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IntroductionSepsis and antibiotic resistance constitute a deadly synergy, causing the loss of millions of lives across the world, with their economic and developmental consequences posing a threat to global prosperity. Their impact is disproportionately felt in resource-limited settings and among vulnerable populations, especially children. A key challenge is prompt diagnosis and timely commencement of appropriate antibiotic therapies. These challenges are compounded in low-income and middle-income countries by a lack of comprehensive epidemiological data, with Nigeria being one such country for which it is lacking. Kaduna is the third largest state in Nigeria, with over 10 million inhabitants, of whom more than half are children under 14 years old. While bacterial sepsis and antimicrobial resistance (AMR) are recognised as a growing problem in the state, there are huge gaps in the current understanding of their aetiology. This project employs a cross-sectional design to investigate the clinical and haematological markers of paediatric sepsis, alongside determining the bacterial cause and prevalence of AMR at four high-turnover hospitals in Kaduna State, Nigeria. Further, whole-genome sequencing of isolated bacterial pathogens will be performed to determine the genetic features of resistance. This project represents the largest surveillance study of paediatric sepsis in Kaduna to date. Additionally, we aim to use the clinical, haematological, microbiological and genomic data to derive predictive models for sepsis causes, treatment strategies and patient outcomes.Methods and analysisThis is a hospital-based, cross-sectional study that will recruit up to 461 children with bacterial sepsis who were admitted at the two teaching and two general hospitals in Kaduna State, Nigeria. Children presenting with features of fever, subnormal temperature and body weakness would be recruited into the study and have their blood samples collected. The blood samples will be used for culture, complete blood count, HIV and malaria testing. Accordingly, we will capture clinical presentation, haematological characteristics, causative pathogen from blood culture and patient outcomes. Nutritional status, known congenital immunosuppressive diseases, HIV infection and malaria infection will also be determined and documented. The bacterial isolates will be phenotypically characterised for AMR and genotypically following whole genome sequencing. Known and potential confounders to the outcomes of bacterial sepsis would be assessed in all participants, and adjustment for confounding would be performed using logistic regression and/or stratification±Mantel-Haenszel estimator where applicable.Ethics and disseminationEthical approvals were granted by the University of Birmingham (ERN_2115-Jun2024), the Ahmadu Bello University Teaching Hospital (ABUTHZ/HREC/H45/2023), Barau Dikko Teaching Hospital, Kaduna (NHREC/30/11/21A) and the Kaduna State Ministry of Health (MOH/AD M/744/VOL.1/1110018). The study will be conducted using the international guidelines for good clinical practice and based on the principles of the Declaration of Helsinki. The results will be disseminated via oral and poster presentations in scientific conferences and published in peer-reviewed journal articles.

Background Carbapenem resistant Enterobacterales (CRE) are important cause of antimicrobial resistance (AMR). AMR is a global problem that disproportionately affects the low and middle income countries (LMIC) more. Appreciating what these risk factors were before the recent COVID-19 epidemic would help us appreciate what changes have happened in the post COVID-19 era. Methods This was a hospital-based cross-sectional study conducted in 2017 in the largest tertiary health facility in northern Nigeria. Epidemiologic risk factors of interest were investigated using an interviewer administered questionnaire, followed by collection of a rectal swab sample. Regression analyses were conducted to appreciate what were the strengths of association between the outcome of interest as rectal carriage of CRE and the investigated risk factors. Results Rectal carriage of CRE was 4.2% ( N  = 168) in this study. Increasing age was independent risk factor (adjusted OR = 0.2, CI:0.04–0.98, p  = 0.047) that increased the risk of rectal carriage of CRE. Education appeared to decrease the risk (unadjusted OR = 0.21, CI:0.06–0.76, p  = 0.018) while length of admission stay in Nigeria increased the risk of rectal carriage of CRE (adjusted OR = 3.9, CI: 1.12–13.49, p  = 0.030) against rectal carriage of CRE. Also the ward a patient was admitted into was an important risk factor that increased the risk (adjusted OR = 3.1, CI:1.14–8.20, p  = 0.030) for rectal carriage of CRE. Conclusions Length of hospital stay and the ward a patient was admitted into were associated with increasing risk for rectal carriage of CRE. Epidemiologic risk factors for rectal carriage of CRE are quite similar within the LMIC context. It will be important to appreciate how these risk factors have changed since the COVID-19 pandemic. This would help make policies that focus on the most efficient counter measures to reduce the burden antimicrobial resistance in the LMIC. Clinical trial number Not applicable.

Antimicrobial resistance (AMR) is a major cause of morbidity and mortality. AMR is a global problem that disproportionately affects the low and middle-income countries (LMIC), and Extended Spectrum Beta-lactamases producing Enterobacterales (ESBL-PE) are an important contributor. This study was aimed at understanding what risk factors were associated with the rectal carriage of ESBL-PE before the recent COVID-19 epidemic. This was a cross-sectional study conducted in 2017 at a tertiary health facility in northern Nigeria. Risk factors of interest were investigated using an interviewer-administered questionnaire, and a rectal swab sample was collected for analysis. Multiple logistic regression analyses were done to appreciate what risk factors were associated with rectal ESBL-PE carriage. This study found a rectal ESBL-PE carriage of 87.5% (N = 168). Significant risk factors included length of hospital stay in the past year outside Nigeria (X2 = 14.3, p = 0.003), any form of antibiotic use outside Nigeria (X2 = 8.2, p = 0.004), and beta-lactam antibiotic use outside Nigeria (X2 = 8.2, p = 0.004). Previous hospital admission outside Nigeria was found to be a protective independent risk factor against rectal ESBL-PE carriage (OR = 0.065, CI 0.005-0.806, p = 0.004). Rectal ESBL-PE carriage was high during the pre-COVID era in the LMIC context. As the COVID pandemic era ensures, it will be necessary to appreciate what risk factors for the rectal carriage of CRE look like. This would enable LMIC policymakers to contextualize countermeasures to be effective in mitigating the problem of AMR.

Abstract Background Hospital acquired infection (HAI) is a major problem in healthcare delivery worldwide despite medical advances. A low HH compliance rate of 17.1% was found among surgical health workers at Ahmadu Bello University Teaching Hospital (ABUTH) Zaria, Nigeria. Although hand hygiene (HH) is a proven low-cost means to curtail HAI, low HH compliance is a global reality. The WHO multimodal strategy attempts to address low HH compliance within the frame of contextual realities. Methods This was an interventional study utilizing action research through a mixed method approach to investigate the effectiveness of employing a contextualized multimodal strategy to enhance the HH compliance rate of doctors at ABUTH Zaria. The study was from August to October 2022. A behavioural change campaign (BCC) HH workshop was carried out on doctors, and data collection followed immediately in the surgical wards (i.e. clusters) that had received environmental modification through the provision HH posters and nurses for visual and verbal reminders, respectively. The four clusters were: visual reminders only, verbal reminders only, visual and verbal reminders combined and neither visual nor verbal reminders (i.e. control). All clusters received an uninterrupted supply of alcohol-based hand rubs (ABHR) throughout the study period. The HH observation proforma for ‘five moments of HH’ template was used to collect the quantitative data through direct observation while qualitative data were by one-on-one interviews on doctors in surgical wards at ABUTH Zaria. Results The cumulative HH compliance rate by doctors was 69% (N = 1774). This was significantly different from the baseline HH compliance rate of 17.1% before this study’s intervention (P < 0.0001, C. I. 45.5% to 57.7%). HH was observed from doctors most in wards with both visual and verbal reminders (78%) while lowest (59%) where visual and verbal reminders were not provided, i.e. C4 (n = 444). Compared with the baseline HH compliance, all interventions were significant. However, compared with C4, visual reminders only (C1) had insignificant effect on influencing the HH practice of doctors while visual and verbal reminders combined. Verbal reminders only (C2) were found to be as effective as when combined with visual reminders (78%) as the difference was statistically insignificant (P = 0.4791, CI −3.5% to 7.5%, χ2 = 0.5). However, all doctors reported being motivated to perform HH by the presence of ABHR which was similar to the significance found even in the ward where no verbal or visual reminders (59%, n = 444) were used compared with the baseline (17%, n = 286) before this intervention study (P < 0.0001, CI 35% to 48%, χ2 = 125). All respondents reported hearing about the HH behavioural change workshop even though only one attended. Conclusions Continuous workshop on HH is necessary to sustain awareness of health workers on the importance of hand hygiene. The presence of ABHRs alone was enough motivation for doctors to perform HH but verbal reminders were significant in sustaining this positive attitude towards HH. A scaling of this intervention is needed in other departments so that staff can have changes made to their values towards healthcare delivery as well at ABUTH Zaria. Contextualizing the WHO multimodal strategy is an efficient and acceptable means of addressing the problem of low HH compliance.