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This content is taken from the BSAC, Infection Control Africa Network (ICAN) & College of Medicine University of Lagos (CMUL)'s online course, Antimicrobial Stewardship for Africa. Join the course to learn more.

Skip to 0 minutes and 26 seconds You’ve got to stop worrying. Stop worrying. We’ve gotten all the drugs they asked us to get Everything will be fine. Ee-en? Just a minor accident, everything will be fine. Doctor, how is he? Good morning Yes [INTERPOSING VOICES] What’s happening? Is he not my husband? Mommy, calm down. Doctor, what—how is he? [Doctor] I’m so sorry but we lost Mr Anote this morning. Jesus! [Doctor] Please calm down. Take it easy. Be strong for your family. We did the very best that we could. I’m so sorry for your loss. It must seem shocking. I’m very sorry. [Crying] Ha aaa, no, no, no.

Skip to 1 minute and 23 seconds [Narrator 1] We are outside the ward where Mr. Anote Morounfolu has died after two months in the hospital. He was rushed here from the accident and emergency unit of another hospital. On his way to work as a commercial bus driver, Mr. Anote Morounfolu was hit non-fatally in the lower abdomen by a reversing truck. He thought nothing of the incident and went to work where he complained to his boss, who asked him to go home and rest. Later in the evening, Mr. Anote complained that the ache had now grown in intensity, and his wife rushed him to a nearby chemist. Getting to the chemist, he was given painkillers and an antibiotic.

Skip to 2 minutes and 1 second His brother remembered to have seen a red and yellow pill, believed to be tetracycline. However the dose and the quantity were unknown. He was also given vitamins and a sedative. In the night, Mr. Anote Morounfolu was feeling very bad and was taken to a nearby hospital, where he was given further painkillers and antibiotics. In the morning, Mr. Anote Morounfolu complained severely, and was rushed to a tertiary health institution. On getting there, he was in obvious distress with suspected internal organ damage, and was rushed into the theatre. He was then placed on broad spectrum antibiotics prophylactically. He was suspected of internal organ damage. His family was given the list of the antibiotics to go and buy, but they were very expensive.

Skip to 2 minutes and 47 seconds His family run around for the money. Eventually, did find some money, but it was not nearly enough.

Skip to 2 minutes and 59 seconds [Doctors talking] Welcome, Doctor. How was your night? Fine, thank you. How was yours? Oh mine was hectic. The patient gave us some tough time, but we were able to pull over and I’m going to give you a report on him.

Skip to 3 minutes and 18 seconds The results came .. Good morning. Good morning. It’s so earl to have a lot of things in the lab? This is the file on Anote’s with recent laboratory results that come in. Why don’t you please briefly tell us on the patients case. OK. After Mr. Anote’s surgery, after the first exploratory laparotomy and repair of ruptured viscous, he came around but required intensive care, unit care, which we did. As a precaution, he was placed on antibiotic regimen, which was started from the theatre. Wound dressing was done adequately and catheterisation in line with protocol. So the surgeon said this is sufficient clinical reason so keep him on more expensive antibiotics, which he did.

Skip to 4 minutes and 8 seconds But his postoperative period was jeopardised by a breakdown of intestinal anastomosis which required a repeat laparotomy. OK. During the surgery a lot of fluid was drained out from the abdomen. But none of it was sent to the microbiology. This is what I have on Anote’s case for now. OK. Thank you. Thank you very much, nurse Joke. Let’s review the patient and see how he’s doing clinically. That would be nice.

Skip to 4 minutes and 42 seconds Doctor, how’s this? [INTERPOSING VOICES]

Skip to 4 minutes and 51 seconds Thank you.

Skip to 4 minutes and 58 seconds Mr. Anote Morounfolu returned to the ICU, where he continued to have a stormy postoperative period. He was placed on the antibiotic regimen that was prescribed to him in the theatre. However, no samples were sent to the lab for culture and sensitivity or for biomarkers.

Skip to 5 minutes and 16 seconds How are you? Sorry about your loss. The Lord is our strength. It’s a lot. I’m so sorry about it. We are completely confused. I mean, he went to work that day by himself after the lorry hit him. And then now we are here after a new operation, we are told that he needed another one, and that we are to bring money. The drugs they placed him on were so costly. And after a while it became difficult for us to get money to buy the drugs, to pay for his dressings, the operations, even the ICU. And then it was even difficult to assist in feeding his children at home. I’m so sorry about this. It’s a lot.

Skip to 5 minutes and 56 seconds I mean, I’m so sorry. Please take heart. Thank you, mum. I’m so sorry about it. It’s the usual practice for some so-called dirty environment to be placed on prophylactic antibiotic cover, in Lagos and some bus depots… usually come in filthy and un- washed from several days. It only makes sense to place them on high dose of broad-spectrum antibiotic, but they usually come in intravenous infusion. Mr. Anote Morounfolu continued to have a rocky convalescent period, developing bedsores and wound infections. He was left on the very expensive antibiotic regimens. Now, despite various opportunities, no samples were taken from the wound and sent to the lab for culture and sensitivity.

Mr Anote's story Part 1

In the hospital setting, antibiotics misuse has been noted as a driver of antibiotic resistance.

Antibiotic misuse includes:

Underuse - An antibiotic is not used when it could improve health.

Unnecessary use – where an antibiotic is not indicated and there is no health benefit for the patient (e.g. treatment of an upper respiratory infection caused by a virus or an antibiotic is not recommended).

Inappropriate use – there is an indication for empirical treatment but choice of antibiotics, timing, dose, route, frequency of administration or duration of treatment is incorrect. For example, choice of an antimicrobial with an unnecessarily broad spectrum or too narrow a spectrum, dose is too high or too low, duration is too long or too short; treatment is not de-escalated or changed when microbiological culture data become available; duration is > 24 hours for surgical prophylaxis, (except in surgical procedures with a long duration).

Now watch this extract from Mr Anote’s story. Looking at this case history there were instances of antibiotic misuse in the tertiary hospital setting.

Can you identify such areas of antibiotic abuse from the video?

Make notes to refer to later.

The transcript for this video is available below.

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