Prevalence, Risk Factors, and Microbiological Profile of Early Surgical Site Infection Following Orthopaedic Implant Surgery at Kenyatta National Hospital

Background: The prevalence of surgical site infections (SSI) in orthopaedic surgery has been on the rise especially in low and middle-income countries (LMIC). This has been attributed to the increased number of trauma patients due to the increased incidence of motor vehicle and motor cycle crashes. Kenya has witnessed a similar increase, more so from motor cycle related crashes, leading to an increase in the number of fractures treated operatively. Time to ORIF, duration of surgery, antibiotic prophylaxis are some of the risk factors for SSI, however, data on prevalence and risk factors of SSI within our population to inform preventive strategies remain scarce. Study objective: To determine the prevalence, risk factors and causative bacterial pathogens using microscopy culture and antibiotic sensitivity patterns of SSI following surgery for long bone fractures at level 6 referral hospital Kenyatta(KNH). Study design: Prospective observational analytic . Study setting: The study was carried out in orthopaedic clinic (OC) and wards (OW) at the Kenyatta National Hospital (KNH) between 11th February 2022 and 2nd May 2022 Patients and methods: The collected data were transferred from password-coded data digital collection sheets into analysis software for data cleaning and coding prior to analysis. Data was stored in password-protected computer folders to maintain anonymity of the study subjects. Data analysis was carried out using the Prism 7 (GraphPad Software, San Diego, CA, USA) and SPSS (IBM Statistics Software Version 25, Armonk, New York, USA). Categorial data was reported as frequencies (%). Continuous data were subjected to normality tests (histogram and Q-Q plots with Kolmogorov-Smirnov test) and reported as mean and standard deviation (SD). Comparison of patient and fracture characteristics between patients with and without SSI was carried out using the Independent Student’s-t test (continuous variables) and Chi-square xii statistic (categorical variables). Multivariate logistic regression analysis was performed to identify risk factors for SSI, adjusting for the age,BMI ,sex and comorbidities, and to calculate adjusted odds ratios (ORs) with the corresponding 95% Wald CI. Throughout the analysis, a p<0.05 was considered statistically significant at a 95% confidence interval. Results: A total of 130 patients were recruited into this study. They were generally young (mean age: 33±12.8 years) with a male predominance (83%). The mean body mass index (BMI) was 23.7±2.1 Kg/M2, with 13 (10%) having diabetes mellitus (DM). The most fractured bone was femur (n=66 patients, 50.8%). The mean injury severity score (ISS), pre-operative hospital stay and ASA (American Society of Anaesthesiology) score were 21.6±11.2, 12±9.2 days 1.0±0.1 and respectively. A total of 18 patients (13.8%) developed surgical site infection (SSI). Compared to those without SSI, patients with SSI were predominantly male (p=0.007), had higher BMI (p=0.003) and diabetes mellitus (DM) (p=0.007), had higher incidence of open fractures (p=0.046), higher ISS (p=0.008), and were more likely to require pre-operative blood transfusion (p<0.001) and ICU admission (p<0.001). In the multivariate adjusted logistic regression model, female sex (OR= 5.52, 95% CI 1.15-26.65, p=0.033), presence of diabetes (OR= 9.72, 95% CI 1.83-51.76, p=0.008), higher BMI (OR= 1.31, 95% CI 1.02-1.69, p=0.033), need for pre-operative blood transfusion (OR= 68.21, 95% CI 5.42-858.32, p<0.001) and need for ICU admission (OR= 8.10, 95% CI 5.18-12.65, p<0.001) were significant predictors of development of SSI. The commonest organism isolated was staphylococcus aureus (SA) (70%). Conclusion: The burden of surgical site infections (SSI) following orthopaedic surgery remains high. Diabetes mellitus (DM), higher body mass index (BMI), pre-operative blood transfusion and intensive care unit admission were associated as risk factors for SSI in this study cohort. Commonest isolated organism was Staphylococcus aureus (n= 7patients,70%). Culture isolates display a concerning trend of increased resistance to commonly prescribed antibiotics. Recommendation: 1.Increased SSI surveillance mearures in Orthopaedic patients with diabetes and obesity comorbidities 2. Routine establishment of sensitivity patterns of SSI isolates to guide antimicrobial selection is recommended.

Healthcare utilization by children with neurological impairments and disabilities in rural Kenya: a retrospective cohort study combined with secondary analysis of audit data

Background: There is a paucity of data on healthcare utilization by children with neurological impairments (NI) in sub-Saharan Africa. We determined the rate, risk factors, causes, and outcomes of hospital admission and utilization patterns for rehabilitative care among children with NI in a defined rural area in Kenya.
Methods: We designed two sub-studies to address the primary objectives. Firstly, we retrospectively observed 251 children aged 6–9 years with NI and 2162 age-matched controls to determine the rate, causes and outcomes of hospitalization in a local referral hospital. The two cohorts were identified from an epidemiological survey conducted in 2015 in a defined geographical area. Secondly, we reviewed hospital records to characterize utilization patterns for rehabilitative care.
Results: Thirty-four in-patient admissions occurred in 8503 person-years of observation (PYO), yielding a crude rate of 400 admissions per 100 000 PYO (95% confidence interval (Cl): 286–560). The risk of admission was similar between cases and controls (rate ratio=0.70, 95%CI: 0.10–2.30, p = 0.31). The presence of electricity in the household was associated with reduced odds of admission (odds ratio=0.32, 95% Cl: 0.10–0.90, p < 0.01). Seizures and malaria were the main causes of admission. We confirmed six (0.3%) deaths during the follow-up period. Over 93% of outpatient paediatric visits for rehabilitative care were related to cerebral palsy and intellectual developmental delay. Health education (87%), rehabilitative exercises (79%) and assistive technology (64%) were the most common interventions. Conclusions: Surprisingly, the risk of hospitalization was not different between children with NI and those without, possibly because those with severe NI who died before this follow-up were under seclusion and restraint in the community. Evidence-based and tailored rehabilitative interventions are urgently required based on the existing secondary data.

Self-reported involvement in road traffic crashes in Kenya: A cross-sectional survey of a nationally representative sample

Road traffic crashes (RTCs) are a global public health burden whose resulting morbidity and mortality disproportionately impact low- and middle-income countries with stressed health systems. There is a paucity of published studies that evaluate the sociodemographic distribution of RTCs using nationally representative samples from the African region.

To examine population-wide associations between sociodemographic factors and involvement in RTCs in Kenya.

Data were obtained from the 2014 Kenyan Demographic Health Survey, representing all 47 counties in Kenya, from May to October of 2014. We estimated the prevalence of RTCs and utilized logistic regression for bivariate and multivariable analyses to determine the sociodemographic factors associated with RTCs. Study variables included age, place of residence, household wealth index, educational attainment, and history of alcohol consumption. We computed odds ratios (ORs) and their corresponding 95% confidence intervals (CIs).

A higher prevalence was reported among men (8.76%) versus women (3.22%). The risk factors among men included being 20−34 years of age, living in a rural area (OR 1.38, 95% CI 1.09, 1.74), drinking alcohol (OR 1.33, 95% CI 1.11, 1.59), and having not higher than a primary (OR 1.90, 95% CI 1.19, 3.03) or secondary (OR 1.68, 95% CI 1.04, 2.71) education. The strongest risk factors for women included the being aged 45−49 (OR 2.30, 95% CI 1.44, 3.67) and 20−24 years (OR 1.81, 95% 1.17, 2.79) as well as being in the fourth wealth quintile (OR 1.83, 95% CI 1.15, 2.91).

Men and the most economically productive age groups were more likely to report being involved in RTCs. Strategies to reduce the occurrences of RTCs should prioritize the most vulnerable sociodemographic groups.

Qualitative Analysis of the Host-Perceived Impact of Unidirectional Global Surgery Training in Kijabe, Kenya: Benefits, Challenges, and a Desire for Bidirectional Exchange

As globalization of surgical training increases, growing evidence demonstrates a positive impact of global surgery experiences on trainees from high-income countries (HIC). However, few studies have assessed the impact of these largely unidirectional experiences from the perspectives of host surgical personnel from low- and middle-income countries (LMIC). This study aimed to assess the impact of unidirectional visitor involvement from the perspectives of host surgical personnel in Kijabe, Kenya.

Voluntary semi-structured interviews were conducted with 43 host surgical personnel at a tertiary referral hospital in Kijabe, Kenya. Qualitative analysis was used to identify salient and recurring themes related to host experiences with visiting surgical personnel. Perceived benefits and challenges of HIC involvement and host interest in bidirectional exchange were assessed.

Benefits of visitor involvement included positive learning experiences (95.3%), capacity building (83.7%), exposure to diverse practices and perspectives (74.4%), improved work ethic (51.2%), shared workload (44.2%), access to resources (41.9%), visitor contributions to patient care (41.9%), and mentorship opportunities (37.2%). Challenges included short stays (86.0%), visitor adaptation and integration (83.7%), cultural differences (67.4%), visitors with problematic behaviors (53.5%), learner saturation (34.9%), language barriers (32.6%), and perceived power imbalances between HIC and LMIC personnel (27.9%). Nearly half of host participants expressed concerns about the lack of balanced exchange between HIC and LMIC programs (48.8%). Almost all (96.9%) host trainees expressed interest in a bidirectional exchange program.

As the field of global surgery continues to evolve, further assessment and representation of host perspectives is necessary to identify and address challenges and promote equitable, mutually beneficial partnerships between surgical programs in HIC and LMIC.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Evaluation of capacity to deliver emergency obstetrics and newborn care updated midwifery and reproductive health training curricula in Kenya: Before and after study

Provision of emergency obstetric and newborn care (EmONC) by skilled health personnel reduces maternal and newborn mortality. Pre-service diploma midwifery and clinical medicine (reproductive health) curricula in Kenya were reviewed and updated integrating the competency based EmONC curriculum. A two-part (virtual for theoretical component and face-to-face for the skills-based component) capacity building workshop for national midwifery/clinical medicine trainers of trainers to improve their capacity to implement the updated curricula and cascade it to colleagues nationwide was conducted.

This paper measured change in confidence of pre-service midwifery/clinical medicine educators to deliver the updated competency-based curricula in Kenya.

A before-after study among 51 midwifery/clinical medicine educators from 35 training colleges who participated in upskilling workshops as trainers-of-trainers for the updated curricula between September-November 2020. Assessment included self-reported confidence using a 3-point Likert scale (not confident, somewhat confident or extremely confident) in facilitating online teaching (as COVID-19 pandemic containment measure), EmONC skills teaching/demonstration; scenario/simulation teaching, small group discussions, peer review and giving effective feedback. Analysis involved test of proportions with p-values < 0.05 statistically significant. Results Educators’ confidence significantly improved in facilitating virtual teaching (46% to 70%, p = 0.0082). On the competency-based training, the confidence among educators significantly increased in facilitating EmONC skills teaching/demonstration (44% to 96%), facilitating scenario/simulation teaching (46% to 92%), facilitating small group discussions (46% to 94%), giving effective feedback (46% to 92%), and peer review and feedback (47% to 77%), p < 0.05). Conclusion The blended training improved the confidence of pre-service educators to deliver the updated midwifery/clinical medicine curricula.

Essential Emergency and Critical Care as a health system response to critical illness and the COVID19 pandemic: What does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, low-cost care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in low resource settings with Kenya and Tanzania as case studies.

The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.

The costs per patient day of EECC is estimated to be 1.01 USD, 10.83 USD and 32.84 USD in Tanzania and 1.76 USD, 14.86 USD and 37.43 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13.11 USD and 17.33 USD for severe and 297.30 USD and 369.64 USD for critical COVID-19 patients in Tanzania and Kenya, respectively.

EECC, an approach of providing the essential care to all critically ill patients, is low-cost. The components of EECC are basic and universal and, when assessed against the existing gaps in critical care coverage and costs of advanced critical care, suggest that it should be a priority area of investment for health systems around the globe.

Epidemiological profile and clinico-pathological features of pediatric gynecological cancers at Moi Teaching & Referral Hospital, Kenya

The main pediatric (0–18 years) gynecologic cancers include stromal carcinomas (juvenile granulosa cell tumors and Sertoli-Leydig cell tumors), genital rhabdomyosarcomas and ovarian germ cell. Outcomes depend on time of diagnosis, stage, tumor type and treatment which can have long-term effects on the reproductive career of these patients. This study seeks to analyze the trends in clinical-pathologic presentation, treatment and outcomes in the cases seen at our facility. This is the first paper identifying these cancers published from sub-Saharan Africa.

Retrospective review of clinico-pathologic profiles and treatment outcomes of pediatric gynecologic oncology patients managed at MTRH between 2010 and 2020. Data was abstracted from gynecologic oncology database and medical charts.

Records of 40 patients were analyzed. Most, (92.5%, 37/40) of the patients were between 10 and 18 years. Ovarian germ cell tumors were the leading histological diagnosis in 72.5% (29/40) of the patients; with dysgerminomas being the commonest subtype seen in 12 of the 37 patients (32.4%). The patients received platinum-based chemotherapy in 70% of cases (28/40). There were 14 deaths among the 40 patients (35%)

Surgery remains the main stay of treatment and fertility-sparing surgery with or without adjuvant platinum-based chemotherapy are the standard of care with excellent prognosis following early detection and treatment initiation. LMICs face several challenges in access to quality care and that affects survival of these patients. Due to its commonality, ovarian germ cell cancers warrant a high index of suspicion amongst primary care providers attending to adnexal masses in this age grou

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study

Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined.

This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach.

This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research.

Trial registration
This study was retrospectively registered with the database on December 15, 2021, NCT05177393.

The status and future of emergency care in the Republic of Kenya

Kenya is a rapidly developing country with a growing economy and evolving health care system. In the decade since the last publication on the state of emergency care in Kenya, significant developments have occurred in the country’s approach to emergency care. Importantly, the country decentralized most health care functions to county governments in 2013. Despite the triple burden of traumatic, communicable, and non-communicable diseases, the structure of the health care system in the Republic of Kenya is evolving to adapt to the important role for the care of emergent medical conditions. This report provides a ten-year interval update on the current state of the development of emergency medical care and training in Kenya, and looks ahead towards areas for growth and development. Of particular focus is the role emergency care plays in Universal Health Coverage, and adapting to challenges from the devolution of health care.