Diagnosing childhood pulmonary tuberculosis using a single sputum specimen on Xpert MTB/RIF at point of care

Background. The GeneXpert MTB/RIF (Cepheid, USA) (Xpert) has proved successful for pulmonary  tuberculosis (TB) diagnosis on decontaminated/concentrated induced sputum specimens from children.  Capacity to perform induction in many settings is limited.Objective. To assess: (i) volumes of ‘routinely obtained’ sputum in a district-level academic hospital; (ii) whether sputum specimens not meeting Xpert-required testing volumes could still be tested; and (iii) performance of Xpert on a single paediatric sputum specimen at point of care (POC).Methods. Two sputa were collected from paediatric TB suspects (≤14 years) at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa. One specimen was weighed at POC; if the volume was  ≥0.1 mL but <0.5 mL, it was increased to 0.5 mL using saline. On-site Xpert testing (G3 cartridge) was performed by a dedicated laboratory technician. The second specimen was referred for TB smear microscopy and culture as per standard of care (SOC).Results. A total of 484 patients presumed to have TB (median age 24 months) were eligible for this  study, performed between June 2011  and May 2012. Xpert could not be used on 4.1% of specimens because of volumes <0.1 mL, and 62.8% required addition of saline prior to Xpert testing. Xpert  generated a 2.2% error and 3.7% invalid rate, compared with the SOC that rejected 2.3% because of insufficient volume and 2.3% that were contaminated. The diagnostic performance compared with culture was 62.5% (95% confidence interval (CI) 24.7 - 91) and 99.1% (95% CI 97.4 - 99.8) sensitivity and specificity, respectively, for Xpert (n=345) and 33.3% (7.9 - 69.9) and 99.5% (98.1 - 99.9) sensitivity and specificity, respectively, for smear microscopy (n=374).Conclusions. Up to 67% of ‘routinely obtained’ sputum specimens from children (≤14 years) are below the required volume for Xpert testing but can be ‘topped up’ with saline. Xpert MTB/RIF performed better than microscopy and generated clinically relevant, timeous results, but sensitivity did not reach the  same levels as culture in children

An investigation of fingerstick blood collection for pointof- care HIV-1 viral load monitoring in South Africa

Background: Viral load (VL) quantification is an important tool in determining newly developed drug resistance or problems with adherence to antiretroviral therapy (ART) in HIV-positive patients. VL monitoring is becoming the standard of care in many resource-limited settings. Testing in resource-limited settings may require sampling by fingerstick because of general shortages of skilled phlebotomists and the expense of venepuncture supplies and problems with their distribution.Objective: To assess the feasibility and ease of collecting 150 μL capillary blood needed for the use of a novel collection device following a classic fingerstick puncture.Methods: Patients were recruited by the study nurse upon arrival for routine ART monitoring at the Themba Lethu Clinic in Johannesburg, South Africa. Each step of the fingerstick and blood collection protocol was observed, and their completion or omission was recorded.Results: One hundred and three patients consented to the study, of whom three were excluded owing to the presence of callouses. From a total of 100 patients who consented and were enrolled, 98% of collection attempts were successful and 86% of participants required only one fingerstick to successfully collect 150 μL capillary blood. Study nurse adherence to the fingerstick protocol revealed omissions in several steps that may lower the success rate of capillary blood collection and reduce the performance of a subsequent VL assay.Conclusion: The findings of this study support the feasibility of collecting 150 μL of capillary blood via fingerstick for point-of-care HIV-1 VL testing in a resource-limited setting

Evaluating initial antimicrobial use in an adult intensive care unit at an academic teaching hospital in Pretoria, South Africa

Antimicrobial resistance is increasing globally. It is estimated that in hospitals around the world 50% of antimicrobial usage is either unnecessary or inappropriate. The study aimed to explore factors surrounding initially prescribed antibiotics and direct medicine related costs in the adult Medical Intensive Care Unit (MICU), at Steve Biko Academic Hospital (SBAH). A clinically trained pharmacist was included as part of the multi-disciplinary team and evaluated antibiotics prescribed after admission. These were considered as the initial course of antibiotics. The antimicrobial agents that the patient was admitted with were documented and are referred to as “antibiotics prior to review”. Just less than half of the patients, 23 (44.2%; n = 52) were initiated on antibiotics on the first day of admission to the MICU. The majority of antibiotics 46 (60.5%) were prescribed appropriately during the study period. The total cost of initial antibiotic use for the treatment period during the study was R209 140.40, with an average cost of R31 240.77 per day for all initial antibiotics. A coordinated effort from the infectious diseases specialist and clinical pharmacist within the multi-disciplinary team, assisted in appropriate prescribing of antibiotics to patients that were admitted to the MICU

SASOCP position statement on the pharmacist’s role in antibiotic stewardship 2018

Antibiotics are the most commonly prescribed medicines in global healthcare practice today. Their effectiveness is crucial and often life-saving in humanity’s battle against pathogens and infectious diseases. Antibiotic/antimicrobial stewardship strategies and programmes have become vital to the preservation of effective antibiotics and the optimisation of their use. The South African Society of Clinical Pharmacy (SASOCP) has written this guideline to outline the importance, role and purpose of pharmacists in such stewardship programmes, both in the public, as well as the private hospital sectors in South Africa. It also provides an overview of various approaches to antibiotic preservation, behavioural change, stewardship measures, and monitoring strategies

Comparison of Xpert MTB/RIF with Other Nucleic Acid Technologies for Diagnosing Pulmonary Tuberculosis in a High HIV Prevalence Setting: A Prospective Study

In this prospective, real-world cohort study nested within a national screening program for tuberculosis, Lesley Scott and colleagues compare the performance of Xpert MTB/RIF on a single sputum sample with different TB sputum detection technologies

Ash agglomeration and deposition during combustion of poultry litter in a bubbling fluidized-bed combustor

peer-reviewedn this study, we have characterized the ash resulting from fluidized bed combustion of poultry litter as being dominated by a coarse fraction of crystalline ash composed of alkali-Ca-phosphates and a fine fraction of particulate K2SO4 and KCl. Bed agglomeration was found to be coating-induced with two distinct layers present. The inner layer (0.05–0.09 mm thick) was formed due to the reaction of gaseous potassium with the sand (SiO2) surface forming K-silicates with low melting points. Further chemical reaction on the surface of the bed material strengthened the coating forming a molten glassy phase. The outer layer was composed of loosely bound, fine particulate ash originating from the char. Thermodynamic equilibrium calculations showed slag formation in the combustion zone is highly temperature-dependent, with slag formation predicted to increase from 1.8 kg at 600 °C to 7.35 kg at 1000 °C per hour of operation (5.21 kg of ash). Of this slag phase, SiO2 and K2O were the dominant phases, accounting for almost 95%, highlighting the role of K-silicates in initiating bed agglomeration. The remaining 5% was predicted to consist mainly of Al2O3, K2SO4, and Na2O. Deposition downstream in the low-temperature regions was found to occur mostly through the vaporization–condensation mechanism, with equilibrium decreasing significantly with decreasing temperatures. The dominant alkali chloride-containing gas predicted to form in the combustion zone was KCl, which corresponds with the high KCl content in the fine baghouse ash

Dexamethasone intravitreal implant in previously treated patients with diabetic macular edema : Subgroup analysis of the MEAD study

Background: Dexamethasone intravitreal implant 0.7 mg (DEX 0.7) was approved for treatment of diabetic macular edema (DME) after demonstration of its efficacy and safety in the MEAD registration trials. We performed subgroup analysis of MEAD study results to evaluate the efficacy and safety of DEX 0.7 treatment in patients with previously treated DME. Methods: Three-year, randomized, sham-controlled phase 3 study in patients with DME, best-corrected visual acuity (BCVA) of 34.68 Early Treatment Diabetic Retinopathy Study letters (20/200.20/50 Snellen equivalent), and central retinal thickness (CRT) 65300 \u3bcm measured by time-domain optical coherence tomography. Patients were randomized to 1 of 2 doses of DEX (0.7 mg or 0.35 mg), or to sham procedure, with retreatment no more than every 6 months. The primary endpoint was 6515-letter gain in BCVA at study end. Average change in BCVA and CRT from baseline during the study (area-under-the-curve approach) and adverse events were also evaluated. The present subgroup analysis evaluated outcomes in patients randomized to DEX 0.7 (marketed dose) or sham based on prior treatment for DME at study entry. Results: Baseline characteristics of previously treated DEX 0.7 (n = 247) and sham (n=261) patients were similar. In the previously treated subgroup, mean number of treatments over 3 years was 4.1 for DEX 0.7 and 3.2 for sham, 21.5 % of DEX 0.7 patients versus 11.1 % of sham had 6515-letter BCVA gain from baseline at study end (P = 0.002), mean average BCVA change from baseline was +3.2 letters with DEX 0.7 versus +1.5 letters with sham (P = 0.024), and mean average CRT change from baseline was -126.1 \u3bcm with DEX 0.7 versus -39.0 \u3bcm with sham(P < 0.001). Cataract-related adverse events were reported in 70.3 % of baseline phakic patients in the previously treated DEX 0.7 subgroup; vision gains were restored following cataract surgery. Conclusions: DEX 0.7 significantly improved visual and anatomic outcomes in patients with DME previously treated with laser, intravitreal anti-vascular endothelial growth factor, intravitreal triamcinolone acetonide, or a combination of these therapies. The safety profile of DEX 0.7 in previously treated patients was similar to its safety profile in the total study population