A laboratory-based study to identify and speciate non-tuberculous mycobacteria isolated from specimens submitted to a central tuberculosis laboratory from throughout KwaZulu-Natal Province, South Africa.

BACKGROUND: Non-tuberculous mycobacteria (NTM) are important environmental pathogens capable of causing a spectrum of infection. The different species exhibit varied geographical prevalence worldwide. Identification of the infecting organism may be helpful in determining the clinical significance of the isolate. OBJECTIVE: To describe the spectrum of NTM isolated from clinical specimens received at the National Health Laboratory Service central tuberculosis laboratory in KwaZulu-Natal Province, South Africa. METHOD: In a laboratory-based prospective study, 200 suspected NTM were randomly selected over a period of 1 year and identified to species level using a commercially available DNA strip assay (GenoType Mycobacterium, CM/AS; Hain Lifescience, Germany). RESULTS: Of the 200 suspected NTM, 133 (66.5%) were confirmed to be NTM by the molecular test. The most frequently isolated NTM species were Mycobacterium intracellulare (45.9%), M. avium subspecies (11.3%), M. gordonae (6.0%) and M. kansasii (4.5%). CONCLUSION: It is important for laboratories to document the local spectrum of NTM because of the geographical variation in the different NTM species isolated. Although molecular tests for identifying NTM are relatively expensive, they have the advantage of providing rapid and accurate identification of the various NTM species.

Influence of sex on clinical features, laboratory findings, and complications of typhoid fever.

Clinical features, laboratory findings, and complications of typhoid fever were correlated with sex through a retrospective case note review of 102 hospitalized culture-positive patients in Durban, South Africa. Intestinal perforation (P = 0.04), occult blood losses in stools (P = 0.04), and a mild reticulocytosis in the absence of hemolysis (P = 0.02) occurred more frequently in males than in females. A single pretreatment Widal O antibody titer > or = 1:640 was also a statistically significant occurrence in males (P = 0. 006). Female patients were significantly more severely ill (P = 0.0004) on admission and had chest signs consistent with bronchopneumonia (P = 0.04), transverse myelitis (P = 0.04), abnormal liver function test results (P = 0.0003), and abnormal findings in urinalyses (P = 0.02). Typhoid hepatitis (P = 0.04) and glomerulonephritis (P = 0.02) were present significantly more frequently in females. Whether these differences were due to differences in host's immune response to acute infection need to be determined in a prospective study.

Clinical significance of hepatic dysfunction with jaundice in typhoid fever.

A retrospective case note review was undertaken to assess the clinical significance of hepatic dysfunction with jaundice in typhoid fever. Of the 57 patients, 21 (36.8%) had jaundice, while 36 (63.2%) did not have jaundice. Significantly higher proportions of jaundiced patients were females (P = 0.04). Confusion (P = 0.01), upper abdominal pain (P = 0.02), right upper quadrant tenderness (P = 0.0001), and low prothrombin index (P = 0.04) were statistically significant occurrences in jaundiced patients on admission. Admission mean values of serum bilirubin (P = 0.0001), gamma-glutamyltranspeptidase (GGT; P = 0.009), and alanine aminotransferase (ALT; P = 0.0005) were significantly higher in icteric patients while mean values of total serum protein (P = 0.0009) and albumin (P = 0.0001) were significantly higher in anicteric patients. There were no deaths. Glomerulonephritis occurred significantly (P = 0.001) more frequently in icteric patients. It is concluded that hepatic dysfunction with jaundice in typhoid fever indicates more severe hepatic injury, which may precipitate the development of clinically detectable glomerulonephritis.

The early diagnosis of typhoid fever prior to the Widal test and bacteriological culture results.

In an attempt to evaluate various clinical and laboratory features available within 24 h of admission, prior to the Widal test and bacteriological culture results as potential diagnostic aids in typhoid fever, we undertook a retrospective unit-based case control study in 90 febrile adult and paediatric patients admitted to King Edward VIII Hospital, Durban, South Africa with an initial diagnosis of typhoid fever. A total of 30 blood culture-proven typhoid fever patients (cases) were matched to 60 patients confirmed as not having typhoid fever (controls) by age, sex, race and severity of illness on admission. Features significantly associated with a final diagnosis of typhoid fever were: a pre-admission duration of fever > or = 7 days (odds ratio (OR) 6.9); hepatomegaly (OR 3.2); a normal leucocyte count (OR 10.8); a leucocyte count of < 10.0 x 10(3)/mm3 (OR 30.2); and leucopenia due to absolute neutropenia with a relative lymphocytosis (OR 11.8). Although the sensitivity, specificity and predictive values of any of these features cannot be used reliably to distinguish typhoid fever from other non-typhoidal febrile illness, it is concluded that leucopenia due to absolute neutropenia with relative lymphocytosis, when present, is highly suggestive of typhoid fever. A leucocyte count of > 10.0 x 10(3)/mm3 (OR 0.03) provides strong presumptive evidence against such a diagnosis.

Cryptococcal meningitis in Durban, South Africa: a comparison of clinical features, laboratory findings, and outcome for human immunodeficiency virus (HIV)-positive and HIV-negative patients.

We retrospectively compared the clinical manifestations, laboratory features, and outcome of cryptococcal meningitis in 44 human immunodeficiency virus (HIV)-positive and 21 HIV-negative patients in Durban, South Africa, and contrasted our findings with those in the developed world. Cryptococcal meningitis was the initial AIDS-defining illness in 84% of patients. Headache, fever, convulsions, neck stiffness, and neurological signs were more common in HIV-positive patients. We detected neurological abnormalities in 50% of the HIV-positive group. Seventeen percent of HIV-positive patients had completely normal CSF indices. HIV-positive patients with cryptococcal meningitis frequently had oral candidiasis and tuberculosis as coexistent illnesses. Prognostic factors identified in the West do not appear to be applicable in Africa. Death during hospitalization was significantly higher in the HIV-positive group. HIV-associated cryptococcal meningitis in Africa is apparently associated with higher rates of neurological complications and death than is such disease in developed countries of the world.

A 4-year study of neonatal meningitis: clinical and microbiological findings.

The clinical and microbiological data of 60 neonates, 23 from the Neonatal Unit (Group I) and 37 (Group II) from the General Paediatric Wards with meningitis are presented. The overall prevalence/1000 was significantly lower in Group I (0.36) than in Group II (1.11; P < 0.0001). This low incidence follows the introduction of amikacin for the treatment of the ill neonate in 1986. Streptococcus agalactiae 21 (35 per cent), Klebsiella pneumoniae 17 (28 per cent) and E. coli 10 (17 per cent) were the commonest pathogens accounting for 80 per cent of the cases. Streptococcus agalactiae isolates were uniformly susceptible to penicillin and chloramphenicol. Gram negative isolates showed resistance to ampicillin, chloramphenicol and sulphamethoxazole-trimethoprim. In addition K. pneumoniae isolates showed resistance to gentamycin and amikacin. All isolates were fully susceptible to cefotaxime. Recently, four of six cases of K. pneumoniae in the Neonatal Unit were resistant to amikacin. Low birth weight, additional clinical problems, and ultrasound changes on cranial scanning carried a poor prognosis. Emphasis should be placed on close collaboration between clinicians and microbiologists in the choice of antimicrobial agents and aseptic techniques for the care of neonates.

Ascitic fluid gamma interferon concentrations and adenosine deaminase activity in tuberculous peritonitis.

The gamma interferon (gamma-IFN) concentration and the adenosine deaminase (ADA) activity were evaluated in 30 patients with tuberculous peritonitis, 21 patients with ascites due to a malignant disorder, and 41 patients with cirrhosis. The gamma-IFN concentrations were significantly higher (p < 0.0001) in tuberculous peritonitis patients (mean: 6.70 U/ml) than in the malignant (mean: 3.10 U/ml) and cirrhotic (mean: 3.08 U/ml) groups. Use of a cut off value of > or = 3.2 U/ml gave the assay a sensitivity of 93% (25 of 27), a specificity of 98% (54 of 55), positive (P+) and negative (P-) predictive values of 96% and a test accuracy of 96%. The ADA activity was significantly (p < 0.0001) higher in the tuberculous peritonitis group (mean: 101.84 U/l) than in the control groups (cirrhosis (mean: 13.49 U/l) and malignancy (mean: 19.35 U/l)). A cut off value of > 30 U/l gave the ADA test a sensitivity of 93% (26 of 28) a specificity of 96% (51 of 53), a (P+) value of 93%, a (P-) value of 96%, and a test accuracy of 95%. There was a significant (p < 0.0001) correlation (r = 0.72) between ADA activity and gamma-IFN values in patients with tuberculous peritonitis. These results show that a high concentration of gamma-IFN in ascitic fluid is as valuable as the ADA activity in the diagnosis of tuberculous peritonitis. Both are rapid non-invasive diagnostic tests for tuberculous peritonitis.

Disseminated strongyloidiasis in a diabetic patient.

A case of disseminated strongyloidiasis in an Indian diabetic patient who was not receiving any immunosuppressive therapy, is reported. Strongyloides stercoralis was detected in peritoneal fluid, stools and blood. To our knowledge this represents the first such case to be reported in the English literature. The need for both clinicians and microbiology laboratories to be on the alert for this parasite in patients who are compromised either because of underlying disease or therapy with immunosuppressive drugs, is emphasised.

Multiresistant Klebsiella pneumoniae in a neonatal nursery: the importance of maintenance of infection control policies and procedures in the prevention of outbreaks.

During a 3-week period, nine babies in the neonatal unit of a large teaching hospital in Durban were infected or colonized with Klebsiella pneumoniae resistant to a range of antimicrobial agents including amikacin and cefotaxime. Resistance to cefotaxime was reduced by clavulanic acid in vitro suggesting production of extended-spectrum beta-lactamase activity. All the isolates had the same antibiotic resistance profile, belonged to the same serotype (K17), were non-typable with bacteriophages, and had identical plasmid profiles indicating that they belonged to the same strain. During a 1-day microbiological survey of the ward, the outbreak strain was isolated from the nose and hands of a doctor based in the nursery and from the hands of a nurse and the mother of an infected baby. The strain was also isolated from nine of 67 environmental samples. Investigation revealed that infection control practices which had been instituted following a previous outbreak in the nursery with multi-resistant methicillin-resistant Staphylococcus aureus (MRSA) were not being adhered to. The re-introduction and strict enforcement of these procedures under the supervision of an Infection Control Nurse resulted in the abrupt end of the outbreak.

An outbreak of multiresistant Salmonella typhi in South Africa.

Typhoid fever caused by Salmonella typhi remains endemic to many parts of South Africa, including Natal and KwaZulu, Northern Transvaal and the Transkei. Until recently, the majority of S. typhi isolates from South Africa have remained susceptible to ampicillin/amoxycillin and chloramphenicol, and only three cases of typhoid due to multi-antibiotic resistant strains of S. typhi have been documented. Ampicillin/amoxycillin and chloramphenicol are, therefore, still recommended as first line therapy for patients with typhoid fever in this country. We describe a cluster of six cases of typhoid caused by S. typhi that was resistant to ampicillin, chloramphenicol and trimethoprim-sulphamethoxazole. All these patients presented over a 3-month period; the patients were from three adjacent districts in the Northern Natal area of South Africa. The high rate of intestinal perforation (two of six) was a direct consequence of inappropriate antibiotic treatment. Failure of surgical intervention, renal impairment as well as delay in starting appropriate antibiotic treatment were factors contributing to the high mortality (three of six). The good clinical outcome in the remaining three patients probably resulted from treatment with appropriate antibiotics; however, mild disease in two of these patients may have been a contributing factor. All isolates showed high minimal inhibitory concentrations (MIC) of greater than or equal to 256 micrograms/ml to ampicillin, chloramphenicol and trimethoprim-sulphamethoxazole. The isolates were all highly sensitive to the third generation cephalosporins (MIC less than or equal to 0.06 micrograms/ml) and quinolones (MIC less than or equal to 0.03 micrograms/ml). Conjugation studies suggest a genetic transfer of resistance, probably plasmid mediated. The presence of beta-lactamase and chloramphenicol acetyl transferase enzymes in all six isolates tested would account for the resistance to ampicillin and chloramphenicol respectively. The transfer of such plasmids to erstwhile sensitive strains could conceivably occur in this typhoid-endemic area, where sanitary conditions are poor and living conditions crowded, thus further exacerbating the problem. It is recommended that in areas where such multiresistant strains are encountered, the third generation cephalosporins or quinolones be used as empiric therapy for typhoid fever.

Listeria monocytogenes meningitis at King Edward VIII Hospital, Durban. A 10-year experience, 1981-1990.

Nine cases, 3 adults and 6 children, with Listeria monocytogenes meningitis were seen over a 10-year period at King Edward VIII Hospital, Durban. These cases accounted for 0.8% (3/374) and 0.6% (6/1,210) of all culture-positive cases of acute bacterial meningitis in adults and children, respectively, and represented 2.9% (4/136) of all culture-positive cases in the neonatal age group and 5.7% (3/53) of culture-positive cases in adults 50 years and older. The patients had positive blood and cerebrospinal fluid (CSF) cultures. All isolates were sensitive to ampicillin, chloramphenicol, sulphamethoxazole-trimethoprim combination and gentamicin. One isolate in an 11-month-old child was resistant to penicillin and 2 isolates in the adult patients displayed intermediate sensitivity to this antibiotic. The adults were over 50 years of age and presented with an abrupt onset of a pyrexial illness, meningitis and focal neurological signs; only 1 survived. Only 1 8-week-old infant of the paediatric cases survived. A polymorphonuclear leucocytosis, low serum glucose and elevated protein values were common findings in the CSF and the features in some patients mimicked tuberculous or viral meningitis. The fulminant course of the disease and the fact that penicillin and not ampicillin is the first-line antibiotic makes it essential to consider listeriosis as a possible diagnosis, particularly in the very ill patient.

The white cell count in typhoid fever.

Leucopenia with neutropenia and a relative lymphocytosis are believed to be common findings in patients with typhoid fever. This paper reviews 191 adult patients with typhoid. The total and differential leucocyte counts done on admission were analysed. In this study leucopenia was found in only 24.6% of patients. Whilst complications occurred at any white cell count, the prevalence of complications increased significantly to 70% in patients with a white cell count above 8 x 10(9)/l. Neutropenia was found in 25% of patients, and none of the patients had an absolute lymphocytosis, whereas 75.8% of patients had true lymphopenia.

Neonatal group B streptococcal infections in Indian (Asian) babies in South Africa.

In this, the first report of group B streptococcal (GBS) infections in Asian neonates in South Africa, the incidence was 2.65/1000 live births over a period of 3.5 years. Early onset disease (EOD), defined as arising less than or equal to 5 days after birth, was present in 79% cases; in most of these, the onset was before the age of 24 h. One baby presented with two episodes of late onset GBS infection. The incidence of culture-proven neonatal septicaemia during the same period was 12.3/1000 live births, GBS being commonest organism isolated. It was also the most frequent cause of bacterial meningitis in the newborn, accounting for 89% cases. Although neurological signs were present in 40% patients with EOD, only 13.3% had CSF-culture-positive meningitis. Radiographic features of hyaline membrane disease were found in half of the babies with EOD and for whom a chest radiograph was performed, while one had a pneumothorax. The overall mortality was 13.2% which is much lower than that reported in other series.

Infection control in a Third World burn facility.

A study of wound colonization by bacteria in 49 consecutive admissions was conducted over a 2-month period in patients with burns at King Edward VIII and Clairwood Hospitals, Durban, neither of which possess proper burn units. Specimens for culture were collected from patients, staff and the environment. Bacteria most frequently isolated were Staph. aureus, Klebsiella spp., Ps. aeruginosa and Enterobacter spp. Cross-infection occurred due to breakdown of aseptic techniques. Staff hands and contaminated baths and benches were also implicated. Recommendations to reduce cross-infection are presented.

Typhoid fever in the adult and paediatric Indian population of Durban.

The features of typhoid fever in Indian South Africans are described. In children the illness was usually uncomplicated. However, anaemia, thrombocytopenia and hypo-albuminaemia were found in both adults and children. The initial symptoms on presentation of diarrhoea and vomiting frequently led to a misdiagnosis of gastro-enteritis. The previous administration of antibiotics also resulted in failure to isolate Salmonella typhi in 41% of patients studied. Typhoid acquired in the microbiology laboratory and that seen in visitors returning from India and the Far East is emphasised. The S. typhi isolates were uniformly sensitive to all antibiotics tested. The disproportionately high number of Indians of south Indian ancestry presenting to the R. K. Khan Hospital needs to be investigated.

Hospital-acquired neonatal bacterial meningitis: the impacts of cefotaxime usage on mortality and of amikacin usage on incidence.

All cases of bacterial meningitis in the neonatal unit at King Edward VIII Hospital, Durban for the period 1 January 1981 to 31 December 1987 were reviewed. In particular, we looked at the impact of cefotaxime on mortality rates and amikacin on the incidence of hospital-acquired Gram-negative bacillary (GNB) meningitis. Klebsiella was found to be the commonest cause of neonatal meningitis, followed by Escherichia coli and Streptococcus agalactiae. Eighty-four per cent of all cases of GNB meningitis presented more than 3 days after birth, with the vast majority being caused by gentamicin-resistant Klebsiella. A decline in the incidence of meningitis from 1.27/1000 live births in 1981 and 0.95/1000 for the period 1981-1986 to 0.22/1000 live births in 1987, with no cases of Klebsiella meningitis being seen in that year, coincided with the exclusive use of amikacin as the parenteral aminoglycoside in place of gentamicin in the unit after August 1986. The initial decline in the incidence of meningitis from 0.93/1000 in 1985 to 0.46/1000 in 1986 was attributed to the introduction in 1985 of strict hand disinfection measures to prevent cross-infection in the unit. The case mortality rate (CMR) fell from 0.65 for the period 1981-1984 to 0.42 for the period 1985-1987, and we believe this was largely a result of the introduction of cefotaxime in 1984 as first-line therapy for GNB meningitis, together with better patient care facilities.(ABSTRACT TRUNCATED AT 250 WORDS)