A profile of HIV-related paediatric admissions at Chris Hani Baragwanath Hospital, Johannesburg, South Africa

MMed (Paediatrics), Faculty of Health Sciences, University of the Witwatersrand, 2009Aim: To describe the prevalence of HIV infection, and the disease profile and outcome of 440 HIV-infected children admitted to the general paediatric wards at Chris Hani Baragwanath Hospital (CHBH). Methods: A comprehensive list of all paediatic patients admitted to the general wards between October and December 2007 was compiled using hospital admission records. Hospital folder and laboratory records were used to determine HIV prevalence. A retrospective review of inpatient hospital records was conducted for all confirmed HIV-infected paediatric patients admitted during the study period. Results: The prevalence of confirmed HIV infection amongst paediatric admissions at CHBH during the study period was 29.5% (95% CI 27.2 -31.9%). Of these children, 54.1% were newly diagnosed with HIV during the current hospital admission. Despite the majority (92.7%) of admissions having advanced HIV disease (WHO Stage 3 or 4), only 17% were accessing ART. Of the 202/440 (45.9%) children known to be HIV-infected before hospital admission, only 74/202 (36.6%) were currently receiving ART. Of the remaining 128/202 children known to be HIV-infected before hospital admission, 121/128 (94.5%) had WHO HIV stage 3 or 4 disease and thus were eligible for ART. Only 19% of children had a normal weight. Amongst infants aged less than 6 months uptake of PMTCT interventions was poor - only 36% of mother-infant pairs received single dose nevirapine and 28% of infants received cotrimoxazole prophylaxis. Respiratory illness was the principal reason for hospitalization in 37.5% of admissions. Gastroenteritis, sepsis and tuberculosis accounted for 22%, 19.5% and 21% of principal diagnoses respectively. The overall case fatality rate was 12% (95% CI 9.2–15.5%), with deaths in HIV-infected children contributing 58% of all deaths in the general paediatric wards. Over half (52%) of all deaths in the HIV-infected group occurred in infants younger than 6 months of age. vi Conclusion: HIV infection remains a major contributor to morbidity and mortality among paediatric admissions at CHBH. Poor uptake of PMTCT interventions, late diagnosis of HIV infection and delay in accessing ART are immediate barriers to improved care in HIV-infected children at CHBH. The underlying reasons for poor accessibility and under- utilisation of paediatric HIV-related services requires further investigation. Efforts to reduce mortality amongst HIV-infected paediatric admissions at CHBH should focus on early diagnosis of HIV infection and prompt initiation of antiretroviral treatment, especially in infants under 6 months of age

When students become patients: TB disease among medical undergraduates in Cape Town, South Africa

Background. Medical students acquire latent tuberculosis (TB) infection at a rate of 23 cases/100 person-years. The frequency and impact of occupational TB disease in this population are unknown.Methods. A self-administered questionnaire was distributed via email and social media to current medical students and recently graduated doctors (2010 - 2015) at two medical schools in Cape Town. Individuals who had developed TB disease as undergraduate students were eligible to participate. Quantitative and qualitative data collected from the questionnaire and semi-structured interviews were analysed with descriptive statistics and a framework approach to identify emerging themes.Results. Twelve individuals (10 female) reported a diagnosis of TB: pulmonary TB (n=6), pleural TB (n=3), TB lymphadenitis (n=2) and TB spine (n=1); 2/12 (17%) had drug-resistant disease (DR-TB). Mean diagnostic delay post consultation was 8.1 weeks, with only 42% of initial diagnoses being correct. Most consulted private healthcare providers (general practitioners (n=7); pulmonologists (n=4)), and nine underwent invasive procedures (bronchoscopy, pleural fluid aspiration and tissue biopsy). Substantial healthcare costs were incurred (mean ZAR25 000 for drug-sensitive TB, up to  ZAR104 000 for DR-TB). Students struggled to obtain treatment, incurred high transport costs and missed academic time. Students with DR-TB interrupted their studies and experienced severe side-effects (hepatotoxicity, depression and permanent ototoxicity). Most participants cited poor TB infection-control practices at their training hospitals as a major risk factor for occupational TB.Conclusions. Undergraduate medical students in Cape Town are at high risk of occupationally acquired TB, with an unmet need for comprehensive occupational health services and support.

A framework for preventing healthcare-associated infection in neonates and children in South Africa

CITATION: Dramowski, A., Cotton, M. F. & Whitelaw, A. 2017. A framework for preventing healthcare-associated infection in neonates and children in South Africa. South African Medical Journal, 107(3):192-195, doi:10.7196/SAMJ.2017.v107i3.12035.The original publication is available at http://www.samj.org.zaHealthcare-associated infection (HAI) is a frequent and serious complication affecting 4 - 8% of hospitalised children and neonates in high-income countries. The burden of HAI in South African (SA) paediatric and neonatal wards is substantial but underappreciated, owing to a lack of HAI surveillance and reporting. Maternal and child health and infection prevention are priority areas for healthcare quality improvement in the National Core Standards programme. Despite increasing recognition in SA, infection prevention efforts targeting hospitalised children and neonates are hampered by health system, institutional and individual patient factors. To ensure safe healthcare delivery to children, a co-ordinated HAI prevention strategy should promote development of infection prevention norms and policies, education, patient safety advocacy, healthcare infrastructure, surveillance and research. We present a framework for SA to develop and expand HAI prevention in hospitalised neonates and children.http://www.samj.org.za/index.php/samj/article/view/11817Publisher's versio

Trends in paediatric bloodstream infections at a South African referral hospital

CITATION: Dramowski, A., Cotton, M.F., Rabie, H. & Whitelaw, A. 2015. Trends in paediatric bloodstream infections at a South African referral hospital. BMC Pediatrics, 15(33), doi:10.1186/s12887-015-0354-3.The original publication is available at http://bmcpediatr.biomedcentral.comPublication of this article was funded by the Stellenbosch University Open Access Fund.Background: The epidemiology of paediatric bloodstream infection (BSI) in Sub-Saharan Africa is poorly documented with limited data on hospital-acquired sepsis, impact of HIV infection, BSI trends and antimicrobial resistance. Methods: We retrospectively reviewed paediatric BSI (0–14 years) at Tygerberg Children’s Hospital between 1 January 2008 and 31 December 2013 (excluding neonatal wards). Laboratory and hospital data were used to determine BSI rates, blood culture contamination, pathogen profile, patient demographics, antimicrobial resistance and factors associated with mortality. Fluconazole resistant Candida species, methicillin-resistant Staphylococcus aureus (MRSA), multi-drug resistant Acinetobacter baumannii and extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae were classified as antimicrobial resistant pathogens. Results: Of 17001 blood cultures over 6 years, 935 cultures isolated 979 pathogens (5.5% yield; 95% CI 5.3-5.7%). Contamination rates were high (6.6%, 95% CI 6.4-6.8%), increasing over time (p = 0.003). Discrete BSI episodes were identified (n = 864) with median patient age of 7.5 months, male predominance (57%) and 13% HIV prevalence. BSI rates declined significantly over time (4.6–3.1, overall rate 3.5 per 1000 patient days; 95% CI 3.3–3.7; Chi square for trend p = 0.02). Gram negative pathogens predominated (60% vs 33% Gram positives and 7% fungal); Klebsiella pneumoniae (154; 17%), Staphylococcus aureus (131; 14%) and Escherichia coli (97; 11%) were most prevalent. Crude BSI mortality was 20% (176/864); HIV infection, fungal, Gram negative and hospital-acquired sepsis were significantly associated with mortality on multivariate analysis. Hospital-acquired BSI was common (404/864; 47%). Overall antimicrobial resistance rates were high (70% in hospital vs 25% in community-acquired infections; p < 0.0001); hospital-acquired infection, infancy, HIV-infection and Gram negative sepsis were associated with resistance. S. pneumoniae BSI declined significantly over time (58/465 [12.5%] to 33/399 [8.3%]; p =0.04). Conclusion: Although BSI rates declined over time, children with BSI had high mortality and pathogens exhibited substantial antimicrobial resistance in both community and hospital-acquired infections. Blood culture sampling technique and local options for empiric antimicrobial therapy require re-evaluation.http://www.biomedcentral.com/content/pdf/s12887-015-0354-3.pdfPublisher's versio

South African medical students’ perspectives on COVID-19 and clinical training

The COVID-19 pandemic has disrupted clinical training programmes for medical students globally. Continuation of clinical training is important but should be weighed against the risk of transmission of COVID- 19 infection from students to susceptible peers, healthcare workers (HCWs) and patients. Furthermore, teaching of medical students may place an additional burden on busy clinicians during the pandemic and increase utilisation of personal protective equipment (PPE).(2–5) All South African universities, including medical faculties, were forced to close when a national lockdown was implemented in March 2020. The Stellenbosch University Faculty of Medicine and Health Sciences (SU-FMHS) implemented a phased return to clinical training for senior students in May 2020 to ensure timely graduation; all other medical students continued the academic year via online learning. We conducted a cross-sectional survey of SU-FMHS Bachelor of Medicine and Bachelor of Surgery (MBChB) students’ attitudes to and perceptions regarding the COVID-19 pandemic and clinical training.https://journals.co.za/journal/wjcmam2021Paediatrics and Child Healt

Implementation of infection prevention and control for hospitalized neonates: A narrative review

Background The most prevalent infections encountered in neonatal care are healthcare-associated infections. The majority of healthcare-associated infections are considered preventable with evidence-based infection prevention and control (IPC) practices. However, substantial knowledge gaps exist in IPC implementation in neonatal care. Furthermore, the knowledge of factors which facilitate or challenge the uptake and sustainment of IPC programmes in neonatal units is limited. The integration of implementation science approaches in IPC programmes in neonatal care aims to address these problems. Objectives The aim of this narrative review was to identify determinants which have been reported to influence the implementation of IPC programmes and best practices in inpatient neonatal care settings. Sources A literature search was conducted in PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online) and CINAHL (Cumulative Index to Nursing and Allied Health Literature) in May 2022. Primary study reports published in English, French, German, Spanish, Portuguese, Italian, Danish, Swedish or Norwegian since 2000 were eligible for inclusion. Included studies focused on IPC practices in inpatient neonatal care settings and reported determinants which influenced implementation processes. Content The Consolidated Framework for Implementation Research was used to identify and cluster reported determinants to the implementation of IPC practices and programmes in neonatal care. Most studies reported challenges and facilitators at the organizational level as particularly relevant to implementation processes. The commonly reported determinants included staffing levels, work- and caseloads, as well as aspects of organizational culture such as communication and leadership. Implications The presented knowledge about factors influencing neonatal IPC can support the design, implementation, and evaluation of IPC practices

Clonal expansion of colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa

CITATION: Snyman, Y., et al. 2020. Clonal expansion of colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. International Journal of Infectious Diseases, 91:94-100, doi:10.1016/j.ijid.2019.11.021.The original publication is available at https://www.journals.elsevier.com/international-journal-of-infectious-diseasesPublication of this article was funded by the Stellenbosch University Open Access FundObjectives: To describe colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. Methods: A. baumannii isolates identified on Vitek 2 Advanced Expert System were collected from Tygerberg Hospital referral laboratory between 2016 and 2017. Colistin resistance was confirmed using broth microdilution and SensiTest. mcr-1–5 were detected using PCR and strain typing was performed by rep-PCR. Whole genome sequencing (WGS) was performed on a subset of isolates to identify chromosomal colistin resistance mechanisms and strain diversity using multilocus sequence typing (MLST) and pairwise single nucleotide polymorphism analyses. Results: Twenty-six colistin-resistant and six colistin-susceptible A. baumannii were collected separately based on Vitek susceptibility; 20/26 (77%) were confirmed colistin-resistant by broth microdilution. Four colistin-resistant isolates were isolated in 2016 and 16 in 2017, from five healthcare facilities. Thirteen colistin-resistant isolates and eight colistin-susceptible isolates were identical by rep-PCR and MLST (ST1), all from patients admitted to a tertiary hospital during 2017. The remaining colistin-resistant isolates were unrelated. Conclusions: An increase in colistin-resistant A. baumannii isolates from a tertiary hospital in 2017 appears to be clonal expansion of an emerging colistin-resistant strain. This strain was not detected in 2016 or from other hospitals. Identical colistin-susceptible isolates were also isolated, suggesting relatively recent acquisition of colistin resistance.https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1201971219304606?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1201971219304606%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2FPublisher's versio

Impact of a Multi-Strain Probiotic on Healthcare-Associated Bloodstream Infection Incidence and Severity in Preterm Neonates

Aim:Hospital acquired bloodstream infection (HA-BSI) is a major contributor to morbidity and mortality in preterm, very low birthweight infants, especially in low-to-middle- income countries.Materials and Methods:We conducted a double-blind, placebo-controlled, randomized clinical trial to investigate the effect of a multi-strain probiotic formulation (LabinicTM) on the incidence and severity of HA-BSI in preterm neonates.Results:Two hundred neonates (100 per arm) were included in this trial. Fifteen neonates developed HA-BSI events (2 in the probiotic arm and 13 in the placebo arm). The median day of life at HA-BSI onset for the probiotic group was 10.5±3.5, and for the placebo group, it was 11.2±6.4. The incidence of HA-BSI in neonates receiving the probiotic was significantly lower compared to those receiving the placebo [0.93 versus 5.99 HA-BSI events/1,000 neonate-days; incidence rate ratio (IRR) of 0.156 [95% confidence interval (CI): 0.017 to 0.691], p=0.0046]. Calculating the incidence rate of the combined outcome (sepsis/death) was also lower in the probiotic group versus the placebo group [2.34 versus 6.45 events/1,000 neonate days; IRR 0.33 (95% CI: 0.11 to 0.97), p=0.043].Conclusion:The use of a multi-strain probiotic significantly reduced HA-BSI incidence in this cohort of preterm neonates

Managing and preventing vascular catheter infections : a position paper of the international society for infectious diseases

CITATION: Lutwick, L., et al. 2019. Managing and preventing vascular catheter infections : a position paper of the international society for infectious diseases. International Journal of Infectious Diseases, 84:22-29, doi:10.1016/j.ijid.2019.04.014.The original publication is available at https://www.clinicalkey.com/ENGLISH ABSTRACT: A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview recommendations on managing and preventing vascular catheter infections, specifically for the prevention and management of central line-associated bloodstream infections. These recommendations are intended to provide insight for healthcare professionals regarding the prevention of infection in the placement and maintenance of the catheter and diagnosis as well as treatment of catheter infection. Aspects of this area in pediatrics and in limited-resource situations and a discussion regarding the selection of empiric or targeted antimicrobial therapy are particular strengths of this position paper.https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1201971219301845?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS1201971219301845%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2FPublisher's versio