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

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

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.

Pandemic escape plan : discontinuing policies that have reached their expiry date

CITATION: Van Zyl, G. U., Dramowski, A. & Preiser, W. 2022. Pandemic escape plan : discontinuing policies that have reached their expiry date. South African Medical Journal, 112(3), doi:10.7196/SAMJ.2022.v112i3.16381.The Latin phrase ‘Primum non nocere’, meaning ‘First, do no harm’, is a key principle in medicine. However, few interventions, whether at individual or community level, are without harmful effects. Practitioners therefore have to weigh up the potential benefits and negative effects of any medical or surgical intervention. The same applies to public health-level interventions for COVID-19.Publisher'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

Why healthcare workers are sick of TB.

Dr Thato Mosidi never expected to be diagnosed with tuberculosis (TB), despite widely prevalent exposure and very limited infection control measures. The life-threatening diagnosis of primary extensively drug-resistant TB (XDR-TB) came as an even greater shock. The inconvenient truth is that, rather than being protected, Dr Mosidi and thousands of her healthcare colleagues are at an increased risk of TB and especially drug-resistant TB. In this viewpoint paper we debunk the widely held false belief that healthcare workers are somehow immune to TB disease (TB-proof) and explore some of the key factors contributing to the pervasive stigmatization and subsequent non-disclosure of occupational TB. Our front-line workers are some of the first to suffer the consequences of a progressively more resistant and fatal TB epidemic, and urgent interventions are needed to ensure the safety and continued availability of these precious healthcare resources. These include the rapid development and scale-up of improved diagnostic and treatment options, strengthened infection control measures, and focused interventions to tackle stigma and discrimination in all its forms. We call our colleagues to action to protect themselves and those they care for

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

Epidemiology of clinically suspected and laboratory-confirmed bloodstream infections at a South African neonatal unit

CITATION: Dramowski A, Bekker A, Cotton MF, Whitelaw AC, Coffin S (2021) Epidemiology of clinically suspected and laboratory-confirmed bloodstream infections at a South African neonatal unit. J Infect Dev Ctries 15:943–952. doi. 10.3855/jidc.13971The original publication is available at:jidc.orgIntroduction: Data from Africa reporting the epidemiology of infection in hospitalised neonates are limited. Methodology: A prospective study with convenience sampling was conducted to characterise neonates investigated with blood culture/s for suspected infection at a 132-bed neonatal unit in Cape Town, South Africa (1 February-31 October 2018). Enrolled neonates were classified as having proven bloodstream infection (BSI) (blood culture-positive with a pathogen) or presumed infection (clinically suspected but blood culture-negative) or as potentially at risk of infection (maternal risk factors at birth). Results: Of 1299 hospitalised neonates with >1 blood culture sampling episode, 712 (55%) were enrolled: 126 (17.7%) had proven BSI; 299 (42%) had presumed infection and 287 (40.3%) were potentially at risk of infection. Neonates with proven BSI had lower birth weight and higher rates of co-existing surgical conditions versus the presumed/potential infection groups (p < 0.001). Median onset of proven BSI versus presumed infection was at 8 (IQR = 5-13) and 1 (IQR = 0-5) days respectively (p < 0.001). Most proven BSI were healthcare-associated (114/126; 90.5%), with Klebsiella pneumoniae (80.6% extended-spectrum β-lactamase producers) and Staphylococcus aureus (66.7% methicillin-resistant) predominating. Mortality from proven BSI (34/126; 27%) was substantially higher than that observed in presumed (8/299; 2.7%) and potential infections (3/287; 1.0%) (p < 0.001). The odds of death from proven BSI was 3-fold higher for Gram-negatives than for Gram-positive/fungal pathogens (OR = 3.23; 95% CI = 1.17-8.92). Conclusions: Proven BSI episodes were predominantly healthcare-associated and associated with a high case fatality rate. Most neonates with presumed infection or at potential risk of infection had favourable 30-day outcomes.Publisher’s versio

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