High Prevalence of Non-Typhoid Salmonella Bacteraemia Among Febrile HIV Adult Patients Admitted at a Tertiary Hospital, North-Western Tanzania.

Bacterial blood stream infections constitute a significant public-health problem and it is an important cause of morbidity and mortality in HIV infected patients. Little is known in developing countries regarding salmonella bacteraemia among HIV patients. The purpose of this study was to determine the bacterial pathogens causing blood stream infection among febrile adults attending in a tertiary hospital North-Western, Tanzania. A prospective cross-sectional study involving 346 consecutive, febrile adult patients admitted at Bugando Medical Centre was conducted. Demographic and other data were collected using standardized questionnaires. Blood culture was done followed by susceptibility testing using disc diffusion method. HIV testing was also performed as per Tanzania national algorithm and total white blood cell counts and CD4+ counts determined. Of 346 febrile adult patients 33 (9.5%) had blood stream infections. The common isolates were Salmonella spp 13(39.4%), Escherichia coli 8 (24.2%), Streptococcus pneumonia 5(15.2%), Staphylococcus aureus 4(12.1%), Citrobacter spp 1(3%), Streptococcus pyogenes 1(3%) and Klebsiella pneumonia 1(3%). A total of 156 (45.1%) patients were HIV infected; of whom 12/156 (7.6%) were infected by non-typhoid Salmonella spp compared to 1/190 (0.5%) of non-HIV infected patients (RRR 11.2, p=0.029) infected with Salmonella typhi. HIV infected patients with bacteraemia had significantly lower CD4+ count than those without bacteraemia (median 28 vs. 88 cells/ml, p=0.01). Patients with salmonella bacteraemia had significantly lower median of WBC than those with non-salmonella as well as those without bacteraemia (median, 3.6 vs. 17.5 vs. 9.8x109, p=0.0001). All Salmonella spp were sensitive to ceftriaxone and imipenem, while being 84%, 69.2%, 38% and 8% resistant to chloramphenicol, ampicillin, sulphamethaxazole/trimethoprim and ciprofloxacin respectively. Predictors of mortality were HIV infection (OR 2.3, p=0.006), Glasgow coma score of less than 15 (OR 3.4, p=0.0001) and night sweats (OR 2.4, p=0.014). Non-typhoid Salmonella spp that are highly resistant to common antibiotics are predominant cause of bacterial blood stream infection among HIV patients attending Bugando Medical Centre. Continuous surveillance and intervention strategies should be put in place to monitor and manage cases of bloodstream infections in HIV-positive patients in Mwanza, Tanzania

High Prevalence of Tuberculosis among Adults with Fever Admitted at a Tertiary Hospital in North-western Tanzania

Tuberculosis is a leading cause of death in developing countries where HIV is endemic. This hospital based study was done to estimate the magnitude of pulmonary and extra-pulmonary tuberculosis and to determine predictors of tuberculosis among febrile adults admitted at Bugando Medical Centre (BMC), Mwanza, Tanzania. A total of 346 adults febrile patients admitted in medical wards were studied. Sputum for AFB microscopy and chest X-rays was used to diagnose tuberculosis. Clinical features were collected using standardized data collection tool. HIV testing and CD4 counts were determined. Data were analyzed using STATA version 11 software. Of 346 febrile adults patients 116 (33.5%) were diagnosed to have tuberculosis; of which 79 (68.1%) and 37 (31.9%) had pulmonary tuberculosis (PTB) and extra-pulmonary tuberculosis, respectively. Smear negative PTB were more common in HIV positive than in HIV negative patients (50% vs. 18.5%, p=0.007). Extra-pulmonary tuberculosis was more common in HIV positive patients than pulmonary tuberculosis (86.4% vs. 13.6%), p=0.0001). On multivariate logistic regression analysis the predictors of tuberculosis were; age above 35 years (OR =2.38, p=0.007), cardinal symptoms (OR=37, p<0.0001), pleural effusion (OR=24, p=0.0001), and HIV status (OR =3.2, p=0.0001). Of 79 patients with PTB, 48 (60.7%) were AFB smear positive and 31(39.3%) were AFB smear negative. HIV patients with smear negative tuberculosis had significantly lower CD4 count than HIV patients with smear positive tuberculosis (63.5 cells/μl versus 111.5 cells/μl) [Mann- Whitney test p=0.0431]]. No different in mortality was observed between patients with TB and those without TB admitted in BMC medical wards (28.5% vs. 23.0%, p= 0.1318). Tuberculosis is the commonest cause of fever among adults patients admitted at BMC and is predicted by age above 35 years, positive HIV status, cardinal PTB symptoms, and pleural effusion. Routinely TB screening is highly recommended among adults with fever, cough, night sweating and wasting in countries where HIV is endemic.\u

In vitro activity of cefepime against extended spectrum β-lactamase- producing Escherichia coli and Klebsiella pneumoniae from clinical specimens at Bugando Medical Centre, Mwanza, Tanzania

There is an increase in isolation of extended spectrum beta-lactamase (ESBL) producing isolates from clinical samples worldwide. In developing countries the treatment option of ESBL producing isolates is limited. Recently fourth generation cephalosporins have been introduced for use in Tanzania. This study was done to determine in vitro activity of cefepime against ESBL producing clinical isolates. Disc diffusion testing was performed to 235 ESBL producing isolates; of which 73 (31%) were Escherichia coli and 162 (69%) Klebsiella pneumoniae. The sensitivity rate of E. coli and K. pneumoniae to cefepime were 15.1% and 4.3%, respectively (P=0.012); intermediate sensitivity rate was observed in 13.7% for E. coli and 19.8% for K. pneumoniae. The mean zones of inhibition diameter among sensitive isolates were 24.9mm and 20.0mm for E. coli and K. pneumonia, respectively (P=0.0085). Cefepime is less active against ESBL producing organisms; hence the use of this drug should be guided using local resistance profile

Quality of drug prescription in primary health care facilities in Mwanza, north-western Tanzania

Background: Drug therapy can improve a patient’s quality of life and health outcomes if only used properly. However, data on prescription quality at primary health care facilities in Tanzania is scanty. The objective of this study was to assess the quality of drug prescriptions in selected health care facilities in two districts of Mwanza, Tanzania.Methods: This descriptive cross-sectional study was carried out in Ilemela and Nyamagana districts in Mwanza, Tanzania. The study included 20 randomly selected public and private health care facilities. A random sample of the patient records in each facility was included. From each patient record, the latest prescription was assessed. Information assessed and recorded included prescribing indicators, frequency of prescription error, various formulations and groups of drugs prescribed. Prescribers were interviewed on factors affecting prescribing practices.Results: A total of 570 prescriptions were studied. The average number of drugs prescribed per encounter was 2.8. The percentage of encounters with an antibacterial agent prescribed was 33.8% and injections constituted 7.9% of cases. Prescriptions by generic name were 85.8% while 90.6% of drugs prescribed were from the national essential drug list. Antibacterial agents, analgesics and antimalarial agents accounted for 75.3% of all drugs prescribed. Of all prescriptions, 485 (85.1%) had at least an error. A total of 1,177 errors were made. Errors of omissions accounted for the majority (99.3%) of all errors. The most commonly observed missing prescription particulars were the drug strength (23.2%) and patient weight (22.2%).  The average number of drugs per encounter was higher in private facilities (3.2) than in public facilities (2.4) (P &lt;0.0001). The range of drugs per prescription was also higher in private (1-7) than in public facilities (1-5) (P&lt;0.0001). There were statistically significant differences in the distribution of various drug groups prescribed between public and private facilities and between health centres and dispensaries (P &lt;0.001 and 0.027, respectively).Conclusion: Prescribing of higher number of drugs than the WHO recommendations and overuse of antibiotics is still a problem at health care facilities in Mwanza Tanzania. The frequency of occurrence of prescription errors found during the study was considerably high

Experiences With Surgical Treatment of Chronic Lower Limb Ulcers at a Tertiary Hospital in Northwestern Tanzania: A Prospective Review of 300 Cases.

Chronic lower limb ulcers constitute a major public health problem of great important all over the world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting. This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0. A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma (45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was 4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study period. Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority of patients in our environment present late when the disease is already in advanced stages. Early recognition and aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close follow-up are urgently needed to improve outcomes of these patients in our environment

Pattern and Factors Associated with Congenital Anomalies among Young Infants Admitted at Bugando Medical Centre, Mwanza, Tanzania.

Congenital anomalies or birth defects are among the leading causes of infant mortality and morbidity around the world. The impact of congenital anomalies is particularly severe in middle- and low-income countries where health care resources are limited. The prevalence of congenital anomalies varies in different parts of the world, which could reflect different aetiological factors in different geographical regions. Between October 2012 and January 2013, a cross-sectional study was conducted involving young infants below 2 months of age, admitted at a university teaching hospital in Tanzania. Face-to-face interviews with parents/caretakers of young infants were carried out to collect socio-demographic and clinical information. Physical examinations were performed on all young infants. Echocardiography, X-ray, cranial as well as abdominal ultrasonographies were performed when indicated. Analysis of the data showed that among 445 young infants enrolled in the study, the prevalence of congenital anomalies was 29%, with the Central Nervous System (CNS) as the most commonly affected organ system. Maternal factors that were significantly associated with congenital anomalies included the lack of peri-conceptional use of folic acid (OR = 3.1; 95% CI = 1.4-6.7; p = 0.005), a maternal age of above 35 years (OR = 2.2; 95% CI = 1.1-4.3; p = 0.024) and an inadequate attendance to antenatal clinic (OR = 2.1; 95% CI = 1.4-3.3; p < 0.001). Infant factors that were significantly associated with congenital anomalies were female sex, a birth weight of 2.5 kg or more, singleton pregnancy and a birth order above 4. Due to the high prevalence of congenital anomalies observed in this particular context, the hospital should mobilize additional resources for an optimal and timely management of the patients with congenital anomalies. In this study, the proportion of women taking folic acid supplements during early pregnancy was very low. Efforts should be made to ensure that more women use folic acid during the peri-conceptional period, as the use of folic acid supplement has been linked by several authors to a reduced occurrence of some congenital anomalies

Prevalence of undernutrition and risk factors of severe undernutrition among children admitted to Bugando Medical Centre in Mwanza, Tanzania

BACKGROUND: Malnutrition is a major public health problem in developing countries including Tanzania, contributing up to 50 % of under-five mortality. East Africa region was among the three United Nations (UN) subregions with the highest prevalence of stunting in 2011. In resource limited countries, the available little resources in hospitals are likely to be used focusing the primary clinical problem that led to admission of children leaving moderate and mild malnutrion unattended. This work was conducted to determine the prevalence of under-nutrition and risk factors associated with severe malnutrition among undernourished children aged 6–60 months admitted to Bugando Medical Centre (BMC) paediatric wards. METHOD: This was a hospital-based cross sectional study where by 720 children were screened in order to determine their nutritional status. Data were collected through measurement of weight/length or height, mid upper arm circumference (MUAC) and interpretation was done using Z-score (mild malnutrition ≤1SD, moderate malnutrition ≤2SD and severe malnutrition ≤3SD). The socio-demographic data were obtained using a questionnaire that was completed by interviewing children’s parents/caregiver. RESULTS: Out of 720 screened children, 402 (55.8 %) were undernourished. Severe malnutrition was found in 178 (24.7 %) children and among these 97 (54.5 %) had marasmus. Risk factors associated with severe malnutrition were children with age less than 2 years, lack of vaccination, taking unbalanced diet, low maternal education and single parent, with p-value (&lt;0.001, &lt; 0.001, &lt;0.001, 0.02, &lt; 0.001) respectively. CONCLUSION: This study show a high prevalence of malnutrition in hospitalized children and the majority was marasmic. The risk factors associated with severe malnutrition were described. We recommend improving the screening for undernutrition in all admitted patients so that proper management of this problem can be done concurrently with the primary clinical disease that led to admission

Sero-Prevalence and Factors Associated with Toxoplasma gondii Infection among Pregnant Women Attending Antenatal Care in Mwanza, Tanzania.

Serological screening of pregnant women for Toxoplasma gondii-specific antibodies is not practiced as an antenatal care in Tanzania; and there is a limited data about sero-prevalence of T. gondii infection in developing countries. We therefore conducted this study to determine the sero-prevalence and factors associated with T. gondii infection among pregnant women attending antenatal care clinics in Mwanza, Tanzania. Between 1st November 2012 and 31st May 2013 a total of 350 pregnant women attending antenatal care clinics in Mwanza were enrolled and screened for IgG and IgM antibodies against T. gondii using the ELISA technique. Of 350 pregnant women, 108 (30.9%) were sero-positive for T. gondii-specific antibodies. The risk of contracting T. gondii infection increases by 7% with each yearly increase in a woman's age (OR=1.07, 95% CI: 1.02 - 1.11, p=0.002). The sero-positivity rate of T. gondii-specific antibodies was higher among pregnant women from the urban than those from rural communities (41.5% versus 22.0%); [OR=2.2, 95% CI; 1.4 - 3.7, p=0.001]. Likewise employed/business women were more likely to get T. gondii infection than peasants (40.0% versus 25.9%) [OR=1.9, 95% CI: 1.2 - 3.0, p=0.006]. Sero-prevalence of T. gondii-specific antibodies is high among pregnant women in Mwanza with a significant proportion of women at risk of contracting primary T. gondii infections. Screening of T. gondii infections during antenatal care should be considered in Tanzania as the main strategy to minimize congenital toxoplasmosis

Immune recovery among HIV-infected patients in northwestern Tanzania after 2 years of anti-retroviral therapy use: a retrospective cohort study

 Background: The use of antiretroviral therapy (ART) for the treatment of human immunodeficiency virus (HIV) is associated with significant and sustained decrease in the viral RNA levels that allows the immune system to recover. The extent of this immune recovery depends on the baseline CD4 count. Evidence on the extent of immune recovery in patients with advanced HIV from resource limited settings is scarce. The objective of this study was to determine immune recovery in a cohort of HIV infected outpatients after using ART for a period of 2 years. Methods: This retrospective cohort study was conducted in an outpatient HIV clinic at Bugando Medical Centre in northwestern Tanzania. CD4+ T-cell counts for HIV-positive adults at the time of enrolment were measured and retrospectively followed up during ART eligibility screening process prior to initiation of antiretroviral (ARV) drugs. We then compared the CD4+ T-cell counts at baseline and that during the enrolment. Results: A total of 238 patients files were screened for enrolment. Of the 238 patients, 171 (71.8%) fulfilled the criteria and were enrolled for the study. The lack of participation was due to death 17 (7.1%), lost to follow-up 32 (13.4%) and refusal 18 (9.5%). Of the 171 patients, the median CD4 count at the time of ART initiation was 153 cells/µl [Interquartile range (IQR): 78 – 199], 164 (95.9%) had increased their CD4 cells count, with 74.3% having an increase of more than 150 cells/µl. Only 8 (4.7%) patients had a decline of CD4 cell count. The median CD4 cells count after a 2-year follow up was significantly higher (396 [IQR: 295 – 567]) than at baseline (153 [IQR: 78 – 199]) cells/ul; p-value &lt;0.0001). Conclusion: The CD4 cells count increased significantly after a follow up period of 2 years after ART use in this cohort. Early diagnosis and ART initiation could therefore improve outcomes in HIV-infected patients in resource limited settings.

Low Sputum Smear Positive Tuberculosis among Pulmonary Tuberculosis Suspects in a Tertiary Hospital in Mwanza, Tanzania

Early diagnosis of tuberculosis (TB) and prompt initiation of treatment are essential for an effective tuberculosis control programme. In many resource limited settings microscopic diagnosis is still the pivotal tool in the diagnosis of pulmonary TB. This study aimed at evaluating laboratory microscopic diagnosis of tuberculosis in a tertiary hospital in Mwanza, Tanzania. This retrospective hospital based study reviewed consecutively from TB registry and patients’ files a total of 5,922 TB suspects who submitted their sputum for examination between January 2007 and May 2010 at Bugando Medical Centre (BMC). Among TB suspects (mean age=36.1±13.6 years) female accounted for 54.1% of the patients. The prevalence of HIV among TB patients was 59.4%. The sputum smear positivity rate among the TB suspects was 6.1%; the rate was higher in HIV positive than in HIV negative patients (9.9 % versus 3.2%, P-value < 0.001). The overall positivity rate for the first smear was 94.2% with an incremental percentage yield of 5.2% and 0.6% for the second and third smears, respectively. The study found that 28.6% of patients who were positive in the first smear did not return for the second smear. The risk factors among smear positive TB patients were co-illness (32.5%), previous history of TB (7.5%) and history of positive TB contact (4.7%). These findings also show that as CD4+ T Cells count increases, the quantity AFB in sputum smear also increase although not statistically significant. The sputum smear positivity rate at Bugando Medical Centre is low and more than a quarter of initial TB suspects who were positive in the first smear were lost to follow up posing a threat of continuous transmission of tuberculosis to the community. The finding of more sputum smear positivity rate among HIV positive than HIV negative patients at BMC requires a prospective study to ascertain whether it is a reality or a coincidence.\u