An Investigation of the Antimicrobial Activity of Acmella caulirhiza

Background: Acmella caulirhiza is a plant that is used traditionally to treat several disorders such as mouth ulcers, sore throat, toothache and earache, among others. It is a small annual or perennial herb whose location is widespread worldwide. Objectives: The objective of the study was to determine whether the leaves, stem and the flowers extract of the plant possess antibacterial and antifungal activity and to find out which part of the plant is the most active, if any. Methodology: Acmella caulirhiza was collected from the wild in Kericho County. The flower heads, the leaves and the stems were dried separately, ground into a powder and extracted with chloroform. The plant extracts were tested for activity against Escherichia Coli, Staphylococcus aureus, Candida albicans and Bacillus pumilus. Results and Discussion: The plant extracts inhibited the growth of Escherichia Coli, Staphylococcus aureus and Bacillus pumilus. The activity was highest in the stems extracts. The extracts, however, did not have any anti-fungal activity when tested against Candida albicans. It was concluded from these results that the anti-bacterial activity may aid in the efficacy when the plant is used to treat mouth ulcers or sore throat. Key words: Acmella caulirhiza, anti-fungal activity, anti-bacterial activity, traditional medicin

Patterns of antimicrobial use in the neurosurgical ward of Kenyatta National Hospital

Background: Antibiotics in neurosurgery are used for prophylaxis and treatment of already established infection.  Guidelines state that prophylactic antibiotics should be given for up to 24 hours. For treatment of already established infections, empiric therapy with intravenous antibiotics for four to eight weeks is indicated. Studies have shown no distinction between antibiotic use for prophylaxis and treatment of established infection in neurosurgery. Objectives: To identify antibiotic use patterns and medication errors and their association with development of surgical site infections. Methods: A prospective cohort study involving adult neurosurgical patients was carried out at Kenyatta National Hospital, between April 2015 and July 2015. Patient demographic data as well as data on surgical procedures carried out, antibiotics used and medication errors was collected. Descriptive data analysis was done for all variables. To test for association between antibiotic use patterns and development of surgical site infections, the Fischer exact Chi square test was used. Results: Out of the 84 participants recruited in the study, 87.2% (n=68) used antibiotics. Ceftriaxone was the most commonly used (63.7%, n= 44), followed by metronidazole (40.4%, n=23).  Medication errors that were noted involved inappropriate choice and use of antibiotics. There was no distinction between use of antibiotics for prophylaxis and treatment of infection. There was no statistically significant association between patterns of antibiotic use and development of surgical site infection. Conclusion: Antibiotic use patterns do not affect the incidence of neurosurgical site infections. Prescribing errors of various types were prominent. An antibiotic use protocol should guide antimicrobial selection and use in neurosurgery. Key words: antibiotic, prophylaxis, medication error

Prevalence and Risk Factors for Medication Discrepancies on Admission of Elderly Diabetics at Kenyatta National Hospital, Kenya

Background: Medications discrepancies are defined as the variations in drug regimens during transition from one health care worker or hospital to another.  The elderly diabetic patients are at risk of medication discrepancies due to their multiple comorbidities resulting in different medications from the many healthcare providers they are likely to see and physiological changes as a result of advanced age; hence the need for medication reconciliation. Objectives: The main objective of the study was to measure the prevalence and identify risk factors for medication discrepancies at admission of inpatient elderly diabetics at Kenyatta National Hospital (KNH). Methods: The study design was cross sectional descriptive study in which patients aged 60 years and above were recruited at the time of admission at the medical wards in 2016. Convenient sampling was conducted. A comparison of the medication used before and after admission was done to determine the number of discrepancies if any.  Admitting clinicians were interviewed to determine if discrepancies were intentional or not. Linear regression was conducted to determine risk factors for the number of errors per patient. Results: Among the 163 patients recruited, 1089 medication discrepancies were identified, 63.2% of the patients had at least one unintentional discrepancy. The number of unintentional discrepancies per patient was 1.5 per patient. The most common discrepancy was omissions 236 (98.3%).  Independent risk factors for discrepancies were the number of medications prior to admission (adjusted β coefficient 1.377 (95% CI: 0.767, 1.987)), hypertension (β 0.992 (95% CI: 0.094, 1.890)) and those with discharge forms from other facilities (β 0.701 (95% CI: 0.010, 1.392)). Age had a negative association with medication discrepancies (β -0.755 (95% CI: -1.284, -0.226)). Conclusion: The prevalence of medication discrepancies was high hence the need for medication reconciliation to reduce these discrepancies. Key words: Medication Reconciliation, Unintentional discrepancies, Diabetes, Elderly diabetic

Impact of neurosurgical site infections on patient expenditure at a national referral hospital in Kenya: a cost of illness study

Background: Neurosurgical site infections result in prolonged hospitalisation and increased treatment costs. Cost of illness studies are important in computing the total costs of treatment of disease, as they quantify the burden of disease in terms of direct costs, productivity losses and intangible costs. Neurosurgical site infections do not occur at a high rate in most clinical settings. Their economic impact has been assumed to be minimal, and most studies have not exclusively studied their economic impact. Objective: To assess the economic burden of treatment of surgical site infections among trauma patients admitted at the neurosurgical ward of Kenyatta National Hospital. Methods: A prospective cost of illness study was conducted between April 2015 and June 2015 as part of a larger prospective cohort study. The patient perspective was adopted. The time horizon was the hospitalization period of the patients, which was a median of ten days. No discounting was done because the study was done within a year. A micro costing approach was used to compute direct costs on medication, laboratory and radiologic tests, cost of surgical procedures and nursing care, and direct non-medical costs incurred by patients for the average 10 day hospitalisation period. Productivity losses were also computed. Results: The total median cost of treating patients with neurosurgical site infections was higher, at USD 203.95 than that of patients without infection at USD 141.20. The median cost on antibiotics was USD 18.70 while that of non- antibiotic drugs was USD 33.03. The total median cost on laboratory and radiologic tests was USD 20 and USD 55 respectively. The key cost drivers were expenditures on meropenem, phenytoin, urea, electrolyte and creatinine tests and CT scans. With regards to costs of services, care-giver costs accounted for the highest median expenditure, followed by costs of surgery and nursing care. Conclusion: Neurosurgical site infections increase hospitalisation duration and costs. Prevention of these will reduce patient expenditure. Key words: cost of illness, neurosurgical site infection, productivity losse

Determinants of Appropriate Antibiotic Dosing in Patients with Chronic Kidney Disease in a Kenyan Referral Hospital

Background: Reduced renal function in chronic kidney disease (CKD) necessitates appropriate dose alterations to avoid drug accumulation. Objectives: The main objective of the study was to determine the prevalence of inappropriate antibiotic dosing in patients with CKD in the largest referral hospital in eastern Africa. Variables associated with inappropriate dosing were identified. Methods: The design was a retrospective review of patients’ records. The study population was adult patients, with CKD admitted between January, 2006 and December, 2010.  Data was abstracted from patient files. Logistic regression was used to determine variables associated with appropriate antibiotic dosing. Results: Ceftriaxone and amoxicillin-clavulanic acid were the most frequently prescribed antibiotics. Dose adjustment was required for 379 (59.9%) antibiotic prescriptions. Of these, 105 doses (27.7% [95% CI: 23.2 – 32.2%]) were appropriate and 274 (72.3% [95% CI 67.8 – 76.8%]) were inappropriate.  The resultant dosing errors were: 271 (98.9%) and 3 (1.1%) cases of over and under dosing respectively. Key explanatory variables for appropriate dosing were: stage of renal disease (adjusted odds ratio (OR) 0.159 [95% CI: 0.082, 0.309]); administration; (adjusted OR 1.724 [95% CI:1.185, 2.508]); and treatment with amoxicillin-clavulanic acid (adjusted OR 0.101 [95% CI 0.024, 0.420]. Conclusion: Antibiotic doses in patients with CKD were often inappropriate. Keywords: Antibiotic, dose adjustment, chronic kidney diseas

Determinants of insulin-related knowledge among healthcare providers at a county referral hospital in Kenya

Background: Insulin is a high alert medication with potential to cause hypoglycaemia if used incorrectly. Inadequate healthcare provider knowledge regarding insulin contributes to errors in its use that may cause patient harm. Objective: To identify the determinants of healthcare provider knowledge regarding insulin use in type 2 diabetes. Methodology: A cross-sectional study was conducted at Thika Level V Hospital in March 2015. A 20-item questionnaire was used to assess insulin knowledge in pharmaceutical, nursing and medical staff working in the outpatient department and the medical wards. The outcomes of interest were the scores on types, prescribing, administration and monitoring of insulin. Descriptive and regression data analyses were performed using IBM SPSS Statistics Version 20. Results: The participants’ mean (±SD) age was 32.6±10.2 years. The mean (±SD) duration of clinical practice was 8.3±9.03 years. Nurses formed the largest (36, 40%) cadre in the study. Determinants of the overall score in the insulin knowledge test were professional cadre (p<0.0001), in-patient care (p=0.044) and reading of journals (p=0.005). Insulin pharmacology scores were correlated with younger age (21-30 years, (p=0.02), clinical experience of <5 years, (p=0.013), use of information from drug representatives (p=0.023) and being a pharmacist intern or medical officer (p=0.002). Good prescribing scores were found among the medical officers, consultants and the clinical pharmacist (p=0.035). Conclusion: Several factors account for the differences in insulin-related knowledge among the healthcare providers evaluated in this study. Interventions are required to address these variations and equip the health workers with knowledge on all areas related to insulin use. Such interventions should include development of a curriculum on certified diabetes education, improved access to journals, collaboration with pharmaceutical companies in provision of drug-related information, continuing medical education and staff duty rotation to ensure that the healthcare providers gain experience in in-patient diabetes care. Keywords: diabetes, healthcare provider, insulin-related knowledg

Systematic Review, Meta-Analysis and Grading of Evidence on the Effectiveness of Antimicrobial Prophylaxis for Neurosurgical Site Infections

Background: Antimicrobial prophylaxis is crucial for neurosurgical procedures, even though they are clean procedures. Observational studies have shown the effectiveness of different antibiotics in preventing neurosurgical site infections, but there remains paucity of systematic reviews and meta-analyses which have assessed their effectiveness in East Africa. Objectives: To generate and appraise the quality of evidence that would inform antimicrobial prophylaxis in neurosurgery. Methodology: A systematic review and meta-analysis was conducted between October 2014 and December 2015. Studies that involved the administration of systemic antibiotics for prophylaxis, use of antibiotic impregnated shunt catheters among adult patients aged over 18 years were included and subjected to abstract, title and full text screening. A meta-analysis was carried out using RevMan (Review Manager) version 5 software. The quality of evidence was evaluated using the GRADE system. Results: One systematic review of randomized controlled trials (n=17) and 11 randomised controlled trials were included in the study. From the first meta-analysis, use of systemic antibiotics demonstrated an overall protective effect of 52% from development of surgical site infections [OR 0.48 (95% CI 0.30, 0.79)]. In the second meta-analysis, the use of antibiotic impregnated shunt catheters was associated with a higher risk of mortality compared to use of the standard shunt [(OR 1.47(95% CI 0.82, 2.62)]. Following evaluation of quality of evidence, in the antibiotics versus placebo arm, the quality of evidence was moderate, while that for antimicrobial impregnated shunts was very low. Conclusion: Antimicrobial prophylaxis using systemic antibiotics or antimicrobial impregnated shunts is effective in preventing neurosurgical site infections. Antimicrobial impregnated shunts are too expensive for our study population. Key words: systematic review, meta-analysis, antimicrobial prophylaxi

One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (>4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers. Keywords: Drug utilisation studies, generics, prescribing patterns, prescribing indicators, polypharmacy, WHO indicators, Keny

Comparison of zidovudine and tenofovir based regimens with regard to quality of life and prevalence of syptoms in HIV patients in Kenya

Zidovudine and tenofovir form the back bone of antiretroviral therapy in Kenya, with sub-Sahara Africa having the highest prevalence of HIV worldwide. However, they have side effects which may adversely affect health related quality of life (HRQoL) and adherence. More women than men have HIV in sub-Sahara Africa; consequently, crucial to conduct studies in Africa. Objective: Compare the Health Related Quality of Life of adult patients on tenofovir versus zidovudine based regimens in a leading referral hospital in Kenya to guide future management decisions. Methods: Comparative cross sectional study conducted on adult out-patients on either tenofovir or zidovudine at Kenyatta National Hospital between 2015 and 2016. The Medical Outcome Study HIV Health Survey (MOS) was administered. Linear regression analysis was performed to identify determinants of HRQoL. Results: Of the total 501 patinets included, participants on zidovudine (39.9%, n=200) had a higher median Physical (PHS) and Mental Health Scores (MHS) (61.9, IQR: 59.5, 62.8) compared to those on tenofovir (60.1, IQR: 55.1, 62.3). Presence of any symptom of disease and stated inability to cope were negatively associated with PHS whilst having regular source of income improved PHS. Being on tenofovir, symptom of illness (β -1.24, 95 % CI; -2.253, -0.226), absence of pain (β 0.413, 95 % CI; 0.152, 0.674) and patient stated inability to cope with HIV (β -1.029, 95 % CI; -1.441, -0.617) affected the MHS. Patients on tenofovir and second line regimens also had more signs and symptoms of illness. Conclusion: Participants on zidovudine based regimens had a better performance across all aspects of HRQoL, and should be actively considered in the future where pertinent

Comparison of Zidovudine and Tenofovir Based Regimens With Regard to Health-Related Quality of Life and Prevalence of Symptoms in HIV Patients in a Kenyan Referral Hospital

Aim: Zidovudine and tenofovir form the backbone of antiretroviral therapy in Kenya. However, their side-effects may affect the quality of life (QoL) of patients. The aim was to compare the health-related quality of life (HRQoL) of adult patients on tenofovir versus zidovudine based regimens in a referral hospital in Kenya to provide future guidance.Methods: A comparative cross sectional study among 501 adult out-patients on either tenofovir or zidovudine was undertaken in Kenyatta National Hospital between 2015 and 2016. The Medical Outcome Study HIV Health Survey (MOS-HIV) was administered along with other key aspects of treatment. Linear regression analysis was performed to identify determinants of HRQoL.Results: Patients on zidovudine had a higher Physical Health Summary Score (PHSS) and Mental Health Summary Score (MHSS) compared to those on tenofovir. The presence of any symptom of the disease and a stated inability to cope were negatively associated with PHSS, whilst having a regular source of income improved PHSS. Being on tenofovir, symptom of illness [β = -1.24; 95% CI (-2.253, -0.226)], absence of pain [β=0.413; 95% CI (0.152, 0.674)] and patient stated inability to cope with HIV [β = -1.029; 95% CI (-1.441, -0.617)] affected the MHSS. Patients on tenofovir and second line regimens had more signs and symptoms of illness.Conclusion: Participants on zidovudine based regimens showed a better performance across all aspects of HRQoL. These are considerations for the future