Antifibrinolytic drugs for acute traumatic injury

In South Africa, trauma is a major concern, with violence and road traffic accidents being the fifth and seventh leading causes of death, respectively. Antifibrinolytic agents have been used in trauma and major surgery to prevent fibrinolysis and reduce blood loss. We highlight an updated Cochrane review investigating the effect of antifibrinolytic drugs in patients with acute traumatic injury. The review authors conducted  comprehensive literature searches in January 2015 with regard to all randomised  controlled trials comparing antifibrinolytic agents after acute traumatic injury. Three randomised controlled trials, of which two (n=20 451) assessed the effect of  tranexamic acid (TXA), were included. The authors concluded that TXA safely reduces  mortality in trauma with bleeding without increasing the risk of adverse events. TXA should be administered as early as possible, and within 3 hours of injury. There is still uncertainty with regard to the effect of TXA on patients with traumatic brain injury; however, ongoing randomised controlled trials should shed more light on this

Building capacity for development and implementation of clinical practice guidelines

Robust, reliable and transparent methodologies are necessary to ensure that clinical practice guidelines (CPGs) meet international criteria. In South Africa (SA) and other low- and middle-income countries, upskilling and training of individuals in the processes of CPG development is needed. Since de novo CPG development is time-consuming and expensive, new emerging CPG-development approaches (adopting, contextualising, adapting and updating existing good-quality CPGs) are potentially more appropriate for our context. These emerging CPG-development methods are either not included or sparsely covered in existing training opportunities. The SA Guidelines Excellence (SAGE) team has responded innovatively to the need for CPG training in SA. We have revised an existing SA course and developed an online, open-access CPG-development toolkit. This Guideline Toolkit is a comprehensive guideline resource designed to assist individuals who are interested in knowing how to develop CPGs. Findings from the SAGE project can now be implemented with this innovative CPG training programme. This level of CPG capacity development has the potential to influence CPG knowledge, development, practices and uptake by clinicians, managers, academics and policy-makers around the country

South African Guidelines Excellence (SAGE): Adopt, adapt, or contextualise?

Clinical practice guideline (CPG) activities must be planned carefully for efficient use of available resources and evidence-based implementation. De novo development of CPGs may sometimes ‘recreate the wheel’ and delay implementation. Three innovative alternatives to de novo CPG development (adopt, contextualise or adapt) are outlined, which have greater potential than de novo development to best use the limited available resources, personnel and time in settings such as South Africa

Task-shifting from doctors to non-doctors for initiation and maintenance of antiretroviral therapy

'Cochrane Corner’ in the August SAMJ offers evidence relating to articles published in this issue, namely ‘Improving access to antiretrovirals in rural South Africa – a call to action’, ‘Multimorbidity, control and treatment of non-communicable diseases among primary healthcare attenders in the Western Cape, South Africa’ and ‘Prevalence of tobacco use among adults in South Africa: Results from the first South African National Health and Nutrition Examination Survey’, and the editorial by Yach and Alexander, ‘Turbo-charging tobacco control in South Africa’.

What are health policy and systems research priorities for universal health coverage in South Africa?

We report here on the process and findings of a research prioritisation exercise for universal health coverage (UHC) in South Africa, conducted during the course of 2019. As plans to roll out National Health Insurance (NHI) gather momentum and we transition into a pandemic recovery phase, we believe that it is now time to revisit these priorities, while recognising that experiences with the COVID‑19 pandemic have revealed new system challenges and strengths and introduced new priorities. The UHC research priority-setting methodology followed a stepwise process of collation of evidence, expert brainstorming and the development of a survey completed by 68 members of the Public Health Association of South Africa. Themes related to leadership and governance were ranked most highly, and with other priorities generated, provide an initial road map of knowledge needs that could guide individual institutions and commissioning by funding bodies. We further reflect on the importance of researcher-decision-maker dialogue and strengthening the contribution of health policy and systems research to policy and practice, especially as new reforms are implemented

Antibiotic prescription patterns of South African general medical practitioners for treatment of acute bronchitis

Background: Antibiotic resistance is a significant public health problem. Prudent use of antibiotics is crucial in reducing this resistance. Acute bronchitis is a common reason for consultations with general medical practitioners, and antibiotics are often prescribed even though guidelines recommend not prescribing them for uncomplicated acute bronchitis. Objective: To analyse the antibiotic prescription patterns of South African (SA) general medical practitioners in the treatment of acute bronchitis. Methods: The 2013 claims for members of 11 health insurance schemes were analysed to assess antibiotic prescription patterns for patients diagnosed with acute bronchitis. The patterns were assessed by type of bronchitis, chronic health status of the patients, sex and age group. The types of antibiotic prescribed were also analysed. Results: Of 166 821 events analysed, an antibiotic was prescribed in more than half (52.9%). There were significant differences by type of bronchitis and chronic health status. Patients with viral bronchitis were more likely to be prescribed an antibiotic than those with bacterial bronchitis (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.08 - 1.26). Patients with a chronic illness were less likely to be prescribed an antibiotic than those without (OR 0.58, 95% CI 0.57 - 0.60). More than 70% of the antibiotics prescribed were cephalosporins, penicillins and other beta-lactams. Conclusions: Prescription rates of antibiotics for acute bronchitis by SA general medical practitioners are high. There is an urgent need to follow the guidelines for antibiotic use for acute bronchitis to reduce the likelihood of increasing resistance to available antibiotics.IS

The use of anticoagulants in patients hospitalised with COVID-19

In this Cochrane Corner, we highlight the main findings of a Cochrane Review by Flumignan et al. entitled ‘Anticoagulants for people hospitalised with COVID‐19’ and discuss the implications of these findings for research and practice in South Africa. In particular, we underscore the need for additional, high‐quality, randomised controlled trials comparing different intensities of anticoagulation in patients with COVID‐19 illness. Individuals in the intensive care unit and those hospitalised with another illness who are incidentally found to be infected with SARS‐CoV‐2 should still only be treated with prophylactic‐dose low‐molecular‐weight heparin