High Prevalence of Comorbidity and Need for Up-Referral Among Inpatients at a District-Level Hospital with Specialist Tuberculosis Services in South Africa--the Need for Specialist Support (Original Articles) (Report‪)‬

Tuberculosis (TB) in HIV-co-infected (HIV-TB) patients is characterised by high rates of smear-negative pulmonary and extrapulmonary disease, with increasing levels of antimycobacterial drug resistance and high rates of co-morbid opportunistic infections (OIs). (1,2) Difficulty in making the diagnosis of TB in HIV-infected patients results in diagnostic delay and the need for increased hospital admission. Prior to the HIV era, South Africa's district hospitals that offered specialist TB services generally housed patients who were unable to mobilise and care for themselves or who required enhanced adherence monitoring, drug rechallenge for toxicity, or treatment for drug-resistant TB. At Brooklyn Chest Hospital (BCH), a district-level hospital offering specialist TB services in Cape Town, we have observed an increase in the complexity and severity of illness in HIV-TB patients in the HIV era. Anecdotal experience suggests that this complexity is in part due to mycobacteriologically unconfirmed TB, HIV-related comorbidity such as opportunistic processes or organ-specific damage due to the virus itself, and increasing case numbers of drug-resistant TB. In our experience, these patients commonly require upreferral to secondary-and tertiary-level services because, in part, of lack of training and specialised radiology services at the hospital. To investigate the complexity of patients at BCH, we performed a cross-sectional study to document patient types housed at BCH, their co-morbidities and their requirement for up-referral to other institutions.