Referral Hospital In South Africa Research Articles

Diagnosis and presenting features of autoimmune hepatitis at a central referral hospital in South Africa.

Introduction Autoimmune hepatitis (AIH) has scarcely been reported on in patients of black African descent. Similarly, few studies have focused on the relationship between AIH and Human-Immunodeficiency Virus (HIV) infection. Aim We aim to describe the presenting features of AIH from a single referral centre in a Sub-Sahara African setting. We also compare the presenting features of HIV-infected and HIV-uninfected patients. Methods This study was a retrospective chart review. Patients were included if they fulfilled criteria for the International AIH Group simplified score for probable or definite AIH, were 18 years or older at inclusion, and attended the adult Gastroenterology clinic at Inkosi Albert Luthuli Central Hospital (IALCH) for the period 1/1/2015 to 31/12/2020 on at least 2 occasions. Results Forty cases were included, of which 33 (82.5%) were female and 33 (82.5%) were black African. Median age at diagnosis was 26 years. A diagnosis of a coexistent autoimmune disease was made in 22.5% of patients, with Systemic Lupus Erythematosus (SLE) being the most common (12.5%). Sixteen patients were HIV-infected, all of whom were female (p =0.03), with a significantly older age of disease onset as compared to their HIV-uninfected counterparts (median age 38 vs 17.5 years, p <0.001). Conclusion AIH is a disease most commonly affecting young females. Female sex and older age of onset is associated with AIH in HIV-infected individuals.

Bacterial Diversity in Placentas from Complicated Pregnancies Using 16s rRNA Gene Sequencing

Introduction: The ‘sterile womb paradigm’ is currently under debate and the advent of next generation 16S rRNA gene sequencing is driving the characterization of microbes associated with the amniotic cavity during pregnancy. Objective: To characterize the bacterial diversity in placentas from preterm and term births using next generation 16S rRNA gene sequencing in association with adverse pregnancy outcomes and histopathology studies. Methods: In this prospective study, placentas were collected consecutively from patients attending a public tertiary referral hospital in South Africa, delivering preterm (n=42; 28-34 weeks gestational age) and term (n=20; &gt;37 weeks gestational age). Placentas underwent histopathology tests and next generation 16S rRNA gene sequencing. Results: Analysis of microbial diversity in the placenta showed a significantly higher alpha diversity in term placentas compared to preterm placentas (P=0.000075), in placentas with acute chorioamnionitis compared to placentas without acute chorioamnionitis (P=0.0061), between HIV negative term births and both HIV negative and HIV positive preterm births (P=0.0118 and P=0.0008), respectively. Beta diversity was significantly different between preterm and term births (unweighted UniFrac distance, P=0.003996; Jaccard distance, P=0.03696) and Escherichia/Shigella, Shuttleworthia, Anaeroglobus and Megasphaera were differentially expressed. Conclusion: This is the first South African study to characterize the bacterial diversity in placentas from complicated pregnancies using next generation 16S rRNA gene sequencing in conjunction with full placental histology. Microbial diversity differs between preterm and term placentas where HIV may act as a cofactor associated with decreased bacterial alpha diversity in placentas from preterm birth.

Placental histopathology, maternal characteristics and neonatal outcome in cases of preterm birth in a high-risk population in South Africa.

Preterm birth remains a global health concern and is one of the most common pregnancy complications associated with perinatal morbidity and mortality. To investigate placental pathology and its associations with obstetric, maternal and neonatal outcomes in the Eastern Cape region of South Africa (SA) in order to help understand its associations with preterm birth in that region. In this prospective study, placentas were collected consecutively from patients attending a public tertiary referral hospital in SA, delivering preterm (n=100; 28 - 34 weeks gestational age) and term (n=20; >36 weeks gestational age). Placentas were submitted for histopathology, and comparisons with maternal characteristics and neonatal outcomes in preterm birth were undertaken. Histological analysis revealed pathology in all preterm placentas (100%), with maternal vascular malperfusion (47%) and abruptio placentae (41%) most commonly identified. Acute chorioamnionitis (21%) was associated with term births (p=0.002). Maternal characteristics and neonatal outcomes significantly associated with preterm birth included pre-eclampsia (p=0.006), neonatal respiratory distress syndrome (p=0.004) and neonatal jaundice (p=0.003). Intrauterine demise (p=0.004) and alcohol abuse (p≤0.005) were significantly associated with term delivery. The number of mothers delivering preterm who were HIV-positive was high (41%). The pathology identified in all preterm placentas supports the need to update institutional policies for submission of placentas from all preterm births for histopathology, particularly in countries with a high burden of preterm birth.

The effects of exposure to HIV in neonates at a referral hospital in South Africa

BackgroundFewer infants are infected with HIV through mother-to-child transmission, making HIV-exposed but uninfected (HEU) infants a growing population. HIV-exposure seems to affect immunology, early growth and development, and is associated with higher morbidity and mortality rates. Currently, there is a lack of information regarding the clinical effects of HIV-exposure during the neonatal period.ObjectivesTo identify a possible difference in mortality and common neonatal morbidities in HEU neonates compared to HIV-unexposed neonates.MethodsThis was a retrospective, descriptive study of all neonates admitted to the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital between 1 January 2017 and 31 December 2018. HEU neonates were compared to HIV-unexposed neonates.ResultsThere were 3236 neonates included, where 855 neonates were HEU. The HEU neonates had significantly lower birth weight and gestational age. The HEU neonates had higher rates of neonatal sepsis (19.8% vs 14.2%, OR 1.49, p < 0.001), specifically for late onset sepsis, and required more respiratory support. NCPAP and invasive ventilation was more common in the HEU group (36.3% vs 31.3% required NCPAP, p = 0.008, and 20.1% vs 15,0% required invasive ventilation, p < 0.001). Chronic lung disease was more common among HIV-exposed neonates (12.2% vs 8.7%, OR 1.46, p = 0.003). The difference in mortality rates between the study groups was not significant (10.8% of HEU neonates and 13.3% of HIV-unexposed).ConclusionsHEU neonates had higher rates of neonatal sepsis, particularly late-onset sepsis, required more respiratory support and had higher rates of chronic lung disease. Mortality of HEU neonates was not different HIV-unexposed neonates.

The role of treatment delays in surgical site infection after appendicectomy in a South African rural regional hospital

Background. Delays to surgery for acute appendicitis in low- and middle-income countries lead to significant morbidity. Objectives. To investigate the role of time to surgery in the development of complicated appendicitis and surgical site infection (SSI) in a rural referral hospital in South Africa (SA). Methods. A prospective cohort study was conducted of all patients presenting to a regional hospital in SA with acute appendicitis during 2017. Inpatient interview and data collection were followed by 30-day post-surgical follow-up to assess time periods to surgery and operative outcomes. Results. A total of 188 patients underwent surgery for acute appendicitis. The median (interquartile range (IQR)) age was 19 (3 - 73) years, and 62% were male. The median (IQR) time from symptoms to surgery was 60 (42 - 86) hours and from hospital admission to surgery 8 (4 - 16) hours. Forty-one percent were managed laparoscopically, 62% had complicated appendicitis, and 25% developed SSI. Time from symptoms to surgery &gt;72 hours was associated with an increased risk of complicated appendicitis (odds ratio (OR) 4.32; 95% confidence interval (CI) 1.36 - 13.75; p =0.013). Patients with SSI had an increased median delay of 15 hours ( p =0.05) compared with those without SSI. Multivariable analysis showed that the risk of SSI increased with complicated appendicitis (OR 8.96; 95% CI 2.73 - 29.41; p &lt;0,001) and decreased with laparoscopic surgery (OR 0.21; 95% CI 0.07 - 0.59; p =0.003). Time to surgery had no effect on the risk of SSI in adjusted analyses. Conclusions. Delays to surgery beyond 72 hours significantly increased complicated appendicitis, an important risk factor for SSI. Access to facilities with surgical capability and the use of laparoscopic surgery are modifiable risk factors for SSI.

Colonisation with extended spectrum beta-lactamase-producing and carbapenem-resistant Enterobacterales in children admitted to a paediatric referral hospital in South Africa.

There are few studies describing colonisation with extended spectrum beta-lactamase-producing Enterobacterales (ESBL-PE) and carbapenem-resistant Enterobacterales (CRE) among children in sub-Saharan Africa. Colonisation often precedes infection and multi-drug-resistant Enterobacterales are important causes of invasive infection. In this prospective cross-sectional study, conducted between April and June 2017, 200 children in a tertiary academic hospital were screened by rectal swab for EBSL-PE and CRE. The resistance-conferring genes were identified using polymerase chain reaction technology. Risk factors for colonisation were also evaluated. Overall, 48% (96/200) of the children were colonised with at least one ESBL-PE, 8.3% (8/96) of these with 2 ESBL-PE, and one other child was colonised with a CRE (0.5% (1/200)). Common colonising ESBL-PE were Klebsiella pneumoniae (62.5%, 65/104) and Escherichia coli (34.6%, 36/104). The most frequent ESBL-conferring gene was blaCTX-M in 95% (76/80) of the isolates. No resistance- conferring gene was identified in the CRE isolate (Enterobacter cloacae). Most of the Klebsiella pneumoniae isolates were susceptible to piperacillin/tazobactam (86.2%) and amikacin (63.9%). Similarly, 94.4% and 97.2% of the Escherichia coli isolates were susceptible to piperacillin/tazobactam and amikacin, respectively. Hospitalisation for more than 7 days before study enrolment was associated with ESBL-PE colonisation. Approximately half of the hospitalised children in this study were colonised with ESBL-PE. This highlights the need for improved infection prevention and control practices to limit the dissemination of these microorganisms.

Blood transfusion related to procedure in adult patients undergoing cardiac surgery

Introduction: Blood transfusions are associated with increased adverse outcomes and healthcare costs. While the aim of transfusion is to improve patient outcomes by enhancing tissue oxygenation, this must be weighed against the risks of transfusion-associated complications. Patient blood management programmes (PBM) have been implemented in many developed countries and have shown decreased blood utilisation and improved outcomes. Cardiac surgery is a significant consumer of blood supplies, despite evidence demonstrating the safety of restrictive transfusion strategies. This study aimed to determine the risk of blood transfusion, according to type of surgical procedure, in cardiac surgical patients in a quaternary level referral hospital in South Africa. Methods: This single centre, prospective observational study conducted over 18 weeks at Inkosi Albert Luthuli Central Hospital investigated the risk of packed red blood cell (PRBC) transfusion from the intraoperative period until discharge in adult patients undergoing elective CABG (n = 30), valve surgery (n = 53) or redo surgery (n = 11) under cardiopulmonary bypass. Poisson regression assessed the effect of type of procedure, age, gender, body mass index, preoperative haemoglobin and EuroSCORE II as risk factors for PRBC transfusion. Results: Ninety-four patients were recruited. There was no statistically significant association between risk of PRBC transfusion in valve surgery (IRR 0.71; 95% CI 0.51–1; p = 0.052) and redo surgery (IRR 0.87; CI 0.49–1.52; p = 0.621) when compared to CABG. Increased risk of PRBC transfusion was associated with female gender (IRR 1.72; 95% CI 1.24–2.41; p = 0.001) and EuroSCORE II (IRR 1.06; 95% CI 1.02–1.1; p = 0.001). Increasing preoperative haemoglobin levels were associated with a lower risk of PRBC transfusion (IRR 0.89; 95% CI 0.82–0.98; p = 0.013). Median number of PRBC units transfused was: 2 units (entire cohort); 3 units (CABG); 2 units (valve surgery); and 3 units (redo surgery). Conclusions: PRBC transfusion occurred in 80% of patients undergoing cardiac surgery, however the risk of blood transfusion was not associated with the type of surgical procedure. Implementation of a PBM protocol may decrease the incidence of preoperative anaemia, which was present in half the study population.

The value of histopathology of the placenta in a tertiary referral hospital in South Africa

Background. Unexplained intrauterine death (IUD) remains the most common cause of perinatal death in babies of 24 weeks’ gestation. Results. The total sample ( N =822) comprised 60.9% live-birth placentas and 39.1% IUD placentas. In the IUD group, the cause of death was clinically unexplained in 55.9% of cases. Histopathology identified in this group included chorioamnionitis (CA) (34.5%), maternal vascular malperfusion (32.1%), abruptio placentae (31.5%), delayed villous maturation (17.8%) and toxoplasmosis, other agents, rubella, cytomegalovirus and herpes simplex (TORCH) infections (6.1%), most commonly syphilis. No pathology was found in only 2% of IUD cases. Among live births, preterm labour accounted for 41.9% of placental submissions, of which the cause was unknown in 46.2% of cases. Clinically indicated and histologically defined CA was poorly correlated. Conclusion. This study demonstrates the value of placental histopathology in cases of adverse perinatal outcome.

A ten-year review of ESBL and non-ESBL Escherichia coli bloodstream infections among children at a tertiary referral hospital in South Africa.

IntroductionThere are few studies describing Escherichia coli (E. coli) bloodstream infection (BSI) among children in Africa, yet E.coli is increasing in importance as a cause of antibiotic resistant infection in paediatric settings.MethodsIn this retrospective, descriptive study aspects of E. coli BSI epidemiology are described over a 10-year period including incidence risk, risk factors for extended-spectrum β-lactamase (ESBL)-producing E. coli BSI, antibiotic susceptibility of the bacterial isolates and outcome including risk factors for severe disease.ResultsThere were 583 new E. coli BSI episodes among 217,483 admissions, an overall incidence risk of 2.7 events/1,000 hospital admissions. Of 455 of these E. coli BSI episodes that were analysed, 136 (29.9%) were caused by ESBL-producing isolates. Risk factors for ESBL-producing E. coli BSI included hospitalization in the 28-day period preceding E. coli BSI episodes, having an underlying chronic illness other than HIV infection at the time of the E. coli BSI and having a temperature of 38° Celsius or higher at the time of the E. coli BSI. None of the E. coli isolates were resistant to carbapenems or colistin. The mortality rate was 5.9% and admission to the intensive care unit was required in 12.3% of BSI episodes. Predictors of severe disease included age less than 1 month, hospitalization in the 28-day period preceding E. coli BSI and BSI without a definable focus.ConclusionsThese findings extend our understanding of E. coli BSI in a sub-Saharan African setting, provide useful information that can guide empiric treatment choices for community- and hospital-acquired BSI and help inform prevention strategies.

Posttubercular syringomyelia in HIV-infected patients: A report of 10 cases and literature review

ObjectivesTo describe the clinical presentation, spinal magnetic resonance imaging (MRI) findings and outcome of HIV-infected patients with tuberculosis (TB)-associated syringomyelia and to compare these findings between all HIV-infected and -uninfected cases published in the literature. MethodsA retrospective observational study conducted over a 12.5-year period at a public-sector referral hospital in South Africa. HIV-infected adults with neurological TB in whom MRI confirmed a syrinx were included. We searched PubMed to identify all published syringomyelia cases.RESULTS: Ten patients were enrolled. Syringomyelia complicated neurological TB within four years of initial diagnosis in all patients (median: 21 months, range: 0–39) after initial diagnosis. Six patients were treated conservatively (TB treatment = 5, no treatment = 1); four improved, but only one was ambulant during follow-up. Four patients underwent syringoperitoneal shunting; three improved and one died three months later. Our literature review identified 50 additional cases (HIV-infected = 2, HIV-uninfected = 9, HIV status not documented = 39 [presumed HIV-uninfected]). Clinical and imaging findings and outcomes were similar between HIV-infected and -uninfected cases, except for time of presentation following neurological TB diagnosis, which was delayed (>4 years) in 46% of HIV-uninfected cases, compared to 8% of HIV-infected cases.ConclusionsSyringomyelia is a disabling complication of neurological TB that usually presents early after neurological TB diagnosis in HIV coinfected patients.

Performance of free prostate-specific antigen ratio in differentiating between prostatic cancer and benign prostatic lesions at a referral hospital in South Africa

Background: Prostate cancer is a leading cause of morbidity and mortality in our male population, thus screening initiatives will help to improve outcomes. The current screening marker, total prostate-specific antigen (PSA), is not prostate cancer specific. The development of percentage free PSA (%FPSA) has largely improved the detection of prostate cancer.Objectives: To assess the performance of %FPSA ratio at the 25% cut-off and its ability to distinguish between prostate cancer and benign prostatic lesions.Methods: This was a retrospective study conducted on male patients with total prostate-specific antigen values 10 ng/ml and with prostate histology results. Male patients with total prostate-specific antigen between 4 and 10 ng/ml had their free prostate-specific antigen determined together with the calculation of the free prostate-specific antigen ratio. The ratio was then correlated with prostate histology results to determine the presence of prostate cancer at the cut-off ratio of 25%.Results: Prostate cancer was detected in 28 (21.37%) patients out of the total population of 131. Ninety-two patients had a FPSA ratio of 25%, 22 (22.8%) of whom were found to have prostate cancer. Notably the sensitivity and specificity were found to be 86% and 27% respectively, with a positive predictive of value of 21% at this cut-off.Conclusions: The study demonstrates a %FPSA ratio of 25% not to be a good discriminator between prostatic cancerous and benign lesions. It is thus recommended that a prostate biopsy should be done based on clinical examination findings rather than the level of total prostate specific antigen from 0–10 ng/ml or %FPSA ratio.

Performance of free prostate-specific antigen ratio in differentiating between prostatic cancer and benign prostatic lesions at a referral hospital in South Africa

Background: Prostate cancer is a leading cause of morbidity and mortality in our male population, thus screening initiatives will help to improve outcomes. The current screening marker, total prostate-specific antigen (PSA), is not prostate cancer specific. The development of percentage free PSA (%FPSA) has largely improved the detection of prostate cancer. Objectives: To assess the performance of %FPSA ratio at the 25% cut-off and its ability to distinguish between prostate cancer and benign prostatic lesions. Methods: This was a retrospective study conducted on male patients with total prostate-specific antigen values < 10 ng/ml and with prostate histology results. Male patients with total prostate-specific antigen between 4 and 10 ng/ml had their free prostate-specific antigen determined together with the calculation of the free prostate-specific antigen ratio. The ratio was then correlated with prostate histology results to determine the presence of prostate cancer at the cut-off ratio of 25%. Results: Prostate cancer was detected in 28 (21.37%) patients out of the total population of 131. Ninety-two patients had a FPSA ratio of < 25%, 22 (22.8%) of whom were found to have prostate cancer. Notably the sensitivity and specificity were found to be 86% and 27% respectively, with a positive predictive of value of 21% at this cut-off. Conclusions: The study demonstrates a %FPSA ratio of 25% not to be a good discriminator between prostatic cancerous and benign lesions. It is thus recommended that a prostate biopsy should be done based on clinical examination findings rather than the level of total prostate specific antigen from 0–10 ng/ml or %FPSA ratio. Keywords: diagnostic accuracy, non-communicable diseases, prostatic neoplasm, screening

Quality of life 1year after a maternal near-miss event.

To evaluate quality of life (QoL) parameters among women categorized with a maternal near-miss during pregnancy. The present prospective cohort study was conducted at a tertiary referral hospital in South Africa between April 1, 2013, and March 31, 2016. Patients who experienced maternal near-miss events were included and patients with uncomplicated low-risk pregnancies were enrolled as a control group. Various parameters were assessed using a WHO QoL questionnaire. The maternal near-miss and uncomplicated low-risk pregnancy (control) groups comprised 95 and 51 women. The maternal near-miss group scored lower than the control group in all four domains of the questionnaire (P<0.001). Overall, 42 (82%) women in the control group and 41 (43%) women in the maternal near-miss group desired future fertility (P<0.001). Women in the maternal near-miss group who had experienced perinatal loss scored lower in the physical health and well-being (P=0.009), psychological health and well-being (P=0.007), and environment (P=0.031) domains compared with women in the maternal near-miss group who experienced a live delivery. Nonetheless, QoL scores among women in the maternal near-miss group who had experienced perinatal loss remained lower than those reported by women in the control group (P<0.001). A maternal near-miss event during pregnancy was associated with reduced QoL, especially among women who had experienced perinatal loss.

Speckle tracking echocardiography in acute lupus myocarditis: comparison to conventional echocardiography

Aims Lupus myocarditis occurs in 5–10% of patients with systemic lupus erythematosus (SLE). No single feature is diagnostic of lupus myocarditis. Speckle tracking echocardiography (STE) can detect subclinical left ventricular dysfunction in SLE patients, with limited research on its utility in clinical lupus myocarditis. We report on STE in comparison to conventional echocardiography in patients with clinical lupus myocarditis.Methods and results A retrospective study was done at a tertiary referral hospital in South Africa. SLE patients with lupus myocarditis were included and compared to healthy controls. Echocardiographic images were reanalyzed, including global longitudinal strain through STE. A poor echocardiographic outcome was defined as final left ventricular ejection fraction (LVEF) <40%. 28 SLE patients fulfilled the criteria. Global longitudinal strain correlated with global (LVEF: r=-0.808; P=0.001) and regional (wall motion score: r=0.715; P<0.001) function. In patients presenting with a LVEF =50%, global longitudinal strain (P=0.023), wall motion score (P=0.005) and diastolic function (P=0.004) were significantly impaired vs controls. Following treatment, LVEF (35–47% (P=0.023)) and wall motion score (1.88–1.5 (P=0.017)) improved but not global longitudinal strain. Initial LVEF (34%; P=0.046) and global longitudinal strain (-9.5%; P=0.095) were lower in patients with a final LVEF <40%.Conclusions This is the first known report on STE in a series of patients with clinical lupus myocarditis. Global longitudinal strain correlated with regional and global left ventricular function. Global longitudinal strain, wall motion score and diastolic parameters may be more sensitive markers of lupus myocarditis in patients presenting with a preserved LVEF =50%. A poor initial LVEF and global longitudinal strain were associated with a persistent LVEF <40%. Echocardiography is a non-invasive tool with diagnostic and prognostic value in lupus myocarditis.

Ultrasound findings in 42 patients with cytotoxic tissue damage following bites by South African snakes

BackgroundSnakebites that have cytotoxic venom can cause significant soft tissue swelling. Assessing the site and degree of swelling using ultrasound as a non-invasive technique would be an important tool for...

Use of Polyclonal Intravenous Immunoglobulin at a Paediatric Referral Hospital in South Africa Between 2009 and 2012.

Polyvalent intravenous immunoglobulin (IVIG) is registered for a limited number of specific indications in South Africa but is increasingly being used for unregistered uses. No guideline exists nationally to monitor and control IVIG prescription, which results in its use in many clinical situations with varying levels of evidence. This study describes the registered and unregistered use, and cost of IVIG at a tertiary paediatric hospital in South Africa. A cross sectional descriptive study design was employed. Data on all patients (0 to 18 years) who attended the hospital during a 39 month period from 2009 to 2012 as out- or inpatients and were dispensed IVIG, was obtained from the pharmacy dispensing and National Health Laboratory Service electronic databases, and supplemented by a patient record review. During the study period, 185 patients received at least one dose of IVIG and a total 916 issues (3641.5 g) were dispensed. In 70 (41 %) of the 171 patients (involving 398 IVIG issues, 46 %), the South African Medicines Control Council registered indications for its use were followed. IVIG accounted for between 1.6, 1.7 and 4.6 % of the annual pharmacy expenditure during this 3-year study period. More than half of all IVIG dispensed at this paediatric hospital was used for unregistered indications. Considering the pressures on supply and the pharmaceutical costs, a more standardized, protocol-driven approach to the prescription of IVIG is called for.

Urine lipoarabinomannan testing for diagnosis of pulmonary tuberculosis in children: a prospective study.

SummaryBackgroundUrine tests for mycobacterial lipoarabinomannan might be useful for point-of-care diagnosis of tuberculosis in adults with advanced HIV infection, but have not been assessed in children. We assessed the accuracy of urine lipoarabinomannan testing for the diagnosis of pulmonary tuberculosis in HIV-positive and HIV-negative children.MethodsWe prospectively recruited children (aged ≤15 years) who presented with suspected tuberculosis at a primary health-care clinic and paediatric referral hospital in South Africa, between March 1, 2009, and April 30, 2012. We assessed the diagnostic accuracy of urine lipoarabinomannan testing with lateral flow assay and ELISA, with mycobacterial culture of two induced sputum samples as the reference standard. Positive cultures were identified by acid-fast staining and tested to confirm Mycobacterium tuberculosis and establish susceptibility to rifampicin and isoniazid.Findings535 children (median age 42·5 months, IQR 19·1–66·3) had urine and two induced specimens available for testing. 89 (17%) had culture-confirmed tuberculosis and 106 (20%) had HIV. The lateral flow lipoarabinomannan test showed poor accuracy against the reference standard, with sensitivity of 48·3% (95% CI 37·6–59·2), specificity of 60·8% (56·1–65·3), and an area under the receiver operating characteristic curve of 0·53 (0·46–0·60) for children without HIV and 0·64 (0·51–0·76) for children with HIV. ELISA had poor sensitivity in children without HIV (sensitivity 3·0%, 95% CI 0·4–10·5) and children with HIV (0%, 0·0–14·3); overall specificity was 95·7% (93·4–97·4).InterpretationUrine lipoarabinomannan tests have insufficient sensitivity and specificity to diagnose HIV-positive and HIV-negative children with tuberculosis and should not be used in this patient population.FundingUS National Institutes of Health, the National Health Laboratory Services Research Trust, the Medical Research Council of South Africa, and the Wellcome Trust.

P3.299 Tetracycline Resistance inUreaplasmaSpecies Isolated from Women Presenting For Termination of Pregnancy in Pretoria, South Africa

<h3>Background</h3> The risks of untreated sexually transmitted infections in association with termination of pregnancy are known to increase the risk of post-termination complications. Local studies have shown a high genital tract carriage of mycoplasmas. Tetracyclines are widely used as first line agents against when ureaplasmal infection is detected However, there is limited data on the susceptibility profiles and mechanisms of resistance amongst <i>Ureaplasma</i> strains circulating in the Pretoria community. This study was undertaken to determine antimicrobial resistance to tetracycline among <i>Ureaplasma</i> species isolated from women presenting for termination of pregnancy at a tertiary referral hospital in South Africa. <h3>Methods</h3> Two vaginal swabs were collected from each of 100 women after written informed consent was obtained. The first swab was used for PCR detection of genital ureaplasmas and tetracycline- resistance genes. The second swab was used for culture (<i>Mycoplasma</i> Duo kit) and phenotypic antimicrobial susceptibility testing (SIR <i>Mycoplasma</i> kit). <h3>Results</h3> <i>Ureaplasma</i> species were isolated from 46 women (46%). Forty-two women were infected with <i>U. urealyticum</i>, 1 with <i>U. parvum</i> and 3 were dually infected. Susceptibility profiles were obtained for 41 isolates. Fifteen (36.6%) demonstrated resistance to tetracycline. Fourteen (34.1%) were also resistant to doxycycline with 1 isolate showing intermediate resistance. All 41 strains contained the <i>tetM</i> gene, 39 contained the 1.7kb fragment of the tetracycline resistance gene and 36 strains contained the <i>int</i>-Tn gene. <h3>Conclusion</h3> Genital ureaplasmas were isolated from nearly half the study population of women presenting for TOP. The predominant species identified was <i>U urealyticum. </i>Tetracycline and doxycycline resistance was detected nearly a third of the isolates and this has implications for management of patients to prevent post-partum complications. The study will be expanded and communicated to the National Department of Health as this will impact future strategies of intervention in this country.

Pulmonary Resection for Extensively Drug Resistant Tuberculosis in Kwazulu-Natal, South Africa

Extensively drug resistant tuberculosis (XDR-TB) has been reported in 58 countries around the world and has emerged as a major public health challenge. Our objective was to determine the impact of pulmonary resection on XDR-TB treatment outcomes in a resource-constrained setting. We conducted a retrospective case review of 11 patients with XDR-TB who were referred for pulmonary resection between January 2007 and June 2010 at a tertiary care referral hospital in South Africa. Two pneumonectomies and three upper lobectomies were performed. Occurrence of surgical complications and TB treatment outcome were assessed. No perioperative mortality or major morbidity was noted. All patients achieved sputum conversion, with 4 regarded as "cured." One patient defaulted on treatment, but subsequently returned and is regarded as a probable cure. We describe pulmonary resection for XDR-TB management in Africa. Although the initial cohort of XDR-TB patients from Tugela Ferry demonstrated nearly complete mortality, our results demonstrate the potential of adjuvant surgical methods in XDR-TB treatment. With appropriate chemotherapy and timely adjuvant surgery, patients with XDR-TB localized to lobe or lung may achieve a "cure" with low morbidity and mortality. Consequently, this approach may be the most cost effective treatment for patients suitable for lung resection.

Burden of antituberculosis and antiretroviral drug-induced liver injury at a secondary hospital in South Africa

G F Jooste Hospital (GFJH) is a secondary-level referral hospital in a high HIV and tuberculosis (TB) co-infection setting. To assess the proportion of significant drug-induced liver injury (DILI) due to tuberculosis treatment (TBT) and/or antiretroviral therapy (ART) among patients presenting with liver dysfunction at GFJH and to describe management and outcomes. A retrospective observational study was performed of all cases referred to GFJH with significant liver dysfunction from 1 January to 30 June 2009. Significant liver dysfunction was defined by alanine transaminase (ALT)≥200 U/l or total bilirubin (TBR)≥44 µmol/l. TBT- or ART-associated DILI was defined as significant liver dysfunction attributed to TBT and/or ART and which resulted in the halting of treatment or the adjustment thereof. Outcome measures included case numbers, descriptive data, and in-hospital and 3-month mortality. A total of 318/354 cases of significant liver dysfunction were reviewed: 71 were classified as TBT- or ART-associated DILI, while liver dysfunction was attributed to other causes in the remainder. In-hospital and 3-month mortality of TBT- or ART-associated DILI patients was 27% (n=19) and 35% (n=25), respectively. The majority of deaths were related to sepsis or sepsis complicating liver dysfunction. Twenty-three patients (32%) were lost to follow-up; 23 (32%) were alive and in outpatient care 3 months after presentation. TBT- or ART-associated DILI is a common reason for presentation at a referral hospital in South Africa. In-hospital and 3-month mortality are high. Prospective studies are needed to define optimal management.