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Introduction: it has been estimated that about 11.8% of the Nigerians suffer serious fungal infections annually. A high index of suspicion with early diagnosis and institution of appropriate therapy significantly impacts on the morbidity and mortality of invasive fungal infections (IFIs). Methods: we conducted a cross-sectional multicentre survey across 7 tertiary hospitals in 5 geopolitical zones of Nigeria between June 2013 and March 2015. Knowledge, awareness and practice of Nigerian resident doctors about the diagnosis and management of invasive fungal infections were evaluated using a semi-structured, self-administered questionnaire. Assessment was categorized as poor, fair and good. Results: 834(79.7%) of the 1046 participants had some knowledge of IFIs, 338(32.3%) from undergraduate medical training and 191(18.3%) during post-graduate (specialty) residency training. Number of years spent in clinical practice was positively related to knowledge of management of IFIs, which was statistically significant (p < 0.001). Only 2 (0.002%) out of the 1046 respondents had a good level of awareness of IFIs. Only 4(0.4%) of respondents had seen > 10 cases of IFIs; while 10(1%) had seen between 5-10 cases, 180(17.2%) less than 5 cases and the rest had never seen or managed any cases of IFIs. There were statistically significant differences in knowledge about IFIs among the various cadres of doctors (p < 0.001) as level of knowledge increased with rank/seniority. Conclusion: knowledge gaps exist that could militate against optimal management of IFIs in Nigeria. Targeted continuing medical education (CME) programmes and a revision of the postgraduate medical education curriculum is recommended.
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Article
Rita Oladele et al. PAMJ - 36(297). 18 Aug 2020. - Page numbers not for citation purposes.
1
Research
Evaluation of knowledge and awareness of invasive
fungal infections amongst resident doctors in Nigeria
Rita Oladele, Akaninyene Asuquo Otu, Olubunmi Olubamwo, Olufunmilola Bamidele Makanjuola,
Ernest Afu Ochang, Joan Ejembi, Nicholas Irurhe, Iember Ajanaku, Halimat Ayodele Ekundayo, Adebola Olayinka,
Oluwole Atoyebi, David Denning
Corresponding author: Rita Oladele, College of Medicine, University of Lagos, Lagos, Nigeria. oladelerita@gmail.com
Received: 03 May 2020 - Accepted: 31 Jul 2020 - Published: 18 Aug 2020
Keywords: Invasive fungal infections, Nigeria, resident doctors, continuing medical education
Copyright: Rita Oladele et al. Pan African Medical Journal (ISSN: 1937-8688). This is an Open Access article distributed
under the terms of the Creative Commons Attribution International 4.0 License (https:
//creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Cite this article: Rita Oladele et al. Evaluation of knowledge and awareness of invasive fungal infections amongst
resident doctors in Nigeria. Pan African Medical Journal. 2020;36(297). 10.11604/pamj.2020.36.297.23279
Available online at: https: //www.panafrican-med-journal.com//content/article/36/297/full
Evaluation of knowledge and awareness of
invasive fungal infections amongst resident
doctors in Nigeria
Rita Oladele1,&, Akaninyene Asuquo Otu2,
Olubunmi Olubamwo3, Olufunmilola Bamidele
Makanjuola4, Ernest Afu Ochang5, Joan Ejembi6,
Nicholas Irurhe1, Iember Ajanaku7, Halimat
Ayodele Ekundayo8, Adebola Olayinka8, Oluwole
Atoyebi9, David Denning10
1College of Medicine, University of Lagos, Lagos,
Nigeria, 2Department of Internal Medicine, College
of Medical Sciences, University of Calabar, Cross
River State, Nigeria, 3Department of Public Health,
University of Eastern Finland, Kuopio, Finland,
4College of Medicine, University of Ibadan, Oyo
State, Nigeria, 5Department of Medical
Microbiology, College of Medical Sciences,
University of Calabar, Cross River State, Nigeria,
6Department of Medical Microbiology, Ahmadu
Bello University Teaching Hospital, Zaria, Nigeria,
7University of Abuja Teaching Hospital, Abuja,
Nigeria, 8Ilorin General Hospital, Ilorin, Kwara
State, Nigeria, 9National Postgraduate Medical
College of Nigeria, Abuja, Nigeria, 10The National
Aspergillosis Centre, University Hospital of South
Manchester, Manchester, United Kingdom
&Corresponding author
Rita Oladele, College of Medicine, University of
Lagos, Lagos, Nigeria
Article
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Abstract
Introduction: it has been estimated that about
11.8% of the Nigerians suffer serious fungal
infections annually. A high index of suspicion with
early diagnosis and institution of appropriate
therapy significantly impacts on the morbidity and
mortality of invasive fungal infections (IFIs).
Methods: we conducted a cross-sectional
multicentre survey across 7 tertiary hospitals in 5
geopolitical zones of Nigeria between June 2013
and March 2015. Knowledge, awareness and
practice of Nigerian resident doctors about the
diagnosis and management of invasive fungal
infections were evaluated using a semi-structured,
self-administered questionnaire. Assessment was
categorized as poor, fair and good.
Results: 834(79.7%) of the 1046 participants had
some knowledge of IFIs, 338(32.3%) from
undergraduate medical training and 191(18.3%)
during post-graduate (specialty) residency
training. Number of years spent in clinical practice
was positively related to knowledge of
management of IFIs, which was statistically
significant (p < 0.001). Only 2 (0.002%) out of the
1046 respondents had a good level of awareness
of IFIs. Only 4(0.4%) of respondents had seen > 10
cases of IFIs; while 10(1%) had seen between 5-10
cases, 180(17.2%) less than 5 cases and the rest
had never seen or managed any cases of IFIs.
There were statistically significant differences in
knowledge about IFIs among the various cadres of
doctors (p < 0.001) as level of knowledge increased
with rank/seniority. Conclusion: knowledge gaps
exist that could militate against optimal
management of IFIs in Nigeria. Targeted
continuing medical education (CME) programmes
and a revision of the postgraduate medical
education curriculum is recommended.
Introduction
Invasive fungal infections (IFIs) are life threatening
infections caused by various types of fungal
species [1]. The last two decades have recorded a
significant increase in the global incidence of IFIs.
This increase has been attributed to the human
immunodeficiency virus (HIV) pandemic, medical
and oncological therapeutic advances and the
presence of better diagnostics for IFIs [2]. Other
identified risk factors for IFI include malnutrition,
severe burns, systemic corticosteroids for > 7 days,
diabetes mellitus and multiple major surgery [3,
4]. However the high morbidity and mortality from
IFIs has been linked to delayed diagnosis and
treatment, the development of resistance and the
severity of illness [5]. The commonest causative
organisms of IFIs include Candida spp,
Cryptococcus neoformans, Aspergillus spp,
Histoplasma capsulatum and Pneumocystis
jirovecii [1, 6, 7]. The estimated annual incidence
of invasive mycoses due to some of these
pathogens is > 400,000 infections per year with
30-95% mortality for Candida species, > 1,000,000
infections per year with 20-70% mortality for C.
neoformans; > 200,000 infections per year with
30-95% mortality for Aspergillus species and
> 400,000 infections per year with 20-80%
mortality for Pneumocystis jirovecii [6]. In the
African continent, the high prevalence of HIV/AIDS
has provided substantial data on the burden of
cryptococcal infections and Pneumocystis jirovecii
(carinii) pneumonia (PCP) [8, 9]. There is however
a paucity of data on invasive candidiasis,
aspergillosis, mucormycoccosis, and other
systemic mycotic infections like histoplasmosis.
Nigeria has an estimated population of 170 million
people and 72,000 doctors registered with the
Medical and Dental Council of Nigeria (MDCN).
There is dearth of data on IFIs in Nigeria despite it
being a high burden HIV and TB country [10]. New
estimates from 2019 indicate a national HIV
prevalence in Nigeria of 1.4% among adults aged
15-49 years [11]. A modelling study estimated that
11.8% of Nigerians suffer serious fungal infections
annually [12]. Currently, there are only four
licensed antifungal agents for IFIs (amphotericin B,
fluconazole, itraconazole and voriconazole) in
Nigeria and these are not readily accessible [13].
Liposomal amphotericin B, flucytosine, micafungin,
caspofungin, anidulafungin, posaconazole and the
recently approved (in Europe and the USA)
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isavuconazole are not available. Most of the
routine laboratories in the country only utilize
conventional diagnostic tests such as direct
microscopy, histopathology and culture, but not
immunodiagnostics or molecular detection
techniques. This severely limits the capacity to
effectively diagnose and treat IFIs, despite early
diagnosis being a critical component for
prognosis [5]. Given the dearth of clinical
microbiologists and Infectious Diseases physicians
in Nigeria today, it is doubtful that IFIs teaching is
being prioritized in the medical training curriculum
in Nigeria with attendant consequences for
persons who develop IFIs. We set out to evaluate
the knowledge and awareness of IFIs amongst
resident doctors from all the geo-political zones in
Nigeria via a multicentre survey.
Methods
Study design: this was a cross-sectional
multicentre survey evaluating Nigerian resident
doctors´ knowledge, awareness and practice about
pathogenic fungi, patients at risk, diagnosis and
treatment of IFIs. We conducted this across 7
tertiary hospitals in 5 geopolitical zones of the
country. The seven tertiary care hospitals that
participated in the study were: Lagos University
Teaching Hospital (LUTH) Lagos, Lagos State
University Teaching Hospital (LASUTH), University
of Calabar Teaching Hospital (UCTH) Calabar,
University College Hospital, Ibadan (UCH),
University of Ilorin Teaching Hospital (UITH) Ilorin,
Ahmadu Bello University Teaching Hospital
(ABUTH) Zaria and National Hospital Abuja. The
study was conducted between June 2013 and
March 2015. The study protocol was duly
reviewed and national approval given by the ethics
review committee of the Lagos University
Teaching Hospital (LUTH). Resident doctors
working in areas typically engaged with diagnosing
and managing patients with IFIs were targeted (i.e.
hematology, pathology, medical microbiology,
oncology, internal medicine, paediatrics, surgical
units, radiology and intensivists) and invited to
participate in the survey. Participation in the
survey was voluntary and verbal consent was
sought in all cases. The consenting doctors were
then issued a questionnaire which was self-
administered on the spot. No incentives were
provided to participating doctors and consultation
of any medical literature (i.e. books, apps and
websites) was discouraged. The specialties were
grouped based on the structure of the faculties in
the West African College of Medicine as follow: 1)
internal medicine, public health, and family
medicine; 2) paediatrics; 3) all surgical
subspecialties including anesthesiology; 4)
laboratory medicine; 5 others.
Data collection and collation: a semi-structured,
self-administered questionnaire was used to
retrieve data on knowledge and awareness of IFIs.
It was divided into the following sections: general
demographic (age, sex, rank, specialty and post-
graduate years), knowledge/awareness and
management practices regarding IFIs. It included
several multi-stem true or false questions. Correct
answers were determined by ROO, OOO, OO, OE
and MOB and it was based on current
international guidelines [14, 15]. Key operational
definitions included: 1) IFIs: this term was used to
describe severe, systemic infections with yeasts or
molds. 2) Molds: this referred to multinucleated,
filamentous fungi composed of branching tubular
structures called hyphae. 3) Yeasts: this referred to
eukaryotic, single-celled microorganisms with
some species having the ability to develop
multicellular budding cells known as
pseudohyphae or false hyphae. 4)
Dermatophytosis: this referred to fungal infections
by dermatophytes (Trichophyton, Microsporum,
and Epidermophyton) that infect keratinous tissue
and are able to invade the superficial layers of
hair, skin, and nails of a living host. Under the
awareness section, the questions centred around
organisms that caused IFI and risk factors for IFI.
Under the management of IFI section, the
questions bordered on diagnostic modalities for
IFIs and the specific therapeutic options for
various IFIs including medications used for
prophylaxis. Each correct answer was scored as 1
point and each incorrect answer as 0 point. The
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questionnaire was pretested amongst ten resident
doctors in medical microbiology at LUTH.
Statistical analysis: the questionnaires were
reviewed and incomplete forms were omitted. The
data was coded, entered and analysed using the
Statistical Package for Social Sciences (SPSS) IBM
version 21. The total number of items under
assessment of awareness of IFIs was 26.
Awareness of IFI was categorized as poor if < 11
(< 40%) was answered correctly, fair if between 11
and 18 (40-69%) were answered correctly and
good if ≥ 19 (≥ 70%) were answered correctly. The
total number of items under management of IFI
was 38. Management of IFI was categorized as
poor if ≤ 15 (< 40%) was answered correctly, fair if
between 16 and 26 (40-69%) were answered
correctly and good if 27 (≥ 70%) were answered
correctly. The results were collated and
summarized as percentages and proportions and
represented in tables. Continuous variables were
presented as means. Chi squared test was used to
compare the differences across groups.
Results
There were a total of 1046 respondents;
675(64.5%) were males while 367(35.1%) were
females; with male to female ratio of 1.8: 1. Five
hundred and Eighty-one (55.5%) of the
respondents were within the age range of 31-40
years while those within the age range of 21-30
years constituted 38.4% of the respondents. The
mean age of all the respondents was 32.36 ± 0.16.
With respect to cadre, the junior resident doctors
were in the majority (504; 48.2%) while the
consultants were in the minority (6; 0.6%). Five
hundred and eighty-two (55.6%) of the
participants were from the surgical subspecialties
(3), while only 70(6.7%) were specializing in
laboratory medicine as shown in Table 1.
In relation to knowledge of IFIs; 834(79.7%) of the
respondents had some knowledge of IFIs. The
commonest source of knowledge about IFIs was
from undergraduate training in medical school 338
(32.3%) followed by 303(29.0%) from personal
reading while others 191(18.3%) learnt about IFIs
during the course of their post-graduate residency
training. The ability to identify common IFIs
appeared to be high as 813(77.7%) and
820(78.4%) were able to correctly identify invasive
aspergillosis and invasive candidiasis as IFIs
respectively. The level of non-response to these
two questions was similar (18.4% and 18.1%).
When asked to identify organisms that cause IFIs;
Fusarium spp, Candida spp, Aspergillosis spp,
Mucor spp and Cryptococcus spp were correctly
identified by 52.4%, 69.7%, 67.9%, 20.6%, and
62.3% respectively. There were varied responses
with regards to the best method of diagnosing IFIs.
While 324 (31%) agreed that the diagnosis of IFIs
could be based on a combination of clinical and
laboratory parameters; 40 (3.8%) of respondents
did not think that the diagnosis should be based
on several criteria (Table 2). Only 4(0.4%) of
respondents had seen more than ten cases of IFIs;
while 10(1%) had seen 5-10 cases, 180(17.2%)
< 5cases and the rest had never seen or managed
any cases of IFIs. Respondents were more likely to
diagnose yeast than mold infections (50.4% vs
16.1%). Five hundred and eighty-eight (56.2%) of
the respondents would not base their treatment
of IFIs on laboratory tests while 616 (58.9%) of
them would embark on empirical treatment with
antifungals in suspected cases of cases IFIs.
Fluconazole was identified as the ideal antifungal
of choice for pre-emptive therapy against
Aspergillus by 442(42.3%) of the respondents; and
for Candida, fluconazole was again the commonest
choice among 599(57.3%) of the respondents
(Table 3).
There were statistically significant differences in
knowledge about IFIs among the various cadres of
doctors (p < 0.001) as level of knowledge
increased with rank/seniority. There were also
statistically significant differences in participants´
perceived knowledge among the various
specialties with the highest proportions coming
from doctors in Anesthesiology and
Ophthalmology 17(94.4%). The lowest proportions
were recorded among doctors in Public Health
16(61.5%) and Radiology 23(67.6%) (Table 4). A
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statistically significant difference was also
observed with respect to suspicion of IFI among
the various specialties. Higher proportions of
doctors who suspected IFI during their medical
practice were recorded among doctors from
internal medicine 87(64.0%) and anesthesiology
10(62.5%). The lowest proportions were recorded
among doctors in general surgery 45(44.6%) and
radiology 16(48.5%) (Table 5). There was a weak
positive correlation between the age (p < 0.001)
and rank (p = 0.004) of the respondents with the
awareness and management of IFIs. The years
spent in clinical practice showed a negative
correlation with awareness of IFI but this
relationship was not statistically significant (p =
0.858). However, the years spent in clinical
practice showed a weak positive relationship with
knowledge of management of IFIs and was
statistically significant (p < 0.001). Awareness of
IFIs among the respondents was strongly positively
correlated with management of IFIs and this was
statistically significant (p < 0.001) (Table 6). The
rate of non-response for the all knowledge based
questions was high and this was most probably
due to poor or no knowledge of the subject
matter. Overall, the awareness of IFI was low
across the centres that participated in this survey
as only 2 (0.002%) out of the 1,046 respondents
scored ≥ 27 (≥ 70%).
Discussion
Our survey confirms the existence of knowledge
gaps in awareness, knowledge and management
of IFIs among resident doctors across Nigeria. This
finding may be linked to the paucity of data on IFIs
from sub-Saharan Africa and in Nigeria in
particular. A study commissioned by International
Society for Human and Animal Mycology (ISHAM)
in 2000 to identify training gaps in developing
countries reported that “the extent of diagnostic
services in mycology in West Africa, based on
questionnaire responses, showed that microscopy
and culture were available in Nigeria and Gambia
but serological tests were not and antifungal
testing was routinely performed only in
Gambia [16]. The ISHAM study also evaluated the
publication trends on fungal diseases in Nigeria
over the last 10 years and found that 44 of the 65
publications were on oral and vulvovaginal
candidiasis, dermatophytes and African
histoplasmosis and did not reflect IFIs. Strikingly, a
10-year retrospective study of mycological
infections at a major tertiary hospital in Nigeria
revealed no laboratory diagnosis of an IFI was
made throughout the study period [17].
Unfortunately, this lopsided nature of things
appears to have persisted in Nigeria.
Amongst those that claimed knowledge of IFIs;
rank was statistically significant (p < 0.001) with
majority being senior registrars (88.4%) and
consultants (100%). However, when asked about
whether they ever entertained the suspicion of
IFIs in their routine practice it was mainly
consultants (100%) and some senior registrars
(68.7%) that had. Although majority (582; 55.6%)
of the respondents were from surgical
subspecialties, only doctors from anesthesiology
appeared to have a fair awareness of IFIs (Table 4,
Table 5). This is not surprising because in the
Nigerian setting, intensive care units (ICU) are
managed by anaesthesiologists. However, surgery
remains a known risk factor for IFIs. Over fifty
percent of the respondents stated that they would
rely on laboratory reports for diagnosis of IFIs,
favoring histology, culture or serology. This
suggests that most of the respondents consider
the clinical features of IFIs to be unreliable.
Interestingly, amongst the doctors in Laboratory
medicine, only 60% would routinely suspect IFIs,
suggesting a major knowledge gap challenge
which is likely to impact upon the outcome of
persons with IFIs.
Whereas international practice guidelines (at the
time of study) advocate for the use of fluconazole
and voriconazole to treat Candida and Aspergillus
infections respectively [14, 15], 57.2% and 42.3%
of respondents opted for fluconazole as drug of
choice for Candida and Aspergillus infections
respectively. Such practice is likely to result in poor
treatment outcomes as fluconazole is not active
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against invasive Aspergillosis. The knowledge gap
demonstrated in this survey is concerning given
that Nigeria has a Postgraduate Medical College of
Medicine that trains resident doctors and awards
fellowships. It is imperative that awareness of IFIs
be developed so that IFIs are considered in the list
of differential diagnosis especially among at-risk
groups. In reality, the index of suspicion of IFI is
usually low and the diagnosis is delayed or
completely missed [18].
A cross-sectional cohort study in Europe showed
that systemic antifungal therapy was administered
to 7% of all patients admitted to an ICU, with only
one-third of them having a documented IFI [19]
and previous European studies demonstrating that
inappropriate use of antifungal drugs may reach
67-74% in tertiary care hospitals [20]. Physicians in
Europe have been reported to have problems
differentiating colonization from infection when
Candida spp. is isolated in urine or in a tracheal
aspirate, which could lead to an over-prescription
of antifungals [20]. Although it is important to
entertain the diagnosis of IFIs especially in
situations where the risk factors for IFIs are
present, it is crucial to collect specimens for
laboratory diagnosis of IFIs prior to
commencement of antifungal therapy. It is also
vital to make a distinction between colonization,
superficial mycoses and IFIs.
In recent times, postgraduate training
programmes have made concerted efforts to
provide accurate, assessments of the competence
of resident doctors. Such assessments are targeted
at optimizing the capabilities of residents by
providing motivation and direction for future
learning [21]. In preventing IFI-related
management errors, it is important to appreciate
that the awareness of the burden of a disease
condition and knowledge of its etiology, diagnosis
and appropriate treatment, are related in a causal
loop [22]. General awareness of the burden of IFI
among physicians should influence the proportion
of patients having IFI that will have a timely
diagnosis or the probability that a physician will
suspect IFI in relevant situations. Physician
awareness together with Physician experience is
likely to increase the probability of diagnosing IFIs
where relevant. This will improve overall
diagnostic accuracy, which is crucial for successful
treatment. One limitation of this study is that we
included mainly resident doctors in tertiary
hospitals who are more likely to influence initial
diagnoses and treatment. However, their opinions
may not mirror that of the consultant physicians
who have the duty to ratify interim treatment
plans. Another limitation stemmed from the fact
that some of the residents who participated were
in supernumerary posts so we could not attribute
the level of knowledge displayed to the centre of
training.
Conclusion
The knowledge gaps among medical doctors
across Nigeria with respect to IFIs need to be
urgently addressed. These gaps can be filled
through improved and targeted continuing
medical education (CME) programs in Nigeria and
a review of the postgraduate medical curriculum.
What is known about this topic
Invasive fungal infections (IFIs) are life
threatening infections caused by various
types of fungal species;
There is dearth of data on IFIs in Nigeria
despite it being a high burden HIV and TB
country;
General awareness of the burden of a
disease among physicians should influence
the proportion of patients with that disease
that will have a timely diagnosis and
receive appropriate treatment.
What this study adds
There was a low level of knowledge of IFIs
among the majority of the 1046 doctors
sampled across Nigeria. Doctors with
greater years of practice experience had
better knowledge of management of IFIs;
The knowledge gaps demonstrated among
doctors across Nigeria with respect to IFI is
profound and is likely to impact negatively
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7
on patients with these serious clinical
conditions;
Targeted continuing medical education
(CME) programmes and a revision of the
postgraduate medical education curriculum
is recommended.
Competing interests
The authors declare no competing interests.
Authors' contributions
Rita Oladele, Olubunmi Olubamwo, David
Denning, Ernest Afu Ochang, Akaninyene Asuquo
Ou, Olufunmilola Bamidele Makanjuola and
Adebola Olayinka contributed to the conception
and design of the study; analysis and
interpretation of data; drafting and revising the
data and have given final approval of the version
to be published. Nicholas Irurhe, Halimat Ayodele
Ekundayo, Iember Ajanaku, Olufunmilola Bamidele
Makanjuola, Akaninyene Asuquo Ou, Joan Ejembi,
and Adebola Olayinka contributed to the
acquisition of the data, revision of the manuscript
and have approved the version to be published.
David Denning critically reviewed the draft. The
manuscript was read and approved by all the
authors and the requirements for authorship were
met. Each author believes that the manuscript
represents honest work.
Tables
Table 1: characteristics of the respondents
Table 2: methods of diagnosing invasive fungal
infections
Table 3: prophylaxis of fungal infections
Table 4: knowledge of invasive fungal infections by
rank and specialty
Table 5: suspicion of invasive fungal infections by
rank and specialty
Table 6: correlation of age, years of practice, and
rank with awareness and management of invasive
fungal infections
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Article
Rita Oladele et al. PAMJ - 36(297). 18 Aug 2020. - Page numbers not for citation purposes.
9
Table 1: characteristics of the respondents
Frequency
Percentage (%)
675
64.5
367
35.1
4
0.4
1046
100.0
402
38.4
581
55.5
58
5.5
5
0.5
1046
100.0
236
22.6
505
48.2
259
24.8
30
2.9
6
0.6
11
1.1
1046
100.0
218
20.9
78
7.5
582
55.6
70
6.7
98
9.4
1046
100.0
The specialties of the respondents were grouped using as follow: 1. Internal medicine, public health, and
family medicine; 2. Pediatrics; 3. All surgical subspecialties including anesthesiology; 4. Laboratory medicine;
5. others
Table 2: methods of diagnosing invasive fungal infections
How best do you believe IFIs should
be diagnosed
Yes frequency (%)
No frequency (%)
No response frequency
(%)
Clinically
534(51.1)
75(7.2)
437(41.8)
Histology
511(48.9)
86(8.2)
449(42.9)
Culture
473(45.2)
56(5.4)
517(49.4)
Serology
347(33.2)
80(7.6)
619(59.1)
Polymerase chain reaction
206(19.7)
45(4.3)
795(76.0)
Combination of above
324(31.0)
40(3.8)
672(65.2)
Article
Rita Oladele et al. PAMJ - 36(297). 18 Aug 2020. - Page numbers not for citation purposes.
10
Table 3: prophylaxis of fungal infections
Choice of pre-emptive therapy
Yes Frequency (%)
No Frequency (%)
No response
Frequency (%)
Aspergillus
Fluconazole
442 (42.3)
56(5.4)
548(53.4)
Amphotericin B deoxycholate
183(17.5)
113(10.8)
750(71.7)
Liposomal amphotericin
114(10.9)
118(11.3)
814(77.8)
Echinocarndins
164(15.7)
126(12.0)
756(72.3)
Voriconazole
73(7.0)
124(11.9)
849(81.2)
Candida
Fluconazole
599(57.3)
41(3.9)
406(38.8)
Amphotericin B deoxycholate
124(11.8)
169(16.2)
753(72.0)
Liposomal amphotericin
160(15.3)
105(10.0)
781(74.6)
Echinocarndins
154(14.8)
111(10.6)
781(74.6)
Voriconazole
130(12.4)
91(8.7)
825(78.8)
Table 4: knowledge of invasive fungal infections by rank and specialty
Do you know about Invasive
fungal infection?
X2
df
P-value
Yes
No
Rank of respondents
47.094
4
0.000**
Senior registrar
205(88.4)
27(11.6)
Junior registrar
423(86.9)
64(13.1)
House officer
169(69.0)
76(31.0)
Medical officer
25(92.6)
2(7.4)
Consultant
6(100.0)
0(0.0)
Total
828(83.0)
169(17.0)
Specialty of respondents
68.080
12
0.000**
General Surgery
90(82.6)
19(17.4)
Public health
16(61.5)
10(38.5)
Internal medicine
131(89.1)
16(10.9)
Family medicine
89(89.1)
10(10.1)
Paediatrics
126(85.7)
21(14.3)
O&G
116(82.3)
25(17.7)
Pathology/ Lab medicine
106(92.2)
9(7.8)
Anaesthesiology
17(94.4)
1(5.6)
ENT
51(78.5)
14(21.5)
Dentistry
0(0.0)
4(100.0)
Ophthalmology
17(94.4)
1(5.6)
Radiology
23(67.6)
11(32.4)
Others
8(50.0)
8(50.0)
Total
790(84.1)
149(15.9)
Article
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11
Table 5: suspicion of invasive fungal infections by rank and specialty
In your experience on patient
management, do you ever suspect
invasive fungal infection?
X2
df
P-value
Yes
No
Rank of respondents
51.369
4
0.000**
Senior registrar
149(68.7)
68(31.3)
Junior registrar
245(53.7)
211(46.3)
House officer
81(36.7)
140(63.3)
Medical officer Consultant
18(62.1) 6(100.0)
11(37.9) 0(0.0)
Total
499(53.7)
430(46.3)
Specialty of respondents
24.456
12
0.018**
General Surgery
45(44.6)
56(55.4)
Public health
13(50.0)
13(50.0)
Internal medicine
87(64.0)
49(36.0)
Family medicine
60(61.9)
37(38.1)
Paediatrics
74(53.6)
64(46.4)
O&G
65(48.5)
69(51.5)
Pathology/ Lab medicine
68(60.2)
45(39.8)
Anaesthesiology
10(62.5)
6(39.8)
ENT
27(46.6)
31(53.4)
Dentistry
0(0.0)
4(100.0)
Ophthalmology
8(53.3)
7(46.7)
Radiology
16(48.5)
17(51.3)
Others
5(33.3)
10(66.7)
Total
478(54.0)
408(46.0)
Table 6: correlation of age, years of practice, and rank with awareness and management of invasive fungal
infections
Awareness of invasive fungal infections
Spearman´s rank correlation
P-value
Age
0.117
0.000
Years of practice
-0.006
0.858
Rank
0.090
0.004
Management of invasive fungal infections
Spearman´s rank correlation
P-value
Age
0.172
0.000
Years of practice
0.145
0.000
Rank
0.049
0.116
Awareness of IFI
0.472
0.000
... Once conditions in their host become favorable, Candida sp. often proliferate and invade the cells, tissues and even organs of their host, resulting in varying health disorders ranging from discomforting diaper rash, oral and vaginal thrush [7,8] to life-threatening invasive Candidiasis [9][10][11]. ...
... responsible for invasive candidiasis. Studies by Oladele et al., [11], Ezenwa et al., [12], Sule et al., [13], and Uchegbu et al., [14], all reported the incidence of one or more of the causative agents of candidiasis in Nigeria. However, clinicians have found candidiasis difficult to eradicate using conventional drugs owing to the constant abuse of antimicrobial products, which have now resulted in emergence of resistant strains of Candida sp. ...
... Once conditions in their host become favorable, Candida sp. often proliferate and invade the cells, tissues and even organs of their host, resulting in varying health disorders ranging from discomforting diaper rash, oral and vaginal thrush [7,8] to life-threatening invasive Candidiasis [9][10][11]. ...
... responsible for invasive candidiasis. Studies by Oladele et al., [11], Ezenwa et al., [12], Sule et al., [13], and Uchegbu et al., [14], all reported the incidence of one or more of the causative agents of candidiasis in Nigeria. However, clinicians have found candidiasis difficult to eradicate using conventional drugs owing to the constant abuse of antimicrobial products, which have now resulted in emergence of resistant strains of Candida sp. ...
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... Pertaining to invasive aspergillosis (IA), 38% of clinicians knew that voriconazole is a better antifungal agent than either liposomal amphoteric B (25.9%) or echinocandin (12.1%) for the management of IA. These results were concordant with Valerio et al.'s study [21], where 57% of the European physicians chose voriconazole as a first-line agent, as adopted by the international guidelines [27]. ...
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Management of invasive fungal infections (IFI) and subsequent treatment choices remain challenging for physicians in the ICU. Documented evidence shows increased practice of the inappropriate use of antifungal agents in the ICU. Continuous education of healthcare providers (HCPs) represents the cornerstone requirement for starting an antifungal stewardship program (AFS). This study aimed at evaluating knowledge gaps in systemic antifungal prescribing among physicians and clinical pharmacists in a critical care setting. A cross-sectional, multi-center, survey-based study was conducted in five tertiary hospitals located in Al-Ahsaa, Saudi Arabia between January and May 2021. A self-administered questionnaire was distributed among the targeted clinicians. A total of 63 clinicians were involved (65.5% ICU physicians and 34.5% clinical pharmacists). It was noted that a minority of the participating HCPs (3.2%) had overall good knowledge about antifungal prescribing, but the majority had either moderate (46%) or poor (50.8%) knowledge. The difference in overall knowledge scores between the ICU physicians and the clinical pharmacists (p = 0.925) was not significant. However, pharmacists showed better scores for the pharmacokinetics of antifungal therapy (p = 0.05). This study has revealed a significant gap in the knowledge and practice of clinicians as regards prescribing antifungal therapy in our area. Although the results cannot be generalized, the outcome of this study has exposed the need for a tailored training program essential for carrying out an AFS program.
... Though there have been schemes aimed at screening to mitigate fungal infections, such as the CDC/CHAI/Unitaid initiative towards ending cryptococcosis deaths by 2030, the allocation of more funds for the diagnosis and treatment of malaria, HIV, and TB has made fungal infections remain a major concern (see S1 Table). Furthermore, fungal infections are always secondary, have relatively long latency period, and being that superficial nonfatal infections are common, IFIs are misconceived, affecting awareness among the endemic areas' dwellers, and even among clinicians [5]. Fungal infections are also significantly influenced by other infections in so many ways ( Fig 1). ...
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Invasive fungal infections (IFIs) have been described as diseases of the poor. The mortality rate of the infections is comparable to that of malaria, HIV, and TB, yet the infections remain poorly funded, neglected in research, and policy at all levels of human resources. The Coronavirus Disease 2019 (COVID-19) pandemic has further worsened the current state of management for IFIs. At the same time, response to COVID-19 has stirred and boosted vaccine production, vaccine substance manufacturing, and building of next-generation sequencing capacity and genomics data sharing network in the continent. Through collaboration and transdisciplinary research effort, these network and technology can be extended to encourage fungal research to address health issues of existing and emerging fungal pathogens.
... In addition, the poor awareness and the low index of suspicion for IFIs by physicians which ultimately affects requests for investigations on IFIs have also contributed to the paucity of data on IFIs. [29,30] The emergence of azole resistance is common amongst organisms causing IFIs in HMs. Prompt identification of the fungal pathogen and susceptibility testing is invaluable for the effective management of the patient with HM. [31,32] The mainstay for prophylaxis and treatment for IFIs is the azoles. ...
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... A poor awareness of fungal diseases among health-care professionals and policy makers, as well as the unaffordability of, toxicity of, and little access to antifungal treatment options are some of the challenges facing the continent. [11][12][13] With few exceptions (such as testing for cryptococcal antigen), advances within the past 5 years in non-culturebased diagnostics have not reached most low-income and middle-income countries (LMICs). Therefore, it is necessary to assess the present status of the diagnosis of fungal infections in these regions to guide health professionals, patients, and policy makers. ...
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... The demand for fungal tests was generally low at 0-9 requests per week in more than three quarters of centres. This is likely a chicken and egg conundrum where it is difficult to establish if the low 19 Virtually all centres offered intensive care and haematology and most offered oncology services. Patients who receive such care have an inherent as well as hospital associated risk for IFIs including invasive candidiasis and invasive aspergillosis. ...
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Background: An estimated 11.8% of Nigerians suffer from invasive fungal infections (IFIs) yearly. Laboratory capacity to diagnose IFIs in Nigeria has not been objectively assessed. Objective: To identify the gaps in laboratory capacity for diagnosis of IFIs in Nigerian tertiary hospitals. Methods: Clinical microbiologists in Nigerian tertiary hospitals were invited to partake in a 21-item online survey via a professional chat group and email. A descriptive crosssectional study of survey responses was conducted. Frequencies were computed for microscopy, culture, antifungal sensitivity, and non-culture based diagnostic modalities. Findings: Respondents were from 22 tertiary hospitals spread across the six geo-political zones of Nigeria. Gaps identified include absence of mycology laboratory/bench in 5/22 (22.7%), no access to a biosafety cabinet in 5/22 (22.7%), lack of laboratory scientists formally trained in mycology in 9/22 (40.9%), lack of participation in external quality assurance in all (100%), lack of automated blood culture facilities in 9/22 (40.9%), no yeast identification beyond germ tube test in12/22 (54.5%), and no anti-fungal sensitivity testing in 17/22 (77.3%). Galactomannan, cryptococcal antigen lateral flow assay and latex agglutination tests are used in 1(4.5%), 3 (13.6%) and 5 (22.7%) centres respectively; antigen/antibody based non-culture diagnostics were totally absent in 12/22 (54.5%) hospitals. Conclusion: Nigerian tertiary hospitals have gaps in the laboratory capacity to diagnose invasive fungal infections despite the significant size of the population at risk of these life-threatening infections in the country. Economically feasible diagnostic solutions and models as well as capacity building are urgently required.
... Low demand may, however, be linked to low levels of awareness and index of suspicion for fungal diseases among physicians; a recent study revealed only 0.002% of doctors had good knowledge of IFIs. 19 Virtually all centres offered intensive care and haematology and most offered oncology services. Patients who receive such care have an inherent as well as hospital associated risk for IFIs including invasive candidiasis and invasive aspergillosis. ...
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Background: An estimated 11.8% of Nigerians suffer from invasive fungal infections (IFIs) yearly. Laboratory capacity to diagnose IFIs in Nigeria has not been objectively assessed. Objective: To identify the gaps in laboratory capacity for diagnosis of IFIs in Nigerian tertiary hospitals. Methods: Clinical microbiologists in Nigerian tertiary hospitals were invited to partake in a 21-item online survey via a professional chat group and email. A descriptive crosssectional study of survey responses was conducted. Frequencies were computed for microscopy, culture, antifungal sensitivity, and non-culture based diagnostic modalities. Findings: Respondents were from 22 tertiary hospitals spread across the six geo-political zones of Nigeria. Gaps identified include absence of mycology laboratory/bench in 5/22 (22.7%), no access to a biosafety cabinet in 5/22 (22.7%), lack of laboratory scientists formally trained in mycology in 9/22 (40.9%), lack of participation in external quality assurance in all (100%), lack of automated blood culture facilities in 9/22 (40.9%), no yeast identification beyond germ tube test in12/22 (54.5%), and no anti-fungal sensitivity testing in 17/22 (77.3%). Galactomannan, cryptococcal antigen lateral flow assay and latex agglutination tests are used in 1(4.5%), 3 (13.6%) and 5 (22.7%) centres respectively; antigen/antibody based non-culture diagnostics were totally absent in 12/22 (54.5%) hospitals. Conclusion: Nigerian tertiary hospitals have gaps in the laboratory capacity to diagnose invasive fungal infections despite the significant size of the population at risk of these life-threatening infections in the country. Economically feasible diagnostic solutions and models as well as capacity building are urgently required.
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Background The increasingly complex medical environment highlights the importance of milestones and entrustable professional activities (EPAs) to realize the ideals of competency-based medical education (CBME). However, if enormous amounts of assessment results need to be compiled, the development of a digital system to manage, integrate, and synthesize learning and assessment data will be necessary. Furthermore, this system should be able to facilitate real-time assessment with feedback and therefore enhance users’ learning through coaching in the moment in the clinical workplace. Objective The main purpose of this study was to develop a competency-based electronic platform system to provide resident physicians with clinical assessments and learning in order to enhance the learning of trainees and reduce the burden of assessments. Methods A competency-based learning and assessment system (CBLAS) for residency training was designed, developed, and evaluated in this study. Opinion interviews and a focus group consensus meeting of key users, including trainees, clinical teachers, and administrative staff, were conducted as needs assessments. The structure of the CBLAS was designed according to the thematic analysis of needs assessments. Clinical teachers’ acceptance of using CBME assessments, according to the constructs of attitude, perceived usefulness, and perceived ease of use, was surveyed in the beginning and half a year after implementation of the CBLAS. Additionally, the satisfaction of using the CBLAS, according to information, system, and service qualities, was surveyed after implementation. Results The main functions of the CBLAS, including milestones, EPAs, learning portfolios, teacher/student feedback, e-books, learning materials, assessment progress tracking, and statistical analysis of assessment results, were designed and developed for responding to nine themes, which emerged from the needs assessments of the three user groups. Twenty clinical teachers responded to the CBME assessment acceptance surveys before and after CBLAS implementation, which revealed a significant improvement in the factor of “attitude” (P=.02) but no significant differences in the two factors of “usefulness” (P=.09) and “ease of use” (P=.58) for CBME assessments. Furthermore, satisfaction surveys were performed in 117 users, and 87.2% (102/117) were satisfied with the CBLAS in terms of information, system, and service qualities. There was no significant difference in satisfaction among different user groups. Conclusions The CBLAS is a user-centered platform that supports clinical teachers’ assessment exercises and residents’ learning, as well as administrative work for staff according to users’ needs assessments and operationalized features of CBME assessments. With the system, clinical teachers had a more positive attitude to conduct the assessment activities of milestones and EPAs and learners could arrange their study schedules to enhance their learning effectiveness. The CBLAS sheds light on how to effectively design and develop a digital system to execute milestone- and EPA-based assessments for enhancing competency-based education among residents, according to our experiences in Taiwan.
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Background: Invasive fungal diseases (IFDs) remain important causes of morbidity and mortality. The consensus definitions of the Infectious Diseases Group of the European Organization for Research and Treatment of Cancer and the Mycoses Study Group have been of immense value to researchers who conduct clinical trials of antifungals, assess diagnostic tests, and undertake epidemiologic studies. However, their utility has not extended beyond patients with cancer or recipients of stem cell or solid organ transplants. With newer diagnostic techniques available, it was clear that an update of these definitions was essential. Methods: To achieve this, 10 working groups looked closely at imaging, laboratory diagnosis, and special populations at risk of IFD. A final version of the manuscript was agreed upon after the groups' findings were presented at a scientific symposium and after a 3-month period for public comment. There were several rounds of discussion before a final version of the manuscript was approved. Results: There is no change in the classifications of "proven," "probable," and "possible" IFD, although the definition of "probable" has been expanded and the scope of the category "possible" has been diminished. The category of proven IFD can apply to any patient, regardless of whether the patient is immunocompromised. The probable and possible categories are proposed for immunocompromised patients only, except for endemic mycoses. Conclusions: These updated definitions of IFDs should prove applicable in clinical, diagnostic, and epidemiologic research of a broader range of patients at high-risk.
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Fungal diseases kill more than 1.5 million and affect over a billion people. However, they are still a neglected topic by public health authorities even though most deaths from fungal diseases are avoidable. Serious fungal infections occur as a consequence of other health problems including asthma, AIDS, cancer, organ transplantation and corticosteroid therapies. Early accurate diagnosis allows prompt antifungal therapy; however this is often delayed or unavailable leading to death, serious chronic illness or blindness. Recent global estimates have found 3,000,000 cases of chronic pulmonary aspergillosis, ~223,100 cases of cryptococcal meningitis complicating HIV/AIDS, ~700,000 cases of invasive candidiasis, ~500,000 cases of Pneumocystis jirovecii pneumonia, ~250,000 cases of invasive aspergillosis, ~100,000 cases of disseminated histoplasmosis, over 10,000,000 cases of fungal asthma and ~1,000,000 cases of fungal keratitis occur annually. Since 2013, the Leading International Fungal Education (LIFE) portal has facilitated the estimation of the burden of serious fungal infections country by country for over 5.7 billion people (>80% of the world’s population). These studies have shown differences in the global burden between countries, within regions of the same country and between at risk populations. Here we interrogate the accuracy of these fungal infection burden estimates in the 43 published papers within the LIFE initiative.
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Background: Cryptococcus is the most common cause of meningitis in adults living with HIV in sub-Saharan Africa. Global burden estimates are crucial to guide prevention strategies and to determine treatment needs, and we aimed to provide an updated estimate of global incidence of HIV-associated cryptococcal disease. Methods: We used 2014 Joint UN Programme on HIV and AIDS estimates of adults (aged >15 years) with HIV and antiretroviral therapy (ART) coverage. Estimates of CD4 less than 100 cells per μL, virological failure incidence, and loss to follow-up were from published multinational cohorts in low-income and middle-income countries. We calculated those at risk for cryptococcal infection, specifically those with CD4 less than 100 cells/μL not on ART, and those with CD4 less than 100 cells per μL on ART but lost to follow-up or with virological failure. Cryptococcal antigenaemia prevalence by country was derived from 46 studies globally. Based on cryptococcal antigenaemia prevalence in each country and region, we estimated the annual numbers of people who are developing and dying from cryptococcal meningitis. Findings: We estimated an average global cryptococcal antigenaemia prevalence of 6·0% (95% CI 5·8-6·2) among people with a CD4 cell count of less than 100 cells per μL, with 278 000 (95% CI 195 500-340 600) people positive for cryptococcal antigen globally and 223 100 (95% CI 150 600-282 400) incident cases of cryptococcal meningitis globally in 2014. Sub-Saharan Africa accounted for 73% of the estimated cryptococcal meningitis cases in 2014 (162 500 cases [95% CI 113 600-193 900]). Annual global deaths from cryptococcal meningitis were estimated at 181 100 (95% CI 119 400-234 300), with 135 900 (75%; [95% CI 93 900-163 900]) deaths in sub-Saharan Africa. Globally, cryptococcal meningitis was responsible for 15% of AIDS-related deaths (95% CI 10-19). Interpretation: Our analysis highlights the substantial ongoing burden of HIV-associated cryptococcal disease, primarily in sub-Saharan Africa. Cryptococcal meningitis is a metric of HIV treatment programme failure; timely HIV testing and rapid linkage to care remain an urgent priority. Funding: None.
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