Confronting resistance from the laboratory bench to the patients’ bed
Microbiology laboratories are the cornerstone of the quality of care of infectious diseases in Paraguay
National Reference Laboratory in Asuncion, Paraguay, recently updated with bio safety measures. Microbiologists provide assessment, technical guidance and training to the sentinel sites of the National Resistance Network. In 2008, the National Reference Laboratory helped to detect and characterize nosocomial outbreaks.
When dealing with an infection, physicians are often faced with the need to identify pathogens and resistance patterns in order to prescribe an effective treatment. Microbiology laboratories should have the capacity to provide this information to clinicians in a timely and accurate manner.
In April 2008, a hospital outbreak was reported by the Infection Prevention and Control Department of the Hospital de Clinicas in Asuncion, Paraguay. The Department collected specimens from hospital patients, and with the joint collaboration of the National Reference Laboratory, these specimens were identified and studied with classic microbiology and molecular techniques.
The frequent communication between the Hospital and the Laboratory allowed the prompt implementation of the most efficient antibiotic treatment and, more importantly, from the public health perspective, the instauration of adequate measures to prevent dissemination in the health care facility. Rigorous hand washing with alcohol gel solution and proper use of protective personal equipment were applied by the health care workers to contain the spread of the resistant pathogens.
Under antibiotic pressure, any bacteria can develop resistance, as was the case for Enterococcus faecium that showed resistance to vancomycin since the late 80’s. In Paraguay, the resistance surveillance program, coordinated by the National Reference Laboratory, has analyzed more than 270 samples since 2000 to determine the resistance pattern and genotyping of the Enterococcus faecium. Introducing new technology, such as molecular techniques, increases the capacity of the microbiology laboratories and impacts directly in the adoption of adequate measures of care, prevention and control of infections acquired in health care facilities.
The USAID/PAHO technical support provided the opportunity not only to update the laboratory and human resources capacity, but to develop a comprehensive quality assurance of the national surveillance resistance network. This network standardized laboratory techniques and include public and private microbiology laboratories from seven national regions.
Strategies for containment of antimicrobial resistance pathogens start at the microbiology laboratories, which provide data on resistance patterns needed for an effective treatment of infections. Reliable laboratory results provide the base for quality clinical care, as in the Hospital de Clinicas in Asuncion.
Maternal Deaths: The countdown has started
A husband who lost his wife due to post-abortion hemorrhage receives a health team at home. “USAID is contributing to the discovery of the real magnitude of maternal mortality in Paraguay, identifying unnoticed maternal deaths.”
Knowledge of the exact number of maternal deaths is vital in order to establish an accurate baseline to measure intervention success. Knowing the real causes of death is the first step for effective health policy design to reduce maternal mortality.
It is estimated that in Paraguay, for every 100.000 live births, 153 women die of complications that arise during pregnancy, delivery and puerperium. Although these figures are exceptionally high, they are only the tip of the iceberg. Many deaths in women of reproductive age are unnoticed maternal deaths. Identifying them and developing policies to avoid future deaths is a challenge that, together with the Ministry of Health of Paraguay and with the help of the U.S. Centers for Disease Control and Prevention (CDC), USAID and PAHO/CLAP-WR are currently tackling.
USAID and PAHO/CLAP-WR have supported the Ministry of Health of Paraguay in developing RAMOS (Reproductive Age Mortality Survey) methodology in three important regions: Alto Paraná, Central Region and Asunción (including the capital city). With the technical support of CDC and the commitment of the Ministry of Health all deaths of women of childbearing age have been investigated, in an effort to identify the real number of maternal deaths. Where clinical records did not exist or were insufficient, trained personnel visited the residences of deceased women and interviewed their families, neighbors, and friends in order to identify unnoticed maternal deaths.
Even though the results are preliminary, they show that from a total of 512 deaths of women between 10 and 54 years old, there was uncertainty regarding pregnancy in 212 cases. It was possible to recover information for 208 cases (a loss of less than 2%). Of the 208 doubtful deaths researched, 28 were maternal deaths. This indicates that in the study period alone, there were 13% unnoticed maternal deaths that were not captured by the official surveillance system, which confirms that the invisible part of the iceberg is still significantly large in Paraguay and requires immediate action.