RESUMEN
Determining the death burden for prioritising public health interventions necessitates detailed data on the causal pathways to death. Postmortem minimally invasive tissue sampling (MITS), incorporating histology, molecular and microbial culture diagnostics, enhances cause-of-death attribution, particularly for infectious deaths. MITS proves a valid alternative to full diagnostic autopsies, especially in low- and middle-income countries. In Soweto, South Africa (SA), the Child Health and Mortality Prevention Surveillance (CHAMPS) programme has delineated over 1 000 child and stillbirth deaths since 2017. This SA CHAMPS site supports advocating for the use of postmortem MITS as routine practice, for more granular insights into under-5 mortality causes. This knowledge is crucial for SA's pursuit of Sustainable Development Goal 3.2, targeting reduced neonatal and under-5 mortality rates. This commentary explores the public health advantages and ethicolegal considerations surrounding implementing MITS as standard of care for stillbirths, neonatal and paediatric deaths in SA. Furthermore, based on the data from CHAMPS, we present three pragmatic algorithmic approaches to the wide array of testing options for cost-effectiveness and scalability of postmortem MITS in South African state facilities.
Asunto(s)
Mortalidad del Niño , Nivel de Atención , Niño , Recién Nacido , Embarazo , Femenino , Humanos , Sudáfrica , Causas de Muerte , Mortinato , AutopsiaRESUMEN
Enhanced surveillance for CREs was established at national sentinel sites in South Africa. We aimed to apply an epidemiological and microbiological approach to characterise CREs and to assess trends in antimicrobial resistance from patients admitted to tertiary academic hospitals. A retrospective analysis was conducted on patients of all ages with CRE bacteraemia admitted at any one of 12 tertiary academic hospitals in four provinces (Gauteng, KwaZulu-Natal, Western Cape and Free State) in South Africa. The study period was from July 2015 to December 2018. A case of CRE bacteraemia was defined as a patient admitted to one of the selected tertiary hospitals where any of the Enterobacteriaceae was isolated from a blood culture, and was resistant to the carbapenems (ertapenem, meropenem, imipenem and/or doripenem) or had a positive result for the Modified Hodge Test (MHT) according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. A positive blood culture result obtained after 21 days of the last blood culture result was regarded as a new case. To distinguish hospital-acquired (HA) from the community-acquired (CA) bacteraemia, the following definitions were applied: the HA CRE bacteraemia was defined as a patient with CRE isolated from blood culture ≥ 72 h of hospital admission or with any prior healthcare contact, within 1 year prior to the current episode or referral from a healthcare facility where the patient was admitted before the current hospital. A case of the CA CRE bacteraemia was defined as a patient with CRE isolated from blood culture < 72 h of hospital admission and with no prior healthcare contact. The majority of carbapenem-resistant Enterobacteriaceae (CRE) (70%) were hospital-acquired (HA) with Klebsiella pneumoniae being the predominant species (78%). In-hospital mortality rate was 38%. The commonest carbapenemase genes were bla-OXA-48 (52%) and bla-NDM (34%). The high mortality rate related to bacteraemia with CRE and the fact that most were hospital-acquired infections highlights the need to control the spread of these drug-resistant bacteria. Replacement with OXA-48 is the striking finding from this surveillance analysis. Infection control and antibiotic stewardship play important roles in decreasing the spread of resistance.
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Bacteriemia/epidemiología , Bacteriemia/microbiología , Enterobacteriaceae Resistentes a los Carbapenémicos/aislamiento & purificación , Infecciones por Enterobacteriaceae/epidemiología , Infecciones por Enterobacteriaceae/microbiología , Centros de Atención Terciaria/estadística & datos numéricos , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Proteínas Bacterianas/genética , Enterobacteriaceae Resistentes a los Carbapenémicos/clasificación , Enterobacteriaceae Resistentes a los Carbapenémicos/efectos de los fármacos , Enterobacteriaceae Resistentes a los Carbapenémicos/genética , Carbapenémicos/farmacología , Carbapenémicos/uso terapéutico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , ADN Bacteriano/genética , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Monitoreo Epidemiológico , Femenino , Humanos , Masculino , Pruebas de Sensibilidad Microbiana , Estudios Retrospectivos , Factores de Riesgo , Sudáfrica/epidemiología , beta-Lactamasas/genéticaRESUMEN
BACKGROUND: Invasive bacterial disease causes significant morbidity and mortality in children in developing countries. The burden of invasive disease caused by Staphylococcus aureus and S. aureus antimicrobial resistance patterns in African children in settings with a high prevalence of HIV infection remain ill-defined. AIMS AND OBJECTIVES: To describe the burden of community-onset bacteraemic S. aureus infections in children in an area with a high prevalence of paediatric HIV infection, and to describe the antimicrobial resistance patterns. METHODS: A retrospective record review of children hospitalised at Chris Hani Baragwanath Hospital, Soweto, with S. aureus bacteraemia between January 2005 and December 2006 was conducted. Community-onset S. aureus bloodstream infections were defined as S. aureus cultured from blood obtained within 48 hours of admission. RESULTS: Community-onset S. aureus bacteraemia was identified in 161 children, representing an incidence of 26/100,000, with 63 (39%) isolates identified as methicillin-resistant (10/100,000). The incidence of community-onset S. aureus bacteraemia, both methicillin-susceptible and methicillin-resistant, was inversely related to age and greater in HIV-infected than uninfected children. High rates of antibiotic resistance were observed in MRSA isolates and only resistance to amikacin, fusidic acid and ciprofloxacin was <40%. MRSA isolates were frequently multidrug-resistant. Among HIV-infected children, resistance to trimethoprim-sulfamethoxazole was 100% and to rifampicin was 78%. CONCLUSIONS: This study highlights the burden of S. aureus bacteraemia in a setting with a high prevalence of paediatric HIV infection. The high incidence of S. aureus bacteraemia coupled with a high prevalence of methicillin resistance, particularly in HIV-infected children, needs to be considered in the empirical management of paediatric sepsis in settings such as ours.
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Bacteriemia/epidemiología , Infecciones Comunitarias Adquiridas/epidemiología , Farmacorresistencia Bacteriana Múltiple , Infecciones por VIH/complicaciones , Infecciones Estafilocócicas/epidemiología , Staphylococcus aureus/efectos de los fármacos , Bacteriemia/microbiología , Niño , Preescolar , Infecciones Comunitarias Adquiridas/microbiología , Femenino , Hospitalización , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Prevalencia , Sudáfrica/epidemiología , Infecciones Estafilocócicas/microbiología , Staphylococcus aureus/aislamiento & purificaciónRESUMEN
BACKGROUND: Infection with resistant gram-negative bacteria is a growing threat to hospitalised patients. AIM: To determine factors associated with mortality among infants infected by extended-spectrum beta-lactamase-producing Klebsiella species (Klebs-ESBL) and to assess whether selective empirical use of meropenem (MERO) is associated with high mortality. METHODS: Medical records of neonates admitted from January 2002 to December 2003 who had positive blood and/or cerebrospinal fluid (CSF) culture with Klebs-ESBL were reviewed for clinical, management and outcome information. Univariate and multivariate logistic regression analyses were performed to determine factors associated with mortality among infants with culture-proven Klebs-ESBL. RESULTS: A hundred patients had positive blood (n=97) and/or CSF cultures (n=9) owing to Klebs-ESBL. Overall mortality rate was 30%. The mortality rates among those who were empirically started on a combination of piperacillin-tazobactam and amikacin (Pip-Taz+Amik) (n=48), meropenem (MERO) (n=40) and in those not started on MERO or Pip-Taz+Amik) (n=12) were 25%, 32% and 42%, respectively. Non-survivors were younger (p=0.01), had cardio-respiratory compromise or required assisted ventilation at presentation (p<0.001), and were not started on antibiotics, MERO or Pip-Taz+Amik (p<0.001). On multivariate analysis, factors associated with mortality were vaginal delivery (OR -7.07, 95% CI 2.14-23.39), a need for assisted ventilation at onset of illness (OR -4.94, 95% CI 1.12-21.86) and not starting empirical MERO or Pip-Taz+Amik (OR -17.01, 95% CI 2.41-120.23). CONCLUSION: While empirical use of carbapenems for nosocomial sepsis might be appropriate in areas where Klebs-ESBL is prevalent, their use can be restricted to those with cardio-respiratory compromise or severe sepsis without an increase in mortality.
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Antibacterianos/administración & dosificación , Infecciones por Klebsiella/mortalidad , Tienamicinas/administración & dosificación , Amicacina/administración & dosificación , Estudios de Cohortes , Esquema de Medicación , Femenino , Humanos , Recién Nacido , Klebsiella/enzimología , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/microbiología , Masculino , Meropenem , Ácido Penicilánico/administración & dosificación , Ácido Penicilánico/análogos & derivados , Piperacilina/administración & dosificación , Combinación Piperacilina y Tazobactam , Embarazo , Análisis de Regresión , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Resistencia betalactámica , beta-Lactamasas/biosíntesisRESUMEN
Retrospective antibiotic surveillance data of selected invasive pathogens isolated from blood and cerebrospinal fluid at public sector hospitals in South Africa in 2007 are presented. Antimicrobial susceptibilities were determined according to the 2007 Clinical and Laboratory Standards Institute criteria. Klebsiella pneumoniae remains a highly resistant pathogen; with approximately half of all strains producing extended-spectrum beta-lactamases. All laboratories reported considerable resistance among Acinetobacter spp. Approximately 50-60of Staphylococcus aureus isolates from blood were resistant to cloxacillin. Among Streptococcus pneumoniae isolates from blood and cerebrospinal intermediate resistance to penicillin. Resistance to ceftriaxone in S. pneumoniae was rare
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Antiinfecciosos , Resistencia a Medicamentos , Enterobacteriaceae , Hospitales , Staphylococcus aureusRESUMEN
We examined data from the ARTEMIS DISK Antifungal Surveillance Program to describe geographic and temporal trends in the isolation of Candida parapsilosis from clinical specimens and the in vitro susceptibilities of 9,371 isolates to fluconazole and voriconazole. We also report the in vitro susceptibility of bloodstream infection (BSI) isolates of C. parapsilosis to the echinocandins, anidulafungin, caspofungin, and micafungin. C. parapsilosis represented 6.6% of the 141,383 isolates of Candida collected from 2001 to 2005 and was most common among isolates from North America (14.3%) and Latin America (9.9%). High levels of susceptibility to both fluconazole (90.8 to 95.8%) and voriconazole (95.3 to 98.1%) were observed in all geographic regions with the exception of the Africa and Middle East region (79.3 and 85.8% susceptible to fluconazole and voriconazole, respectively). C. parapsilosis was most often isolated from blood and skin and/or soft tissue specimens and from patients hospitalized in the medical, surgical, intensive care unit (ICU) and dermatology services. Notably, isolates from the surgical ICU were the least susceptible to fluconazole (86.3%). There was no evidence of increasing azole resistance over time among C. parapsilosis isolates tested from 2001 to 2005. Of BSI isolates tested against the three echinocandins, 92, 99, and 100% were inhibited by concentrations of < or = 2 microg/ml of anidulafungin (621 isolates tested), caspofungin (1,447 isolates tested), and micafungin (539 isolates tested), respectively. C. parapsilosis is a ubiquitous pathogen that remains susceptible to the azoles and echinocandins; however, both the frequency of isolation and the resistance of C. parapsilosis to fluconazole and voriconazole may vary by geographic region and clinical service.
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Antifúngicos/farmacología , Candida/efectos de los fármacos , Candida/aislamiento & purificación , Candidiasis/microbiología , Fungemia/microbiología , África , Asia , Candida/clasificación , Farmacorresistencia Fúngica , Equinocandinas/farmacología , Europa (Continente) , Fluconazol/farmacología , Salud Global , Humanos , América Latina , Pruebas de Sensibilidad Microbiana , Medio Oriente , América del Norte , Vigilancia de la Población/métodos , Pirimidinas/farmacología , Triazoles/farmacología , VoriconazolRESUMEN
Since May 2000, extended-spectrum beta-lactamase-producing (ESBL) Salmonella Isangi were isolated from pediatric patients at a tertiary hospital. A total of 41 patients with positive cultures were reviewed, and the majority presented with gastroenteritis, fever, or both. One ESBL phenotype was noted in all isolates, and clonality was confirmed by pulsed-field gel electrophoresis. This is the first report of Salmonella sp. ESBL resistance in our hospital.
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Infección Hospitalaria/epidemiología , Infección Hospitalaria/microbiología , Brotes de Enfermedades , Infecciones por Salmonella/epidemiología , Salmonella enterica/aislamiento & purificación , beta-Lactamasas/biosíntesis , Preescolar , Electroforesis en Gel de Campo Pulsado/métodos , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Infecciones por Salmonella/microbiología , Salmonella enterica/enzimología , Resistencia betalactámicaRESUMEN
We report on the first case of a typhoid liver abscess treated at the Chris Hani Baragwanath Hospital in Johannesburg, which responded well to percutaneous catheter drainage and intravenous ampicillin therapy.