Corresponding author: R J Green (robin.green@up.ac.za) Background. Colonisation of the airway by Pseudomonas spp. in cystic fibrosis has been reported to be an important determinant of decline in pulmonary function. Objective. To assess pulmonary function decline and the presence of bacterial colonisation in patients with cystic fibrosis (CF) attending a CF clinic in a developing country. Methods. A retrospective audit of patients attending the CF clinic at Steve Biko Academic Hospital, Pretoria, South Africa, was performed. The data included spirometric indices and organisms routinely cultured from airway secretions (Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA)).Results. There were 29 study subjects. Analysis of variance for ranks (after determining that baseline pulmonary function, age, gender and period of follow-up were not contributing to pulmonary function decline) revealed a median decline in forced expiratory volume in 1 second, forced vital capacity and forced expiratory flow over 25 -75% expiration of 12%, 6% and 3%, respectively, for individuals colonised by PA. There was no pulmonary function decline in individuals not colonised by PA, or in individuals colonised by SA. Conclusion. Pulmonary function decline in this South African centre is significantly influenced by chronic pseudomonal infection. Other influences on this phenomenon should be explored.
The management of fever in children is a subject that garners many different opinions and interventions. Various approaches seem to be acceptable, from the physician who never uses antipyretic medication, to the use of multiple combination therapies. Following the recent publication of guidelines for the management of acute fever in children, there is now a standard against which fever in children should be managed. These guidelines aim to standardise the process of examining pyrexial children, elicit a reasonable history and then investigate the likely illnesses, so as to justify appropriate therapy.
Within South Africa (SA) (as in many other countries), HIV infection is a significant cause of morbidity in women and their infants. In SA, 26% of pregnant women are HIV-infected, and in the absence of preventive therapy there is a 15-30% risk of HIV infection in their infants. [1,2] Even children who are part of the prevention of motherto-child transmission (PMTCT) programme have an increased risk of HIV-related infection relative to those who are not exposed, although that risk is substantially reduced. Mortality in HIV-infected children results primarily from respiratory tract infections. [3,4] In children (especially HIV-infected children) with acute severe respiratory disease requiring endotracheal intubation and ventilation, a number of pathogens (including Pneumocystis jiroveci and cytomegalovirus (CMV)) have been isolated. (The term PCP (P. pneumonia) was retained when P. carinii was taxonomically renamed P. jiroveci). Although there has been considerable focus on P. jiroveci as a cause of mortality, [5] CMV infection has been reported to affect nearly 90% of HIV-exposed infants, [6] especially HIVexposed infants with severe pneumonia. Admitting HIV-infected infants with severe pneumonia to an intensive care unit (ICU) in a resource-limited setting has created a number of ethical dilemmas for paediatricians, which have been accentuated by the historically poor outcome for these patients and the pressure on scarce resources. [7] However, previous reports have suggested that severe pneumonia can now be successfully treated when the mode of ventilation and antibiotic therapy is appropriate for all pathogens that may be present. [8] The successful management of PCP requires careful attention to ventilation strategies, fluid restriction and multiple antibiotics. [9] Objective To report on the progress in improving survival of HIV-exposed and-infected infants admitted to a PICU with respiratory failure and acute respiratory distress syndrome (ARDS), and to explore the relationship between therapeutic strategies (which have not changed since the previous study) [9] and patient outcomes. In addition, this follow-up study reports on the use of highly active antiretroviral treatment (HAART) initiated in the PICU. Methods All HIV-exposed infants admitted to the PICU at the Steve Biko Academic Hospital in Pretoria, SA, with respiratory failure were recruited into this study. Patients had to fit the diagnosis of ARDS as described by Bernard et al., [8] the most important criterion being hypoxic acute lower respiratory tract infection with a partial pressure of oxygen in mmHg over fraction of inspired oxygen (P/F) ratio of <200. Each infant was ventilated using a strategy of high positive end expiratory pressure (PEEP) of 10-15 cm of water, a tidal volume of 6-8 mL/kg and a positive inspiratory pressure (PIP) not exceeding 30 cm of water. Tidal volume was read from the ventilator display despite limitations of this technique. [10,11] None of the infants was offered high-frequency oscillation ventilation. Total fluid in...
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