CT before lumbar puncture in suspected meningitis in Botswana: how established guidelines may not apply

Introduction:According to established guidelines from high-income countries; computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana; meningitis in HIV-infected patients is common but CT is not widely available.Objective:Develop a rational; evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence.Methods :Emergency center (EC) staff at Princess Marina Hospital in Gaborone; Botswana; reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses; and to specialists in other hospital departments for review and comment before finalization. Result: Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT; in contradiction to established guidelines. Discussion: The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources

The development of an emergency sepsis care algorithm in Botswana

Introduction :Sepsis is a common cause of morbidity and mortality in populations with a high prevalence of HIV; but the full package of early goal directed therapy (EGDT) for sepsis is not feasible in most low and middle-income countries. The objective was to develop emergency adult sepsis care guidelines for Botswana appropriate to available resources and local epidemiology in referral hospitals and in lower levels of care. Methods : The individual components of guidelines from the Surviving Sepsis Campaign were compared with available resources for their applicability in a tertiary referral hospital in Botswana. Antibiotics were chosen based on the hospital antibiogram; national antibiotic guidelines; and the cost and availability of antibiotics. The preliminary algorithm was presented to emergency centre medical officers in a referral hospital for feasibility and acceptability of implementation. The referral hospital guideline was further modified as part of a National Guidelines Project for suitability to all levels of care: Results :An acceptable and feasible sepsis algorithm was developed and implemented in a referral hospital in Botswana in accordance with the established hospital process. In turn; it served as the basis for the development of a national guideline. Discussion The principles of EGDT are adaptable to Botswana; and are likely to be adaptable to a variety of low- and middle-income countries on the basis of local resources and epidemiology. Further research is needed to study adherence and outcome related to the modified guidelines