The development of the National ARI Control Programme in Lesotho.
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Acute Disease↗
Biomedical subjects
S C Redd
Publications and source records attributed to S C Redd.
Emergence of highly trimethoprim-sulfamethoxazole-resistant Shigella in a native American population: an epidemiologic study.
Resistance to trimethoprim-sulfamethoxazole (TMP-SMX) emerged among Shigella isolates from the Navajo Reservation in the southwestern United States in 1985, years after this antimicrobial agent came into common use. In the study area, TMP-SMX resistance increased dramatically from 3 per cent in 1983 to 21 per cent in 1985. Resistance was polyclonal and occurred in both S. sonnei and S. flexneri. No single plasmid was common to all resistant strains. However, all 28 TMP-SMX resistant isolates examined were resistant to ampicillin and streptomycin and had minimum inhibitory concentrations to sulfamethoxazole of greater than or equal to 4,096 micrograms/ml and to trimethoprim of greater than or equal to 1,024 micrograms/ml. The authors found that 28 of 101 Navajo children with gastrointestinal symptoms who were not taking antimicrobials had TMP-SMX-resistant aerobic fecal flora. To determine risk factors for acquiring resistant strains, they compared 40 case-patients with TMP-SMX-resistant Shigella to 66 controls with TMP-SMX-sensitive Shigella. Case-patients were more likely than controls to have used antimicrobials recently (p = 0.004) and to be hospitalized for shigellosis (p = 0.05). These findings suggest that polyclonal highly TMP-SMX-resistant Shigella emerged by transfer of trimethoprim resistance genes from aerobic bowel flora to endemic Shigella strains, that use of antimicrobials can lead to symptomatic shigellosis and thus the persistence of trimethoprim-resistant Shigella, and that appropriate therapy of shigellosis on the reservation is now a major challenge.
Adolescent↗
Legionella prosthetic-valve endocarditis.
Since 1982 seven patients at Stanford University Medical Center have been shown to have prosthetic-valve endocarditis caused by Legionella pneumophila or L. dumoffii. We studied the clinical features of legionella endocarditis at the time of diagnosis and performed a case-control study to analyze risk factors for the infection. All patients with endocarditis had a chronic course (3 to 19 months after surgery) of fever, night sweats, weight loss, and anemia, but no embolic events or immune-complex deposition disease. Five patients required surgical replacement of their infected prosthetic valves. The case-control study revealed that during the early postoperative period, patients who later contracted legionella endocarditis were more likely to have had symptoms and signs attributable to postcardiomyotomy syndrome than were patients who did not contract endocarditis (P less than 0.013). Examination of the legionella isolates by means of molecular techniques demonstrated that the Stanford L. pneumophila isolates were genotypically identical to isolates from the hospital drinking water. L. dumoffii isolates from patients with endocarditis were derived from a single strain apparently unique to this medical center. We conclude that legionella infection was nosocomially acquired in the perioperative period. These cases demonstrate an expanding spectrum of illness caused by legionella species and emphasize the need to consider legionella as a cause of "culture-negative" endocarditis.
Endocarditis, Bacterial↗
Legionellosis in cardiac transplant recipients: results of a nationwide survey.
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Heart Transplantation↗
Immunoblot analysis of humoral immune responses following infection with Bordetella pertussis or immunization with diphtheria-tetanus-pertussis vaccine.
To help develop better diagnostic tests for pertussis, we examined the serologic response to whole-cell proteins of Bordetella pertussis after natural infection or vaccination with diphtheria-tetanus-pertussis vaccine. Serum specimens collected during a pertussis outbreak investigation and from uninfected persons were used in Western blot (immunoblot) analyses to determine the presence of immunoglobulin G (IgG) and IgA antibodies to specific B. pertussis proteins. IgG antibodies to proteins of molecular masses 220 and 210 kilodaltons (kDa) were detected in 14 of 18 serum samples obtained from patients with culture-confirmed pertussis greater than or equal to 40 days after the onset of coughing. IgA antibodies were detected in 15 of the 18 samples. Of 19 serum samples obtained from patients who had not been ill with pertussis, 6 contained IgG antibodies to these proteins and 1 contained IgA antibodies. The two proteins bound antiserum specific for filamentous hemagglutinin and comigrated with purified filamentous hemagglutinin. IgG antibodies to two additional protein bands of molecular masses 84 and 75 kDa were associated with previous vaccination. Antibody to the 84-kDa protein was detected in 15 of 17 vaccinated, never-infected persons, and antibody to the 75-kDa protein was detected in 16 of the 17. None of 11 nonvaccinated, never-infected persons tested had antibodies to either protein. All seven fully vaccinated persons with culture-documented infection had antibodies to both proteins. Antibodies to the 84-kDa protein were detected in 6 of 22 nonvaccinated and infected persons, and antibodies to the 75-kDa protein were detected in 8 of the 22. Use of Western blot analysis in this study allowed us to distinguish antibody responses to infection and immunization.
Adolescent↗
Rapid group A streptococcal antigen detection kit: effect on antimicrobial therapy for acute pharyngitis.
Newly introduced rapid diagnostic tests for group A streptococcal pharyngitis should facilitate appropriate antimicrobial use in patients with group A streptococcal pharyngitis. Because of high rates of acute pharyngitis in Tuba City, AZ, at the Navajo Indian reservation, the use of rapid diagnostic test was prospectively evaluated. The sensitivity and specificity of the test was measured and changes in physician prescribing patterns attributable to use of the test were correlated. Of 320 patients with pharyngitis enrolled during the present 3-week study, 86 met the study's definition of a patient with streptococcal pharyngitis and 163 met the study's definition of a patient with nonstreptococcal pharyngitis. The rapid test was 62.8% sensitive and 96.9% specific in identifying patients from whom group A streptococci were isolated. Although treatment of patients with streptococcal pharyngitis at the time of the first visit increased from 36.5% in a retrospective sample to 72.5% during the study, treatment of patients in whom cultures were negative remained the same. Further analyses showed that physicians tended to treat patients with signs characteristic of streptococcal pharyngitis and, as the study progressed, to rely less on negative rapid test results as a reason to withhold antimicrobial agents. It was concluded that rapid tests with good specificity but limited sensitivity may improve treatment of patients with streptococcal pharyngitis by allowing earlier specific therapy. A more sensitive test with a higher negative predictive value would be necessary to prevent treatment of persons with nonstreptococcal pharyngitis.
Adolescent↗
Legionella in water: what should be done?
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Humans↗
Peritoneovenous shunts. Lessons learned from an eight-year experience with 70 patients.
The peritoneovenous shunt (PVS) is preferred over other treatment modalities in the treatment of the cirrhotic patient who has intractable ascites. The favorable effects on nutrition, pulmonary, and renal function, in addition to prompt control of ascites, frequently overshadow potentially life-threatening complications. We summarized our experience with the PVS in 70 patients with portal hypertension at Emory University, Atlanta, and identified the perioperative complications and operative mortalities. Late complications of sepsis and variceal hemorrhage were frequent and often were fatal. Of the multiple preoperative clinical and laboratory determinants, only the serum bilirubin level (greater than or equal to 3 mg/dL) was predictive of the operative mortality and longevity of survivors. The PVS should be reserved for patients with disabling, truly refractory ascites.
Adolescent↗
Hypocitraturia in calcium nephrolithiasis.
Several investigators have reported that hypocitraturia is frequent in patients with idiopathic kidney stones. In these studies, however, glomerular filtration rate, urinary tract infection, sex, diet, time of day, and medications, all potentially influential variables, were uncontrolled. Fifteen men, aged 30-52 yr, with recurrent idiopathic calcium oxalate stones and 15 normal age-matched men were studied. Patients with hyperparathyroidism, renal tubular acidosis, reduced creatinine clearance (less than 80 ml . min/1.73 M2), or urinary infection were excluded. Medications were stopped 2 weeks before the study began. A standard constant diet, furnishing 800 mg calcium and free of citrate, was fed for 20 days. During the last 10 days, 4.5 g sodium citrate were given orally. Eight-hour collections of urine were analyzed for calcium and citrate. Filtered load and net tubular reabsorption of citrate were also calculated. The 24-h urinary excretion of calcium was elevated in eight stone formers, and citrate excretion was depressed in seven. Five patients were both hypercalciuric anc hypocitraturic. The hypocitraturia resulted from excessive net tubular reabsorption of a normal filtered load of citrate. Urinary citrate was highest between 0800-1600 h, whereas calcium was highest between 1600-2400 h; both components were lowest between 2400-0800 h. The diurnal profiles of urinary calcium and citrate were similar in the stone formers and in the normal men. Oral sodium citrate did not influence urinary citrate in either group. These data suggest that in adult men, hypocitraturia may be a common predisposing factor for calcific nephrolithiasis.
Adult↗
Comparison of the clinical and radiographic diagnosis of paediatric pneumonia.
Pneumonia causes 3.2 million deaths per year in children under 5 years old according to the World Health Organization. In spite of the number of deaths, no single clinical or radiological definition for the diagnosis of pneumonia is widely accepted. To determine the extent of agreement between clinical and radiographic diagnoses of pneumonia, we compared the clinical diagnoses made by an experienced paediatrician with diagnoses based on a paediatric radiologist's interpretation of chest radiographs. In 226 children with respiratory illness brought to a hospital outpatient department in Lesotho, pneumonia was the clinical diagnosis for 39 and the radiographic diagnosis for 40; however, for only 19 children did the 2 diagnoses concur. Children with a radiographic diagnosis of pneumonia tended to have been ill longer, to be older, and to be more likely to have a technically adequate radiograph than children with negative radiographs, independent of the clinical diagnosis. In this comparison, radiographic and clinical diagnoses for pneumonia differed substantially. Some of this discrepancy may be explained by misinterpretation of suboptimal films and different rates of evolution of radiographic and clinical manifestations of pneumonia. Radiographic studies and clinical evaluations produced complementary data in this evaluation: of the 60 children with clinical or radiographic evidence of pneumonia, 14 would not have been treated with an antimicrobial drug without radiography. Wider availability of radiography is needed to supplement clinical examination for the diagnosis of pneumonia, and may be particularly valuable in children more than 18 months old, those who have been ill for more than 6 d, and those with fever.
Female↗
Validity of mother's history regarding antimalarial drug use in Malawian children under five years old.
History obtained from parents and carers is an important, and often the only, source of information for health workers treating children for malaria, but its validity has not been well evaluated. At 2 hospitals in Malawi, we obtained malaria treatment histories from mothers of 973 ill children reported to have had fever as part of the illness. Urine samples were collected from 755 of the 973 children (78%). Of the 755, 457 (61%) were reported to have received some kind of treatment. Among those who reportedly received treatment, 79 (17%) were said to have received chloroquine and 23 (5%) a sulphonamide-containing medicine; however, when urine specimens were tested for antimalarial drugs, chloroquine was found in 182 specimens (40%) and a sulphonamide in 148 (32%). Among urine specimens collected from 291 children who were reported to have received no treatment (no report was recorded for 7 children), chloroquine was detected in 56 (19%) and a sulphonamide in 44 (15%). Although not statistically significant, mothers often reported a child as not having received an antimalarial drug if the child was younger than 12 months or had been sick for more than 3 d. The mothers' information regarding home treatment of fever in children was highly inaccurate. Malaria treatment histories, whether collected at health facilities or in surveys of knowledge, attitudes, and practices, must be interpreted with caution.
Antimalarials↗
Malaria and human immunodeficiency virus infection among male employees of a sugar estate in Malawi.
In sub-saharan Africa, where malaria is endemic and diagnostic and laboratory services are limited, fever is generally presumed to be due to malaria; however, the proportion of fevers actually related to malaria is unknown in most places. This study was conducted to determine the relationship between fever, malaria parasitaemia and human immunodeficiency virus (HIV) infection. Between February and April 1994, 643 consenting adult male workers of the Sugar Corporation of Malawi (SUCOMA) in Nchalo, Chikwawa District, Malawi were enrolled in a cross-sectional study. Participants underwent routine physical examinations and data were collected on age, axillary temperature, and history of fever or other illness in the 2 weeks before enrollment. Patients with axillary temperature > or = 37.5 degrees C were considered to be febrile. Blood was collected and thick blood films were prepared and examined for the presence of malaria parasites. HIV testing was done using the Wellcozyme enzyme-linked immunosorbent assay. Complete information was obtained from 605 subjects (94%), of whom 248 (41%) reported a history of fever (only 15% of the fever reporters were parasitaemic), 139 (23%) were HIV positive, and 131 (22%) received an antimalarial drug. HIV infection was significantly associated with fever but not with parasitaemia. Fever reporters and non-fever reporters were of similar age (means 32.8 and 33.1 years, respectively). These data suggest that in this population there was both high HIV seroprevalence and gross overestimation of fever as malaria. High HIV prevalence makes it necessary to re-examine the common practice in Malawi of treating all fever among adults as malaria.
Adolescent↗