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

HIV-1 pol Diversity among Female Bar and Hotel Workers in Northern Tanzania

A national ART program was launched in Tanzania in October 2004. Due to the existence of multiple HIV-1 subtypes and recombinant viruses co-circulating in Tanzania, it is important to monitor rates of drug resistance. The present study determined the prevalence of HIV-1 drug resistance mutations among ART-naive female bar and hotel workers, a high-risk population for HIV-1 infection in Moshi, Tanzania. A partial HIV-1 pol gene was analyzed by single-genome amplification and sequencing in 45 subjects (622 pol sequences total; median number of sequences per subject, 13; IQR 5–20) in samples collected in 2005. The prevalence of HIV-1 subtypes A1, C, and D, and inter-subtype recombinant viruses, was 36%, 29%, 9% and 27%, respectively. Thirteen different recombination patterns included D/A1/D, C/A1, A1/C/A1, A1/U/A1, C/U/A1, C/A1, U/D/U, D/A1/D, A1/C, A1/C, A2/C/A2, CRF10_CD/C/CRF10_CD and CRF35_AD/A1/CRF35_AD. CRF35_AD was identified in Tanzania for the first time. All recombinant viruses in this study were unique, suggesting ongoing recombination processes among circulating HIV-1 variants. The prevalence of multiple infections in this population was 16% (n = 7). Primary HIV-1 drug resistance mutations to RT inhibitors were identified in three (7%) subjects (K65R plus Y181C; N60D; and V106M). In some subjects, polymorphisms were observed at the RT positions 41, 69, 75, 98, 101, 179, 190, and 215. Secondary mutations associated with NNRTIs were observed at the RT positions 90 (7%) and 138 (6%). In the protease gene, three subjects (7%) had M46I/L mutations. All subjects in this study had HIV-1 subtype-specific natural polymorphisms at positions 36, 69, 89 and 93 that are associated with drug resistance in HIV-1 subtype B. These results suggested that HIV-1 drug resistance mutations and natural polymorphisms existed in this population before the initiation of the national ART program. With increasing use of ARV, these results highlight the importance of drug resistance monitoring in Tanzania

Prevalence of drug resistance mutations and HIV type 1 subtypes in an HIV type 1-infected cohort in rural Tanzania

The development of resistance mutations in drug-targeted HIV-1 genes compromises the success of antiretroviral therapy (ART) programs. Genotyping of these mutations enables adjusted therapeutic decisions both at the individual and population level. We investigated over time the prevalence of HIV-1 primary drug resistance mutations in treatment-naive patients and described the HIV-1 subtype distribution in a cohort in rural Tanzania at the beginning of the ART rollout in 2005-2007 and later in 2009. Viral RNA was analyzed in 387 baseline plasma samples from treatment-naive patients over a period of 5 years. The reverse transcriptase (RT) and protease genes were reversely transcribed, polymerase chain reaction (PCR) amplified, and directly sequenced to identify HIV-1 subtypes and single nucleotide polymorphisms associated with drug resistance (DR-SNPs). The prevalence of major DR-SNPs in 2005-2007 in the RT gene was determined: K103N (5.0%), Y181C (2.5%), M184V (2.5%), and G190A (1.7%), and M41L, K65KR, K70KR, and L74LV (0.8%). In samples from 2009 only K103N (3.3%), M184V, and T215FY (0.8%) were detected. Initial frequencies of subtypes C, A, D, and recombinants were 43%, 32%, 18%, and 7%, respectively. Later similar frequencies were found except for the recombinants, which were found twice as often (15%), highlighting the subtype diversity and a relatively stable subtype frequency in the area. DR-SNPs were found at initiation of the cohort despite very low previous ART use in the area. Statistically, frequencies of major mutations did not change significantly over the studied 5-year interval. These mutations could reflect primary resistances and may indicate a possible risk for treatment failure

Quality of paediatric blood transfusions in two district hospitals in Tanzania: a cross-sectional hospital based study.

BACKGROUND: Blood transfusion (BT) can be lifesaving for children; however, monitoring the quality of BT is important. The current study describes the quality of paediatric BT delivered in two district hospitals in north-east Tanzania in order to identify areas for quality assurance and improvement in the administration of BT. METHODS: All 166 children admitted in the paediatric wards and receiving BT through April to June 2007 were prospectively observed. Medical records, request forms and registers in the laboratories were reviewed to identify blood source, blood screening and indications for BT. BT was observation before, during and after transfusion process. RESULTS: Malaria related anaemia accounted for 98% of the BTs. Ninety-two percent of the children were assessed for paleness. Clinical signs such as difficult breathing and symptoms of cardiac failure were only assessed in 67% and 15% of the children respectively, prior to the BT decision. Pre-transfusion haemoglobin and body temperature were recorded in 2/3 of the patients, but respiratory rate and pulse rate were not routinely recorded. In 40% of BTs, the transfusion time exceeded the recommended 4 hours. The zonal blood bank (ZBB) and local donors accounted for 10% and 90% of the blood, respectively. ABO and RhD typing and screening for HIV and syphilis were undertaken in all transfused blood. Evidence for hepatitis B or C infection was not checked except in the ZBB. CONCLUSION: Criteria for BT are not always fulfilled; time to initiate and complete the transfusion is often unacceptable long and monitoring of vital signs during BT is poor. Blood from the ZBB was often not available and BT often depended on local donors which implied lack of screening for hepatitis B and C. It is recommended that an external supervision system be established to monitor and evaluate the quality of BT performance in the laboratories as well as in wards

Distribution of HIV-1 subtypes among female bar and hotel workers in Moshi, Kilimanjaro, Tanzania in 2005.

<p>*Kiwelu et al., 2013.</p

Polymorphisms in protease gene in HIV-1 subtypes A1 and C, compared to ARV-naïve individuals from the Stanford HIV-1 Drug Resistance Database.

<p>Polymorphisms in protease gene in HIV-1 subtypes A1 and C, compared to ARV-naïve individuals from the Stanford HIV-1 Drug Resistance Database.</p

Distribution of HIV-1 V1-C5 <i>env</i> and <i>pol</i> sequences among female bar and hotel workers in Moshi, Kilimanjaro, Tanzania, with at least one inter-subtype recombinant virus.

<p>U* unclassified region.</p

Mutations and polymorphisms at positions associated with drug resistance to PIs, NRTIs, and NNRTIs among female bar and hotel workers in Moshi, Kilimanjaro, Tanzania, in 2005.

<p>Mutations and polymorphisms at positions associated with drug resistance to PIs, NRTIs, and NNRTIs among female bar and hotel workers in Moshi, Kilimanjaro, Tanzania, in 2005.</p

ML phylogenetic tree of HIV-1 protease and reverse transcriptase sequences of the <i>pol</i> gene from 45 subjects.

<p>The ML was constructed by PhyML 3.0.1 and visualized in FigTree. The tree is rooted with the HIV-1 group N consensus sequence as an outgroup. 488 non-recombinant <i>pol</i> sequences generated from the 45 subjects were analyzed with HIV-1 reference subtypes from the Los Alamos HIV-1 Sequence Database. HIV-1 inter-subtype recombinant <i>pol</i> DNA sequences were excluded in this figure. HIV-1 reference subtypes A1, C, and D are shown in red, pink and blue, respectively. The other references are shown in orange. Approximate likelihood ratio test (aLRT) values of ≥0.95 were considered significant and are shown by an asterisk (*). The scale at the bottom of the figure corresponds to 0.01 nucleotide substitutions per site.</p

Schematic representation of recombinant viruses detected in 12 subjects showing recombination breakpoints.

<p>Localization of breakpoints between HIV-1 subtypes was done by SimPlot analysis and identified breakpoints were visually inspected in BioEdit. The numbers in each bar indicate breakpoints and were given HXB2 numbering. The first bar represents the protease and reverse transcriptase genes. The dashed lines indicate the positions where protease gene starts, 2, 253 (HXB2 numbering), and ends, 2,549 (HXB2 numbering). The genome segments are colored according to HIV-1 subtypes. Red, orange, yellow, blue, green, and light blue represent sequences from HIV-1 subtypes A1, A2, C, D, CRF10_CD and CRF35_AD, respectively. The black bar represents the unclassified (U) regions. Confirmation of recombination was conducted by constructing phylogenetic trees of the putative recombinant regions against reference HIV-1 subtypes.</p