Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa.

BACKGROUND: Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown. OBJECTIVES: To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients. METHODS: Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital. RESULTS: A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge. CONCLUSION: Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Delirium: a disorder of consciousness?

Delirium is recognised as a disorder of consciousness, however, no evidence has been previously generated to specifically address this premise. In order to evaluate this established notion, we have attempted to review consciousness, the components of consciousness and the emerging evidence for neuroanatomical correlates and then relate this to the recognized features of delirium. We have established that the level of awareness is modulated by alertness and arousal, focused by attention and has the ability to switch between the personal resonances of the experience to the precision of cognition. We have discussed consciousness's relationship with delirium and how the degree of integration of CNS function is mandatory for realisation of higher order function and this has implications for the conceptualisation and management of delirium. We have explored the understanding of downstream, components of consciousness as not giving rise to the full condition of delirium but as a subsyndromal state. We have argued that there is a need for future diagnostic criteria, such as DSM-V, to operationalize disturbance of consciousness together with non-cognitive manifestations of delirium. Intervention studies in delirium have focussed on drugs that improve memory (cholinesterase inhibitors). If memory is only one element of consciousness then we reason instead on evaluating the determinants of consciousness that may be modifiable, such as awareness. Reinforcement of environmental awareness by managing a patient within a low stimulus or familiar surrounding may therefore offer a therapeutic intervention. Overall there seemed support for, or no evidence against, the belief that delirium is a disorder of consciousness. From Descartes 'I think therefore I am' we can say 'I am aware not therefore delirious I am'.