BackgroundManaging blood stream infection in Africa is hampered by lack of bacteriological support needed for antimicrobial stewardship, and background data needed for empirical treatment. A combined pro- and retrospective approach was used to overcome thresholds in clinical research in Africa.MethodsOutcome and characteristics including age, HIV infection, pancytopenia and bacteriological results were studied in 292 adult patients with two or more SIRS criteria using univariate and confirming multivariate logistic regression models. Expected randomly distributed resistance covariation was compared with observed co-resistance among gram-negative enteric bacteria in 92 paediatric blood culture isolates that had been harvested in the same hospital during the same period of time.ResultsMortality was fivefold increased among patients with positive blood culture results [50.0% vs. 9.8%; OR 11.24 (4.38–25.88), p < 0.0001], and for this group of patients mortality was significantly associated with antimicrobial resistance [OR 23.28 (3.3–164.4), p = 0.002]. All 11 patients with Enterobacteriaceae resistant to 3rd. generation cephalosporins died. Eighty-nine patients had pancytopenia grade 3–4. Among patients with negative blood culture results, mortality was significantly associated with pancytopenia [OR 3.12 (1.32–7.39), p = 0.01]. HIV positivity was not associated with increased mortality. Antimicrobial resistance that concerned gram-negative enteric bacteria, regardless of species, was characterized by co-resistance between third generation cephalosporins, gentamicin, chloramphenicol, and co-trimoxazole.ConclusionMortality was strongly associated with growth of bacteria resistant to empirical treatment, and these patients were dead or dying when bacteriological reports arrived. Because of co-resistance, alternative efficient antibiotics would not have been available in Ethiopia for 8/11 Enterobacteriaceae-infected patients with isolates resistant to third generation cephalosporins. Strong and significant resistance covariation between 3rd. generation cephalosporins, chloramphenicol, gentamicin, and co-trimoxazole was identified. Pronounced pancytopenia was common and associated with increased mortality. HIV positive patients had no excess mortality.

The correlation between metronidazole MIC readings obtained in vitro on two different media for two different inoculum dilutions was studied after two, three, and five days of incubation using 20 clinical isolates of Helicobacter pylori. The PDM epsilometer (E test) was used. After two days of incubation, log MIC values on chocolate PDM and Vestfold charcoal medium, a new charcoal medium, showed good correlation. Charcoal media can thus be used for metronidazole sensitivity tests. In terms of double-dilution gradients, prolongation of incubation time from two to three days and change of inoculum dilution from 0.5 to 4 McFarland had little impact when studied separately. However, the combined effect of the two variables was marked. The matching of a sparse inoculum incubated for two days against a heavy inoculum incubated for three days resulted in readings which, for 30% of the pairs, differed by two double-dilution gradients or more. On the other hand, the separate influence of both variables was found to affect the correlation coefficients significantly. Five days of incubation was associated with a poor correlation when the variables on MIC readings was not exposed in a scale of double-dilution gradients because the intervals were too large. For this reason, scales without thresholds are recommended.

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The number and diameter of colonies of Helicobacter pylori isolates growing on agar plates were determined to compare five methods that produce a culture atmosphere. No catalyst was applied. No significant difference was found between two hydrogen-based kits that have a different capacity for production of H2. These hydrogen-based methods were significantly better than all others evaluated, including one kit that produces ascorbic acid that binds with oxygen. Growth was significantly improved when the atmosphere outside the plastic incubation jars was enriched with 10% CO2, but carbon dioxide enrichment alone (i.e., no reduction of the oxygen concentration) gave a very poor yield. The colony diameter was a sensitive and reliable measure of atmospheric conditions, as the mean intra- and interobserver difference between repeated readings was < or = 0.1 mm for 82% and < or = 0.2 mm for 95% of the isolates.