Browsing by Author "Swe Swe-Han, Khine."

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Causes of meningitis in the era of HIV.
(2021) Ramjathan, Praksha.; Swe Swe-Han, Khine.
No abstract available.
A descriptive analysis of the routine use of genotype MTBDRsl in a high HIV/TB prevalent region in South Africa.
(2020) Lutchminarain, Keeren.; Mvelase, Nomonde Ritta.; Swe Swe-Han, Khine.
Background. Since the implementation of shortened drug regimens for the management of drug resistant tuberculosis (TB), there is a growing need for rapid detection of resistance to second line antimycobacterial drugs. The GenoType MTBDRsl Version 2 allows for the rapid molecular detection of resistance conferring mutations to fluoroquinolones (FQ) and second line injectable drugs (SLIDs). Although the GenoType MTBDRsl is recommended for use directly on smear positive and smear negative clinical specimens, the feasibility of using this assay routinely within a programmatic setting in high HIV/TB endemic areas requires exploration. Objectives. To assess the feasibility of routinely using the GenoType MTBDRsl in a high HIV/TB prevalent region and to describe the various circulating resistance patterns detected by this test in KwaZulu-Natal. Methods. A retrospective data analysis of all GenoType MTBDRsl results in newly diagnosed rifampicin resistant (RR-TB)/multidrug resistant TB (MDR-TB) specimens was performed. The assays performance on direct testing of smear positive and smear negative specimens was compared. The various mutation patterns for FQ and SLIDs identified by this test was observed. 21 Results. Of 1873 RR-TB/MDR-TB, 37,4% were smear negative and 62,5% was smear positive. In smear negative specimens, the GenoType MTBDRsl showed an inconclusive rate of 61,2%, whilst amongst the smear positive specimens, an inconclusive rate of only 6,6% was observed. The commonest mutation pattern observed for FQ occurred at the gyrA gene at codon 90 (A90V) 61/158(38,6%) followed by the D94G mutation 31/158 (19,6%). Heteroresistance for FQ was observed in the gyrA gene for 6/158 (10,1%) isolates. For SLIDs, the commonest mutation occurred in the rrs region specifically A1401G, 71/108 (65,7%) followed by C1402T at 20/108 (18.5%). Conclusion. The routine use GenoType MTBDRsl Version 2 assay is more feasible in smear positive specimens as compared to smear negative specimens in high HIV/TB settings. To improve future development of the assay, further studies looking at the various resistance patterns are required.
External ventricular drain infections: a retrospective analysis at a central hospital in KwaZulu-Natal, South Africa.
(2022) De Meyer, Jenine Naomi.; Mahabeer, Yesholata.; Swe Swe-Han, Khine.
Objectives We describe clinical, laboratory and microbiological characteristics of patients with suspected EVD-related infections (EVDRIs), colonisation and contamination. Methods An observational analytical retrospective descriptive cohort study was conducted on all positive cerebrospinal fluid (CSF) cultures from external ventricular drains (EVDs) at a referral hospital from 2019 - 2021. Episodes were categorised as infection, colonisation or contamination based on pre-defined clinical and laboratory characteristics. Demographic data, clinical information and identification and susceptibility results of microbes isolated from CSF were analysed for each of these episodes. Results One hundred and sixty-three patients were included with 337 positive CSF cultures. Positive cultures were grouped into 213 episodes; 76 (36%) infection, 13 (6%) colonisation and 124 (58%) contamination. The median duration of EVD insertion to infection was 17 days. In the infection group 58 episodes (76%) had low CSF glucose, persistently low or decreasing CSF glucose. Sixty-seven patient episodes (88%) had high CSF protein or increasing protein. The CSF white cell count (WCC) was higher in the infection group versus colonisation and contamination groups with a wide range. The causative organisms of EVDRIs were predominantly Enterobacterales (33%), extensively drug-resistant (XDR) A. baumannii (27.6%) and coagulase-negative staphylococci (CoNS) (13%). The causative organisms of EVD-related colonisation and contamination were predominantly CoNS. Conclusion Laboratory parameters (CSF glucose, protein and WCC) were useful to distinguish EVDRIs from colonisation and contamination. However clinical manifestations require correlation with laboratory abnormalities to diagnose EVDRIs. Multidrug resistant (MDR) Enterobacterales and extensively drug-resistant (XDR) A. baumannii were the commonest cause of EVDRIs.
Fosfomycin: an oral treatment option for multi drug resistant uropathogens.
(2021) Naidoo, Alicia.; Swe Swe-Han, Khine.; Mvelase, Nomonde Ritta.
Introduction Urinary tract infections (UTIs) are commonplace in both the community and hospital environment where it is accepted clinical practice to treat empirically. Consequently, this has led to an alarming increase in antimicrobial resistance in frequently prescribed oral treatment options. In light of the global shortage of newly discovered antibiotics, there is a need to relook at older antimicrobial agents, such as fosfomycin, to fill the gap in therapeutic guidelines. Purpose of the Study It was the purpose of this study to ascertain the extent of antimicrobial resistance in commonly isolated urinary pathogens to frequently prescribed antibiotics. This was done with the intention of bringing to light the severity of the situation. We also looked at fosfomycin as a possible alternative to the currently recommended treatment options most especially in multi drug resistant (MDR) infections. Method A retrospective analysis of antimicrobial susceptibility data of positive urine specimens collected during 2018 – 2020 was performed. Additionally, fosfomycin susceptibility testing was performed in 178 stored MDR uropathogenic isolates using the gold standard agar dilution method. We also compared agar dilution (reference method) to disk diffusion and E test as they are less labour intensive. All data and isolates were obtained from RK Khan Laboratory located in KwaZulu Natal, South Africa. The Clinical and Laboratory Standards Institute guidelines was utilised as the guiding document. Results While conducting the laboratory information system (LIS) based review, it was determined that within the study time frame, 3044 common urinary pathogens were isolated, with Escherichia coli being the most frequent cause of UTI (1603: 53%), followed by Klebsiella spp (437: 14%). Both organisms showed high rates of resistance to amoxicillin clavulanic acid (AMC) (29.8% and 42.3%) and ciprofloxacin (37.7% and 30.4%) which are popular treatment options. Our study on fosfomycin susceptibility in MDR uropathogenic isolates revealed that of the 178 isolates, E. coli was the most prevalent isolate (97: 55%), followed by Klebsiella spp (55: 30.9%). E. coli had a susceptibility rate of 93.8% to fosfomycin, while Klebsiella spp had susceptibility rate of 78%. Categorical agreement was achieved between agar dilution and disk diffusion at 91%, although there was a high rate of false susceptibility at 42.9%. Categorical agreement between agar dilution and E tests at only 89% did not meet CLSI guideline. Conclusion While E. coli remains the most commonly isolated uropathogen, resistance rates for both E. coli and Klebsiella spp to frequently prescribed oral treatment options are alarmingly high, leaving clinicians very little in the way of viable treatment options. There is a need to keep abreast of current antimicrobial resistance trends as well as look at alternative treatment options. To that end, the use of fosfomycin as an alternative oral treatment option in a UTI is a viable solution, most especially when the infection is caused by a MDR E. coli. Lastly, though laborious, agar dilution remains the most reliable method in establishing antimicrobial susceptibility in fosfomycin.
Investigating the prevalence of vaginitis pathogens in HIV infected and uninfected pregnant women In Durban, South Africa.
(2020) Mzimela, Ntokozo.; Swe Swe-Han, Khine.; Abbai, Nathlee Samantha.
BACKGROUND: Vaginitis in pregnancy significantly contributes to obstetric complications such as preterm labor. Human Immunodeficiency Virus (HIV) infection is thought to increase risk of acquiring vaginitis in pregnancy and vice versa. Currently, there are limited data on the prevalence of vaginitis pathogens in vaginal infections and uninfected pregnant women from Durban. This study compared the prevalence of bacterial vaginosis (BV), Candida spp. and Trichomonas vaginalis (T. vaginalis) across HIV infected and uninfected pregnant women, thereby contributing to the body of knowledge in this area. In addition, this study identified risk factors associated with HIV infection, BV, Candida species (spp). and T. vaginalis in the studied population. METHODS: This study was a sub-study of a larger study which enrolled 273 pregnant women from King Edward VIII hospital in Durban. For the larger study, data obtained from eligible women included; sociodemographic, sexual behavior and clinical data. All participants were tested for HIV as part of standard of care at the clinic and two self-collected swabs were obtained from each woman. Permission to obtain data on their HIV status was requested from each women. One vaginal swab was used to test for the presence of vaginal pathogens and the second swab was stored for future use. The BD Max vaginal assay was used to detect BV, T. vaginalis and Candida spp. from a single swab. The prevalence estimates for HIV, BV, T. vaginalis and Candida spp. were calculated using percentage frequencies. Univariate and multiple logistic regressions were used to assess risk factors for HIV status and vaginitis pathogens. All analysis were conducted using RStudio. RESULTS: Of the n=273 enrolled in the larger study, n=128 women provided permission to access data on their HIV statuses. Therefore, for the current study a sample size of n=128 was available for analysis. Of the n=128 women in this study, 52/128 tested positive for HIV resulting in a HIV prevalence of 40.6%. The most prevalent vaginal infection diagnosed in the study population was Candida spp. (73/ 128, 57%), followed by BV (61/ 128, 47.7%) and T. vaginalis (14/128, 10.9%). BV positivity increased the likelihood for HIV by >2-fold (OR: 2.91, 95% CI: 1.08 – 8.63, p= 0.042), being Candida positive increased risk for HIV by 4-fold (OR: 4.04, 95% CI: 1.52 – 11.68, p= 0.007) and testing positive for T. vaginalis increased risk for HIV by 10-fold (OR: 10.15, 95% CI: 2.38 – 55.81, p= 0.018). Having 2-4 lifetime sex partners increased the likelihood of being HIV infected by 9-fold (OR: 9.78, 95% CI: 2.69 – 47.07, p= 0.001) and having >4 lifetime sex partners increased the likelihood of being HIV infected by 33-fold (OR: 33.88, 95% CI: 5.62 – 274.00, p< 0.001). In the adjusted analysis, not knowing if their partner had other partners, increased the risk of being BV positive by 4-fold (OR: 4.05, 95% CI: 1.58 -11.16, p=0.005) and alcohol consumption increased the risk of being BV positive by 4-fold (OR: 4.44, 95% CI: 1.54 -14.96, p=0.009). Having a current abnormal vaginal discharge and HIV infection were significantly associated with Candida infection (OR: 3.63, 95% CI: 1.45- 9.90, p=0.008), and (OR: 5.19, 95% CI: 1.98 – 15.21, p=0.001), respectively. Similarly, to Candida infection, having a current abnormal vaginal discharge increased the risk of T. vaginalis infection by 5-fold (OR: 5.37, 95% CI: 1.39 – 24.59, p=0.019) and HIV infection increased the risk of T. vaginalis infection by 23-fold (OR: 23.25, 95% CI: 4.52 – 174.17, p=0.001). CONCLUSION: In this study, behavioral factors played a significant role in the risk for contracting infections. It is imperative that women must first perceive themselves to be at risk for contracting infections before they can be motivated to reduce that risk. This can be accomplished by conducting future studies which administer a risk assessment tool to the women so that they can be made aware of actual risk versus perceived risk. Older age group (25-34 years) of pregnant women has also been identified to be at higher risk of HIV transmission, therefore this group should be mainly targeted for risk assessment and prompt HIV testing during pregnancy. Lastly, routine screening of BV, Candida & T. vaginalis is recommended during pregnancy, as many women in this particular study population were found to be co-infected with all three pathogens. The screening is highly recommended largely, due to the fact that vaginitis in pregnancy has been identified as a risk factor for HIV infection.
The phenotypic and clinical characterisation of tigecycline coresistant carbapenem-resistant Enterobacterales observed at Inkosi Albert Luthuli Central Hospital, Durban, South Africa.
(2021) Sheik Aboo, Khathija Bibi.; Swe Swe-Han, Khine.
Background Rising rates of carbapenem-resistant Enterobacterales (CRE) and limited therapeutic options have resulted in clinical dependence on tigecycline with subsequent emergence of tigecycline coresistant CRE (TGC Co-R CRE). Characterisation of TGC Co-R CRE is imperative to limiting its propagation. Objective We sought to determine the frequency, clinical implication, and microbiologic characteristics of TGC Co-R CRE at Inkosi Albert Luthuli Central Hospital from 2017 to 2019. Methodology We undertook a retrospective descriptive study. Data sources comprised the laboratory and hospital information systems. The frequency of TGC Co-R CRE was calculated. Specimen type, species, antimicrobial resistance, infection onset, antimicrobial exposure, age, sex, comorbidities, ward, and clinical outcome were characterised. Results The frequency of TGC Co-R CRE was 2/53 (3.8%) in 2017, 0/90 (0.0%) in 2018 and 4/123 (3.3%) in 2019. The decrease was not significant (p = 0.148). Six isolates were recorded. Acquisition was uniformly healthcare associated. Most cases (5/6; 83,3%) were female and two-thirds (4/6; 66.7%) were paediatric. Most cases were ICU patients (5/6; 83,3%). Most cases (5/6; 83.3%) were carbapenem-exposed. None were tigecycline-exposed. Comorbidities included HIV (2/6; 33.3%), SLE (1/6; 16.7%), burns (1/6; 16.7%) and surgery (2/6; 33.3%). Half the patients (3/6; 50.0%) demised. Specimens comprised peritoneal dialysis fluid (1/6; 16.7%), blood culture (1/6; 16.7%), endotracheal aspirate (2/6; 33.3%), catheter urine (1/6; 16.7%) and wound swab (1/6; 16.7%). Species comprised Klebsiella pneumoniae (3/6; 50.0%), Enterobacter cloacae (2/6; 33.3%) and Serratia species (1/6; 16.7%). All isolates were multidrug-resistant (MDR). Conclusion The advent of TGC Co-R CRE is a phenomenon warranting further research into prevalence, resistance mechanisms and acquisitional risk factors. The results of this study are of hypothesisgenerating value for subsequent research.
Spectrum of organisms and outcome of neonatal infections in HIV-exposed and unexposed newborns at a tertiary care hospital in KwaZulu-Natal.
(2021) Mahabeer, Prasha.; Mlisana, Koleka Patience.; Swe Swe-Han, Khine.
The World Health Organisation’s (WHO) recommendation of life-long antiretroviral prophylaxis to pregnant women who are positive for Human Immunodeficiency Virus (HIV) has increased HIV-exposed but uninfected infants. These infants are more likely to be born premature and small for their gestational age. They require prolonged hospitalisation, making them susceptible to nosocomial infections. The study aimed to determine the organisms causing infections in these HIV-exposed newborns, their susceptibility profiles, risk factors and outcome compared to their unexposed counterparts. Methods: This prospective descriptive study was conducted at King Edward VIII Hospital in Durban between January 2014 and December 2019. Laboratory and clinical data of neonates admitted to the neonatal unit with possible bacterial infection were collected. The organisms and their susceptibility profiles from blood cultures, cerebrospinal fluid and endotracheal aspirates were reviewed. Results: A total of 276 neonates were included in the final analysis, 50.7% of which were HIV-exposed. Group B Streptococcus was the predominant organism isolated in the HIV-exposed neonates in early-onset sepsis while Group B Streptococcus and Klebsiella pneumoniae in the HIVunexposed. Gram-negative bacilli accounted for 65.8% of the bloodstream organisms causing late-onset sepsis of which Klebsiella pneumoniae was the most common Gram-negative pathogen with 61% being extended-spectrum β-lactamase (ESBL) producing and 23% carbapenemase-producing. Antimicrobial resistance was common in endotracheal aspirates which included ESBL producing and carbapenemase resistant Klebsiella pneumoniae, ESBL producing E. coli and multidrug-resistant (MDR). Acinetobacter spp. as well as Gram-positive bacteria that were resistant to Cloxacillin. HIV-exposure was found to be associated low birth weight (p <0.001). Conclusion: Group B Streptococcus remains the most common pathogen causing early-onset sepsis in both HIV-exposed and unexposed neonates and is covered by the current empiric antibiotics prescribed in the unit. Resistant gram-negative bacteria caused the majority of the episodes of late-onset sepsis in both groups. A review of antibiotic treatment for late-onset sepsis and infection prevention and control policies is warranted.
A standardised approach to the treatment and management of significant acinetobacter species infection at academic complex hospitals in KwaZulu-Natal.
(2017) Swe Swe-Han, Khine.; Mlisana, Koleka Patience.; Baba, Kamaldeen.; Pillay, Manormoney.
Introduction: Carbapenem-resistant Acinetobacter species (Acinetobacter spp.) are increasingly recognised as important pathogens, whose resistance patterns present a high-risk global challenge. However, there is limited scientific data and a lack of a standardised approach to help the clinician select optimal therapy in local setting. This study aimed to provide a standardised approach for the management of significant Acinetobacter spp. infection based on phenotypic and genotypic characterisation of local isolates, as well as clinical characteristics and outcomes of patients at academic complex hospitals in KwaZulu-Natal. Objectives: The significance of Acinetobacter spp. infections and the most effective drug combinations for optimal therapy were determined. Acinetobacter spp. isolates were phenotypically and genotypically characterised. This was followed by the development of a standard management guideline for local use, based on the data obtained in the different objectives. Methods: The research consisted of a retrospective and prospective observational and experimental laboratory component. The laboratory component included synergy testing of colistin, susceptibility to antimicrobial agents in use at local hospitals, polymerase chain reaction and sequencing for analysis of the resistant genes related to carbapenem, colistin and amikacin. Phenotypic, genotypic, and clinical characterisation were utilised to develop a standardised management approach of significant Acinetobacter spp. infection. Results: Acinetobacter spp. was identified as a significant cause of sepsis and mortality among patients in a surgical intensive care unit (ICU). Cases of multidrug-resistant (MDR) and extensively drug-resistant (XDR) Acinetobacter spp. increased over seven years, together with the emergence of pandrug-resistant (PDR) isolates. The results of synergy testing of colistin combinations with amikacin, carbapemens (imipemen, meropenem), ciprofloxacin, tazocin, linezolid, rifampicin and vancomycin against Acinetobacter spp. was highly diverse and speciesdependent. Characterisation of Acinetobacter spp. isolates showed that oxacillinase β-lactamase (OXA-23)-producing MDR isolates correlated with their antibiogram. Pulsed field gel electrophoresis (PFGE) showed horizontal transfer between seven clusters, each containing two patients each, totalling 14 patients. However, the PFGE typing revealed a diverse collection of MDR Acinetobacter spp. clones, and that isolates from not more than two patients were related. This suggests, therefore, that no outbreak had occurred based on the PFGE typing interpretation. Further genetic investigation revealed that the aphA6 gene were associated with amikacin resistance and IpxA gene may be associated with colistin resistance in our local setting. Conclusion: The results highlighted the importance of antibiotic stewardship in the treatment of Acinetobacter spp. infection. Individual-specific antibiograms are recommended as the best 2 approach for treatment in KwaZulu-Natal (KZN) and synergy testing should be performed for individualised direct therapy. The clinical and microbiological indicators of significant infection are crucial when establishing the decision to treat. The study provided a valuable standardised approach, including a flow chart of criteria for sepsis and colonisation; a standardised algorithm for the management; and synergy test at academic complex hospitals, Medical Microbiology laboratory, National Health Laboratory Service (NHLS) in KZN.