Non-adherence to highly active antiretroviral therapy in children attending HIV treatment clinic at harare Children's Hospital, Zimbabwe.

Background: Non-adherence reduces the effectiveness of antiretroviral therapy. Knowledge of factors associated with non-adherence would assist clinicians and program planners to design and implement interventions to improve adherence and therefore treatment outcomes. Objective: To determine the prevalence and factors associated with non-adherence to Highly Active Antiretroviral Therapy (HAART) in children less than 10 years of age. Methods: A cross-sectional study of 216 caregivers and children less than 10 years of age who had received HAART for at least 60 days prior to this study. Non-adherence was defined as taking less than 95% of prescribed doses. Caregiver self-reports of missed doses in the 30 days preceding a clinic visit, and clinic based pill counts were used to determine non-adherence. Results: Of the 228 children selected, 216 (94.7%) study participants were assessed using the self-report method. Pill count assessment was done on only 96 (44%) participants who produced unused pills on their review dates. Caregiver self-reports (n=216) estimated the prevalence of non-adherence to be 7.4% (95%: CI 3.90 10.90) whereas clinic-based pill counts (n=96) yielded a higher estimate of 18.8% (95% CI 10.94 26.56). In a regression analysis based on pill count, two or fewer siblings (OR=6.26, 95% CI 1.64-23.95) or adults (OR=3.73, 95% CI: 1.01-13.78) in the household were independently associated with non-adherence to HAART. Of the 16 participants who were non adherent by pill count the reasons for missing doses were, attending gatherings (funeral, church), caregiver forgetting to give dose, medication running out, not understanding dosing instructions, concurrently taking other medicines such as anti tuberculosis drugs and cotrimoxazole, child visiting relatives during school vacation, and inconsistent supply of drugs in the hospital. Conclusion: The prevalence of non adherence using pill count method was high at this clinic. Caregiver reports of missed doses underestimated the prevalence of non-adherence to HAART. Having fewer siblings or adults in the household to assist with dosing are strongly associated with non-adherence to HAART in this population of children.

Clinical predictors of HIV infection in hospitalized children aged 2-18 months in Harare, Zimbabwe.

BACKGROUND: In Africa without antiretroviral treatment more than half of the HIV infected children die by 2 years. The recommended HIV virological testing for early infant diagnosis is not widely available in developing countries therefore a presumptive diagnosis is made in infants presenting with symptoms suggestive of HIV disease. OBJECTIVES: To identify presenting signs and symptoms predictive of HIV infection in hospitalized children aged between 2- 18 months at Harare Hospital, Zimbabwe. METHODS: In a cross sectional study the baseline clinical information was collected and HIV infection confirmed using DNA PCR. Multiple logistic regression analysis was used to identify significant predictors of symptomatic HIV infection. Diagnostic parameters (sensitivity, specificity) and their 95% confidence intervals were calculated. RESULTS: 355 children with an overall median age of 6 months (IQR: 3, 10.5 months) of whom 203 (57.2%) were HIV DNA PCR positive. Clinical signs independently predictive of HIV infection were cyanosis, generalized lymphadenopathy, oral thrush, weight for age z-score <-2 and splenomegaly. The sensitivity of these signs ranged from 43-49% with a higher specificity (ranging from 72.3-89.5%). CONCLUSION: Clinical identification using individual signs for probable HIV infection in hospitalized children below 18 months would provide an opportunity for early diagnosis, treatment.

Adoption of safer infant feeding and postpartum sexual practices and their relationship to maternal HIV status and risk of acquiring HIV in Zimbabwe.

OBJECTIVE: To examine the relationships between maternal knowledge and concern about HIV status, adoption of preventive practices and risk of acquiring HIV in Zimbabwe. METHODS: Knowledge and behavioural data were collected via interview from 2595 mothers enrolled in ZVITAMBO, a randomized trial of postpartum vitamin A supplementation that also offered education on safer infant feeding and sexual practices. Mothers were tested for HIV at delivery; those uninfected at baseline were retested during study follow-up. Logistic regression methods were used to identify variables associated with adoption of preventive behaviours and, for HIV-negative mothers, their relationship to risk of acquiring HIV post-delivery. RESULTS: A total of 518 mothers (20%) reported practicing safer sex and 289 mothers (11%) reported modifying their feeding behaviour because of HIV. Fear of transmitting HIV (50.4%) and protecting the baby's health (30.9%) were the most frequently cited reasons for behaviour change. Forty-nine HIV-negative mothers acquired HIV during the first postpartum year. After taking into account other significant covariates, mothers who were concerned about their own HIV status were 1.9 times more likely (95% CI: 1.05-3.52; P = 0.03), and those reporting safer sex practices were 58% less likely to become infected (adjusted odds ratio: 0.42; 95% CI: 0.17-1.04; P = 0.06). Married women who reported practicing abstinence to prevent HIV were 3.2 times more likely to become infected than non-abstaining mothers (P = 0.01), while there were no new HIV infections among abstaining single mothers. CONCLUSIONS: Greater emphasis should be given to safer sex practices among women who test negative in mother-to-child HIV prevention programmes.

HIV-1 and HIV-2 prevalence and associated risk factors among postnatal women in Harare, Zimbabwe.

Studies of antenatal women form the predominant source of data on HIV-1 prevalence in Africa. Identifying factors associated with prevalent HIV is important in targeting diagnostic services and care. Between November 1997 and January 2000, 14,110 postnatal women from Harare, Zimbabwe were tested by ELISAs reactive to both HIV-1 and HIV-2; a subset of positive samples was confirmed with assays specific for HIV-1 and HIV-2. Baseline characteristics were elicited and modelled to identify risk factors for prevalent HIV infection. HIV-1 and HIV-2 prevalences were 32.0% (95% CI 31.2-32.8) and 1.3% (95% CI 1.1-1.5), respectively; 4% of HIV-1-positive and 99% of HIV-2-positive women were co-infected. HIV-1 prevalence increased from 0% among 14-year-olds to >45% among women aged 29-31 years, then fell to <20% among those aged>40 years. In multivariate analyses, prevalence increased with parity, was lower in married women than in single women, divorcees and widows, and higher in women with the lowest incomes and those professing no religion. Adjusted HIV-1 prevalence increased during 1998 and decreased during 1999. Age modified the effects of parity, home ownership and parental education. Among older women, prevalence was greater for women who were not homeowners. Among younger women, prevalence increased with parity and low parental education. None of these factors distinguished women co-infected with HIV-2 from those infected with HIV-1 alone. Prevalent HIV-1 infection is associated with financial insecurity and weak psychosocial support. The ZVITAMBO study apparently spanned the peak of the HIV-1 epidemic among reproductive women in Harare.

A clinical evaluation of children under the age of five years who are household contacts of adults with sputum positive tuberculosis in Harare, Zimbabwe.

OBJECTIVE: To determine the prevalence and risk factors for transmission of tuberculosis in children under five years of age who are household contact of sputum smear positive tuberculosis adults in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: City Health Infectious Diseases Hospital Outpatient Department. SUBJECTS: 174 children in contact with 102 index cases. MAIN OUTCOME MEASURES: TB infection status in children according to modified WHO classification of tuberculosis. METHODS: Under five year old contacts of sputum smear positive TB adults were recruited over a three month period. A coded questionnaire was used to document the following: socio-demographic profile of caregivers, duration of stay with the index case and presenting complaints. Contacts were evaluated by clinical examination, Mantoux testing, HIV antibody testing and chest radiographs. RESULTS: Of the 174 children in contact with 102 index cases evaluated, 109 (62.6%) were Mantoux positive (> or = 10 mm), 42% had abnormal chest X-ray, with hilar lymphadenopathy being the commonest abnormality. Forty nine percent of the children evaluated had probable TB, 28% had suspected TB and 23% had no TB. High alcohol acid fast load (AAFB) in the index case was independently associated with probable and suspected TB (OR 2.27 95% CI (1.05 to 4.87). CONCLUSION: The documented high transmission rate among under five years contacts in the study justifies the need for strengthening contact tracing and appropriate therapeutic management of identified children.

Fatal Pneumocystis carinii pneumonia in HIV-seropositive infants in Harare, Zimbabwe.

Lung biopsies taken post mortem from 24 HIV-seropositive children who died of pneumonia in Harare Hospital (Zimbabwe) during 1995 were examined for pathogens using histology, culture, microscopy and polymerase chain reaction (PCR). Pneumocystis carinii was detected in 16 (67%) children, in 5 of whom bacterial pathogens were also detected. There were 2 cases of cytomegalovirus infection. On the basis of histology and PCR, none of the children had tuberculosis. These data add to the evidence that P. carinii pneumonia may be a significant cause of death in HIV-infected children in southern Africa. Policies on treatment for severe pneumonia, and on prophylaxis for children born to HIV-seropositive mothers need to be re-examined.

Serum IgG subclasses levels in paediatric patients with pneumonia.

OBJECTIVES: To determine the IgG subclass levels of patients admitted to Harare Central Hospital paediatric wards with pneumonia. DESIGN: A cross sectional study. SETTING: Harare Central Hospital, Departments of Immunology and Paediatrics, University of Zimbabwe; Department of Paediatric Immunology, University of Utrecht, The Netherlands. SUBJECTS: 56 paediatric patients. MAIN OUTCOME MEASURES: IgG subclass profiles of children with pneumonia. RESULTS: Of the 56 children tested, 40 (71%) had antibodies to human immunodeficiency virus (HIV). The levels of IgG1 and IgG3 subclasses were significantly higher in HIV antibody positive children (p < 0.001, p < 0.01 respectively) than in those without detectable HIV antibodies in their sera. There was no significant relationship between IgG subclass levels and the presence of HIV p24 antigen. Furthermore, age and gender also had no significant influence on the levels of IgG subclasses in this population. CONCLUSION: High levels of IgG1 and IgG3, but not IgG2 and IgG4, occur frequently in children with pneumonia and are associated with the presence of HIV antibodies.

Prevention of hypoxemia during feeding in infants with bronchopneumonia.

Administration of oxygen via a tube held close to the nose prevented hypoxemia during breastfeeding in 15 of 20 infants with bronchopneumonia.

Pattern of admissions to the paediatric medical wards (1995 to 1996) at Harare Hospital, Zimbabwe.

OBJECTIVE: To document the pattern of disease and outcome of medical paediatric admissions at Harare hospital. DESIGN: Cross sectional study from 1 June 1995 to 30th May 1996. SETTING: Medical paediatric wards, Harare Central Hospital. SUBJECTS: All admissions below the age of nine years. MAIN OUTCOME MEASURES: Socio-demographic features, nutritional status, clinical diagnoses, duration of hospital stay and mortality. RESULTS: A total of 8,826(90.0%) of the admissions were assessed. The majority(51.8%) of the patients were one year and below. "Road to Health" cards, available for 94.4% children, showed 88.0% had appropriate immunizations for age. Forty nine percent had lower respiratory tract infection either as only, or concurrent with other diagnoses, with an overall fatality rate of 16.2%. Acute diarrhoea was the second most frequent condition (21.0%) with an associated case fatality rate of 11.3%. Mortality rates for neonatal sepsis and bacterial meningitis were 12.3% and 32.8% respectively. Severe malnutrition defined as less than 60% of the expected weight for age, was present in 12.5% with an associated fatality rate of 28.7%. Based on clinical suspicion 23.2% of the total children were tested for HIV antibodies and 82.0% were positive. Overall case fatality among the inpatients was 17.8% and 36.7% of the total deaths occurred within 24 hours of admission. CONCLUSION: There is a need to re-evaluate our management strategies for common conditions including those with HIV infection. Standardization of case management is an important and essential step towards reduction in mortality both at the primary and referral health institutions.

Serum immunoglobulin levels in paediatric patients with pneumonia.

OBJECTIVE: To determine levels of serum immunoglobulins IgG, IgM and IgA in patients admitted with pneumonia to Harare Central Hospital paediatric wards. DESIGN: A cross sectional pilot study. SETTING: Harare Central Hospital, Department of Immunology, University of Zimbabwe; Department of Paediatrics, University of Zimbabwe; Immunology Laboratory, University of Utrecht (The Netherlands). SUBJECTS: 71 paediatric patients. MAIN OUTCOME MEASURES: Immunoglobulin profiles for children with pneumonia. RESULTS: Of the 71 children tested, 43 had high IgG levels of between two and half and five times the upper end of the normal age-matched reference range. While the same 43 children with high IgG had similarly elevated levels of IgM, only 25 of them had elevated IgA levels. Of this group of 43 children with hypergammaglobulinaemia, all but one, had antibodies to human immunodeficiency virus (HIV), 50% of whom had detectable levels of p24 antigen in their sera. A small minority, 4% of the 71 patients, had very low levels of total immunogloblins. CONCLUSIONS: High levels of total immunoglobulins occur frequently in children with pneumonia and are associated with the presence of HIV 1/2 antibodies and also p24 antigen.

Predictors of mortality in children hospitalized with dysentery in Harare, Zimbabwe.

OBJECTIVES: To document the pattern of complications and identify risk factors for subsequent mortality in a hospitalized paediatric population during a Shigella dysenteriae type 1 epidemic. DESIGN: Hospital based prognostic study. SETTING: Paediatric wards in Harare and Parirenyatwa tertiary referral hospitals. SUBJECTS: All children aged one month to 12 years admitted to the wards with a history of bloody diarrhoea between January 1993 to June 30 1994 were included in the study (n = 312). MAIN OUTCOME MEASURES: Patterns of complications and predictors of mortality. RESULTS: The peak age group of the patients was 12 to 23 months. Ninety five children died giving an overall case fatality rate (CFR) of 30.4% (95% CI, 25.3 to 35.6). One third (n = 107) had haemolytic uraemic syndrome (HUS), among whom the CFR was 43%. Other complications included altered consciousness (35%), seizures (12%), coma (4.5%), severe dehydration (14%), abdominal distention (17%), rectal prolapse (5%) and ileus (6%). In a multivariate analysis, temperature < 36 degrees C (OR 2.12; 95% CI, 1.33 to 3.39), severe dehydration (OR, 1.70; 95% CI, 1.15 to 2.53), hyperkalemia (> 5.5 mmol/L) (OR, 1.74; 95% CI, 1.01 to 1.97), hyponatremia (< 120 mmol/L) (OR, 1.57; 95% CI, 1.17 to 2.11), urea (> 8 mmol/L) (OR, 1.74; 95% CI, 1.29 to 2.36), and abdominal distention (OR, 1.67; 95% CI, 1.16 to 2.41) were found to be predictors of mortality. CONCLUSION: Some of the major clinical and laboratory features allowing the early identification of children at increased risk of dying during dysentery outbreaks have been delineated. The high fatality associated with complicated dysentery highlights the need for preventive strategies which are sustainable in the region.

Clinicopathological features of Zimbabwean patients with sustained proteinuria.

OBJECTIVE: To describe clinico-pathological features of patients admitted with significant proteinuria. DESIGN: Hospital based prospective survey conducted from 1982 to 1987. SETTING: Paediatric and medical wards at both tertiary referral hospitals in Harare. SUBJECTS: 119 patients who presented with significant proteinuria were investigated. RESULTS: Of the primary nephritides, diffuse mesangial proliferative glomerulonephritis was the most common finding (25/119); IgM was the dominant or sole immunoglobulin identified in 17/25. Minor glomerular abnormalities were common (19/119); there were 11 patients with minimal change disease and this number accounted for 42% of the children aged three to 12 years who were nephrotic. This incidence is higher than previously reported from Africa. Diffuse membranous nephropathy was frequent (18/119); hepatitis B surface antigen was present in only five of these patients. Focal sclerosing glomerulo-sclerosis was as frequent as diffuse membranous nephropathy (18/119) and appeared to be idiopathic. Diffuse mesangiocapillary glomerulonephritis (membranoproliferative) was present in 15/119 patients; no causal association was made. CONCLUSION: The pattern of primary glomerulonephritis is described from 1982 to 1987. We describe a slightly higher number of patients with minimal change disease and minor glomerular abnormalities than previously reported and a surprisingly small number of patients with diffuse endocapillary glomerulonephritis. In common with other African series, no patient with IgA nephropathy was found.

HIV infection in malnourished children in Harare, Zimbabwe.

A descriptive study was undertaken to compare the pattern of socio-demographic features, nutritional profile and presenting features of HIV infected and uninfected children with malnutrition. A total of 140 children aged above 15 months admitted to the paediatric wards, Harare Hospital from December 1993 to February 1994 were studied. Sixty eight (48.6%) children were found to be HIV seropositive and 72 negative. The socio-demographic features were similar in both groups. Marasmus and marasmic kwashiorkor were predominant in the HIV infected children, whilst the majority (64%) of the children in the HIV uninfected group had kwashiorkor (p = 0.001). Pneumonia, lymphadenopathy, chronic discharging ears and oral thrush were significantly more frequent in the HIV infected than in the non HIV infected children (p < 0.01). Factors predictive of HIV infection were marasmus (OR 2.72, 95% CI 1.04-8.10), generalised lymphadenopathy (OR 2.77, 95% CI 1.16-6.64), oral thrush (OR 2.72, 95% CI 1.16-6.37) and discharging ears (OR 6.05, 95% CI 1.89-19.42) with a sensitivity of 57.6% (95% CI 45.7%-69.5%), specificity of 71.4% (95% CI 60.8% 82.0%). The high prevalence of HIV infection among the malnourished children emphasises the impact of the HIV epidemic on childhood nutritional morbidity.

PIP: The HIV epidemic in Zimbabwe has increased the prevalence of child malnutrition. This descriptive study compared sociodemographic features, the nutritional profile, and clinical features of 140 HIV-positive and HIV-negative children 15 months of age and older with malnutrition admitted to Harare Hospital in 1993-94. 68 children (48.6%) were HIV-infected. There were no significant differences between infected and non-infected children in terms of sociodemographic factors such as area of residence, maternal education, caretaker, and breast feeding status. HIV-infected children were most likely to have marasmus and marasmic kwashiorkor; 64% of children in the HIV-negative group had kwashiorkor. Pneumonia, lymphadenopathy, chronic ear discharge, and oral thrush were significantly more prevalent among HIV-infected children. Four factors were predictive of HIV infection: marasmus (odds ratio (OR), 2.72; 95% confidence interval (CI), 1.04-8.10), generalized lymphadenopathy (OR, 2.77; 95% CI, 1.16-6.64), oral thrush (OR, 2.72; 95% CI, 1.16-6.37), and ear discharge (OR, 6.05; 95% CI, 1.89-19.42). 32 children (22.8%) died during their hospitalization. Mortality was significantly greater among children less than 60% of expected weight (severe malnutrition), but was not significantly related to HIV status.

Shigella dysenteriae type 1 in Zimbabwe.

PIP: Shigella dysenteriae type 1 (SD1) is an unusually virulent enteric pathogen which causes endemic or epidemic dysentery with high death rates. SD1 has been responsible for large-scale regional outbreaks of dysentery in Africa, Central America, and south Asia. Shigella dysentery epidemics have been reported in Africa since the 1800s and overall, more than 250 million people in the African region are at risk and subject to a case fatality rate of possibly 1-10%. In Zimbabwe, the 1994 national incidence of dysentery was 13.0/1000 and the national case fatality rate was 4.5%. The transmission of SD1, its clinical presentation, management, complications, the role of the laboratory, outbreak identification and adequate preparedness, and the prevention of infection are discussed.^ieng

Community-acquired bacteremia in human immunodeficiency virus-infected children in Harare, Zimbabwe.

BACKGROUND: HIV infection is common in mothers and their children in Zimbabwe, and HIV-infected children are particularly susceptible to bacterial infections. There is little information on the etiology and outcome of HIV-related bacteremia in African children. METHODS: Blood cultures from 309 hospitalized children in Zimbabwe, of whom 168 were diagnosed as having HIV, were examined for pathogens. The association among significant bacteremia, HIV infection and mortality was assessed in these children. RESULTS: The most common isolates were coagulase-negative staphylococci (31 children, 25 clinically significant), Staphylococcus aureus (22 children) and Streptococcus pneumoniae (20 children). Nontyphoidal Salmonella (10 children), Escherichia coli (4 children) and Klebsiella sp. (4 children) were the most frequent Gram-negative bacteria. Two children had Rhodococcus equi pneumonia. HIV-infected children showed increased risk of bacteremia (odds ratio (OR) = 2.68), especially if younger than 18 months of age (OR = 2.94), and high risk of enterobacteremia (OR = 15.76). There was no significant association of bacteremia with nutritional status. Mortality was 17% overall but was higher in HIV-infected children up to 6 months of age (OR = 2.81) and in bacteremic children of any age (OR = 2.03). CONCLUSIONS: Prompt recognition of pathogens and early administration of appropriate antimicrobials is important in reducing the morbidity and mortality associated with bacteremia in HIV-infected children in Africa.

PIP: Researchers compared data on 168 HIV-positive pediatric patients with data on 141 HIV-negative pediatric patients to examine the etiology and outcome of HIV-related bacterial infections in a pediatric population admitted to Harare Hospital in Zimbabwe during June 1993 to December 1994. The age of the children ranged from less than 1 month to 96 months. 72% were less than 12 months old. 54% of all pediatric patients tested were HIV-infected. HIV-infected children were more likely to have a bacterial infection than HIV-negative children (40% vs. 20%; odds ratio [OR] = 2.68; p 0.001). The difference in the bacterial infection rate was only significant for children aged less than 18 months (41% vs. 19%; OR = 2.94; p 0.001), however. 14% of the children suffered from severe malnutrition. Nutritional status was not significantly associated with bacterial infection. In both HIV-positive and HIV-negative children, Staphylococcus aureus was the most frequent bacterial pathogen (29% for HIV-positive and 18% for HIV-negative children). Many Gram-positive and Gram-negative isolates were resistant to the combination therapy of trimethoprim-sulfamethoxazole. Only 1 child, who was HIV-positive, had more than one bacterial infection (both Streptococcus pneumoniae and Actinomyces israelii). HIV-positive children were more likely to have an enterobacterial infection than HIV-negative children (10% vs. 0.7%; p 0.001). Mortality was significantly higher among HIV-infected children aged less than 6 months old than their HIV-negative counterparts (28% vs. 12%; OR = 2.81; p 0.05). Even though it was also higher among HIV-positive children aged more than 6 months (17% vs. 7%), the difference was not significant. Regardless of HIV status, children with bacteremia were more likely to die than those without bacteremia (24% vs. 14%; OR = 2.03; p 0.05). These findings stress the importance of early and effective antibiotic therapy. This therapy will reduce the morbidity and mortality associated with bacteriemia in HIV-infected children in Africa.

Hypoxaemia and bronchopneumonia in infants less than six months of age.

OBJECTIVE: To determine the association of both oxygen saturation (SaO2) in high levels of inspired oxygen (FiO2) and the rate of desaturation in air among survivors and non survivors (death within 7 days of admission) in infants with bronchopneumonia. DESIGN: Hospital based prognostic study. SETTING: Tertiary level Paediatric ward, Harare Hospital. SUBJECTS: Total of 40 infants aged less than six months with pneumonia were studied. INTERVENTIONS: Oxygen saturation was measured with a pulse oximeter and F1O2 with an analyser. F1O2 was increased until the SaO2 reached maximal values, SaO2 was recorded for five minutes: three in O2 (oxygen) and two in air and the rate of desaturation calculated. MAIN OUTCOME MEASURES: Mortality within seven days of admission. RESULTS: Eleven died within seven days of admission. Mortality was not associated with age, weight for age, severity of pneumonia, or SaO2 in high oxygen (99pc versus 95pc). It was related to the rate of oxygen desaturation in air; 8pc/minute versus 24pc/minute in survivors and non survivors, respectively (p < 0.001). CONCLUSION: This study suggests that current nursing procedures and feeding practices may need to be modified in these very ill infants.

Haemolytic uraemic syndrome following Shigella dysenteriae type 1 outbreak in Zimbabwe: a clinical experience.

Shigella dysenteriae type 1 related dysentery outbreak in Zimbabwe at the end of 1992 has been associated with an increase in the frequency of haemolytic uraemic syndrome (HUS). In order to document this new clinical experience a retrospective study was undertaken to document clinical and laboratory features, treatment and outcome of children with HUS. During the period January 1993 to June 1994, 96 children with HUS were seen at the referral hospitals in Harare. Severe and prolonged anaemia was a common feature and 80 pc of the children were given blood transfusions. Severe anaemia (HB < 6g/dl) was however, present in 50 pc of the children prior to death. Leucocytosis (white blood cell count > 20 x 10(9)/L) was present in 87 pc of the children on admission and there was no association between the level of leucocytosis and anuria. Anuria was present in 37 (39 pc) and was associated with a mortality of 68 pc. Peritoneal dialysis was performed in 26 (27 pc) patients. Major neurological complications were seen in a third of the children. Thirty eight children died, an overall case fatality rate (CFR) of 40 pc. Earlier recognition, prompt and comprehensive supportive therapy may improve the immediate survival in children with HUS in Zimbabwe.

High prevalence of Enterocytozoon bieneusi infections among HIV-positive individuals with persistent diarrhoea in Harare, Zimbabwe.

Infection with the microsporidian parasite Enterocytozoon bieneusi may be a major cause of prolonged diarrhoea in individuals also infected with human immunodeficiency virus (HIV). The parasite has been reported from Europe, Australia and the Americas, with a prevalence of 7-29%. Faecal specimens were obtained from 202 adults and 106 children in Harare, Zimbabwe, all of whom were in hospital and had diarrhoea. HIV serology was available for 119 adults: 106 were HIV seropositive. There were clinical grounds for suspecting HIV infection in 23 of the remaining patients. E. bieneusi was identified in specimens from 13/129 patients (10%) for whom HIV infection was indicated by serology and/or clinical signs, 1/60 patients (2%) of uncertain HIV status, and 0/13 seronegative patients. 18/106 children were HIV seropositive and 12 were not; HIV serology was not available for the remainder, but 19 were strongly suspected of being infected with HIV on clinical criteria. E. bieneusi was not detected in samples from any child. As is common in Zimbabwe, the prevalence of other parasites in faecal specimens was low and, amongst patients with proven or suspected HIV infection, E. bieneusi was the most prevalent parasite identified, particularly in patients with diarrhoea of over 4 weeks duration.

Antimicrobial susceptibilities of Shigella dysenteriae type 1 isolated in Zimbabwe--implications for the management of dysentery.

Shigella dysenteriae type 1 was cultured from 56/170 (33 pc) rectal swab specimens collected from patients presenting to hospitals in Harare, Zimbabwe with dysentery. All of the isolates were resistant in vitro to trimethoprim-sulfamethoxazole, with MICs > 32 mg/l, and all except one were resistant to ampicillin, most with an MIC > 256 mg/l. One isolate was resistant to nalidixic acid (MIC > 256 mg/l), but all of the others were sensitive, most with an MIC of 2 mg/l or less. Using antibiotic disks, 96 pc isolates were resistant to chloromphenicol and 94 pc to tetracycline. All isolates were sensitive in vitro to gentamicin. On the basis of these findings, we suggest that commonly available antibiotics including ampicillin, cotrimoxazole, chloramphenicol or tetracycline should not be used for the treatment of dysentery. The most appropriate antimicrobial agent at the present time would be nalidixic acid. Resistance to this is, however, likely to emerge and data on susceptibilities to fluoroquinolones as well as to cephalosporins should be obtained so that further recommendations can be given timeously.