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Pathology Project

Azra Khan's Experience in Nandom  

Azra KhanAzra Khan, Senior Biomedical Scientist, working in a Hospital Infection Research Laboratory found the perfect opportunity for her skills through her involvement with Freed UK.

The result was a fulfilment of a deep personal ambition to improve and provide healthcare in a developing country. With the charity, she travelled to Ghana in October, where she worked in challenging surroundings with limited resources to begin to transform the microbiology laboratory of Nandom hospital.

The 'cleaned up' pathology laboratoryThe hospital is 40 years old and serves a population of 500,000 people with just three doctors and 171 beds. Even the most basic hygiene and infection prevention procedures are ignored.

The site is filled with families, who are cooking, washing and cleaning on the grounds of the hospital so they can give food and clean clothes to their hospitalised relatives. Many of them remain camped outside for several days and weeks.

Azra was one of the team of 20 who travelled to Nandom for the two-week trip. Her first task was to roll her sleeves up and give the place a good clean and throw out broken equipment and chemicals that were out-of –date and had no use. Her second major task was to assess and improve the services of pathology.

Azra discusses chemicals with GayeHer commitment to the project is now a life-time pledge. She will travel back to Ghana in 2008 to teach microbiology and infection prevention and control and to continue the work started this time. She would like to take out desperately needed equipment that is in good working order for her hospital, including fridges, incubators, biochemical and haematology analysers, centrifuges, computers and printer, and would be grateful to anyone who could help with donations.

One of the most exciting and unexpected aspects of the trip for Azra was the enthusiasm of the Muslim community in Nandom, which took real inspiration from her achievements as a professional Muslim woman.

The pathology laboratory being equipped.“The whole experience was such a heart rendering journey for me, mainly because I finally achieved my dream to be able to use my skills to help others less fortunate. I felt a sense of achievement as each day we progressed to improve another detail and was always deeply touched by the simplicity of living conditions of the community and their genuine kind gestures in appreciation of our work and presence in Nandom. I have also made long lasting and true friendships with the other team members. From the bottom of my heart I would like to thank my family members, friends and colleagues for all their support and encouragement and help in realising this aspiration”.

Report of Visits in 2011 and 2013

Azrah Khan and Marilena Iouanou  report on further visits to Nandom

The return visit to St. Theresa’s Hospital in October 2013 concentrated on developing the microbiology services. The range of microbiological tests carried out are basic Gram-stains, urine dipsticks, ZN stains for TB, malaria films, and faecal microscopy for ova, cysts and parasites and have not changed much over the years. However, without culture methods to support microscopy results, diagnosis is often inconclusive and of no real value in ensuring effective patient management and administration of correct antibiotic. Since our first visit in 2007 discussions have taken place regularly with the hospital management team and the FREEDUK hospital team members to move this forwards.

Developing Microbiology Services and Implementing Culture Methodology 2011

A small store room within one of the microbiology laboratories was identified as suitable for conversion into a media preparation room. Work to transform the room took place in our 2011 visit, by enrolling hospital assistants to clear out the room of all its contents, and to wash down and paint the walls. The window seal had to be repaired to prevent any dust from entering the room from gaps and contaminating the media. The room took almost a week to clean and refurbish. Wood, paint and other materials were bought from Jirapa (18 miles away), which meant waiting for someone to be available to drive out and purchase the items. Our carpenter was also busy making shelving and restoring tables and chairs for the library project, and he had limited time in-between for designing and producing the wooden laboratory benching and shelving we had requested.

Our Ghanaian colleagues located a small dental bench top autoclave for our use. This autoclave was only able to take one 500ml Schott bottle at a time. We had brought with us from the UK only small amounts of MacConkey agar (selects for coliform bacteria) and Iso-sensitest agar (for sensitivity testing) powders, 40 sterile petri dishes, one Schott bottle (for sterilisation of media) and a short panel of Gram-negative antibiotics and ESBL identification discs (all acquired from De Montfort University).

We set about to prepare our first batch of agar culture media. The autoclave was able to reach the 121degC temperature required for media preparation but subsequently could not hold at that temperature for 15 minutes as required. However, we poured out the media aseptically as possible and hoped there would be no contamination. On settling and drying, the plates showed no obvious signs of contamination, and as there was no way of quality controlling the plates we could only hope they would be good.

We were brought three swabs for culture, taken from three different patients showing signs of post-operative infection. These were plated out onto the agar plates. As we did not have an incubator the plates were left on the bench overnight. The temperature in that room often far exceeds 37degC and drops only 1- 2degC in the night.

The next morning on examination of the plates, all three samples had isolated a pure growth of a coliform bacteria. We prepared Iso-sensitest agar plates for carrying out sensitivity tests of these isolates, in the same way as the culture agar media. In the UK we follow BSAC guidelines to achieve a confluent growth for sensitivity testing. In our rural village hospital laboratory with limited resources we inoculated 3 - 4 colonies into 5mls of sterile water and visually checked that the suspension was not too heavy. Then a sterile swab was immersed into the suspension, and used to manually spread onto the surface of the Iso-sensitest agar plate to hopefully produce a confluent lawn of growth. Antibiotic discs were applied manually using forceps and once again the plates were left on the bench overnight to “incubate”.

The following morning we examined the sensitivity plates and identified one organism to be a multi-resistant strain (possibly a carbapenamase producer) and one to be an ESBL producer. As we had no additional resources to confirm the identification of the isolates we were unable to conclude our findings. Unfortunately that morning we were leaving Nandom to return back to the UK and had to leave our strains and hopes for any further work behind.

2013 Wound study

Enthused by the work and results obtained in our 2011 visit to St. Theresa’s Hospital, we planned to develop the microbiology service fully and to train the hospital staff to carry out culture, identification and sensitivity tests, so that they would be able to continue the service after we had left. We also planned to carry out an extended wound study to expand on the results obtained previously. With this in mind, a commercial company was approached for support and donation of a full range of antibiotics, reagents and kits. Thermo Fisher Scientific – Oxoid Ltd., Basingstoke, UK., generously provided us with a full panel of Gram-positive and Gram-negative antibiotic discs, disc dispensers, culture media powder, Gram-positive latex agglutination kits and reagents to help us to carry out our wound study at St. Theresa’s Hospital. Ideally we wished to take pre-prepared media which would be quality controlled and prepared under sterile conditions, but this was not possible as we could not be assured of media stability due to the high temperatures and extended travelling time before we reached Nandom, therefore, dehydrated agar media was used in the study (provided by Thermo Fisher Scientific and De Montfort University).

When we walked into the laboratory suite that first morning, we were horrified to see that the laboratory and adjacent media preparation room were in a state. The room was being re-tiled and so all the equipment was displaced out in the corridor, but more worrying was the fact that the disruption may be contaminating the media preparation room. We were in a state of panic, disappointment and subdued as it would seem we would not be able to start our study. We contacted our colleague Dominic, to ascertain the situation. Through phone calls he found out that the workmen had gone home for the day and as the next day was a bank holiday due to Eid, there would be no-one around to finish the work. There would however, be someone available the following day to complete the work. However, the day after when we returned to the laboratory expecting it to be finished, we found out that the workman who should have been laying the tiles had unfortunately been involved in an accident and was admitted to hospital and so would be unable to finish the work whilst we were there! The best that could be done would be to wash and wipe down all the walls and window frames in the media preparation room and adjoining microbiology room in an attempt to create a clean environment. The hospital assistants were called in to carry out this work and to finish within a day.

Our first attempt to prepare MacConkey agar did not go well. Twice whilst at the critical stage of reaching 121degC there was a power-cut (a common occurrence during the day, which we would experience on subsequent days) and the media had to be discarded. Then on our third attempt, the power-cut occurred during the holding time. Although we could not be guaranteed of the sterility of the media, we decided to continue to pour the molten media into sterile petri dishes, as we were running out of time (and patience!). The poured plates were left to dry on the bench for a few hours before using to process the swab samples. Each morning fresh MacConkey and Iso-sensitest agar plates were prepared for use for the day.

On a daily basis, our surgical and nursing colleagues would bring us patient swabs for processing. In total 23 patients were sampled; 13 post-operative specimens obtained from the surgical ward, and 10 samples from the out-patient department, from patients showing general wound infections. The OPD samples were taken mainly from infected snake bite infections, farming accidents involving sharp equipment, bicycle falls and boils.

Results

On culture, each swab sample showed multiple (2 – 3) strains of coliform as well as skin flora. All the coliform isolates were selected for sensitivity testing in order to determine the prevalence of different strains causing these infections and/or colonisation. As we had an extensive range of antibiotic discs available to us we carried out full sensitivities. We did not have any biochemical identification kits to fully identify the coliforms, but sloped isolates onto nutrient agar slopes to bring back to the UK for identification. The isolates were identified using the commercial API 20E kits (BioMerieux). We were able to identify Staphylococcus species as Staphylococcus aureus using the Staph Plus Latex Kit (Thermo Fisher Scientific), and MRSA strains were confirmed by resistance to cefoxitin.

Table showing prevalence of isolates detected from 23 swab samples cultured

19 Enterobacteriaceae

7 ESBL positive

(37%)

Identification confirmed:

 

4 E.coli

2 Klebsiella pneumonia

1 Acenitobacter sp.,

4 Staphylococcus aureus

2 MRSA

(50%)

 

14 Pseudomonas aeruginosa

4 = Colistin resistant

 

1 Haemolytic Streptococcus Group A

 

 

Conclusion of Study Results

The results of the study collected interesting but not completely unsurprising data in this short wound study, which has detected a consistent presence of ESBL positive E. coli strains. We did hope to type the ESBL positive strains so that we could determine the prevalence and distribution of the strains as well as an indication of possible cross-infection, but financial constraints have not allowed this. We had thought that we would detect carbapenamase producing organisms but surprisingly we did not isolate any. BSAC guidelines do not give breakpoint sensitivities for Colistin, but recommend performing MIC. However, four strains out of 14 Pseudomonas strains isolated gave an indication of resistance to colistin as growth was detected right up to the antibiotic disc. Although, a small study, the results gave an indication of the prevalence of multi-resistant organisms in developing countries where antibiotic stewardship or effective antibiotic prescribing is not carried out. As expected MRSA was not a real problem in patients from St. Theresa’s Hospital, but from four isolates of Staphylococcus aureus 50% of these were MRSA strains which is a significant figure.

For our team and our Ghanaian colleagues, the most exciting and fulfilling part of the study was that for the first time ever, visiting doctors at St. Theresa’s Hospital were able to review the antibiotic regimen and adjust antibiotic therapy accordingly, i.e. for a short time during our visit to Nandom, patients could be treated with appropriate antibiotics to manage their infections effectively. Patients are treated blindly with a “cocktail” of antibiotics to cover infections caused by both Gram-positive and Gram-negative organisms as well as anaerobes, and our results often indicated that the patient was not on the correct antibiotic. This was quite an achievement, and supported the need for a full microbiology service to improve the level of care and treatment, and especially so, if the hospital is to become a regional Centre of Excellence. However, in the short space of time we had it was difficult to expect our Ghanaian colleagues to be fully confident in continuing with preparing media and culture of samples when we had left the village. It is hoped in our next visit we can concentrate on teaching and training the staff so that they are more confident and competent at recognising significant pathogens, setting up and interpreting sensitivity test results and reporting accurate results. We left the remaining antibiotic discs and dispensers with the laboratory staff, and directed them to the comprehensive guidelines of the BSAC web page so we hope that in our absence they will continue to build and develop their newly gained expertise.