Browsing by Author "Dramowski, Angela"
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- ItemBacterial pathogens and resistance causing community acquired paediatric bloodstream infections in low- and middle-income countries : a systematic review and meta-analysis(BMC (part of Springer Nature), 2019-12-30) Droz, Nina; Hsia, Yingfen; Ellis, Sally; Dramowski, Angela; Sharland, Mike; Basmaci, RomainBackground: Despite a high mortality rate in childhood, there is limited evidence on the causes and outcomes of paediatric bloodstream infections from low- and middle-income countries (LMICs). We conducted a systematic review and meta-analysis to characterize the bacterial causes of paediatric bloodstream infections in LMICs and their resistance profile. Methods: We searched Pubmed and Embase databases between January 1st 1990 and October 30th 2019, combining MeSH and free-text terms for “sepsis” and “low-middle-income countries” in children. Two reviewers screened articles and performed data extraction to identify studies investigating children (1 month-18 years), with at least one blood culture. The main outcomes of interests were the rate of positive blood cultures, the distribution of bacterial pathogens, the resistance patterns and the case-fatality rate. The proportions obtained from each study were pooled using the Freeman-Tukey double arcsine transformation, and a random-effect meta-analysis model was used. Results: We identified 2403 eligible studies, 17 were included in the final review including 52,915 children (11 in Africa and 6 in Asia). The overall percentage of positive blood culture was 19.1% [95% CI: 12.0–27.5%]; 15.5% [8.4– 24.4%] in Africa and 28.0% [13.2–45.8%] in Asia. A total of 4836 bacterial isolates were included in the studies; 2974 were Gram-negative (63.9% [52.2–74.9]) and 1858 were Gram-positive (35.8% [24.9–47.5]). In Asia, Salmonella typhi (26.2%) was the most commonly isolated pathogen, followed by Staphylococcus aureus (7.7%) whereas in Africa, S. aureus (17.8%) and Streptococcus pneumoniae (16.8%) were predominant followed by Escherichia coli (10.7%). S. aureus was more likely resistant to methicillin in Africa (29.5% vs. 7.9%), whereas E. coli was more frequently resistant to third-generation cephalosporins (31.2% vs. 21.2%), amikacin (29.6% vs. 0%) and ciprofloxacin (36.7% vs. 0%) in Asia. The overall estimate for case-fatality rate among 8 studies was 12.7% [6.6–20.2%]. Underlying conditions, such as malnutrition or HIV infection were assessed as a factor associated with bacteraemia in 4 studies each. Conclusions: We observed a marked variation in pathogen distribution and their resistance profiles between Asia and Africa. Very limited data is available on underlying risk factors for bacteraemia, patterns of treatment of multidrugresistant infections and predictors of adverse outcomes.
- ItemBronchoscopy in children with COVID‐19 : a case series(John Wiley & Sons, 2020) Goussard, Pierre; Van Wyk, Lizelle; Burke, Jonathan; Malherbe, Annemie; Retief, Francois; Andronikou, Savvas; Mfingwana, Lunga; Ruttens, Dries; Van der Zalm, Marieke; Dramowski, Angela; Da Costa, Aishah; Rabie, HelenaIntroduction: The coronavirus disease‐2019 (COVID‐19) era is a challenging time for respiratory teams to protect their patients and staff. COVID‐19 is predominantly transmitted by respiratory droplets; in the clinical setting, aerosol generating procedures pose the greatest risk for COVID‐19 transmission. Bronchoscopy is associated with increased risk of patient‐to‐health care worker transmission, owing to aerosolized viral particles which may be inhaled and also result in environmental contamination of surfaces. Methods: We describe our experience with the use of modified full‐face snorkeling masks for pediatric bronchoscopy procedures in four COVID‐19 infected children when filtering facepieces/respirators were in limited supply. Results: Bronchoscopy was urgently required in four children, and could not be delayed until COVID‐19 test results were available. During the pandemic peak, when respirators were in short supply, modified full‐face snorkel masks (SEAC Libera, SEAC, Italy) were worn by the bronchoscopy team. Each mask was fitted with an O‐ring, adapter, and heat and moisture exchanger filter. To date, there have been no COVID‐19 infections among the bronchoscopy team staff, whereas the overall Hospital staff COVID‐19 prevalence rate has exceeded 13.5% (667/4949). Conclusion: Emergency bronchoscopy procedures on COVID‐19 infected patients or patients with unknown infection status can be safely performed using modified full‐ face snorkel masks.
- ItemCentral-line-associated bloodstream infections in a resource-limited South African neonatal intensive care unit(Health and Medical Publishing Group, 2017) Geldenhuys, C.; Dramowski, Angela; Jenkins, A.; Bekker, A.Background. The rate of central-line-associated bloodstream infection (CLABSI) in South African (SA) public sector neonatal intensive care units (NICUs) is unknown. Tygerberg Children’s Hospital (TCH), Cape Town, introduced a neonatal CLABSI surveillance and prevention programme in August 2012. Objectives. To describe CLABSI events and identify risk factors for development of CLABSI in a resource-limited NICU. Methods. A retrospective case-control study was conducted using prospectively collected NICU CLABSI events matched to four randomly selected controls, sampled from the NICU registry between 9 August 2012 and 31 July 2014. Clinical data and laboratory records were reviewed to identify possible risk factors, using stepwise forward logistic regression analysis. Results. A total of 706 central lines were inserted in 530 neonates during the study period. Nineteen CLABSI events were identified, with a CLABSI rate of 5.9/1 000 line days. CLABSI patients were of lower gestational age (28 v. 34 weeks; p=0.003), lower median birth weight (1 170 g v. 1 975 g; p=0.014), had longer catheter dwell times (>4 days) (odds ratio (OR) 5.1 (95% confidence interval (CI) 1.0 - 25.4); p=0.04) and were more likely to have had surgery during their NICU stay (OR 3.5 (95% CI 1.26 - 10); p=0.01). Significant risk factors for CLABSI were length of stay >30 days (OR 20.7 (95% CI 2.1 - 203.2); p=0.009) and central-line insertion in the operating theatre (OR 8.1 (95% CI 1.2 - 54.7); p=0.03). Gram-negative pathogens predominated (12/22; 54%), with most isolates (10/12; 83%) exhibiting multidrug resistance. Conclusion. The TCH NICU CLABSI rate is similar to that reported from resource-limited settings, but exceeds that of high-income countries. Prolonged NICU stay and central-line insertion in the operating theatre were important risk factors for CLABSI development. Intensified neonatal staff training regarding CLABSI maintenance bundle elements and hand hygiene are key to reducing CLABSI rates.
- ItemClonal expansion of colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa(Elsevier, 2020) Snyman, Yolandi; Whitelaw, Andrew Christopher; Reuter, Sandra; Dramowski, Angela; Maloba, Motlatji Reratilwe Bonnie; Newton-Foot, MaeObjectives: To describe colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. Methods: A. baumannii isolates identified on Vitek 2 Advanced Expert System were collected from Tygerberg Hospital referral laboratory between 2016 and 2017. Colistin resistance was confirmed using broth microdilution and SensiTest. mcr-1–5 were detected using PCR and strain typing was performed by rep-PCR. Whole genome sequencing (WGS) was performed on a subset of isolates to identify chromosomal colistin resistance mechanisms and strain diversity using multilocus sequence typing (MLST) and pairwise single nucleotide polymorphism analyses. Results: Twenty-six colistin-resistant and six colistin-susceptible A. baumannii were collected separately based on Vitek susceptibility; 20/26 (77%) were confirmed colistin-resistant by broth microdilution. Four colistin-resistant isolates were isolated in 2016 and 16 in 2017, from five healthcare facilities. Thirteen colistin-resistant isolates and eight colistin-susceptible isolates were identical by rep-PCR and MLST (ST1), all from patients admitted to a tertiary hospital during 2017. The remaining colistin-resistant isolates were unrelated. Conclusions: An increase in colistin-resistant A. baumannii isolates from a tertiary hospital in 2017 appears to be clonal expansion of an emerging colistin-resistant strain. This strain was not detected in 2016 or from other hospitals. Identical colistin-susceptible isolates were also isolated, suggesting relatively recent acquisition of colistin resistance.
- ItemClonal expansion of colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa(Elsevier, 2020-02) Snyman, Yolandi; Whitelaw, Andrew Christopher; Reuter, Sandra; Dramowski, Angela; Maloba, Motlatji Reratilwe Bonnie; Newton-Foot, MaeObjectives: To describe colistin-resistant Acinetobacter baumannii isolates in Cape Town, South Africa. Methods: A. baumannii isolates identified on Vitek 2 Advanced Expert System were collected from Tygerberg Hospital referral laboratory between 2016 and 2017. Colistin resistance was confirmed using broth microdilution and SensiTest. mcr-1-5 were detected using PCR and strain typing was performed by rep-PCR. Whole genome sequencing (WGS) was performed on a subset of isolates to identify chromosomal colistin resistance mechanisms and strain diversity using multilocus sequence typing (MLST) and pairwise single nucleotide polymorphism analyses. Results: Twenty-six colistin-resistant and six colistin-susceptible A. baumannii were collected separately based on Vitek susceptibility; 20/26 (77%) were confirmed colistin-resistant by broth microdilution. Four colistin-resistant isolates were isolated in 2016 and 16 in 2017, from five healthcare facilities. Thirteen colistin-resistant isolates and eight colistin-susceptible isolates were identical by rep-PCR and MLST (ST1), all from patients admitted to a tertiary hospital during 2017. The remaining colistin-resistant isolates were unrelated. Conclusions: An increase in colistin-resistant A. baumannii isolates from a tertiary hospital in 2017 appears to be clonal expansion of an emerging colistin-resistant strain. This strain was not detected in 2016 or from other hospitals. Identical colistin-susceptible isolates were also isolated, suggesting relatively recent acquisition of colistin resistance.
- ItemCOVID-19 : getting ahead of the epidemic curve by early implementation of social distancing(Health & Medical Publishing Group, 2020) Preiser, Wolfgang; Van Zyl, Gert; Dramowski, AngelaThe response to the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), has largely been reactive. There are a few exceptions of countries taking proactive measures. Some countries in Asia, including Taiwan and Singapore, were able to limit the spread despite close links to China,[1,2] and South Korea and China were able to mobilise to contain an initial rapidly spreading epidemic through mass testing and early interventions.[2,3] As COVID-19 has now reached Africa, South Africa (SA) could be a regional leader in its response and reduce the impact of the disease on its population by acting early.
- ItemDeterminants of healthcare-associated infection among hospitalized children(Stellenbosch : Stellenbosch University, 2017-03) Dramowski, Angela; Cotton, Mark F.; Whitelaw, Andrew; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH SUMMARY: Healthcare-associated infection (HAI) is the most frequent complication of hospitalization resulting in suffering, excess mortality and increased healthcare costs. Although paediatric HAI burden and impact is well-described in high-income countries, it is largely unquantified in Africa. Our research aimed to: (i) comprehensively describe the epidemiology and impact of HAI and HA-bloodstream infections in an African cohort of hospitalized children; (ii) establish appropriate HAI surveillance methods for our setting; (iii) investigate selected local determinants of paediatric HAI (including healthcare worker HAI-related knowledge, attitudes and practices, isolation facility utilization and terminal cleaning practices). In a retrospective analysis of paediatric bloodstream infection trends at Tygerberg Hospital, we reported the highest estimate of HA-bloodstream infections rates among African children to date. HIV-infection, HA-bloodstream infection, fungal and Gram-negative pathogens were important predictors of bloodstream infection-associated mortality. We conducted prospective clinical surveillance in paediatric wards and the intensive care unit at Tygerberg Children’s Hospital. HAI incidence (31/1000 patient days) exceeded published rates in high and low-middle income countries, with highest infection density in the paediatric intensive care unit (94/1000 patient days). Children experiencing HAI events were young (median 8.4 months), more likely to be malnourished, HIV-exposed uninfected or HIV-infected and to have pre-existing co-morbidities. Hospital-acquired pneumonia, bloodstream and urinary tract infections predominated. The increased odds for HAI in HIV-exposed uninfected and HIV-infected children is a novel association. Two-thirds of in-patient mortality was associated with HAI and patients with any HAI event had a 6-fold increase in crude mortality. Patients experiencing HAI had 3-fold higher rates of re-hospitalization within 30 days. Direct costs of HAI were substantial; mean duration of hospitalization, bed availability, antimicrobial consumption and laboratory investigation usage were significantly impacted by HAI. Although prospective clinical HAI surveillance is considered the reference standard, its use in Africa is limited by lack of resources and expertise. We compared the performance of three alternate HAI surveillance methods (point prevalence surveys [PPS], laboratory surveillance and tracking of antimicrobial prescriptions) using the prospectively collected paediatric HAI dataset as the reference standard. Although repeated PPS, laboratory and antimicrobial prescription tracking were demonstrated to be feasible HAI surveillance methods, a combination of laboratory-antimicrobial surveillance achieved best sensitivity (85%) and positive predictive value (97%), and required fewer resources to perform. South African paediatric healthcare facilities should individualise HAI surveillance, selecting a method suited to available resources and practice context. We identified a shortage of isolation facilities and sub-optimal identification of patients requiring isolation as potential contributors to infection transmission. The need for negative-pressure ventilation and airborne isolation facilities on children’s wards in TB-endemic settings was also highlighted. For terminal cleaning of paediatric isolation rooms we investigated three evaluation methods; fluorescent markers emerged as most cost-effective and feasible for our resource-limited setting. Finally, we surveyed two-thirds of our paediatric department’s staff regarding their knowledge, attitudes and practices related to HAI, identifying several knowledge gaps and opportunities for improved infection prevention practice. Owing to the extreme paucity of data, paediatric HAI in Africa remains an underappreciated and underfunded public health problem. We believe that this doctoral research dissertation provides unequivocal justification for greater resource allocation to HAI surveillance and prevention programmes for hospitalized African children.
- ItemDoes undergraduate teaching of infection prevention and control adequately equip graduates for medical practice?(Health and Medical Publishing Group, 2015) Dramowski, Angela; Marais, Frederick; Willems, B.; Mehtar, Shaheen; SURMEPI curriculum review working groupBackground. Knowledge, skills and desirable clinical practices in infection prevention and control (IPC) should be acquired during undergraduate medical training. Although knowledge and skills are learnt in the formal curriculum, attitudes and practices are assimilated by observation and modelling. We investigated whether undergraduate teaching and learning of IPC at Stellenbosch University adequately prepared graduates for medical practice. Methods. A situational analysis of IPC teaching was conducted, including development of IPC competencies, a curriculum review, an email survey of MB,ChB graduates and semistructured focus group or personal interviews with teaching faculty. Qualitative data were assessed using a framework analysis approach. Results. All graduate survey respondents who completed the IPC-related questions (n=180) agreed that teaching of IPC was important and most (156; 87.8%) felt that IPC teaching had adequately prepared them for practice. Despite this perception, graduates encountered difficulty implementing IPC best practice owing to lack of management support for IPC and resource constraints. Faculty members disagreed regarding the adequacy of IPC teaching and some were concerned that the curriculum failed to prepare graduates for medical practice. Graduates and faculty felt strongly that undergraduate IPC teaching and learning could be improved by addressing suboptimal IPC practices and lack of clinician role models for IPC at training institutions. Conclusion. IPC knowledge transfer appears adequate in most competency areas. However graduates struggled to implement IPC best practice in the clinical field. Undergraduate IPC teaching and learning could be enhanced by development of clinician role models for IPC and strengthened IPC practices in training institutions.
- ItemEpidemiology of clinically suspected and laboratory-confirmed bloodstream infections at a South African neonatal unit(JIDC, 2021-07) Dramowski, Angela; Bekker, Adrie; Cotton, Mark Frederic; Whitelaw, Andrew Christopher; Coffin, SusanIntroduction: Data from Africa reporting the epidemiology of infection in hospitalised neonates are limited. Methodology: A prospective study with convenience sampling was conducted to characterise neonates investigated with blood culture/s for suspected infection at a 132-bed neonatal unit in Cape Town, South Africa (1 February-31 October 2018). Enrolled neonates were classified as having proven bloodstream infection (BSI) (blood culture-positive with a pathogen) or presumed infection (clinically suspected but blood culture-negative) or as potentially at risk of infection (maternal risk factors at birth). Results: Of 1299 hospitalised neonates with >1 blood culture sampling episode, 712 (55%) were enrolled: 126 (17.7%) had proven BSI; 299 (42%) had presumed infection and 287 (40.3%) were potentially at risk of infection. Neonates with proven BSI had lower birth weight and higher rates of co-existing surgical conditions versus the presumed/potential infection groups (p < 0.001). Median onset of proven BSI versus presumed infection was at 8 (IQR = 5-13) and 1 (IQR = 0-5) days respectively (p < 0.001). Most proven BSI were healthcare-associated (114/126; 90.5%), with Klebsiella pneumoniae (80.6% extended-spectrum β-lactamase producers) and Staphylococcus aureus (66.7% methicillin-resistant) predominating. Mortality from proven BSI (34/126; 27%) was substantially higher than that observed in presumed (8/299; 2.7%) and potential infections (3/287; 1.0%) (p < 0.001). The odds of death from proven BSI was 3-fold higher for Gram-negatives than for Gram-positive/fungal pathogens (OR = 3.23; 95% CI = 1.17-8.92). Conclusions: Proven BSI episodes were predominantly healthcare-associated and associated with a high case fatality rate. Most neonates with presumed infection or at potential risk of infection had favourable 30-day outcomes.
- ItemFit for purpose? a review of a medical curriculum and its contribution to strengthening health systems in South Africa(Health and Medical Publishing Group, 2015) Dudley, Lilian; Young, T. N.; Rohwer, A. C.; Willems, B.; Dramowski, Angela; Goliath, C.; Mukinda, Fidele K.; Marais, Frederick; Mehtar, Shaheen; Cameron, N. A.ENGLISH SUMMARY : Background: Medical education in the 21st century needs to produce health professionals who can respond to health systems challenges and population health needs. Although research on medical education is increasing, insufficient attention is paid to the outcomes of medical training, in particular graduates’ competencies and the effects of their training on healthcare and population health in Africa. Method: This baseline study assessed whether the current Stellenbosch University medical curriculum enabled graduates to acquire health systems strengthening competencies. The teaching of competencies in public health, evidence-based healthcare, health systems and services research, and infection prevention and control was assessed through a document review of study guides and a survey of recent medical graduates. Results: We found that teaching of most competencies was included in the curriculum, but appeared fragmented with a lack of continuity across phases of the curriculum. Health systems and health leadership and management teaching was weak, and important public health competencies in human rights and health advocacy received little attention. Recent graduates said their training was ‘adequate’, but were unable to apply knowledge and skills to address health systems challenges within working environments. They wanted more integrated, practical, problem-based teaching in environments in which they would one day work, and their teachers to be role models for the competencies students were expected to acquire. This study is contributing to improvements to the medical curriculum at Stellenbosch University.
- ItemA framework for preventing healthcare-associated infection in neonates and children in South Africa(Health & Medical Publishing Group, 2017) Dramowski, Angela; Cotton, M. F.; Whitelaw, A.Healthcare-associated infection (HAI) is a frequent and serious complication affecting 4 - 8% of hospitalised children and neonates in high-income countries. The burden of HAI in South African (SA) paediatric and neonatal wards is substantial but underappreciated, owing to a lack of HAI surveillance and reporting. Maternal and child health and infection prevention are priority areas for healthcare quality improvement in the National Core Standards programme. Despite increasing recognition in SA, infection prevention efforts targeting hospitalised children and neonates are hampered by health system, institutional and individual patient factors. To ensure safe healthcare delivery to children, a co-ordinated HAI prevention strategy should promote development of infection prevention norms and policies, education, patient safety advocacy, healthcare infrastructure, surveillance and research. We present a framework for SA to develop and expand HAI prevention in hospitalised neonates and children.
- ItemHealthcare-associated infections in paediatric and neonatal wards : a point prevalence survey at four South African hospitals(Health & Medical Publishing Group, 2018) Olivier, C.; Kunneke, H.; O'Connell, N.; Von Delft, E.; Wates, M.; Dramowski, AngelaBackground. Healthcare-associated infections (HAIs) cause substantial morbidity, mortality and healthcare costs. The prevalence of neonatal/paediatric HAI at South African (SA) district and regional hospitals is unknown. Objectives. To document HAI rates, antimicrobial use for HAI, infection prevention staffing, hand hygiene (HH) provisions and HH compliance rates in neonatal and paediatric wards in two district and two regional hospitals in the Western Cape Province, SA. Methods. An HAI point prevalence survey (PPS) was conducted in neonatal and paediatric wards at two district and two regional hospitals in the Western Cape during December 2016, applying National Healthcare Safety Network HAI definitions. HAI events and antimicrobial therapy active at 08h00 on the PPS day and during the preceding 7 days (period prevalence) were documented. Provisions for HH and HH compliance rates were observed on each ward using the World Health Organization’s HH surveillance tool. Results. Pooled point and period HAI prevalence were 9.9% (15/151; 95% confidence interval (CI) 6 - 15.8) and 12.6% (19/151; 95% CI 8 - 18.9), respectively. Hospital-acquired pneumonia (5/15, 33.3%), bloodstream infection (3/15, 20.0%) and urinary tract infection (3/15, 20.0%) were predominant HAI types. Risk factors for HAI were a history of recent hospitalisation (8/19, 42.1% v. 17/132, 12.9%; p<0.001) and underlying comorbidity (17/19, 89.5% v. 72/132, 54.5%; p<0.004). HH provisions (handwash basins/alcohol hand rub) were available and functional. HH compliance was higher in neonatal than in paediatric wards (125/243, 51.4% v. 25/250, 10.0%; p<0.001). Overall HH compliance rates were higher among mothers (46/107, 43.0%) than nurses (73/265, 27.8%) and doctors (29/106, 27.4%). Conclusions. Neonatal and paediatric HAIs are common adverse events at district and regional hospitals. This at-risk population should be prioritised for HAI surveillance and prevention through improved infection prevention practices and HH compliance.
- ItemImpact of a quality improvement project to strengthen infection prevention and control training at rural healthcare facilities(Health and Medical Publishing Group, 2015) Dramowski, Angela; Marais, Frederick; Goliath, C.; Mehtar, ShaheenBackground: South Africa (SA) has a dire shortage of skilled infection prevention and control (IPC) practitioners with limited opportunities for IPC training, especially in rural areas. Methods: This quality improvement research-based case study surveyed healthcare workers’ IPC training needs and measured the impact of a targeted IPC training intervention at four healthcare facilities in a rural sub-district in the Western Cape Province of SA. Transfer and implementation of IPC knowledge and best practice were evaluated at the participating facilities, both pre and post intervention. Results: Most survey respondents (239/271; 88.2%) practised in rural districts and reportedly received infrequent (either annual or no) in-service training in IPC (138/271; 51%). The IPC education intervention (five short courses) was attended by almost one-third of clinical staff (129/422; 30.6%) at the four rural healthcare facilities. The pre-intervention IPC assessment identified the following: poor knowledge and implementation of tuberculosis-IPC measures; limited knowledge of medical device decontamination; high rates of needle-stick injuries; low hand-hygiene compliance rates and poor compliance with personal protective equipment use. At the post-intervention assessment, IPC knowledge scores and hand-hygiene compliance rates improved significantly but some IPC practices were unchanged. Conclusion: A structured IPC training programme in rural healthcare facilities can improve healthcare workers’ IPC knowledge, but has limited impact on clinical practice.
- ItemInfectious disease exposures and outbreaks at a South African neonatal unit with review of neonatal outbreak epidemiology in Africa(Elsevier, 2017) Dramowski, Angela; Aucamp, M.; Bekker, A.; Mehtar, ShaheenBackground: Hospitalized neonates are vulnerable to infection, with pathogen exposures occurring in utero, intrapartum, and postnatally. African neonatal units are at high risk of outbreaks owing to overcrowding, understaffing, and shared equipment. Methods: Neonatal outbreaks attended by the paediatric infectious diseases and infection prevention (IP) teams at Tygerberg Children’s Hospital, Cape Town (May 1, 2008 to April 30, 2016) are described, pathogens, outbreak size, mortality, source, and outbreak control measures. Neonatal outbreaks reported from Africa (January 1, 1996 to January 1, 2016) were reviewed to contextualize the authors’ experience within the published literature from the region. Results: Thirteen outbreaks affecting 148 babies (11 deaths; 7% mortality) over an 8-year period were documented, with pathogens including rotavirus, influenza virus, measles virus, and multidrug-resistant bacteria (Serratia marcescens, Acinetobacter baumannii, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci). Although the infection source was seldom identified, most outbreaks were associated with breaches in IP practices. Stringent transmission-based precautions, staff/parent education, and changes to clinical practices contained the outbreaks. From the African neonatal literature, 20 outbreaks affecting 524 babies (177 deaths; 34% mortality) were identified; 50% of outbreaks were caused by extended-spectrum β-lactamase-producing Klebsiella pneumoniae. Conclusions: Outbreaks in hospitalized African neonates are frequent but under-reported, with high mortality and a predominance of Gram-negative bacteria. Breaches in IP practice are commonly implicated, with the outbreak source confirmed in less than 50% of cases. Programmes to improve IP practice and address antimicrobial resistance in African neonatal units are urgently required.
- ItemManaging and preventing vascular catheter infections : a position paper of the international society for infectious diseases(Elsevier, 2019) Lutwick, Larry; Saif Al-Maani, Amal; Mehtar, Shaheen; Memish, Ziad; Rosenthal, Victor Daniel; Dramowski, Angela; Lui, Grace; Osman, Tamer; Bulabula, Andre; Bearman, GonzaloENGLISH ABSTRACT: A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview recommendations on managing and preventing vascular catheter infections, specifically for the prevention and management of central line-associated bloodstream infections. These recommendations are intended to provide insight for healthcare professionals regarding the prevention of infection in the placement and maintenance of the catheter and diagnosis as well as treatment of catheter infection. Aspects of this area in pediatrics and in limited-resource situations and a discussion regarding the selection of empiric or targeted antimicrobial therapy are particular strengths of this position paper.
- ItemMaternal colonization or infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae in Africa : a systematic review and meta-analysis(Published by Elsevier on behalf of International Society for Infectious Diseases, 2017) Bulabula, Andre N.H.; Dramowski, Angela; Mehtar, ShaheenObjective: To summarize published studies on the prevalence of and risk factors for maternal bacterial colonization and/or infection with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) in pregnant and/or post-partum women in Africa. Methods: A systematic review was conducted using the PubMed, Scopus, and Google Scholar databases. Bibliographies of included eligible studies were manually searched to identify additional relevant articles. No language restriction was applied. The timeframe of the search included all records from electronic database inception to July 15, 2017. A random-effects meta-analysis was performed to summarize the prevalence and the 95% confidence intervals (CI) of ESBL-E colonization or infection in pregnant or post-partum women in Africa. The meta-analysis was conducted using STATA IC 13.1 software and the metaprop function/plugin. Results: Ten studies (seven on pregnant women and three on post-partum women) were included, documenting a 17% prevalence of maternal colonization with ESBL-E in Africa (95% CI 10–23%). The prevalence of ESBL-E in community isolates exceeded that in isolates from the hospital setting (22% vs. 14%). The most frequently reported ESBL-encoding gene was CTX-M (cefotaxime hydrolyzing capabilities). Data on risk factors for maternal ESBL-E colonization and infection are very limited. Conclusions: The prevalence of colonization and/or infection with ESBL-E in pregnant and post-partum women in Africa exceeds that reported from high- and middle-income settings, representing a risk for subsequent neonatal colonization and/or infection with ESBL-E.
- ItemMinimizing the risk of non-vertical, non-sexual HIV infection in children - beyond mother to child transmission(BIOMED CENTRAL LTD,, 2012) Cotton MF; Marais B.J; Andersson MI; Eley B; Rabie H; Slogrove, Amy L.; Dramowski, Angela; Schaaf H.S; Mehtar S
- ItemNeonatal and paediatric bloodstream infections : pathogens, antimicrobial resistance patterns and prescribing practice at Khayelitsha District Hospital, Cape Town, South Africa(Health & Medical Publishing Group, 2018) Crichton, H.; O'Connell, N.; Rabie, H.; Whitelaw, A. C.; Dramowski, AngelaBackground. The epidemiology of neonatal and paediatric community-acquired and healthcare-associated bloodstream infections (BSI) at South African (SA) district hospitals is under-researched. Objective. Retrospective review of neonatal and paediatric BSI (0 - 13 years) at Khayelitsha District Hospital, Cape Town, SA, over 3 years (1 March 2012 - 28 February 2015). Methods. We used laboratory, hospital, patient and prescription data to determine BSI rates, blood culture yield and contamination rates, pathogen profile, antimicrobial resistance, patient demographics, BSI outcome and antibiotic prescribing practice. Results. From 7 427 blood cultures submitted, the pathogen yield was low (2.1%, 156/7 427) while blood culture contamination rates were high (10.5%, 782/7 427). Paediatric and neonatal BSI rates were 4.5 and 1.4/1 000 patient days, respectively. Gram-positive BSI predominated (59.3%); Staphylococcus aureus (26.8%) and Escherichia coli (21.6%) were common pathogens. The median patient age was 3 months, with a predominance of males (57.7%) and a 12.8% prevalence of HIV infection. Crude BSI-associated mortality was 7.1% (11/156), the death rate being higher in neonates than in infants and children (6/40 (15.0%) v. 5/116 (4.3%), respectively; p=0.03) and in patients with Gram-negative compared with Gram-positive bacteraemia (6/66 (9.1%) v. 5/89 (5.6%), respectively; p=0.5). Most BSI episodes were community-acquired (138/156; 88.5%), with high levels of extended-spectrum β-lactamase (ESBL) carriage among Klebsiella pneumoniae and E. coli isolates (5/5 (100%) and 8/33 (24.2%), respectively). Antimicrobial management of BSI was inappropriate in 30.6% of cases (45/147), including incorrect empirical antibiotic (46.7%), dual antibiotic cover (33.3%) and inappropriately broad-spectrum antibiotic use (17.8%). Conclusions. Antimicrobial-resistant pathogens (notably ESBL-producing Enterobacteriaceae) were common in community-acquired BSI. Paediatric clinicians at district hospitals require ongoing training in antibiotic stewardship and blood culture sampling.
- ItemNeonatal listeriosis during a countrywide epidemic in South Africa : a tertiary hospital’s experience(Health & Medical Publishing Group, 2018) Dramowski, Angela; Lloyd, L. G.; Bekker, A.; Holgate, S.; Aucamp, M.; Reddy, K.; Finlayson, H.Background. A countrywide epidemic of Listeria monocytogenes (LM) in South Africa began in the first quarter of 2017, rapidly becoming the world’s largest LM outbreak to date. Methods. We describe the clinical course of neonates with culture-confirmed LM infection admitted to a tertiary neonatal unit at Tygerberg Hospital, Cape Town (1 January 2017 - 31 January 2018). Current epidemic LM cases were compared with a historical cohort of sporadic neonatal LM cases at our institution (2006 - 2016). The global literature on epidemic neonatal LM outbreaks (1 January 1978 - 31 December 2017) was reviewed. Results. Twelve neonates (median gestational age 35 weeks, median birth weight 2 020 g) were treated for confirmed LM bacteraemia in 2017/18, presenting at a median age of 0.5 days. In 5 cases, neurolisteriosis was suspected. Three neonates died (25.0%) v. 8/13 neonatal deaths (61.6%) in the sporadic listeriosis cohort (2006 - 2016) (p=0.075). The institution’s neonatal LM infection incidence increased significantly in 2017 from a historical rate of 0.17/1 000 live births to 1.4/1 000 (p<0.001). During the current LM epidemic, the crude neonatal fatality rate exceeded the average calculated global epidemic neonatal LM mortality (3/12 (25.0%) v. 50/290 (17.2%); p=0.448). Possible factors contributing to the high mortality rate in this epidemic LM neonatal cohort may include more virulent disease associated with sequence type 6 and the predominance of early-onset disease. Conclusions. Epidemic neonatal listeriosis at Tygerberg Hospital was associated with a predominance of bacteraemic, early-onset disease. Listeriosis-associated mortality rates were higher than previously published, but lower than the rate in a historical institutional cohort.
- ItemNeonatal septicaemia : prevalence and antimicrobial susceptibility patterns of common pathogens at Princess Marina Hospital, Botswana(Medpharm Publications, 2015) Mudzikati, Lydia; Dramowski, AngelaBackground: Septicaemia is the third most common cause of neonatal death after prematurity and birth asphyxia. The prevalence of neonatal sepsis and the spectrum of causative microorganisms fluctuates over time, thus facility-specific surveillance of neonatal bloodstream infections is important. Increasing levels of antimicrobial resistance documented worldwide, necessitate regular monitoring of institutional resistance patterns to ensure appropriate and effective empirical antimicrobial therapy. Method: The laboratory blood culture reports and patient records from a neonatal unit at a Botswana referral hospital were retrospectively reviewed to determine the one-year prevalence of neonatal sepsis and the antimicrobial susceptibility patterns of common pathogens. Results: Of 909 neonates investigated for suspected sepsis using 1 119 blood cultures, 89 (9.8%) had laboratory-confirmed episodes of bloodstream infection (septicaemia). The most prevalent pathogens included Klebsiella pneumoniae (29.4%), group B streptococcus (16.3%) and Escherichia coli (11.9%). Blood culture contamination rates were high at 18.6% (208/1 119). Gramnegative pathogens showed low susceptibility to gentamicin (40%) and cefotaxime (47%), but high susceptibility to amikacin (86%). Streptococci and enterococci were moderately sensitive to ampicillin (79%), and fully susceptible to vancomycin. Methicillin-resistant Staphylococcus aureus was not isolated. Exposure to maternal syphilis and previous antibiotic exposure were significantly associated with neonatal septicaemia. Conclusion: Neonatal sepsis is common, with a predominance of Gram-negative pathogens. The high rate of blood culture contamination should be addressed. Emerging antibiotic resistance may require clinicians to review currently used antibiotics for the empirical treatment of late-onset neonatal septicaemia.