Surveillance of antimicrobial susceptibility patterns among pathogens isolated in public sector hospitals associated with academic institutions in South Africa

Background: Antimicrobial resistance (AMR) is a global public health challenge since infection with resistant organisms may cause death, can spread across the community, and increase health care costs at individual, community and government level as more expensive antimicrobials will have to be made available for the treatment of infections caused by resistant bacteria. This calls for urgent and consolidated efforts in order to effectively curb this growing crisis, to prevent the world from slipping back to the pre-antibiotic era. The World Health Organization made a call in 2011 advocating for strengthening of surveillance and laboratory capacity as one-way of detecting and monitoring trends and patterns of emerging AMR. Knowledge of AMR guides clinical decisions regarding choice of antimicrobial therapy, during an episode of bacteraemia and forms the basis of key strategies in containing the spread of resistant bacteria. The current study focused on Staphylococcus aureus (SA), Klebsiella pneumoniae (KP), and Pseudomonas aeruginosa (PA), as they are common hospital acquired infections which are prone to developing resistance to multiple antibiotics. Aim: The aim of this project was to assess and utilize the laboratory information system (LIS) at the National Health Laboratory Services (NHLS), as a tool for reporting AMR and monitoring resistance patterns and trends over time of clinical isolates of SA, KP and PA, cultured from the blood of patients admitted to seven tertiary public hospitals in three provinces in South Africa. Methods: A retrospective and prospective analysis was done on isolates of SA, KP, PA from blood specimens collected from patients with bacteraemia and submitted to diagnostic microbiology laboratories of the NHLS at seven tertiary public hospitals in three provinces in South Africa. These hospitals comprised the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Chris Hani Baragwanath Hospital (CBH), Helen Joseph Hospital (HJH), Steve Biko Pretoria Academic Hospital (SBPAH), Groote Schuur Hospital (GSH), Tygerberg Hospital (TH) and the Universitas Hospital of the Free State (UH). For retrospective analysis, data submitted during the period July 2005 to December 2009 were used and for prospective analysis, data relating to AMR in SA, KP, PA, collected by the Group for Enteric, Respiratory and Meningeal disease Surveillance in South Africa, (GERMS-SA) from July 2010 to June 2011 were used. AMR in these three pathogens to commonly used antimicrobial drugs was systematically investigated. Multivariate logistic regressions models were used to assess factors associated with AMR. In addition, a systematic review of research done to date on AMR in bacterial pathogens commonly associated with hospital-acquired infections was conducted in order to understand the existing antimicrobial surveillance systems and baseline resistance patterns in South Africa. Results: A total of 9969 isolates were reported from the retrospective dataset. These were 3942 (39.5%) SA, 4466 (44.8%) KP and 1561 (15.7%) PA. From the prospective dataset, a total of 3026 isolates were reported, 1494 (49.4%) SA and 1532 (50.6%) KP isolates respectively. The proportion of invasive bacteraemia was higher in the 30% up to as high as 80% were resistant to methicillin-related drugs among~560 invasive SA isolates over the two year period. Methicillin resistant Staphylococcus aureus (MRSA) rates significantly differed between hospitals (p=<0.001). The proportion of MRSA isolates in relation to methicillin-susceptible strains showed a declining trend from 22.2% in 2005 to 10.5% in 2009 (p=0.042). Emerging resistance was observed for vancomycin: 1 isolate was identified in 2006 and 9 isolates between July 2010-June 2011, and all except 1 were from Gauteng hospitals. The study found increasing rates of carbapenem-resisant KP of 0.4% in 2005 to 4.0% in 2011 for imipenem. The mean rate of extended spectrum beta lactamase (ESBL-KP) producing KP was 74.2%, with the lowest rate of 62.4% in SBPAH and the highest rate of 81.3% in UH, showing a significant geographical variation in rates of resistance (p=0.021). PA showed a tendency for multi-drug resistance with resistance rates of >20% to extended spectrum cephalosporins, fluoroquinolones and aminoglycosides respectively. Emerging resistance in PA isolates was observed to colistin, showing a resistance rate of 1.9% over the 5 years period. In the multivariate model, age <5 years, male gender, and hospital location were factors significantly associated with MRSA, while ESBL-KP was significantly associated with age <5 years and hospital location. Concluding remarks: The study has clearly demonstrated that AMR is relatively common in South Africa among children <5 years. Enhancement of continued surveillance of nosocomial infections through use of routine laboratory data should be reinforced as this will facilitate effective interpretation and mapping of trends and patterns of AMR. Therefore, the LIS as a tool for gathering such data should be strengthened to provide reliable AMR data for improved understanding of the extent of the AMR, and present evidence on which future policies and practices aimed at containing AMR could be based. Key words: Laboratory information system, Trends, Patterns, Antimicrobial resistance, Bacterial pathogens, Nosocomial infections, Surveillance, Bacteraemia, Blood culture

Risk factors for mortality in patients with invasive pneumococcal disease in South Africa

ABSTRACT Introduction Invasive pneumococcal disease (IPD) is an important cause of morbidity and mortality in many parts of the world. It is estimated that pneumococcal disease causes more than one million-childhood deaths every year and the burden of disease is greater in developing countries. The main aim of this study was to analyze risk factors associated with mortality in invasive pneumococcal disease in all ages in South Africa. Materials and Methods We performed an analytical cross-sectional analysis of secondary data from national population-based surveillance for invasive Streptococcus pneumoniae infection in South Africa. The study period was 1 January 2003 to 31 December 2005, and the mortality analysis used a subset of laboratory-confirmed cases who had a completed case report form and available mortality data. Multiple logistic regression models were constructed to identify risk factors significantly associated with the increased risk of death in patients with invasive pneumococcal disease. Separate models were used to evaluate risk factors for death in patients with meningitis and those with other IPD. Results There were 1154 (24%) cases of Streptococcus pneumoniae meningitis and 3736 (76%) cases of other invasive disease. The overall case fatality rate was 1360/4890 (27.8%) of which 911 (67%) patients died within 2 days of admission and 449 (33%) died between 2 days and 30 days of admission. Variables associated with mortality in a logistic regression analysis of all IPD patients included meningitis (OR 2.8, CI 1.9 – 3.9, P=<0.001), HIV-infection (OR 2.8, CI 1.6 – 4.6, P=<0.001), acute severe illness measured by Pitt bacteraemia score >=4 (OR 4.7, CI 2.8 – 7.7, P=<0.001) and prior antibiotic use within 2 months before first positive culture (OR 2.1, CI 1.4 – 3.1, P=<0.001). In addition to this children less than 1 year and adults ≥45 years were more likely to die compared to other age groups. Patients from Western Cape Province were significantly less likely to die (OR 0.27, CI 0.15 – 0.50, P=<0.001) compared to other provinces. Amongst HIV-positive patients severe immunosuppression (low CD4+ count) was a risk factor for death. Risk factors for death were similar in patients with other IPD and meningitis except for HIV which was associated with death in the meningitis group but not in the other IPD group. Antibiotic resistance and vaccine-serotype disease were not associated with increased risk of death. Discussion and Conclusions IPD is associated with a high mortality in South Africa. Our findings of increased risk of death in HIV-positive patients especially those with low CD4+ count are of importance given the high prevalence of HIV amongst patients with IPD. Introduction of the pneumococcal conjugate vaccine as part of the national expanded program for immunization (EPI) and ensuring access to antiretroviral therapy for HIV-positive patients where indicated should be prioritized

“My condition is my secret”: perspectives of HIV positive female sex workers on differentiated service delivery models in Kampala Uganda

Background: Diferentiated service delivery (DSD) models for female sex workers (FSWs) continue to be scaled up with the goal of expanding access to HIV services and treatment continuity. However, little is known about FSWs’ perspectives on their preferences, facilitators, and barriers to the efective utilization of various DSD models. Methods: We conducted 24 in-depth interviews among FSWs on antiretroviral therapy for at least one year in two drop-in centres and two public health facilities in Kampala, Uganda in January 2021. Results: The facility-based individual management model was most preferred, due to a wide array of comprehensive health services, privacy, and professional health workers. Community DSD models were physically accessible, but least preferred due to stigmatization and discrimination, lack of privacy and confdentiality, and limited health services ofered. Conclusion: Targeted strategies to reduce stigma and discrimination and the provision of high-quality services have potential to optimise FSWs’ access to HIV services

A Retrospective study of the pre-hospital trauma burden managed by the Western Cape Government Emergency Medical Services

Background: Trauma is one of the leading causes of premature death and disability in South Africa. There is a lack of data describing the pre-hospital trauma burden in sub-Saharan Africa. This study aimed to describe the epidemiology of common trauma emergencies managed by the Western Cape Government (WCG) emergency medical services (EMS) in South Africa. Methods: The WCG EMS call centre registry was retrospectively analysed for all trauma patients managed between 01 July 2017 to 30 June 2018. A descriptive analysis of the data was performed using standard procedures for all variables. To date, this Is the first analysis of this dataset or any prehospital trauma burden managed in the Western Cape of South Africa. Results: The WCG EMS managed 492 303 cases during the study period. Of these, 168 980 (34.3%), or 25.5 per 1000 population, were trauma related. However, only 91 196 met the inclusion criteria for the study. The majority of patients (66.4%) were men between the socio-economically active ages of 21–40 years (54.0%). Assaults were the most common cause of trauma emergencies, accounting for 50.2% of the EMS caseload. The patient acuity was categorised as urgent in 47.5% of the cases, and 74.9% of the prehospital trauma burden was transported to a secondary level health care facility for definitive care. Conclusion: This is the first report on the prehospital trauma burden managed in the Western Cape of South Africa. The Western Cape suffers a unique trauma burden that differs from what is described by the World Health Organization (WHO) or any other low- and middle-income countries (LMICs). It also provides the foundation for further research on emergency care needs in South Africa and support for Afrocentric health care solutions to address this public health crisis

Understanding Laboratory Methods and Their Impact on Antimicrobial Resistance Surveillance, at Muhimbili National Hospital, Dar es Salaam, Tanzania

The study sought to describe laboratory methods and blood culture procedures and their impact on antimicro-bial resistance surveillance among nosocomial bacteria. We conducted a systematic audit of blood culture pro-cedures and practices in the Department of Microbiology, Central Pathology Laboratory at Muhimbili National Hospital, between 19th and 23rd March 2012. A total of 25 - 30 blood culture specimens were received each day as an indication of low volumes of blood culturing at this site. More blood culture requests came from the neonatal unit of the hospital, and were performed manually with high culture negative specimens. The laboratory per-formed antibiotic susceptibility testing as per the CLSI guidelines. No vancomycin resistance was ever reported at this site. All blood culture results were entered into the JEEVA laboratory information system, where results could be accessed by clinicians in the wards and data could be retrieved to assess patterns of antimicrobial resis-tance. Blood culture data entry system lacked quality control checks hence numerous errors and missing data were observed. Our results support the relevance of having improved laboratory procedures and good quality blood culture since surveillance of antimicrobial resistance primarily depends on good laboratory procedures, good quality and reliable blood culture data. This would essentially minimise imprecise estimates of rates of an-timicrobial resistance at this hospital.\u

Factors affecting effective communication about sexual and reproductive health issues between parents and adolescents in zandspruit informal settlement, Johannesburg, South Africa

INTRODUCTION: Communication between parents and adolescents regarding sexuality is an important reproductive health topic. Due to complexities associated with adolescent's physiological development, sexuality should be dealt with holistically. This study aimed to investigate factors affecting effective communication between parents and adolescents concerning sexual and reproductive health issues. METHODS: An exploratory qualitative study using the focus group discussions method was done to explore amongst other things; social, cultural and religious barriers to communication. Thematic content analysis was done. RESULTS: Factors identified included: embarrassment when discussing sexual topics; adolescent misperceptions that guardians want to engage in sexual activities with them; strong belief amongst guardians that reproductive health discussions with adolescents encourages sexual experimentation; belief that adolescents were too young to understand; non-conducive environment for open discussions of sexual and reproductive health matters; cultural and religious beliefs. CONCLUSION: In view of these findings, there are still barriers in terms of parent-adolescent engagement on issues related to risks associated with sexual behaviours and erroneous reproductive health choices among adolescents. Therefore, there is a need to encourage engagement by creating neutral platforms facilitated by community healthcare providers and/ or social workers. This will help create awareness and bridge the communication and interaction gap by emphasising the importance of effective engagement among adolescents and their parents on matters related to risks associated with sexual behaviours and erroneous reproductive health choices. Post implantation intervention studies are needed to inform on the outcomes of the intervention

Public awareness and knowledge of the National Health Insurance in South Africa

Introduction: Individuals residing in Limpopo, KwaZulu-Natal and the Eastern Cape provinces who had access to public health services were surveyed to determine public knowledge and awareness of the new National Health Insurance (NHI). Methods: A descriptive cross-sectional study was conducted and a total of 748 adult respondents were sampled using a two-stage systematic sampling design. Data were  collected using mobile phone assisted personal interviews. Results: The study found that 80.3% of the respondents were aware of the NHI and slightly less than half (49.8%) of the respondents did not have knowledge of how the NHI works and 71.8% lacked awareness  about the origin of the development of the NHI concept in South Africa. The knowledge of what the NHI would pay for was poor and 48.1% knew that the NHI Fund would pay for medical expenses if a person got sick and 45.7% knew that with health insurance, basic health requirement is ensured and that if one  becomes ill, medical treatment would be paid for by the NHI Fund, 50.9% of respondents did not  understand how the NHI Fund will pay for health care received, only 44.8% understood how the NHI will pay for health care services received. Conclusion: The public education campaigns to increase knowledge and understanding of the NHI  scheme might have been inadequate hence might not have penetrated many communities. It is  recommended that a comprehensive community consultation plan be established to increase awareness and knowledge of the NHI among community members targeting clinics, schools, pension pay points and other community sites.Key words: Awareness, knowledge, National health insurance, South Afric

Methicillin-resistant Staphylococcus aureus multiple sites surveillance: a systemic review of the literature.

PURPOSE: The objective of this study was to evaluate the optimal number of sampling sites for detection of methicillin-resistant Staphylococcus aureus (MRSA) colonization. METHODS: We performed a Medline search from January 1966 to February 2014 for articles that reported the prevalence of MRSA at different body sites. Studies were characterized by study design, country and period of the study, number of patients and/or isolates of MRSA, specimen type, sites of MRSA isolation, study population sampled, diagnostic testing method, and percentage of the MRSA isolates at each site in relation to the total number of sites. RESULTS: We reviewed 3,211 abstracts and 177 manuscripts, of which 17 met the criteria for analysis (n=52,642 patients). MRSA colonization prevalence varied from 8% to 99% at different body sites. The nasal cavity as a single site had MRSA detection sensitivity of 68% (34%-91%). The throat and nares gave the highest detection rates as single sites. A combination of two swabs improved MRSA detection rates with the best combination being groin/throat (89.6%; 62.5%-100%). A combination of three swab sites improved MRSA detection rate to 94.2% (81%-100%) with the best combination being groin/nose/throat. Certain combinations were associated with low detection rates. MRSA detection rates also varied with different culture methods. CONCLUSION: A combination of three swabs from different body sites resulted in the highest detection rate for MRSA colonization. The use of three swab sites would likely improve the recognition and treatment of MRSA colonization, which may in turn reduce infection and transmission of MRSA to other patients

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

Background: Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa. Methods: We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics. Results: The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage. Conclusions: The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery

Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis

Background: Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa. Methods: We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies. Results: A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56–74), viral load suppression was 55% (95%CI 46–64), un-suppressed viral load rate of 41% (95%CI 32–50), and loss to follow up of 17% (95%CI 10–24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies. Conclusion: ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence