Ventilator-associated pneumonia in an academic intensive care unit in Johannesburg, South Africa.

Background: Ventilator-associated pneumonia (VAP) has an estimated incidence of 10 - 41.5 events per 1 000 ventilator days in developing countries, and carries high mortality. Little is known about the incidence and outcomes of VAP in Johannesburg, South Africa. Objectives: To describe VAP in a tertiary public hospital in Johannesburg, assess the microbiological pathogens associated with VAP (both early and late), and outline the outcomes of these patients. Methods: The study was a retrospective record review of patients admitted to the Helen Joseph Hospital intensive care unit (ICU) between March 2013 and January 2016. Results: VAP developed in 24/842 ventilated patients (2.9%; 95% confidence interval (CI) 1.8 - 4.2), with an incidence of 23 events per 1 000 ventilator days, during the study period. Of these patients, one-third (29.2%) died and 70.8% were discharged from the ICU. Late-onset VAP (onset ≥5 days after intubation, incidence 45.8%) was associated with higher mortality (54.6%) than early-onset VAP (onset within 4 days after intubation, incidence 54.2% and mortality 7.7%). Commonly isolated organisms were Klebsiellai pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa. There was a trend towards an increased risk of multidrug-resistant organisms with late-onset VAP (adjusted relative risk 2.26; 95% CI 0.92 - 5.57; p=0.077) and airway access through a tracheostomy (relative risk 1.68; 95% CI 0.78 - 3.57). Conclusion: The study showed a low to moderate incidence of VAP of 23 events per 1 000 ventilator days. A tracheostomy and late-onset VAP were associated with infection by drug-resistant organisms. The mortality rate was 29.2% in this setting, with a seven-fold increase in mortality with late-onset VAP. Study synopsis: What the study adds. This study helps to improve understanding of the incidence of ventilator-associated pneumonia in South Africa, a low- to middle-income country, and the commonly encountered causative pathogens. It indicates the importance of a short intensive care unit (ICU) stay as a target outcome for prevention of nosocomial infections and other complications.Implications of the findings. The study: reinforces the importance of preventive mesures in the ICU and keeping up to date with the evidence in the fieldhighlights the importance of knowing local microbial resistance patterns in order to develop precise antibiogramsshows the need for research in ICU care for people of advanced age, and the impact that admission rationing has on our ICU populations.

Time to thrombolysis and factors contributing to delays in patients presenting with ST-elevation myocardial infarction at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

BACKGROUND: Acute coronary syndrome is a public health burden both worldwide and in South Africa (SA). Guidelines recommend thrombolysis within 1 hour of symptom onset and 30 minutes of hospital arrival for patients with ST-elevation myocardial infarction (STEMI) in order to prevent morbidity and mortality. There is a paucity of data pertaining to the time between onset of chest pain and thrombolysis in STEMI patients in SA. OBJECTIVES: To elucidate the time to thrombolytic therapy, establish the reasons for treatment delays, and calculate the loss of benefit of thrombolysis associated with delays in treatment of patients presenting with STEMI at Chris Hani Baragwanath Academic Hospital (CHBAH), Johannesburg, SA. METHOD: A prospective observational study of 100 consecutive patients with STEMI was conducted at CHBAH (2021 - 2022). RESULTS: The mean (standard deviation) age was 55.6 (11.6) years, with a male predominance (78%). Thrombolytic therapy was administered to 51 patients, with a median (interquartile range (IQR)) time to thrombolysis of 360 (258 - 768) minutes; 10 of the patients who received a thrombolytic (19.6%) did so within 30 minutes of arrival at the hospital. The median (IQR) time from symptom onset to calling for help was 60 (30 - 240) minutes, the median time from arrival of help to hospital arrival was 114 (48 - 468) minutes, and the median in-hospital delay to thrombolysis after arrival was 105 (45 - 240) minutes. Numerous reasons that led to delay in treatment were identified, but the most frequent was prehospital delays related to patient factors. Late presentation resulted in 26/49 patients (53.1%) not receiving thrombolytic therapy. Five patients died and 43 suffered from heart failure. Thirty per 1 000 participants could have been saved had they received thrombolytic therapy within 1 hour from the onset of chest pain. CONCLUSION: Prehospital and hospital-related factors played a significant role in delays to thrombolysis that led to increased morbidity and mortality of patients with STEMI.

Right heart echocardiography findings in hypoxic pneumonia patients during the COVID-19 pandemic in a South African population.

Aims: The right ventricle is affected by Coronavirus disease 19 (COVID-19) via multiple mechanisms, which can result in right ventricular dysfunction (RVD). This study aimed to provide an assessment of right heart function using conventional echocardiography and advanced strain imaging, in patients with hypoxic pneumonia during the COVID-19 pandemic. Methods and results: This study was an observational, prospective, single-centre study, including adults with hypoxic pneumonia, in two groups: COVID-19 pneumonia; and non-COVID-19 pneumonia. Bedside echocardiography was performed according to a pre-specified protocol and all right heart measurements were done as per standard guidelines. Right ventricular free wall strain (RVFWS) was measured using Philips® QLAB 11.0 speckle tracking software. Descriptive and comparative statistics were used to analyse data. Spearman Rank Order Correlations were used to determine the correlation between right ventricular (RV) parameters and clinical parameters. Univariate and multivariate logistic regression analyses were performed to characterize the predictors of in-hospital mortality. We enrolled 48 patients with COVID-19 pneumonia and 24 with non-COVID-19 pneumonia. COVID-19 patients were significantly older with a higher frequency of hypertension and diabetes and a trend towards a lower severity of illness score. Mean RVFWS yielded the highest estimates for the prevalence of RVD (81%), with no difference between the two pneumonia groups. Median Tricuspid Annular Plane Systolic Excursion (TAPSE) and right ventricular systolic excursion velocity (RVS') were not significantly different between COVID-19 (TAPSE 17.2 and RVS' 12), and non-COVID-19 pneumonia (TAPSE 17.8 and RVS' 12.1) with P values of 0.29 and 0.86, respectively. Non-COVID-19 pneumonia patients with moderate to severe hypoxaemia (PF < 150) were at greater risk of an elevated RV Systolic Pressure >30 mmHg respiratory rate = 3.25 (CI 1.35-7.82) on admission. Troponin levels discriminated between COVID-19 survivors (6 ng/L) and non-survivors (13 ng/L), P = 0.04. The mortality rate for COVID-19 was high (27%) compared to non-COVID-19 pneumonia (12%). Conclusion: Patients with COVID-19 pneumonia had a similar admission prevalence of RVD when compared to patients with non-COVID-19 pneumonia. Despite preserved traditional parameters of RV systolic function, RVFWS was diminished in both groups, and we propose that RVFWS serves as an important marker of the subclinical disease of RV.

Evaluation of the use of low-molecular-weight heparin for venous thromboembolism prophylaxis in medical patients.

BACKGROUND: Venous thromboembolism (VTE) complicates a significant proportion of medical admissions. As well as increasing patient morbidity, pulmonary embolism is one of the commonest preventable causes of in-hospital death. An increase in the use of pharmacological preventive measures has been advocated in recent years. South African (SA) and international guidelines have been published in an effort to promote the safe use of VTE prophylaxis. OBJECTIVES: To describe adherence to both local and international recommendations for VTE prophylaxis in an SA hospital with regard to appropriateness of the decision to prescribe or withhold low-molecular-weight heparin (LMWH), and to observe the practice of dose adjustment in special population groups. METHODS: This was a prospective, observational study, and data were collected from consenting adults admitted to the medical wards. We assessed the patients' VTE risk, bleeding risk and the presence of contraindications at the time of LMWH prescription as well as the dose prescribed, specifically taking into consideration adjustment for renal dysfunction and obesity. RESULTS: Three hundred and fifty-two patients were enrolled, of whom 51.4% were male and 58.5% received LMWH. Primary outcomes. The appropriate overall decision according to both SA and international guidelines was made in 254 cases (72.2%). The inappropriate decision according to both guidelines was made in 79 cases (22.4%) and the appropriate decision according to one guideline only was made in 18 cases (5.1%), while 1 case (0.3%) was not categorised. Contraindications to VTE prophylaxis were present in 35 patients (9.9%), but 9 of these patients nevertheless received LMWH. An incorrect dose was prescribed in 36 cases (17.5%), the most common reason being an inappropriate reduction in the dose in mild renal dysfunction. SECONDARY OUTCOMES: Other medications that may have increased bleeding risk were prescribed in 46 patients who received LMWH (22.3%). Mechanical prophylaxis was indicated in 25 (7.1%) of the total sample; however, none received this. CONCLUSIONS: Overall adherence to published guidelines for VTE prophylaxis has improved compared with other published reviews on the topic, but documentation of patients' VTE risk in files is poor. Overuse in low-risk patients may be an unintended consequence of the widespread advocacy of LMWH use in hospital, highlighting the importance of adequate VTE risk stratification. Incorrect dosing in special population groups is an issue that needs to be addressed, as is non-utilisation of mechanical prophylaxis methods.