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Introduction: The decision as to the most appropriate site of care of a patient with community-acquired pneumonia (CAP), especially whether hospitalisation is warranted or not, is one of the most important decisions in the overall emergency department management of such patients. It has consequences both with regard to the level of treatment received by the patient as well as the overall costs of treatment. Several tools have been developed to predict mortality and/or determine which patients could be sent home and treated safely with good clinical outcomes. The CRB-65 score is one of the validated severity of illness scoring tools recommended. This scoring system may be of particular benefit in resourceconstrained areas, as it is easier to use. Study’s aim: To determine whether it would be useful to introduce the CRB-65 severity of illness score in the routine evaluation of patients with CAP in the Helen Joseph Hospital Emergency Department (HJH ED). Study’s objectives: To determine what criteria HJH ED doctors use in their decision to admit or discharge CAP patients; to determine the frequency with which the CRB-65 severity of illness score is used in current practice by the HJH ED doctors for admitting or discharging CAP patients; and to determine the potential performance of the CRB-65 severity of illness score in the management of patients with CAP in the HJH ED. Design: Prospective, observational, hospital-based study.Patients and methods: All patients 18 years of age and older with the diagnosis of CAP constituted our study population. Data from 152 patients seen between February 2011 and April 2011 was collected and analysed. Outcome measures included hospital admission or discharge, time to clinical stability, length of hospital stay, and mortality. Results: Overall, 152 patients (79 females and 73 males) were included in the analysis. The median age was 36.5 years, with a range from 20 to 87 years. The chest radiograph was the commonest criterion (41%) used by the HJH ED doctors to determine the need for admission of the patients with CAP, while the haemodynamic parameters were the commonest criteria used (25.9%) for discharge decisions. On only three occasions was the CRB-65 score utilised out of the 193 criteria documented (1.55%). There was a significantly shorter time to clinical stability (p = 0.0069), but no tendency to a shorter length of hospital stay in patients with a lower CRB-65 score (p = 0.5694). Patients with a higher CRB-65 score were at significantly higher risk of death compared to patients with a lower CRB-65 score (p < 0.001). There were no deaths from outpatients, but there were a total of five deaths observed from the inhospital patients of which 3/5 patients (60%) would potentially have been classified as intermediate mortality risk and the remaining 2/5 patients (40%) as high mortality risk if the CRB-65 score had been the only criterion used as the standard for site of care decisions by the HJH ED doctors. Conclusion: The chest radiograph was the commonest criterion used by the HJH ED doctors to determine the need for admission of the patients with CAP, while the haemodynamic parameters were the commonest criteria used for discharge decision. The CRB-65 score is not frequently being used in current practice by the HJH ED doctors for admitting or discharging CAP patients. This study demonstrates the ability of the CRB-65 severity of illness score to accurately predict both the time to clinical stability for patients hospitalised with CAP and the risk of death associated. In addition, this study documents that the CRB-65 severity of illness score performed well in its ability to determine the initial site of care for patients with CAP. Setting: Emergency Department of the Helen Joseph Hospital.

M.Sc. (Med.), Faculty of Health Sciences, University of the Witwatersrand, 2011 / Pneumocystis pneumonia (PCP) is one of the most prevalent diseases in HIV-positive and other immunosuppressed patients. It is caused by the opportunistic fungal pathogen Pneumocystis jirovecii. Dihydropteroate synthase (DHPS) mutations in P. jirovecii have been linked to resistance to trimethoprim-sulphamethoxazole (cotrimoxazole), the main treatment and prophylaxis used for PCP. DHPS mutations have been identified globally, predominantly in developed countries. This study investigated the P. jirovecii DHPS genotypes in PCP-positive patients from Chris Hani Baragwanath Hospital in Gauteng Province, South Africa. During the period March 2005 through June 2009, 266 patients were enrolled in the study and 306 specimens were collected. P. jirovecii was identified in 67% (205/306) of these specimens with quantitative real-time PCR (qPCR). The qPCR had a sensitivity of 98% and a specificity of 70%, compared with the immunofluorescence assay (IFA). Using sequencing and cloning techniques, 64% (110/173) of the nested PCR-positive specimens contained P. jirovecii with mutant DHPS genotypes. There was no association between patients harbouring P. jirovecii with mutant DHPS genotypes and in-hospital patient outcome (p-value = 0.19). As part of this project the Roche MagNA Pure Compact (RMPC) instrument and technology was validated for use as a new DNA extraction method. The RMPC was quick and easy to use compared to the Qiagen manual extraction method. The specificity of the qPCR was compromised by the high number of apparent false positive results obtained by the assay. However, as the IFA is an imperfect gold standard, these are probably true cases of infection or colonisation. This study found a higher proportion of P. jirovecii with DHPS mutant genotypes than wild type in PCP patients, which is unusual. The most probable reason for this is the widespread use of sulfa drugs, which are thought to select for these mutations. While this study did not find an association between DHPS mutations and adverse patient outcome, there have been contradictory findings. If further investigations reveal that DHPS mutations affect patient treatment or outcome, it will have major implications for the management of PCP in the country.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Clinical Microbiology and Infectious Diseases. Johannesburg, 2013 / Introduction To determine the spectrum of aetiological agents in adult Community Acquired Pneumonia (CAP) admitted to an academic hospital in Johannesburg using a novel transport medium (PrimeStore™ MTM), in addition to traditional specimen processing. PrimeStore™ MTM preserves released nucleic acids, including labile RNA. Materials and Methods Forty-eight adult patients with radiologically confirmed CAP were prospectively studied over three months. Microbiological investigation included culture from blood and sputum, with pulmonary tuberculosis being excluded by sputum microscopy and culture. Nasopharyngeal swabs (PrimeStore™ MTM) were analysed using two commercial multiplex PCR assays for the detection of 6 major bacteria and 12 major respiratory viruses. The BinaxNOW Legionella urinary antigen test was also used. Results A probable microbial aetiology of CAP was established for 62.5% (30 of the 48 patients) when the PCR platform was added to the conventional methods with the use of the PrimeStore™ MTM swabs. In contrast, the definite bacterial aetiology was 16.7% (8 of 48 patients) when conventional culture methods were used; none had more than one bacterial species identified. Five patients had no aetiological pathogens determined. The urine Legionella pneumophila antigen was negative in all patients. Of the eight patients (16.7%) with a definite bacterial aetiology; Streptococcus pneumoniae was isolated from blood cultures of all eight patients.

Thesis (M. Sc.)--Carleton University, 1985. / Also available in electronic format on the Internet.

Thesis (Ph. D.)--Carleton University, 1985. / Also available in electronic format on the Internet.

Thesis (M.D.)--University of Adelaide, Dept. of Medicine, 1974.

Thesis (M.S.P.H.)--University of Michigan, 1942.

Thesis (M.S.P.H.)--University of Michigan, 1940.

Thesis (M.S.P.H.)--University of Michigan, 1940.