South African Medical Journal (SAMJ)
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The use of a urine lipoarabinomannan test in clinical decision-making regarding empiric tuberculosis treatment among HIV-positive patients suspected to have tuberculosis
Get PDFBackground. Tuberculosis (TB) is a major contributor to mortality among patients affected by HIV. TB diagnosis can be challenging, especially in those who are severely ill and unable to produce sputum. Urine lipoarabinomannan (LAM) is a rapid point‐of‐care diagnostic tool that is used on urine. The dilemma arises if a urine LAM test yields a negative result when the clinical presentation is strongly suggestive of TB.
Objective. To investigate how a urine LAM test result changes the physician’s decision to start TB treatment in people living with HIV in Kalafong Provincial Tertiary Hospital (KPTH).
Method. A cross‐sectional study was done at KPTH in the internal medicine wards, family medicine and HIV outpatient departments. Patients who were HIV positive with a strong TB diagnosis suspicion, had a CD4 count <200 cells/mm3, were aged >13 years and had a urine LAM done to investigate TB were included. Outcomes investigated were: presenting symptoms, clinical signs, radiological and haematological investigations, including CD4 count and HIV viral load, urine LAM results and whether TB treatment was initiated or not. At KPTH, a register of all patients who have been given a urine LAM test is held at the TB notification centre, which was where the information regarding urine LAM results was retrieved from, as well as whether treatment was initiated or not. The patients’ clinical hospital records and National Health Laboratory Service lab results were retrieved for necessary information.
Results. There were 430 patient records and urine LAM results retrieved: 307 (71.4%) had negative results and 123 (28.6%) had positive results. Of the 307 (71.4%) with a negative result, 120 (39.1%) were initiated on treatment, and only 3 of those who had positive results (1.6%) did not receive treatment. The urine LAM test results appeared to influence clinicians’ decisions to treat when the result was positive. If the urine LAM was negative, clinicians still initiated treatment based on adequate clinical suspicion and other investigations. There was significant incongruency between patients with a negative urine LAM test who received TB treatment (p<0.001).
Conclusion. The use of the urine LAM did not change the physician’s decision to start TB treatment where the was a high suspicion of TB based on clinical presentation and other investigations. Physicians depended more on their clinical intuition where the urine LAM was negative
Effective cannabis testing protocols for workplace safety in South Africa post legalisation: Navigating the new normal
Get PDFThe legalisation of private cannabis use in South Africa presents significant challenges for occupational health, especially in safety- sensitive environments. This article analyses the medical, legal and ethical issues surrounding workplace cannabis use, focusing on the pharmacodynamics and pharmacokinetics of delta-9-tetrahydrocannabinol (THC), the primary psychoactive compound. The recent legal precedent that critiques the effectiveness of zero-tolerance policies is reviewed, and the establishment of per se THC thresholds that are medically and legally sound is proposed. The study advocates for a tailored approach to risk categorisation and testing protocols in workplaces, aiming to support occupational health professionals in developing policies that are effective, ethical and compliant with legal standards
Prevalence of Plasmodium species in asymptomatic individuals in North-Eastern South Africa: 2018 - 2019
Get PDFBackground. Asymptomatic Plasmodium infections in endemic areas pose a challenge to malaria prevention and control strategies. The Ha-Lambani area in Vhembe district, Limpopo Province, South Africa, experiences periodic malaria outbreaks, possibly influenced by asymptomatic Plasmodium infections. In addition, the identification and monitoring of the Plasmodium falciparum Kelch 13 (Pfk13) gene associated with artemisinin resistance are crucial for understanding the emergence and spread of drug-resistant malaria in endemic areas.
Objective. To determine the prevalence of asymptomatic Plasmodium infection and Pfk13 gene polymorphisms in the Ha-Lambani area in the absence of a malaria outbreak.
Methods. Finger-prick dried blood spots from 985 asymptomatic individuals were collected from November 2018 to May 2019. A P. falciparum-specific rapid diagnostic test (RDT) was used to test for Plasmodium infection. High-resolution melt (HRM) analysis was used to test for P. falciparum, P. ovale, P. vivax and P. malariae. The prevalence of Plasmodium infection was determined by the proportion of positive cases detected by at least one of the tests. The Pfk13 gene was amplified from P. falciparum-positive samples, sequenced by Sanger and Illumina next-generation sequencing (NGS) and analysed for genetic diversity and resistance mutations to artemisinin.
Results. A prevalence of 7.1% (70/985; 95% confidence interval (CI): 0.054 - 0.087) of Plasmodium infection was observed. The dominant species was P. ovale (57.14%; n=40), followed by P. falciparum (37.1%; n=26), P. malariae (1.43%) and P. vivax (1.43%). Mixed infections were P. falciparum/P. ovale (2.9%). Plasmodium infections differed significantly by village (p<0.01). The Pfk13 gene was amplified from 5/30 (95% CI: 0.03 - 0.29). Analysis of NGS reads revealed 57 single nucleotide polymorphisms (SNPs) across the Pfk13 gene (≥20% minority level). Up to 70.1% (39/57; 95% CI: 0.59 - 0.83) of the SNPs were non-synonymous and none was previously associated with artemisinin resistance. However, novel SNPs (H719Q, P701T, M472I, I526R and P443S) were detected in the propeller domain.
Conclusion. A relatively high asymptomatic Plasmodium infection prevalence was observed in the study area, with P. ovale being the most prevalent species. Therefore, P. ovale infections may be missed with the Plasmodium RDT. R21 and RTS,S vaccines may not offer protection against P. ovale in the study area. Further research is needed to link asymptomatic infections in the study area and the periodic malaria outbreaks, and to determine the significance of the novel SNP in the Pfk13 gene
Intravenous antibiotic use in a private mining hospital in North West Province, South Africa
Get PDFBackground. The misuse and overuse of intravenous (IV) antibiotics contribute to the spread of multidrug resistance, consequently increasing mortality. These effects can be minimised through treatment reviews that aim to optimise antibiotic therapy without compromising patient clinical outcomes. There is therefore a need to evaluate and monitor intravenous antibiotic usage in hospitals.
Objectives. To describe IV antibiotic use in admitted patients at a private hospital in North West Province, South Africa.
Methods. A cross-sectional study design was followed using retrospective data from patient files and the hospital electronic healthcare software (TriMed) between 1 January and 31 December 2022. A Microsoft Excel spreadsheet was used to capture demographic information for each patient profile that met the inclusion criteria, and data on IV antibiotic use were captured for each admission episode. The data were analysed using IBM statistical software.
Results. Demographic data were recorded for 677 patient profiles, with males representing 53.8% (n=364). A total of 731 admissions occurred during the study period. The most prevalent indication for IV antibiotic use, according to the provisional diagnosis, was upper and lower respiratory tract disorders, which represented 25.2% of the total admissions. Staphylococcus aureus was the most commonly treated micro-organism, representing 22.8% (n=23) of the total isolated micro-organisms. IV antibiotics were initiated 885 times, and amoxicillin-clavulanic acid was the most used antibiotic (51.2%). Most antibiotics (48.2%) were used at a dose of 1 200 mg, with a dosing frequency of three times a day (72.3%). A total of 806 review actions, out of 885 intravenous antibiotic initiations, were conducted (91.1%). The prevalence of IV-to-oral switch was 49.0%, while 41.3% of IV antibiotics were stopped after review. IV antibiotic de-escalation represented 7.2% of the total reviews, while an oral antibiotic was added to 1.7% of the IV antibiotics after review. At review, the prevalence of adding IV antibiotics to another IV antibiotic was 0.7%. The average length of hospital stay was 5.8 days, while patients continuously received IV antibiotics for 3.4 days on average.
Conclusion. There is a need to monitor IV antibiotic use and encourage IV antibiotic de-escalation to limit the rampant use of broad- spectrum antibiotics and manage the most prevalent infections effectively in the shortest possible time, consequently reducing the average duration of hospitalisation. IV antibiotic treatment review is therefore pivotal to optimise antibiotic therapy, the transition of IV to oral antibiotics, and discontinuation of IV antibiotics when they are no longer necessary
The rights of graduate medical practitioners and reforming community service non-placements
Get PDFSouth Africa’s public healthcare sector faces a severe shortage of medical practitioners, exacerbated by the failure to place newly qualified graduates in internship and community service positions. Despite the country’s urgent need for doctors, many graduates remain unplaced each year, preventing them from practising independently. This article proposes a legislative reform to address these challenges. Currently, the Health Professions Act 56 of 1974 mandates a compulsory year of community service for medical graduates before full professional registration. However, systemic placement failures result in many graduates being left in limbo, unable to work in either the public or the private sector. The article advocates a legally recognised exemption from community service for medical graduates who remain unplaced for more than 3 months after completing their internship. The proposed amendment to the Health Professions Act would enable these individuals to enter private practice or pursue further specialisation, ensuring that trained professionals are not lost to bureaucratic inefficiencies that infringe on their labour rights
Thrombosis and bleeding outcomes with warfarin conversion to rivaroxaban during the COVID-19 pandemic
Get PDFBackground. In 2020, during the coronavirus disease 2019 (COVID‐19) outbreak, eligible patients were converted from warfarin to rivaroxaban therapy to limit the transmission of COVID‐19 infection.
Objective. To assess the thrombosis and bleeding outcomes associated with converting patients on warfarin therapy to rivaroxaban during the COVID‐19 pandemic.
Methods. A retrospective audit was performed that identified 190 participants with venous thromboembolism (VTE) and 112 participants with non‐valvular atrial fibrillation at the anticoagulation clinic service at Charlotte Maxeke Johannesburg Academic Hospital, South Africa. Participants were converted to rivaroxaban 20 mg for a median (interquartile range) period of 4 (2) months between April and October 2020. Follow‐ups were conducted telephonically and face‐to‐face on conversion back to warfarin. Rates of COVID‐19 infections, bleeding and thrombosis were objectively confirmed.
Results. The COVID‐19 infection rate among participants was 3.3% (95% confidence interval (CI) 1.6 ‐ 6.0), with five (1.7%) hospital admissions and two (0.7%) COVID‐19‐related deaths. The deaths occurred in one participant on rivaroxaban, and in another after switching back to warfarin. One week after switching to rivaroxaban, the rate of clinically relevant non‐major bleeding was 0.7% (95% CI 0.02 ‐ 2.54), while minor bleeding occurred at a rate of 9.2% (95% CI 6.16 ‐ 13.40). No major bleeding events were reported, and bleeding rates on rivaroxaban were not significantly higher compared with warfarin. Additionally, two (0.7%) myocardial infarctions were recorded. One occurred on rivaroxaban and the other after switching back to warfarin. A single (0.3%) VTE presenting as a newly diagnosed pulmonary embolism was reported in a participant on rivaroxaban.
Conclusion. This study provides practical insights regarding the conversion of eligible participants from warfarin to rivaroxaban during the first wave of COVID‐19, with the aim of informing future public health interventions in similar crisis settings.
Response to the letter by the National Department of Health regarding ‘Achieving universal healthcare access in South Africa’
Get PDFA critical analysis of adult platelet product utilisation in South Africa, 2014 - 2021
Get PDFBackground. Platelet products are usually prescribed for the prevention and treatment of bleeding in patients with reduced platelet counts, or those with dysfunctional platelets. Between 2008 and 2017, platelet use across 12 multinational transfusion centres increased by 10.2%, and a further increase of 3.9% is predicted by 2032. The National Health Insurance (NHI) Bill has been signed into South African (SA) law, starting the transition from a two-tiered healthcare system to universal access to healthcare. Healthcare sector-specific platelet recipient and utilisation profiles for SA are largely unknown. Quantifying differences in utilisation patterns between the SA healthcare sectors is essential for long-term planning, and to provide valuable insights to inform policy.
Objectives. To critically analyse platelet utilisation patterns at the South African National Blood Service (SANBS) according to SA healthcare sector.
Methods. The SANBS provides blood products to eight out of the nine provinces in SA. We conducted a descriptive, cross-sectional, retrospective analysis of all platelet requisitions processed by the SANBS between 1 January 2014 and 31 December 2021. Healthcare sector- specific demographic and utilisation patterns were determined, and per capita utilisation calculated.
Results. Of the 445 803 platelet units issued in the specified time period, 200 856 (45.1%) were issued to the public sector, compared with 244 922 (54.9%) to the private sector. The public sector recipients were mostly female (55.7%), with a median (interquartile range (IQR)) age of 29 (15 - 42) years, and in the private sector, mostly male (53.1%), with a median (IQR) age of 53 (36 - 65) years. The private sector issued more units of platelets per 1 000 population on average than the public sector, with 3.89 units per 1 000 private sector population v. 0.59 units per 1 000 public sector population.
Conclusion. Platelet utilisation between SA’s healthcare sectors is distinctly different. The drivers underpinning these patterns are interdependent, including population and demographic characteristics, disease patterns, transfusion practices and healthcare demands. A greater understanding of socioeconomic and disease drivers is required to provide policy-relevant insights to predict utilisation and assist transfusion services with planning in light of the NHI rollout
