Volume7,Issue4 1stDecember2016

FIDSSAQuarterlyNewsletterofthe

FederationofInfectiousDiseasesSocietiesofSouthernAfrica

Candidaauris:thenewsuperbugontheblock

SASCMreportsurgentneedforlocalguidelinestomanageinfectioncausedbyCandidaaurisinSouthAfricanhospitals

Candidaaurishasrecentlyemergedacrosstheglobeasacauseofinvasivehumaninfectionswithacrudemortalityrangingfrom33%to72%.OverathousandpatientshavehadC.aurisculturedfromdiagnosticspecimensatpublicandprivatelaboratoriesinSouthAfrica,withmostcasesathospitalsinJohannesburg&Pretoria.Alargeproportionoftheseisolateswerefromnormally-sterilesitespecimens(bloodandcentralvenouscatheters(CVC).Woundsepsisandotitishavealsobeendescribed.

Patientsusuallyacquiretheinfectionafterhospitalizationandpossibleriskfactorsmayincludediabetesmellitus,recent

MarcMendelson(President),AndrewWhitelaw(SecretaryTreasurer),NeleshGovender(President-Elect&SASCM),GaryReubenson(SecretaryTreasurer-Elect),AdrianBrink(Past-President),ChetnaGovind(SASCM),JoyCleghorn&BrietteduToit(ICSSA),NicoletteduPlessis&MarkCotton(SASPID),JohnBlack&TomBoyles(IDSSA),LeeBaker&GarthBrink

(SASTM),MarcelleleRoux&FransRadebe(STDSSA),LeaLourens(FIDSSAAdministrator–info@fidssa.co.za)

ContentsPage1

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SASCMreport

STDSSANews

ICSSANews

IDSSANews

FIDSSAExecutiveCommittee

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SASPIDNews

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surgeryandCVCsorurinarycathetersinsitu.ItispostulatedthatC.aurismightspreadfromcolonizedorinfectedpatientsortheirimmediateenvironment(intowhichtheorganismisshed)tootherpatientsviathehandsofhealthcareworkersoronfomites.Ofgreatconcernisthatthisorganismisusuallyresistanttofluconazole,whichisthefirst-lineantifungalagentusedinmanycentres.Furthermore,recentglobaldataindicatethatmorethan40%ofisolatesareresistanttotwoormoremajorclassesofantifungals.

Unfortunately,thelaboratoryidentificationofC.aurisisdifficultemployingroutinemethods.UsingtheAPIsystems(bioMérieux,France),C.aurismaybemisidentifiedasRhodotorulaglutinis,withAuxacolor(Bio-Rad,USA)asSaccharomycescerevisiaeandwithVITEK-2YSTandVITEKMassSpectrometry(MS)systems(bioMérieux,France)asCandidahaemulonii,CandidasakeandCandidafamata.AsoftwareupgradeforVITEKMSisimmediatelyavailablewhichwouldalleviatetheproblemandtheVITEK-2YSTdatabaseisexpectedtobeupgradedearlynextyear.MALDIBiotypersystem(BrukerCorporation,USA)ormolecularmethodsreliablyidentifythisorganism.AlthoughbreakpointshavenotbeenestablishedforC.auris,antifungalsusceptibilitytestingshouldbeperformedonclinicallysignificantisolatestoguidepatienttherapy.EchinocandinsmaybeusedasempirictherapywithamphotericinBasanalternativeagentinthepublic-sector,untilfullsusceptibilityresultsareavailable.

Infectionpreventionandcontrolmeasuresincludeisolationorcohortingofpatients,standardcontactprecautionsandenvironmentaldecontaminationwithachlorine-releasingsolution.

C.aurisislikelytobeamajorpathogencausinginfectionsinallhospitals.Clinical,laboratoryandinfectionpreventionandcontrolconsensusguidelinesforSAhospitalsareurgentlyneededwiththeinvolvementofmajorstakeholdersfromNICD,SASCM,ICSSA,privateandpublichospitals,privateandNHLSlaboratories,andICUphysicians.SASCMwillendorsethespeedydevelopmentandimplementationoftheseguidelinesoverthecomingmonths.

Weconcludethisyearwithincreasedconcernsonthespreadofmulti-drugresistantorganismsinhospitalswithoneoftheunexpectedandthelatestconcernbeingCandidaauris.

InfectionPreventionandControlrecommendationsare:

Appropriateinfectionpreventionandcontrolmeasures:

o Bare-below-the-elbowspolicymustbeenforcedforallhealthcarepersonnel

o Scrupuloushandhygiene

o Standardprecautions

o IsolationofallpatientscolonizedorinfectedwithC.aurisinasingleroomwithensuitefacilitieswhereverpossible

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o Useofcontactprecautions(glovesandaprons)ifriskofsoilingwithblood/bodyfluids.

o Briefvisitorsabouttheimportanceofhandhygiene&theuseofprotectiveapronsisadvised

o Ahypochloritesolutionshouldbeusedfordisinfectionoftheenvironment,atastrengthof1000ppmavailablechlorine(i.e.higherthanthatroutinelyused)–bothforroutineterminalcleaninganddisinfection.

o Terminalcleaningofthebedspacemustbeperformedafterthepatienthasleft,preferablyusinghydrogenperoxidevapourwherefeasible.

o Particularattentionmustbepaidtocleaningofmultiple-useequipment(e.g.BPcuffs,thermometers,computers/equipmentonwheels,ultrasoundmachines)fromthebedspaceofpatientswithC.auris.

o Ifthepatientneedstogototheatreorradiologyetc.,theyshouldbescheduledlastonthelistforthedayandtheenvironmentcleanedasdescribedabove(i.e.usinghypochloritesolutionatastrengthof1000ppmavailablechlorine).

o Wasteandlinendisposalproceduresasroutineforothermultidrug-resistantorganisms.

o Alertingwards/otherhospitalsontransferofapatientwithC.auris.

o C.auriscolonisationisdifficulttoeradicateandpatientscanremaincolonizedforprolongedperiods,somaycontinuetoposeariskfortransmission.

LastmonthweinterviewedthenewChairoftheGautengInfectionControlSociety(GICS)andreportedbackontheirplansgoingforward.ThisquarterweinterviewedYolandavanZyl,ChairpersonoftheWesternCapeSociety.

“Wehavehadasuccessfulyearwiththesupportofmyteam,includingVidaMorris(treasurer)andMichelleOsborne(Secretary).Wekickedoffwithourfirstmeetingonthe25thFebruaryattheRedCrossHospitalwiththetheme:“Outbreakmanagementandreporting”.SpeakersincludedProfessorMehtarandDoctorDramowski,whospoketousaboutthemanagementofoutbreaks.RNBRhode(Melomed)andRNVMorris(GrooteSchuurHospital)alsosharedtheirexperienceswithoutbreaksattheirinstitutions.

Onthe26thMayweheldoursecondmeetingatAmpathLaboratorieswiththetopic“IPCChallengesinICU”.DrWKleintjiesfromTygerbergHospitalandDrJVanWykfromAmpathsharedtheirknowledgeonthesubject.

Then,onthe25thAugustwehadourthirdmeetingatKarlBremerHospitalwiththetopic:“InfectionControlinEmergencyServices(EMS)andAirMercyServices(AMS)”.Wehadspeakersfrompublicandprivateambulanceservices.WewereveryenlightenedregardingthechallengesthattheyhaveandhowtheytrytomaintainIPCprinciples.Wewereallreadytogoandofferthemourservicesintrainingandsupportwhenwerealizedhowfortunateweareallworkinginstructuredhealthcarefacilitiescomparedtobeingoutthere,“ontheroad”.

Ourfinalmeetingtookplaceon22ndNovemberandthemeetingwasdedicatedtotheannualAGMandfeedbackfromtheICANconference.Thesocietypartiallysponsored(conferencefees)threeWCISmemberstoattendtheICANconferencefromthe25-28September2016inJohannesburg”.

ThankstoYolandaandteamforyourfeedback.

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SAPA2016FathimaNaby,PaediatricIDspecialist,KZN

Thebiennial SouthAfricanPaediatricAssociationandSouthAfricanAssociationofPaediatricsurgeons(SAPA/SAAPS)conferencewashostedinthecoastalcityofeThekwini(Durban)fromthe1-4September2016.Theprogramconstitutedofanarrayofmulti-disciplinaryscientificworkshopsonthe31August2016,whichwaswellattended.

“Infection Prevention and Control (IPC) and Antibiotic Stewardship” was the title of the Southern AfricanPaediatric InfectiousDiseaseSociety (SASPID)workshopwiththethreesessionschairedbyProfNicoletteduPlessis,DrMelissaLawlerandDrMoArchary.

ProfduPlessissetthestage,byopeningthesessionwithaninteractivecasediscussion.DrAngelaDramowski(Stellenbosch) presented a South African perspective on Health-care associated infections with a practicalguideline for clinicians to investigateandmanageHAI inbusypaediatricunits suchas ICU/NICUs.Paediatricdata show an increase in multidrug-resistant HAIs, emphasizing the importance of implementing andmaintaining IPC practices in paediatric services. Amicrobiologist perspective on strategies to preventMDRorganism spread and decreasing antimicrobial resistance in HAIs was presented by local KZN experts ProfMoodleyandDrCGovind.

Part of IPC practice is appropriate and prompt outbreak investigation andmanagement. An approach to apatientwith suspectedHAI (Dr FathimaNaby, Pietermaritzburg), practical outbreak investigation (DrAngelaDramowski)andethicsofoutbreakreporting(ProfNicoletteduPlessis)werecoveredinthissession.Thefinalsession highlighted important factors when deciding about the duration of antibiotic therapy (Dr UteHallbauer)andutilizingtherapeuticdrugmonitoringinPaediatricpractice.DrRamsamy,amicrobiologistfromPrinceMshiyeniHospitalputintoperspectivetheroleofthemicrobiologylaboratoryinHAI.ProfNicoletteduPlessis and Dr Melissa Lawler addressed the challenges in paediatric antimicrobial stewardship and put aproposalforwardofwheretostartwithantibioticstewardshipintheSouthAfricancontext.

Thoughtsabout2016…(NicoletteduPlessis)

SASPIDwould liketowelcomeallnewlyqualifiedpaediatric IDspecialist in2016andwishallcurrent fellowsthebestofluckwiththeirstudies.WeareencouragedbytheincreasingpaediatricIDexpertiseinSA.

Paediatric IPC and antimicrobial stewardship are important focus areas that the executive members haveidentified and will support in the future. This focus area will also be at the African Society of PaediatricInfectiousDiseases(AfSPID)meetings.

SASPIDmemberscontinuetobeauthoritiesinthefieldsofHIVmanagementofnewborns,HIVinadolescence,newTBdrugsandtreatmentdurationandvaccine-preventablediseases.

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STDSSAReportonBacterialvaginosisContribution:RudzaniMathebula:FELTPResidentStudent-STIUnit–NICD

Bacterial vaginosis (BV) is a vaginal infection that occurs when there is overgrowth of anaerobic relatedorganisms suchasGardnerella vaginalis,Atopobiumspp,Provetella spp,Mycoplasma sppandMobiluncusspp in the vagina.1 The overgrowth of these organisms replaces lactobacilli and increases the pH of thevagina.2 Risk factors that are associated with BV include young age, multiple sex partners, a new sexualpartner,perfumedsoaps,douching,smokingandIUDascontraceptive.3Approximately50%ofwomenwhopresentwithBVareasymptomaticandthereforedonotshowanysymptomsoftheinfection.4TheotherhalfwithsymptomsofBVpresentswithincreaseddischargeandafishyodor.1

BViscurablewithsyndromicmanagementhowever,itoftendevelopsintoarecurrentdisease.3Trialstudiesconductedontheeffectivenessofmetronidazolereportacurerateof80%to90%inthefirstmonth,andrecurrenceratesof30%at3monthsand50%at12months.1,3It isassumedthatrecurrentinfectionofBVoccurstowardsmenstruationwherethevaginalPHlevelishighandoestrogenislow.3RecurrentinfectionofBV isassociatedwithseriousriskswhichmay includepretermlabour,sexuallytransmittedinfections(STIs)such as gonorrhoea or chlamydia, human immunodeficiency virus (HIV) and pelvic inflammatory disease(PID).4,5A cohort studyconducted inUganda found recurrentepisodesofBVat58%after treatmentwithmetronidazolewhich suggest prolonged period of infectiousnesswhich increase susceptibility to STIs andHIV.5

ThemanagementofrecurrentBVisdifficultbecausetheaetiologyandtransmissionofthediseaseispoorlyunknown.2,3,4 Furthermore, there is no optimal management strategy exclusive for recurrent BV. Eventreatment of a sexual partner demonstrated no benefit in the reduction of recurrent infection amongwomen.2TheSouthAfricantreatmentguidelinesofSTIadvocatetheuseofasingledoseofmetronidazolehoweverdoesn’tprovidetreatmentoptionforrecurrentBV.SomestudiessuggestasimultaneoustreatmentofprobiotictogetherwithmetronidazolegeltobeeffectiveinthemanagementofrecurrentBVcomparedtojustmetronidazolealone.6However,furtherclinicaltrialsintotheusefulnessofthisapproachareneeded.Inthemeantime,behaviouralchangeandproperhealtheducationaboutSTIsshouldbeencouragedathealthfacilitiestoensurewomenunderstandtherisksandhowtoprevent furthercomplications.FocusedeffortsarerequiredtoimprovethemanagementofBVtopreventSTIsandHIVinSouthAfrica.

References:

1. MillerM.Recurrentvulvovaginitis:Tipsfortreatingacommoncondition.2014.2. WilsonJ.Managingrecurrentbacterialvaginosis.Sex.Transm.Infect.2004;80(1):8-11.3. TruterI,GrazM.Bacterialvaginosis:Literaturereviewoftreatmentoptionswithspecificemphasison

non-antibiotictreatment.AfricanJournalofPharmacyandPharmacology.2013;7(48):3060-7.4. BradshawCS,SobelJD.Currenttreatmentofbacterialvaginosis—limitationsandneedforinnovation.

J.Infect.Dis.2016;214(suppl1):S14-S20.5. FrancisSC,LookerC,VandepitteJ,BukenyaJ,MayanjaY,NakubulwaS,etal.Bacterialvaginosis

amongwomenathighriskforhivinuganda:Highrateofrecurrentdiagnosisdespitetreatment.Sex.Transm.Infect.2016;92(2):142-8.

6. MenardJ-P.Antibacterialtreatmentofbacterialvaginosis:Currentandemergingtherapies.Internationaljournalofwomen'shealth.2011;3:295-305.

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SASTMNews

TravelHealthAfrica:theboilingpoint?

SASTMwastheproudhostofthe7thRegionalConferenceoftheInternationalSocietyofTravelmedicineheldattheBoardwalk,PortElizabethinSeptember.Nationalandinternationaldelegateswereprivilegedtoattendoutstandingpresentationsgivenbylocalandinternationalspeakers.Notonlywereinfectiousdiseasesdiscussedbutothertopicscoveredincludedthetravellerwithdisabilities,thetravellerwithend-stagedisease,thecaveatsoftravelinsurance,towardrabieseliminationinAfricaandthe“ThirdCultureKid”.

ProfessorMichaelMuehlenbeinfromtheUnitedStatesconvenedanexcellentsymposiumonOneHealthwhichisthefirsttimethatsuchatopichasbeenincludedinaSASTMCongress.SuchwastheinterestthataOneHealthSpecialInterestGrouphasbeenformedwithinSASTM.

Itwasanexhilaratingandinspirationalmeetingof250colleagues.

TheOlderTraveller–aguideforthehealthprofessional

Eightyisthenewsixty!Peopleareageingmoresuccessfullyandremainphysicallyandmentallyactiveforlonger.

SASTM, in collaboration with the South African GeriatricSociety (SAGS) and the International Association for MedicalAssistance to Travellers (IAMAT www.iamat.org) has recentlypublished “The Older Traveller – a guide for the healthprofessional”.

This Guide provides clinicians advice on health issuesencountered by older travellers and practical information onhow tocounselolderpersons for travel.Chapters include thephysiology of ageing, prescribing for the elderly,immunosenescence, venous thromho-embolism, yellow fevervaccination in the elderly, chronic disease and the oldertraveler,travellingwithdementia,andmore.

For further information and to order a copy, visitwww.sastm.org.za

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StrengtheningHealthSystems&capacitytodiagnoseandmanageTBandARTFailure–experiencefromKZN

Theadvancedclinicalcare(ACC)programmehasestablished5toll-freehelplineswereestablishedtofacilitatetimelyupreferralsforcomplexTBandHIVpatientsandprovidespecialistclinicalsupportandadvicetohealthfacilities.Thepurposeofthetoll-freehelplinesistostrengthenreferralpathwaysandenhancedirectedmentorshipandsupportforclinicaldecisionmaking.ThehelplinesprovideassistancewithimmediateadviceforthediagnosisandmanagementofcomplicatedHIV-TBcasesaswellasfacilitate

timeousreferralofpatientstothemostappropriatereferralsitebybridgingthecommunicationgapbetweenspecialistsandprimarycareanddistrictlevelhealthcareproviders.TheMDRTBbookingline,isthemostpopularandbusiestofthehelplines.ThishelplinereducedwaitingtimesforreferraltoKingDinuzuluHospitalfrom6weeksto7days.Additionally,therehasbeensignificantuptakeofthenewlyintroducedAdultInfectiousDiseasesHelplineThenumberofdecentralizedtreatmentsitesfordrugresistance(DR)TBservicesincreasedfromfourto19sitesinKZN.ThiswascompletedthroughaprogramofactivitiesthatincludedmentorshipoutreachsupportbyexpertDRTBtreatmentdoctors,implementationofatollfreehealthcareworkerhelpline,aclinicbookingline,clinicianandnursementorshipandsupport,multidisciplinarytrainingofallhealthcareworkersmanagingDRTBandHIVco-infectionatdecentralizedandsatellitesites.ACCTrainingsareCPD(continuingprofessionaldevelopment)accreditedbytheUniversityofKwaZulu-NatalandservesasanincentiveforHCWstoattendtrainings.Atotalof423Doctors,200Pharmacists,365Nurses,33ProgramManagersand39otherstaffcategoriesreceivedAdvancedClinicalCaretraininginHIVandTBDrugResistanceandComplexHIVdiseasemanagement.HealthsystemsstrengtheningtoimproveviralloadsuppressionratesandtriageofpatientswithcomplicatedpatientsisongoingwiththeaimwastoimprovetimeousdetectionandaccesstosecondandthirdlineARTintheprovince.

InothernewsfromKZN:DrJadeMogamberryhasrelocatedtoNgwelazanaasofthe1November2016.ShehasjoinedDrThandiManzini(infectiousdiseasesspecialistphysician).ThiswillenablefurtherdevelopmentofanInternalMedicineandinfectiousdiseasesservicesinNorthernKwazuluNatal.

Finally,CONGRATULATIONStoDrArifaParkerofTygerbergHospital,whopassedCertID(SA)PhysandbecomesSouthAfrica’snewestIDSpecialist!

ANDFINALLY

Theendofanotheryear,givestimetopauseandsaythankyoutoallthecontributorstoourFIDSSAQuarterlynewsletter.Itiswonderfultohearmorevoicesthanbefore,andwewouldliketoencourageallmemberstobeactiveinthefederationanditssocietiessoastosharetheworkloadandtogainfreshopinionsandperspectives.

WewishyouandyourfamiliesaveryhappyfestiveseasonaheadandhopethatyougetsomeR&Rsothat2017willbeabumperyearforyouall!

TheFIDSSATeam

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