Time series analysis of consumption and short term forecasting of female contraceptives in the Kenyan public health sector

Background: Contraceptive security is crucial in ensuring access to family planning services and improving the contraceptive prevalence rate. This requires proper forecasting and procurement of contraceptives. It is therefore important to study consumption patterns and apply forecasting techniques so as to adjust for any changes in the choice of contraceptives over a given time period. Objectives: The objectives of this study were to analyze trends, identify any seasonal or cyclic patterns in consumption of contraceptives, compare service point and consumption data, forecast consumption for six months and determine optimal models for forecasting contraceptives. Methods: Data on consumption of implants, injectables, pills, and Intrauterine Contraceptive Devices (IUCDs) were extracted from the Kenya District Health Information System for the years 2014-2018. An exploratory analysis was done and the data decomposed to evaluate the trends and seasonal components. Service point and consumption data of contraceptives were compared. Short-term forecasting using the Autoregressive Integrated Moving Average (ARIMA) and the Exponential Smoothing (ES) models was done. The optimal model for forecasting was determined and the models validated using actual facility consumption data for 2018. Results: The consumption of pills, injectables, and IUCDs declined while that of implants increased significantly across the 4 years. There were differences in the data reported for consumption and service point data for injectables, implants, and IUCDs. The ES models recorded the least error when forecasting consumption of all contraceptives except for one-rod implants in which the ARIMA model had the least errors. Conclusion: There was a general shift towards the use of long-acting reversible methods especially implants in Kenya. The difference in the reporting of consumption and service point data for injectables, implant, and IUCDs showed gaps in the documentation and reporting of contraceptives. The ETS models were generally superior to the ARIMA models for predicting consumption of contraceptives. Keywords: Contraceptives, consumption, forecasting, time series, trend

Herbal Product Processing Practices of Traditional Medicine Practitioners in Kenya- Key Informant Interviews

Introduction: Herbalists in Kenya use self-taught processing practices which are inadequate. The objective of this study was to conduct an assessment of selected practices used by herbalists during drug processing and to identify knowledge gaps. Method: Four long practicing traditional medicinal practitioners were identified using purposive sampling. An interview guide and field visits were used to gather data. Data analysis was done using content thematic approach. Results: Sources of herbal knowledge were varied with the use of internet being a key finding. Regulatory compliance presented various challenges to the herbalists. The wild and cultivation of herbs were identified as key medicinal sources although the protection of biodiversity was a key concern of the herbalists. The facilities, area of practice and general hygiene were inadequate. Positive and negative practices were identified in processing of the herbal medicines. Conclusions: Secrecy by the herbalists has resulted in limited in innovation. More training of herbalists is required to improve on the quality of their drugs.  It is however encouraging that they have adopted some modern methods in their practice. Keywords: Herbalists, processing practices, herbal drug

Socio-demographic and treatment-related variables associated with CD4 cell counts in Kenyan HIV patients on second-line regimens

Background: CD4 cell response in patients on second-line therapy has not been evaluated in Kenya. Patients failing second-line are changed to third-line, however, the drugs used for third-line are expensive and unavailable. Therefore, early identification of potential poor responders to treatment would lead to early intervention and thus improve therapy of patients on second-line. Objectives: To identify socio-demographic and treatment related variables that affect CD4 response of HIV-positive patients on second-line regimens in Kenyatta National Hospital (KNH). Methods: A historical cohort study carried out at KNH between January and April 2016 and entailed collection of patient data from the files. The main outcome variable was CD4 cell count.  The predictor variables of interest were sex, age, education level, and ART regimens. Results: All the study participants were on a lopinavir-based regimen. The study involved 84 study participants, 59.5% female study participants and 40.5% male. Male patients had significantly lower baseline CD4 cell counts and lower CD4 cell counts at ART (antiretroviral therapy) switch to second line compared to female patients. Efavirenz-based regimens were significantly associated with low CD4 cell count at ART switch to second-line. Conclusion: Patients should be started on nevirapine-based regimens unless contraindicated. Keywords: CD4 cell count, ART switch, second-lin

Management of Type 2 Diabetes Mellitus by Traditional Medicine Practitioners in Kenya- Key Informant Interviews

Introduction: Worldwide, plant based medicines are increasing in popularity due to perceptions of safety and efficacy. Herbalists in Kenya are widely consulted for the management of many diseases including Type 2 Diabetes Mellitus (T2DM). This study investigated the level of knowledge of the herbalists in management of T2DM. Methods: Purposive sampling was used to identify 4 herbalists working in the urban areas who actively manage T2DM. Key informant interviews were used to gather data about the management of T2DM. It was analyzed using a content thematic approach. Results: Diverse management methods which included both pharmacological and non- pharmacological were noted. Glycemic control was assessed with the help of a glucometer. In addition, presenting signs and symptoms were key in diagnosing T2DM. The herbalists used various herbs, minerals and animals as medicinal sources. The drugs were dispensed as decoctions with excipients being added appropriately. Adverse effects were recorded. The herbalists acknowledged that patients use both herbal and allopathic medicine together. A level of record keeping was observed but patient follow-up was poor. The cost of the herbal drugs was perceived to be excessive. Conclusion: Some similarities exist in the management of T2DM between allopathic and traditional medicine practitioners. Training of herbalists is required to improve the quality of care given to patients.Pan African Medical Journal 2015; 2

Evaluation of the clinical practice of aminoglycosides use in paediatric patients in Kenya : findings and implications to Low-middle Income Countries

Objectives To evaluate the practice of aminoglycoside use/monitoring in Kenya and explore healthcare worker (HCW) perceptions of aminoglycoside monitoring to identify gaps and opportunities for future improvements, given the low therapeutic index of aminoglycosides. Methods This was a two-phase study whereby we reviewed patients' medical records at Kenyatta National Hospital (October-December 2016) in Phase 1 and interviewed HCWs face to face in Phase 2. Outcome measures included describing and evaluating the practice of aminoglycoside use and monitoring and compliance to guidelines. Data were analysed using descriptive and inferential analysis. Results Overall, out of the 2318 patients admitted, 192 patients (8.3%) were prescribed an aminoglycoside, of which 102 (53.1%) had aminoglycoside doses that did not conform to national guidelines. Aminoglycoside-related adverse effects were suspected in 65 (33.9%) patients. Monitoring of aminoglycoside therapy was performed in only 17 (8.9%) patients, with no therapeutic drug monitoring (TDM), attributed mainly to knowledge and skill gaps and lack of resources. Out of the 28 recruited HCWs, 18 (64.3%) needed training in how to perform and interpret TDM results. Conclusions The practice of using and monitoring aminoglycosides was suboptimal, raising concerns around potential avoidable harm to patients. The identified gaps could form the basis for developing strategies to improve the future use of aminoglycosides, not only in Kenya but also in other countries with similar settings and resources

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

Point prevalence survey of antibiotic use and resistance at the biggest national referral hospital in Kenya : findings and implications

Background: A substantial amount of antibiotic use in hospitals may be inappropriate, leading to an increase in antibiotic resistance, adverse effects, mortality and increased costs. This can be reduced by documenting and understanding current utilisation patterns to instigate appropriate measures. Objective: To assess antibiotic use patterns and prevalence of antibiotic resistance in the biggest national referral hospital in Kenya; subsequently identify opportunities for quality improvement. Methodology: A point prevalence survey (PPS) was carried out with data abstracted principally from patient medical records supplemented by interviews from physicians, using the global PPS data collection tool and methodology. Patients were selected using universal sampling. Descriptive analysis was used to describe the pattern of antibiotic use. Differences in antibiotic use and indications between the selected wards were compared using the Chi-square test or Fisher’s exact tests. Results: Among the patients surveyed (n=269), 67.7% (n=182) were on antibiotics. The most common classes of antibiotics prescribed were third generation cephalosporins (55%), imidazole derivatives, e.g. metronidazole (41.8%), and broad spectrum penicillins (41.8%). Most common indication for antibiotic use was medical prophylaxis (29%). Dosing of antibiotics was seen as typically optimal when assessed against current recommendations. Among gram positive organisms, Staphylococcus aureus isolates were resistant to cotrimoxazole (90%), amoxicillin (69%), co-amoxyclav (67%) and cefaclor (67%). Among gram negative bacteria, Escherichia coli isolates were resistant to piperacillin (90%). Pseudomonas aeruginosa isolates were resistant to imipenem (100%). Conclusion: Whilst the dosing of antibiotics seemed adequate, there was high use of antibiotics, exacerbated by the high proportion being prescribed without reference to current guidelines. Antibiotic resistance also seems to be very high especially against the broadest spectrum antibiotics, which is a real concern and imposes sever negative clinical implications. Programmes are currently being instigated to address these concerns