000			04444nam a22003737a 4500
003			OSt
005			20240305193746.0
008			221206b |||||||| |||| 00| 0 eng d
028			_b Phone: +255 28 298 3384
028			_b Fax: +255 28 298 3386
028			_b Email: vc@bugando.ac.tz
028			_b Website: www.bugando.ac.tz
040			_bEnglish _cDLC
041			_aEnglish
100			_aRiaz Aziz _920186
245			_aPre-post effects of a tetanus care protocol implementation in a sub-Saharan African intensive care unit
260			_aMwanza, Tanzania: _bPublic Library of Science & _b Catholic University of Health and Allied Sciences [CUHAS – Bugando] _c August 30, 2018
300			_aPages e0006667
490			_a Aziz R, Colombe S, Mwakisambwe G, Ndezi S, Todd J, Kalluvya S, et al. (2018) Pre-post effects of a tetanus care protocol implementation in a sub-Saharan African intensive care unit. PLoS Negl Trop Dis 12(8): e0006667. https://doi.org/10.1371/journal.pntd.0006667
520			_aAbstract: Background: Tetanus is a vaccine-preventable, neglected disease that is life threatening if acquired and occurs most frequently in regions where vaccination coverage is incomplete. Challenges in vaccination coverage contribute to the occurrence of non-neonatal tetanus in sub-Saharan countries, with high case fatality rates. The current WHO recommendations for the management of tetanus include close patient monitoring, administration of immune globulin, sedation, analgesia, wound hygiene and airway support [1]. In response to these recommendations, our tertiary referral hospital in Tanzania implemented a standardized clinical protocol for care of patients with tetanus in 2006 and a subsequent modification in 2012. In this study we aimed to assess the impact of the protocol on clinical care of tetanus patients and their outcomes. Methods and findings: We examined provision of care and outcomes among all patients admitted with non-neonatal tetanus to the ICU at Bugando Medical Centre between 2001 and 2016 in this retrospective cohort study. We compared three groups: the pre-protocol group (2001–2005), the Early protocol group (2006–2011), and the Late protocol group (2012–2016) and determined associations with mortality by univariable logistic regression. We observed a significant increase in provision of care as per protocol between the Early and Late groups. Patients in the Late group had a significantly higher utilization of mechanical ventilation (69.9% vs 22.0%, p< 0.0001), provision of surgical wound care (39.8% vs 20.3%, p = 0.011), and performance of tracheostomies (36.8% vs 6.7%, <0.0001) than patients in the Early group. Despite the increased provision of care, we found no significant decrease in overall mortality in the Early versus the Late groups (55.4% versus 40.3%, p = 0.069), or between the pre-protocol and post-protocol groups (60.7% versus 50.0%, p = 0.28). There was also no difference in 7-day ICU mortality (30.1% versus 27.8%, p = 0.70). Analysis of the causes of death revealed a decrease in deaths related to airway compromise (30.0% to 1.8%, p<0.001) but an increase in deaths due to presumed sepsis (15.0% to 44.6%, p = 0.018). Conclusion: The overall mortality in patients suffering non-neonatal tetanus is high (>40%). Institution of a standardized tetanus management protocol, in accordance with WHO recommendations, decreased immediate mortality related to primary causes of death after tetanus. However, this was offset by an increase in death due to later ICU complications such as sepsis. Our results illustrate the complexity in achieving mortality reduction even in illnesses thought to require few critical care interventions. Improving basic ICU care and strengthening vaccination programs to prevent tetanus altogether are essential components of efforts to decrease the mortality caused by this lethal, neglected disease.
700			_aJennifer A Downs _923034
700			_a Robert N Peck _922982
700			_aBernard Kenemo _946781
700			_a Arndt Koebler _946782
700			_aReed Magleby _946783
700			_a Halinder S Mangat _946678
700			_a Samuel Kalluvya _922760
700			_a Jim Todd _945114
700			_aSolomon Ndezi _946784
700			_aGibonce Mwakisambwe _946785
700			_a Soledad Colombe _945967
856			_u https://doi.org/10.1371/journal.pntd.0006667
942			_2ddc _cVM
999			_c19943 _d19943