Provision of guideline-based care for drug-resistant tuberculosis in South Africa: Level of concordance between prescribing practices and guidelines

A national, multicentre web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa

OBJECTIVES

Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa is limited. These needs to be addressed to improve future use and reduce antimicrobial resistance rates. Consequently, the objective is to quantify antimicrobial usage;and identify and classify which antimicrobials are used in the peadiatric population in public sector hospitals in South Africa according to World Health Organiosation (WHO) AWaRe list of antimicrobials METHODS: Conduct a point prevalence survey among 18 public sector hospitals from nine provinces using a newly developed web-based application. The data will be analysed according to the WHO AwaRe list to guide future quality improvement programmes.

RESULTS

1261 paediatric patient files were reviewed with 49.7% (627/1261) receiving at least one antimicrobial, with 1013 antimicrobials prescribed overall. The top five antimicrobials included ampicillin (16.4%), gentamycin (10.0%), amoxicillin and enzyme inhibitor (9.6%), ceftriaxone (7.4%), and amikacin (6.3%). Antimicrobials from the Access classification were the most used (55.9%) with 3.1% being from the Reserve classification. The most common infectious conditions were pneumonia (21.3%; 148/1013) and clinical sepsis (16.0%; 111/1013). Parenteral administration (75.6%) and prolonged surgical prophylaxis (66.7%; 10/15) were common and concerns. 28% of the paediatric patients had cultures requested for them before antimicrobial treatment (284/1013) however only 38.7% (110/284) of culture results were available in the files.

CONCLUSION

Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.

Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

BACKGROUND

Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the "TB consilium") to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019.

METHODS

We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed.

RESULTS

Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and "observation while on current regimen" (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed.

CONCLUSION

Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important "gatekeepers" for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.

Treatment Compliance of Multidrug Resistant Tuberculosis in Uzbekistan: Does Practice Follow Policy?

Compliance with treatment guidelines is essential to achieve successful outcomes in tuberculosis patients. Thus, we assessed if multidrug-resistant tuberculosis treatment practices from 2012-2018 in Uzbekistan were compliant with national guidelines in terms of regimens prescribed, weight-based drug dosages used, and documentation of treatment changes (such as prolongation of intensive phase, change of drugs, and their reasons) in the treatment card and Consilium form. A total of 1481 patients were included. Of them, only 25% received standardized regimens as per guidelines and the remaining received individualized regimens. There was an increasing trend in using standardized regimens from 2% in 2012 to 44% in 2018. Compliance to recommended weight-based drug dosages was observed in 85% of the patients during the intensive phase and 84% in the continuation phase-ranged 71-91% over the years. Prolongation of the intensive phase was done in 42% of patients. The treatment was changed in 44% of patients during the intensive phase and 34% of patients during the continuation phase. The documentation of treatment changes was suboptimal (42-75%) during the initial years (2012-2014); however, it improved significantly during later years (86-100%). Future research should explore reasons for non-compliance so that the quality of patient care can be improved.