BACKGROUND:It is well documented that inappropriate use of antimicrobials is the major driver of antimicrobial resistance. To combat this, antibiotic stewardship has been demonstrated to reduce antibiotic usage, decrease the prevalence of resistance, lead to significant economic gains and better patients' outcomes. In Nigeria, antimicrobial guidelines for critically ill patients in intensive care units (ICUs), with infections are scarce. We set out to develop antimicrobial guidelines for this category of patients.METHODS:A committee of 12 experts, consisting of Clinical Microbiologists, Intensivists, Infectious Disease Physicians, Surgeons, and Anesthesiologists, collaborated to develop guidelines for managing infections in critically ill patients in Nigerian ICUs. The guidelines were based on evidence from published data and local prospective antibiograms from three ICUs in Lagos, Nigeria. The committee considered the availability of appropriate antimicrobial drugs in hospital formularies. Proposed recommendations were approved by consensus agreement among committee members.RESULTS:Candida albicans and Pseudomonas aeruginosa were the most common microorganisms isolated from the 3 ICUs, followed by Klebsiella pneumoniae, Acinetobacter baumannii, and Escherichia coli. Targeted therapy is recognized as the best approach in patient management. Based on various antibiograms and publications from different hospitals across the country, amikacin is recommended as the most effective empiric antibiotic against Enterobacterales and A. baumannii, while colistin and polymixin B showed high efficacy against all bacteria. Amoxicillin-clavulanate or ceftriaxone was recommended as the first-choice drug for community-acquired (CA) CA-pneumonia while piperacillin-tazobactam + amikacin was recommended as first choice for the treatment of healthcare-associated (HA) HA-pneumonia. For ventilatorassociated pneumonia (VAP), the consensus for the drug of first choice was agreed as meropenem. Amoxycillin-clavulanate +clindamycin was the consensus choice for CAskin and soft tissue infection (SSIS) and piperacillin-tazobactam + metronidazole ±vancomycin for HA-SSIS. Ceftriaxone-tazobactam or piperacillin-tazobactam + gentamicin was consensus for CA-blood stream infections (BSI) with first choice+regimen for HA-BSI being meropenem/piperacillin-tazobactam +amikacin +fluconazole. For community-acquired urinary tract infection (UTI), first choice antibiotic was ciprofloxacin or ceftriaxone with a catheter-associated UTI (CAUTI) regimen of first choice being meropenem + fluconazole.CONCLUSION:Data from a multicenter three ICU surveillance and antibiograms and publications from different hospitals in the country was used to produce this evidence-based Nigerian-specific antimicrobial treatment guidelines of critically ill patients in ICUs by a group of experts from different specialties in Nigeria. The implementation of this guideline will facilitate learning, continuous improvement of stewardship activities and provide a baseline for updating of guidelines to reflect evolving antibiotic needs.

Purpose: Antimicrobial resistance (AMR) is a major determinant of outcome for patients in the intensive care unit (ICU). Susceptibility data derived from surveillance can be a barometer for emerging resistance. This study determined the rates of ICU acquired infections, clinical outcome, and antimicrobial resistance pattern of pathogens causing these infections in in a low resource setting. Methods & Materials: This was a 6-month prospective cohort study in 2 ICUs in Nigeria. Patients were recruited and followed-up until they were either discharged from the ICU or died. Sociodemographic and clinical data was obtained from each patient. Relevant clinical specimens were collected aseptically and processed accordingly. All pathogens isolated were identified using vitek 2. Primary outcome was ICU discharge or mortality. Results: One hundred and five patients were recruited; 73(69.5%) had clinical features suggestive of infection and 140 samples were collected and processed. ICU infection rate was 52.1% (38/73). 71(97.3%) had antibiotherapy; commonly used were Ceftriaxone and metronidazole (30), followed by Meropenem (26). 16(44.4%) had more than one infection, and a total of 90 different infections were documented. Blood stream Infection was 37%, Urinary tract infection was 31.5%, Respiratory tract infection was 6.9% and Soft Skin and tissue infection was 4.1%. Candida species 21.2%, Klebsiella pneumonia 18.9%, Acinetobacter baumannii 15.6% were the most predominate pathogens. Multidrug resistant (MDR) gram-negative organisms accounted for 72.9% (43) of the pathogens. 17 isolates of Klebsiella pneumonia and 10 isolates of Acinetobacter baumannii were MDR. Five of the Klebsiella pneumonia were ESBLs producers. High level of resistance was found against Cefazolin with only 2 isolate showing susceptibility and cabapenem resistance was 64%(34) among gram negative organisms with 64% been observed among Klebsiella spp and Acinetobacter spp. No Methicillin resistant Staphylococcus (MRSA) was isolated. Crude mortality rate was 50.7% (37/73); 10 of whom had gram-negative bacteraemia, 8 of which were MDR. Conclusion: We documented high AMR rates in a resource limited setting, where patients pay from pocket for ICU care. A robust antimicrobial stewardship program with educational intervention is critical to combat this problem.

Purpose: Candida auris is an emerging pan resistant pathogen, which is of particular importance in resource limited settings such as ours, with poor availability of drugs needed to treat its infections. It was identified in 4 blood culture samples from 4 hospitals in Nigeria. Three patients were in the ICU and one was critically ill, in a Gynaecological ward. The objective of this work was to investigate the potential reservoirs of the organism in the patients’ environment. Methods & Materials: Two hospitals gave consent for environmental investigation which was carried out using the environmental surveillance toolkit adapted from CDC's website. Swabs were collected from relevant environmental sources according to the toolkit's guidance. The samples were cultured on Saboraud Dextrose Agar slants at 37°C for 24 to 72 hours. Identification of yeast isolates was done using the Biomerieux Vitek® 2 Compact, data analysis was done using Microsoft Excel. Results: 141 swab samples were collected from both sites, 60(42.5%) of them yielded growth. There were 9 yeast isolates: Candida rugosa 3(33.3%) from a bedside locker, mattress and a pulse monitor; Cryptococcus laurentii 2(22.2%) from an axilla and groin composite skin swab and a sink. Candida albicans 1(11.1%) was from a bed railing, Candida lusitaniae 1(11.1%) from a bedside locker, Candida parapsilosis 1(11.1%) and Candida tropicalis 1(11.1%) was from drug carts. There were 20 mold isolates from bed railings (14;70%), drug carts (3; 15%), bedside lockers (1;5%), mattress (1;5%) and a sphygmomanometer (1;5%). There were 31(22%) bacteria isolates. No Candida auris was isolated in this study. Three patients died and one was discharged without any antifungal therapy. Conclusion: Candida auris was not isolated from the patients’ environment and this is not surprising, we lacked resources to do this, like the environmental sponge sticks, circulating stomacher and the C.auris Chromagar. Interestingly, a significant number of molds were isolated from bed rails, but not surprising because we have a tropical climate and the ward windows are open. It is imperative that in view of possible outbreaks of C.auris, these resources be made available in our setting. Educating clinicians is also critical to curtail possible outbreaks.