South African Thoracic Society position statement on the management of non-cystic fibrosis bronchiectasis in adults: 2023.

Background: Bronchiectasis is a chronic lung disorder that affects the lives of many South Africans. Post-tuberculosis (TB) bronchiectasis is an important complication of previous pulmonary TB and a common cause of bronchiectasis in South Africa (SA). No previous statements on the management of bronchiectasis in SA have been published. Objectives: To provide a position statement that will act as a template for the management of adult patients with bronchiectasis in SA. Methods: The South African Thoracic Society appointed an editorial committee to compile a position statement on the management of adult non-cystic fibrosis (CF) bronchiectasis in SA. Results: A position statement addressing the management of non-CF bronchiectasis in adults in SA was compiled. This position statement covers the epidemiology, aetiology, diagnosis, investigations and various aspects of management of adult patients with non-CF bronchiectasis in SA. Conclusion: Bronchiectasis has largely been a neglected lung condition, but new research has improved the outlook for patients. Collaboration between interprofessional team members in patient management is important. In SA, more research into the epidemiology of bronchiectasis, especially post-TB bronchiectasis and HIV-associated bronchiectasis, is required. Abstract: The South African Thoracic Society mandated a multidisciplinary team of healthcare providers to compile a position statement on the management of non-cystic fibrosis bronchiectasis in South Africa (SA). International guidelines on the management of bronchiectasis were reviewed and used as a basis from which the current position statement was compiled. This is the first position statement on the management of adult non-cystic fibrosis bronchiectasis in SA. A description of the epidemiology and aetiology of bronchiectasis is provided, as well as guidance on its diagnosis and management. The position statement provides guidance on the management of bronchiectasis to healthcare providers, policymakers and regulatory authorities.

Outcomes of patients with haematological malignancies and febrile neutropenia at the Universitas Academic Hospital multidisciplinary intensive care unit, Free State Province, South Africa.

Background: Mortality rates in patients with haematological malignancies who required intensive care unit (ICU) admission have in the past been high. More recently, however, improved outcomes for critically ill haematological patients have been reported. Objectives: To determine outcomes, average length of ICU stay, and factors associated with mortality in patients with haematological malignancies and neutropenic fever in the multidisciplinary ICU (MICU) at Universitas Academic Hospital (UAH), Bloemfontein, Free State Province, South Africa. Methods: We conducted a retrospective review of medical and laboratory records of all patients admitted to the UAH MICU with haematological malignancies and febrile neutropenia between 2010 and 2019. Results: A total of 182 patients with haematological malignancies were admitted to the MICU between 1 January 2010 and 31 December 2019, of whom 51 (28.0%) fulfilled the inclusion criteria for the study. The median age was 33 years, and 29 patients (56.9%) were female. Most patients had either acute myeloid leukaemia (n=22; 43.1%) or acute lymphocytic leukaemia (n=16; 31.4%), while B-cell lymphoma (n=12; 23.5%) and multiple myeloma (n=1; 2%) were less frequent. The median length of stay in the ICU was 3 days. ICU mortality was 76.5% and hospital mortality 82.4%. Factors associated with mortality included septic shock, vasoactive agent use and mechanical ventilation. Conclusion: Patients with haematological malignancies and febrile neutropenia in the UAH MICU have high ICU and hospital mortality rates. More needs to be done with regard to timeous management of patients with haematological malignancies and septic shock in our setting to improve survival. Study synopsis: This is the first study to report on ICU mortality of adult patients with haematological malignancies and neutropenic sepsis in a tertiary hospital ICU in the Free State. These patients had a high mortality rate. What the study adds. Our study shows that septic shock, vasoactive agent use and mechanical ventilation were associated with increased ICU mortality.Implications of the findings. Strict adherence to infection prevention and control measures in haematology wards is required. Early recognition and treatment of sepsis before it progresses to septic shock is important. ICUs must be designed so that isolation cubicles are readily available to prevent cross-infection of patients.

Core competencies in critical care for general medical practitioners in South Africa: A Delphi study.

Background: Despite a high burden of disease that requires critical care services, there are a limited number of intensivists in South Africa (SA). Medical practitioners at district and regional public sector hospitals frequently manage critically ill patients in the absence of intensivists, despite these medical practitioners having had minimal exposure to critical care during their undergraduate training. Objectives: To identify core competencies in critical care for medical practitioners who provide critical care services at public sector hospitals in SA where intensivists are not available to direct patient management. Methods: A preliminary list of core competencies in critical care was compiled. Thereafter, 13 national and international experts were requested to achieve consensus on a final list of core competencies that are required for critical care by medical practitioners, using a modified Delphi process. Results: A final list of 153 core competencies in critical care was identified. Conclusion: The core competencies identified by this study could assist in developing training programmes for medical practitioners to improve the quality of critical care services provided at district and regional hospitals in SA. Contribution of the study: The study provides consensus on a list of core competencies in critical care that non-intensivist medical practitioners managing critically ill patients in healthcare settings in South Africa, especially where intensivists are not readily available, should have. The list can form the core content of training programmes aimed at improving critical care competence of general medical practitioners, and in this way hopefully improve the overall outcomes of critically ill patients in South Africa.

Respiratory technologists in the frontlines against COVID-19.

Background: The COVID-19 pandemic overwhelmed healthcare resources globally, but especially those of resource-limited countries. Strategies to supplement the number of healthcare workers attending COVID-19 patients had to be implemented. Several institutions used non-respiratory clinicians to work in COVID-19 wards. At Universitas Academic Hospital (UAH), Bloemfontein, South Africa, respiratory technologists were requested to assist with managing the oxygen supportive care of patients with severe COVID-19 and respiratory failure. Objectives: To highlight the contribution that respiratory technologists made in the management of severe COVID-19 pneumonia patients by describing the baseline characteristics and mortality of patients with COVID-19, whose oxygen supportive care was managed primarily by respiratory technologists at UAH. Methods: This was a retrospective study. The investigators extracted data from the hospital files of all adult patients admitted with severe COVID-19 to UAH and where respiratory technologists were involved in their care between 1 January and 31 December 2020. Results: A total of 781 patients were admitted to UAH, of whom 106 fulfilled the inclusion criteria. The majority of the patients were female (n=68; 64.1%), and the median age (interquartile range (IQR)) was 59.5 (51 - 68) years. Hypertension (n=69; 65.1%) and diabetes mellitus (n=39; 36.8%) were the most frequent comorbidities. At the time of admission, the median oxygen saturation was 92% and the median respiratory rate oxygenation (ROX) index was 3.2. The median length of stay was 7 days and the mortality was 41.5%. Conclusion: The clinical characteristics and mortality of patients whose oxygen support was managed by respiratory technologists were similar to those in previously reported studies from resource-limited settings. Respiratory technologists can form a valuable addition to the front-line team when clinicians and nurses are faced with overwhelming patient numbers in subsequent COVID-19 surges and where the mainstay of treatment is oxygen supportive care.

Central line-associated bloodstream infections at the multidisciplinary intensive care unit of Universitas Academic Hospital, Bloemfontein, South Africa.

Background: Central line-associated bloodstream infections (CLABSIs) are frequently encountered device-related healthcare-associated infections in critically ill patients, causing substantial morbidity, mortality and prolonged hospitalisation. Objectives: To determine the incidence of CLABSI, median catheter dwell-time prior to developing CLABSI, as well as the causative microorganisms of CLABSI among patients admitted to the multidisciplinary intensive care unit (MICU) at Universitas Academic Hospital, Bloemfontein. Methods: We conducted a retrospective review of medical and laboratory records of all MICU patients who had a central line placed between January and December 2018. Results: A total of 377 patients were admitted to the MICU in 2018, of which 182 met the inclusion criteria for the present study. From the cohort of 182 patients, 16.5% (n=30) of patients presented with 32 CLABSI episodes, with two patients having had two independent episodes each. A total of 1 215 central line days were recorded, yielding a CLABSI rate of 26.3/1 000-line days. Laboratory analysis identified microorganisms in 38 blood cultures, with Gram-negative organisms (55.3%; n=21) being predominant over Gram-positive organisms (39.5%; n=15) and fungi (5.3%; n=2). Conclusion: The incidence of CLABSI at the MICU at Universitas Academic Hospital is high. Urgent intervention with strict compliance to prevention bundles is required to reduce the high incidence of CLABSI.

Wolf in sheep's clothes: An uncommon case of pneumonic-type adenocarcinoma.

We report a case of a patient who presented with clinical and radiological features of a non-resolving pneumonia. Special investigations and a poor response to antibiotic therapy excluded an infective aetiology. A diagnosis of invasive mucinous adenocarcinoma, previously termed bronchioloalveolar carcinoma, was made from lung biopsy. This case illustrates the challenges of establishing a timely diagnosis of an uncommon pneumonic-type of adenocarcinoma.

Treatment outcomes of Acinetobacter baumannii -associated pneumonia and/or bacteraemia at the intensive care unit of Universitas Academic Hospital, Bloemfontein, South Africa.

BACKGROUND: Nosocomial infection with multidrug-resistant (MDR) Acinetobacter baumannii is associated with high mortality rates and the optimal treatment regimen is uncertain. OBJECTIVES: To compare outcomes, as well as ICU and in-hospital survival rates of patients with A. baumannii pneumonia and/or bacteraemia who were treated with colistin monotherapy v. colistin/tigecycline combination therapy. METHODS: This was a retrospective cross-sectional study of patients admitted to the multidisciplinary ICU of Universitas Academic Hospital, Bloemfontein, South Africa, between 1 January 2018 and 31 December 2019. RESULTS: Sixteen patients were included in the study. Nine patients were treated with a combination of colistin and tigecycline, while 7 patients were treated with colistin only. Seven out of 9 (77.8%) patients in the colistin/tigecycline combination therapy group were treated successfully and survived until discharge from ICU, as opposed to 2 out of 7 (28.6%) in the colistin monotherapy group (relative risk (RR) 2.7; 95% CI 0.80 - 9.24). Five out of 9 (55.6%) in the colistin/tigecycline combination therapy group v. 2 out of 7 (28.6%) in the colistin monotherapy group survived until discharge from hospital (RR 1.94; 95% CI 0.53 - 7.20). CONCLUSION: Although ICU survival in patients with A. baumannii infection was better when treated with colistin/tigecycline combination therapy compared with colistin monotherapy, a statistically significant difference could not be detected. Adequately powered prospective clinical trials are required to detect statistically significant differences in treatment outcomes.

Diffuse pulmonary meningotheliomatosis - a case report.

Diffuse pulmonary meningotheliomatosis is a rare condition of the lung that presents with nonspecific respiratory symptoms, and usually follows a benign course. It should, however, be considered in the differential diagnosis of a miliary pattern on chest-imaging studies, as illustrated in the case reported.

Outcomes of severe traumatic brain injury at time of discharge from tertiary academic hospitals in Bloemfontein.

BACKGROUND: Despite the condition being a major public health concern, limited data are available regarding survival rates and the requirement for post-hospitalisation support of patients with traumatic brain injury (TBI) in South Africa (SA). OBJECTIVES: To describe the clinical profile and in-hospital outcomes of patients with TBI at intensive care units (ICUs) of tertiary referral hospitals in the Free State Province, SA, between 2013 and 2017. METHODS: This retrospective descriptive study of patients with TBI was conducted at Pelonomi Tertiary and Universitas Academic Hospitals. Patients' demographic information and variables such as mechanism and type of injury, Glasgow Coma Scale (GCS) prior to ICU admission, neurosurgical intervention, duration of stay in ICU and hospital, GCS and final outcome at discharge were recorded. RESULTS: The 138 patients included in the final data analysis had a median (range) age of 30.5 (13 - 70) years, with a male predominance of 82.6%. The median lengths of stay in ICU and hospital were 6 and 16 days, respectively. Outcomes data showed that 65.9% of patients survived until discharge from hospital. Of patients whose GCS could be determined at discharge, 52.8% were deceased, 7.9% were in a persistently vegetative state, 11.2% had severe and 13.5% moderate disability, and 14.6% had a good recovery. CONCLUSION: TBI is associated with high mortality and morbidity. The lack of post-hospitalisation rehabilitation, and support for patients and their caregivers, requires urgent redress.