaching Hospital Gombe (FTHG) Nigeria. Methods: BCI in children (0 - 18 years) by conventional method from 2008-2012 and Bactec Automated culture system from 2015-2020 were retrieved from the clinical microbiology laboratory register. Information analyzed included, age, sex, month, and year and blood culture isolates. Results: There were 5276 (56.9% males, 43.1% females) and 1169 (54% males, 46% females) Blood Culture Isolates by CM and ABCS respectively. Overall positive culture isolates were 9.7% (515/5276) in CM and 45.9% (536/1169) in ABCS (p = 0.01). Positivity rate in newborn was 13.3% (282/2114) by CM and 40.9% (219/263) by ABCS p = 0.01;under-5 was 10.5% (448/4253) vs. 37% (359/873) (p = 0.01);Gram positive 32.6% (172) vs. 65% (759) (p = 0.01;Gram negative 55% (2910) vs. 34% (397) (p = 0.01). Staph aureus 22% (114/515) by CM vs. 61.9% (332/536)) by ABCS (p = 0.01);Klebsiella 24.9% (128/515) by CM vs. 7.5% (40/536) p = 0.01) in ABCS, E. coli 8.9% (46/515) vs. 2.1% (11/536) p = 0.01;Proteus vs. 1.1% (6/515) by ABCS, Pseudomonas 3.3% (17/515) vs. 5.6% (30/536) p = 0.05, Alkaligenes 1% (5/515) vs. 8.2% (44/536) p = 0.01 and Citrobacter 1% (5/515) vs. 8.4% (45/536) p = 0.01. Conclusion: Blood culture yield was five times higher with Bactec compared with Conventional method.

Low Level of Hepatitis B Surface Antigen Screening in a Tertiary Health Facility in Nigeria 2000-2014: Imperative for Provider Initiated Testing and Counselling for Hepatitis B Virus?

Introduction: Viral hepatitis is a major public health challenge that requires an urgent response. Reducing mortality requires major scale-up in prevention, testing and treatment access;coverage in HBV vaccination, testing and treatment is low and must accelerate massively to achieve the 2030 targets. Less than 1% of HBV-infected individuals are diagnosed in Sub-Sahara Africa, despite the availability of rapid tests with good diagnostic accuracy. Materials and Methods: This was retrospective cross sectional study conducted in Federal Teaching Hospital Gombe, in North East Nigeria. All children and adults who presented to the out-patient departments, and those that were admitted irrespective of their HIV and or Hepatitis C virus status and had Hepatitis B and/or Hepatitis B envelope antigen test were conducted between 2000 to 2015. All children and adults were tested using the Hospital standard for Hepatitis B surface antigen test strip. Results: Between 2000 and 2014, 739,456 children and adults were admitted and reviewed in the outpatient units of the Federal Teaching Hospital Gombe;there were 685,552 adults and 53,904 children. Children constituted 7.3% (53,904/739,456) of admissions and outpatient consultations. 2.8% (210/7570), 3.3% (773/23,783), 3.6% (1145/32,142), 5.2% (1694/33,043), 3.3% (986/29,216), 1.9% (661/3321), 0.1% (53/41,626), 0.2% (113/46,634), 2.6% (1418/54,423), 5.4% (3717/69,696), 3.7% (2332/62,086), 3.5% (3241/90,623), 3.2% (2881/89,398), 3.8% (2428/62,687), 2.8% (1835/63,208) of children and adults were tested for HBsAg in 2000, 2001, 20002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, 2013 and 2014 respectively. 23,487 children and adults were tested for HBsAg with a cumulative testing rate of 3%. Overall 4465/23,487 children and adults were seropositive for HBsAg giving a cumulative prevalence of 19%. Conclusion: HBV screening in our health facility is very low. Massive scale up in awareness and HBV vaccination are required. Provider initiated testing and counseling for HBV in health facilities needs support for implementation in Health Facilities in Sub Saharan Africa.

Trends in Bacterial Blood Culture Isolates and Resistance in Children in Two Microbiologic Eras from a Tertiary Health Facility in North East Nigeria

Introduction: Antimicrobial Resistance surveillance is predicated on blood culture as a priority clinical specimen in especially resource limited settings. Establishing trends in blood stream infections and resistance patterns can inform institutional and national policy on antimicrobial stewardship, surveillance, infection prevention and control. Methodology: Blood Culture isolates in children (0 - 18 years) by conventional method from 2008-2012 and Bactec Automated culture system from 2015-2020 were retrieved. Information analyzed included age, sex, month, and year and culture growth/identity of microorganisms and their sensitivity/resistance patterns. Clinical and Laboratory Standards Institute (CLSI) guideline for antibiotic susceptibility testing was used. Results: 20,540 children were admitted: 8964 (44.6%) and 11,630 (55.4%) in the Manual and Bactec blood culture era respectively. Blood cultures were done in 5271 in the manual culture era and 1077 in the Bactec culture era;of these cultures, 514 (9.7%) and 461 (42.8%) were positive for isolates in the respective era (p = 0.01). There were no statistically significant differences in trend between positive and negative blood cultures in males and females. Newborns, followed by children 1 - 5 years had more blood culture performed on them than other age categories. In general, there is no significant relationship in blood culture outcomes between the age categories and sex of the patients. The isolation of Staph aureus, Citrobacter and Alkaligenes increased two-fold with Bactec automated system. Resistance to the quinolones and the penicillin was high. Resistance trend to Genticin, an aminoglycoside was less than 40%. Resistance to Ceftazidime was high. Conclusion: Antimicrobial resistance surveillance is critical to reduce AMR related morbidity and mortality.

Spectrum of Poisoning and Outcome among Children in a Tertiary Hospital, North-East Nigeria: A 20 Years Restrospective Review, 2000-2019

Introduction: Acute poisoning in children is cause of hospitalization and death worldwide. It is a Paediatrics emergency with significant economic cost. There are epidemiological differences in acute poisonings in children evaluated in Emergency departments across different countries and regions of the world. The aim of this study was to determine the causes of poisoning in children in our health facility during the period 2000-2019. Methodology: Case notes of children 6 months to 18 years managed for acute poisoning from January 2000 to December 2019 at Paediatrics unit, Federal Teaching Hospital Gombe (FTHG), were analysed. The International classification of Disease ICD 10 was used. Ethical Clearance was obtained. Results: 26,716 children were admitted with 76 cases of Acute poisoning giving a prevalence rate of 2.8/1000 children. 56.6% (43) were males. 63.2% (48) of children were years of age. 69.7% (53) were urban dwellers and 59.2% (45) from low socioeconomic class. 52.6% (40) of poisoning occurred in rainy season. 97.3% (74) of children had unintentional poisoning. Organophosphates 22.3% (17) and kerosine 22.3% (17) were the most common substances ingested. Snake-bite and corrosive ingestion occurred in 13.1% and 11.8% of children respectively. Ingestion was the route in 84.2% of cases. 75.0% (57) of poisoning occurred at home. ACP occurred in children aged 1 - 5 years (p-value = 0.025);More in Children from low socioeconomic status (p-value = 0.001) and urban settings (p-value = 0.001). There was no statistically significant relation between type of poisoning and gender p = 0.839, season p = 0.608, religion p = 0.504 and ethnic background p = 0.342. 4.2% (3) children died each from organophosphate, snake bite and tramadol poisoning. Conclusion: Kerosine and organophosphate were the leading cause of accidental childhood poisoning.

Virologic Response among Children and Adults in an Antiretroviral Therapy Programme in Northern Nigeria: A Cross-Sectional Descriptive Study

Introduction: Viral load suppression is a key determinant of successful anti-retroviral therapy. The study aimed to determine virologic response to Antiretroviral therapy in the large cohort of children and adults living with Human Immune deficiency Virus. Materials and Methods: Viral Load results from the HIV Ribonucleic Acid Polymerase Chain Reaction register of 10,887 children and adults on cART in 4 states in Northern Nigeria between 2017 and 2019 were retrieved and analyzed in the PCR Molecular Laboratory of the Federal Teaching Hospital, Gombe. Results: 10,887 children and adults were analyzed. Males were 28.4% (3094) and 71.6% (7793) females. 2.9% (311);3.5% (386);7.3% (797);65.2% (7098);14.5% (1583);5.2% (562) and 1.3% (150) were aged 0 - 9 years, 11 - 18 years;19 - 25 years, 26 - 45 years;46 - 55 years;56 - 65 years and 10 years. The most recent CD4count before viral load request was ≥1000/μL in 7.4% (810/10887);500 -999/μL in 39.0% (4240);350 - 499 μL in 22.7% (2466) and 1000 c/mL in 26.5% (821/3094) males and 24.1% (1876/7793) females. Viral load was significantly lower among females (p-value 0.007). 50.5% (157/311);52.1% (201/386);28.5% (227/797);23.5% (1670/7098);19.9% (315/1583);17.8% (100/562) and 18.0% (27/150) aged 0 - 9 years, 11 - 18 years;19 - 25 years, 26 - 45 years;46 - 55 years;56 - 65 years and 1000 c/mL respectively. Viral load was >1000 c/mL in 28.2% (229/811) for those on HAART for 6 months - 1 year and 23.6% (1243/5275) after receiving Highly Active Antiretroviral Therapy (HAART) for 1 - 5 years. 26.3% (1072/4075) and 21.1% (153/726) had viral load > 1000 c/mL after receiving HAART for 6 - 10 and >10 years respectively (p-value 0.001). Conclusion: HIV viral suppression was below the WHO recommended threshold.

HIV Viral Suppression in Children in a Subnational Antiretroviral Treatment Programme in Nigeria

Background: Despite years of Paediatric Antiretroviral therapy in Nigeria, the National implementation plan for the scale up of viral load testing was only rece ntly launched. Viral load determination is the most important indicator of ART response. Material & methods: First viral load samples were collected from 663 children living with HIV between December 2017-Decemb er 2019 aged 0 - 18 years on highly active antiretroviral therapy from 4 states within Nigeria. Samples were analyzed at a Polymerase Chain Reaction laboratory of the Federal Teaching Hospital Gombe. Results: Males were 311 (46.9%) and 352 (53.1%) female. Children aged 0 - 9 years constituted 44.9% (298);55.1% (365) were aged 10 - 18 years. This first viral load was primarily routine in 94 .2% (625);2.9% (19) of children respectively had suspected clinical or immunological failure. ART combination was AZT/3TC/NVP in 78.1% (518/663) of CLHIV;TDF/3TC/EFV in 21.2% (141);AZT/3TC/LPV/rtv in 4 (0.6%). Prior to initiation of routine viral load testing $0.55 (366/663) CLHI V had received HAART for 1 - 5 years;7.8% (52/663) for 6 months but < 1 year;32.8% (218/663) 6 - 10 years and 4.1% (27) for >10 years. The most recent CD4 count before viral load request was ≥1000/μL in 24.7% (164) of CLHIV;500 - 999/μL in 42.9% (285);350 - 499 μL in 11% (73) and <350 μL in 21.3% (141) of children. Viral load was ≥1000 c/ml in 51.3% (340/663) of children. Viral load was >1000 c/ml in 59.9% (174/311) males and 47.2% (166/352) females. Viral load was significantly lower among females (P-value 0.02). Of children aged 0 - 9 years 50.3% (150/298) had viral load > 1000 c/ml and 10 - 18 years 52.1% (190/365) (P value 0.660). Viral load was >1000 c/ml in 38.5% (20/52) of children on HAART for 6 months - 1 year and 52.2% (191/366) after receiving HAART for 1 - 5 years. 52.3% (114/218) and 55.6% (15/27) CLHIV had viral load > 1000 c/ml after receiving HAART for 6 - 10 and >10 years respectively (P value 0.29). Conclusion: About half of children on HAART have viral load > 1000 c/ml after more than 1 - 5 years on HAART. Longer duration of ART and use of AZT/3TC/NVP are associated with viral load > 1000 c/ml. Key considerations are poor adherence and/or viral drug resistance. Optimizing ART adherence and resistance monitoring remain key strategies for ART programmes.

Viral Suppression in Adult Nigerians in a Regional Antiretroviral Therapy Programme: A Cross Sectional Descriptive Study

Background: The adult ART (antiretroviral therapy) programme started in Nigeria in 2002. After many years of ART in the country, the National implementation plan for the scale up of viral load testing was launched in 2016. Viral load estimation is the most important indicator of ART response. Aim: To describe viral suppression in adults on the HIV ART programme Material & methods: Viral load blood samples of 9450 adults on highly active antiretroviral therapy living with HIV from 4 states within Nigeria were analyzed for HIV RNA in Polymerase Chain Reaction laboratory of the Federal Teaching Hospital, Gombe between December 2017 and December 2019. Results: Males were 2577/9450 (27.3%) and 6873 (72.7%) females. Adults aged 26 - 45 years constituted 69.5% (6572). Viral load test was primarily routine in 96.3% (9098). ART was AZT/3TC/NVP in 52.5% (4962);TDF/3TC/EFV in 46.3% (4375). 48.3% (4568/9450) adults had received HAART for 1 - 5 years;7.4% (699) for 6 months but <1 year;37.6% (3551) 6 - 10 years and 6.7% (632) for >10 years. The most recent CD4 count before viral load request was ≥1000/μL in 6.5% (612) of adults;500 - 999/μL in 38.6% (3651);350 - 499 μL in 23.2% (2195) and <350 μL in 31.7% (2992). Viral load was ≥1000 c/ml in 22.9% (2167/9450) of adults. Viral load was >1000 c/ml in 22.8% (587/2577) males and 23.0% (1580/6873) females. Of adults aged 19 - 25 years, 28.4% (211/743) had viral load >1000 c/ml;23.5% (1544/6572);20.0% (294/1473);17.8% (93/523) and 18.0% (25/139) aged 26 - 45 years, 46 - 55 years;56 - 65 years and >65 years also had viral load >1000 c/ml (p value < 0.001) Viral load was >1000 c/ml in 26.0% (182/699) of adults on HAART for 6 months - 1 year and 21.3% (975/4568) after receiving HAART for 1 - 5 years. 24.9% (885/3551) and 19.8% (125/632) adults had viral load > 1000 c/ml after receiving HAART for 6 - 10 and >10 years respectively. (p value < 0.001) Conclusion: Over all viral suppression of 77% in our study is high but fell below the WHO threshold of 90%. ART programme in Nigeria requires strengthening.

Deoxyribonucleic Acid-Polymerase Chain Reaction Status of HIV Exposed Infants in a Sub Regional Prevention of Mother-to-Child Transmission of HIV Programme during the Period 2009-2020

Introduction: Transitioning to more efficacious Antiretrovirals for HIV infected pregnant women and infant prophylaxis has reduced Mother to child transmission of HIV significantly. This study aimed to determine HIV infection status in HIVexposed infants who had their first DNA polymerase chain reaction test in our molecular Laboratory. Subjects, Materials and Methods: Dried Blood Spots for HIV DNA results from 5 states between 2009 and 2020 were analyzed in the PCR laboratory of the Federal Teaching Hospital, Gombe. Results: Nine thousand eight hundred and twenty-three Human Immunodeficiency Virus Deoxyribonucleic acid polymerase Chain Reaction results were analysed;4937 (50.2%) were males. During the study period, there was an overall declining trend in the mother-to-child transmission rate from 3.8% in 2009 to 1.0% in 2020. 6120 (62.3%) of HIV + mothers received Highly active antiretroviral therapy HAART before pregnancy. 7845 (76.2%) of the infants received Nevirapine prophylaxis. Dried blood spot samples were collected from 4077 (41.5%) at 6 - 8 weeks. 8438 (85.9%) received cotrimoxazole. 9469 (96.4%) were ever breastfed. Of the 9823 HIV DNA PCR results, 255 (2.6%) were positive while 69/4077 (1.7%) and 109/2662 (4.1%) were positive for HIV DNA at 6 - 8 weeks and > 12 weeks respectively. (p = 0.001). 86/747 (11.5%) of infants whose HIV-positive mothers received no ARVS were HIV DNA positive. (p = 0.001). 106/884 (12.0%) of infants who had no Antiretroviral prophylaxis had positive HIV DNA results;7/413 (1.7%) with Zidovudine/Nevirapine prophylaxis had positive results. (p = 0.001). 246/9469 (2.6%) of infants that were ever breastfed were positive for HIV DNA;11/354 (3.0%) that never breastfed had positive HIV DNA. Conclusion: Lack of maternal/infant ARVs and prolonged breastfeeding increased the risk of infant HIV infection.