Vivek Bhat

Factors associated with poor adherence to anti-retroviral therapy in patients attending a rural health centre in South Africa

South Africa has a very high HIV disease burden and proper patient adherence to anti-retroviral therapy (ART) is crucial in achieving optimal treatment outcomes. Factors influencing adherence include demographic and psychosocial factors, medication-related issues and other patient-related matters. This study was carried out in order to determine factors associated with poor compliance to anti-retroviral (ARV) medications in a rural setting. This interview-based descriptive and analytical study was carried out in a health centre where 168 patients who received ARVs were interviewed with pre-structured questionnaires, which covered various important compliance-related aspects. The results showed that 37.5% of the patients were non-adherent. Amongst men, poor adherence was seen in those who were single (48.9%), with tertiary education (60%), in those who consumed alcohol regularly (47.1%) and in those who were unemployed (56.1%). Higher rates of non-adherence in women was associated with being single (36.5%) and in those who used alcohol (60.7%). Medication-related adverse effects were reported in 47% of patients, notably, neuropathy, headache, nausea, loss of memory, diarrhoea and fatigue. Common reasons for missing doses were: being away from home (57.1%), simply forgot (41.3%), side effects (50.8%) and being too busy (49.2%). Poor adherence to ART is an important concern relating to HIV management in our setting and needs to be addressed with more patient-oriented interventions.

Postmortem findings in HIV/AIDS patients in a tertiary care hospital in rural South Africa.

South Africa has the largest number of people living with HIV/AIDS, and various associated infectious and noninfectious conditions contribute towards mortality. The objective of this study was to determine the important post-mortem findings in HIV-infected individuals in a high HIV burden rural area in South Africa. The patient population included HIV patients who died at the tertiary care hospital, from 2000–2008. Autopsies were performed according to standard protocols and diagnoses were made with additional laboratory investigations wherever required. A total of 86 patients were autopsied (30 males, 56 females). The major postmortem findings were related to infections, with 38% of the patients having had some form of tuberculosis, followed by pyogenic infections – pneumonias (21.5%), meningitis (10.1%) and septicemias (5.1%). Other important infections included opportunistic fungi like cryptococcosis (7.6%) and pneumocystis pneumonia (8.9%). Among the noninfectious conditions, the findings seen were predominantly related to liver (10.1%) and cardiac involvement (10.1%).

Prevalence of intestinal parasites in primary school children of mthatha, Eastern Cape Province, South Africa

Background: The presence of intestinal parasites in a population group is indicative of lack of proper sanitation, low economic standards and poor educational background. Aim: To determine the prevalence of intestinal parasites in primary school children of Mthatha, South Africa and relate this to their socio-economic status. Subjects and Methods: The study population was randomly selected from four governmental schools, rural and urban, from April 2009 to September 2009. A total of 162 learners (85 boys and 77 girls) participated in this survey. Parasitological data were collected by analyzing stool samples using Formalin ethyl-acetate concentration technique. Socio-economic and epidemiologic data were collected by means of a pre-tested structured questionnaire, covering the important relevant aspects, in this descriptive, cross sectional and analytical study. Data were analyzed descriptively and inferentially with SPSS satistical software, and P values of <0.05 were considered as significant. Results: Out of 162 learners analyzed, 64.8% (105/162) stool samples were positive for ova and cysts of which 57.4% (93/162) were known pathogenic parasites. The most common parasite was Ascaris lumbricoides 29.0% (47/162), followed by Giardia lamblia 9.9% (16/162) and Entamoeba histolytica/dispar 6.8% (11/162) (Other parasites observed but at lower rates of occurrence were Iodamoeba butschlii, Trichuris trichiura, Hymenolepis nana, Taenia spp, Chilomastix mesnili, and Fasciola spp. Our findings showed no significant difference in parasitic infections between urban and rural learners, gender and the age of these learners. Significant associations between parasitic infections and parents’ unemployment and lower education were observed. Conclusion: Prevalence of worm infestation was more than 50%; therefore, there was a need for mass de-worming of school children in these communities and also a need for other public health interventions like health education programs and improvement of sanitation.

Cytomegalovirus infection in the bone marrow transplant patient

Cytomegalovirus (CMV) infection is an important contributor to the morbidity and mortality associated with bone marrow transplantation (BMT). Infection may lead to CMV disease involving multiple organs such as pneumonia, gastroenteritis, retinitis, central nervus system involvement and others. CMV seropositivity is an important risk factor and approximately half of BMT recipients will develop clinically significant infection most commonly in the first 100 d post-transplant. The commonly used tests to diagnose CMV infection in these patients include the pp65 antigenemia test and the CMV DNA polymerase chain reaction (PCR) assay. Because of its greater sensitivity and lesser turnaround time, the CMV PCR is nowadays the preferred test and serves as a main guide for pre-emptive therapy. Methods of CMV prevention include use of blood products from seronegative donors or leukodepleted products. Prophylaxis or pre-emptive therapy strategies for CMV prevention may be used post-transplant with the latter becoming more common. The commonly used antivirals for pre-emptive therapy and CMV disease management include intravenous gancyclovir and foscarnet. The role of intravenous immunoglobulin, although used commonly in CMV pneumonia is not clear.

Analysis of laboratory sample rejections in the pre-analytical stage at an oncology center.

BACKGROUND Effective patient management depends on the accuracy of laboratory results. Sample collection errors constitute an important reason for repeat collections. This study was conducted at the laboratory diagnostic services of a tertiary care oncology center with a hematopoietic stem cell transplant unit to determine the common causes of sample rejections and see the effects of corrective action. METHODS A retrospective, intervention and prospective analysis of the samples rejected from the total samples received in our laboratories, during a nine month period from January to September 2011 was undertaken. Causes of sample rejections were determined and intervention in the form of training relevant staff was instituted. RESULTS Out of 32,548 samples received during Jan-Sep 2011, 177 samples (0.54%) were rejected. The most common reasons for rejection in hematology and biochemistry areas were clotted blood specimen (51.2%), improperly labeled specimen containers (14.46%) and hemolyzed blood samples (11.45%). For microbiology these included labeling errors, collection of specimen in wrong containers and specimen collection date and time not being entered, unacceptable specimen source and delayed transit time (18.2% each). CONCLUSIONS Directed interventions may help reduce the incidence of sample rejections.

Bacteriological profile and antibiogram of aerobic burn wound isolates in Mthatha, Eastern Cape, South Africa

Burn wound colonisation and infection is not only associated with delayed wound healing and scar formation, but may also lead to sepsisrelated mortality. A wide variety of microorganisms, like staphylococcus aureus, Pseudomonas aeruginosa , and Enterobacteriaceae -like Klebsiella pneumoniae and Escherichia coli , are involved. Resistance is generally increasing, with reports of multidrug-and pan-resistant isolates. This study was conducted to determine the common aerobic bacterial isolates in our setting and describe their antimicrobial susceptibility. This retrospective, descriptive study was carried out on 243 patients, from whom 312 burn wound specimens were received by the Nelson Mandela Academic Hospital microbiology laboratory of the National Health Laboratory Service, Mthatha. All samples were processed according to standard laboratory protocols; isolates were tabulated according to age and gender of the patients, and their percentage susceptibilities to relevant antibacterials were computed. A total of 229 patient specimens showed growth on culture. The total number of isolates was 629, out of which 269 were Gram-positive cocci and 360 were Gram-negative bacilli. The commonest organism was S. aureus (27.7%), followed by K. pneumoniae (13.4%), Proteus mirabilis (12.4%), Group D streptococcus (9.4%), P. aeruginosa (8.9%) and E. coli (6.2%). A generally high level of resistance was observed in many organisms. Methicillinresistant S. aureus accounted for 57.5% of the S. aureus . Resistance among the Gram-negative bacilli was, in general, least to imipenem, amikacin and ciprofloxacin. The common organisms causing burn wound infections in our setting include staphylococci, Klebsiella, Proteus and Pseudomonas and there is a high level of resistance against commonly used antimicrobials. Regular surveillance of burn wound organisms and their antimicrobial resistance patterns will help in determining empirical antibiotic therapy for subsequent related septic events.

Hepatitis B-related serological events in hematopoietic stem cell transplant patients and efficacy of lamivudine prophylaxis against reactivation

Reactivation of remote hepatitis B infection (RHBI) is an important cause of morbidity in hematopoietic cell transplant (HCT) patients. We analyzed the prevalence of RHBI in 205 patients who underwent HCT in our centre, serological events related to hepatitis B virus (HBV) reactivation and role of lamivudine prophylaxis in HCT patients with RHBI. The prevalence of RHBI was 14% (28/205 patients). Of these 28 patients, 15 received lamivudine prophylaxis (14 anti‐HBcIgG positive and 1 only anti‐HBs positive) while 13 did not receive lamivudine prophylaxis (12 anti‐HBs positive and 1 anti‐HBcIgG positive). None in prophylaxis group developed HBV reactivation while 12 of 13 in no‐prophylaxis group reactivated (P < 0.001). The rate of HBV reactivation was 10% (21/205 patients), which included 9 patients with no evidence of RHBI pre‐transplant. We conclude that lamivudine prophylaxis protects against HBV reactivation in HCT patients with evidence of RHBI. Lamivudine prophylaxis should be used not only in patients with anti‐HBcIgG positivity but also in those with isolated anti‐HBs positivity pre‐transplant given the high rate of HBV reactivation in these patients. HBV serology cannot identify all cases with RHBI and therefore does not preclude HBV reactivation post‐transplant. Copyright

Challenges in the Laboratory Diagnosis and Management of Dengue Infections

Dengue fever is considered the most important arthropod-borne viral diseases in terms of morbidity and mortality. An accurate and efficient diagnosis of dengue plays an important role in case confirmation. The virus may be isolated during the viremic phase (within day 5 of illness), from serum, plasma and peripheral blood mononuclear cells. Enzyme linked immunoassay (ELISA) has demonstrated the presence of high levels of dengue NS1 antigen and tests may be performed by enzyme-immunoassays (EIAs) or immune-chromatographic (ICT) methods. These assays are specific with respect to different flaviviruses. Conventional and real time RT PCR, nested PCR, multiplex PCR and Nucleic acid sequence based amplification (NASBA) have been described as sensitive and relatively rapid method of detecting the virus during the early viremic phase. Other tests used include assay of anti-dengue specific IgM and IgG ELISA. Currently no curative treatment in terms of anti-viral drugs is available for dengue and patients are managed with rest and aggressive supportive therapy. Management may be done at home or in the hospital depending on the severity of the illness. Hospital management includes fluid therapy, blood component transfusion and other modalities of treatments like steroids, recombinant factor VII and management of complications. Various vaccines are in trial stages and may become available in the near future.

Detection of bacterial growth in blood components using oxygen consumption as a surrogate marker in a tertiary oncology setup

Microbiological contamination of blood and blood products is a well-recognised transfusion risk. This study was performed in the blood bank of our oncology centre, with an objective to detect bacterial contamination in our blood products using oxygen consumption as a surrogate marker [Pall Enhanced Bacterial Detection System (eBDS)]. Results revealed that the percentages of failed units were 1.16% for random donor platelets (RDP), 0.81% for single donor platelets (SDP) and 2.94% for packed red blood cells (PRBCs), of which one RDP and one SDP grew coagulase-negative staphylococcus, while one PRBC culture grew Gram-positive bacilli.

Cryptococcus laurentii diarrhea post hematopoietic stem cell transplant

We report the recent isolation of Cryptococcus laurentii from the feces of a patient with Hodgkins lymphoma who underwent autologous hematopoietic stem cell transplant (HSCT). The organism was identified using microscopic morphology, cultural characteristics, and biochemical tests including sugar assimilation. Minimum inhibitory concentration of various antifungals was determined by microbroth dilution method. The recovery of pure culture of C. laurentii from stool culture, and the patients response to treatment with voriconazole support its potential etiological role. To the best of our knowledge, we report the first case of diarrhea caused by C. laurentii in an HSCT recipient.