Key Points Staphylococcus is an increasingly important cause of IE in LMICs, and is the leading cause of IE in UMICs  RHD remains the major underlying cardiac pathology of IE in LMICs, identified in almost half of reported cases  The rate of microorganism non-identification is high, reaching up to 60% of IE cases in LMICs, and hampering diagnosis and treatment  Rates of access to surgery in UMICs for complicated IE are as high as in HICs, but remain dismal in lower-middle income countries SynopsisInfective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of upto 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high income countries, conclusions on the state of IE in low and middle income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article is a review of IE studies conducted in LMICs documenting clinical experiences from the year 2000 to present. We present the causes of IE, management of patients with IE and the prevailing challenges in diagnosis and treatment of IE in LMICs.

To cite this article: Manji I, Pastakia SD, Do AN, Ouma MN, Schellhase E, Karwa R, Miller ML, Saina C, Akwanalo C. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost 2011; 9: 2215-20.Summary. Background: It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. Objective: To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings. Methods: A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. WilcoxonÕs rank sum analyses were used to establish predictors of TTR. Results: For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of followup of < 120 days were associated with having a lower TTR (P < 0.05). Conclusions: The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.

Through the inclusion of clinical data within the electronic medical record, there is an ongoing effort to research various aspects of diabetes care in this understudied population, with the goal of addressing many of the unanswered questions surrounding diabetes care in sub-Saharan Africa. The lessons learned from this pilot program will be used to create sustainable infrastructure for diabetes care in partnership with the Kenyan government and will serve as a model for similar programs.

BackgroundRifampicin’s ability to induce hepatic enzymes is responsible for causing a clinically significant drug interaction with warfarin. Little data exists to guide clinicians on managing this interaction, especially in Sub-Saharan Africa where many patients are exposed to this combination due to a higher burden of tuberculosis.ObjectiveThe objective of the case series is to provide insight to practicing clinicians of the unique dynamics of this drug interaction in resource-constrained settings. The case series will provide details on commonly encountered scenarios and the dosage adjustments required to maintain a therapeutic INR.MethodsA retrospective chart review was conducted of patients attending the Moi Teaching and Referral Hospital anticoagulation clinic in Eldoret, Kenya. Patients were included if they had a history of concurrent rifampicin and warfarin therapy and a minimum follow up of 2 months. Descriptive statistics were used to explain the demographic characteristics, time to therapeutic INR and average weekly warfarin dose. The inference on proportions test was conducted to compare the time in the therapeutic range (TTR) for patients on concurrent rifampicin to the rest of the patients not receiving rifampicin in the clinic.ResultsOf the 350 patient charts evaluated, 10 met the inclusion criteria. The median percentage increase of the weekly warfarin dose from baseline was 15.7 %. For the patients in this analysis, the median TTR was 47 %.DiscussionPatients on concurrent therapy should be rigorously monitored with regular INR checks and warfarin dosage adjustments. Empiric dosage adjustments of warfarin should be avoided but patient characteristics can aid in understanding the alterations seen in INR.