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Item Open Access The association between serum procalcitonin levels and outcomes of patients admitted to two tertiary paediatric intensive care units in the Bloemfontein academic complex: a retrospective analytical study(University of the Free State, 2021-01) Luyo Sanchez, Augusto Martin; Pienaar, M. A.Background: The risk of mortality should be assessed in all patients admitted to the Paediatric Intensive Care Unit (PICU). Procalcitonin (PCT) is a valuable biomarker in the diagnosis of sepsis in the PICU. Its use as a prognostic marker has been widely investigated with conflicting results. This study was done to assess the association between PCT and outcomes in the PICU in our setting thereby investigating its prognostic capabilities. Objectives: The primary objectives were to determine the admission PCT, the PCT between 48 – 72 hours of admission, and the PCT change within this time frame, of patients admitted to the PICU at two tertiary hospitals within the Bloemfontein academic complex as well as their primary (PICU mortality) and secondary (length of PICU stay, number of ventilatory days) outcomes. The secondary objectives were to compare these PCT trends with the primary and secondary outcomes. Methods: The study was a retrospective analytical cross-sectional medical record review of patients, between 1 to 60 months of age, who were admitted to the PICU within the Bloemfontein academic hospital complex from 01 January 2017 to 31 December 2018. Admission PCT and trends within 72 hours of admission were compared to the participant outcomes (PICU mortality, length of PICU stay and number of ventilator days). Data was obtained from the participants electronic and paper medical records and the National Health Laboratory Services database. De-identified data was submitted for analysis by the Department of Biostatistics, University of Free State. Results: 381 participants were included in the study. 55 participants died. 220 required mechanical ventilation. The median length of PICU stay was 6 days. Non-survivors had a higher median admission PCT (13.94ng/ml, IQR 1.0 – 100.0) than survivors (1.45ng/ml, IQR 0.36 – 13.08) (p<0.0001, 95% CI 1.28 – 15.12). Non-survivors had a higher median PCT at 48-72(12.79ng/ml, IQR 2.08 – 100.00) hours than survivors (1.31ng/ml, IQR 0.29 – 7.15) (p<0.0001, 95% CI 2.50 – 21.72). Non-survivors had less of a median decrease in PCT (-0.12ng/ml, IQR -3.68 to +4.125) than survivors (-0.40ng/ml, IQR -4.88 to +0.05) (p=0.22, 95% CI -0.59 - 4.72). The area under the receiver operating characteristics curve (AUROCC) for admission PCT to discriminate for mortality was 0.6702 and for the 48-72-hour PCT it was 0.7369. The strongest profile for PCT to discriminate for mortality was found at the 48-72hour PCT at a threshold of 3.16ng/ml (sensitivity 73.3%; specificity 64.5%). The median PCT change in participants requiring ventilation (-0.23ng/ml, IQR -2.72 to +0.52) was less than for those not requiring ventilation (-0.76ng/ml, IQR -6.34 to -0.05) (p= 0.0044, 95% CI -1.67 - -0.16). There was a positive correlation between PCT and number of ventilator days (spearman correlation co-efficient =0.1477, p=0.0138). There was no significant correlation between the length of PICU stay and admission PCT(p=0.7579), the PCT change (p=0.2034) or the percentage PCT change (p=0.2625). Conclusion: PCT displays some ability to discriminate for PICU mortality. Serial PCT measurements provide greater prognostic information. Non-survivors had a significantly greater median admission PCT, median PCT at 48-72 hours and a lower median PCT decrease than survivors. PCT above 3.16ng/ml at 48-72 hours had the strongest profile to discriminate for mortality.Item Open Access The incidence, clinical profile and antimicrobial susceptibility pattern of Acinetobacter baumannii sepsis in premature neonates at Universitas Academic Hospital for the period 1 January 2016 to 31 December 2018, a retrospective descriptive study(University of the Free State, 2021-02) Moodley, Mark; Pienaar, Michael A.BACKGROUND: Acinetobacter baumannii is an emerging and challenging pathogen in neonatal units, due to its ability to develop resistance against antibiotics. Studies on Acinetobacter baumannii infection in premature neonates are lacking in developing countries. OBJECTIVES: To determine the incidence, clinical presentation, antibiotic susceptibility profiles and the morbidity and mortality rate of premature neonates with Acinetobacter baumannii infection. METHODS: We conducted a retrospective descriptive study at a tertiary hospital in Bloemfontein, South Africa. Medical records were reviewed over 36 months. Premature neonates admitted to the neonatal intensive care unit with positive blood, urine or cerebrospinal culture for Acinetobacter baumannii were identified through the National Health Laboratory Services. RESULTS: Fifty premature neonates were enrolled. There was an incidence of 103 cases per 1000 admissions/ year. The median age at the onset of sepsis was 17 days (IQR 9-26). Known risks such as central venous catheters and parental nutrition were found in 78% (39/50), and 68% (34/50) respectively. Respiratory distress (56% [28/50]) and abdominal distension (50% [25/50]) were the most common clinical signs. Of all the isolates, 86% (43/50) were susceptible to colistin only. Supportive therapy was frequently required, 48% (24/50) received vasoactive drugs, and 70% (35/50) were mechanically ventilated. Mortality related to infection was 36% (18/50). CONCLUSION: There was a high incidence of Acinetobacter baumannii sepsis in premature neonates at Universitas Academic Hospital. A significant number of neonates had a central catheter and received parental nutrition. Most isolates were resistant to the carbapenems but susceptible to colistin. Vasoactive drugs and mechanical ventilation were frequently required. The mortality rate was high from Acinetobacter infection which is in keeping with most studies. Strict infection control and antibiotic stewardship are imperative.Item Open Access Characteristics and outcomes of infants with cytomegalovirus infection in Bloemfontein(University of the Free State, 2020-09) Moodley, Melisha; Van der Byl, Arina; Goedhals, DominiqueBackground: Cytomegalovirus (CMV) can be transmitted from mother to child and can be congenital or postnatally acquired. Emerging evidence has shown that CMV and other congenital and neonatal infections, are under-appreciated causes of morbidity and mortality in African children. Research regarding the mortality rate and characteristics of CMV infected infants, specifically in a population with high HIV prevalence, is limited. Objective: The primary objectives of the study were to establish the mortality rate and final outcomes of inpatients with a positive CMV test. Secondary objectives were to determine the demographical, clinical and laboratory characteristics of these infants, as well as maternal characteristics. Tertiary objectives were to describe the special investigations, morbidity, complications and management of these infants. Methods: A retrospective, descriptive study was conducted by reviewing hospital records of infants younger than 12 months, who had a positive CMV test and were admitted to the academic hospitals in Bloemfontein, South Africa. Results: Inpatient mortality for CMV infected infants was 13.3% (18 of 135 patients). 66.6% (12/18) of patients who died were HIV exposed and 33.3% (6/18) had CMV/HIV co-infection. The most common causes of death were sepsis (38.9%), pneumonia/pneumonitis (33.3%) and multi-organ failure (11.2%). 60.7% (82/135) of all CMV positive infants were HIV exposed and 20.7% (28/135) were HIV infected. 55.6% had a birth weight of less than 2,5 kg and were preterm, and 33.3% were small for gestational age. 5.9% were classified as congenital CMV and 94.1% as postnatally acquired. The most common clinical presentations were CMV pneumonia/pneumonitis (60%) and hepatomegaly (50.4%). Thrombocytopenia was a common finding (41.5%). 33.3% of infants had intra-uterine growth restriction and postnatal growth was suboptimal in 62.2%; 25.2% were underweight, and 37% of infants had failure to thrive. Microcephaly was present at birth in 25.2%, but poor brain growth led to postnatal microcephaly in 46.6%. Infants that were untreated for CMV infection were more likely to have developmental delay (P-value <0.05). 50% (9/18) of the infants that demised were not treated for CMV. Conclusion: CMV infection in infancy is under-appreciated in South Africa. It contributes to morbidity and mortality, particularly in preterm and low birth weight infants, and HIV exposed or infected infants. Clinicians should have a high index of suspicion for CMV infection in infants who have postnatal growth failure and postnatal microcephaly.Item Open Access Prevalence of thrombocytopaenia in neonates admitted in neonatal high care unit of Pelonomi Tertiary Hospital Bloemfontein between January 2017 and June 2017(University of the Free State, 2019-08) Onwugbolu, Anselm Uche; Van Rooyen, J.BACKGROUND: Thrombocytopaenia is the most common haematological abnormality, besides anaemia, found in the neonates admitted to a neonatal intensive care unit. Even though most cases are mild or moderate, requiring minimal or no intervention, and resolving spontaneously within the first week of life; a few infants, especially the very sick ones or the extremely low birth weights (<1000g), may present with severe and in some cases persistent thrombocytopaenia, which may require intervention such as platelet transfusion. OBJECTIVES: The primary objective of this study was to determine the prevalence of thrombocytopaenia in neonates admitted to the neonatal high care unit (NHCU) of Pelonomi Tertiary Hospital (PTH). METHODS: The study was a retrospective descriptive study conducted on 694 infants admitted to the NHCU of PTH between January 2017 and June 2017. Data included were neonatal demographic information, information regarding the clinical data of neonate and the mother obtained from the neonatal admission book used routinely at PTH by the admitting medical doctor. Infants with thrombocytopaenia were identified using the National Health Laboratory Service web results viewer. The data regarding the rate of performance of platelet count per patient in the cohort group was not collected as the primary objective was to determine whether or not thrombocytopaenia was present in the samples taken within the 72 hours of birth. Also, the common reason for doing blood investigations in the cohort group was not specified during the data collection because this attribute was not documented in the patients’ records. The data analysis was performed using the SAS System version 9.4. RESULTS: During the study period, a total of 694 neonates were admitted to the NHCU of PTH. Of these, 16.3% (n=113) infants were diagnosed with thrombocytopaenia (platelet count < 150 x 109/L), but 5 neonates were excluded in the study as their medical files were either incomplete or missing. Of the remaining 15.6% (n=108) neonates with defined thrombocytopaenia whose medical files were available, thrombocytopaenia was almost equally distributed across the gender, 50.9% (n=55) for females, and 49.1% (n=53) for male infants; low birth weight infants (1500 - 2499g) were mostly affected, 41.7% (n=45). According to gestational age, infants born between 32 and 37 weeks of gestation were mostly affected than others, 50% (n=54). Thrombocytopaenia was seen more in neonates whose birth weight was appropriate for their gestational age, 59.3% (n=64), than in small for gestational age counterparts, 38.9% (n=42). Early onset thrombocytopaenia (≤ 72h of life) occurred in 55.6% (n=60), while 44.4% (n=48) were of late onset (>72h of life). According to severity, neonatal thrombocytopaenia were predominantly mild, 51.9% (n=56). Twenty infants (18.5%) were diagnosed with sepsis based on a positive blood culture (bacterial and fungal), including 4 infants (20%) who demised. Of these, gram negative sepsis was the most common, 55% (n=11), with a mortality rate of 36.4% (n=4). Six infants (5.6%) had confirmed congenital abnormality with thrombocytopaenia. 3 of these infants (50%) were confirmed Trisomy 21. Sixteen (14.8%) of the infants diagnosed with thrombocytopaenia developed IVH. 43.8% (n=7) of these infants demised. NEC was seen in 15.7% (n=17), with 3 deaths (17.6%) occurring in this group. Of the 108 infants confirmed with thrombocytopaenia, only 3.7% (n=4) received a platelet transfusion in our unit, including 3 (75%) who demised. The most common maternal conditions were PET 29.6% (n=32), and PIH 21.3% (n=23). The study showed that chorioamnionitis was not a common maternal variable found in babies diagnosed with thrombocytopaenia in our unit, as only 0.93% (n=1) of this variable was identified during the study. Other main outcome measures identified were number of infants with thrombocytopenia discharged alive 87% (n=94) vs those who demised 13% (n=14). An equal gender distribution for mortality was seen with 50% mortality occurring in male and female infants. CONCLUSION: The prevalence of neonatal thrombocytopaenia in NHCU of PTH between January 2017 and June 2017 was 15.6%. The thrombocytopaenia which were mostly mild (51.9%), occurred slightly more in female infants than their male counterparts (50.9% vs 49.1%). Of these, the low birth weight infants were mostly affected (41.7%). The study confirms thrombocytopaenia is a common problem in our unit, thus physicians caring for the infants must be aware of this in order to curb the morbidity and mortality burden thereof.Item Open Access Screening, diagnosis and management of autism spectrum disorders amongst healthcare practitioners in South Africa(University of the Free State, 2021-05) Matlou, M. J.; Griessel, D. J.Background: There is a global increase in Autism spectrum disorders (ASD) prevalence, awareness and its effect on the burden of disease. It is crucial that ASD is recognized and diagnosed timeously for early intervention during the age of high neuroplasticity for optimal outcomes. We do not know if Health Care Practitioners (HCPs) in South Africa working in paediatric departments are able to diagnose and manage these children with complex medical needs. Objectives: This study was done to determine how paediatric HCPs in South Africa screen for, diagnose and manage autism spectrum disorders in both the public and private sector. Paediatric healthcare workers, general practitioners and primary level personnel are typically the first point of contact for family members concerned with ASD traits. Methods: A cross sectional descriptive analytical study design was conducted over a period of 11 months, from 1 March 2020 to 31 January 2021. An in-depth questionnaire was sent out via an electronic platform, namely Chatbot to eligible participants. A random sample of 116 completed questionnaires were captured on Google spreadsheets by Dekode IT Company and used for statistical analysis. Results: The majority of HCPs (70.7%) do not routinely screen children for ASD between 18-24 months as recommended by the American Academy of Paediatrics.10 Common methods used for screening ASD were; milestones, development and occasionally the checklist for Autism (CHAT)/Modified-CHAT. There was lack of knowledge about diagnostic tools used for ASD in 40% of HCPs that made ASD diagnosis. HCPs opted for developmental history, medical examination, unstructured behavioural observation, parental concern and DSM 5 criteria to make the diagnosis, which might under- or overestimate ASD statistics. Following the diagnosis 78.5% of HCPs referred patients to another discipline. Common referrals to speech therapists and occupational therapists for coordinated multidisciplinary assessment were noted. Hearing screen was a frequent investigation undertaken when making the ASD diagnosis. Other investigations occasionally used were CT/MRI, EEG, fragile X and genetic microarray analysis. Of the HCPs that managed ASD patients, less than 25% initiated treatment by prescribing risperidone followed by methylphenidate and valproate respectively. Supplements used were multivitamins, omega acids and Vitamin B6. Barriers to diagnosing and managing ASD identified in this survey were lack of experience, educational resources, referral centers, family support, specialists in the field, therapists, time and parental denial. In 85% of cases a HCP would provide information to the caregiver about autism. Conclusions: HCPs in SA lack knowledge, awareness, and training to diagnose and manage children with ASD. Autism is not screened for routinely or as recommended in practice. There is a lack of knowledge about the diagnostic tools to diagnose ASD. Not all suspected Autism cases were referred for multidisciplinary assessment and a hearing screen. There were multiple barriers contributing to making an early diagnosis of Autism noticed.Item Open Access Association between Hypochromic Microcytic Anaemia and Febrile Seizure in patients admitted at Pelonomi Tertiary Hospital in Bloemfontein from January 2019 to December 2019(University of the Free State, 2021-07) Madikizela, Thozamile; Jardim Eleftheriou, P. R.BACKGROUND: Febrile seizure, which affects 2-5% of neurologically healthy children, is the most common type of seizure in children. The seizures occur in the context of a global iron deficiency that stands out as the most common nutritional deficiency especially prevalent in developing countries. Studies carried out to determine the association between febrile seizures and iron deficiency anaemia have yielded contradictory results. OBJECTIVES: To evaluate the association, if any, between febrile seizures and hypochromic microcytic anaemia (iron deficiency anaemia). Hypochromic microcytic anaemia is a surrogate for iron deficiency anaemia. METHODS: This was a retrospective cross-sectional study. A study population consisting of 244 patients, admitted over the period of twelve months with infective febrile illnesses, was included in the study. The age group was between six months and five years. In addition, 55 of these patients had febrile illnesses complicating with febrile seizures while 189 had febrile illnesses without febrile seizures. All of the patients’ full blood counts (FBC) were used to determine if each had hypochromic microcytic anaemia. The following FBC parameters were used: haemoglobin (HB), mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH) and red cell distribution width (RDW). Chi-square and Fischer’s exact tests were conducted for statistical interpretation. Finally, a comparison of full blood count parameters between the children with febrile seizures and those without was made. RESULTS: The mean age of all patients included in the study was 17 months. The study had 153 male patients who constituted 62.7% of the study population. The majority of patients had lower respiratory tract infection. Full blood count parameters of patients with febrile seizures and those without febrile seizures were similar. There was no statistical significance between the two groups (p=0.826). CONCLUSION: The results of the study, based on hypochromic microcytic anaemia used as surrogate for iron deficiency anaemia, showed no association between iron deficiency anaemia and febrile seizures. This was due to the lack of difference between patient with febrile seizures and those without febrile seizures, with no statistical difference.Item Open Access Clinical presentation and outcomes of anomalous left coronary artery from the pulmonary artery: a retrospective study from January 1998 - August 2019 at the Department of Paediatrics Cardiology, Universitas Hospital(University of the Free State, 2020-09) Makhoba, Ntombikayise Gladys; Ferris, A. R.; Brown, S. C.BACKGROUND: Anomalous left coronary artery from the pulmonary artery (ALCAPA) or Bland-White-Garland syndrome is a rare congenital anomaly that has profound effects on heart function. Patients with ALCAPA present with non-specific symptoms like irritability, feeding difficulties and signs and symptoms of cardiac failure. If left untreated, ALCAPA has a 90% mortality rate in the first year of life, primarily due to myocardial ischemia and heart failure. It is therefore important to diagnose them in time and offer surgery. OBJECTIVES: The primary objective of the study was to determine the clinical presentation and severity of symptoms using the Ross classification and to describe the clinical status of the patients at last follow up, including the clinical outcome (Ross classification) and survival. METHODS: This was a retrospective descriptive study at the Department of Pediatric Cardiology between January 1998 and August 2019. All patients with the diagnosis of ALCAPA during the study period were included. Medical records of patients referred from Free State, Northern Cape and Lesotho were reviewed. Data collection included demographics of patients, clinical presentations, referral diagnosis, echocardiography before and after surgery, catheterization data, surgical data, clinical presentation at last follow up and ECHO at last follow up. Data was captured using the REDCap® online database. The researchers considered a Ross classification of more than two as clinically diagnostic of heart failure. The SF ranges were classified as follows: SF >28% = normal, SF 20-25% = mild, SF 15-20% = moderate and SF <15% =severe. RESULTS: During the study period a total of 30 patients presented to Universitas Paediatric Cardiology Unit with the diagnosis of ALCAPA. At presentation, 89% (n=25) of patients were in cardiac failure with a Ross classification for age of more than two. The diagnosis of ALCAPA was made primarily by echocardiography in 75.8% (n=22) of patients. Most patients 83.3% (n=25) had a dilated heart at presentation, with a median LVEDD z-score of 6.4 and 37% (n=11) had severe LV dysfunction (SF <15%). About half of the patients, 43% (n=13) had severe MR. ALCAPA repair was done in 76.6% (n=23) of our patients. The median age at surgery was 35 months (range: 1 day - 73 months), with a median weight of 6kg (range: 4kg - 20kg). The median days from diagnosis to the day of surgery was 11 days (range: 1 day to 6 years). Most patients had re-implantation of the anomalous left coronary artery except for two where the left coronary artery was tied off. One child required a left ventricular assist device (LVAD) for 7 days post operatively and survived. Immediately post-surgery there was some improvement on left ventricular function with 17% (n=4) of patients demonstrating normal SF and 13% (n=3) had mild left ventricular dysfunction. Heart failure symptoms (Ross) at follow-up improved significantly from original presentation (p < 0,01): forty five percent, (n=8) of our patients had no symptoms of cardiac failure, with Ross classification of two and less. At last follow a marked improvement on LV function was observed with 73% (n=11) patients having a normal SF. SF at last follow up showed a statistically significant difference compared to, at presentation with a p-value of 0.014. Seventy eight percent (n=18) of patients were alive at the end of the study and mortality post-surgery was 22% (n=5). CONCLUSION: Our results show that most children in central South Africa present in the first year of life with clinical features of heart failure. The most common echocardiographic features at presentation are impaired systolic function, dilated left ventricles and mitral regurgitation. Furthermore, surgery results in significant clinical and echocardiographic improvement. It is of paramount importance to have a high index of suspicion based on the clinical presentation and ECHO to ensure early referral, so corrective surgery may be offered timeously.Item Open Access PIM 3 predicted mortality compared to the observed mortality rate for patients in the PICU in Universitas Academic Hospital, segregated into four physico-chemical aspects for acid-base disturbances(University of the Free State, 2020-07) Robbetze, John Werner; Solomon, L. J.Background: The PIM 3 score is widely used in PICU’s, to monitor the quality of care of patients. The reason for this study is to compare the mortality rate for the PICU at Universitas Academic Hospital with the PIM 3 predicted mortality rate and like previous studies to see if there is any association between mortality and the magnitude or nature of the metabolic acidosis. Objective: The primary objective is to determine the SMR for the PICU at Universitas Academic Hospital for the period 1 January 2016 to 31 December 2018 and the secondary objective, to determine the association between mortality and the different variable for D.A. Story’s four equations for the base excess (BESID, BELact, BEAlb and BEOI). Method: It was a retrospective cross-sectional chart review of all patients, between 0 and 156 months of age, admitted from 1 January 2016 to 31 December 2018. The data used was obtained from the statistics kept in the PICU, patient’s files and NHLS Trackcare system. The data was analysed by the Department of Biostatistics at the University of the Free State and Fisher’s Exact Test was applied to the data to determine if there is any statistical significance. Results: 711 patients were admitted. 12 were excluded due to their ages being more than 156 months. 251 patient files had complete bloodgas information. There were 74 deaths (10.9%) in the PICU during this period. The SMR was calculated as 1.5. Among patients with complete data, an association was noted between mortality and increasing PIM 3 risk score (p-value of 0.0001). Hyperlactataemia (>2 mmol/L) and hyperchloraemia (above 120 mmol/L), had a strong association with mortality with p-values of 0.0041 and 0.013 respectively. Conclusion: The observed mortality rate was higher than the predicted mortality rate according to the PIM 3 score. The study also concluded that mortality is not associated with the magnitude of the metabolic acidosis, but rather the nature (Hyperlactataemnia and hyperchloraemia) of the acidosis.Item Open Access Blood culture contamination in the Department of Paediatrics of Universitas- and Pelonomi Hospitals(University of the Free State, 2020-08) Krause, R. C.; Simmons, S.Background: Sepsis and septic shock are one of the most important risk factors for mortality in children. Blood cultures remain the gold standard to identify the causative organisms of sepsis and to obtain the antibiotic sensitivity profile. The shortcoming of blood cultures is that only 5 to 13% of cultures will turn out to be positive and roughly 20 to 56% of these will represent contaminants. The South African Society for Clinical Microbiology (SASCM) endorses the blood culture sampling technique as described by Ntusi e t al . (2010). Abrahams et al . (2015) described that there was poor adherence to these standards which contributes to a high blood culture contamination rate. There is a shortage of South African studies addressing the problem of blood culture contamination. Objective: To determine the blood culture contamination rates in the Department of Paediatrics at Pelonomi- and Universitas Hospital for the month of May to 27 August 2019 by reviewing blood culture results. To assess blood culture sampling technique amongst clinicians by means of anonymous questionnaires. Methods: This is a descriptive study. The blood culture contamination rate for 1 May 2019 to 27 August 2019 was determined by analysing NHLS data. Clinician blood culture sampling practices were described by using information from anonymous questionnaires which were handed out to clinicians working in the Department of Paediatrics during the same period. Results: Of the 244 blood cultures reviewed, 61 (25%) had positive growth, 36 (15%) grew contaminants and 7 (3%) grew more than one organism. The blood culture contamination rate was 15%. Thirty-two percent of clinicians were aware of the SASCM guidelines regarding blood culture sampling technique, but only 3% indicated that they complied with the guidelines. Conclusion: This study found a blood culture contamination rate which is almost five times higher than internationally accepted rate. It also found that clinicians were not aware of blood culture sampling guidelines and in the few cases where clinicians were aware of these guidelines, compliance with these guidelines was not met. Recommendations made, include quarterly review of blood culture contamination rate at these institutions and making clinicians aware of correct technique or optimising technique within the limited circumstances by putting together guidelines on blood sampling techniques for blood cultures for local use.Item Open Access A retrospective analysis of the incidence of invasive candidiasis in the extreme - and very low birth weight neonates admitted to the neonatal ICU and high care unit in Universitas Academic Hospital over a 2 year period from January 2016 to December 2017 to determine if the unit will qualify for the use of fluconazole prophylaxis(University of the Free State, 2020-06) De Klerk, Leandri; Van Zyl, R.Background: Invasive Candida infection is a leading cause of mortality and morbidity during the neonatal period, specifically in premature neonates admitted to intensive care units. Fluconazole prophylaxis has been proven to effectively reduce the incidence of invasive candidiasis in neonates admitted to high care facilities. Methods: A retrospective, descriptive, cross-sectional, non-experimental study was conducted. Data was collected from the Meditech and National Health Laboratory Service databases. Positive culture results on sterile body fluids were analyzed to determine the incidence of invasive candidemia in the neonatal unit at Universitas Academic Hospital. Sterile body fluids included blood, urine and cerebrospinal fluid. Results: The results revealed an incidence of 13.5% of invasive candidiasis in the extremely- and very low birth weight neonates admitted to the neonatal unit at Universitas Academic Hospital. These results included all the positive cultures done on urine, cerebrospinal fluid and blood. The study population was 324 neonates admitted to the neonatal unit of Universitas Academic Hospital with a birth weight of less than 1.5 kg for the years 2016 and 2017. The population group included 183 female neonates (56%) and 141 male neonates (44%). The median gestational age was 29 weeks and the median birth weight was 1110g. The positive Candida culture results included 43 blood cultures, 5 urine cultures and zero cerebrospinal fluid cultures. Conclusion: The incidence rate for invasive candidiasis in very low birth weight and extremely low birth weight neonates at Universitas Academic Hospital was 13.5% during the study period. Previous research studies concluded that an incidence rate higher than ten percent of invasive Candida infection is significant and a neonatal unit will benefit from the use of fluconazole prophylaxis. Decreasing the incidence will have a direct effect on the morbidity associated with neonatal invasive Candida infection. The recommendation following the findings of the study would be to include the use of fluconazole prophylaxis as standard of care in the neonatal unit at Universitas Academic Hospital and to adapt policies and protocols accordingly.Item Open Access Necrotising enterocolitis in the Bloemfontein academic complex(University of the Free State, 2020-06) Osman, Tabassum; Moodley, P.Background: Necrotising enterocolitis (NEC) is a serious acquired gastrointestinal emergency affecting predominantly premature neonates, especially those with a birthweight of <1500g. Despite advances in neonatal care, the condition still accounts for a high mortality and morbidity. In a resource limited setting, the disease may be more devastating. While other centres in South Africa have reported on the epidemiology, risk factors and outcomes of neonates with NEC, there are no comparable studies to date in the Free State Province. This study aims to lessen this gap. Objectives: The primary objective was to describe the prevalence and short-term outcomes of infants with NEC in terms of death, discharge or transfer. Secondarily it aimed to describe the presence of known risk factors and the course of illness and to compare all the above parameters between the weight categories - < 1000g, 1001g to 1499g and 1500g to 2000g. Methodology: This was a retrospective, descriptive cross-sectional study of infants with a birth weight of ≤2000g. There were 184 participants that were included in the study. Medical records and discharge summaries were used to extract relevant data. Descriptive statistics for categorical data and medians and percentiles for numerical data were calculated, per group. The groups were compared by means of Kruskal-Wallis test for numerical data and Chi-square or Fisher’s exact test for categorical data. The prevalence was calculated and described by means of 95% confidence interval for the prevalence. Results: There were 2574 neonatal discharge summaries of babies born with a weight ≤2000g that was screened and after exclusion criteria was applied, 184 neonates with confirmed NEC were identified. The prevalence of NEC was 7.1% [6.2%; 8.2%]. The distribution of cases according to weight were 47 in < 1000g, 101 in 1001 to 1499g and 36 in > 1500g categories. Fifty-six infants (30.4%) died [23 (41.1%) were < 1000g, 28 (50%) were 1001g to 1499g and 5 (8.9%) were >1500g], 106 (57.6%) were discharged and 22 (12%) were transferred to their base hospital. Mortality rates were higher in NEC grade 3A [11 (19.7%), RR 3.22 (95% CL 2.23 ; 4.52), P<. 001] and NEC grade 3B [ 28 (50%), RR 3.09 (95% CL 2.07 ; 4.61), P< .001]. Significant risk factors per weight category were maternal pre-eclampsia, RDS, mechanical ventilation and blood transfusion. Conclusion: NEC remains a formidable challenge to clinicians caring for neonates with prevalence and mortality rates comparable to other tertiary neonatal units.Item Open Access The incidence of acute kidney injury amongst very low birth weight neonates in the neonatal unit at Universitas Academic Hospital during the period of January 2016 to June 2016(University of the Free State, 2019-12) Ngwenyama, P. Z.; Mosia, T. B.Background. Acute kidney injury is common amongst patients admitted in neonatal intensive care. It is associated with mortality and mobility especially in very low birth weight infants. We diagnose and define Acute kidney injury using the kidney disease improving global outcomes guidelines and looked at the incidence especially before two weeks of age. Objectives. The main objective of this study is to determine the incidence of Acute Kidney injury in Very low birth neonates admitted at neonatal intensive care unit of the Universitas Academic Hospital, from January 2016 to June 2016. Using recent proposed neonatal Acute kidney Injury classifications by Kidney disease: Improving Global Outcomes workgroup definition modified for neonates secondary objective was to look at the risk factors associated with AKI and that the Acute kidney injury in the first two weeks of life is associated with increased mortality in Very Low birth infants. Method. This was a retrospective descriptive study of Very Low Birth Weight infants (<1500) infants admitted in Neonatal Intensive Care Unit at the Universitas Academic Hospital. This study included 58 patients that fulfilled the inclusion criteria and other patients were excluded. Patients’ data were obtained through files, Medical records (Meditech) and National Laboratory health services. KIDGO (Kidney disease improving global outcomes) guidelines was used to make the diagnoses of Acute kidney Injury. Results were then classified as Early and Late onset Acute kidney injury and creatine categorized to look at the outcome. Ethical approval was obtained from Health Sciences Ethic committee: Faculty of Health sciences of the University of Free state. Results. The overall incidence of Acute kidney injury was noted to be 8.6 %(n=7). The incidence of AKI in the early onset Acute Kidney injury group were 6.9 % (n=4) as compared to lower rates of 5.2% (n=3) in the late onset Acute kidney injury group. The most common risk factors for Acute kidney injury was noted to be Sepsis, drug exposure, Perinatal asphyxia and Respiratory distress syndrome. Suspected Sepsis being the highest at 80%. There was a 14.28% (n=1) mortality rate amongst those who had Neonatal Acute kidney injury. Conclusion. Neonatal AKI is common among VLBW infants in our setting corresponding to other single Centre studies in developed countries. However, we could not establish a relationship between Acute kidney injury and in hospital increased mortality. Risk of Acute kidney injury among infants diagnosed with suspected sepsis was higher compared to those without suspicion of sepsis.Item Open Access Coarctation of the Aorta: a 10-year follow-up study of patients treated at the Department of Peadiatric Cardiology, Universitas Academic Hospital(University of the Free State, 2019-12) Nyindi, Nompi Margaret; Buys, D.; Brown, S.Background: Coarctation of the aorta accounts for 6-8% of all congenital cardiac lesions. It can be treated surgically or percutaneously depending on the age and weight at presentation and associated cardiac lesions. Objectives: To describe the outcomes of management in patients with native coarctation of aorta with regard to re-intervention and mortality rate. Methods: A retrospective, descriptive review of patients with native coarctation of aorta was done at Universitas Academic Hospital using an electronic database. Included were patients who presented from 01 Jan 2007 – 31 Dec 2016, from birth to 19yrs. Results: The study comprised of 107 patients, median age of 33 days (1 – 4940) with a median weight of 3.9kg (1 – 53.5kg).Common associated cardiac lesions included PDA (n=61; 57%), bicuspid valves (n=41; 38.3%) and VSD (n=31; 29%). A total of 82 patients (75.7%) required an intervention in which 71(86.6%) had surgery with 12(14.6%) requiring a second intervention, while 11(13.6%) had percutaneous procedures with 7(63.6%) requiring a second intervention. Overall mortality was 17(15.9%), the cause of death in 14(82.4%) was cardiac related. Conclusion: From the results of this review surgery remains the preferred treatment for coarctation of the aorta and are associated with a lower recoarctation rate compared to percutaneous interventions.Item Open Access A retrospective analysis of the mortality, and the perinatal risk factors for mortality, of very low birth weight infants admitted to Universitas Academic Hospital over a 2-year period – January 2016 to December 2017(University of the Free State, 2020-07) De Abreu, Nelson Serrao; Van Der Byl, A.Background: A rise in preterm deliveries of very low birth weight (VLBW) infants, less than 1 500 grams, is currently introducing a global public health dilemma. VLBW infants are at increased risk for morbidity and mortality. Identifying and addressing perinatal risk factors in order to improve the prognosis of VLBW infants are fundamental. Objectives: The primary objectives of this study were to determine mortality rate and disease profile of VLBW infants admitted into the neonatal unit at Universitas Academic Hospital (UAH). The secondary objective was to determine perinatal factors which impacted the mortality of VLBW infants. Methods: A retrospective analytical cross-sectional study was conducted. Study participants, namely VLBW infants, were identified by making use of admission registries, electronic and paper patient records. This data was then used to identify causes of mortality, and perinatal risk factors that increased the risk of mortality. Results: Mortality of VLBW infants was 25.3%. The main causes of mortality were pulmonary haemorrhage (26.3%), necrotising enterocolitis (20%), multi-organ prematurity (20%) and intraventricular haemorrhage (3.8%). Male gender, low birth weight, low gestational age, no antenatal steroids received, hypothermia, surfactant administration, and the need for ventilation were all factors associated with increased mortality. Metabolic acidosis and hyperlactataemia also demonstrated a strong association with mortality. Conclusion: Survival rates of VLBW infants compare favourably with tertiary hospitals in South Africa and developing countries. Basic interventions, such as improving antenatal care and avoiding neonatal hypothermia, and limiting risk factors associated with pulmonary haemorrhage will minimise the mortality risk. Policy change, regarding admission of infants weighing more than 900 grams to intensive care, should be considered to allow escalation of care to improve survival.Item Open Access Mortalities in the neonatal unit: after-hours compared with normal working hours at Pelonomi Tertiary Hospital over a 1-year period (January 2017 to December 2017)(University of the Free State, 2020-04) Duba, S. E.; Van Rooyen, J. J.Background: Neonatal mortality remains one of the leading causes of under-5-mortality in South Africa. South Africa has not reached the Millennium Development Goals targets for 2015 as set out by the WHO. The leading causes for neonatal mortality remains immaturity related (48.1%), complications of hypoxia (24.2%) and infections (11.2%). According to the PPIP and CHPIP program data, many of these deaths do have avoidable factors that are administrative and staff related. If there is a difference found in mortalities when comparing normal working hours with after-hours, then it is possible that administrative and staffing differences for these hours could be a reason for differences seen. This could assist relevant stakeholders to optimize allocation of resources (including staffing) as well as guide further research to investigate possible reasons for differences in mortalities for different time intervals. Objectives: This research set out to investigate whether or not there are differences in the number of neonatal mortalities at Pelonomi Tertiary Hospital, Bloemfontein, when comparing normal working hours with after-hours. If there are differences, then to determine if there are differences in the avoidable factors involved in these mortalities (according to the PPIP and CHPIP data). Method: This was a descriptive, cross-sectional study. The total number of mortalities (January 2017 – December 2017) for normal working hours and after-hours were investigated, and avoidable factors (according to PPIP and CHPIP codes) for these mortalities were compared. Results: A total number of 103 neonatal mortalities for this time period were included in this study. More deaths occurred after-hours (16:00 – 07:30 on weekday, whole weekends and whole public holidays) when compared to normal working hours (all other weekdays 07:30 – 16:00) (n=67, 65.05% vs n=36, 34.95%). When the time frames are divided into after-hours (any day 16:00 – 07:30) and normal working hours (any day 07:30 – 16:00), more deaths occurred after-hours (n=55, 53.4%). Most of these (any day) after-hour mortalities occurred between 16:00 and 00:00 (n=31, 56.4%). The most common causes of death for these neonates reflect the same causes as the national PPIP/CHPIP data, being 1. Infection related (n=26, 25.24%), 2. multi-organ immaturity (n=21, 20.39%) and 3.Complications of hypoxia (n=18, 17.48%). There were no major differences in administrative and staff-related avoidable factors when comparing these different time intervals. Conclusion: This study confirms that during this time period there were more neonatal deaths occurring after-hours when compared to normal working hours at Pelonomi Tertiary Hospital, Bloemfontein. Due to the design of this study we could not conclude whether or not these differences are statistically significant. To optimize allocation of limited resources and staffing, the researcher concludes that further research to determine the factors which may contribute to these differences in mortalities for different time intervals is warranted.Item Open Access The disclosure of HIV status to vertically infected HIV positive children before the age of 12 years at Pelonomi Centre of Excellence(University of the Free State, 2020-02) Bodiba, Tshepho Lesiba Laurence; Van Zyl, RianaHIV is a chronic infection which, although cannot be cured, can be controlled with life-long treatment, provided there is good adherence. Good adherence requires a holistic approach. The patients need to have adequate food, good social support system and participation in their treatment decisions. The lack of any of the above-mentioned factors can have deleterious effects. This is particularly a problem in children. Adherence is dependent on the carer when they are still young. Once they get to teenage years, they start asking questions. The National Department of Health has provided guidelines on step wise disclosure for children. This study explored the prevalence of disclosure to vertically infected children from 6 to 18 years of age. The study was conducted in a South African tertiary hospital paediatric HIV clinic in Bloemfontein, Pelonomi Hospital. Data was collected in the form of a questionnaire, which was completed by the caregiver, and in those that met the criteria the children filled a different section. Convenient sampling method was used. The results showed a better outcome (76% disclosure prevalence, 65% being full disclosure), compared to the other studies (Western Cape, South Africa, 23.7%, 2019 and Zimbabwe, 29.6%, 2019). The difference in the level of care of the current study compared to the previous studies, which were mostly primary level of care, could contribute to the results as well. Of note is that the patients in this study were complicated patients, most of whom were on second line treatment. The suggested average age of disclosure by the children themselves was 12, which is higher than the South African guidelines of full disclosure by the age of 10 years. The best person to disclose and the place where it should be done was also suggested by the children. This study augments the platform that has been set for the authorities to implement a disclosure program into paediatric HIV care.Item Open Access Late onset neonatal sepsis in very low birth weight premature infants in the neonatal high care unit, Pelonomi Hospital, Bloemfontein: a cohort study(University of the Free State, 2018) Pienaar, Michael A.; Van der Vyver, A. E.Background: Late onset neonatal sepsis (LOS) is a common problem in very low birth weight (VLBW) infants and is associated with increased mortality, morbidity and cost of care. Several known risk factors are reported in the literature, which may be maternal, host or healthcare related. Hygiene practices, overcrowding, staffing and healthcare interventions all play a role in the risk of LOS. Pelonomi Neonatal High Care is a 32-bed regional neonatal unit. The study period was from September 2015 to March 2016. Methods: This was a prospective cohort study. Study Population: All VLBW infants with birth weight between 1000g and 1499g excluding those referred to tertiary centers and those born with major congenital abnormalities were enrolled and followed up to 28 days of life. Results: 117 infants were included. 43,6% of infants had at least one episode of LOS (incidence 435 per 1000 births per annum). There was a higher incidence of gram-negative (31%) and fungal infections (17%) than reported elsewhere. The use of invasive ventilation, nasal CPAP, nasal prong oxygen and surfactant were significantly associated with LOS as was increased duration of umbilical venous catheterisation. Longer periods to the initiation of feeding and the use of cefotaxime increased the risk of LOS. Breastfeeding appears to confer protection against LOS. Exposure to human immunonvirus and high maternal viral load may be a risk factor for LOS. LOS was present in 40% of deaths beyond 72hours of life and 10% of infants with LOS died. LOS was associated with increased morbidity in the form of increased length of stay, longer duration to full enteral feeding, longer duration of parenteral nutrition and increased necrotising enterocolitis. Only 50% of the infants received antenatal steroid therapy and 96.5% of infants experienced some degree of hypothermia. The unit was persistently overcrowded and key consumables for hand hygiene were frequently unavailable. Due to the persistence of overcrowding and the short duration of the study period a statistical relationship with LOS could not be proven. Conclusion: LOS was significantly more frequent in this study population than reported in the literature with serious consequences for patients. Many identified risk factors are associated with routine practices in the care of VLBW infants in this unit. The unit was persistently overcrowded and there were several barriers to appropriate hand hygiene. Several factors such as role of genetic factors and HIV require investigation.