a clinical ausit of selected predictors of mortality of patients admitted to Charlotte Maxeke Johannesburg academic hospital intensive care unit with human immunodeficiency virus and tuberculosis co-infection

• Main Author: Singh, Avani
• Format: Others
• Language: en
• Published: 2019
• Subjects: HIV infections > mortality; Comorbidity; Substance abuse > Treatment
• Online Access: Singh, Avani (2019) A clinical audit of selected predictors of mortality of patients admitted to Charlotte Maxeke Johannesburg Academic Hospital Intensive Care Unit with Human Immunodeficiency Virus and Tuberculosis co-infection, University of the Witwatersrand, Johannesburg, <http://hdl.handle.net/10539/28161>; https://hdl.handle.net/10539/28161

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 Masters of Medicine. Johannesburg 2019 === Background: The high level of co-morbid TB/HIV cases with severe organ failure on presentation in South Africa, results in an increased number of ICU admissions often with a poor prognosis at presentation. In this study, the aim was to identify patients admitted with HIV/TB co-infection and calculate the APACHE II scores and SOFA scores for each patient. Predicted percentage mortality was compared with actual mortality. Predictors of mortality were further identified, as well as the benefit of initiating ARV treatment in patients who are ARV naive upon admission to ICU. Methods: A retrospective audit of consecutive cases over a 24 month period was completed. Patient demographics; CD 4 count; ARV treatment status; ICU and 30 day mortality; the APACHE II Score; SOFA scores and correlating predicted percentage mortality were documented. The survival of patients was assessed using Kaplan Meier survival curves, and a univariate analysis was performed to identify risk factors for mortality. Calculated predicted mortality was compared with actual mortality to validate each scoring system and infer which was the better tool. Results: Of 75 patients admitted with pulmonary (43 cases) or extra-pulmonary (32 cases) TB, 23 died in the ICU (mortality 30,7%), and a further 10 died in the first 30 days of hospitalisation (30 day mortality 44%). A survival analysis established ARV treatment and CD 4 counts greater than 50 cells/mm3 were associated with a higher survival rate at any point of the analysis. In the entire study period, only 2 patients were initiated on ARV therapy during their ICU stay, 1 survived to discharge and 1 died in ICU. The APACHE II Predicted Mortality was within the 95% Confidence Intervals for all groups while the SOFA score was outside the upper bound limit of the 95% confidence intervals of actual mortality for those patients taking ARV treatment (52%, 95% CI 43,1% - 59,5% vs actual mortality 30%, 95% CI 17,7% - 46,1%), those with a CD 4 count of more than 50 (53,5% 95% CI 45,4% - 60,6% vs actual mortality 34%, 95% CI 22,1% - 48,4%) and female patients (51,2%, 95% CI 41,6% - 58,1% vs actual mortality 35,1%, 95% CI 21,4% - 50,4%). Conclusion: The study found that both the APACHE II and SOFA scoring systems were both statistically significant in prognosticating mortality in the study population. The APACHE II scoring system however showed a slightly improved prognostication in specific cohorts who had improved survival. It was also confirmed that patients with a CD 4 count of more than 50 cells/mm3, and those on ARV therapy had a statistically significant improved mortality. Further studies reviewing survival benefit of ARV initiation in ICU are warranted. ACKNOWLEDGEMENTS Supervisor: Prof GA Richards Co-Supervisor: Dr SHH Mohamadali Statistician: Mr MH Zondi Assistant - Data Collection: Ms S Madanlall === E.K. 2019