by Jordan Anderson
Well, here we are at the end. I am sorry that my blog post is coming so close to the conclusion of my trip. Sometimes it takes until the end to truly understand the beginning.
First, let me introduce myself. My name is Jordan Anderson and I am going into my second year at UCSD SOM. I am originally from Marin County in Northern California. I went to Tufts University in Boston, MA where I got a degree in Economics. I have been interested in global health ever since my first Community Health class in my freshman year of college. Ever since then, I have been dying to work abroad. Although, I had the opportunity to work in Uganda for a couple of weeks with a microloan organization, I have never worked abroad in a health care capacity. I went into this trip thinking that I knew at least something about global health. After all, I had worked in global health after college and focused most of my collegiate career on it. Boy, was I wrong. I learned on this trip that understanding health care in low-income settings at a macro level is nothing like seeing it at the micro level (Sorry for the terminology…econ major! 😊).
So….Welcome to Mozambique. Or should I say, bem vinda!? I arrived in Mozambique after a 35 hour flight from San Francisco. I was exhausted, but ready to work. I came to Mozambique to work with Doctor Clotilde Nhatave in the medical wards at Maputo Central Hospital on antibiotic resistance. Maputo Central Hospital is the main public hospital in Maputo (the capital of Mozambique). This wonderful hospital spans multiple city blocks and is built like a fortress. It is surrounded by walls on all four sides. The purpose of my visit is to determine the patterns of bacterial infections and antibiotic resistance in patients with sepsis in the medical wards at HCM. Doctor Clotilde, an internal medicine doctor, has made it her mission to develop an antibiotic stewardship program at HCM. She has just finished a major study in the medical wards in 2018 where she identified the most commonly used antibiotics. Now, she is trying to figure out what specific bacteria patients were sick from and what antibiotics were available to treat them.
If you aren’t aware of the problems we face regarding antibiotic resistance (don’t worry, I didn’t know much about it before I started the project), here is a quick history lesson. The first antibiotic, Penicillin, was discovered in 1928 by Alexander Fleming. Soon after the discovery, Fleming began to warn against resistance. Essentially, bacteria develop defense mechanisms that help them survive when antibiotics are used against them. When a patient takes an antibiotic, only the resistant bacteria survive. They can pass on their antibiotic resistant traits to other bacteria. Over the last 90 years, since the discovery of penicillin, bacteria have developed more defense mechanisms against our medications. Humans have overcome this with a constant supply of new antibiotics from pharmaceutical companies. However, with the antibiotic pipelines running dry, some researchers fear that we are moving into a post-antibiotic world. The WHO predicts that antibiotic resistant infections will cause 10 million deaths per year worldwide by 2050.
So, this takes us back to Mozambique. Due to a lack of funding for research and insufficient electronic health data, Mozambique does not currently have adequate information on their microbial infection and antibiotic resistance patterns. Physicians in the medical wards use information from South Africa as it’s the closest country. However, microbial patterns vary by location so it is vital to use local information. Doctor Clotilde and my project aimed to identify these patterns in order to develop a protocol for prescribing antibiotics at HCM and reduce the use of ineffectual antibiotics in patient care.
I started my first day completely lost (as I spent most of my trip). I used my limited data and google maps to find my way to HCM. I met Clotilde at the entrance to the hospital. She is a wonderful doctor in her 30s. We spent the day on a tour of the hospital. She showed me the medical ward where we would identify the patients. She showed me the ER laboratory where the blood cultures are first brought for identification. We also visited the microbiology lab where positive blood cultures from the ER lab are tested for the specific species using chemical reactions. They also test antibiotic resistance patterns using antibiotic discs.
We spent the next week finalizing our application for IRB approval from HCM so that we could start the project. After approval, the work began. I went to each medical ward every morning (there are a total of 4 medical wards). I looked through each patient chart to determine if the patient fit the criteria for sepsis. We used the SIRS criteria for sepsis. A patient had to have 2 of the below 4 criteria:
- Temperature: >38 degrees or <36 degrees Celsius
- Heart Rate: >90 beats per minute
- Respiration: >20 breaths per minute
- WBC: >12,000/mm3 or <4,000/mm3
Now, let me tell you, reading through patient charts when it is written in a language you do not understand (and you do not have a translator) and in terrible doctor handwriting, is its own type of challenge. At first, I thought that the job was impossible for me. How could I diagnose this patient with sepsis if all I could read was scribbles? After a lot of time scanning through lines, I found an efficient way to sift through the information. After I identified the patients, I gave the list of patients to the nurse. Our nurse, Irondina, was a wonderful contribution to our team. She is kind and funny and willing to improve. She did our blood collection.
Besides identifying the patients, I oversaw the collection of blood culture results. Twice a week I went to the ER laboratory to collect results and twice a week I went to the microbiology lab. Although, I couldn’t speak to the people that worked there, I began to feel at home in these laboratories as I began to recognize faces. After I collected data from the patient’s medical charts, ER laboratory results, and Microbiology laboratory results, I put the data into a database. This database allowed me to follow the patient’s specimens through the convoluted and paper-based system.
And so my weeks repeated. Each day I would go through the medical wards identifying patients and tracking their specimens. I would record the information in the database and begin analyzing the data. As the results started trickling in, we began to learn new things about the process of blood culture processing, but not what we had expected.
We had expected to receive a list of pathogens that caused sepsis in our patients. We found a list of contaminations. So here comes another microbiology lesson. 🙂 We have bacteria all over our body, including our skin. One of the most common bacteria on our skin is staphylococcus coagulase negative or staphylococcus epidermis. This bacteria can contaminate blood draws and lead to false positives. We found that in the first couple of weeks, over 60% of identified bacteria were staphylococcus coagulase negative. These results forced us to go back to the drawing board. We retrained the nurses we were working with. We added iodine to the regimen and swapped out alcohol on cotton balls with alcohol swabs. After months of planning this research, I was shocked that the major intervention we implemented was alcohol swabs. This is just one example of the hoops that we had to jump through to get this study done.
We were also challenged in specimen identification. HCM does not use one number to identify each patient, so you have to follow specimens using names. This turns out to be like a game of telephone. The patient’s name might be Maria Tomas Sitoe, but by the microbiology lab it looks like Martha Tique. I don’t know how this happens, but it makes for quite the challenge. I can add to the list of roadblocks, but I won’t bore you. Suffice to say that I learned many things from helping to design and implement this study. I learned that conducting research in low income environments (without an electronic health record and without WiFi) is a slow, arduous process. It requires a lot of patience (something I can be short on) and understanding. However, it is vital to conduct because even basic information, like the types of bacteria causing sepsis and their resistance pattern may be critical to improve patient care.
Today, I got to present the preliminary results to the residents and attendings in the medical wards. It was wonderful to see the results of months of hard work pay off. I hope this research leads to real change in antibiotic use on the medical wards. I know that Dr. Clotilde will fight tooth and nail to make sure the results of the study have an impact.
This whole trip has been a whirlwind. It’s definitely had its ups and downs. As I head off to hike Kilimanjaro tomorrow, I am reminded just how lucky I am. I get to work in the best profession…medicine. I get to collaborate with physicians around the world to improve the lives of others. I can’t ask for more. Thanks for reading and I hope you get to go on your own adventure soon!