South African Medical Journal - Volume 105, Issue 5, 2015
Volumes & issues
Volume 105, Issue 5, 2015
Author Jean SchuermansSource: South African Medical Journal 105 (2015)More Less
Philippe was born in Ghent, Belgium, on 8 July 1943. His father was a stockbroker and private banker in that city. However, his grandfather and ancestors prior to his grandfather's generation had been general practitioners, and he was determined to follow the same profession, but in Africa.
Author A.M. CilliersSource: South African Medical Journal 105, pp 261 –262 (2015) http://dx.doi.org/10.7196/SAMJ.9433More Less
Acute rheumatic fever (ARF), with its varied and potentially devastating cardiac complication of rheumatic heart disease (RHD), has largely been eradicated from developing countries, but continues to be a scourge mainly in poorly resourced areas of the world and also among the indigenous populations of some wealthy countries such as New Zealand and Australia. The disease is particularly prevalent in populations where there is overcrowding and high levels of poverty. Efforts have been made to commit to the elimination of ARF/RHD in South Africa (SA) and the rest of Africa. The Drakensberg Declaration, which initiated and promoted the Awareness, Surveillance, Advocacy and Prevention (ASAP) programme to raise public awareness, establish surveillance programmes, advocate for support and promote prevention, was adopted at the 1st All Africa Workshop on Rheumatic Fever and Rheumatic Heart Disease held in the Drakensberg, SA, in 2005.
Author Marc MendelsonSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9644More Less
If our overuse and misuse of antibiotics is not halted now, about 10 million people will die annually from drug-resistant bacterial infections within 35 years. The hammer blow will fall hardest on Africa and Asia, accounting for 4.1 and 4.7 million deaths, respectively, and the world's economy will lose more than 7% of its gross domestic product (USD210 trillion) by 2050.
Source: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9472More Less
To the Editor: South Africa (SA) has been conducting annual cross-sectional anonymous unlinked antenatal HIV seroprevalence surveys in sentinel sites (ANCHSS) for more than 20 years. These sites are randomly selected using probability proportional to size sampling (PPS) methods as this combines a random approach with a bias towards larger clinics, resulting in a self-weighted sample. First-time antenatal attendees are enrolled into the ANCHSS, and blood for unlinked anonymous antenatal HIV testing (UAT) is drawn at the same time as first antenatal booking bloods.
Outcomes in treatment with darunavir/ritonavir in ART-experienced paediatric patients : correspondenceSource: South African Medical Journal 105, pp 330 –331 (2015) http://dx.doi.org/10.7196/SAMJ.9211More Less
To the Editor: Increasing development of resistant mutations to first- and second-line antiretroviral (ART) regimens among children is a matter of concern, as limited third-line paediatric ART preparations are available in the public sector. There are various explanations for this increase, including drug interactions leading to reduced bioavailability as seen in tuberculosis (TB) co-infection.
Better menstrual management options for adolescents needed in South Africa : what about the menstrual cup? : correspondenceSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9205More Less
To the Editor: Providing forms of menstrual management to women and girls in need has been on the South African (SA) government's agenda for the past 4 years. A sanitary pads campaign launched in 2014 reported that almost nine million SA girls aged 13 - 19 miss time at school because of lack of sanitary products. In 2010, the World Health Organization reported that the lack of school toilets with privacy and facilities for menstrual hygiene contributes to sporadic attendance and drop-out among young women in Africa. Several other SA initiatives have focused on disposable sanitary towels, as the environmental impact of menstrual waste on sewage systems is considerable. Menstrual pads, tampons and rags routinely block pipes and joints, which is costly, takes time to resolve and imposes health hazards.
Author Francois MaiSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJ.9303More Less
To the Editor: When I was a medical student at the University of Cape Town, South Africa, in the mid-1950s a wise old professor introduced me to the treatment concept of masterly inactivity. Sometimes just waiting and seemingly doing nothing is the favoured therapeutic modality. Over a lifetime in medicine, I have seen many occasions when this approach was successful, and other times when physicians, including myself, have broken this rule with unfortunate and anti-therapeutic results.
Source: South African Medical Journal 105, pp 333 –334 (2015) http://dx.doi.org/10.7196/SAMJ.9684More Less
A filtration unit that can deliver cheap, safe drinking water to 200 people for 3 years, giving dysfunctional rural municipalities more than enough time to fix broken pipes and polluted water sources and/or increase their maintenance capacity, is being ignored by South Africa (SA)'s health officials.
Source: South African Medical Journal 105, pp 334 –336 (2015) http://dx.doi.org/10.7196/SAMJ.9682More Less
Source: South African Medical Journal 105, pp 337 –338 (2015) http://dx.doi.org/10.7196/SAMJ.9683More Less
The South African Medical Association (SAMA) is investigating setting up a fund to compensate patients who fall victim to unavoidable adverse events (through no fault of their treating physician), while working with government to improve the overall quality of care in both the public and private sectors.
Source: South African Medical Journal 105, pp 338 –339 (2015) http://dx.doi.org/10.7196/SAMJ.9555More Less
Source: South African Medical Journal 105, pp 342 –344 (2015) http://dx.doi.org/10.7196/SAMJ.8996More Less
Foreign bodies (FBs) are potentially life-threatening when inhaled by a child, depending on where they lodge. Symptoms can range from acute upper airway obstruction to mild, vague respiratory complaints. Between 80% and 90% of inhaled FBs occlude the bronchi, while the larynx is a less common site. The commonest inhaled paediatric FBs are organic, e.g. seeds or nuts. Plastic FBs are less common and more difficult to diagnose. They are generally radiolucent on lateral neck radiographs and are often clear and thin. We report three cases of an unusual plastic laryngeal FB, the bread tag. Plastic bread tags were first reported in the medical literature as an ingested gastrointestinal FB in 1975. Since then, over 20 cases of gastrointestinal complications have been described. We report what is to our knowledge the first paediatric case of an inhaled bread tag, and also the first case series, briefly discuss the symptoms and options for removal of laryngeal FBs, and highlight the dangers of the apparently harmless bread tag. Images of the bread tags in situ and after their removal are included.
Updated recommendations for the management of upper respiratory tract infections in South Africa : forum - recommendationsSource: South African Medical Journal 105, pp 345 –352 (2015) http://dx.doi.org/10.7196/SAMJ.8716More Less
Background. Inappropriate use of antibiotics for non-severe upper respiratory tract infections (URTIs), most of which are viral, significantly adds to the burden of antibiotic resistance. Since the introduction of pneumococcal conjugate vaccines in South Africa in 2009, the relative frequency of the major bacterial pathogens causing acute otitis media (AOM) and acute bacterial rhinosinusitis (ABRS) has changed.
Recommendations. Since URTIs are mostly viral in aetiology and bacterial AOM and ABRS frequently resolve spontaneously, these recommendations include diagnostic criteria to assist in separating viral from bacterial causes and hence select those patients who do not require antibiotics. Penicillin remains the drug of choice for tonsillopharyngitis and amoxicillin the drug of choice for both AOM and ABRS. A dose of 90 mg/kg/d is recommended for children, which should be effective for pneumococci with high-level penicillin resistance and will also cover most infections with Haemophilus influenza. Amoxicillin-clavulanate (in high-dose amoxicillin formulations available for both children and adults) should be considered the initial treatment of choice in patients with recent antibiotic therapy with amoxicillin (previous 30 days) and with resistant H. influenza infections pending the results of studies of local epidemiology (β-lactamase production ≥15%). The macrolide/azalide class of antibiotics is not recommended routinely for URTIs and is reserved for β-lactam-allergic patients.
Conclusion. These recommendations should facilitate rational antibiotic prescribing for URTIs as a component of antibiotic stewardship. They will require updating when new information becomes available, particularly from randomised controlled trials and surveillance studies of local aetiology and antibiotic susceptibility patterns.
Description of an internal medicine outreach consultant appointment in western KwaZulu-Natal, South Africa, 2007 to mid-2014 : forum - healthcare deliverySource: South African Medical Journal 105, pp 353 –356 (2015) http://dx.doi.org/10.7196/SAMJ.9173More Less
This is a description of an internal medicine outreach appointment in western KwaZulu-Natal Province (KZN), South Africa (SA), from 2007 to mid-2014, facilitated by the transport services of the Red Cross Air Mercy Service (AMS) and funded by the KZN Department of Health. The hospital visits represented 'multifaceted' as opposed to 'simple' outreach. The AMS database of outreach visits was analysed according to frequencies of visits, number of patient contacts and number of contacts with medical personnel. A brief history of the outreach visits is given and their nature described. From January 2007 to the end of June 2014, the outreach physician undertook 481 hospital visits and visited seven hospitals (out of 21) more than 40 times each. A total of 3 340 medical personnel contacts were made, and 5 239 patients were seen. Other internal medicine specialists undertook an additional 199 visits, during which they made 1 157 personnel contacts and saw 2 020 patients. The combined total was therefore 680 visits undertaken, 4 497 medical personnel contacts made and 7 259 patients seen. The appointment of a dedicated outreach consultant for a particular discipline together with a reliable air and road transport system was successful in providing access to specialist care in rural settings. This strategy could be recommended throughout SA. Further studies would be required in order to assess outcomes.
Key to antimicrobial stewardship success : surveillance by diagnostic microbiology laboratories : editorialAuthor Warren LowmanSource: South African Medical Journal 105, pp 359 –360 (2015) http://dx.doi.org/10.7196/SAMJ.9615More Less
The important role of laboratories in enhancing antimicrobial stewardship activities through improved diagnostics and provision of surveillance data is globally recognised. Consider the aim of an antimicrobial stewardship programme: 'optimize clinical outcomes while minimizing the unintended consequences of antimicrobial use'. The clinical microbiology laboratory plays a critical role in achieving these aims through the provision of culture and susceptibility data that are both patient-specific (optimisation of clinical outcomes) and informative for surveillance activities that guide empirical antimicrobial selection (minimising unintended consequences of antimicrobial use).
Community- versus healthcare-acquired bloodstream infections at Groote Schuur Hospital, Cape Town, South Africa : researchSource: South African Medical Journal 105, pp 363 –369 (2015) http://dx.doi.org/10.7196/SAMJ.8183More Less
Background. Bloodstream infections (BSIs) cause considerable morbidity and mortality. The epidemiology of bacterial infections differs in community and hospital settings. Regular surveillance and reporting of pathogens and antimicrobial susceptibility can assist in appropriate management of BSIs.
Objectives. To describe the distribution of organisms and of antibiotic susceptibility among isolates from blood cultures at a tertiary academic hospital during a 1-year period, stratifying by place of infection acquisition.
Methods. This was a retrospective descriptive study of bloodstream isolates from cultures from adults (>13 years of age) routinely submitted between 1 October 2011 and 30 September 2012 to the clinical laboratory at Groote Schuur Hospital, Cape Town, South Africa. Community-acquired infections were compared with healthcare-acquired infections, defined as infections developing at least 48 hours after admission or within 3 months of admission to a healthcare facility. Frequencies and proportions of infecting organisms are presented, along with susceptibility results for selected pathogens. The hospital-acquired isolates were stratified by ward (emergency, general medical or general surgical ward or intensive care unit (ICU)) to determine organism frequency and susceptibility patterns by hospital ward.
Results. Among adults, 740 non-duplicate pathogens were isolated from BSIs. Nearly three-quarters of infections were healthcare acquired. Enterobacteriaceae and non-fermentative Gram-negative bacilli were predominant among healthcare-acquired pathogens (39.2% and 28.5%, respectively), while Enterobacteriaceae and Gram-positive organisms were the most common among community-acquired pathogens (39.2% and 54.3%, respectively). The majority of community-acquired Enterobacteriaceae were highly susceptible to antibiotics (gentamicin 95.6%, ceftriaxone 96.1% and ciprofloxacin 92.2%), whereas 64.6% of healthcare-associated isolates were susceptible to gentamicin, 58.5% to ceftriaxone and 70% to ciprofloxacin. All community-acquired Staphylococcus aureus isolates v. 52.4% of healthcare-acquired isolates were susceptible to cloxacillin. The susceptibility of healthcare-acquired Pseudomonas aeruginosa and Acinetobacter baumanii complex isolates was < 80% to all antibiotics with the exception of colistin. Klebsiella spp., S. aureus and Escherichia coli were the commonest causes of healthcare-acquired infections in all areas outside of the ICUs, whereas Acinetobacter was common in the ICUs and rare in all other areas.
Conclusion. The distinction between community- and healthcare-acquired infections is critical in antibiotic selection because narrow-spectrum agents can be utilised for community-acquired infections. The considerable antibiotic resistance of healthcare-acquired pathogens highlights the importance of infection prevention and control. This type of surveillance could be incorporated into routine laboratory practice.
A prospective observational study of bacteraemia in adults admitted to an urban Mozambican hospital : researchSource: South African Medical Journal 105, pp 370 –374 (2015) http://dx.doi.org/10.7196/SAMJ.8780More Less
Background. Bacteraemia is a common cause of fever among patients presenting to hospitals in sub-Saharan Africa. The worldwide rise of antibiotic resistance makes empirical therapy increasingly difficult, especially in resource-limited settings.
Objectives. To describe the incidence of bacteraemia in febrile adults presenting to Maputo Central Hospital (MCH), an urban referral hospital in the capital of Mozambique, and characterise the causative organisms and antibiotic susceptibilities. We aimed to describe the antibiotic prescribing habits of local doctors, to identify areas for quality improvement.
Methods. Inclusion criteria were: (i) ≥18 years of age; (ii) axillary temperature ≥38°C or ≤35°C; (iii) admission to MCH medical wards in the past 24 hours; and (iv) no receipt of antibiotics as an inpatient. Blood cultures were drawn from enrolled patients and incubated using the BacT/Alert automated system (bioMerieux, France). Antibiotic susceptibilities were tested using the Kirby-Bauer disc diffusion method.
Results. Of the 841 patients enrolled, 63 (7.5%) had a bloodstream infection. The most common isolates were Staphylococcus aureus, Escherichia coli, and non-typhoidal Salmonella. Antibiotic resistance was common, with 20/59 (33.9%) of all bacterial isolates showing resistance to ceftriaxone, the broadest-spectrum antibiotic commonly available at MCH. Receipt of insufficiently broad empirical antibiotics was associated with poor in-hospital outcomes (odds ratio 8.05; 95% confidence interval 1.62 - 39.91; p=0.04).
Conclusion. This study highlights several opportunities for quality improvement, including educating doctors to have a higher index of suspicion for bacteraemia, improving local antibiotic guidelines, improving communication between laboratory and doctors, and increasing the supply of some key antibiotics.
Source: South African Medical Journal 105, pp 375 –378 (2015) http://dx.doi.org/10.7196/SAMJ.8773More Less
Background. The incidence of Kaposi's sarcoma (KS) has increased dramatically since the onset of the AIDS epidemic. Of the estimated 66 200 cases of KS worldwide, 58 800 are considered to have occurred in sub-Saharan Africa.
Objectives. To describe the epidemiology and pathological characteristics of KS at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, South Africa.
Methods. A retrospective cross-sectional study design was used. Nine hundred and thirty-eight histopathology reports of KS diagnosed in 901 patients at CHBAH between 2005 and 2009 were reviewed. Age, gender, topographic site, CD4 count, HIV status, KS histological stage, findings of human herpesvirus 8 latency-associated nuclear antigen 1 immunohistochemistry and concomitant pathological findings were recorded.
Results. The male/female ratio was 1.2:1, the mean age 37 years and the median CD4 count 128 cells/µL. Lower limb skin biopsies accounted for 49.6% of cases. Paediatric, visceral and endemic KS accounted for only limited proportions (1.4%, 1.4% and 1.3% of biopsies, respectively). There were concomitant pathological findings in 4.6% of biopsy specimens, infections and inflammatory dermatoses being the most frequent.
Conclusion. The findings of this study highlight the need for allocation of diagnostic and treatment resources for KS. Documentation of the various demographic aspects of KS will prove to be of historical, clinical and histopathological interest as the long-term outcomes of antiretroviral therapy begin to emerge.