Assessment of drug resistance to the malaria parasite in residents of Kampala, Uganda.

OBJECTIVE: To assess drug-resistance of the malaria parasite in elite residents of Kampala city, Uganda. DESIGN: Recruited into the study were patients with complaints of fever, backache and headache or general malaise and body joint pains, could recall their previous treatment for the current complaints and could show laboratory reports indicating presence of malaria parasites. Blood was taken from those patients and examined for malaria parasites. SETTING: Kampala Diagnostic and Imaging Consultants Clinic, Kampala, Uganda from 1994 to 1997. RESULTS: Out of 268 patients, 27%, 26%, 12%, 11%, 6%, 6% and 5% strains of malaria parasites were respectively resistant to chloroquine, quinine, metakelfin, fansidar, halfan, artenam and camoquine. Double drug resistance was also observed in the patients who had taken chloroquine and quinine (21%), chloroquine and fansidar (16%) and quinine and fansidar (10%) out of 86. Some strains exhibited resistance to chloroquine, quinine and fansidar (12.6%) out of 71. R III was observed in 17 strains of malaria parasites, eight of them were for chloroquine, four for fansidar and three for quinine. Twenty-six patients had frequent recurrence of malaria lasting for over one year. CONCLUSION: One third of Plasmodium falciparum strains by 1997 had acquired resistance to chloroquine and quinine and some were gradually acquiring multi-drug resistance, leading to frequent recurrence of malaria and use of many different types of antimalarials.

PIP: This study assessed the resistance of malaria parasites to single and multiple drugs among elite residents of Kampala City, Uganda. The study was conducted at Kampala Diagnostic and Imaging Consultants Clinic from 1994 to 1997. It enrolled patients with complaints of fever, backache and headache or general body malaise and joint pains, who could recall their previous treatment for the current complaints and could show laboratory reports indicating the presence of malaria parasites. Blood samples of the patients were collected and examined. Out of 268 patients, 27%, 26%, 12%, 11%, 6%, 6%, and 5% strains of malaria parasites were respectively resistant to chloroquine, quinine, metakelfin, fansidar, halfan, artenam, and camoquine. Among patients who had taken two drugs, double drug resistance was observed in those who had taken chloroquine and quinine (21%), chloroquine and fansidar (16%), and quinine and fansidar (10%). Moreover, 26 patients had frequent recurrence of malaria lasting for over 1 year. In conclusion, one-third of Plasmodium falciparum strains by 1997 had acquired resistance to chloroquine and quinine and some were slowly acquiring multidrug resistance resulting in frequent recurrence of malaria and use of many different types of antimalarials.

Selected laboratory tests in febrile patients in Kampala, Uganda.

A study was undertaken to determine the role of typhoid in febrile illness. It was found that in 1992, Salmonella typhi, the causative agent of typhoid, played a 2.3% role in 25404 diagnostic specimens sent to Mulago Hospital, Kampala, the largest hospital in Uganda. The rates of isolation fell gradually from 2.3% in 1992 to 0.3% by 1995. Instead malaria was found to play a major role in febrile illnesses. Out of 355 patients attending a private clinic in Kampala, whose blood was examined for both malaria and typhoid, 97% were positive for malaria parasites compared to 0.84% with significant O and H Salmonella typhi antibody titres of > 1:80. Also malaria parasites were found in 60% (out of 105) of patients who had had persistent fevers and in whom doctors had also requested for HIV antibodies. Those who had HIV antibodies alone were six per cent and the ones with both were 28%, a finding which showed relatively low association of malaria and HIV. Where multiple tests were requested on one patient having general malaise or body joint pains and/or constant headaches, malaria was found to play a major role (73%) compared to syphilis (4.3%) and brucellosis (13.3%). Malaria parasites were seen in normal sizes and in somehow young or stunted forms. The latter were found more often in patients who had experienced one or a combination of the following: intermittent fevers, backache, headache, tiredness, joint and/or neck pains, and who had already received treatment for malaria.

Antimicrobial resistance of enteropathogenic Escherichia coli strains from a nosocomial outbreak in Kenya.

The majority of the 78 enteropathogenic (EPEC) and the 151 non-EPEC Escherichia coli strains isolated from preterm neonates during an outbreak of gastroenteritis in a hospital in Nairobi, Kenya, were resistant to trimethoprim-sulfamethoxaxole, chloramphenicol, oxytetracycline and ampicillin, but only a few strains were resistant to cefazolin, cefamandole, cefotaxime, amikacin and nalidixic acid. Fourteen different antimicrobial resistance patterns were observed in the 229 strains of E. coli analysed. Eighty-two percent of the EPEC strains belonged to two resistance pattern compared with 79% of non-EPEC strains which exhibited three resistance patterns. There was no consistent relationship between plasmid profile group and antimicrobial resistance pattern, although one resistance pattern was more frequently observed in EAF-positive strains belonging to the dominant plasmid profile group. Nine percent of the EPEC strains were resistant to gentamicin compared to 37% in the non-EPEC group. No correlation was observed between administration of gentamicin and percentage of resistant strains isolated. None of the nine neonates receiving gentamicin died during the outbreak. Gentamicin resistance was observed in E. coli strains from six out of these nine neonates. Five out of fourteen neonates who received other antimicrobials, or no antibiotic treatment at all, died.

Aetiology of diarrhoea in pre-term neonates at Kenyatta National Hospital nursery, Nairobi, Kenya.

The aetiology of two outbreaks of diarrhoea in pre-term neonates (March-August; September, 1987), at Kenyatta National Hospital was studied. The first outbreak involved 98 neonates and enteropathogenic E. coli of different serotypes were the most commonly isolated agents (54%), with serotype 086a:K61 dominating. These were followed by Salmonella (16%) also of different groups, and then rotavirus (6%). Two campylobacter and two Shigella were isolated from four individual neonates. Mixed infections were mainly those of Salmonella and E. coli (5 cases). E. coli serotype 086 was found to be in circulation throughout the study period (March-August, 1987), whilst 044:0125 and 0128 circulated for a limited period. Salmonella and some strains of E. coli caused persistent diarrhoea despite antibiotic therapy. Nosocomial infections were found to play a role in subsequent diarrhoeas. In the second diarrhoea outbreak, again enteropathogenic E. coli and Salmonella were the most frequently isolated. However, in this outbreak, there was no single E. coli serotype revealed that some possessed plasmids of 120-160 megadalton. However, a search for human immunodeficiency viral antibodies in 120 stools produced negative results.

Mixed infections in childhood diarrhoea: results of a community study in Kiambu District, Kenya.

One thousand four hundred and twenty diarrhoea specimens from 846 children aged 0 to 60 months were collected and analysed for bacteria, parasites and rotavirus over a 16 month period, from June 1985 to September 1986 inclusive. The study was conducted in 4 villages situated in Kiambu District, Kenya. All the specimens were analysed for rotavirus and parasites, including Cryptosporidium. The majority of the specimens were analysed for enteropathogenic Escherichia coli (EPEC), Shigella, Salmonella, Campylobacter and Aeromonas. Only 387 specimens were analysed for enterotoxigenic E. coli (ETEC). However, of this proportion analysed for ETEC, 33% were positive. A total of 344 specimens were negative for any organisms while a further 140 were only positive for parasites which have been implicated as being pathogenic, including Ascaris lumbricoides, Hymenolepis nana, Trichomonas hominis and Blastocysts hominis were considered to be at least potentially pathogenic and capable of causing diarrhoea. An average of only 29.4% of these organisms occurred as single isolates. The remaining infections were mixed, with a maximum of 7 potentially pathogenic organisms occurring together in a single specimen. The associations of certain organisms were significant, notably Campylobacter with Giardia lamblia. Campylobacter with EPEC, EPEC with Ascaris, and G. lamblia with rotavirus. The latter was a negative association.

Colonization of neonates in a nursery ward with enteropathogenic Escherichia coli and correlation to the clinical histories of the children.

Stool samples were examined from 30 preterm neonates admitted to a nursery ward; 16 neonates had diarrhea, 12 constituted an age-matched control group without diarrhea, and 2 had an unknown history regarding diarrhea. Variable numbers of enteropathogenic Escherichia coli serotype O111:HNT strains possessing the gene coding for the enteroadherence factor (EAF) were found in stool samples from 13 of the neonates. No other microbiological enteropathogen was found. A total of 294 strains (9 or 10 from each neonate, comprising 229 E. coli and 65 Klebsiella pneumoniae strains) were characterized with respect to plasmid content and grouped into 37 plasmid profile groups. Diarrhea was found not to be correlated with any specific plasmid profile or with the presence of the EAF-positive strains but rather with the number of strains with one specific plasmid profile or with the number of EAF-positive strains (of the 9 or 10 strains) isolated from each stool sample. All the neonates who died had diarrhea (5 died of 16 with diarrhea); all five of the neonates who died possessed strains with one specific plasmid profile group, and EAF-positive strains were isolated from four of them. Of the seven neonates from whom seven or more EAF-positive isolates were isolated, three died, compared with only one of five of those from whom only a few (1 to 3 of 10) EAF-positive strains were isolated. Both plasmid profiling and genetic probing with the EAF probe were found to be good alternatives when serotyping is not available for identification of O111:HNT enteropathogenic E. coli strains.

Adaptation of a method of measuring zone diameters of bacterial growth inhibition by antibiotics to suit developing countries.

A study that devised a modified method of reporting antibiotic sensitivity results was undertaken. Enterobacteriaceae and Gram positive cocci were tested for drug sensitivity by a disc diffusion method. Zones of bacterial growth inhibition were measured, dividing the isolates into four groups: the highly sensitive, the moderately sensitive, the slightly sensitive and the resistant ones. The slightly sensitive isolates were taken as indicators of antibiotic resistance acquisition. By that system, when more than 50% of the isolates fell into the slightly and resistant groups, that meant that the antibiotic concerned would be discontinued for some time until the bacteria reverted to being moderately sensitive. The study also provided a method of making antibiotic discs from local blotting papers, and a sample of a form on which antibiotic sensitivity results could be recorded was presented. The method is considered to be easy and very appropriate for developing countries in detecting gradual and abrupt acquisition of antibiotic resistance by bacteria.

Enteropathogenic Escherichia coli serotype O111:HNT isolated from preterm neonates in Nairobi, Kenya.

This investigation was initiated as a consequence of several cases of diarrhea in a nursery ward for preterm babies in Nairobi, Kenya. Ten lactose-positive colonies were isolated from the stools of each of 30 neonates, regardless of whether they had diarrhea; 229 strains were identified as Escherichia coli and 65 strains were identified as Klebsiella pneumoniae. Six strains were lost during laboratory handling. No other bacterial, viral, or parasitic enteropathogens were identified. Using synthetic alkaline phosphatase-labeled probes, the bacterial isolates were found to be negative for the presence of genes coding for heat-stable and heat-labile enterotoxins. Seventy-eight E. coli strains isolated from a total of 13 neonates possessed the E. coli enteropathogenic adhesion factor (EAF) gene, as demonstrated by the use of a cloned radiolabeled DNA fragment probe. These strains possessed similar plasmid profiles constituting a core plasmid profile, and while all adhered to HeLa cells, none produced Vero cell cytotoxins. The EAF gene was located on a 65-megadalton plasmid. Serotyping showed the strains to be of serogroup O111 and serotype H nontypable, a well known enteropathogenic type. Five neonates died during the outbreak, and the fatality rate was 30.7% (4 of 13) for neonates infected with EAF-positive E. coli strains compared with 7.7% (1 of 13) for neonates from whom only EAF-negative E. coli strains were isolated. K. pneumoniae only was isolated from five neonates.

Bacteriology of unheated expressed breast milk stored at room temperature.

Thirty samples of unheated expressed breast milk (EBM) from thirty lactating mothers, stored at room temperature (RT) and in the refrigerator (at +4 degrees C), were examined for the degree of bacterial contamination at two hourly intervals upto eight hours. All the EBM samples contained bacteria, mostly of normal skin flora; Staphylococcus albus 76.7%; Streptococcus viridans 40%. Potential pathogens were isolated in small numbers: Escherichia coli 26%, Streptococcus faecalis 13.6% and Staphylococcus aureus 6.7%. The bacterial colony counts (BCC) were consistently low; Mean initially 5.438 x 10(3) cfu/mm3 with a range of 0.15-23.1 x 10(3) cfu/mm3 and showed a significant reduction on storage in both EBM samples stored at RT and at +4 degrees C. The study proved that it is safe for mothers to keep unheated EBM at RT for at least eight hours before bacteria can multiply beyond unacceptable levels.

Antigenic characterization of rotaviruses isolated in Kenya from 1982 to 1983.

The electropherotypes of human rotavirus RNAs from 100 diarrheic stool specimens collected in two major districts of Kenya from 1982 to 1983 were previously reported (Y. Chiba, C. Miyazaki, Y. Makino, L. N. Mutanda, A. Kibue, E. O. Lichenga, and P. M. Tukei, J. Clin. Microbiol. 19:579-582, 1984). Of these specimens, 25 that contained rotaviruses with different RNA electropherotypes were subjected to a virus isolation experiment with MA-104 cells, and 16 rotavirus strains were isolated. The use of an enzyme-linked immunosorbent assay with subgroup-specific monoclonal antibodies enabled us to successfully subgroup 15 isolates: 4 in subgroup I and 11 in subgroup II. By fluorescent-focus-neutralization test with serotype-specific rabbit antisera, 13 isolates could be serotyped: 7 as serotype 1, 4 as serotype 2, and 2 as serotype 3. Of the remaining three isolates, F153, F247, and G402, the former was doubly neutralizable with serotype 1 and serotype 4 antisera and the latter two were neutralizable with serotype 3 and serotype 4 antisera. Detailed analysis with the antisera against F153 and F247 and four serotype-specific, VP7-directed monoclonal antibodies suggested that F153 is a serotypic mosaic strain with serotype 4-specific VP3 and serotype 1-specific VP7 outer capsid proteins and F247 and G402 are possibly antigenic mosaic strains with serotype 3 and serotype 4 antigens. On the basis of the correspondence of the rotavirus isolate serotypes determined in this study to the electropherotypes reported previously, it was inferred that serotype 1 strains were most prevalent in two districts of Kenya from 1982 to 1983, followed by any type of serotypic mosaic strains.

Aetiology of diarrhoea in malnourished children at Kenyatta National Hospital.

PIP: 3 groups of children aged 0-5 years were studied at Kenyatta National Hospital between September 1983 and September 1984 to determine the incidence of enteric agents causing diarrhea in infants and children. The 1st group consisted of children with diarrhea alone, the 2nd group had diarrhea and kwashiorkor, and the 3rd had diarrhea and marasmus. Diarrhea occurring alone peaked in the 0-5 month age group; diarrhea and marasmus peaked in the 6-11 month group, and diarrhea and kwashiorkor, the 6-17 month group. Isolation rates of enteric agents (Campylobacter, Shigella, Salmonella, Rotavirus) for the 3 groups were not significantly different; however E. coli was isolated with a higher frequency from children who had diarrhea with marasmus. The most common mixed infection was that of E. coli and Rotavirus, occurring more often in children with marasmus. Most children had a history of diarrhea for 3-5 days duration. Among agents isolated from cases of more than 8 days duration, Campylobacter was most common, and was only isolated from malnourished children. Results indicate that duration of diarrhea before admission was longer in kwashiorkor or marasmic children than children with diarrhea alone. Treatment for diarrhea in all cases should be similar.^ieng

Age distribution and seasonal pattern of rotavirus infection in children in Kenya.

PIP: The age distribution and seasonal pattern of rotavirus infection were investigated in infants and young children admitted with acute diarrhea at the Kenyatta National Hospital from December 1981 through June 1983. They had acute diarrhea of not more than 10 days duration and had not received antibiotic treatment. Presence of rotavirus in stool was detected by using the WHO enzyme linked immnoabsorbent assay (ELISA) kit. The rotavirus isolation rate ranged from 14% to 54% in infants aged 1-12 months and peaked in the 6-12 month age group. Rotavirus peak incidences were observed in the January-March periods of both 1982 and 1983 which are times of hot, dry weather, with low relative humidity. These peak periods differ from results reported by Schoub et el. where no seasonal rotavirus infection variation in black infants in South Africa was observed. Other reports of rotavirus infection prevalence and weather conditions are cited. This study fails to show that rainfall influences the occurrence of rotavirus infection, as has been reported in Ethiopia by Stintzng et al.^ieng

Rotavirus infection of young children in two districts of Kenya from 1982 to 1983 as analyzed by electrophoresis of genomic RNA.

Employing techniques of polyacrylamide gel electrophoresis of viral RNA segments, we studied rotavirus strains and their relative contributions to rotavirus gastroenteritis epidemics in two major districts of Kenya. From early 1982 to the middle of 1983, 18 representative electropherotypes, including 6 short strains, were detected in 30 rotavirus specimens obtained from Nairobi, whereas 16, including 3 short strains, were detected in 70 virus specimens from coastal areas. With the exception of one strain, there were no identical electropherotypes between the two groups of rotaviruses obtained from these different districts. A change in predominant electropherotypes was observed in Mombasa in early 1983, and subsequently, newly occurring strains were detected in a small town along the coast when an apparent increase in gastroenteritis was observed in the district.