Evaluation of a proposed clinical case definition of paediatric acquired immune deficiency syndrome.

OBJECTIVE: To evaluate the proposed criteria against the laboratory parameters and to identify the clinical features with the highest predictive value in the diagnosis of paediatric AIDS. DESIGN: A cross sectional study. SETTING: Kenyatta National Hospital, Nairobi. RESULTS: More than twenty three per cent of the children studied were seropositive and 14% were diagnosed as having AIDS. Almost 70% of the children studied were below 24 months. AIDS was significantly associated with mouth lesions, both ulcers and oral candidiasis, skin lesions especially eczema and generalised pruritic dermatitis, prolonged cough, prolonged fever and generalised lymphadenopathy. The WHO criteria had a sensitivity of 60%, a specificity of 94%, positive predictive value of 60%, and negative predictive value of 94%. The Nairobi diagnostic criteria had a sensitivity of 80%, a specificity of 79%, a positive predictive value of 38% and a negative predictive value of 96%. CONCLUSION: The Nairobi Diagnostic Criteria are superior to the WHO criteria as a screening test due to their higher sensitivity, 80% against 60% for WHO.

Correlates of mother-to-child human immunodeficiency virus type 1 (HIV-1) transmission: association with maternal plasma HIV-1 RNA load, genital HIV-1 DNA shedding, and breast infections.

To determine the effects of plasma, genital, and breast milk human immunodeficiency virus type 1 (HIV-1) and breast infections on perinatal HIV-1 transmission, a nested case-control study was conducted within a randomized clinical trial of breast-feeding and formula feeding among HIV-1-seropositive mothers in Nairobi, Kenya. In analyses comparing 92 infected infants with 187 infants who were uninfected at 2 years, maternal viral RNA levels >43,000 copies/mL (cohort median) were associated with a 4-fold increase in risk of transmission (95% confidence interval [CI], 2.2-7.2). Maternal cervical HIV-1 DNA (odds ratio [OR], 2.4; 95% CI, 1.3-4.4), vaginal HIV-1 DNA (OR, 2.3; 95% CI, 1.1-4.7), and cervical or vaginal ulcers (OR, 2.7; 95% CI, 1.2-5.8) were significantly associated with infant infection, independent of plasma virus load. Breast-feeding (OR, 1.7; 95% CI, 1.0-2.9) and mastitis (relative risk [RR], 3.9; 95% CI, 1.2-12.7) were associated with increased transmission overall, and mastitis (RR, 21.8; 95% CI, 2.3-211.0) and breast abscess (RR, 51.6; 95% CI, 4.7-571.0) were associated with late transmission (occurring >2 months postpartum). Use of methods that decrease infant exposure to HIV-1 in maternal genital secretions or breast milk may enhance currently recommended perinatal HIV-1 interventions.

Rational approach to limiting emergence of antimicrobial drug resistance.

Microbial resistance to the available antimicrobial agents continues to be a major problem with regard to nosocomial and community acquired pathogens. The development of resistance to commonly used antimicrobials is of particular concern when it occurs in pathogenic organisms that cause invasive disease. This has implications on morbidity and mortality of infectious diseases, and will also result in escalated costs of care due to the use of alternative antimicrobials which are often more costly. The increasing frequency of drug resistance has been attributed to combinations of microbial characteristics, selective pressure of antimicrobial use and societal factors that enhance the transmission of drug resistant organisms. The emergence of antibiotic resistant bacteria has generally correlated with the rise and fall of specific antibiotic use in clinical practice. Although the discovery of a new drug temporarily confers therapeutic superiority over bacterial pathogens, the subsequent rapid evolution of resistance limits the duration of the effectiveness of specific agents against pathogens. Surveillance and the development of drug policies that encourage judicious use of antimicrobials will help to minimise the spread of resistant infections. This paper reviews how this dual strategy may be used to control antimicrobial resistance.

Efficacy of halofantrine in the treatment of uncomplicated falciparum malaria.

In the last decade, Plasmodium falciparum resistance to a number of commonly used anti-malarials especially chloroquine, has increased considerably. Newer anti-malarial drugs are therefore being aggressively evaluated as alternatives. A randomized double-blind controlled trial was therefore undertaken, to compare the efficacy of halofantrine to that of metakelfin, in the treatment of moderately severe infections of Plasmodium falciparum in an endemic malaria area in Kenya. Three hundred and thirty five subjects with laboratory confirmed malaria were recruited and randomized to receive treatment with either halofantrine (171 subjects) or metakelfin (164 subjects). Two thirds (66%) of the study subjects were under the age of five years, and were therefore considered to have minimal immunity. All study subjects were initially admitted to hospital for three days and then followed up as out-patients on days 7, 14, 21, and 28. The level of parasitaemia, the presence of fever and the occurrence of adverse effects were evaluated. Halofantrine was found to be comparable to metakelfin in terms of resolution of fever (mean time 45 and 51 hours respectively). No major adverse side effects were observed. Halofantrine is a viable drug in the treatment of uncomplicated P. falciparum malaria.

Prevalence of persistent diarrhoea in children aged 3-36 months at the Kenyatta National Hospital, Nairobi, Kenya.

Three hundred and eighty four children aged 3-36 months admitted to the Infectious Diseases Hospital (IDH) with diarrhoea were studied for persistent diarrhoea (PD), defined as diarrhoea lasting more than 14 days. To establish the duration of diarrhoea, the children were evaluated daily while in hospital and on days seven, fourteen, twenty one and twenty eight of the diarrhoea episode, if discharged. Of these children, 268 (69.8%) were less than 12 months. There was a slight male preponderance with a male to female ratio of 1.2:1. Twenty (5.4%) children presented with diarrhoea of more than 14 days at admission while of the 364 who presented with diarrhoea of less than 14 days at admission, 40 (11%) developed persistent diarrhoea, giving a total PD rate of 16.5%. The peak age for PD was nine months with no sex difference. Some possible risk factors for PD were identified as blood in stools, pneumonia, malnutrition, not breastfeeding, severe dehydration and antibiotic treatment. The total number of deaths in the study cases was 50, giving a case fatality rate of 13.6%. Of the children with PD, 19(31.7%) died. The children with PD were at a four times greater risk of dying (P<0.001, OR = 4.16). This study indicates that prevalence of PD among children admitted to IDH is high; and carries a high case fatality.