The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis.

Background: Hospital-acquired infections (HAI) are a leading cause of morbidity and mortality globally. These infections are diverse, but the majority are lower respiratory tract infection (LRTI), surgical site infection (SSI), bloodstream infection (BSI), and urinary tract infection (UTI). For most sub-Saharan African countries, studies revealing the burden and impact of HAI are scarce, and few systematic reviews and meta-analysis have been attempted. We sought to fill this gap by reporting recent trends in HAI in sub-Saharan Africa (SSA) with attention to key patient populations, geographic variation, and associated mortality. Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a literature search of six electronic databases (Web of Science, Pubmed, APA PsycInfo, CINAHL, Embase, and the Cochrane Library) to identify studies assessing the prevalence of HAI in SSA countries. Studies published between 01 January 2014 and 31 December 2023 were included. We applied no language or publication restrictions. Record screening and data extractions were independently conducted by teams of two or more reviewers. Using the R software (version 4.3.1) meta and metafor packages, we calculated the pooled prevalence estimates from random-effect meta-analysis, and further explored sources of heterogeneity through subgroup analyses and meta-regression. This study is registered with PROSPERO, CRD42023433271. Findings: Forty-one relevant studies were identified for analysis, consisting of 15 from West Africa (n = 2107), 12 from Southern Africa (n = 2963), 11 from East Africa (n = 2142), and 3 from Central Africa (n = 124). A total of 59.4% of the patient population were associated with paediatric admissions. The pooled prevalence of HAI was estimated at 12.9% (95% CI: 8.9-17.4; n = 7336; number of included estimates [k] = 41, p < 0.001). By subregions, the pooled current prevalence of HAI in the West Africa, Southern Africa, East Africa and Central Africa were estimated at 15.5% (95% CI: 8.3-24.4; n = 2107; k = 15), 6.5% (95% CI: 3.3-10.7; n = 2963; k = 12), 19.7% (95% CI: 10.8-30.5; n = 2142; k = 11) and 10.3% (95% CI: 1.1-27.0; n = 124; k = 3) of the patient populations respectively. We estimated mortality resulting from HAI in SSA at 22.2% (95% CI: 14.2-31.4; n = 1118; k = 9). Interpretation: Our estimates reveal a high burden of HAI in SSA with significant heterogeneity between regions. Variations in HAI distribution highlight the need for infection prevention and surveillance strategies specifically tailored to enhance prevention and management with special focus on West and East Africa, as part of the broader global control effort. Funding: No funding was received for this study.

Acute cypermethrin and other pyrethroid poisoning - An organophosphate-like poisoning: A case report and review.

Background: South Africa is one of the largest importers of pesticides in Africa. Pesticides play an integral role in food security and ensuring economic survival. Cypermethrin is a type II pyrethroid and is commonly and widely used as an insecticide. Poisoning arises from exposure through inhalation, skin contact or ingestion. Its toxic effects manifest predominantly as neurological and gastrointestinal symptoms. Severe pyrethroid poisonings are rare but can present as an organophosphate-like toxidrome. This poses a diagnostic conundrum. Case report: This case concerns a 36-year-old male from a rural town in the Eastern Cape province of South Africa, who was diagnosed with intentional cypermethrin poisoning after a suicide attempt. He was initially diagnosed as a suspected organophosphate poisoning with coma. He made a full recovery after mechanical ventilation and symptomatic treatment with a low dose muscarinic antagonist, atropine sulphate. Conclusions: With the ease of over-the-counter procurement, cypermethrin and other pyrethroid poisonings pose an increasing diagnostic dilemma to frontline and critical care personnel. This case report intends to raise awareness about the organophosphate-like toxidrome at presentation and the potential complications of high dose atropine treatment, commonly used to treat organophosphate poisoning. The treatment of cypermethrin is largely supportive with dermal decontamination of skin as an essential component. Low dose atropine may be utilized if required.

Retrospective Review of ART Regimens in HIV-Positive to HIV-Positive Kidney Transplant Recipients.

Introduction: The management of complex interactions between antiretroviral therapy (ART) and calcineurin inhibitor (CNI) immunosuppression regimens in HIV-positive to HIV-positive renal transplant recipients can be challenging. Literature describing ART regimens and indications for regimen switching in these patients is limited. Methods: This retrospective review included 53 HIV-positive to HIV-positive renal transplant recipients. Data on ART regimens, reasons for ART switching, and timing of switches were described from day of transplant to study endpoint (end of study date, death, or graft failure). The association between rejection and ART regimen (protease inhibitor [PI] -based vs. non-PI-based regimen) was analyzed using negative binomial regression. Results: There were a total of 46 switches in 31 of 53 patients (58%). Protocol switches (n = 17 of 46, 37%) accounted for most switches, of which the majority were from non-nucleoside reverse transcriptase inhibitors (NNRTIs) to PIs. Other common reasons for switching include cytochrome P450 enzyme induction from efavirenz (EFV) (9 of 46, 20%), tenofovir disoproxil fumarate (TDF) nephrotoxicity (8 of 46, 17%) or side effects (6 of 46, 13%). Of the 46 switches, nearly half (n = 21, 46%) occurred during the transplant admission period, and approximately two-thirds (n = 28, 62%) were during the first year post-transplantation. There was an association between rejection and being maintained on a PI-based regimen (incidence rate ratio 2.77 (95% confidence interval 1.03-7.48), P = 0.044). Conclusion: Despite frequent switching of ART regimens, HIV viral loads remained supressed and graft function remained stable in most HIV-positive kidney transplant recipients in our cohort. There was however a concerning signal for increased rejection rates in those on a PI-based regimen.

Multisystem inflammatory syndrome in an adult (MIS-A) due to SARS-CoV-2 infection presenting to a South African hospital.

Kawasaki-like multisystem inflammatory syndrome related to SARS-CoV-2 infection is a well-described condition in children and adolescents (MIS-C) and now also in adults (MIS-A). We report a case of MIS-A in a previously well woman in her mid-30s who presented with vasopressor-dependent shock 2 weeks after initial recovery from suspected SARS-CoV-2 infection, accompanied by fever, vomiting, diarrhoea, weakness, arthralgia, rash, cough and headache. Examination was notable for fever, tachycardia, hypotension, cervical lymphadenopathy, mucocutaneous involvement, neck stiffness, pansystolic murmur and bilateral crepitations. Inflammatory markers were elevated. Echocardiogram showed mitral regurgitation with preserved ejection fraction. She was treated with vasopressors, admitted to the intensive care unit and subsequently required invasive mechanical ventilation. Both PCR and antibodies for SARS-CoV-2 were positive. Treatment with intravenous methylprednisolone and intravenous immunoglobulin was initiated with rapid improvement in clinical condition and inflammatory markers. She has since made a full recovery with normal echocardiogram 8 months later.

A rare case of hypokalaemia and hypophosphataemia secondary to geophagia.

We report a case of severe hypokalaemia and moderate hypophosphataemia from clay ingestion. A 60-year-old woman presented with flaccid paralysis. Investigations revealed a serum potassium level of 1.8 mmol/L, phosphate level of 0.56 mmol/L and creatine kinase level of 30 747 IU/L. She had marked proximal and distal muscle weakness due to severe hypokalaemia and concurrent hypophosphataemia, which likely contributed to the onset of rhabdomyolysis. The patient subsequently admitted to significant pica, most likely secondary to an associated iron deficiency. We conclude that the ingested clay acted as a potassium and phosphate binder. Although we did not investigate the content of the clay in this case, it has been reported that clay can bind potassium in vitro and is rich in minerals such as aluminium that could play a role in the binding of phosphate, although the exact mechanism remains unclear. The patient recovered fully and outpatient follow-up at 6 months and again at 40 months confirmed no electrolyte abnormality, myopathy nor any further geophagia.

Analysis of the vascular access service for patients on haemodialysis in Livingstone Hospital.

BACKGROUND: Reliable vascular access is key to sustainable haemodialysis treatment. Guidelines recommend an arteriovenous fistula (AVF) as the preferred modality in preference to arteriovenous grafts (AVGs) or central venous catheters (CVCs). There are limited data on vascular access in sub-Saharan Africa. This study aimed to evaluate the vascular access used in a South African tertiary hospital and identify problems with achieving the recommended access goals. METHODS: A cross-sectional analysis was performed of the haemodialysis programme at Livingstone Tertiary Hospital. Current and initial vascular access used, timing until the creation of permanent access, and any complications experienced were recorded. RESULTS: CVCs were used in 56% of subjects, 38% were using an AVF and 5% were using an AVG. Only 12% of the group had no AVF attempt. The overwhelming majority (95%) had dialysis initiated with a CVC. The rate of pre-emptive AVF creation was low and a delay in AVF creation was seen in 63% of patients. Central venous stenosis or occlusion was present in 26% of patients and likely due to prior or current CVC use. CONCLUSIONS: The prevalence of CVC use was high and there were significant delays to AVF creation. High rates of central venous stenosis compromise future AVF use and are likely due to prolonged CVC use. Changes needed to improve the vascular access service include a multidisciplinary access clinic, dedicated theatre list, vascular access co-ordinator and further data collection to continually evaluate the vascular access service.

The SAPS 3 score as a predictor of hospital mortality in a South African tertiary intensive care unit: A prospective cohort study.

BACKGROUND: No African countries were included in the development of the Simplified Acute Physiology Score 3 (SAPS 3). This study aimed to assess the performance of the SAPS 3 as a predictor of hospital mortality in patients admitted to a multi-disciplinary tertiary intensive care unit (ICU) in South Africa. METHODS: A prospective cohort study was undertaken in a tertiary single-centre closed multidisciplinary ICU with 16 beds over 12 months in 2017. First time admissions 12 years and over were included. Exclusions were patients who died within six hours of admission, incomplete data sets and unknown outcome after ICU discharge. Demographic data, clinical admission data and co-morbidities were recorded. The SAPS 3 score was calculated within the first hour of ICU admission. The highest Sequential Organ Failure Assessment score, vasopressor use, mechanical ventilation requirements and details of acute kidney injury, if present, were recorded. Discrimination of the model was evaluated using an area under the receiver operating characteristic curve (AUROC) and calibration by the Hosmer-Lemeshow (HL) Goodness of Fit Test (C and H statistic). The observed versus the SAPS 3 model predicted mortality ratios were compared and the standardized mortality ratio (SMR) was calculated. RESULTS: A total of 829 admissions with a mean SAPS 3 (SD) of 48.1 (16) were included. Of patients with a known human immunodeficiency virus (HIV) status, 32,4% were positive. The ICU and hospital mortality rates were 13.3% and 21.4% respectively. The SAPS 3 model had a AUROC of 0.796 and HL C and H statistics were 12.1 and 11.8 (p-values 0.15 and 0.16). The SMR for the model was 1.002 (95%CI: 0.91-1.10). The mortality of 41% for the subgroup with sepsis/septic shock was higher than predicted with a SMR of 1.24 (95% CI 1.11-1.37). CONCLUSIONS: The SAPS 3 model showed good calibration and fair discrimination when applied to the cohort. The SAPS 3 model can be used to describe the case mix in this African ICU with a high incidence of HIV. Ongoing efforts should be made to improve outcomes of septic patients.

The impact of vascular calcification among dialysis-dependent South African patients: A 5-year follow-up study
.

BACKGROUND: Vascular calcification is a major risk factor for cardiovascular morbidity and mortality in patients with end-stage renal disease (ESRD). In Western countries, Blacks appear to have lesser degrees of vascular calcification compared to non-Blacks. However, there is no published data from sub-Saharan Africa. MATERIALS AND METHODS: This study assessed the 5-year change in vascular calcification and mortality in a previously published cohort of patients with ESRD. Vascular calcification was assessed by abdominal aortic calcification score and vascular stiffness by pulse wave velocity (PWV). RESULTS: 66 of the original 74 participants studied at baseline were identified. The median age was 46.6 years (37.6 - 59.2), and 57.6% were women. Abdominal aortic calcification showed no progression among Blacks (baseline range 0 - 5, follow-up range 0 - 8 (p = 1.00)), but a trend to progression among non-Blacks (baseline range 0 - 19, follow up range 0 - 22 (p = 0.066)). Black participants did not display a survival advantage (p = 0.870). Non-Blacks had higher parathyroidectomy rates than Blacks with 9/30 cases compared to 2/36 (p = 0.036). After adjustment for parathyroidectomy at follow-up, the odds ratio of having abdominal vascular calcification score of ≥ 1 amongst non-Blacks was 8.6-fold greater compared to Blacks (p = 0.03). A positive correlation (r = 0.5) was observed between PWV and abdominal aortic calcification (p = 0.047). Elevated baseline coronary artery calcification score and FGF-23 level at baseline were not associated with a difference in mortality. CONCLUSION: There was no significant progression in vascular calcification among Blacks. After adjusting for increased parathyroidectomy rates, there was a greater progression of vascular calcification amongst non-Blacks compared to Blacks.

Risk factors and outcomes of acute kidney injury in South African critically ill adults: a prospective cohort study.

BACKGROUND: There is a marked paucity of data concerning AKI in Sub-Saharan Africa, where there is a substantial burden of trauma and HIV. METHODS: Prospective data was collected on all patients admitted to a multi-disciplinary ICU in South Africa during 2017. Development of AKI (before or during ICU admission) was recorded and renal recovery 90 days after ICU discharge was determined. RESULTS: Of 849 admissions, the mean age was 42.5 years and mean SAPS 3 score was 48.1. Comorbidities included hypertension (30.5%), HIV (32.6%), diabetes (13.3%), CKD (7.8%) and active tuberculosis (6.2%). The most common reason for admission was trauma (26%). AKI developed in 497 (58.5%). Male gender, illness severity, length of stay, vasopressor drugs and sepsis were independently associated with AKI. AKI was associated with a higher in-hospital mortality rate of 31.8% vs 7.23% in those without AKI. Age, active tuberculosis, higher SAPS 3 score, mechanical ventilation, vasopressor support and sepsis were associated with an increased adjusted odds ratio for death. HIV was not independently associated with AKI or hospital mortality. CKD developed in 14 of 110 (12.7%) patients with stage 3 AKI; none were dialysis-dependent. CONCLUSIONS: In this large prospective multidisciplinary ICU cohort of younger patients, AKI was common, often associated with trauma in addition to traditional risk factors and was associated with good functional renal recovery at 90 days in most survivors. Although the HIV prevalence was high and associated with higher mortality, this was related to the severity of illness and not to HIV status per se.

Tuberculosis and pauci-immune crescentic glomerulonephritis.

We report here a case that highlights tuberculosis (TB) as a possible cause for pauci-immune crescentic glomerulonephritis (c-GN), an important and often treatable cause of kidney injury. A 47-year-old HIV-negative man of mixed ethnicity presented with a 2-week history of cough, haemoptysis and unintentional weight loss. Chest examination revealed crepitations over the right upper zone and urinalysis demonstrated an active urinary sediment with red cell casts. Chest radiograph confirmed right upper lobe cavitation. Serum laboratory investigations revealed a serum creatinine of 632 µmol/L and were negative for antineutrophil cytoplasmic antibodies. A diagnosis of pauci-immune c-GN was made on renal biopsy. In addition, sputum PCR confirmed infection with drug-sensitive Mycobacterium tuberculosis Standard TB treatment and immunosuppression with prednisone and cyclophosphamide was commenced, and over the course of 6 months, renal function improved to an estimated glomerular filtration rate >60 mL/min.

Liddle's syndrome in an African male due to a novel frameshift mutation in the beta-subunit of the epithelial sodium channel gene.

Resistant hypertension is a common clinical problem in South Africa and is frequently associated with low renin and aldosterone levels, especially in black Africans. In South Africa, novel variants in the epithelial sodium channel (ENaC) have been described to be associated with varying degrees of hypokalaemia and hypertension due to primary sodium retention. We report here a case of Liddle's syndrome due to a novel c.1709del11 (p.Ser570Tyrfs*20) deletion in the beta-subunit of the ENaC in a young black African male. We discuss the likely pathogenesis of hypertension in this setting as well as the treatment options available in South Africa aimed at the ENaC. This case highlights the need for vigilance in detecting and appropriately treating low-renin and low-aldosterone hypertension in view of the frequency of the described variants of the ENaC channel in our country. Specific therapy such as amiloride should be made more widely available.

Vascular calcification is not associated with increased ambulatory central aortic systolic pressure in prevalent dialysis patients.

INTRODUCTION: Central aortic systolic pressure (CASP) strongly predicts cardiovascular outcomes. We undertook to measure ambulatory CASP in 74 prevalent dialysis patients using the BPro (HealthStats, Singapore) device. We also determined whether coronary or abdominal aortic calcification was associated with changes in CASP and whether interdialytic CASP predicted ambulatory measurement. METHODS: All patients underwent computed tomography for coronary calcium score, lateral abdominal radiography for aortic calcium score, echocardiography for left ventricular mass index and ambulatory blood pressure measurement using BPro calibrated to brachial blood pressure. HealthStats was able to convert standard BPro SOFT(®) data into ambulatory CASP. RESULTS: Ambulatory CASP was not different in those without and with coronary (137.6 vs 141.8 mmHg, respectively, p = 0.6) or aortic (136.6 vs 145.6 mmHg, respectively, p = 0.2) calcification. Furthermore, when expressed as a percentage of brachial systolic blood pressure to control for peripheral blood pressure, any difference in CASP was abolished: CASP: brachial systolic blood pressure ratio = 0.9 across all categories regardless of the presence of coronary or aortic calcification (p = 0.2 and 0.4, respectively). Supporting this finding, left ventricular mass index was also not different in those with or without vascular calcification (p = 0.7 and 0.8 for coronary and aortic calcification). Inter-dialytic office blood pressure and CASP correlated excellently with ambulatory measurements (r = 0.9 for both). CONCLUSION: Vascular calcification was not associated with changes in ambulatory central aortic systolic pressure in this cohort of prevalent dialysis patients. Inter-dialytic blood pressure and CASP correlated very well with ambulatory measurement.

Vascular calcification in South African dialysis patients: ethnic variation, prevalence, detection and haemodynamic correlates.

AIM: Studies from the US have shown little effect of ethnicity on vascular calcification in dialysis patients. This has not been examined in the multi-ethnic population of South Africa where genetic and environmental differences may exist. We assessed the extent and severity of vascular calcification in South African dialysis patients according to race and known risk factors. We further evaluated the association of abdominal aorta calcification with coronary artery calcification. METHOD: Seventy-five CKD-5D patients and 20 healthy controls were enrolled consecutively. All subjects underwent chest computed tomography for coronary calcium score and abdominal X-ray for abdominal aorta calcium score. Ambulatory blood pressure monitoring was generated via radial artery applanation tonometry. RESULTS: Coronary calcification was present in 38.6% of patients and was associated with age and prior cardiovascular disease on multivariate analyses. The median coronary calcium score in black patients was 0 (IQR 0) and 66 in non-Blacks (IQR 383, P < 0.001); controls had a coronary calcium score of 0 (IQR 0). Black race remained a significant negative predictor for coronary calcification after adjustment, prevalence ratio = 0.14 and 95% confidence interval (CI): 0.0-0.53. Vascular calcification was not associated with any ambulatory blood pressure parameter. Using receiver operator characteristic curves, an abdominal aorta calcification score of ≥1 showed an area under the curve of 0.83 to predict a coronary calcium score ≥ 10. CONCLUSION: Black race appears to protect from vascular calcification in South African CKD-5D patients and this warrants further study regarding the underlying mechanism. The abdominal X-ray is a useful screening tool for coronary calcification.