Browsing by Author "Stewart, Annemie"

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    Cases of antiretroviral-associated gynaecomastia reported to the National HIV & Tuberculosis Health Care Worker Hotline in South Africa
    (BioMed Central, 2016-11-16) Njuguna, Christine; Swart, Annoesjka; Blockman, Marc; Maartens, Gary; Chisholm, Briony; Stewart, Annemie; Uys, Anri; Cohen, Karen
    Background: Gynaecomastia is associated with exposure to antiretroviral therapy (ART), in particular efavirenz. There is limited data on clinical characteristics of patients with ART-associated gynaecomastia in resource-limited settings and little guidance on the optimal management of this adverse drug reaction (ADR). We describe the clinical characteristics, management and outcomes of gynaecomastia cases reported to the National HIV & Tuberculosis Health Care Worker Hotline in South Africa. Methods: We identified all gynaecomastia cases in adolescent boys and men on ART reported to the hotline between June 2013 and July 2014. We collected follow up data telephonically at monthly intervals to document clinical management and outcomes. Results: We received 51 reports of gynaecomastia between June 2013 and July 2014; 11% of the 475 patient-specific ADR queries to the hotline. All patients were on efavirenz-based ART. Mean age was 34 years (standard deviation 12) and seven were adolescents. The median onset of gynaecomastia was 15 months after efavirenz initiation (interquartile range 6–42). Gynaecomastia was bilateral in 29 patients (57%) and unilateral in 16 (31%). Serum testosterone was quantified in 25 of 35 patients with follow up data, and was low in 2 (8%). Efavirenz was replaced with an alternative antiretroviral in 29/35 patients (83%) and gynaecomastia improved in 20/29 (69%). Conclusions: Gynaecomastia was a frequently reported ADR in our setting, occurring with prolonged efavirenz exposure. Testosterone was low in the minority of tested cases. Most clinicians elected to switch patients off efavirenz, and gynaecomastia improved in the majority.
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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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    Prognostic indicators in the World Health Organization’s algorithm for seriously ill HIV-infected inpatients with suspected tuberculosis
    (BioMed Central, 2018-02-12) Griesel, Rulan; Stewart, Annemie; van der Plas, Helen; Sikhondze, Welile; Mendelson, Marc; Maartens, Gary
    Background: Criteria for the 2007 WHO algorithm for diagnosing tuberculosis among HIV-infected seriously ill patients are the presence of one or more danger signs (respiratory rate > 30/min, heart rate > 120/min, temperature > 39 °C, and being unable to walk unaided) and cough ≥ 14 days. Determining predictors of poor outcomes among HIV-infected inpatients presenting with WHO danger signs could result in improved treatment and diagnostic algorithms. Methods: We conducted a prospective cohort study of inpatients presenting with any duration of cough and WHO danger signs to two regional hospitals in Cape Town, South Africa. The primary outcome was all-cause mortality up to 56 days post-discharge, and the secondary outcome a composite of any one of: hospital admission for > 7 days, died in hospital, transfer to a tertiary level or tuberculosis hospital. We frst assessed the WHO danger signs as predictors of poor outcomes, then assessed the added value of other variables selected a priori for their ability to predict mortality in common respiratory opportunistic infections (CD4 count, body mass index (BMI), being on antiretroviral therapy (ART), hypotension, and confusion) by comparing the receiver operating characteristic (ROC) area under the curve (AUC) of the two multivariate models. Results: 484 participants were enrolled, median age 36, 66% women, 53% had tuberculosis confrmed on culture. The 56-day mortality was 13.2%. Inability to walk unaided, low BMI, low CD4 count, and being on ART were independently associated with poor outcomes. The multivariate model of the WHO danger signs showed a ROC AUC of 0.649 (95% CI 0.582–0.717) for predicting 56-day mortality, which improved to ROC AUC of 0.740 (95% CI 0.681–0.800; p = 0.004 for comparison between the two ROC AUCs) with the multivariate model including the a priori selected variables. Findings were similar in sub-analyses of participants with culture-positive tuberculosis and with cough duration ≥ 14 days. Conclusion: The study design prevented a rigorous evaluation of the prognostic value of the WHO danger signs. Our prognostic model could result in improved algorithms, but needs to be validated.
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    Serious adverse drug reactions at two children’s hospitals in South Africa
    (2020-01-04) Mouton, Johannes P; Fortuin-de Smidt, Melony C; Jobanputra, Nicole; Mehta, Ushma; Stewart, Annemie; de Waal, Reneé; Technau, Karl-Günter; Argent, Andrew; Kroon, Max; Scott, Christiaan; Cohen, Karen
    Abstract Background The high HIV prevalence in South Africa may potentially be shaping the local adverse drug reaction (ADR) burden. We aimed to describe the prevalence and characteristics of serious ADRs at admission, and during admission, to two South African children’s hospitals. Methods We reviewed the folders of children admitted over sequential 30-day periods in 2015 to the medical wards and intensive care units of each hospital. We identified potential ADRs using a trigger tool developed for this study. A multidisciplinary team assessed ADR causality, type, seriousness, and preventability through consensus discussion. We used multivariate logistic regression to explore associations with serious ADRs. Results Among 1050 patients (median age 11 months, 56% male, 2.8% HIV-infected) with 1106 admissions we found 40 serious ADRs (3.8 per 100 drug-exposed admissions), including 9/40 (23%) preventable serious ADRs, and 8/40 (20%) fatal or near-fatal serious ADRs. Antibacterials, corticosteroids, psycholeptics, immunosuppressants, and antivirals were the most commonly implicated drug classes. Preterm neonates and children in middle childhood (6 to 11 years) were at increased risk of serious ADRs compared to infants (under 1 year) and term neonates: adjusted odds ratio (aOR) 5.97 (95% confidence interval 1.30 to 27.3) and aOR 3.63 (1.24 to 10.6) respectively. Other risk factors for serious ADRs were HIV infection (aOR 3.87 (1.14 to 13.2) versus HIV-negative) and increasing drug count (aOR 1.08 (1.04 to 1.12) per additional drug). Conclusions Serious ADR prevalence in our survey was similar to the prevalence found elsewhere. In our setting, serious ADRs were associated with HIV-infection and the antiviral drug class was one of the most commonly implicated. Similar to other sub-Saharan African studies, a large proportion of serious ADRs were fatal or near-fatal. Many serious ADRs were preventable.
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    Short term adherence tool predicts failure on second line protease inhibitor-based antiretroviral therapy: an observational cohort study
    (BioMed Central, 2014-12-04) Court, Richard; Leisegang, Rory; Stewart, Annemie; Sunpath, Henry; Murphy, Richard; Winternheimer, Philip; Ally, Mashuda; Maartens, Gary
    Background: Most patients who experience virologic failure (VF) on second line antiretroviral therapy (ART) in low-middle income countries fail due to poor adherence rather than antiretroviral resistance. A simple adherence tool designed to detect VF would conserve resources by rationally limiting need for viral load (VL) testing and, in those countries with access to third line ART, the need for resistance testing. Methods: We conducted an observational cohort study of patients who initiated second line ART at a clinic in Kwazulu-Natal, South Africa. Using clinical and pharmacy refill data extracted from the clinic’s electronic database, we determined risk factors for VF. Three different methods of calculating short term pharmacy refill adherence were evaluated and compared with long term adherence since second line initiation. We also explored the ability of differing durations of short term pharmacy refill to predict VF on second line ART. Results: We included 274 patients with a median follow up of 27 months on second line ART. VF ranged between 3% and 16% within each six month interval after initiating second line ART. 243 patients with at least one VL after 4 months on second line were analysed in the statistical analysis. Pharmacy refill adherence assessed over shorter periods (4 to 6 months) predicted virologic suppression as well as pharmacy refill assessed over longer periods. The risk of VF fell 73% with each 10% increase in adherence measured from pharmacy refills over a 4 month period. Low CD4 count at second line ART initiation was a significant independent risk factor for VF. Conclusion: Patients identified as poorly adherent by short term pharmacy refill are at risk for VF on second line ART. This pragmatic adherence tool could assist in identifying patients who require adherence interventions, and help rationalize use of VL monitoring and resistance testing among patients on second line ART.