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Mr Anote’s story

Mr Anote's story - a fictitious scenario video to set the scene for this course.
You’ve got to stop worrying.
Please, calm down. Take it easy. Be strong for your family. We did the very best that I could. I’m so sorry for your loss. It must seem shocking. I’m very sorry.
Ha aaa, no, no, no.
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 dull 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.
His brother remembered to have seen a red and yellow pill, believed to be tetracycline. However, the dose only 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 giving 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 didistress 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.
His family ran around for the money, eventually did find some money. But it was not nearly enough.
[Doctors talking] Welcome, doctor, how’s your night? Fine, thank you. How was yours? Oh mine was hectic. The patients gave us a tough time, but we are able to pull over and I’m going to give a report on him.
Good morning. Good morning. Good morning. It’s so early to have a lot of things in the lab. This is a file on Mr Anote with recent laboratory results that come in. Why don’t you please briefly tell us on the patient’s case. OK. After Mr Anote’s surgery, after the first exploratory laparotomy and repair a ruptured viscous, he came around but required intensive care, unit care, which we did. As precaution he was placed on antibiotic regimen which we 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.
But his post-operative period was jeopardised by a breakdown of intestinal anastomosis, which required repeat laparotomy. During this surgery a lot of fluid was drained out from the abdomen, but none of it was sent to microbiology. This is what I have on Mr Anote’s case for now. Thank you very much, nurse Joke. Let’s review the patient and see how he’s doing clinically. That would be nice.
Thank you.
Mr. Anote Morounfolu returned to the ICU where he continued to have a stormy post-operative 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.
How are you? Sorry about the loss.
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 one 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. 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 patients to be placed on prophylactic antibiotic cover, in Lagos and some bus depots… usually come in filthy and unwashed from several days. It only makes sense to place them on high dose of broad spectrum antibiotic, but they usually come in with intravenous infusion. Mr. Anote Morounfolu continued to have a rocky convalescent period, developing bedsores and would infections. He was left on the very expensive antibiotic regimen. Now, despite various opportunities, no samples were taken from the wound and sent to the lab for culture and sensitivity.
After a long time in the ICU, the doctors finally released him to the general ward and changed the drugs to another one, which was also given by drip. It was very, very difficult for us by the time. If we had only be told, were there no cheaper versions of the drugs we were told to buy?
Sometimes we should be courageous enough to tell the consultants one or two things. It was obvious that there were financial constraints from the family’s side. Even though it’s not the best to treat a patient based on financial consideration. Up until Anote died, there was no sensitivity done to confirm if he was on the best antibiotic regimen. After the ICU care, he was transferred to the general ward, where where you have nursing staff that were not sufficient enough to care for the bedsores and do normal wound dressing. Even the consultant microbiologists visited and recommended a much cheaper antibiotic than the one he was on. But no consultants changed the treatments on the chart. The surgery was done thirty-six hours after admission.
On admission, he had been placed on intravenous ceftriaxone 500 milligrams and intravenous metronidazole 500 milligrams 8 hourly. During the surgery, no sample of the peritoneal fluid collection was sent to the lab for culture. The patient was then commenced on intravenous meropenem 2 grams 8 hourly, together with the metronidazole, and the ceftriaxone was discontinued. He was admitted into the ICU for ventilatory support. The medical microbiologist reviewed his case (as medical microbiologists usually review antibiotics of patients in the ICU), and he recommended that meropenem be reduced to one gram 8 hourly and metronidazole be discontinued. However, the managing team continued with meropenem two hours, 8 hourly and metronidazole 500 milligrams 8 hourly.
While in the ICU, he developed some complications and a second laparotomy was required to repair an anastomotic leak. This was done seven days after the first operation and meropenem two grams 8 hourly and metronidazole 500 milligrams 8 hourly were still being administered. Once again, no sample of the peritoneal fluid was taken to the microbiology lab for culture. He continued to receive meropenem and metronidazole intravenously for 20 more days while on admission in the ICU. He was then discharged into the ward as soon as no longer needed ventilatory support and could take his antibiotics orally. His antibiotic regimen then changed to intravenous levofloxacin 500 milligrams daily and metronidazole 500 milligrams 8 hourly.
This was then reviewed after 10 days and changed to intravenous amoxiclav and metronidazole. The basis of changing these antibiotics from one antibiotic to another that was not apparent. And there was no clinical indication either for continuing the antibiotics. The managing team felt they needed to give him antimicrobial cover to prevent infection from the slowly healing wound until he was discharged from the hospital. His antibiotic regimen then changed again after three days to intravenous amoxiclav, ciprofloxacin, and flagyl. He went on to develop bedsores and fever and his antibiotics were changed to intravenous levofloxacyn 500 milligrams daily and metronidazole 500 milligrams 8 hourly and gentamicin 80 milligrams 8 hourly. He continued to deteriorate despite his antibiotics and later died from sepsis.

In her introduction to the course Dr Oduyebu described the situation in Africa where stewardship is not widespread, with freely available antibiotics and no regulation to restrict their use.

As you watch this video, showing a fictitious case, ask yourself the following questions:

What do you need to know or do to prescribe antibiotics rationally? How can you help more to prevent antimicrobial resistance in your community? What policies are already in place, if any, in your locality for antimicrobial stewardship, and what else needs to be done?

The full transcript for this video is available below.

This article is from the free online

Antimicrobial Stewardship for Africa

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