Browsing by Author "Boyles, Tom H"

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    Antibiotic stewardship ward rounds and a dedicated prescription chart reduce antibiotic consumption and pharmacy costs without affecting inpatient mortality or re-admission rates
    (Public Library of Science, 2013) Boyles, Tom H; Whitelaw, Andrew; Bamford, Colleen; Moodley, Mischka; Bonorchis, Kim; Morris, Vida; Rawoot, Naazneen; Naicker, Vanishree; Lusakiewicz, Irena; Black, John
    BACKGROUND: Antibiotic consumption is a major driver of bacterial resistance. To address the increasing burden of multi-drug resistant bacterial infections, antibiotic stewardship programmes are promoted worldwide to rationalize antibiotic prescribing and conserve remaining antibiotics. Few studies have been reported from developing countries and none from Africa that report on an intervention based approach with outcomes that include morbidity and mortality. METHODS: An antibiotic prescription chart and weekly antibiotic stewardship ward round was introduced into two medical wards of an academic teaching hospital in South Africa between January-December 2012. Electronic pharmacy records were used to collect the volume and cost of antibiotics used, the patient database was analysed to determine inpatient mortality and 30-day re-admission rates, and laboratory records to determine use of infection-related tests. Outcomes were compared to a control period, January-December 2011. RESULTS: During the intervention period, 475.8 defined daily doses were prescribed per 1000 inpatient days compared to 592.0 defined daily doses/1000 inpatient days during the control period. This represents a 19.6% decrease in volume with a cost reduction of 35% of the pharmacy's antibiotic budget. There was a concomitant increase in laboratory tests driven by requests for procalcitonin. There was no difference in inpatient mortality or 30-day readmission rate during the control and intervention periods. CONCLUSIONS: Introduction of antibiotic stewardship ward rounds and a dedicated prescription chart in a developing country setting can achieve reduction in antibiotic consumption without harm to patients. Increased laboratory costs should be anticipated when introducing an antibiotic stewardship program.
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    Blood cultures taken from patients attending emergency departments in South Africa are an important antibiotic stewardship tool, which directly influences patient management
    (2015-10-06) Boyles, Tom H; Davis, Kelly; Crede, Thomas; Malan, Jacques; Mendelson, Marc; Lesosky, Maia
    Abstract Background Febrile illness with suspected blood stream infection (BSI) is a common reason for admission to hospital in Africa and blood cultures are therefore an important investigation. Data on the prevalence and causes of community acquired BSI in Africa are scarce and there are no studies from South Africa. There are no validated clinical prediction rules for use of blood cultures in Africa. Methods A prospective observational cohort study of patients attending 2 urban emergency departments in Cape Town, South Africa. The decision to take a blood culture was made by the attending clinician and information available at the time of blood draw was collected. Bottles were weighed to measure volume of blood inoculated. Results 500 blood culture sets were obtained from 489 patients. 39 (7.8 %) were positive for pathogens and 13 (2.6 %) for contaminants. Significant independent predictors of positive cultures were diastolic blood pressure <60 mmHg, pulse >120 bpm, diabetes and a suspected biliary source of infection, but not HIV infection. Positive results influenced patient management in 36 of 38 (95 %) cases with the organism being resistant to the chosen empiric antibiotic in 9 of 38 (24 %). Taking <8 ml of blood was predictive of a negative culture. The best clinical prediction rule had a negative predictive value (NPV) of 92 % which is unlikely to be high enough to be clinically useful. Discussion Blood cultures taken from patients attending emergency departments in a high HIV prevalent city in South Africa are frequently positive and almost always influence patient management. At least 8 ml of blood should be inoculated into each bottle. Conclusion Blood cultures should be taken from all patients attending EDs in South Africa suspected of having BSI particularly if diabetic, with hypotension, tachycardia or if biliary sepsis is suspected.
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    Factors influencing retention in care after starting antiretroviral therapy in a rural South African programme
    (Public Library of Science, 2011) Boyles, Tom H; Wilkinson, Lynne S; Leisegang, Rory; Maartens, Gary
    The prognosis of patients with HIV in Africa has improved with the widespread use of antiretroviral therapy (ART) but these successes are threatened by low rates of long-term retention in care. There are limited data on predictors of retention in care, particularly from rural sites. METHODS: Prospective cohort analysis of outcome measures in adults from a rural HIV care programme in Madwaleni, Eastern Cape, South Africa. The ART programme operates from Madwaleni hospital and seven primary care feeder clinics with full integration between inpatient and outpatient services. Outreach workers conducted home visits for defaulters. RESULTS: 1803 adults initiated ART from June 2005 to May 2009. At the end of the study period 82.4% were in active care or had transferred elsewhere, 11.1% had died and 6.5% were lost to follow-up (LTFU). Independent predictors associated with an increased risk of LTFU were CD4 nadir >200, initiating ART as an inpatient or while pregnant, and younger age, while being in care for >6 months before initiating ART was associated with a reduced risk. Independent factors associated with an increased risk of mortality were baseline CD4 count <50 and initiating ART as an inpatient, while being in care for >6 months before initiating ART and initiating ART while pregnant were associated with a reduced risk. CONCLUSIONS: Serving a socioeconomically deprived rural population is not a barrier to successful ART delivery. Patients initiating ART while pregnant and inpatients may require additional counselling and support to reduce LTFU. Providing HIV care for patients not yet eligible for ART may be protective against being LTFU and dying after ART initiation.
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    Failure to eradicate Isospora belli diarrhoea despite immune reconstitution in adults with HIV--a case series
    (Public Library of Science, 2012) Boyles, Tom H; Black, John; Meintjes, Graeme; Mendelson, Marc
    Isospora belli causes diarrhoea in patients with AIDS. Most respond to targeted therapy and recommendations are that secondary prophylaxis can be stopped following immune reconstitution with ART. We report eight cases of chronic isosporiasis that persisted despite standard antimicrobial therapy, secondary prophylaxis, and good immunological and virological response to ART. Median CD4 nadir was 175.5 cells/mm 3 and median highest CD4 while symptomatic was 373 cells/mm 3 . Overall 34% of stool samples and 63% of duodenal biopsy specimens were positive for oocytes. Four patients died, two remain symptomatic and two recovered. Possible explanations for persistence of symptoms include host factors such as antigen specific immune deficiency or generalised reduction in gut immunity. Parasite factors may include accumulating resistance to co-trimoxazole. Research is required to determine the optimum dose and duration of co-trimoxazole therapy and whether dual therapy may be necessary. Mortality was high and pending more data we recommend extended treatment with high-dose co-trimoxazole in similar cases.
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    The individualised versus the public health approach to treating Ebola
    (Public Library of Science, 2015) Boyles, Tom H
    The mortality rate for patients with Ebola virus disease (EVD) in West Africa is approximately 65% [1]. There are no published figures for high-resource settings, but media sources and individual case reports suggest it is much lower and approaches 0% for those who receive this level of care from the beginning of their illness. In their article "Ebola Viral Disease: Experience and Decision Making for the First Cases outside of Africa," David Stephens and colleagues give insight into the care that can be provided when available resources are not the limiting factor [2]. They describe the decision to open the Serious Communicable Diseases Unit (SCDU) of Emory University Hospital (EUH) when two United States patients contracted EVD while working in West Africa. Using a large specialist team, they provided high-quality care in a safe working environment and disseminated their knowledge and experience widely. In particular, they were able to respond to the huge increase in requests from health care facilities in the US for help in excluding the diagnosis of EVD. Caring for patients using an individualised approach under ideal circumstances contrasts with, but can also inform, the public health approach to care under resource-limited conditions in West Africa. The models of care employed in each environment show some similarities and also have a number of key differences.
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    Knowledge, attitudes and perceptions of antibiotic use and antibiotic resistance among private sector patients and prescribers in South Africa
    (2017) Farley, Elise; Boyles, Tom H; Stewart, Annemie; Davies, Mary-Ann
    Antibiotic resistance (ABR), alternately referred to as antimicrobial resistance, has been labelled as the next big global health crisis. If current levels of ABR continue along the same trajectories, by 2050 ABR will cost the lives of 10 million people a year, ABR cannot be stopped but it can be slowed down. ABR occurs because the bacteria evolve to protect themselves from antibiotics. One of the main causes of ABR is the misuse and over prescription of antibiotics. The primary objective of the study is to ascertain the level of knowledge, attitudes and perceptions of appropriate antibiotic use and ABR, among prescribers and patients in private health care in South Africa. The secondary objective of the study is to explore associations between knowledge, attitudes and perceptions of prescribers and patients regarding antibiotic use and resistance. This project consists of three main sections, a proposal, literature review and a journal ready article. All sections focus on ABR. The proposal lays a foundation for the need for the research, and explains how the research will be conducted. The literature review explores the existing evidence on the topic, and the final section is a secondary analysis of cross sectional study data, in which private practice patients and prescribers in South Africa completed a once-off anonymous survey. Data was analysed using Stata,T-tests, chi-squared tests and logistic regression models were used to assess associations between knowledge, attitudes and perceptions of both patients and prescribers. We found that mean knowledge scores among patients (n=403, mean 9 out of 14, standard deviation [SD] 3) and providers (n=175, median 5 maximum 7, IQR 4, 6), were suboptimal and that poor knowledge was associated with perceptions and behaviours as well as prescribing practices that could lead to ABR. Associations between knowledge, attitudes and perceptions of patients and prescribers were explored in multivariate logistic regression models. After adjusting for education and sex, a 1-unit increase in patient knowledge score was associated with the belief that antibiotics will work less well in future if we over-use them now (aOR 1.3; 95% CI: 1.18, 1.43; pvalue <0.001). Prescribers with higher knowledge scores were less likely to report that they prescribe antibiotics when not necessary as antibiotics cannot harm the patient (aOR 0.55; 95% CI: 0.33, 0.91; pvalue 0.02). We also identified a large proportion (58%) of patients who were interested in alternatives to antibiotics and a large proportion (91%) of prescribers wanting educational material to facilitate conversations about resistance with patients. Our study demonstrates gaps in patient and prescriber knowledge that are associated with potentially harmful perceptions and destructive behaviours regarding antibiotic use. These associations, together with our finding that patients and prescribers would like more education on ABR, suggest that educational tools and patient-provider communication tools could promote rational antibiotic use.
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    The prevalence of hepatitis B infection in a rural South African HIV clinic
    (2011) Boyles, Tom H; Cohen, Karen
    The prevalence of hepatitis B virus (HBV) infection in 1 765 HIVpositive patients in rural Eastern Cape was 7.1%. This is lower than the previously reported rural prevalence and is similar to urban prevalence. Male sex and baseline alanine aminotransferase (ALT) were significant predictors of HBV status. Most HBV-positive patients had normal baseline ALT, making ALT an insensitive screening test for HBV status.