Nosocomial outbreak of extended-spectrum beta-lactamase-producing Salmonella isangi in pediatric wards.

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.

The impact of HIV on Streptococcus pneumoniae bacteraemia in a South African population.

OBJECTIVES: To determine the impact of HIV infection on Streptococcus pneumoniae bacteraemia in adults and children by analysing the prevalence and clinical features of such diseases and determining the prevalent serotypes/serogroups and susceptibility patterns of isolates. DESIGN: Patients were identified prospectively from January to October 1996. SETTING: Chris Hani Baragwanath Hospital, Soweto, a tertiary referral hospital treating adults and children, in an urban district near Johannesburg, South Africa. PATIENTS AND METHODS: All patients with S. pneumoniae isolated from blood culture by the Microbiology Department, Chris Hani Baragwanath Hospital were studied. Clinical and microbiological features were recorded. RESULTS: A total of 178 patients with S. pneumoniae were investigated as part of the study; 49 were aged < 13 years. HIV seroinfection was present in 25 (51%) children and 58 (45%) adults. The incidence of S. pneumoniae bacteraemia was 36.9-fold increased in HIV-seropositive children and 8.2-fold increased in HIV-seropositive adults compared with HIV-seronegative individuals. Both adult and paediatric HIV-seropositive patients with S. pneumoniae bacteraemia were significantly younger than HIV-seronegative patients. Pneumonia was a significantly more common presentation in HIV-seropositive children, otherwise the spectrum of disease and outcome were similar in HIV-seronegative and positive groups. Serotype 1 S. pneumoniae isolates were significantly less common in HIV-infected individuals (both adults and children). Resistance to penicillin was increased in S. pneumoniae isolates from HIV-infected patients (significant in adults). Patients with penicillin-resistant isolates did not have a poorer outcome. The potential coverage of serotypes/serogroups included in the proposed nine-valent conjugate pneumococcal vaccine was 88% in HIV-seronegative children and 83% in HIV-seropositive children. The potential coverage of the currently available 23-valent pneumococcal vaccine for adults was 98.2 and 100)% for HIV-infected and HIV-uninfected adults, respectively. CONCLUSION: The burden of bacteraemia due to S. pneumoniae in HIV-seropositive individuals admitted to our hospital is considerable. Differences in the S. pneumoniae serotypes/serogroups in HIV-infected patients have been demonstrated with resultant differences in antibiotic susceptibility patterns. Excellent potential for vaccine coverage was demonstrated for both HIV-seronegative and HIV-seropositive individuals. Further studies are necessary to test the clinical efficacy of pneumococcal vaccination of HIV-seropositive adults and children as a potential preventative measure against this prevalent disease.

PIP: Findings are presented from a study conducted to determine the impact of HIV infection upon Streptococcus pneumoniae bacteremia in adults and children by analyzing the prevalence and clinical features of such diseases and determining the prevalent serotypes/serogroups and susceptibility patterns of isolates. 178 patients with S. pneumoniae identified prospectively through blood culture during January-October 1996 at Chris Hani Baragwanath Hospital, Soweto, were studied. 49 patients were under 13 years old. 25 (51%) children and 58 (45%) adults were found to be infected with HIV. The incidence of S. pneumoniae bacteremia was 36.9 times higher in HIV-seropositive children and 8.2 times higher in HIV-seropositive adults compared to HIV-seronegative individuals. The HIV-seropositive patients with S. pneumoniae bacteremia were significantly younger than HIV-seronegative patients. Pneumonia was a significantly more common presentation in HIV-seropositive children; otherwise, the spectrum of disease and outcome were similar in HIV-seronegative and seropositive groups. There is extremely good potential for vaccine coverage for both HIV-negative and HIV-positive individuals.

Pneumococcal bacteremia during a decade in children in Soweto, South Africa.

OBJECTIVES: To monitor for a decade the incidence and the clinical and microbiologic characteristics of pneumococcal bacteremia in children in Soweto and to assess the influence of HIV infection on any changes. METHODS: Case records of children with pneumococcal bacteremia at Chris Hani Baragwanath Hospital from July, 1986, to June, 1987 (1986/ 1987), and from July, 1996, to June, 1997 (1996/ 1997), were retrospectively reviewed. RESULTS: There were 194 episodes, 62 in 19861 1987 and 132 in 1996/1997. The minimum annual incidence for children younger than 5 years of age increased from 61 per 100000 (179 per 100000 for those <12 months old) in 1986/1987 to 130 per 100000 (349 per 100000 for those <12 months old) in 1996/1997. Sixty-seven (60%) of 111 patients tested in 1996/1997 were HIV-seropositive; none were tested in 1986/1987. The HIV-infected compared with HIV-noninfected were more likely to be malnourished (61% vs. 36%, P = 0.02), less likely to have other underlying disease (12% vs. 50%, P = 0.00001) and more frequently used antibiotics recently (69% vs. 43%, P = 0.008). Penicillin-nonsusceptible isolates were found in 22 (35%) patients in 1986/1987 and 52 (39%) in 1996/1997. There was no significant change in antimicrobial susceptibility during the decade or by HIV serostatus. CONCLUSIONS: Children in Soweto had a high incidence of pneumococcal bacteremia which doubled during the decade mainly as a result of the impact of the HIV epidemic. There has been no significant change in antimicrobial susceptibility for the decade.

Effect of human immunodeficiency virus infection on episodes of diarrhea among children in South Africa.

BACKGROUND: Infection with HIV is increasing among children in South Africa. Diarrhea is a common cause of morbidity and mortality in Africa, and some studies have shown that HIV-infected children have episodes of severe diarrhea with higher mortality than HIV-uninfected children. OBJECTIVES: To compare the severity, pathogens and outcome of diarrhea in HIV-infected and uninfected children. METHODS: We studied 181 children ages 3 months to 4 years admitted for gastroenteritis to the Chris Hani Baragwanath Hospital in Soweto, South Africa. Demographic details of the children were recorded, as were the details of the episode of diarrhea. Stools specimens were collected and sent for microbiologic evaluation. The clinical course of the child's admission was recorded. Children were diagnosed as being infected with HIV if they tested positive by HIV enzyme-linked immunosorbent assay (ELISA) and were >15 months of age, or if they were ELISA-positive, were < 15 months of age and had clinical signs of HIV infection. RESULTS: Of the 176 children with an HIV ELISA result, 31 (17.6%) were classified as HIV-infected. More HIV-infected children were malnourished (80.6% vs. 39.5%, P < 0.001) and more likely to have had prolonged diarrhea (16.1% vs. 5.9%, P = 0.07) compared with HIV-uninfected children. HIV-infected children had a higher rate of a codiagnosis of pneumonia (43.3% vs. 9.2%, P < 0.0001) and were more likely to require a hospital stay of >4 days (prevalence odds ratio, 5.11; 95% confidence interval, CI 1.49 to 17.52). There were no significant differences in stool pathogens or in the level of dehydration on admission between the HIV-infected and uninfected children. CONCLUSION: HIV-infected children have the same spectrum of enteric pathogens as uninfected children but require more attention because of malnutrition and comorbidity.

Tuberculous meningitis in South African urban adults.

We retrospectively reviewed 56 adults with culture-proven tuberculous meningitis (TBM), investigating clinical signs, cerebrospinal fluid (CSF) findings and outcome. There were 50 patients, aged 18-59 years, 39 with and 11 without human immunodeficiency virus (HIV) infection. Six were aged 60 years or older. Neurological signs of TBM in 18-59-year-olds were unaffected by HIV serostatus while, compared to those > or = 60 years of age, there were more patients with meningism (86.0% vs. 33.3%; p = 0.011) and fewer with seizures (12.0% vs. 50.0%; p = 0.046). The HIV-infected 18-59-year-olds had significantly more extrameningeal tuberculosis compared to the non-HIV-infected (76.9% vs. 9.1%; p = 0.0001) and 23.1% had 'breakthrough' TBM. CSF analysis revealed 12 patients (21.4%) with acellular fluid (more common in those > or = 60 years of age, p = 0.016), of whom three had completely normal CSF. A neutrophil predominance was found in 22 patients (39.3%). Only three patients (5.4%) had a positive CSF smear for acid-fast bacilli. In-hospital mortality occurred in 39 patients (69.1%), was similar in all study groups, and was not related to neurological stage. The diagnosis of TBM can be masked by lack of meningism in the elderly and by atypical CSF findings.

The bacteriology of pulmonary tuberculosis in a population with high human immunodeficiency virus seroprevalence.

SETTING: A public sector urban university hospital in Soweto, South Africa. OBJECTIVE: To describe the utility of sputum smear microscopy and the prevalence of Mycobacterium tuberculosis resistance to antituberculosis drugs according to human immunodeficiency virus (HIV) serostatus in adults. DESIGN: A retrospective descriptive study of consecutive cases using a record review. RESULTS: We studied 412 adults with culture-proven pulmonary tuberculosis, of whom 185 (44.9%) were HIV-seropositive and had a significantly lower sputum smear positivity than HIV seronegatives (68% versus 79%, P < 0.05). Smear positivity was significantly higher in HIV-infected patients with CD4 counts < or = 50/mm3 compared to those with CD4 counts of 201-300/mm3 (P < 0.05). In patients with and those without a history of previous treatment for tuberculosis, resistance to one or more antituberculosis drugs was found in 32.2% and 13.6% of cases, respectively, while resistance to both isoniazid and rifampicin (multidrug-resistant tuberculosis [MDR]) was found in 15.3% and 4.5% of patients, respectively. There was no significant difference in resistance between HIV-positive and seronegative patients. CONCLUSION: A strong tuberculosis control programme and good surveillance will be required to prevent the further spread of MDR tuberculosis. Surveys such as these are useful for monitoring control programmes.

Tuberculosis in children dying with HIV-related lung disease: clinical-pathological correlations.

SETTING: Chris Hani Baragwanath Hospital, Soweto, South Africa. OBJECTIVES: To compare post mortem histological, microbiological and biochemical findings with clinical and radiological data generated ante mortem in children infected with HIV dying from clinical lung disease. METHODS: Post mortem lung and liver biopsies were undertaken on 93 consecutive deaths in children with HIV. Specimens were processed for culture, histology and staining for M. tuberculosis, Pneumocystis carinii pneumonia (PCP) and cytomegalovirus (CMV). Post mortem diagnoses were compared with clinical and radiological data generated during the final hospitalisation. RESULTS: Tuberculosis (TB) was diagnosed post mortem in four (4.3%) cases; a further 17 (18.2%) patients had been treated empirically for TB before death, and the remaining 72 (77.5%) patients had not been treated for TB. TB was more prevalent in children aged 1 year or older (13.4%) than in younger patients (1.4%) (P < 0.025). Patients with PCP, CMV pneumonitis or lymphocytic interstitial pneumonitis (LIP) had the same clinical presentation or radiographic appearances as patients with TB. The only features distinguishing patients with TB were older age and ante mortem gastric aspirate cultures positive for M. tuberculosis. CONCLUSION: The diagnosis of TB in children infected with HIV remains difficult. Clinical and radiographic features are shared with other opportunistic diseases. Case identification strategies relying on clinical and radiographic findings lead to overtreatment, particularly in children younger than 1 year of age. Gastric aspirate cultures remain a reliable tool for the identification of infected patients.

Four years of cryptosporidiosis at GaRankuwa Hospital.

Cryptosporidiosis was first recognised at GaRankuwa Hospital, a reference teaching hospital for mainly black patients near Pretoria, South Africa, in October 1985. Since then 289/6870 specimens (4.21%) submitted to the routine stool laboratory have been found to contain Cryptosporidium parvum oocysts. Seasonal peaks were seen in late summer (January, February, March) and minimum case numbers were recorded during late winter (August, September). The disease was predominantly one of early childhood, with the majority of patients being under 3 years of age. Only six positive stools came from patients older than 12 years. Cryptosporidiosis has replaced giardiasis as the most commonly detected gastrointestinal parasitic infection of patients in this hospital. Oocysts were also found in the sputum of an 84-year-old male patient with a persistent productive cough.

The microbial aetiology of summer paediatric gastroenteritis at Ga-Rankuwa Hospital in South Africa.

Stool material from seventy-eight children below the age of three years was examined for the presence of various enteropathogens. The patients had been admitted to the Ga-Rankuwa hospital for rehydration therapy. A causative agent was identified in 76.9% of the cases studied. The most prevalent organisms identified were 38.5% entero-toxigenic Escherichia coli (ETEC), 25.6% Cryptosporidium parvum, 15.4% Campylobacter sp., 14.1% enteric adenoviruses and 12.8% rotavirus. In 38.5% of cases, a mixed infection was observed with up to four different organisms being identified from a single patient. ETEC elaborating heat-labile toxin (LT) found together with C. parvum was the most common combination seen in mixed infections.

Influenza- and respiratory syncytial virus-associated adult mortality in Soweto.

BACKGROUND: Influenza and respiratory syncytial virus (RSV) infections cause seasonal excess mortality and hospitalisation in adults (particularly the elderly) in high-income countries. Little information exists on the impact of these infections on adults in Africa. OBJECTIVES: To estimate influenza- and RSV-related adult mortality, stratified by age and hospitalisation in Soweto. STUDY DESIGN: A retrospective hospital-based study in Soweto from 1997 to 1999 to estimate influenza- and RSV-related excess all-cause deaths and hospitalisation using a rate-difference method. The study was based on influenza seasons of varying severity, provided by surveillance data. RESULTS: Influenza seasons were significantly associated with excess mortality in adults across all 3 years, except for 18 - 64-year-olds in 1998. Excess mortality was highest in those > or = 65 years of age: 82.8/100 000 population in the mild 1997 season and 220.9/100 000 in the severe 1998 season. Influenza significantly increased adult medical hospitalisation in the severe 1998 season alone. RSV did not significantly affect mortality or hospitalisation. CONCLUSION: Influenza-related mortality was substantial and disproportionately affected the elderly. Influenza vaccination for the elderly warrants consideration. The RSV-related burden was not significantly increased but merits observation over a longer period.

Pseudomonas aeruginosa bacteraemia in an academic hospital in South Africa.

OBJECTIVES: The aim of the study was to determine the clinical manifestations, outcome of and prognostic factors associated with Pseudomonas aeruginosa bacteraemia at Chris Hani Baragwanath Hospital, Johannesburg, during the period 1998 - 1999, to describe and quantify resistance to antipseudomonal drugs, to characterise bacteraemic isolates, and to investigate the clustering and genotype distribution of drug-susceptible and multiply-resistant strains in the hospital. METHODS: Clinical and laboratory investigations, culture and antimicrobial susceptibility testing were performed. Bacteraemic isolates were typed by endonuclease macrorestriction. Those with > or = 97% band pattern similarity were assigned genotype status. RESULTS: Of 91 P. aeruginosa blood isolates, 52 (57.1%) were nosocomially acquired. Underlying conditions associated with episodes were burns in 24 (28%) and HIV infection in 21 (24%). Multidrug resistance was present in 14 (15.4%) of isolates from 91 episodes. In 79 episodes where the outcome was known, 37 (46.8%) of the patients died. Case fatality rates were 75% in adults and 25% in children. Being a child, receiving appropriate antimicrobial treatment and admission to a specialised care unit were significantly associated with improved prognosis. CONCLUSION: P. aeruginosa bacteraemia was associated with outbreaks caused by two multiply-resistant genotypes. Eighteen antimicrobial-susceptible isolates from bacteraemic episodes in paediatric wards, 9 in HIV-seropositive children, could be linked to small outbreaks in both hospitalised and community-based children.

Pneumococcal bacteremia in adults in Soweto, South Africa, during the course of a decade.

We retrospectively reviewed 414 episodes of pneumococcal bacteremia that occurred in adults from July 1986 through June 1987 (1986/1987) and from July 1996 through June 1997 (1996/1997) to monitor the incidence and clinical and laboratory characteristics and to assess the influence of human immunodeficiency virus (HIV) infection on any changes. The incidence increased from 26 per 100,000 persons in 1986/1987 to 36 per 100,000 persons in 1996/1997; the increase was most marked among patients who were aged 25-44 years (24 cases per 100,000 persons to 45 per cases 100,000 persons) and > or =65 years (43 cases per 100,000 persons to 50 cases per 100,000 persons). Of 161 patients who were tested for HIV in 1996/1997, 108 (67%) were HIV seropositive. Among the general population, the prevalence of other underlying diseases and smoking decreased from 45% and 67%, respectively, in 1986/1987 to 23% (P<.0001) and 35% (P<.0001) in 1996/1997. Strains of pneumococci that were not susceptible to penicillin were found in 4% patients in 1986/1987 and 12% in 1996/1997 (P=.005). This increase occurred exclusively among the HIV-infected patients (22% of the HIV-seropositive patients versus 4% of HIV-seronegative patients; P=.008), and there was a parallel increase for childhood serotypes (51% of HIV-seropositive patients versus 17% of HIV-seronegative patients; P<.0001).

Cryptococcal meningitis caused by Cryptococcus neoformans var. gattii, serotype C, in AIDS patients in Soweto, South Africa.

We present four patients from South Africa with meningitis caused by Cryptococcus neoformans var. gattii, serotype C. These are the first patients with human immunodeficiency virus (HIV) infection to be reported with serotype C meningitis.

Actinomadura pelletieri mycetoma from the Transvaal. A case report.

The osteophilic red grain mycetoma due to Actinomadura pelletieri is rare in southern Africa. This report describes an elderly patient with extensive bone involvement in which lymphatic spread to the inguinal lymph nodes had occurred. The diagnosis and management are discussed.

Incidence of toxigenic Campylobacter strains in South Africa.

Campylobacter strains can produce a heat-labile cytotonic toxin (CTON) and various cytotoxins (CTOX). Of 22 South African Campylobacter strains tested, 86% were toxigenic (77% produced CTON, 41% produced CTOX, and 32% produced both types) and 14% were toxin negative. Campylobacter jejuni strains were 67% CTON positive and 47% CTOX positive, whereas Campylobacter coli strains were 100 and 29% positive, respectively.

Invasive group B streptococcal disease in nonpregnant adults.

Forty episodes of invasive group B streptococcal infections in nonpregnant adults at Chris Hani Baragwanath Hospital, Soweto, South Africa, were retrospectively reviewed. The mean age of the patients was 45.6 years. Twenty (50%) patients were bacteraemic. Common predisposing conditions included diabetes mellitus (27.5%), trauma (25%), and HIV infection (12.5%). Soft tissue abscesses and pneumonia accounted for 70% of the presentations. Ten (25%) patients had acquired the infection nosocomially. Death occurred in 14 (35%) patients and was significantly associated with bacteraemia (P = 0.0009) and pneumonia (P = 0.0012). Trauma is an important predisposing condition, and HIV infection may have played a role in the setting described; both factors probably accounted for the relatively young age of the patients.

Feto-maternal haemorrhage following successful and unsuccessful attempts at external cephalic version.

In the present study, 6 out of 100 patients who had an attempted or actual external cephalic version (ECV) showed significant feto-maternal haemorrhage, the amount being greatest in patients with "failed" external versions. Thus ECV may be a source of rhesus iso-immunization in a rhesus negative mother with a rhesus positive fetus and should not be performed unless the father is a rhesus negative. If, however, an ECV has been attempted, fetal cell counts should then be made and rhesus immunoprophylaxis administered if necessary.

Blastomycosis in Africa. A review of known cases diagnosed between 1951 and 1987.

The known African cases of blastomycosis to 1987 are presented, including thirteen previously undescribed cases. This brings to 81 the total number of cases known to have occurred in Africa. The question of whether the disease in Africa is the same in all respects as that in North America is addressed; the age and sex distributions of patients are similar. Minor differences in the clinical features relate particularly to the type of skin lesion, the more frequent bone involvement and the less frequent central nervous system involvement in the African patient. Little is known about the epidemiology of blastomycosis in Africa; one noteworthy feature is the apparent absence of the disease in dogs. Isolates of Blastomyces dermatitidis from the two continents, although closely related, differ in some respects.

Syphilis serology in men attending the Andrology Clinic at Ga-Rankuwa Hospital.

The worldwide resurgence of syphilis may have serious implications on neonatal morbidity. The aim of this study was to evaluate the seroprevalence of syphilis in men attending an infertility clinic. Blood samples from 782 males were screened using the titrated RPR and TPHA tests. If either of these tests was positive, FTA-ABs IgG was performed. The RPR was positive in 63 (8%) cases. In 24 (3%) patients the titer was 1:8 with positive TPHA and FTA-Abs IgG tests and these were regarded as current infections. Thirty-nine (4.9%) cases had RPR titers 1:8 with positive specific tests. These were probably patients either treated inadequately or in the early stage of primary syphilis. In addition, 92 (12%) patients were RPR negative but TPHA and FTA positive. This was evidence of previous exposure to syphilis. The overall seropositivity in this group was 20% (155 cases). Six hundred and twenty-seven (80%) tested negative with RPR and TPHA. Syphilis may still have a major impact on health in Southern Africa. Since syphilis is significantly associated with HIV seropositivity, efforts to prevent and control syphilis may also be important in limiting the spread of HIV.