PRE-CLINICAL CARE, CLINICAL MANAGEMENT AND OUTCOMES OF DOG BITE INJURIES IN HIGH RABIES BURDEN DISTRICTS OF WAKISO AND KAMPALA, UGANDA

PhD Thesis Proposal by Dr. Stevens M. B. Kisaka

W80/52986/2018

University of Nairobi

ABSTRACT

Introduction: There is a rise in dog bites in Uganda. These may result into stigma, morbidity and death. However, the actual burden in the community is not known since all victims do not report to health facilities. In addition, adherence to pre-clinical and clinical guidelines of managing dog bites
are not well known. Furthermore, the bioburden of these injuries and treatment outcomes have not been well assessed.

Objectives: To assess the community burden, pre-clinical care practices and clinical management for dog bite injuries as well as their bearing on the bioburden and outcomes in high rabies burden districts of Wakiso and Kampala in Uganda.

Methods: The community incidence will be determined in households of 2 sub counties of Kawempe (Kampala district) and Nansana Town Council (Wakiso district) for a period of 3 years using an ambi-directional study design. Incidence will be expressed per 10,000 population and defined using descriptive statistics, spatial analysis and spot maps. In both Entebbe and Mulago Hospitals, 360 patients reporting for post-exposure prophylaxis and treatment for dog bite injuries will be interviewed for practices undertaken before presentation to the health facility. Association between adherence to guidelines and associated factors will be determined using logistic regression
with Odds ratios (OR: 95% CI). In addition, health worker practices for treating dog bites will be assessed qualitatively using observations, review of medical records and in-depth interviews with those managing dog bites. Grade II and III wounds will be aseptically swabbed and culture anaerobic
and aerobically for bacterial growth. Bacterial strain identification will be by colony, biochemical characteristics and Matrix Assisted Laser Desorption Time of Flight Mass Spectrometry. Antimicrobial susceptibility testing will be done using Epsilometer test against Metronidazole, methicillin, amoxicillin, doxycycline and cotrimoxazole. The findings will be interpreted using
Guidelines by European Committee on Antimicrobial Susceptibility Testing and analyzed by descriptive and inferential statistics. Lastly, predictors for infection will be determined using a prospective study among the 360 patients who will be followed up for 6 months. Stratified analysis, inferential statistics using logistic regression (RR: 95% CI); Descriptive statistics and Survival analysis: Kaplan meier curves and using Cox regression will be used to assess infection, healing and other outcomes. 

Expected outcomes: Community incidence of dog bite injuries within a 3-year period; factors associated with pre-clinical practices for dog bites; adherence to clinical practices by health care providers; antimicrobial resistance associated with management of dog bites; and predictors of outcomes of dog bite management.

Key words: dog bite, risk factor, antimicrobial resistance, post-exposure prophylaxis, pre-treatment, clinical, practices, outcomes.

ADHERENCE TO CLINICAL GUIDELINES IN THE MANAGEMENT OF DIARRHOEA DISEASES IN CHILDREN AGED BELOW FIVE YEARS ADMITTED AT MAMA LUCY HOSPITAL, NAIROBI

Postgraduate Diploma Research Project by Catherine Wangu Shitemi

W61/8791/2016

University of Nairobi

ABSTRACT

Background: Antimicrobial Resistance has been described as a public health emergency. Antimicrobial stewardship programs have been recommended as one of the ways of combating AMR. Stewardship Programs have been implemented and studied in many parts of the world. We found no studies in literature documenting antimicrobial stewardship in Kenya. 

Objective: The study sought to identify existing antimicrobial stewardship guidelines in Kenya; and to appraise antimicrobial stewardship at Mbagathi County Referral Hospital in Nairobi City County, Kenya.

Methodology: This was a cross-sectional mixed methods survey conducted among health practitioners who prescribe, dispense or administer antimicrobials at the Mbagathi County Referral Hospital. It included a preliminary quantitative followed by a qualitative phase. A self-administered questionnaire was used to collect quantitative data. Qualitative data was collected through key informant interviews.
Descriptive data analysis was done. Variables were analyzed using counts and percentages and results presented using tables and graphs. Audio records of the interviews were transcribed. The data was analyzed using the content analysis approach. Codes were identified and extracted from the transcripts.
The codes were used to build themes on the respondents' views on guidelines, stewardship practices, challenges and opportunities for antimicrobial stewardship.

Results: A total of 171 respondents filled the questionnaire from the 242 that were distributed. Standard documentation of antibiotic prescriptions in patient charts was the most widely used stewardship activity at Mbagathi County Referral Hospital.

Conclusion and recommendations: We found no formal stewardship structure or local policy document available to guide antimicrobial use at the facility. Challenges to be addressed include laboratory capacity for microbiological diagnosis, drug supply and training. We recommend the establishment of an antimicrobial stewardship team to spearhead antimicrobial stewardship at Mbagathi County Referral Hospital.

KNOWLEDGE, ATTITUDE AND PRACTICES OF DOCTORS TOWARDS HIV TESTING AND COUNSELLING IN A PRIVATE TERTIARY HOSPITAL IN KENYA

Masters Research Project by Dr. Linnet Atieno Juma

W64/64530/2010

University of Nairobi

ABSTRACT

Background: Counseling is one of the core principles in HIV testing service package which may be provided as a part of general healthcare or as a specific specialized service.
With involvement of doctors, there is an opportunity to increase uptake of HIV testing services in the private sector.

Objective: To establish knowledge, attitude and practices of doctors towards HIV counseling and testing for patients at the private tertiary Hospital in Kenya.

Method: This was a cross-sectional study conducted among doctors in private tertiary hospital. Quantitative data was collected by pretested online questionnaires whilst in depth interviews were done with key informants. A consecutive sampling was done to obtain 100 doctors from amongst residents and senior house officers working in the hospital. Data storage and protection was done in Microsoft Access 2013. Data was analysed using statistical software SPSS version 21.0. The quantitative analysis was done using descriptive statistics and the results presented using graphs and figures. Inferential statistics were based on cross tabulations (chi square statistic). The qualitative data was analysed based on patterns or themes identified and related to the study objectives.

Results: The doctors interviewed were 57% females, 60% were aged between 31 and 40 years old, 66% had undergraduate qualification and 68% were senior house officers. Most (80%) of the doctors reported offering HIV testing services to their patients though 63% had never attended any training in counseling. Awareness of HIV testing guidelines was low at 16%. The challenges in offering HIV testing services included lack of training (87%)
and time (77%) among doctors. There was a high likelihood to offer HIV testing services among doctors who were older than 30 years [OR 3.2 (95% CI 1.2-8.8), p=O.023] and those who had worked for more than 1 year in the hospital; 1 -4 years [OR 3.8 (95% CI 1.2-11.5), p=0.021] and ~5 years [OR 10.8 (95% CI 2.1-56.3), p=0.005].

Conclusions: A high proportion of doctors in private hospital provided HIV testing services though there was a widespread lack of training and inaccessibility to national guidelines. Most of the testing was guided by the presenting symptoms of patients.

FACTORS THAT CONTRIBUTE TO FIVE YEAR SURVIVAL OF GALL BLADDER CANCER PATIENTS AT KENYATTA NATIONAL HOSPITAL: A RETROSPECTIVE COHORT STUDY

Masters Research Project by Dr. Alice W. Maingi

W62/63975/2010

University of Nairobi

ABSTRACT

Introduction: Gallbladder cancer (GBC) is an uncommon malignancy of the biliary tract with a poor prognosis frequently presenting at an advanced stage. Generally, GBC is the most aggressive of the biliary tract cancers accounting for 80-95% of this malignancy's. In addition, it has the shortest median survival duration. Early diagnosis is crucial for improved prognosis.
However, indolent and non-specific clinical presentations with a paucity of pathognomonic radiological features often preclude accurate recognition of GBC at an early stage. There is limited documented evidence on the survival and associated factors to guide effective management of GBC patients at KNH.

Objectives: This study aims to determine five-year survival and associated factors leading to death of gallbladder cancer patients seen at KNH.

Methodology: The study was a retrospective cohort study of all patients who had a diagnosis of primary GBC and were seen at KNH. The sample size was all patients diagnosed with GBC seen at KNH. Data collected was age, sex, time of diagnosis (pre-op, intra-op), stage of cancer, type of cancer and treatment (surgery, chemotherapy, radiotherapy) given to the patients and it was abstracted from patients' records. Data was analyzed using STATA version 15. Cox regression approach was used to evaluate these factors.

Results: The median survival time for GBC patients is 7.29 months with an interquartile of 2.4-36.75 months. The incidence rate of death among these patients was 7% in a month.
There was no significant difference between the predictor variables of age (p=0.769), gender (p=0.548), time of diagnosis (p=0.742), type of GBC (0.494), advanced stage (p=0.813), treatment (p=0.063) on time to death. However, those with advanced stage had a12%more chance of dying. Participants who underwent surgery and chemotherapy survived longer.

Conclusion: The study established that there was no statistical difference on the predictor variables to time to death on GBC patients. However, late diagnosis leads to finding the malignancy already in its advanced stage hence curative surgery not possible.
Consequently, patients who underwent combined treatment of surgery and chemotherapy management had a longer survival.