Prevalence of multiresistant gram-negative organisms in a tertiary hospital in Mwanza, Tanzania

Background

Antimicrobial resistance is fast becoming a global concern with rapid increases in multidrug-resistant Gram negative organisms. The prevalence of extended spectrum beta-lactamase (ESBL)-producing clinical isolates increases the burden on implementing infectious disease management in low socio-economic regions. As incidence can vary widely between regions, this study was done to determine resistance patterns of Gram-negative organisms at Bugando Medical Center, a tertiary hospital in Mwanza, Tanzania.

Methods

A total of 800 clinical samples (urine, wound swab, pus, blood, aspirate, sputum etc) were processed over a period of 6 months. Gram-negative bacteria were identified using conventional in-house biochemical tests and susceptibility to common antibiotics done using disc diffusion methods. The disc approximation method was used to identify ESBL producers.

Results

A total of 377 Gram-negative bacteria (GNB) recovered from 377 clinical specimens were analyzed of which 76.9% were Enterobacteriaceae. Among all GNB, 110/377 (29.2%) were found to be ESBL producers. Species specific ESBLs rate among Klebsiella pneumoniae, Escherichia coli, Acinetobacter spp, Proteus spp and other enterobacteria were 63.7%, 24.4%, 17.7%, 6.4% and 27.9% respectively. A statistically significant higher number of inpatients 100/283 (35.3%) compared to 10/94 (10.6%) of outpatients had ESBL-producing organisms (p = 0.000023). Rates of resistances to gentamicin, tetracycline, sulphamethaxazole/trimethoprim and ciprofloxacin were significantly higher among ESBLs isolates than non-ESBL isolates (p = 0.000001).

Conclusion

ESBL producing organisms are common at BMC (Bugando Medical Center) and pose a challenge to antibiotic therapy. Successful implementation of a routine detection of ESBL production is essential in designing appropriate antibiotic prescribing policies and infection control intervention programmes.

Typhoid intestinal perforations at a University teaching hospital in Northwestern Tanzania: A surgical experience of 104 cases in a resource-limited setting

BACKGROUND

Typhoid intestinal perforation is still prevalent in many developing countries. Despite the advances in the management, the outcome in these patients in resource limited countries is still very poor. This study was to review our experiences on the surgical management of typhoid intestinal perforation and to determine the prognostic factors for mortality in our local setting.

METHODS

This was a combined retrospective and prospective study of patients who were operated for typhoid intestinal perforation at Bugando Medical Centre between August 2006 and September 2011. Data collected were analyzed using SPSS computer software version 15.

RESULTS

A total of 104 patients were studied representing 8.7% of typhoid fever cases. Males were affected twice more than the females (2.6:1). Their ages ranged from 8 to 76 years with a median age of 18.5 years. The peak age incidence was in the 11-20 years age group. Fever and abdominal pain were the most common presenting symptoms and majority of the patients (80.8%) perforated between within 14 days of illness. Chest and abdominal radiographs revealed pneumoperitonium in 74.7% of cases. Ultrasound showed free peritoneal collection in 85.7% of cases. Nine (10.2%) patients were HIV positive with a median CD4+ count of 261 cells/μl. The perforation-surgery interval was more than 72 hours in 90(86.5%) patients. The majority of patients (84.6%) had single perforations and ileum was the most common part of the bowel affected occurring in 86.2% of cases. Simple closure of the perforations was the most commonly performed procedure accounting for 78.8% of cases. Postoperative complication rate was 39.4% and surgical site infection was the most frequent complication in 55.5% of cases. Mortality rate was 23.1% and it was statistically significantly associated with delayed presentation, inadequate antibiotic treatment prior to admission, shock on admission, HIV positivity, low CD4 count (< 200 cells/μl), high ASA classes (III-V), delayed operation, multiple perforations, severe peritoneal contamination and presence of postoperative complications (P < 0.001). The median overall length of hospital stay was 28 days.

CONCLUSION

Typhoid intestinal perforation is still endemic in our setting and carries high morbidity and mortality. This study has attempted to determine the factors that statistically influence mortality in typhoid perforation in our environment. Appropriate measures focusing at these factors are vital in order to deliver optimal care for these patients in this region.

Predominance of multi-resistant gram-negative bacteria colonizing chronic lower limb ulcers (CLLUs) at Bugando Medical Center

Background

Infections, trauma, malignances and poorly controlled diabetes are common causes of chronic lower limb ulcerations in developing countries. Infected wound with multi-drug resistant bacteria usually are associated with increased morbidity and mortality. We report the distribution of bacteria pathogens colonizing the chronic lower limb ulcers and their drug susceptibility pattern from Bugando Medical Centre (BMC) a tertiary hospital in Tanzania.

Findings

Three hundred non-repetitive wound swabs were aseptically collected from 300 patients with chronic lower limb ulcers using sterile swabs and processed following standard operative procedures. Isolates were identified using in house biochemical testing and in case of ambiguous confirmation was done using API 20NE and API 20E. Susceptibility was determined using disc diffusion test following clinical laboratory standard Institute guidelines (CLSI). Of 300 swabs from patients with chronic lower limbs ulcers, 201 (67.7%) had positive aerobic culture within 48 hours of incubation. Of 201 isolates, 180(89.6%) were gram-negative bacteria. Out of 180 gram negative bacteria, resistance was detected for ampicillin (95%, n = 171), amoxicillin/clavulanate (83.9%, n = 151), trimethoprim-sulphamethoxazole (78.9%, n = 142), ceftriaxone (46.7%, n = 84), ceftazidime (45.6%, n = 82), gentamicin (39.4%, n = 71), ciprofloxacin (17.8%, n = 32) and meropenem 28(15.6%, n = 25). A total of 41 (35%) of enterobacteriaceae were found to be extended spectrum beta-lactamases (ESBL) producers while of 18 Staphylococcus aureus, 8(44.4%) were found to be methicillin resistant Staphylococcus aureus (MRSA).

Conclusion

There is high prevalence of ESBL and MRSA isolates in surgical wards at BMC. We recommend infection control and antibiotic stewardship programs in these wards to minimize spread of multi-resistant organisms.

Kaposi's sarcoma: a 10-year experience with 248 patients at a single tertiary care hospital in Tanzania

BACKGROUND

Kaposi's Sarcoma is the most common sarcoma and second most prevalent cancer seen in Tanzania. Little is known about Kaposi's sarcoma in our setting as there is paucity of recent published data regarding this condition. This study describes the clinicopathological pattern and treatment outcome of Kaposi's sarcoma at Bugando Medical Centre, a tertiary care hospital in northwestern Tanzania.

METHODS

This was a prospective study of histologically confirmed Kaposi's sarcoma that was conducted at Bugando Medical Center between July 2004 and June 2014.

RESULTS

A total of 248 patients (M:F = 1.4:1) representing 2.4% of all malignancies during the study period were enrolled into the study. The median age at presentation was 36 years. Females were younger than males (p = 0.04). Out of 248 patients, 122 (49.2%) were HIV positive. Of these, 46 (37.7%) were males and 76 (62.3%) females. AIDS-related Kaposi's sarcoma were younger than HIV negative Kaposi's sarcoma patients (p = 0.011). Median duration of symptoms was 6 months. Kaposi's sarcoma was the AIDS defining disease in 82 (67.2%) patients while in the remaining 40 (32.8%) it was diagnosed between 1 and 14 months after the initial diagnosis of AIDS. The lower limb was most frequently involved site in 28.9% of patient. Females had more disseminated lesions compared with more localized lesions in the males (p = 0.001). The treatment modalities in this study included chemotherapy, radiotherapy, surgery and highly active antiretroviral therapy. Overall 126 (53.4%) patients had significant improvement in quality of life at the end of 1 year follow up. Treatment related complication and mortality rates were 25.8 and 24.2% respectively. Poor ACTG stage, CD4+ count <200 cells/µl, associated co-morbid illness, disseminated disease and poor adherent to chemotherapy were the significant independent factors associated with deaths (p < 0.001). Patient's follow-up was generally poor and data on long-term survivals were not available as more than two-thirds of patients were lost to follow up.

CONCLUSION

Kaposi's sarcoma is the most common malignant vascular tumor and HIV/AIDS- related cancer in our region. There is an urgent need to develop health education programmes to enhance the understanding of this disease and how it spreads, particularly among the younger generation.

A fibreoptic endoscopic study of upper gastrointestinal bleeding at Bugando Medical Centre in northwestern Tanzania: a retrospective review of 240 cases

BACKGROUND

Upper gastrointestinal (GI) bleeding is recognized as a common and potentially life-threatening abdominal emergency that needs a prompt assessment and aggressive emergency treatment. A retrospective study was undertaken at Bugando Medical Centre in northwestern Tanzania between March 2010 and September 2011 to describe our own experiences with fibreoptic upper GI endoscopy in the management of patients with upper gastrointestinal bleeding in our setting and compare our results with those from other centers in the world.

FINDINGS

A total of 240 patients representing 18.7% of all patients (i.e. 1292) who had fibreoptic upper GI endoscopy during the study period were studied. Males outnumbered female by a ratio of 2.1:1. Their median age was 37 years and most of patients (60.0%) were aged 40 years and below. The vast majority of the patients (80.4%) presented with haematemesis alone followed by malaena alone in 9.2% of cases. The use of non-steroidal anti-inflammatory drugs, alcohol and smoking prior to the onset of bleeding was recorded in 7.9%, 51.7% and 38.3% of cases respectively. Previous history of peptic ulcer disease was reported in 22(9.2%) patients. Nine (3.8%) patients were HIV positive. The source of bleeding was accurately identified in 97.7% of patients. Diagnostic accuracy was greater within the first 24 h of the bleeding onset, and in the presence of haematemesis. Oesophageal varices were the most frequent cause of upper GI bleeding (51.3%) followed by peptic ulcers in 25.0% of cases. The majority of patients (60.8%) were treated conservatively. Endoscopic and surgical treatments were performed in 30.8% and 5.8% of cases respectively. 140 (58.3%) patients received blood transfusion. The median length of hospitalization was 8 days and it was significantly longer in patients who underwent surgical treatment and those with higher Rockall scores (P < 0.001). Rebleeding was reported in 3.3% of the patients. The overall mortality rate of 11.7% was significantly higher in patients with variceal bleeding, shock, hepatic decompensation, HIV infection, comorbidities, malignancy, age > 60 years and in patients with higher Rockall scores and those who underwent surgery (P < 0.001).

CONCLUSION

Oesophageal varices are the commonest cause of upper gastrointestinal bleeding in our environment and it is associated with high morbidity and mortality. The diagnostic accuracy of fibreoptic endoscopy was related to the time interval between the onset of bleeding and endoscopy. Therefore, it is recommended that early endoscopy should be performed within 24 h of the onset of bleeding.

Strongyloides stercoralis infection presenting as an unusual cause of massive upper gastrointestinal bleeding in an immunosuppressed patient: a case report

Strongyloidiasis caused by Strongyloides stercoralis is a rare but well documented cause of massive upper gastrointestinal (GI) bleeding especially in endemic areas. However, oesophagogastroduodenoscopic findings and extractions of S. stercoralis, in the adult worm form, from the duodenum is even rarer. We report a case of a 27-year-old Tanzanian woman with HIV who presented with massive upper GI bleeding. She had S. stercoralis, in the adult worm form, traversing the stomach and duodenum and extracted by oesophagogastroduodenoscopy (OGD). She was treated successfully with Ivermectine and antiretroviral therapy for HIV was initiated. Strongyloidiasis should be included in the differential diagnosis of mass upper GI bleeding in immunosuppressive patients living in, or originating from, endemic areas. We believe this to be the first case to be reported from our environment.

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.

In vitro susceptibility of multi-drug resistant Pseudomonas aeruginosa and extended-spectrum β-lactamase-producing Klebsiella pneumoniae isolated from clinical specimens at Bugando Medical Centre, Tanzania to Piperacillin-Tazobactam

Pseudomonas spp. and Klebsiella pneumoniae are common causes of serious health care associated infections (HCAIs) worldwide. The treatment options for infections caused by multi-drug resistant (MDR) organisms are limited to tigecycline and carbapenems. A total of 172 isolates of multi-drug resistant Pseudomonas. spp and extended-spectrum β- (ESBL) producing Klebsiella pneumoniae isolated from clinical specimens at the Bugando Medical Centre were tested for their in vitro susceptibility to piperacillin-tazobactam 100/10μg using disc diffusion test as recommended by Clinical Laboratory Standard Institute (CLSI). Out of 59 multi-drug resistant Pseudomonas spp, 54 (92.0%) were susceptible to piperacillin-tazobactam while of 113 ESBL producing Klebsiella pneumoniae, 55 (48.7%) were susceptible to piperacillin-tazobactam 100/10μg. Also, 20 (34.0%) of the Pseudomonas spp were both ESBL producers and susceptible to piperacillin-tazobactam 100/10μg. A significant proportion of Pseudomonas spp isolates from clinical specimens in our setting are susceptible to piperacillin/tazobactam. This study shows that piperacillin-tazobactam offer a better option to clinicians for the treatment of health care associated infections due to Pseudomonas spp. and ESBL producing Klebsiella pneumoniae in our setting and other health facilities where these organisms are of significance.

Massive upper gastrointestinal bleeding and diffuse benign gastric inflammatory hyperplastic polyps in a 19 year old patient: a case report

Benign gastric inflammatory hyperplasic polyps are benign lesions that rarely occur in young age. We report a case of diffuse benign gastric inflammatory hyperplastic polyps in a 19 year old male patient who presented with cough, nausea, and haematemesis. In the presented case symptoms such as nausea and vomiting are non specific and may complicate in reaching a prompt diagnosis. We also highlight the importance of gastrointestinal tract (GIT) endoscopy in the diagnosis of GIT diseases.

Seroprevalence of IgG Rubella among Infants with Features Suggestive of Congenital Rubella Syndrome at a Tertiary Hospital in North Western Tanzania

Background: Congenital Rubella Syndrome (CRS) is among the causes of infant mortality and lifelong disability due to severe birth defects. There has been an increasing number of neonates born with congenital abnormalities suggesting CRS, at the same time the rubella seroprevalence among pregnant mothers and healthy school children in the northwestern Tanzania has been noted to be alarmingly high. This study aimed to determine prevalence of rubella antibodies and associated factors among infants suspected to have CRS. Methods: This cross-sectional study included 174 infants aged ≤ 12 months with at least one clinical features of CRS. The study was conducted between Septembers 2017and March 2018 at Bugando Medical Centre, a consultant teaching hospital in North Western Tanzania. Collection of Social demographic and other relevant information was done hand in hand with screening for clinical symptoms suggestive of CRS and Blood samples were collected. Indirect enzyme-linked immunosorbent assay (ELISA) Test were conducted on collected sera to test for specific Rubella IgM and IgG antibodies. Results: The majority of enrolled infants were below 1 year of age; of these 83 (47.7%) were neonates and only 13.2% had received MR vaccine. Out of these, 111 (63.8%, 95%CI: 56.6-70.9) were IgG Rubella seropositive whereas none was IgM Rubella seropositive. In multivariate logistic regression analysis being neonate was the only factor that independently predicted rubella IgG seropositivity (OR 2.3; 95% CI 1.2 – 4.4; p=0.012) Conclusion: A significant proportion children (<12 months) with suspected CRS are IgG seropositive which is predicted by being a neonate (0-4weeks); this indicates high maternal seroprevalence and hence extended surveillance and measures to target women of child bearing age are recommended.

Low uptake of hepatitis B vaccination among healthcare workers in primary health facilities in Mwanza region, North-Western Tanzania

Background

Despite the availability of hepatitis B vaccines (HBV) in Tanzania, their uptake among healthcare workers (HCWs) in high-level facilities, such as tertiary hospitals where the vaccines are available, is low. However, their uptake among HCWs in primary health facilities remains understudied. The lack of this information limits the scaling up of HBV vaccination programs.

Methodology

A cross-sectional analytical study was conducted between June and July 2022 among HCWs in the Misungwi and Ilemela districts, which were purposefully selected. The sample size was calculated using the Taro Yamane formula, and data were collected using a self-administered questionnaire and analyzed using IBM SPSS^® version 25.

Results

A total of 402 HCWs were recruited, their mean age was 34.9 ± 7.77 years, and only 18% (76/402) reported being fully vaccinated. HCWs in Ilemela showed higher uptake (χ² = 23.64, df = 1, p = 0.00) of the vaccine than HCWs in Misungwi. Being male (aOR = 2.38, 95% CI 1.28-4.45, p = 0.006), working in an urban setting (aOR = 5.75, 95% CI 2.91-11.35, p = 0.00), and having an employment duration of more than 2 years (aOR = 3.58, 95%CI 1.19-10.74, p = 0.023) were significantly associated with higher odds of vaccination. Moreover, high perceived susceptibility to HBV infection (aOR = 2.20, 95% CI1.02-4.75, p = 0.044) and history of needle prick injuries (aOR = 6.87, 95%CI 3.55-13.26, p = 0.00) were significantly associated with higher odds of HBV vaccination.

Conclusion

Low uptake of HBV vaccine among HCWs in primary health facilities was observed with a noteworthy difference between rural and urban settings. Therefore, advocacy campaigns and resource mobilization toward the promotion of HBV vaccination in primary health facilities are pivotal.

A 0.85% saline as alternative detection buffer for SD-Bioline HIV rapid test in resource limited setting

Accuracy in the diagnosis is a key step to identify HIV infected individuals for appropriate management. Insufficient supply of manufacturer´s buffers in relation to the number of strips per kit has negative impact on patient´s results hence improper patient´s management. In resource limited settings, some laboratory staff use different substitute buffers which has never been validated on their reliability. This study aimed at comparing the performance of 0.85% saline and SD-Bioline manufacturer´s buffer in detection of HIV antibodies. A total of 220 whole blood specimens: 110 HIV positive specimens from patients attending care and treatment center (CTC) and 110 HIV negative specimens from blood donors were re-tested for HIV status using SD-Bioline HIV rapid test using manufacturer´s buffer and 0.85% saline separately. Data and laboratory results were recorded in Microsoft excel sheet followed by analysis using STATA version 13. For all tested samples, the level of agreement between 0.85% saline and manufacturer´s buffer was 98.64% (kappa=0.9727). The value of kappa indicates very good agreement between 0.85% saline and manufacturer´s buffer. In incidents where manufacturer´s buffer is not sufficient, 0.85% saline can give reliable results. Further studies to evaluate the suitable buffer for other rapid tests for HIV and other diseases are recommended especially in resource limited settings.