title: Reduced referral and case fatality rates for severe symptomatic hyperlactataemia in a South African public sector antiretroviral programme: a retrospective observational study.
abstract: BACKGROUND
  Interventions to promote prevention and earlier diagnosis of severe symptomatic hyperlactataemia (SHL) were implemented in the Western Cape provincial antiretroviral programme (South Africa) from 2004. Interventions included clinician education, point-of-care lactate meters, switch from stavudine to zidovudine in high risk patients and stavudine dose reduction. This study assessed trends in referral rate, severity at presentation and case fatality rate for severe SHL.
  
  
  METHODS
  Retrospective study of severe SHL cases diagnosed at a referral facility from 1 January 2003 to 31 December 2008. Severe SHL was defined as patients with compatible symptoms and serum lactate >/= 5 mmol/l attributable to antiretroviral therapy (ART). Cumulative ART exposure at referring ART clinics was used to calculate referral rates.
  
  
  RESULTS
  There were 254 severe SHL cases. The referral rate (per thousand patient years [py] ART exposure) peaked in 2005 (20.4/1000py), but fell to 1.3/1000py by 2008 (incidence rate ratio [IRR] = 0.07, 95%CI 0.04-0.11). In 2003, 66.7% of cases presented with a standard bicarbonate (SHCO3) level <15 mmol/l, but this fell to 12.5% by 2008 (p for trend < 0.001). Case fatality rate fell from a peak of 33.3% in 2004 to 0% in 2008 (p for trend = 0.002).
  
  
  CONCLUSIONS
  These trends suggest the interventions were associated with reduced referral, less severe metabolic acidosis at presentation and improved survival.
authors.affiliation: Infectious Diseases Unit, GF Jooste Hospital, Duinefontein Road, Manenberg, 7764, Cape Town, South Africa. charlottelouw@discoverymail.co.za.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Schutz
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Dave
authors.initials: D
authors.lastname: Stead
authors.forename: Kevin
authors.initials: K
authors.lastname: Rebe
authors.forename: Meg
authors.initials: M
authors.lastname: Osler
authors.forename: Graeme
authors.initials: G
authors.lastname: Meintjes