Antibiotics prescription practices for provisional malaria cases in three hospitals in Moshi, northern Tanzania

Background: Irrational antibiotic use is an important factor for development and spread of resistance to currently used antibiotics. This study was carried out to assess antibiotic prescribing practices among cases diagnosed as malaria at three hospitals in Moshi Municipality in northern Tanzania.Methods: This was a cross sectional, retrospective study that included patients files from Kilimanjaro Christian Medical Centre (KCMC), Mawenzi Regional Hospital and St Joseph Hospital. Patient files whose primary provisional diagnosis was malaria were analysed using a convenient sampling method. Variables of interest were the types of medications prescribed, whether or not a laboratory test was requested and treatment was initiated before laboratory reports.Results: A total of 250 patients’ files were included in the analysis (KCMC=62.8%; Mawenzi=23.2%; St. Joseph=14.0%). In 232 (92.8%) prescriptions made in the three hospitals, laboratory tests were requested to confirm diagnoses. Among laboratory tests requested, 89.2% were blood slides for microscopic detection of malaria parasites, 3.01% malaria rapid diagnostic tests and 3.01% other tests. The majority of prescriptions across all three hospitals (KCMC=86.4%; Mawenzi=91.4%; St. Joseph= 72.4%; X2=7.787). Clinicians at Mawenzi were more likely to start treatment before laboratory findings than their counterparts at KCMC and St Joseph hospitals (X2=7.787, p≤0.05). A significantly higher number of prescriptions made before laboratory findings were observed at KCMC than Mawenzi and St. Joseph hospitals (X2=7.787, p<0.05). Prescriptions from KCMC were more likely to include at least one type of antibiotic than in the other two facilities. Over one third (KCMC=34.0%; St. Joseph=42.1%; Mawenzi=38.1%) of the prescriptions made contained at least one type of an antibiotic. There was a strong association between health facilities and antibiotics prescription in which KCMC prescribed antibiotics at the highest rate while Mawenzi Regional Hospital prescribed antibiotics at the lowest rates (X2=29.234, p<0.001).Conclusion: Antibiotics are prescribed at a high rate among provisionally diagnosed malaria cases before availability of laboratory results. Efforts should be made to improve laboratory services in terms of trained personnel and equipment to reduce irrational use of antibiotics in provisionally diagnosed malaria cases

Prevalence of reverse transcriptase and protease mutations associated with antiretroviral drug resistance among drug-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions, Tanzania

<p>Abstract</p> <p>Background</p> <p>Access to antiretroviral drugs for HIV-1 infection has increased in sub-Saharan Africa (SSA) during the past few years. Mutations in the HIV-1 genome are often associated with treatment failure as indicated by viral replication and elevated levels of virus in the blood. Mutations conferring resistance to antiretroviral drugs are based on comparing gene sequences with corresponding consensus sequences of HIV-1 subtype B that represents only 10% of the AIDS pandemic. The HIV pandemic in SSA is characterized by high viral genetic diversity. Before antiretroviral drugs become more widely available, it is important to characterize baseline naturally occurring genetic mutations and polymorphisms associated with antiretroviral drug resistance among circulating HIV-1 subtypes.</p> <p>Methods</p> <p>The prevalence of mutations associated with antiretroviral drug resistance in protease (PR) and reverse transcriptase (RT) regions among antiretroviral treatment-naïve HIV-1 infected pregnant women was investigated in Bukoba (Kagera) and Moshi (Kilimanjaro) municipalities, Tanzania, between September and December 2005. The HIV-1 <it>pol </it>gene was amplified using primers recognizing conserved viral sequences and sequenced employing BigDye chemistry from 100 HIV-1 seropositive treatment-naïve pregnant women and 61 HIV-1 seropositive women who had received a single dose of Nevirapine (sdNVP). Positions 1–350 of the RT and 1–99 of the PR genes were analyzed for mutations based on the Stanford University HIV Drug Resistance Database.</p> <p>Results</p> <p>HIV-1 subtypes A, C, D, CRF10_CD and Unique Recombinant Forms (URF) were detected. Primary mutations associated with NRTI and NNRTI resistance were detected among 3% and 4% of treatment-naïve strains, respectively. Primary mutations associated with NRTI and NNRTI resistance were detected in 1.6% and 11.5% of women who had received sdNVP, respectively. None of the primary mutations associated with PI resistance was found. Polymorphisms detected in RT and PR sequences were mainly mutations that are found in the consensus sequences of non-B subtypes</p> <p>Conclusion</p> <p>Based on the WHO HIV Drug Resistance Research Network Threshold of less than 5%, the baseline prevalence of primary mutations among treatment-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions was low. The significance of HIV-1 subtype B polymorphic positions with respect to antiretroviral resistance identified among the prevalent HIV-1 subtypes is unknown. More studies addressing the correlation between polymorphic mutations, antiretroviral resistance and clinical outcome are warranted in regions where non-B subtypes are prevalent.</p

Using dried blood spots collected under field condition to determine HIV-1 diversity and drug resistance mutations in resource limited Tanzania

Introduction: A dried blood spot (DBS) on filter paper has been used for different tests globally and has gained popularities in resource limited settings especially during HIV/AIDS epidemic. We assessed the efficiency of molecular characterization of HIV-1 subtypes using DBS collected under field conditions in northern Tanzania. Materials and Methods In 2011 and 2012, 60 DBS samples were collected under field conditions from exposed and newly diagnosed HIV-1 infected children from Kilimanjaro (n=20), Arusha (n=20), Tanga (n=10) and Manyara (n=10). Results and discussion Of 60 DBS analyzed at both Protease (PR) and Reverse Transcriptase (RT) regions, 45 (75%) were analyzed, including 17 (85%) from Kilimanjaro, 15 (75%) from Arusha, 8 (80%) from Tanga, and 5 (50%) from Manyara region. All 45 DBS characterized had viral load above 1000 copies/mL with mean log10 viral loads of 3.87 copies/mL (SD 0.995). The phylogenetic results indicated presence of subtype and circulating recombinant form (CRF). In which, 24 were subtype A1 (53.33%), 16 were subtype C (35.55%), 3 were subtype D (6.67%) and 2 were CRF10_CD (4.35%). All major mutations were detected in the RT region, none from protease (PR) region. The mutations detected were Y181C (n=8), K103 (n=4) and G190A (n=1), conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs), and M184V (n=1), conferring resistance to lamivudine and emtricitabine. Conclusions: Our results indicate that DBS collected from field conditions in resource scarcity areas can be used to determine the phylogeny of the virus and drug resistance mutations in areas with diverse HIV-1 group M subtypes

Antimicrobial resistance patterns of phenotype Extended Spectrum Beta-Lactamase producing bacterial isolates in a referral hospital in northern Tanzania

Background: Production of Extended Spectrum Beta-Lactamase (ESBL) by bacteria is a chronic problem in a health care set up. In order to have adequate information for treatment of bacterial infections especially ESBL producing isolates, it is crucial to understand the trends in the antibiotic-resistance pattern, occurrence and their geographical spread.  The objective of this study was to determine the antimicrobial resistance pattern among phenotype ESBL producing isolates in northern Tanzania.Methods: From July 2013 to January 2014, urine, pus and blood samples were collected from patients suspected to have bacterial infections at Kilimanjaro Christian Medical Centre in Moshi, Tanzania. The isolates were identified based on standard laboratory procedures. Antimicrobial susceptibility tests were carried out using various antimicrobial discs as per the recommendations of Clinical Laboratory Standard Institute.Results: A total of 330 specimens were collected. They consisted of 46 urine, 264 pus (from wound) and 20 blood samples. Among isolated bacteria, ESBL producers were 29.7% (98) and non-producers were 70.5% (232).  Escherichia coli and Klebsiella pneumoniae were the most isolated bacteria and dominant ESBL producers.  ESBL production was highly associated with moderate condition at discharge and longer periods of admission. More than 60% of the ESBL producing E. coli were resistant to ceftazidime, cefpodoxime, cefotaxime, amoxycilin, ciprofloxacin, and gentamycin. More than 80% of ESBL producing K. pneumonia and Proteus mirabilis were resistant to ceftazidime and cefotaxime. Fifty four percent of ESBL producing K. pneumonia were resistant to gentamycin.Conclusion: This study shows that ESLB phenotypes among Gram-negative bacteria are common among patients attending a tertiary hospital in northern in Tanzania. The findings suggest that clinical microbiology laboratories should take into account the diagnosis of ESBL producers in order to define the degree of the problem so as to establish a proper treatment protocol

HIV-1 drug mutations in children from northern Tanzania

Objectives: In resource-limited settings, it is a challenge to get quality clinical specimens due to poor infrastructure for their collection, transportation, processing and storage. Using dried blood spots (DBS) might be an alternative to plasma for HIV-1 drug resistance testing in this setting. The objectives of this study were to determine mutations associated with antiretroviral resistance among children 400 copies/mL. Results: Genotypic resistance mutations were detected in 13 of 46 children (28%). HIV-1 genotypes were A1 (n = 27), C (n = 10), A/D (n = 4), D (n = 3) and CRF10_CD (n = 2). The median age was 12 weeks (IQR 6–28). The mean log10 viral load was 3.87 copies/mL (SD 0.995). All major mutations were detected in the reverse transcriptase gene and none in the protease gene region. The most frequent mutations were Y181C (n = 8) and K103N (n = 4), conferring resistance to non-nucleoside reverse transcriptase inhibitors. Conclusions: One-third of infants newly diagnosed with HIV in northern Tanzania harboured major drug resistance mutations to currently used antiretroviral regimens. These mutations were detected from DBS collected from the field and stored at room temperature. Surveillance of drug resistance among this population in resource-limited settings is warranted

HIV-1 drug mutations in children from northern Tanzania

Objectives: In resource-limited settings, it is a challenge to get quality clinical specimens due to poor infrastructure for their collection, transportation, processing and storage. Using dried blood spots (DBS) might be an alternative to plasma for HIV-1 drug resistance testing in this setting. The objectives of this study were to determine mutations associated with antiretroviral resistance among children 400 copies/mL. Results: Genotypic resistance mutations were detected in 13 of 46 children (28%). HIV-1 genotypes were A1 (n = 27), C (n = 10), A/D (n = 4), D (n = 3) and CRF10_CD (n = 2). The median age was 12 weeks (IQR 6–28). The mean log10 viral load was 3.87 copies/mL (SD 0.995). All major mutations were detected in the reverse transcriptase gene and none in the protease gene region. The most frequent mutations were Y181C (n = 8) and K103N (n = 4), conferring resistance to non-nucleoside reverse transcriptase inhibitors. Conclusions: One-third of infants newly diagnosed with HIV in northern Tanzania harboured major drug resistance mutations to currently used antiretroviral regimens. These mutations were detected from DBS collected from the field and stored at room temperature. Surveillance of drug resistance among this population in resource-limited settings is warranted

Deciphering the Complex Distribution of Human Immunodeficiency Virus Type 1 Subtypes among Different Cohorts in Northern Tanzania.

Increased understanding of the genetic diversity of HIV-1 is challenging but important in the development of an effective vaccine. We aimed to describe the distribution of HIV-1 subtypes in northern Tanzania among women enrolled in studies preparing for HIV-1 prevention trials (hospitality facility-worker cohorts), and among men and women in an open cohort demographic surveillance system (Kisesa cohort). The polymerase encompassing partial reverse transcriptase was sequenced and phylogenetic analysis performed and subtype determined. Questionnaires documented demographic data. We examined factors associated with subtype using multinomial logistic regression, adjusted for study, age, and sex. Among 140 individuals (125 women and 15 men), subtype A1 predominated (54, 39%), followed by C (46, 33%), D (25, 18%) and unique recombinant forms (URFs) (15, 11%). There was weak evidence to suggest different subtype frequencies by study (for example, 18% URFs in the Kisesa cohort versus 5-9% in the hospitality facility-worker cohorts; adjusted relative-risk ratio (aRR) = 2.35 [95% CI 0.59,9.32]; global p = 0.09). Compared to men, women were less likely to have subtype D versus A (aRR = 0.12 [95% CI 0.02,0.76]; global p = 0.05). There was a trend to suggest lower relative risk of subtype D compared to A with older age (aRR = 0.44 [95% CI 0.23,0.85] per 10 years; global p = 0.05). We observed multiple subtypes, confirming the complex genetic diversity of HIV-1 strains circulating in northern Tanzania, and found some differences between cohorts and by age and sex. This has important implications for vaccine design and development, providing opportunity to determine vaccine efficacy in diverse HIV-1 strains

Co-occurrence of bacteria and viruses and serotype distribution of Streptococcus pneumoniae in the nasopharynx of Tanzanian children below 2 years of age following introduction of the PCV13

IntroductionPneumococcal conjugate vaccines have reduced severe disease attributed to vaccine-type pneumococci in children. However, the effect is dependent on serotype distribution in the population and disease development may be influenced by co-occurrence of viral and bacterial pathogens in the nasopharynx.MethodsFollowing introduction of the 13-valent pneumococcal conjugate vaccine (PCV13) in Tanzania we performed repeated cross-sectional surveys, including 775 children below 2 years of age attending primary healthcare centers. All children were sampled from nasopharynx and pneumococci were detected by single-target PCR. Pneumococcal serotypes/groups and presence of viruses and other bacteria were determined by two multiplex PCR assays.ResultsThe prevalence of PCV13 vaccine-type pneumococci decreased by 50%, but residual vaccine-types were still detected in 21% of the children 2 years after PCV13 introduction. An increase in the non-vaccine-type 15 BC was observed. Pneumococci were often co-occurring with Haemophilus influenzae, and detection of rhino/enterovirus was associated with higher pneumococcal load.DiscussionWe conclude that presence of residual vaccine-type and emerging non-vaccine-type pneumococci in Tanzanian children demand continued pneumococcal surveillance. High co-occurrence of viral and bacterial pathogens may contribute to the disease burden and indicate the need of multiple public health interventions to improve child health in Tanzania

Evolution of HIV-1 in northern Tanzania : a retrospective study

Development of an effective vaccine against HIV has faced great challenges due to the great genetic diversity of the virus. However, in different geographical areas candidate vaccines based on the prevalent HIV-1 subtype(s) are now entering clinical trials. Genotypic and serological assays have been used in HIV-1 subtyping. The peptide-binding enzyme immunoassay has been a useful tool for subtyping HIV-1. This assay in combination with an antigen limiting dilution assay was established at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. HIV-1 positive serum samples stored at KCMC were characterized using these assays to determine the trend since the start of the epidemic. In addition, the distribution of HIV-1 subtypes currently circulating in northern Tanzania was determined in order to provide important information that might be of relevance to future vaccine studies and trials in Tanzania. Frozen HIV-1 positive serum samples from individuals diagnosed at KCMC between 1985 and 2001 were used in this study. Synthetic peptides representing HIV-1 subtypes A, B, C, D and E derived from consensus gp120 V3 sequences were used in an indirect peptide-binding enzyme immunoassay and an antigen limiting dilution assay. The gp41 peptide D was used to increase the specificity by discriminating subtype D from non-D viruses. Two hundred and twenty six samples were analyzed; 196 (87%) samples were successfully subtyped while 30 (13%) could not be typed using these methods. In 1985 the prevalent subtypes were A (52%) and D (48%). Subtype C started to circulate in the late 1980s and in 2001 was the most prevalent circulating subtype in Tanzania. The currently circulating subtypes are A (32%), C (51%) and D (17%). HIV-1 vaccines entering clinical trials in Tanzania should be based on the predominant circulating subtype(s)