Browsing by Author "Taljaard, J. J."
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- ItemBacille Calmette-Guerin (BCG) vaccine and the COVID-19 pandemic : responsible stewardship is needed(The Union, 2020) Schaaf, H. S.; Du Preez, K.; Kruger, M.; Solomons, R.; Taljaard, J. J.; Rabie, H.; Seddon, J. A.; Cotton, M. F.; Tebruegge, M.; Curtis, N.; Hesseling, A. C.We believe that responsible stewardship of the bacille Calmette-Guérin (BCG) vaccine in the context of the COVID-19 epidemic is urgently needed. Live attenuated BCG is currently the only licensed vaccine to protect against tuberculosis (TB). Neonatal BCG vaccination has proven efficacy in protecting infants and young children against life-threatening disseminated forms of TB, including TB meningitis and miliary TB.
- ItemBacterial infection, antibiotic use and COVID-19 : lessons from the intensive care unit(Health & Medical Publishing Group, 2021-04-14) Moolla, M. S.; Reddy, K.; Fwemba, I.; Nyasulu, P. S.; Taljaard, J. J.; Parker, A.; Lalla, U.; Koegelenberg, C. F. N.; Allwood, B. W.Background. Empirical broad-spectrum antibiotics are frequently prescribed to patients with severe COVID-19, motivated by concern about bacterial coinfection. There is no evidence of benefit from such a strategy, while the dangers of inappropriate antibiotics are well described. Objectives. To investigate the frequency, profile and related outcomes of infections by bacterial pathogens in patients admitted to an intensive care unit (ICU) with severe COVID-19 pneumonia. Methods. This was a prospective, descriptive study in a dedicated COVID-19 ICU in Cape Town, South Africa, involving all adult patients admitted to the ICU with confirmed COVID-19 pneumonia between 26 March and 31 August 2020. We collected data on patient comorbidities, laboratory results, antibiotic treatment, duration of admission and in-hospital outcome. Results. We included 363 patients, who collectively had 1 199 blood cultures, 308 tracheal aspirates and 317 urine cultures performed. We found positive cultures for pathogens in 20 patients (5.5%) within the first 48 hours of ICU admission, while 73 additional patients (20.1%) had positive cultures later during their stay. The most frequently isolated pathogens at all sites were Acinetobacter baumannii (n=54), Klebsiella species (n=13) and coagulase-negative staphylococci (n=9). Length of ICU stay (p<0.001) and intubation (p<0.001) were associated with positive cultures on multivariate analysis. Disease severity (p=0.5), early antibiotic use (p=0.5), diabetes mellitus (p=0.1) and HIV (p=0.9) were not associated with positive cultures. Positive cultures, particularly for tracheal aspirates (p<0.05), were associated with longer ICU length of stay and mortality. Early empirical antibiotic use was not associated with mortality (odds ratio 2.5; 95% confidence interval 0.95 - 6.81). Conclusions. Bacterial coinfection was uncommon in patients at the time of admission to the ICU with severe COVID-19. Avoiding early empirical antibiotic therapy is therefore reasonable. Strategies to avoid coinfection and outbreaks in hospital, such as infection prevention and control, as well as the strict use of personal protective equipment, are important to improve outcomes.
- ItemCorticosteroids in critical COVID-19 : are all corticosteroids equal?(Health & Medical Publishing Group, 2021-06-04) Du Plessis, E. M.; Lalla, U.; Allwood, B. W.; Louw, E. H.; Nortje, A.; Parker, A.; Taljaard, J. J.; Ayele, B. T.; Nyasulu, P. S.; Koegelenberg, C. F. N.Background. The hyperinflammation seen as part of a dysregulated immune response to SARS-CoV-2 in its most severe form leads to acute respiratory distress syndrome (ARDS), multiorgan failure and death. Corticosteroid therapy targets this hyperinflammation, otherwise known as a cytokine storm. It is the only therapeutic agent to date with a mortality benefit, with clear guidelines from national and international health authorities guiding its use. Objectives. To compare severity-of-illness indices, survival, length of intensive care unit (ICU) stay and potential ICU complications in patients treated with different corticosteroid regimens (high-dose hydrocortisone, high-dose methylprednisolone and lower-dose dexamethasone). Methods. In this single-centre descriptive retrospective observational study of a cohort of patients with severe COVID-19 admitted to a COVID-dedicated ICU, we compared patients treated with the three different corticosteroid regimens. Results. In 242 cases we could not demonstrate any statistically or clinically significant difference in the outcome of patients with critical COVID-19 treated with high-dose intravenous hydrocortisone (n=88) or methylprednisolone (n=46) compared with a relatively lower dose of dexamethasone (n=108). The survival rates were 38.6%, 39.1% and 33.3%, respectively (p=0.68). Patients treated with methylprednisolone tended to have a shorter length of ICU stay (median (interquartile range) 6 (4 - 10), 4 (2 - 8) and 5 (2 - 8) days; p=0.015) and fewer episodes of nosocomial sepsis (47.7%, 32.6% and 48.1%; p=0.01). Conclusions. Hydrocortisone or methylprednisolone can be given as an alternative to dexamethasone in the management of critical COVID-19, and this is a feasible alternative, especially in resource-constrained settings.
- ItemDiabetes mellitus and COVID-19 : a review and management guidance for South Africa(Health & Medical Publishing Group, 2020-08) Coetzee, A.; Taljaard, J. J.; Hugo, S. S.; Conradie, M.; Conradie-Smit, M.; Dave, J. A.ENGLISH ABSTRACT: This article reviews the association between diabetes mellitus (DM) and COVID-19. We report on the convergence of infectious diseases such as coronavirus infections and non-communicable diseases including DM. The mechanisms for the interaction between COVID-19 and DM are explored, and suggestions for the management of DM in patients with COVID-19 in South Africa are offered.
- ItemEfficacy and patterns of use of antimicrobial prophylaxis for gunshot wounds in a South African hospital setting : an observational study using propensity score-based analyses(Medpharm, 2020-03) Visbeek, M. C.; Taljaard, J. J.; De Boer, M. G. J.; Cronje, U. J.; Steyn, E.BACKGROUND: Limited evidence supports the efficacy of antimicrobial prophylaxis (AP) in prevention of gunshot wound-related (GSW-related) infection in resource restricted areas. At Tygerberg Hospital, South Africa, it is standard care for GSW patients to receive one dose of broad-spectrum AP. For various reasons, this protocol is not consistently followed. This study aimed to assess the efficacy of AP in the reduction of in-hospital GSW-related infection and to identify opportunities for practice improvement METHODS: All patients admitted with GSW over a three-month period were eligible for inclusion. Patients who did and did not receive AP were identified retrospectively the morning of admission; thereafter, data was collected prospectively. Data regarding circumstances of the incident, injury characteristics, type of AP and surgery was obtained. The occurrence of in-hospital GSW-related infection was recorded over 30 days or until discharge. Propensity score matching (PSM) and inverse probability weighting (IPW) methods were utilised to assess the effect of AP on the prevention of GSW-related infection RESULTS: 165 consecutive patients were assessed, of which 103 received AP according to protocol within 12 hours of admission. PSM showed a reduced in-hospital GSW infection risk of 12% (95% CI, 0.2-24%, p = 0.046) with AP. IPW showed that AP reduced the risk for infection by 14% (95% CI, 3-27%, p = 0.015 CONCLUSIONS: Providing AP to GSW patients in a civilian setting appeared to result in a modest but clinically relevant lower risk of in-hospital GSW-related infection. In this study setting, optimisation of AP for all patients with GSWs should significantly lower the burden of wound infection.
- ItemEstablishing a multidisciplinary AIDS-associated Kaposi’s sarcoma clinic : patient characteristics, management and outcomes(Health & Medical Publishing Group, 2018-12) Burger, H.; Ismail, Z.; Taljaard, J. J.Background: Kaposi’s sarcoma (KS) typically occurs in the setting of immunodeficiency and specifically in the presence of HIV infection, when it is called AIDS-associated KS (AIDS-KS). In spite of impressive gains in the South African (SA) antiretroviral therapy (ART) roll-out programme since 2004, AIDS-KS still causes significant morbidity and mortality, and the treatment of advanced disease can be challenging owing to the centralisation of oncology services and the high incidence of concurrent infections. In 2014, a multidisciplinary AIDS-KS clinic (MKSC) was established at Tygerberg Hospital, Cape Town, with the goal of optimising management of AIDS-KS patients. Objectives: To report on the characteristics and outcomes of patients seen during the first 6 months after the inception of the MKSC. Methods: A retrospective observational study was performed of all new cases referred to the MKSC from February to August 2014. Results: Forty-two patients were included in the study. The median age was 34 years (range 20 - 60). Forty-one patients were on ART at time of diagnosis or were initiated by a median of 3 months after diagnosis. The median CD4+ count before diagnosis was 147 cells/µL (range 4 - 811). The HIV viral load was undetectable in 22 cases (52.4%). Thirty-eight patients (90.5%) were classified as AIDS Clinical Trials Group (ACTG) poor risk, 10 patients (23.8%) had visceral KS, 14 patients (33.3%) were on tuberculosis (TB) treatment at time of presentation, and 22 patients (52.4%) received oncological therapy in addition to ART. After median follow-up of 25.6 months, 2-year overall survival (OS) was 61.1%. On univariate analysis, factors significantly associated with poor 2-year OS included ACTG S1 stage (S = systemic illness), visceral KS, being on TB treatment, and Eastern Cooperative Oncology Group performance status score >2. In the T1 (T = tumour extent) subgroup, receiving chemotherapy was significantly associated with improved 2-year OS. Conclusions: Advanced AIDS-KS significantly affects young people in the Western Cape Province of SA despite 10 years of ART roll-out. There is a high prevalence of concomitant TB infection that could adversely affect adherence and response to treatment. Despite advanced disease at presentation and palliative treatment intent, survival outcomes are encouraging and seem to be positively affected by the increased use of chemotherapy. A multidisciplinary approach to diagnosis, staging and treatment and the exploration of prognostic indices specific to the sub-Saharan setting would be valuable in designing appropriate treatment algorithms.
- ItemHigh HIV prevalence in an early cohort of hospital admissions with COVID-19 in Cape Town, South Africa(Health & Medical Publishing Group, 2020) Parker, A.; Koegelenberg, C. F. N.; Moolla, M. S.; Louw, E. H.; Mowlana, A.; Nortje, A.; Ahmed, R.; Brittain, N.; Lalla, U.; Allwood, B. W.; Prozesky, H.; Schrueder, N.; Taljaard, J. J.Background. South Africa (SA) has a high prevalence of HIV and tuberculosis. Cape Town was the SA metropole most affected in the early stages of the COVID-19 pandemic. Early observational data from Africa may provide valuable insight into what can be expected as the pandemic expands across the continent. Objectives. To describe the prevalence, clinical features, comorbidities and outcome of an early cohort of HIV-positive and HIV-negative patients admitted with COVID-19. Methods. This was a descriptive observational study of an early cohort of adults with COVID-19 pneumonia admitted from 25 March to 11 May 2020. Results. Of 116 patients (mean age 48 years, 61% female) admitted, 24 were HIV-positive (21%). The most common symptoms reported were cough (n=88; 73%), shortness of breath (n=78; 69%), fever (n=67; 59%), myalgia (n=29; 25%) and chest pain (n=22; 20%). The most common comorbidities were hypertension (n=46; 41%), diabetes mellitus (n=43; 38%), obesity (n=32; 28%) and HIV (n=24; 21%). Mortality was associated with older age (mean (standard deviation) 55 (12) years v. 46 (14) years; p<0.01); the presence of hypertension or hypertension along with diabetes and/or obesity; lower partial pressure of arterial oxygen to fraction of inspired oxygen ratio; and higher urea level, white cell count, neutrophil count, and C-reactive protein, lactate dehydrogenase and ferritin levels, and high neutrophil to lymphocyte ratio. The overall survival rate for all hospital admissions was 86/116 (73%). In this early cohort, survival was similar in patients with HIV (n=18; 75%) compared with those without HIV (n=67; 75%) (p=1). Of the 74 patients admitted to the wards, 63 (85%) survived, whereas 22 of 42 (52%) admitted to the intensive care unit survived. Conclusions. Patients with HIV infection represented a large proportion of all COVID-19 admissions. The presentation and outcome of patients with HIV did not differ significantly from those of patients without HIV.
- ItemThe impact of HIV infection on the presentation of lung cancer in South Africa(Health & Medical Publishing Group, 2016) Koegelenberg, C. F. N.; Van Der Made, T.; Taljaard, J. J.; Irusen, E. M.ENGLISH ABSTRACT: Background. Despite the very high background prevalence of HIV and smoking-related diseases in sub-Saharan Africa, very little is known about the presentation of lung cancer in HIV-infected individuals. Methods. We prospectively compared HIV-positive (n=44) and HIV-negative lung cancer patients (n=425) with regard to demographics, cell type, performance status and umour node metastasis staging at initial presentation. Results. HIV-positive patients were found to be younger than HIV-negative (mean 54.1 (standard deviation (SD) 8.4) years v. 60.5 (10) years, p<0.01), more likely to have squamous cell carcinoma (43.2% v. 30.1%, p=0.07) and significantly more likely to have a poor Eastern Cooperative Oncology Group (ECOG) performance status of ≥3 (47.7% v. 29.4%, p=0.02). In the case of non-small cell-lung cancer, they were also significantly less likely to have early stage lung cancer (0% v. 10.3%, p=0.02) compared with HIV-negative patients. Conclusions. HIV-positive lung cancer patients were younger, significantly more likely to have a poor performance status at presentation and significantly less likely to have early stage lung cancer when compared with HIV-negative patients.
- ItemLeadership and early strategic response to the SARS-CoV- 2 pandemic at a COVID-19 designated hospital in South Africa(Health & Medical Publishing Group, 2020-04-23) Parker, A.; Karamchand, S.; Schrueder, N.; Lahri, S.; Rabie, H.; Aucamp, A.; Abrahams, R.; Ciapparelli, P.; Erasmus, D. S.; Cotton, M. F.; Lalla, U.; Leisegang, Rory; Meintjes, J.; Mistry, R.; Moosa, M. R.; Mowlana, A.; Koegelenberg, C. F. N.; Prozesky, H.; Smith, W.; Van Schalkwyk, M.; Taljaard, J. J.While many countries are preparing to face the COVID-19 pandemic, the reported cases in Africa remain low. With a high burden of both communicable and non-communicable disease and a resource-constrained public healthcare system, sub-Saharan Africa is preparing for the coming crisis as best it can. We describe our early response as a designated COVID-19 provincial hospital in Cape Town, South Africa (SA).While the first cases reported were related to international travel, at the time of writing there was evidence of early community spread. The SA government announced a countrywide lockdown from midnight 26 March 2020 to midnight 30 April 2020 to stem the pandemic and save lives. However, many questions remain on how the COVID-19 threat will unfold in SA, given the significant informal sector overcrowding and poverty in our communities. There is no doubt that leadership and teamwork at all levels is critical in influencing outcomes.
- ItemProsthetic valve obstruction at Tygerberg Hospital between January 1991 and February 2001(Clinics Cardiv Publishing, 2003-08) Taljaard, J. J.; Doubell, A. F.Background: Prosthetic valve obstruction is a relatively rare, but potentially fatal complication in patients with prosthetic heart valves. The diagnosis and appropriate management of these patients present a challenge to both the cardiologist and the cardiac surgeon. Despite efforts over the last 30 years to prevent this complication, it remains a lifelong risk. Obstruction is caused by pannus formation, thrombus formation or a combination of pannus and thrombus. Valve replacement has traditionally been the treatment of choice. Methods: Patients were selected from echocardiography and surgical reports between January 1991 and February 2001. All patients were analysed with regard to demographic information, clinical features, imaging results, treatment and outcome data. INR values on presentation were obtained from haematology archives. Results: A total of 32 patients presented on 34 occasions. There were 25 women and seven men. Obstruction occurred in the mitral position in 56% of cases and in the aortic position in 44% of cases. All but two valves were St Jude bileaflet valves. Patients generally presented with severe dyspnoea (NYHA class IV in 64.7%) and poor anticoagulation control (INR < 2.5 in 75.8%). The initial imaging modality used in all cases was transthoracic echocardiography. Fluoroscopy was used in five cases and transesophageal echocardiography in only two cases. Valve replacement was performed on 20 patients, six patients received thrombolysis and the remaining eight patients did not receive any treatment. Outcome was poor with an overall mortality of 64.7%. Conclusions: Given the extremely high mortality rate with current management, the treatment of prosthetic valve obstruction with thrombolysis in selected patients deserves consideration in a prospective study.
- ItemA severity-of-illness score in patients with tuberculosis requiring intensive care(Health & Medical Publishing Group, 2021-03-02) Lalla, U.; Irusen, E. M.; Allwood, B. W.; Taljaard, J. J.; Koegelenberg, C. F. N.Background. We previously retrospectively validated a 6-point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (TB) in the intensive care unit (ICU). Parameters included septic shock, HIV infection with a CD4 count <200 cells/µL, renal dysfunction, a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (P/F) <200 mmHg, a chest radiograph demonstrating diffuse parenchymal infiltrates, and no TB treatment on admission. Objectives. To prospectively validate the severity-of-illness scoring system in patients with TB requiring intensive care, and to refine and simplify the score in order to expand its clinical utility. Methods. We performed a prospective observational study with a planned post hoc retrospective analysis, enrolling all adult patients with confirmed TB admitted to the medical ICU of a tertiary hospital in Cape Town, South Africa, from 1 February 2015 to 31 July 2018. The admission data of all adult patients with TB requiring admission to the ICU were used to calculate the 6-point severity-of-illness score and a refined 4-point score (based on the planned post hoc analysis). Descriptive statistics and χ2 or Fisher’s exact tests (where indicated) were performed on dichotomous categorical variables, and t-tests on continuous data. Patients were categorised as hospital survivors or non-survivors. Results. Forty-one of 78 patients (52.6%) died. The 6-point scores of non-survivors were higher than those of survivors (mean (standard deviation (SD)) 3.5 (1.3) v. 2.7 (1.2); p=0.01). A score ≥3 v. <3 was associated with increased mortality (64.0% v. 32.1%; odds ratio (OR) 3.75; 95% confidence interval (CI) 1.25 - 10.01; p=0.01). Post hoc, a P/F ratio <200 mmHg and no TB treatment on admission failed to predict mortality, whereas any immunosuppression did. A revised 4-point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors than survivors (mean (SD) 2.8 (1.1) v. 1.6 (1.1); p<0.001). A score ≥3 v. ≤2 was associated with increased mortality (78.4% v. 29.3%; OR 8.76; 95% CI 3.12 - 24.59; p<0.001). Conclusions. The 6-point severity-of-illness score identified patients at increased risk of death. We were able to derive and retrospectively validate a simplified 4-point score with superior predictive power.