Southern African Journal of Epidemiology and Infection - Volume 28, Issue 1, January 2013

Chronic meningitis, often caused by Mycobacterium tuberculosis or Cryptococcus neoformans, has received a great deal of attention in South Africa as its incidence has increased along with that of HIV. By comparison acute meningitis caused by a different range of pathogens, has received relatively little attention while continuing to exact a large burden of morbidity and mortality. There are a number of guidelines for acute meningitis from high resource countries but these may be less applicable to resource-limited countries like South Africa, a large proportion of whose population live in deeply rural areas with limited access to healthcare.

This guideline provides a rational and cost-effective approach to patients with acute meningitis, which causes considerable morbidity and mortality, predominantly in children.There are many aetiologies, but a small number of bacteria and viruses account for the majority of cases. There should be a low threshold for suspecting acute meningitis, which is a medical emergency and antibiotics should not be delayed. Blood culture and cerebrospinal fluid (CSF) analysis are the most important diagnostic tests and should be performed whenever it is safe and practical. Contraindications to lumbar puncture are discussed and an algorithm is given regarding administering empiric antibiotics and antivirals, performing blood cultures, computer tomography brain scanning and cerebrospinal fluid analysis, depending on the clinical features and availability of resources. Administration of steroids is not recommended. Guidelines are provided for definitive therapy whenever a causative organism is identified. When no organism is identified, treatment and further investigation should be guided by laboratory results and clinical response. An approach to this process is outlined in a second algorithm. The epidemiology of resistance to common pathogens is described and advice given regarding special groups, including those with recurrent meningitis or base-of-skull fractures. Advice regarding infection control, post-exposure prophylaxis and vaccination is provided.

The objectives were to determine the minimum inhibitory concentrations (MICs) of piperacillin-tazobactam against blood culture isolates over a two-year period, and to compare the MICs with isolates from the same site upon the South African launch of piperacillin-tazobactam. The intention was to to use the MIC data to evaluate and contextualise contemporary dosing strategies of piperacillin-tazobactam in South Africa. MICs were determined using broth microdilution antimicrobial susceptibility testing. A comparison of susceptibility between the two time periods was carried out using Fisher's exact test. The MIC data were then used to evaluate current dosing strategies based on current evidence-based pharmacodynamic parameters for piperacillin-tazobactam. A significant decrease in susceptibility was observed for Eschericha coli (p-value = 0.0009), Klebsiella spp. (p-value = 0.0001), Citrobacter spp. (p-value = 0.0001) and Acinetobacter baumannii (p-value = 0.0388) with MIC90 ≥ 128. Enterobacter spp., Serratia marcescens, Morganella morganii and Proteus spp./Providencia spp. demonstrating reduced susceptibility (combined intermediate and resistant) of 44%, 11%, 20% and 0%, respectively. No significant difference in susceptibility between current extended spectrum beta-lactamase (ESBL)- and non-ESBL-producing isolates was seen with a lower MIC90 for ESBL-producing Klebsiella spp. and Enterobacter spp., compared to their non-ESBL-producing counterparts. The MIC data suggest that more targeted dosing strategies that aim to optimise pharmacodynamic parameters are needed. Piperacillin-tazobactam remains a valuable antimicrobial agent whose continued longevity will depend on appropriate optimisation of pharmacodynamic parameters. This requires the application of MIC-based susceptibility data to clinical use, with local assessment of the applicability of various dosing strategies that is based on cumulative antimicrobial susceptibility data.

To elucidate the local epidemiology of Staphylococcus aureus bacteraemia, we characterised blood culture isolates using molecular methods and prospectively collected clinical data to determine the occurrence of community-acquired, methicillin-resistant S. aureus (MRSA). Consecutive S. aureus blood culture isolates were collected over a one-year period from patients who were admitted to Tygerberg Academic Hospital in the Western Cape. A multiplex polymerase chain reaction (PCR) was used for the detection of spa, mecA and lukS/F-PV genes. Strain typing was performed using spa typing. Multiplex PCR for staphylococcal cassette chromosome mec (SCCmec) typing was also performed, as well as multilocus sequence typing (MLST) on selected isolates. Cases were categorised by clinical data as either hospital-acquired, healthcare-associated or community-acquired. One hundred and thirteen S. aureus isolates (30% MRSA) were collected from 104 cases of bacteraemia. According to clinical data, all community-acquired infections, 54% of hospital-acquired cases and the majority of healthcare-associated cases were due to methicillin-sensitive S. aureus (MSSA). Furthermore, all Panton-Valentine leukocidin (PVL)-positive isolates (15.9% of all S. aureus) were MSSA. MRSA strains were isolated from hospital-acquired cases (with a minority of healthcare-associated cases) and clustered mainly in spa-CC701 and CC012. SCCmec type IV was predominant. MLST clones included ST239-MRSAIII, ST36-MRSA-II and ST612-MRSA-IV. The predominant source for S. aureus bacteraemia was catheter-related infection (39%). Community-acquired S. aureus infections in our setting remain sensitive to methicillin and current treatment guidelines suffice. The majority of hospital-acquired and healthcare-associated infections were catheter-related. Prevention and treatment should be targeted accordingly.

Acinetobacter baumannii is an important cause of hospital-acquired infections. The occurrence of carbapenem resistance that is caused by the carbapenem-hydrolysing class D β-lactamases and the metallo-β-lactamases (MBLs) limits the range of therapeutic alternatives in treating A. baumannii infections. In this study, two multiplex polymerase chain reactions were performed to screen for both carbapenem-hydrolysing class D β-lactamases and MBL genes in 97 clinical isolates of A. baumannii. Oxacillinase (OXA)-51 had a prevalence of 83% (81/97), and OXA-23 had a prevalence of 59% (57/97). One isolate was positive for an MBL [Verona integron-encoded metallo β-lactamases (VIM)]. Therefore, continuous surveillance and monitoring of A. baumannii is crucial because of the high prevalence of antibiotic resistance genes.

The Uthungulu District in KwaZulu-Natal province is the area that is most affected by rabies in South Africa. Usually, the transmission of rabies to humans occurs through the bites of infected dogs. In 2008, Uthungulu commenced a programme to eliminate human rabies in the district. This paper describes the epidemiology of dog bites and human rabies in the Uthungulu District from 2008-2010, and the extent of adherence to rabies post-exposure prophylaxis (PEP). The method was a retrospective analysis of dog-bite and human rabies surveillance data that were collected in Uthungulu from January 2008-December 2010. Dog-bite injuries in Uthungulu increased from 1 176 in 2008 to 2 365 in 2009, and decreased to 1 598 in 2010. Of 2 601 patients who were offered rabies PEP in 2009 and 2010, 83.7% [95% confidence interval (CI): 82.4-85.2] completed the treatment. Logistic regression analysis found that investigation of the report by an environmental healthcare practitioner [odds ratio (OR) = 3.95; 95% CI: 2.43-6.43, p-value = 0 .0001], the availability of patient telephone contact details in the healthcare facility's records (OR = 1.76; 95% CI: 1.02-3.03, p-value = 0.041), and bite wounds that were classified as Category 3 exposure injuries (OR = 2.96; 95% CI: 1.39-6.29, p-value = 0.004), were independently associated with completion of rabies PEP. Seven human rabies cases were reported (four in 2008, two in 2009 and one in 2010). Annualised human rabies incidence rates decreased from four cases per million in 2008 to one case per million in 2010. The findings suggest that the rabies elimination initiative is having an impact on the reduction of the incidence of human rabies in Uthungulu. The district should strengthen the follow-up of people who are exposed to rabies to ensure PEP completion.

Climate change has resulted in water mismanagement, increased population, urbanisation, industrialisation, poor sanitation and other developmental activities in the desert of Rajasthan. As a consequence, malariagenic conditions have developed and malaria is now a major public health problem in this area. Malaria control efforts need to identify associated factors and to integrate these efforts with the information, education and communication campaigns and behaviour change communication campaigns that are targeting the community of this region. To this end, a community-based study of knowledge, treatment-seeking behaviour and the socio-economic impact of malaria was conducted in 18 villages of Ramgarh primary health centre in Jaisalmer district. Three hundred and sixty-five subjects who had contracted malaria at least once in the year before the interview were randomly selected. Data were collected through an interview process. More than two thirds of respondents (69.3%) stated that malaria was transmitted by mosquitoes. Nearly three quarters of respondents (73.7%) identified the symptoms of malaria as shivering, alternating fever and chills, and headaches and vomiting. Just over half the respondents (55.1%) believed that antimalarial drugs, such as chloroquine, could not be administered to pregnant women. 11.8% of subjects were aware of the use of preventative measures against mosquito bites. 7.2 days was the mean time taken by respondents to utilise health facilities for diagnosis and treatment. The treatment cost was significantly higher for those who used private health clinics (rupees 1 200) than it was for those who used government health facilities (Rs. 150/-) (p-value < 0.001). Literate respondents had better knowledge of malaria than illiterate respondents.

Lack of diagnostic methods to determine a specific aetiology can contribute to an increase in genital tract infections (GTIs) in women. We determined the aetiology of, and risk factors associated with, GTIs in women with genital symptoms. After obtaining informed consent, genital swabs to detect Neisseria gonorrhoeae, Trichomonas vaginalis, vaginal candidiasis, bacterial vaginosis and Chlamydia trachomatis, were collected from women who attended sexually transmitted infection (STI) clinics in Mwanza in 2010. Demographic data were also gathered. A total of 320 women, with a mean age 26.5 ± 6.9 years, were recruited for the study. The percentages of GTIs in women with genital discharge syndromes were 25.9% for bacterial vaginosis, 25.6% for vaginal candidiasis, 14% for C. trachomatis, 8.7% for T. vaginalis and 8.4% for N. gonorrhoeae. Gonococcal infections were detected more by N. gonorrhoeae PCR than by culture methods (p-value < 0.000). From a sample of 66 women, (24.2%), 14 were infected by > 2 infections of bacterial vaginosis, C. trachomatis and N. gonorrhoeae. Women who were reported to have engaged in sexual intercourse before the age of 18 years and those who had > 2 sexual partners were more likely to be infected by C. trachomatis vs. N. gonorrhoeae and T. vaginalis. Following a sensitivity test, 21 out of 27 (77.7%) of gonococcal isolates were quinolone-resistant N. gonorrhoeae. One isolate was resistant to ciprofloxacin, azithromycin and cefixime, but not ceftriaxone. A high prevalence of bacterial vaginosis, gonorrhoea, trichomoniasis, chlamydia and vaginal candidiasis in women who attended the STI clinics in Mwanza was observed. Drug resistance of N. gonorrhoeae to ciprofloxacin is very high. This calls for an immediate review of the guidelines on its use as a first-line treatment for STIs in Tanzania.

Oral lesions that are associated with human immunodeficiency virus (HIV) infection are often the first clinical signs of an underlying infection. This study aimed to test primary healthcare (PHC) nurses' knowledge and practices before and after an educational intervention on the detection and management of oral diseases, and in particular, those associated with HIV infection. A cross-sectional study was conducted among PHC nurses who were employed in a range of clinical settings within the public sector (hospitals, clinics and nurse training colleges) in urban and rural areas in the uMgungundlovu Health District of KwaZulu-Natal. The convenience sample comprised 121 nurses who completed a self-administered questionnaire, undertook pre-education testing, were provided with educational material and underwent post-education testing. The obtained results showed that most nurses (90%) had received little or no undergraduate or postgraduate training in the examination, diagnosis or treatment of oral lesions. Analysis of the pre-education test results that pertained to the identification of a number of oral lesions revealed a mean correct response rate of 38.5%. Post-education results revealed a statistically significant (p-value < .0001) (24%) improvement to 62.4%. The provision of a basic education intervention can have significant effects on knowledge, treatment and referral patterns, and can lead to early diagnosis, treatment and improved quality of life for persons who are infected with HIV.

The Democratic Republic of Congo (DRC) is experiencing increasing human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) in young adults. This is despite the government's widespread campaign on HIV/AIDS awareness. In this study, high-risk university students who engage in casual sex, but who have good literacy skills, were surveyed to ascertain whether the education campaigns in the country influenced their condom use practice. This study sought to determine Goman University students' knowledge and attitudes about and practices of condom use for the purpose of reducing HIV infection. A descriptive cross-sectional quantitative study, using a self-administered questionnaire, was carried out. The ages of the students varied between 18 and 33. Most of them were men: 111 (80%), 129 (93%) were single, and most participants were Protestants (61, 44%) and Roman Catholics (57, 41%). The majority of participants (137, 99%) knew about condoms, while 132 (96%) were aware that condoms were available from and sold by pharmacies. Seventy-two (52 %) understood that condoms helped to prevent HIV, pregnancy and sexually transmitted infections (STIs). Ninety-four (68%) said that they knew how to use a condom, while 111 (80%) stated that the price of condoms was not a barrier to usage thereof. One hundred and two (74%) suggested that the university should supply students with condoms. Ninety-one (66%) were sexually active and 98 (71%) of participants reported that they had unprotected sex. Condom awareness was high and information was available from varying sources. Condoms were accepted as a means to prevent HIV/AIDS, STIs and pregnancy. Some ethnic groups disapproved of condom use because of religious and cultural beliefs. Consistent use of condoms was low in Goma University students.

A human immunodeficiency virus-infected girl with previous cerebral tuberculosis presented with paraparesis and sphincter dysfunction after improvement in her CD4 count, following antiretroviral therapy. Magnetic resonance imaging of her spinal cord revealed a conus medullaris lesion, in keeping with a tuberculoma. Her neurological signs improved after initiating tuberculosis treatment and steroids. It is most likely that this case demonstrates an unusual central nervous system immune reconstitution inflammatory syndrome (IRIS) response and is probably the first reported case of conus medullaris tuberculoma IRIS in the literature.