South African Medical Journal - June 2023 Vol 113 No 6

Introduction

Approach to the diagnosis and management of snakebite envenomation in South Africa in humans: The hospital phase – emergency unit general principles

Treatment strategies that apply to snake envenomation from the Americas, Middle East, Asia and Australasia are inappropriate for Africa, owing to species and venom-action variance, or the significant antivenom differences. The content of this article is part of a CME series resulting from the multidisciplinary 2-day South African Snakebite Symposium meeting and the many pre-meeting online round-robin sessions. Admittedly, the content is largely expert opinion based on retrospective data, with little or no randomised or prospective studies available (except for those on adrenaline pre-dosing) on the treatment of snake envenomation in South Africa (SA). The document aims to provide the current best evidence and best practice information for the hospital care phase from the general perspective. The essential aspects are also available in the form of a flipchart addressing in-hospital treatment.

Bronchiolitis v. bronchopneumonia: Navigating antibiotic use within the lower respiratory tract infection spectrum

Bronchiolitis and bronchopneumonia are the commonest forms of lower respiratory tract infection (LRTI) in children aged <2 years. In the era of improved childhood pneumococcal and Haemophilus influenzae type b conjugate vaccination, both conditions are predominantly caused by viruses. Among hospitalised cases, the commonest cause is respiratory syncytial virus (RSV) (40 - 80% of bronchiolitis and 20 - 40% of bronchopneumonia). Other respiratory viral pathogens commonly associated with childhood LRTI include human metapneumovirus, influenza, parainfluenza, adenovirus and human rhinovirus. Although bronchiolitis is predominantly caused by a single viral pathogen, a substantial proportion of children with LRTI will have multiple potential pathogens detectable by molecular testing of respiratory samples, so determining the causative bacterial and/or viral pathogens in cases of mixed infection remains challenging. Bacterial co-infection is uncommon in bronchiolitis, but it is reported more frequently in children with severe disease, including those requiring invasive ventilation.

Ivermectin drug-induced liver injury

Ivermectin has been widely touted as being both preventive and curative for COVID-19. The evidence to support these claims has not been forthcoming. In South Africa (SA), official public health policy from the SA Health Products Regulatory Authority (SAHPRA), early during the COVID-19 pandemic and later again confirmed, despite major legal challenges, advised against the use of ivermectin and its claimed medicinal benefits. Despite this, the use of ivermectin remained widespread. Ivermectin toxicity, including seizures and gastrointestinal side-effects, has been reported. Ivermectin drug-induced liver injury (DILI) has been described, albeit only once in 2006 in a patient using the medication for the treatment of Loa Loa infection. We report a patient who used ivermectin for COVID-19 prophylaxis and developed a DILI.

Pro_le of adverse drug reaction reports in South_Africa: An analysis of VigiBase for the year 2017

Medicines have modified how diseases are treated, prolonging and improving the quality of life. However, medicines are associated with adverse effects that may be detrimental to the patient and the_health system at large. This is despite clinical trials being conducted to ensure their safety and efficacy before marketing authorisation. These studies take place in a highly controlled environment,_where small and homogenous populations are monitored for a short period. Clinical trials cannot be powered adequately to detect rare, serious adverse events. Therefore not all adverse effects are detected by the time of marketing authorisation. Rare and very rare ADRs can only be detected when the drug is used by very large populations. Additionally, individual polymorphisms lead to variability in_drug metabolism, and can result in various patient responses to medications that may lead to ADRs.

Periprosthetic joint infection: A South African perspective

Primary total joint arthroplasty (TJA) is one of the most common orthopaedic procedures performed worldwide. According to Sloan et¬ al., total hip arthroplasty (THA) will grow by 71%, to 635¬ 000 procedures per year, whereas total knee arthroplasty (TKA) will grow by 85%, to 1.26¬million procedures per year by 2030 in the USA alone. One of the most common complications of TJA, requiring revision surgery, is periprosthetic joint infection (PJI). The incidence of PJI is 1 - 2% in primary and 4% in revision arthroplasties, respectively. With the increase in TJA procedures being performed worldwide, there will also be the inevitable increase in PJI. This creates a significant financial burden on global healthcare with the cost for revision arthroplasty being up to 76% higher than for primary TJA. Klouche et¬ al. demonstrated that the cost of revision for infection is 2.57 times higher than the cost of revision for non-infective causes. There is also a five-fold increase in mortality in revision procedures for PJI v. revision procedures for aseptic failures. The 5-year survival rate for PJI is lower than that of female breast cancer. Helwig et ¬al. have shown that subjective quality of life in patients following PJI is significantly reduced.

Factors associated with COVID-19 inpatient mortality cases within 24 hours in South Africa

The world came to a halt as a result of the coronavirus (COVID-19) pandemic. The COVID-19 pandemic has had a significant impact on social, economic and population health around the world, and the end date of the outbreak is unknown. African countries with limited healthcare capacity were particularly vulnerable to the novel coronavirus. In some countries, the pandemic left health systems short of resources to safely manage patients and protect healthcare workers. South Africa (SA) is one of the developing countries still battling HIV/AIDS and tuberculosis (TB), leaving the country unsure of how the pandemic will progress. COVID-19 presents as a complicated clinical illness with a potential for complications that may necessitate ongoing clinical care. The disease’s clinical manifestation can be mild, moderate to severe or critical.

Patients’ experiences of termination of pregnancy at a regional hospital in Durban, South Africa

Globally, up to 41% of pregnancies are unintended. Increased contraceptive use has reduced the number of unintended pregnancies, but has not eliminated the need for safe abortion. In addition, ~33 million contraceptive users globally experience accidental pregnancy annually. Since 1996, South Africa (SA) has legalised termination of pregnancy (ToP) through the Choice of Termination of Pregnancy Act 92 of 1996. This Act allows for safe, effective and accessible ToP, allows first-trimester TOP on request, and further stipulates that ToP may only be performed at accredited facilities designated by the province. Since the inception of the Act, up to 7% of pregnant women have sought legal ToP in SA. First-trimester terminations are performed as outpatient procedures by trained midwives. Adequate counselling is given, and women are offered the choice of medical or surgical ToP.

Investigating blood alcohol concentrations in injuryrelated deaths before and during the COVID-19 national lockdown in Western Cape Province, South_Africa: A cross-sectional retrospective review

Alcohol is an important contributor to morbidity and mortality globally, with the World Health Organization (WHO) reporting significant health risks associated with alcohol consumption. The SOuth African (SA) government acknowledged alcohol as an important contributor to violent crime and domestic violence, providing alcohol-related harms interventions in the Western Cape Province (WC). To assess the efficacy of proposed interventions, it is critical for health and government agencies to have access to updated and relevant data on the impact of alcohol on health outcomes.

Microbiological analysis and predictors of gallbladder infection with antimicrobial susceptibility patterns in an HIV setting

Gallstone disease (GD) occurs in up to 20% of the population in developed countries and is the leading cause of acute cholecystitis (AC) and cholecystectomy. In South Africa (SA), recent evidence indicates that the cholecystectomy rate has almost doubled in the past decade. The actual cost of GD to the already overburdened healthcare system in SA is not known. However, in developed countries it is rated as the second-highest gastrointestinal cost burden to the healthcare system. Gallbladder (GB) bile is sterile in the absence of pathology. Pathological conditions of the GB result in bacterial colonisation of bile (bacteriobilia), with GD the major risk factor.