South African Medical Journal - Volume 103, Issue 6, 2013
Volumes & issues
Volume 103, Issue 6, 2013
Author Bridget FarhamSource: South African Medical Journal 103 (2013)More Less
In February 2013, in what the British Medical Journal called a 'spectacular public relations coup', Andrew Witty, the chief executive officer of GlaxoSmithKline (GSK), announced that the company would sign up to AllTrials - a campaign that has been pressing drug companies to disclose all detailed clinical study reports and drug trial results, not just those with favourable results.
Author Paul PorteousSource: South African Medical Journal 103, pp 354 –355 (2013)More Less
With the HPCSA calling for submissions from interested parties to assist in drawing up an ethical tariff that may be charged by practitioners, much thought, discussion and effort has gone into the concept of a new coding and billing structure. Much insightful and informed input has long been given to this process by the South African Private Practitioners Forum (SAPPF). An 'ethical tariff' cannot be established unless the tariff upon which this is based is itself reasonable, fair and ethical.
Thieves of the state and the South African Medical Association (SAMA)
The South African Medical Association responds : correspondenceSource: South African Medical Journal 103 (2013)More Less
'SAMA upholds the principles of honesty, integrity and patient-centredness and does not condone any unethical practice by its members.'
This is reassuring to see in print, even though it should go without saying for a nation's official medical association. The same SAMA mass e-mail's strident objection to the Free State government's withdrawal of approval for RWOPS (Remuneration for Work Outside the Public Service) during office hours is therefore rather surprising. Surely the very principle of RWOPS is that the work is pursued outside of office hours?
A new algorithm for the diagnosis of all forms of tuberculosis is required for South Africa : correspondenceAuthor Andrew BlackSource: South African Medical Journal 103, pp 355 –356 (2013)More Less
Chesed Children's Clinic : a nonprofit, paediatric primary care outreach clinic in the Eastern Cape created by junior doctors and volunteers : correspondenceSource: South African Medical Journal 103, pp 356 –357 (2013)More Less
Mzamomhle in the Eastern Cape is an impoverished, peri-urban informal settlement of approximately 12 000 people living in 3 100 shacks. These dwellings have no running water, electricity or ablution facilities. Healthcare is provided by a single nurse-run primary care day-clinic. The hospital housing the majority of paediatric beds is about 40 km away, and there is no formal public transport or railway link between Mzamomhle and the hospital.
Source: South African Medical Journal 103 (2013)More Less
We write to alert medical and nursing staff to a continuing problem in the neonatal setting, which has featured in the correspondence pages of the SAMJ on at least two prior occasions. Recently, in KwaZulu-Natal province, at least 4 infants with galactosaemia have been affected by the phenomenon of galactose interfering with glucose meters and producing high readings, resulting in the misdiagnosis of hyperglycaemia.
Author Stephen A. CravenSource: South African Medical Journal 103 (2013)More Less
Dr Naidoo is to be commended for reminding readers of the scourge that is rape. However, he has overlooked the main reason for the abysmally low conviction rate. In many, if not most, allegations of rape there is no witness, and no material evidence. He says that consent was given; she denies it. The magistrate has the unenviable task of deciding who is the more convincing of the two.
Author Sergei JarginSource: South African Medical Journal 103 (2013)More Less
In A Moveable Feast by Ernest Hemingway, the author goes to visit Gertrude Stein and, sitting downstairs, hears from above the following by Ms Stein: 'Don't, pussy. Don't. Don't, please don't. I'll do everything, pussy, pussy, but please don't do it. Please don't. Please don't, pussy.' Hemingway immediately leaves, having said to a servant: 'What a shame.' Gertrude Stein might have said that to her cat jumping onto a table and walking upon some manuscripts.
Source: South African Medical Journal 103, pp 358 –359 (2013)More Less
Three top burns-unit surgeons say costly cultured epithelial autographs (CEAs) 'ordered in' from the United States for less-than-critically burnt patients should not become the norm, because far cheaper, well-researched and equally effective treatment methods are freely available locally.
Source: South African Medical Journal 103, pp 359 –361 (2013)More Less
Addiction to prescription and over-the-counter (OTC) medicines is a hidden, little-researched chronic illness - which could be significantly countered by destigmatisation, 'up-scheduling' certain medications, creating a single electronic database across dispensaries and boosting doctor awareness regarding long-term or repeat prescriptions. This is according to Dr Volker Hitzeroth, President of the South African Addiction Medicine Society and convenor of the addictions sub-group of the South African Society of Psychiatrists.
Source: South African Medical Journal 103, pp 361 –364 (2013)More Less
State-employed consultants are beginning to resign in numbers at two top Gauteng hospitals - and many of their Free State counterparts may soon follow - as a clumsy and sweeping nationwide crackdown on the Remunerative Work Outside Public Service (RWOPS) and overtime begins.
Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients, Ben Goldacre : book review - izindabaAuthor Peter FolbSource: South African Medical Journal 103 (2013)More Less
For a new medicine or vaccine to make a meaningful contribution to the prevention and/or treatment of disease, it has to clear a number of hurdles: consistent evidence of efficacy, in the population to be treated; safety, insofar as the benefit of the medicine should justify the risk of possible adverse events; and quality, demonstrated by laboratory studies. All this, it is generally assumed, derives from studies conducted ethically, objectively and honestly by clinical and pharmaceutical scientists.
Source: South African Medical Journal 103, pp 365 –367 (2013)More Less
Recent trials have failed to demonstrate a survival benefit from the use of hydroxyethyl starches (HES) as a colloid in fluid resuscitation and have raised concerns of renal harm. In severe sepsis, there is a concerning signal of increased mortality. New high-quality systematic reviews consistently demonstrate a statistically non-significant relative risk of death of 1.08 - 1.10 and a significant 25% increased chance of requiring renal replacement therapy. The HES literature contains many industry-affiliated reviews of indifferent quality. Traditional efficacy confidence limits may warrant re-evaluation when considering these harms. Newer formulations of HES and more focused indications for use show benefit on surrogate endpoints, but these trials are currently underpowered to ensure safety.
Surveillance alone plays a key role in curbing the overuse of antimicrobials : the major role of antibiotic stewardship : editorialSource: South African Medical Journal 103 (2013)More Less
Multidrug-resistant organisms are a growing problem in every facet of medicine globally. With the need to address this ever-increasing threat comes a need for new drugs and new interventions. Infections caused by multidrug-resistant organisms have resulted in high mortality and morbidity all over the world. This is because there are few, if any, pharmaceutical and antimicrobial options to treat them. The pipeline is running dry, and a 'nil-antibiotic' era is approaching. It's a scary thought - no effective antimicrobial agent available anywhere in the world.
Author P.C. PotterSource: South African Medical Journal 103, pp 369 –370 (2013)More Less
Sixteen years after the first report of latex allergy in healthcare workers at Groote Schuur Hospital, Cape Town, in 1997, latex allergy remains an occupational risk and an ongoing challenge for healthcare institutions in South Africa, particularly those that have not yet adopted stringent latex-powdered glove avoidance measures.
Microbiological surveillance and antimicrobial stewardship minimise the need for ultrabroad-spectrum combination therapy for treatment of nosocomial infections in a trauma intensive care unit : an audit of an evidence-based empiric antimicrobial policy : researchSource: South African Medical Journal 103, pp 371 –376 (2013)More Less
Background. Nosocomial infections are a major cause of morbidity in the critically injured, and the incidence of resistant strains of bacteria is increasing. Management requires a strategy that achieves accurate empiric cover without antibiotic overuse - a goal that may be achieved by surveillance and antibiotic stewardship.
Objectives. With the aim of minimising the use of empirical ultrabroad-spectrum combination antimicrobial prescriptions and reducing bacterial resistance, the level I Trauma Intensive Care Unit (TICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban employs stewardship and an antimicrobial policy based on surveillance. This study was undertaken with three aims: (i) to describe the spectrum and sensitivities of nosocomial pathogens in a level I TICU; (ii) to ascertain, based on surveillance data, how frequently initial empiric choice of antimicrobials was correct; and (iii) to determine how frequently ultrabroad-spectrum antimicrobials were prescribed and were actually necessary.
Methods. Over a 12-month period, all critically injured patients who underwent mechanical ventilation in the TICU were identified from a prospectively gathered database. Information regarding every specimen submitted to the National Health Laboratory Services (NHLS) situated at IALCH was extracted from the laboratory computer database. For each patient, bacterial isolates and antimicrobial susceptibility were identified using standard laboratory techniques. Empiric prescriptions for presumed nosocomial sepsis were identified from the hospital's computerised patient record system and compared with culture results. Acinetobacter species were regarded as colonisers and treatment not offered unless this was the sole isolate in the presence of signs of severe sepsis.
Results. Of 227 patients, 106 (46.6%) had 136 culture-positive isolates with a total of 323 pathogens (201 Gram-negative, 119 Gram-positive, 3 Candida albicans). There were 19 species of Gram-negative pathogens, of which 56% comprised Enterobacteriaceae. Extended spectrum beta-lactamase (ESBL) production was found in 6/31 (19%) Escherichia coli coli and 6/24 (25%) Klebsiella isolates. Staphyloccocal species accounted for 60% of the Gram-positive isolates, of which 18 were methicillin-resistant Staphylococcus aureus (MRSA). All Candida isolates were sensitive to fluconazole. One hundred and one empiric and 14 directed prescriptions were issued. Despite positive cultures, antimicrobials were not prescribed for 21 patients who had no evidence of sepsis. Excluding multidrug-resistant Acinetobacter isolates, there were 87 (93.5%) appropriate and 6 (6.5%) incorrect prescriptions. Ultrabroad-spectrum combination therapy (U-bSCT) was employed for 11 patients but was necessary in only 2.
Conclusions. When combined with regular bacterial surveillance, antimicrobial stewardship allows accurate empiric antimicrobial prescription with minimal need for ultrabroad-spectrum combination therapy. This policy can potentially reduce the emergence of multidrug-resistant pathogens, precluding the need for broad-spectrum antimicrobials and the attendant problems of overuse.
Antimicrobial susceptibility of organisms causing community-acquired urinary tract infections in Gauteng Province, South Africa : researchSource: South African Medical Journal 103, pp 377 –381 (2013)More Less
Background. Patients with community-acquired urinary tract infections (UTIs) frequently present to healthcare facilities in South Africa (SA).
Aim. To provide information on UTI aetiology and antimicrobial susceptibility of pathogens.
Methods. We recruited women with UTI-related symptoms, who tested positive for ≥2 urine dipstick criteria (proteinuria, blood, leucocytes or nitrites) at 1 public and 5 private primary healthcare facilities in 2011. Demographic and clinical data were recorded and mid-stream urine (MSU) specimens were cultured. UTI pathogens were Gram-stained and identified to species level. Etest-based antimicrobial susceptibility testing was performed for amoxicillin/clavulanic acid, cefixime, cefuroxime, ciprofloxacin, fosfomycin, levofloxacin, nitrofurantoin, norfloxacin and trimethoprim/sulphamethoxazole.
Results. Of the 460 women recruited, 425 MSU samples were processed and 204 UTI pathogens were identified in 201 samples. Most pathogens were Gram-negative bacilli (GNB) (182; 89.2%) and 22 (10.8%) were Gram-positive cocci (GPC). Escherichia coli was the most frequent GNB (160; 79.6%), while Enterococcus faecalis was the predominant GPC (8; 4.0%). The UTI pathogens had similar susceptibility profiles for fosfomycin (95.5%; 95% confidence interval (CI) 92.6 - 98.4), the 3 fluoroquinolones (94.1%; 95% CI 90.8 - 97.4), nitrofurantoin (91.7%; 95% CI 87.8 - 95.6), cefuroxime (90.1%; 95% CI 86.0 - 94.3) and cefixime (88.2%; 95% CI 83.7 - 92.6). UTI pathogens were less susceptible to amoxicillin/clavulanic acid (82.8%; 95% CI 77.5 - 88.0) when compared with fluoroquinolones and fosfomycin. Trimethoprim/sulphamethoxazole was the least efficacious antimicrobial agent (44.3% susceptible; 95% CI 37.4 - 51.2).
Conclusion. This study provides relevant data for the empirical treatment of community-acquired UTIs in SA.
Extremely high prevalence of multi-resistance among uropathogens from hospitalised children in Beira, Mozambique : researchSource: South African Medical Journal 103, pp 382 –386 (2013)More Less
Objectives. A prospective surveillance study was conducted to investigate the epidemiology and patterns of antibiotic resistance among uropathogens from hospitalised children in Beira, Mozambique. Additionally, information regarding determinants of a urinary tract infection (UTI) was obtained.
Methods. Bacterial species identification, antimicrobial susceptibility testing and extended-spectrum beta-lactamase testing were performed for relevant bacterial isolates.
Results. Analysis of 170 urine samples from 148 children yielded 34 bacterial isolates, predominantly Escherichia coli and Klebsiella spp., causative of a urinary tract infection in 29 children; 30/34 isolates (88.2%) from 26/29 children (89.7%) were considered highly resistant micro-organisms (HRMOs). No significant determinants of urinary tract infection with HRMOs were detected when analysing gender, antibiotic use during hospital admission and HIV status.
Conclusion. This study shows, for the first time in Mozambique, an extremely high prevalence of HRMOs among uropathogens from hospitalised children with a urinary tract infection.
Bacterial contamination of re-usable laryngoscope blades during the course of daily anaesthetic practice : researchSource: South African Medical Journal 103, pp 386 –389 (2013)More Less
Background and objectives. Hospital-acquired infections (HAIs) are largely preventable through risk analysis and modification of practice. Anaesthetic practice plays a limited role in the prevention of HAIs, although laryngoscope use and decontamination is an area of concern. We aimed to assess the level of microbial contamination of re-usable laryngoscope blades at a public hospital in South Africa.
Setting. The theatre complex of a secondary-level public hospital in Johannesburg.
Methods. Blades from two different theatres were sampled twice daily, using a standardised technique, over a 2-week period. Samples were quantitatively assessed for microbial contamination, and stratified by area on blade, theatre and time using Fisher's exact test.
Results. A contamination rate of 57.3% (63/110) was found, with high-level contamination accounting for 22.2% of these. Common commensals were the most frequently isolated micro-organisms (79.1%), but important hospital pathogens such as Enterobacter species and Acinetobacter baumannii were isolated from blades with high-level contamination. No significant difference in the level of microbial contamination by area on blade, theatre or time was found (p<0.05).
Conclusions. A combination of sub-optimal decontamination and improper handling of laryngoscopes after decontamination results in significant microbial contamination of re-usable laryngoscope blades. There is an urgent need to review protocols and policies surrounding the use of these blades.