Tuberculosis among individuals with community-acquired pneumonia presenting to emergency in Gaborone, Botswana

Delays in diagnosing Tuberculosis (TB) are associated with increased transmission. TB may present as a clinical syndrome that mimics community-acquired pneumonia (CAP). The aim of this paper was to determine frequency of TB among patients with CAP at a referral hospital in Gaborone, Botswana. We performed a retrospective study of adults presenting with CAP from April 2010-October 2011 to the Emergency Department (ED);we matched this cohort to the National Botswana Tuberculosis Registry (NBTR) to identify individuals subsequently diagnosed with TB. We assessed demographics, time to TB diagnosis, clinical outcomes and performed logistic regressions to identify factors associated with TB diagnosis. We identified 1305 individuals presenting with CAP;TB was subsequently diagnosed in 68 (5.2%). The median time to TB diagnosis was 9.5 days. Forty percent were AFB sputum smear positive and 87% were identified as being HIV-positive. Subsequent diagnosis of TB is common among individuals with CAP at our ED, suggesting that TB may be present at the time of CAP presentation. Given the lack of distinguishing clinical factors between pulmonary TB and CAP, adults presenting with CAP should be evaluated for active TB in Botswana

Undergraduate emergency medicine in an african medical school : experiences from Botswana

Introduction: In August 2011; the first cohort of students at the University of Botswana School of Medicine (UBSOM) began their third year of undergraduate medical training. As part of their 2011-2012 curriculum they each completed a 10 week rotation in Emergency Medicine (EM); involving problem based learning (PBL) sessions; maintenance of log books; case presentations; and clinical time at the Emergency Centre (EC) of the main tertiary referral hospital in Gaborone; Princess Marina Hospital. Methods :Since EM rotations are often undertaken in the final year of medical training; students were given an anonymous voluntary survey to study the effect of an EM experience in their first clinical year of training. A 5-point Likert scale was used to evaluate learning opportunities and the overall EM experience. Students described which procedures they had observed or performed in their rotation. The survey concluded with open-ended questions seeking additional feedback. Results : These were very encouraging for both early exposure to EM and the PBL approach. More than 90 of students agreed or strongly agreed that they felt more confident in clinical settings; improved their clinical decision making process; and found the PBL model to be effective over the rotation. 22 different procedures were observed in the EC with 100 observing venesection and plaster applications. 14 different procedures were performed with 83 students performing venesection and over 65 performing chest compressions and venous cannulation. Discussion : It is hoped that this study will provide valuable practical information about undergraduate EM learning in a PBL based Medical School within Sub Saharan Africa that can be replicated across other medical education institutions throughout the region

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