Case Study: Lung transplantation for cystic fibrosis – A complex nutritional setting

No Abstrac

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Fistuloclysis : an option for the nutritional management of adult intestinal failure patients in South Africa

Thesis (MNutr)--Stellenbosch University, 2016.ENGLISH SUMMARY : Introduction: The development of intestinal failure is the consequence of diverse aetiologies and pathophysiological causes. Fistuloclysis is an effective means of nutritional support in selected intestinal failure patients. This study aimed to investigate the management of adult intestinal failure patients in hospitals in South Africa, determining how practical and acceptable fistuloclysis is. Methods: The study included three phases. Phase 1 consisted of a retrospective record review of adult patients admitted to Groote Schuur Hospital Intestinal Failure Unit between January 2009 and May 2014. Data collected included demographics, surgical interventions, gastrointestinal anatomy, nutritional management, biochemical markers and intake and output. Phase 2 consisted of a purposefully selected case study report published in a peer-reviewed journal. Phase 3 investigated the current management of type 2 and type 3 intestinal failure patients in South African hospitals, evaluating perceptions and opinions among South African doctors, stoma therapists and dietitians by means of occupation-specific questionnaires. Results: Phase 1: Seventeen intestinal failure patients receiving fistuloclysis were included in the study. During the fistuloclysis period, the median daily output was 1 478ml with a median of 71% of effluent received back via fistuloclysis. Four patients went home for a median period of 32,5 days on fistuloclysis. There was a statistically significant increase in the median albumin level between day 0 and day 28 of fistuloclysis, however body weight did not improve during this period. Postoperative complications occurred in only three patients. Patients were discharged after a median of 12 days post definitive surgery, with three complicating postoperatively and all patients regaining nutritional autonomy. Phase 3: Twenty-seven dietitians participated in the survey, the majority (67%) having been involved with patient management in this field for one – five years. All indicated high fistula outputs would be defined as intestinal failure. Only 47% gave the correct definition, with 28% currently utilising fistuloclysis. All respondents agreed that unsuccessful implementation of fistuloclysis was due to training shortfalls and resistance from clinicians and nursing staff. Ten stoma therapists entered the survey but only two fitted the inclusion criteria. Both worked in the private sector, with >10 years of experiece in the management of intestinal failure patients. Only one of the two proceeded with further questions. Four doctors managing intestinal failure responded. All respondents indicated high fistula outputs as associated with intestinal failure. The aetiology of intestinal failure indicated was postoperative complications by 75% of the respondents. The majority of respondents (75%) indicated that keeping patients nil by mouth was common practice, 50% of respondents indicated routine usage of pharmacological agents to decrease output or transit time. All respondents gave the correct explanation of fistuloclysis with 50% currently using fistuloclysis. Conclusion: Fistuloclysis is not superior, but equivalent to conventional methods of intestinal failure management. From this study and other available literature it is evident that fistuloclysis can replace PN support in selected patients. From the different occupation group surveys it is evident that there is a positive perception and awareness of fistuloclysis; however numerous stumbling blocks hamper the wider use of this novel treatment.AFRIKAANSE OPSOMMING : Inleiding: Die ontwikkeling van intestinale versaking is die gevolg van diverse etiologiee en patofisiologiese oorsake. Fistuloklisie is ‘n doeltreffende manier van voedingsondersteuning vir geselekteerde pasiente. Hierdie studie was daarop gemik om die behandeling van volwasse pasiente met intestinale versaking in hospitale in Suid-Afrika te ondersoek en te bepaal hoe prakties en aanvaarbaar fistuloklisie is. Metodes: Die studie het bestaan uit drie fases. Fase 1 was ‘n retrospektiewe rekordhersiening van volwasse pasiente wat tussen Januarie 2009 en Mei 2014 in Groote Schuur Hospitaal se eenheid vir intestinale versaking opgeneem is. Data wat ingesamel is, sluit in demografiese gegewens, chirurgiese intervensies, gastrointestinale anatomie, voedingsbehandeling, biochemiese merkers en vloeistofbalans. Fase 2 was ‘n doelgerigte gevallestudie wat gepubliseer is in ‘n vaktydskrif. Fase 3 het gebruik gemaak van beroepspesifieke vraelyste om huidige behandeling van pasiente met tipe 2 en 3 tipe intestinale versaking in Suid-Afrikaanse hospitale te ondersoek, sowel as persepsies en menings oor fistuloklisie onder Suid-Afrikaanse dokters, stomaterapeute en dieetkundiges te bepaal. Resultate: Fase 1: Sewentien pasiente met intestinale versaking wat behandel is met fistuloklisie is ingesluit in die studie. Gedurende die fistuloklisietydperk was die mediaan uitskeiding 1 478ml per dag met ‘n mediaan van 71% wat teruggeplaas is deur fistuloklisie. Vier pasiente kon ontslaan word vir ‘n mediaantydperk van 32,5 dae op fistuloklisie. Daar was ‘n statisties beduidende toename in die mediaanalbumien vlak tussen dag 0 en dag 28 van fistuloklisie, maar liggaamsgewig het nie verbeter nie. Chirurgiese komplikasies het by slegs drie pasiente voorgekom. Pasiente is ‘n mediaan van 12 dae na chirurgie ontslaan en alle pasiente het voedingsoutonomie herwin. Fase 3: Sewe en twintig dieetkundiges het aan die opname deelgeneem. Die meerderheid (67%) het een tot vyf jaar ondervinding gehad in die behandeling van pasiente. Almal het aangedui dat hoe fisteldreinering gedefinieer sou word as intestinale versaking. Slegs 47% het die korrekte definisie vir fistuloklisie gegee, terwyl 28% tans daarvan gebruik maak. Al die respondente het saamgestem dat onsuksesvolle implementering van fistuloklisie te wyte is aan ‘n tekort aan opleiding en weerstand van dokters en verpleegpersoneel. Tien stomaterapeute het deelgeneem, maar slegs twee het voldoen aan die insluitingskriteria. Albei was werksaam in die privaatsektor, met >10jaar ondervinding in die behandeling van hierdie pasiente. Slegs een het die vraelys verder voltooi. Vier dokters het die vraelys voltooi. Almal het hoe fisteldreinering geassosieer met intestinale versaking. Die etiologie van die intestinale versaking is aangedui as chirurgiese komplikasies deur 75% van respondente. Die meerderheid van respondente (75%) het aangedui dat dit algemene praktyk is om pasiente nil per mond te hou, terwyl 50% roetineweg farmakologiese middels voorskryf om dreinering of deurgangstyd te verminder. Al die respondente het die korrekte definisie van die term gegee terwyl slegs 50% tans fistuloklisie gebruik. Gevolgtrekking: Fistuloklisie is gelykstaande aan konvensionele behandeling van intestinale versaking. Uit die resultate van hierdie studie en beskikbare literatuur is dit duidelik dat fistuloklisie parenterale voeding by gepaste pasiente kan vervang. Uit beroepsopnames is daar ‘n positiewe persepsie en bewustheid van fistuloklisie, maar ook talle struikelblokke wat die wyer gebruik belemmer

Enteral formula : selecting the right formula for your patient

CITATION: Blaauw, R. & Du Toit, A. L. 2017. Enteral formula : selecting the right formula for your patient. South African Journal of Clinical Nutrition, 30(2):39-45.The original publication is available at http://www.sajcn.co.zaThe availability of various enteral formulae on the market assists in the individualized management of patients. It provides variety in terms of macronutrient content, fluid options and the addition or omission of certain components, e.g. fibre, electrolytes and immunonutrients. It is imperative that health care practitioners should be familiar with all products locally available and should have the ability to select the most appropriate products to meet the patient’s needs. We provide a brief summary of all enteral formulae in terms of unique features and recommendations for use. Practical application is discussed by means of two case studies.http://www.sajcn.co.za/index.php/SAJCN/article/view/1252Publishers versio

Opinions of South African dietitians on fistuloclysis as a treatment option for intestinal failure patients

CITATION: Du Toit, A. L., Boutall, A. B. T. & Blaauw, R. 2018. Opinions of South African dietitians on fistuloclysis as a treatment option for intestinal failure patients. South African Journal of Clinical Nutrition, 31(2):29–34, doi:10.1080/16070658.2017.1345430.The original publication is available at http://www.sajcn.co.zaIntroduction: Intestinal failure is the consequence of diverse aetiologies and pathophysiological causes. Fistuloclysis is an effective means of nutritional support to selected intestinal failure patients. This study aimed to investigate the management of adult intestinal failure patients in hospitals in South Africa, determining how practical and acceptable fistuloclysis is. Methods: The current management of type 2 and type 3 intestinal failure patients in South African hospitals was investigated by means of occupation-specific questionnaires, evaluating perceptions and opinions among dietitians. Results: Twenty-seven dietitians indicated willingness to participate in the survey, the majority (67%) having been involved with patient management in this field for one to five years. All indicated correctly that high fistula outputs would be defined as intestinal failure. Only 47% gave the correct definition of fistuloclysis, while 28% were currently utilising it as a means of nutrition support. All respondents agreed that unsuccessful implementation of fistuloclysis was due to training shortfalls and resistance from clinicians and nursing staff. Conclusion: There is a positive perception and awareness of fistuloclysis; however, numerous stumbling blocks hamper the wider use of this novel treatment.http://www.sajcn.co.za/index.php/SAJCN/article/view/1215Publisher's versio

Early economic benefits of perioperative nasojejunal tube feeding in non-critical care adult surgical patients with gastric feed intolerance

Background: Fluoroscopy-guided endoscopic placement of nasojejunal tubes (NJT) for perioperative short- or medium-term enteral nutrition (EN) is potentially required for anatomical gastric feed intolerance. Methods: Indication for NJT and successful insertion rates was determined. NJT insertion costs were calculated and compared with central venous catheter (CVC) insertion. Duration of NJT patency in non-critical care surgical patients was determined in days in a local cohort. EN costs were calculated over a hypothetical 28-day period factoring in expected NJT replacements due to blockage and compared with parenteral nutrition (PN) via CVC, which included routine CVC changes every 10 days. Public and private sectors were compared. Results: One hundred and two (93.6%) NJTs were placed successfully, with gastric outlet obstruction the most frequent indication (40.4%) with a median 10 days’ (range 1–68 days, IQR 6–16.75 days) usage. Irrevocable blockage occurred in 33 tubes after a median 9 days (range 3–34 days; IQR 4.75–16 days). Calculated EN costs over 28 days, including NJT replacement every 9 days, reached US$1 676.12 and PN costs with CVC replacement every 10 days, US$3 461.35 (p < 0.001) in the public sector. In the private sector PN costs at 28 days were significantly higher (p < 0.001) at US$5 261.14 compared with EN US$3 780.71. The cost benefit of EN over PN is seen after three days in the public, and four days in the private sector. Conclusion: Exponential cost saving occurs with EN via NJT over time, even when factoring in the likelihood of NJT replacements