Onyema Ogbuagu

High Prevalence of Antimicrobial Resistance Among Common Bacterial Isolates in a Tertiary Healthcare Facility in Rwanda

Antimicrobial resistance (AMR) is a serious public health threat in both developed and developing countries. Many developing countries, including Rwanda, lack adequate surveillance systems, and therefore, the prevalence of AMR is not well-known. We conducted a prospective observational study to assess the prevalence of AMR among common bacterial isolates from clinical specimens obtained from patients on the medical wards of Kigali University Teaching Hospital (KUTH). We evaluated the antibiotic sensitivity patterns of bacterial pathogens cultured from urine, blood, sputum, and wound swab specimens obtained over a 6-month period (July 1 to December 30, 2013). There were 154 positive cultures from specimens obtained from 141 unique patients over the study period. Urine, blood, wound swab, and sputum cultures comprised 55.2%, 25.3%, 16.2%, and 3.3% of the total specimens evaluated; 31.4% and 58.7% of Escherichia coli and Klebsiella isolates, respectively, were resistant to at least one of the third generation cephalosporins. Eight percent of E. coli isolates were resistant to imipenem; 82% and 6% of Staphylococcus aureus strains were oxacillin- and vancomycin-resistant respectively. Antimicrobial resistance rates are high in Rwanda and pose a serious therapeutic challenge to the management of common infections.

Reaching the Unreached: Treatment as Prevention as a Workable Strategy to Mitigate HIV and Its Consequences in High-Risk Groups

While there have been significant advances in curbing the HIV disease epidemic worldwide, there continues to be significant number of incident cases with 2.3 million new infections in the year 2012 alone. Treatment as prevention (TasP), which involves the use of antiretroviral drugs to decrease the likelihood of HIV illness, death and transmission from infected individuals to their noninfected sexual and /or drug paraphernalia-sharing injecting partners, must be incorporated into any HIV prevention strategy that is going to be successful on a large scale. Especially in resource-limited settings, the focus of the prevention approach should be on high-risk groups who contribute disproportionately to community HIV transmission, including people who inject drugs (PWID), men who have sex with men (MSM) and sex workers. Innovative strategies including integrated care services adapted to different patient care settings have to and can be employed to reach these at-risk populations.

Drug interactions between buprenorphine, methadone and hepatitis C therapeutics

ABSTRACT Introduction: People who inject drugs (PWID) and other individuals with opioid use disorders have a dramatically higher prevalence of hepatitis C virus (HCV) infection than the general population. The availability of novel direct acting antivirals (DAAs) for the treatment of HCV infection with very high efficacy, improved tolerability and shortened treatment durations have led to global efforts to ramp up treatment for all HCV-infected individuals to prevent or delay complications of the disease. Individuals with opioid use disorders, including those on medication-assisted therapy such as methadone or buprenorphine, are a key demographic group that can benefit from HCV treatment given their high HCV prevalence; however, pharmacokinetic and pharmacodynamic drug interactions could blunt their utility. Areas covered: We performed a comprehensive literature review of published and unpublished data from PubMed database, relevant conference abstracts/proceedings and FDA approved drug package inserts, to review the pharmacokinetic (PK) profile and drug interactions between currently approved HCV DAAs and methadone and buprenorphine. Expert opinion: The paper highlights specific drug combinations which result in altered opioid drug levels including telaprevir/methadone, daclatasvir/buprenorphine, and Abbvie 3D combination regimen (paritaprevir, ritonavir, ombitasvir and dasabuvir)/buprenorphine. However, concurrent pharmacodynamics assessments did not reveal significant signs and symptoms of opioid withdrawal or toxicity that would preclude concurrent administration.

Extensive Central Nervous System Cryptococcal Disease Presenting as Immune Reconstitution Syndrome in a Patient with Advanced HIV: Report of a Case and Review of Management Dilemmas and Strategies.

One of the complications of the use of antiretroviral therapy (ART), immune reconstitution inflammatory syndrome (IRIS), is particularly problematic in the management of cryptococcal meningitis. We present the case of a 35-year-old male with acquired immune deficiency syndrome diagnosed with extensive central nervous system (CNS) cryptococcal disease, including meningitis and multiple intracranial cysts, diagnosed eight weeks after the initiation of ART. The patient experienced a relapsing and remitting clinical course despite repeated courses of potent antifungal therapy and aggressive management of raised intracranial pressure. This review highlights therapeutic dilemmas and strategies in the management of CNS cryptococcosis complicated with IRIS and highlights gaps in available treatment guidelines.

Association of circulating cytochrome c with clinical manifestations of antiretroviral-induced toxicity

Diagnosis of antiretroviral therapy (ART) toxicity is complicated. Apoptosis has been implicated in ART toxicity. Cytochrome c (Cyt-C) is a mitochondrial protein found in plasma during pro-apoptotic states. We conducted a study of HIV-infected individuals on ART with (cases, n=21) and without (controls, n=21) clinical evidence of toxicity to determine if elevated plasma Cyt-C is associated with ART toxicity. When corrected for CD4 count, viral load, and duration of HIV infection, cases are 7.86 times more likely than controls to have plasma Cyt-C>0.216 ng/mL. Cyt-C could be a useful clinical tool to guide treatment decisions in this population.

Concurrent cryptococcal meningitis and disseminated tuberculosis occurring in an immunocompetent male

A 61-year-old man living in rural Rwanda presented with a 2-month history of fevers, headaches, dry cough, weight loss and confusion. A cerebrospinal fluid analysis revealed neutrophilic pleocytosis, yeast and a positive cryptococcal antigen (CrAg). An HIV antibody test was negative. The patients cough worsened while on antifungal induction therapy with intravenous conventional amphotericin B and high-dose oral fluconazole. Computerised tomography (CT) scan of the chest showed extensive miliary infiltrates. Bronchoalveolar lavage revealed acid-fast bacilli on smear and a positive GeneXpert test without rifampicin resistance. The patient improved with the addition of antitubercular therapy. In this case report, we describe an unusual presentation of two opportunistic infections occurring together in an HIV-negative man with no other known immunocompromising conditions. The case highlights the fact that, in disease endemic areas, multiple disseminated infections can occur in individuals without obvious immunocompromise.

Clinical Profile and Outcome of Patients with Acute Kidney Injury Requiring Hemodialysis: Two Years’ Experience at a Tertiary Hospital in Rwanda

Introduction Acute kidney injury (AKI) requiring renal replacement therapy is associated with high mortality. The study assessed the impact of the introduction of hemodialysis (HD) on outcomes of patients with AKI in Rwanda. Methods A single center retrospective study that evaluated the clinical profile and survival outcomes of patients with AKI requiring HD [AKI-D] at a tertiary hospital in Rwanda. Data was collected on patients who received HD for AKI from September 2014 to December 2016. Patient demographics, comorbidities, clinical presentation, laboratory tests, and mortality were reviewed and analyzed. Predictors of mortality were assessed using age and gender adjusted multivariate analyses. Results Of the 82 eligible patients, median age was 38 years (IQR 28–57 years). Males comprised 51% of the cohort. Infectious diseases including malaria, pneumonia, and sepsis (35.1%) and pregnancy-related conditions (26.9%) were the most frequent comorbidities. Pulmonary oedema (54.9%) and uremic encephalopathy (50%) were top indications for HD. Mortality was 34.1%. On multivariate analysis, receipt of <5 sessions of HD (OR = 4.01, 95% CI 1.185–13.61, P = 0.026) and hyperkalemia (OR = 3.23, 95% CI 1.040–10.065, P = 0.043) were associated with mortality. Conclusion The availability of acute hemodialysis in Rwanda has resulted in improved patient survival and persistent hyperkalemia predicted higher mortality.

Rilpivirine, emtricitabine and tenofovir alafenamide: single-tablet combination for the treatment of HIV-1 infection in selected patients

ABSTRACT Introduction: Co-formulated rilpivirine, emtricitabine and tenofovir alafenamide (RPV/F/TAF) is the 6th single-tablet combination antiretroviral medication approved within the past decade for the treatment of HIV-1 infection. It was approved based on positive bioequivalence studies with already approved drugs with its component compounds, RPV and the single tablet regimen- elvitegravir, cobicistat, F/TAF. Areas covered: This article reviews the chemical, pharmacodynamic and pharmacokinetic properties, key drug interactions, and the efficacy, safety, tolerability and optimal clinical uses of the medication and/or its components in different patient populations. The article incorporates pre-clinical and clinical trial data available from Google, Google scholar, PubMed database, conference abstracts as well as US FDA approved drug prescribing information up till September 30, 2016. Expert commentary: RPV/F/TAF is a once-daily administered, well tolerated, and effective antiretroviral regimen that should be taken with a meal. Desirable properties include less neuropsychiatric toxicity than 1st generation non-nucleoside reverse transcriptase inhibitors, better bone and renal safety than tenofovir disoproxil fumarate containing regimens and it may be used in individuals with a creatinine clearance >30 mL/min. A five-year future view of the role of oral antiretroviral drug therapy as well as evolving treatment options for HIV-infected patients are also discussed in the article.

Unusual presentation of disseminated Nocardia abscessus infection in a patient with AIDS

A 40-year-old man with AIDS presented with symptoms of a chronic cough, subacute headache, generalised weakness with falls, urinary and faecal incontinence, and acute onset subcutaneous nodules. A chest CT scan showed multiple cavitary and nodular pulmonary infiltrates. MRI of his brain and spinal cord revealed innumerable ring-enhancing lesions. Pathological examination of the purulent material obtained from his subcutaneous lesions, as well as transbronchial tissue specimens obtained by biopsy, revealed beaded and branching Gram-positive rods, subsequently identified by 16S RNA sequencing to be Nocardia abscessus species. We observed an excellent therapeutic response to a combination antimicrobial therapy with resolution of the subcutaneous, pulmonary and central nervous system (CNS) lesions. Infections caused by N. abscessus are rare and typically occur in immunocompromised patients. In this article, we will review the presentation, diagnosis and treatment of N. abscessus infection.

Fatal multiple deer tick-borne infections in an elderly patient with advanced liver disease

We present a case of a 66-year-old woman with decompensated alcoholic liver cirrhosis and poorly controlled non-insulin-dependent diabetes mellitus who was admitted with a 1 day history of altered mental status, high-grade fevers, worsening jaundice and generalised malaise with subsequent development of hypotension requiring intensive care. She was diagnosed with severe babesiosis with high-grade parasitaemia. She was also found to have Lyme disease coinfection. Despite aggressive therapeutic measures including appropriate antibiotics and multiple exchange blood transfusions, she developed septic shock and fulminant multiple organ failure with eventual demise. In this article, we highlight multiple tick-borne illnesses in a vulnerable host, in this case an elderly patient with liver cirrhosis, as risk factors for severe morbidity and potentially fatal outcomes.