M. Preziosi MD, K.Lee MD, M. Tomas MD, T. Paunde MD, C. PaivaMD, S. Kinlin MD, R. Bene MD, H.Lopes MD, R. Ryder MD, E.VNoormahomed MD, PhD, E.A Spencer MD PhD, T. Zimba MD

Top 10” HIV prevalence Zimbabwe 25.84% Botswana 25.10%Namibia 19.94%Zambia 19.10%Swaziland 18.50%South Africa 16.70%Malawi 14.92%Moçambique 11.5%Tanzania 9.42%Lesotho 8.35%

Top Causes of Mortality

Malaria ( 29%) AIDS( 27%) Perinatal causes ( 7%) Diarrhea ( 4%) Pneumonia ( 4%) Trauma( 4%) Tb( 3%) CVA ( 3%) Neoplasias(1%) Sepsis(1%)

Mozambique- INE 2009

Bacteremia Study Design

Enrollment

Admitted to Internal Medicine Ward?

Axillary temp ≥ 38C?

HIV status known?

No antibiotics started?

Consent?

Inter

Medicine Wards

Identify problems in workflow

Quality improvement

Clinical Labs

Medical Records Paper charts Illegible Incomplete Hard to find or lost Retrospective

studies not possible

Hematology Lab

Chemistry Lab

Microbiology Lab

TB Reference Lab

Immunology Lab

Pathology

Patient ChartServentes

How do you do a prospective observational study in this environment and have reliable data?

1. Create a Team

Residents Nurse Lab tech ID attending American

collaborators

2. Use touch screen devices and webpage to collect and organize data

3. Repeated QI Cycles

Identify areas for quality improvement Propose solutions Implement and Measure Review Data and Repeat

Initial QI Projects

Increase enrollment Reduce contamination rate Improve documentation of CD4 counts

in charts Improve clinical follow-up in hospital

Preliminary Results- Bacteremia

Patient enrolled: 435

75 % HIV (Avg CD4=120, 44% on ARVs)

42 bloodstream infections (Staph aureus and Non- Typhoidal Salmonella most common.)

BSI 20 % in hospital-mortality

Blood culture contamination rate in study vs. hospital

0

10

20

30

40

50

60

Study

Hospital

P < .001

0

10

20

30

40

50

60

70

80

90

100

Sept Oct Nov Dec Jan Feb March April May June July August

Percentage of Enrolled Patients with documented CD4 count

P < .001

Percentage of patients with documented outcome

0

10

20

30

40

50

60

70

80

90

100

October November December January February March April May June

Infectious Diagnoses other than HIV

N= 320

Microbiologic Confirmation?

Use of Empiric Antibiotics is Common, and Antibiotics are Rarely Changed

Antibiotic Use in Known Bacteremia Cases

Outcomes

Lessons learned

Think more about sepsis/bacteremia in differential diagnosis

Empiric antibiotic choices are often wrong

Blood culture is a useful test QI is possible at MCH Requires multidisciplinary organization,

great communication