South African Medical Journal - Volume 105, Issue 9, 2015
Volumes & issues
Volume 105, Issue 9, 2015
Antimicrobial resistance of bacteria isolated from patients with bloodstream infections at a tertiary care hospital in the Democratic Republic of the Congo : researchSource: South African Medical Journal 105, pp 752 –755 (2015) http://dx.doi.org/10.7196/SAMJnew.7937More Less
Background. Bloodstream infection (BSI) is a life-threatening condition that requires rapid antimicrobial treatment.
Methods. We determined the prevalence of bacterial isolates associated with BSI at Bukavu General Hospital (BGH), South Kivu Province, Democratic Republic of the Congo, and their patterns of susceptibility to antimicrobial drugs, from February 2013 to January 2014.
Results. We cultured 112 clinically relevant isolates from 320 blood cultures. Of these isolates, 104 (92.9%) were Gram-negative bacteria (GNB), with 103 bacilli (92.0%) and one coccus (0.9%). Among GNB, Escherichia coli (51.9%), Klebsiella spp. (20.2%), Enterobacter spp. (6.7%), Shigella spp. (5.8%) and Salmonella spp. (4.8%) were the most frequent agents causing BSIs. Other GNB isolates included Proteus spp., Citrobacter spp. and Pseudomonas aeruginosa (both 2.9%), and Acinetobacter spp. and Neisseria spp. (both 0.9%). High rates of resistance to co-trimoxazole (100%), erythromycin (100%) and ampicillin (66.7 - 100%) and moderate to high resistance to ciprofloxacin, ceftazidime, ceftriaxone, cefuroxime and cefepime were observed among GNB. Furthermore, there were high rates of multidrug resistance and of extended-spectrum β-lactamase (ESBL) production phenotype among Enterobacteriaceae. Gram-positive bacteria includedthree Staphylococcus aureus isolates (2.7%), four oxacillin-resistant coagulase-negative staphylococci (CoNS) isolates (3.6%) and one Streptococcus pneumoniae (0.9%). No oxacillin-resistant S. aureus was isolated. Among clinically relevant staphylococci, susceptibility to co-trimoxazole and ampicillin was low (0 - 25%). In addition, 58 contaminant CoNS were isolated from blood cultures, and the calculated ratio of contaminants to pathogens in blood cultures was 1 : 2.
Conclusions. Multidrug-resistant and ESBL-producing GNB are the leading cause of BSI at BGH.
The role of point-of-care blood testing for ketones in the diagnosis of diabetic ketoacidosis : researchSource: South African Medical Journal 105, pp 756 –759 (2015) http://dx.doi.org/10.7196/SAMJnew.7889More Less
Background. Urine dipstick testing for ketones is widely used when diabetic ketoacidosis (DKA) is suspected in patients with hyperglycaemia. If urinary ketones are positive, patients are referred for further management - often inappropriately, as the test is a poor surrogate for plasmaketones. Plasma beta-hydroxybutyrate (β-OHB) levels >3 mmol/L are diagnostic of DKA, while levels < 1 mmol/L are insignificant.
Objectives. To evaluate a hand-held electrochemical (point-of-care testing; POCT) ketone monitor and compare it with the gold-standardmanual enzymatic method (MEM) for detection of plasma ketones.
Methods. In a prospective and comparative study, we evaluated the measurement of β-OHB by means of POCT and the MEM in 61 consecutive samples from patients with suspected DKA at Tygerberg and Karl Bremer hospitals, Cape Town, South Africa. Capillary (for POCT) and plasma samples (for the MEM) were obtained simultaneously and compared for accuracy. Precision was assessed with control samples.
Results. The POCT method was precise (coefficient of variation < 4.5%), and there was a good correlation between the two methods (r=0.95). Regression analysis showed a proportional bias, with POCT reading higher than the MEM. However, when assessed at the relevant medical decision limits (β-OHB >3 mmol/L and < 1 mmol/L), the total allowable error (bias + imprecision) was not exceeded. Patients will therefore still be classified correctly. The POCT method had a sensitivity of 100% and specificity of 89% for DKA (β-OHB >3 mmol/L), while at levels < 1 mmol/L sensitivity was 100% and specificity 87.5%.
Conclusion. The POCT device provides an accurate and precise result and can be used as an alternative to the MEM in the diagnosis of DKA.
Source: South African Medical Journal 105, pp 760 –764 (2015) http://dx.doi.org/10.7196/SAMJnew.8170More Less
Background. Poorly controlled diabetes is associated with poor maternal and fetal outcomes, yet many women become pregnant before establishing control. Reducing unintended pregnancies is a vital step towards improving perinatal and maternal morbidity and mortality.
Objectives. To assess the reproductive knowledge and use of contraception in women of reproductive age attending diabetes outpatient clinics.
Methods. A prospective descriptive study was conducted of women known to have diabetes, aged 18 - 45 years, attending the diabetic clinics at Groote Schuur Hospital or the local community health centres in Cape Town, South Africa. A questionnaire consisting of social, demographic and family details as well as contraceptive use and knowledge was administered.
Results. Some common themes emerged, namely that 44.2% of the women with previous pregnancies had had unintended pregnancies, and that this was more common among single (58.8%) and younger women. Women with type 1 diabetes had betterknowledge than those with type 2 diabetes of how pregnancy affects diabetes, but better knowledge did not translate to better contraception use. Despite the fact that 102 participants (88.7%) attended diabetes clinics two or more times a year, knowledge of pregnancy - and reproductive health-related complications was limited, and only 30 participants (26.1%) had received advice on contraception at these clinics.
Conclusion. Knowledge about the impact of diabetes on pregnancy and that of pregnancy on diabetes was suboptimal. We recommend that reproductive health services be included at the routine diabetes clinic visit.
Source: South African Medical Journal 105, pp 765 –768 (2015) http://dx.doi.org/10.7196/SAMJnew.8175More Less
Background. South Africa (SA) is likely to meet the National Strategic Plan target of < 2% mother-to-child HIV transmission at 6 weeks of age in 2015. Children infected with HIV after 6 weeks often remain undiagnosed because of poor implementation of post-weaning and final outcome 18-month HIV testing. The World Health Organization recommends a screening HIV rapid test (HRT) in HIV-exposed infants at the 9-month immunisation visit to exclude postnatal infection, with a confirmatory HIV polymerase chain reaction (PCR) test if the HRT is positive.
Objective. To evaluate the impact of substituting this recommendation for the post-weaning HIV testing recommended by SA guidelines.
Methods. Rates of seroreversion and probability of infection at 9 months of age were applied to a theoretical population of 100 HIV-exposed infants, uninfected at birth and breastfed for 1 year with antiretroviral prophylaxis. Nine scenarios were developed and the number of HIV PCRs saved compared with current guidelines was calculated.
Results. Nine-month testing using the HRT reduced the number of follow-up PCR tests done in all scenarios by >50%, with differences ranging from 51% to 59% and 81% to 89% for low and high seroreversion rates, respectively.
Conclusions. Nine-month testing using HRT would increase identification and early treatment of HIV-infected infants, improve monitoring of postnatal transmission rates, and reduce the number of HIV PCR tests done with resultant cost saving. Training of healthcare workers implementing HRT would be required. Ongoing efforts to improve implementation and monitoring of testing at 9 and 18 months will be essential.
Source: South African Medical Journal 105, pp 769 –772 (2015) http://dx.doi.org/10.7196/SAMJnew.7908More Less
Background. HIV-associated sensory neuropathy (HIV-SN) is a common and frequently painful complication of HIV infection and its treatment. However, few data exist describing the frequency, type and dosage of pain medications patients are receiving in the clinic setting to manage the painful symptoms of HIV-SN.
Objective. To report on analgesic prescription for painful HIV-SN and factors influencing that prescription in adults on combination antiretroviral therapy.
Methods. Using validated case ascertainment criteria to identify patients with painful HIV-SN, we recruited 130 HIV-positive patients with painful HIV-SN at Chris Hani Baragwanath Hospital, Johannesburg, South Africa. Demographic and clinical data (including current analgesic use) were collected on direct questioning of the patients and review of the medical files.
Results. We found significant associations, of moderate effect size, between higher pain intensity and lower CD4 T-cell counts withprescription of analgesic therapy. Factors previously identified as predicting analgesic treatment in HIV-positive individuals (age, gender, level of education) were not associated with analgesic use here. Consistent with national guidelines, amitriptyline was the most commonly used agent, either alone or in combination therapy. Importantly, we also found that despite the relatively high analgesic treatment rate in this setting, the majority of patients described their current level of HIV-SN pain as moderate or severe.
Conclusion. Our findings highlight the urgent need for both better analgesic options for HIV-SN pain treatment and ongoing training and support of clinicians managing this common and debilitating condition.
Bone marrow aspirate microscopy v. bonemarrow trephine biopsy microscopy for detection of Mycobacterium tuberculosis infection : researchSource: South African Medical Journal 105, pp 773 –775 (2015) http://dx.doi.org/10.7196/SAMJnew.8171More Less
Background. Tuberculosis (TB) remains a global health problem. According to the 2013 Global Report on Tuberculosis, 8.6 million people developed TB in 2012 and 1.3 million died from the disease. An estimated 13% of people who developed TB in 2012 were HIV-positive, and 75% of these lived in Africa. While pulmonary TB is the commonest form of Mycobacterium tuberculosis infection, extrapulmonary TB is increasingly being detected in HIV-positive patients. Definitive diagnosis of disseminated TB is a challenge owing to atypical presentations and diagnostic difficulties (negative chest radiograph and sputum microscopy and culture). A rapid diagnosis of disseminated TB is desirable, as early initiation of treatment can reduce mortality. Although TB culture is the gold standard for diagnosis of TB, it has a long turnaround time (up to 6 weeks).
Objectives. To identify a potentially faster and more effective diagnostic strategy for disseminated TB.
Methods. A retrospective 18-month review, conducted at a tertiary hospital, comparing histological findings of an auramine O-stained bone marrow aspiration (BMA) smear and a bone marrow trephine (BMT) biopsy specimen with the gold standard of TB culture.
Results. Microscopic examination of BMA smears and BMT biopsy specimens offers a rapid diagnostic strategy, with results available on the same day for the former and within 4 days for the latter. BMT histological examination had a significantly higher detection rate than BMA auramine O staining compared with TB culture.
Conclusion. We recommend that BMT biopsies remain an essential part of the diagnostic work-up for disseminated TB.
Codeine misuse and dependence in South Africa - learning from substance abuse treatment admissions : researchSource: South African Medical Journal 105, pp 776 –779 (2015) http://dx.doi.org/10.7196/SAMJnew.8172More Less
Background. Misuse of prescription and over-the-counter codeine-containing products is a global public health issue.
Objectives. To investigate the extent of treatment demand related to the misuse of codeine or codeine dependence in South Africa (SA) and the profile of patients seeking treatment, so as to understand the nature and extent of the problem.
Method. Data were collected from centres participating in the South African Community Epidemiology Network on Drug Use in 2014. A total of 17 260 admissions were recorded.
Results. There were 435 recorded treatment admissions for codeine misuse or dependence as a primary or secondary substance of abuse (2.5% of all admissions). Of treatment admissions, 137 (0.8%) involved codeine as the primary substance of abuse; 74.9% of patients were males, with an even spread across population groups. Ages ranged from 11 to 70 years, with the highest proportion aged 20 - 29 years; >40% were referred by self, family and/or friends, and 26.7% by health professionals; and 36.8% had received treatment previously. The majority reported misuse of tablets/capsules, with 17.6% reporting misuse of syrups. Oral use comprised 96.6% and daily use 63.1%.
Conclusions. Data from treatment admissions related to codeine misuse and dependence are informative, but provide an incomplete picture of the nature and extent of codeine-related problems in SA. Other data sources must be considered before further regulatory/policy changes regarding codeine are implemented.
Source: South African Medical Journal 105, pp 780 –784 (2015) http://dx.doi.org/10.7196/SAMJnew.8331More Less
Background. Many patients depend on moisturisers issued by public health services in the management of a topic dermatitis (AD).
Methods. In a randomised controlled trial of patients with mild to moderate AD, aged 1 - 12 years, study 1 compared aqueous cream v. liquid paraffin (fragrance-free baby oil) as a soap substitute, all patients using emulsifying ointment as moisturiser, and study 2 compared four moisturisers, emulsifying ointment, cetomacrogol, white petroleum jelly and glycerine/petroleum (proportion 1:2; 'the 1:2 moisturiser'), allusing fragrance-free baby oil as soap substitute. Assessments were one quality of life and three AD severity scores, at baseline and weeks 4, 8 and 12. Differences were compared using repeated measures of analysis of variance.
Results. In both studies (120 children randomised, 20 in each group of the two trials) disease severity scores declined with time. The only significant difference was in one AD severity score (SCORing Atopic Dermatitis) in study 1, both at baseline and over time (p=0.042 and p=0.022). The groups did not differ with regard to topical steroid use or side-effects. Itching from baby oil applied as soap was reported by four patients in the two studies, the petroleum jelly group had more dropouts than the 1:2 moisturiser group, although this was not statistically significant, and 110 patients (91.7%) completed the trial.
Conclusions. The small sample limits generalisability, but the duration was longer than in most AD moisturiser studies. Fragrance-freebaby oil as a soap substitute may be better tolerated (if irritation occurs) as a bath additive. The 1:2 moisturiser may be preferable to white petroleum jelly, but both are equivalent to cetomacrogol and emulsifying ointment. Use of accessible moisturisers could reduce the cost of managing mild to moderate AD.
Chronic obstructive pulmonary disease in South Africa : under-recognised and undertreated : CME - guest editorialSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJnew.8429More Less
Chronic obstructive pulmonary disease (COPD) is a common, preventable but incurable condition currently ranked third in global mortality estimates. Worldwide, 65 million people are estimated to have moderate to severe COPD, and the disease accounts for 3 million deaths annually, of which 90% are said to occur in low - and middle-income countries. Yet, despite these staggering numbers, COPD remains both under - recognised and undertreated in most populations, also in South Africa (SA). There are many reasons for this, not least of which is the attitude of clinicians, which can often be fatalistic with regard to COPD. This edition of CME highlights key aspects of the diagnosis and treatment - pharmacological and non-pharmacological - and new developments in the management of severe disease.Furthermore, we have included articles focusing on non-smoking related COPD and tips for good spirometry.
Source: South African Medical Journal 105, pp 786 –788 (2015) http://dx.doi.org/10.7196/SAMJnew.8421More Less
Chronic obstructive pulmonary disease (COPD) is a common, progressive and preventable non-communicable respiratory disorder. It is often confused with asthma and poorly understood by many lay people. The primary cause of COPD is tobacco smoking, but in the South African (SA) context, biomass fuel exposure/household pollution, tuberculosis, HIV and mining exposure are additional important causes.There is a very high prevalence of COPD in SA and it is the third leading cause of mortality globally. The diagnosis of COPD is based predominantly on symptoms, i.e. progressive shortness of breath and cough in a patient with risk factors- usually smoking. Lung function testing is required to formally make the diagnosis, which places a significant hurdle in correctly identifying COPD in SA, given the limited access to spirometry in many areas. Spirometry is also required to grade the severity of lung function obstruction. Severity assessment, which is used to plan a management strategy (predominantly bronchodilators with inhaled steroids in severe cases), combines symptoms, lung function and exacerbations. Based on these 3 factors, a patient can be categorised into 1 of 4 groups and appropriate management instituted. Additional comorbidities, particularly cardiovascular and mental illness, should also be evaluated. Early identification of COPD, with further avoidance of an aetiological cause such as smoking, is key in preventing disease progression.Appropriate therapy, comprising non-pharmacological and pharmacological interventions and based on a comprehensive severity assessment, should result in symptom improvement and reduced risk for exacerbations.
Source: South African Medical Journal 105, pp 789 –792 (2015) http://dx.doi.org/10.7196/SAMJnew.8424More Less
The importance of chronic obstructive pulmonary disease (COPD) as a global health problem cannot be overstated. According to the latest World Health Organization statistics (2005), 210 million people suffer from COPD worldwide, and 5% of all deaths globally are estimated to be caused by this disease. This corresponds to >3 million deaths annually, of which 90% are thought to occur in low - and middle-income countries. While cigarette smoking remains the major risk factor, and much of the increase in COPD is associated with projected increases in tobacco use, epidemiological studies have demonstrated that in the majority of patients in developing countries the aetiology of COPD is multi-factorial. This article summarises the epidemiology of and risk factors for COPD in Africa, including influences other than cigarette smoking that are important contributors to chronic irreversible airflow limitation in our setting.
Source: South African Medical Journal 105, pp 793 –795 (2015) http://dx.doi.org/10.7196/SAMJnew.8489More Less
Chronic obstructive pulmonary disease (COPD) is the third leading cause of morbidity and mortality globally, contributing to a substantial use of resources. According to World Health Organization estimates, 65 million people have moderate to severe COPD. The condition is also recognised as a systemic disease with extrapulmonary manifestations, such as peripheral muscle dysfunction, malnutrition and depression, which further contribute to disability, poor quality of life, exacerbations and mortality. Optimum management requires non-pharmacological interventions combined with pharmacological treatment. However, the former is often neglected and not widely used in daily practice, with the focus mainly on the latter.
Source: South African Medical Journal 105, pp 796 –798 (2015) http://dx.doi.org/10.7196/SAMJnew.8426More Less
There have been significant changes in the approach to the management of chronic obstructive pulmonary disease (COPD) over the past decade. The World Health Organization suggests four components to a COPD management plan: (i) assess and monitor disease; (ii) reduce risk factors; (iii) manage stable COPD; and (iv) manage exacerbations. Encouraging patients to limit their risk exposure is essential, whether it be smoking cessation or removing exposure to biomass. The main objective of treatment is to relieve daily symptoms, improve quality of life and importantly decrease the risk of future exacerbations. Current guidelines are based on grade A and B evidence. Pneumococcal and annual influenza vaccinations are encouraged. A holistic approach that augments pharmacological treatment includes good nutrition and pulmonary rehabilitation. Bronchodilators are the cornerstone of management. Depending on the patient's placement in the GOLD ABCD classification, treatment is individualised. Short-acting bronchodilators are used as rescue medication, while long-acting bronchodilators or/and long-acting muscarinic agents are the treatment of choice for patients in groups B, C and D. Inhaled corticosteroids are only recommended for groups C and D. Most patients respond well to combinations of the above mentioned medications. For patients who still have frequent exacerbations, alternative choices include long-term macrolides and phosphodiesterase 4 inhibitors.
Source: South African Medical Journal 105, pp 799 –801 (2015) http://dx.doi.org/10.7196/SAMJnew.8427More Less
Pathognomonic features of advanced emphysema include a markedly reduced alveolar surface area due to the formation of blebs and bullae and significantly reduced elastic recoil. The aim of lung volume reduction, which can be achieved by either surgery or endoscopic techniques, is volume loss of the targeted, diseased region(s) and redirecting airflow to less affected regions. Lung volume reduction surgery (LVRS) entails reducing the lung volume by wedge excision of emphysematous tissue. LVRS carries significant morbidity and mortality, but can offer survival benefit and increased exercise capacity in selected patients with predominantly upper-lobe emphysema and low exercise capacity.Endoscopic lung volume reduction (ELVR) refers to bronchoscopically inducing volume loss to improve pulmonary mechanics and compliance, thereby reducing the work of breathing. Globally, this technique is increasingly used as treatment for advanced emphysema with the objective of obtaining similar functional advantages to surgical lung volume reduction, while decreasing risks and costs. Current evidence suggests that patients with either homogeneous or heterogeneous disease may benefit from ELVR. It remains paramount that a systematic approach is followed and selection criteria are met, given the high costs and potential complications related to both LVRS and ELVR.
Author D.M. MareeSource: South African Medical Journal 105 (2015) http://dx.doi.org/10.7196/SAMJnew.8428More Less
Spirometry is critical for the correct diagnosis of chronic obstructive pulmonary disease (COPD) and is part of the severity classification. It ultimately guides treatment choices. When performing spirometry on a COPD patient, one expects a flow volume loop to have some degree of obstruction. To obtain and confirm this result, there are a few important steps that have to be followed and rules that have to be adhered to.