Dispensing antibiotics without prescription at the community pharmacies and accredited drug dispensing outlets in Tanzania : a cross-sectional study

This study was part of the larger 3-country Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) project funded by the National Institute for Health Research, Medical Research Council and the Department of Health and Social Care, Award (MR/S004785/1).Worldwide, antimicrobial resistance is increasing rapidly and is highly associated with misuse of antimicrobials. The HATUA study (a broader 3-country study) investigated the antibiotic dispensing practices of pharmaceutical providers to clients, particularly the propensity to dispense without prescription. A cross-sectional study using a ‘mystery client’ method was conducted in 1,148 community pharmacies and accredited drugs dispensing outlets (ADDO) in Mwanza (n = 612), Mbeya (n = 304) and Kilimanjaro (n = 232) in Tanzania. Mystery clients asked directly for amoxicillin, had no prescription to present, did not discuss symptoms unless asked [when asked reported UTI-like symptoms] and attempted to buy a half course. Dispensing of amoxicillin without prescription was common [88.2, 95%CI 86.3%–89.9%], across all three regions. Further-more, a majority of outlets sold a half course of amoxicillin without prescription: Mwanza (98%), Mbeya (99%) and Kilimanjaro (98%). Generally, most providers in all three regions dispensed amoxicillin on demand, without asking the client any questions with [Chi2 = 11.8851 and p-value = 0.003]. In Mbeya and Kilimanjaro, providers in ADDOs were more likely to do this than those in pharmacies but no difference was observed in Mwanza. While the Tanzanian government has laws, regulations and guidelines that prohibit antibiotic dispensing without prescription, our study suggests non-compliance by drug providers. Enforcement, surveillance, and the provision of continuing education on dispensing practices is recommended, particularly for ADDO providers.Publisher PDFPeer reviewe

Molecular characterizations of the coagulase-negative staphylococci species causing urinary tract infection in Tanzania (dataset)

HATUA stands for Holistic Approach To Unravel Antimicrobial resistance. The HATUA consortium combines expertise in microbiology, pathogen genomics, epidemiology, human geography, anthropology, sociology, computational biology and statistics across 7 institutions, from three East African countries, the UK and the United States. By taking the Swahili word ‘hatua’ (meaning ‘step’ or ‘action’) as inspiration for its acronym, the team aims to uncover and address the social and biological drivers of antibiotic resistance in multiple sites in Kenya, Tanzania and Uganda, using the clinical prism of urinary tract infection (UTI). We sequenced the whole genomes of our bacterial samples to identify their precise taxonomic classification and query their antimicrobial resistance-contributing elements

Molecular characterizations of the coagulase-negative staphylococci species causing urinary tract infection in Tanzania (dataset)

HATUA stands for Holistic Approach To Unravel Antimicrobial resistance. The HATUA consortium combines expertise in microbiology, pathogen genomics, epidemiology, human geography, anthropology, sociology, computational biology and statistics across 7 institutions, from three East African countries, the UK and the United States. By taking the Swahili word ‘hatua’ (meaning ‘step’ or ‘action’) as inspiration for its acronym, the team aims to uncover and address the social and biological drivers of antibiotic resistance in multiple sites in Kenya, Tanzania and Uganda, using the clinical prism of urinary tract infection (UTI). We sequenced the whole genomes of our bacterial samples to identify their precise taxonomic classification and query their antimicrobial resistance-contributing elements

Allele distribution and phenotypic resistance to ciprofloxacin and gentamicin among extended spectrum β-lactamases producing <i>Escherichia coli</i> from urine, stool, animals and environments of patients with presumptive urinary tract infection in Tanzania

Background: Additional antimicrobial resistance to extended spectrum β-lactamases (ESBL)-producing E. coli exhausts treatment options. We investigated allele distribution and resistance to ciprofloxacin and gentamicin among ESBL-producing E. coli isolates from urine, stool, animals and environments of presumptive urinary tract infection (UTI) patients, in order to gain a crucial insight towards devising prevention and control measures, and treatment guidelines.Methods: Archived ESBL-producing E. coli isolates from urine, stool, animals and surrounding environments of presumptive UTI patients were retrieved. Antimicrobial susceptibility profiles to ciprofloxacin and gentamicin were done followed by multi-plex PCR for blaCTX-M, blaTEM and blaSHV, to determine ESBL alleles distribution. Data were analysed using STATA version 17.Results: A total of 472 confirmed ESBL-producing E. coli isolates from Mwanza 243 (51.5%), Kilimanjaro 143 (30.3%) and Mbeya 86 (18.2%) were analyzed. Of these, 75 (15.9%) were from urine, 199 (42.2%) from stool, 58 (12.3%) from rectal/cloaca swabs of animals and 140 (29.7%) from surrounding environments. Out of 472 ESBL producing E. coli, 98.9% (467) had at least one ESBL allele. The most frequent allele was blaCTX-M detected in 88.1% (416/472) isolates, followed by blaTEM allele detected in 51.5% (243/472) isolates. There were 40.7% (192/472) isolates harboring dual blaCTX-M + blaTEM alleles, and only 0.2% (1/472) isolate had dual blaCTX-M + blaSHV alleles whereas 2.3% (11/472) isolates had a combination of all three alleles (blaCTX-M + blaTEM + blaSHV). None of the isolates harbored a combination of blaTEM + blaSHV only. Resistance to ciprofloxacin and gentamicin was observed in 70.8% (334/472) and 46.0% (217/472) isolates, respectively. There was a significant difference in distribution of resistance to ciprofloxacin as well as to gentamicin among ESBL-producing E. coli isolated from various sources (p-value &lt; 0.001 and 0.002, respectively. Conclusion: Almost all ESBL-producing E. coli isolates carry blaCTX-M, blaTEM and blaSHV either alone or in combination with the most common alleles being blaCTX-M. The resistance to cipropfloxacin and gentamicin which are front-line antibiotics for UTIs among ESBL producing E. coli is high. This implies the need to continuously revise the local guidelines used for optimal empirical therapy for UTI and continual surveillance using one health approach

CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label,parallel-group, multicentre trial

Background The benefi t of CT coronary angiography (CTCA) in patients presenting with stable chest pain has not been systematically studied. We aimed to assess the eff ect of CTCA on the diagnosis, management, and outcome of patients referred to the cardiology clinic with suspected angina due to coronary heart disease. Methods In this prospective open-label, parallel-group, multicentre trial, we recruited patients aged 18–75 years referred for the assessment of suspected angina due to coronary heart disease from 12 cardiology chest pain clinics across Scotland. We randomly assigned (1:1) participants to standard care plus CTCA or standard care alone. Randomisation was done with a web-based service to ensure allocation concealment. The primary endpoint was certainty of the diagnosis of angina secondary to coronary heart disease at 6 weeks. All analyses were intention to treat, and patients were analysed in the group they were allocated to, irrespective of compliance with scanning. This study is registered with ClinicalTrials.gov, number NCT01149590. Findings Between Nov 18, 2010, and Sept 24, 2014, we randomly assigned 4146 (42%) of 9849 patients who had been referred for assessment of suspected angina due to coronary heart disease. 47% of participants had a baseline clinic diagnosis of coronary heart disease and 36% had angina due to coronary heart disease. At 6 weeks, CTCA reclassifi ed the diagnosis of coronary heart disease in 558 (27%) patients and the diagnosis of angina due to coronary heart disease in 481 (23%) patients (standard care 22 [1%] and 23 [1%]; p<0·0001). Although both the certainty (relative risk [RR] 2·56, 95% CI 2·33–2·79; p<0·0001) and frequency of coronary heart disease increased (1·09, 1·02–1·17; p=0·0172), the certainty increased (1·79, 1·62–1·96; p<0·0001) and frequency seemed to decrease (0·93, 0·85–1·02; p=0·1289) for the diagnosis of angina due to coronary heart disease. This changed planned investigations (15% vs 1%; p<0·0001) and treatments (23% vs 5%; p<0·0001) but did not aff ect 6-week symptom severity or subsequent admittances to hospital for chest pain. After 1·7 years, CTCA was associated with a 38% reduction in fatal and nonfatal myocardial infarction (26 vs 42, HR 0·62, 95% CI 0·38–1·01; p=0·0527), but this was not signifi cant. Interpretation In patients with suspected angina due to coronary heart disease, CTCA clarifi es the diagnosis, enables targeting of interventions, and might reduce the future risk of myocardial infarction. Funding The Chief Scientist Offi ce of the Scottish Government Health and Social Care Directorates funded the trial with supplementary awards from Edinburgh and Lothian’s Health Foundation Trust and the Heart Diseases Research Fund

Role of multidetector computed tomography in the diagnosis and management of patients attending the rapid access chest pain clinic, The Scottish computed tomography of the heart (SCOT-HEART) trial:study protocol for randomized controlled trial

&lt;p&gt;Background: Rapid access chest pain clinics have facilitated the early diagnosis and treatment of patients with coronary heart disease and angina. Despite this important service provision, coronary heart disease continues to be under-diagnosed and many patients are left untreated and at risk. Recent advances in imaging technology have now led to the widespread use of noninvasive computed tomography, which can be used to measure coronary artery calcium scores and perform coronary angiography in one examination. However, this technology has not been robustly evaluated in its application to the clinic.&lt;/p&gt; &lt;p&gt;Methods/design: The SCOT-HEART study is an open parallel group prospective multicentre randomized controlled trial of 4,138 patients attending the rapid access chest pain clinic for evaluation of suspected cardiac chest pain. Following clinical consultation, participants will be approached and randomized 1:1 to receive standard care or standard care plus ≥64-multidetector computed tomography coronary angiography and coronary calcium score. Randomization will be conducted using a web-based system to ensure allocation concealment and will incorporate minimization. The primary endpoint of the study will be the proportion of patients diagnosed with angina pectoris secondary to coronary heart disease at 6 weeks. Secondary endpoints will include the assessment of subsequent symptoms, diagnosis, investigation and treatment. In addition, long-term health outcomes, safety endpoints, such as radiation dose, and health economic endpoints will be assessed. Assuming a clinic rate of 27.0% for the diagnosis of angina pectoris due to coronary heart disease, we will need to recruit 2,069 patients per group to detect an absolute increase of 4.0% in the rate of diagnosis at 80% power and a two-sided P value of 0.05. The SCOT-HEART study is currently recruiting participants and expects to report in 2014.&lt;/p&gt; &lt;p&gt;Discussion: This is the first study to look at the implementation of computed tomography in the patient care pathway that is outcome focused. This study will have major implications for the management of patients with cardiovascular disease.&lt;/p&gt