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Funding: This study was funded by the 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). 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 < 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. Publisher PDF

Background Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller–client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic. Methods Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms = 415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed. Results Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client’s symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients. Conclusion Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Additional file 1.

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 PDF

Background: Needle-stick injuries (NSIs) and splash exposures carry a risk of occupational acquisition of HIV and other blood borne pathogens to healthcare workers (HCWs) involved in clinical care. This study was carried out to determine the frequency and factors contributing to NSIs and splash exposures as well as post-exposure practices among HCWs in our centre. Methods: This was a cross-sectional study among healthcare workers which was conducted at Bugando Medical Centre (BMC) over a one-year period between April 2013 and March 2014. Results: Out of 436 HCWs who participated in this study, 212 (48.6%) reported incidents of NSIs and splash exposures within the previous 12 months. NSIs were reported by 65.1% (n= 138) and splash exposures by 27.4% (n = 58). Sixteen (7.5%) respondents had both NSIs and splash exposures. High rates of NSIs were observed among nurses (71.0%), during procedures (53.6%) and occurred commonly in the Accident and Emergency department (33.3%). Hollow bore needles were responsible for 63.8% of NSIs. Splash exposures occurred more commonly in operating theatre (41.4%). At the time of the exposure, 116 (54.7%) HCWs wore protective equipment. The most common action following exposure was washing the site with soap and water (55.6%). Only 68 (32.1%) reported the incident of exposure to the relevant authority. Healthcare workers aged ≤ 40 years; those with work experience of ≤ 5 years and those not trained on issues related to infection prevention and occupational risk reduction were more likely to be exposed to any type of occupational injuries studied. While male healthcare workers were less likely to be exposed to NSIs, female were more likely to encounter both NSIs and mucocutaneous splashes (p < 0.001). The majority of HCWs, 185 (87.3%) were not adequately immunized for hepatitis B virus and only 17 (8.0%) were fully vaccinated, having received three doses of the vaccine. Only 16.7% of exposed HCWs received post-exposure prophylaxis for HIV. Subsequent six-month follow-up for HIV showed zero seroconversion. Conclusion: NSIs and splash exposures are common among HCWs at our centre and are under-reported. Post-exposure management is generally poor. All HCWs should be trained on issues related to infection prevention and occupational risk reduction. The hospital should establish surveillance system for registering, reporting and management of occupational injuries and exposures.

Background: Streptococcus pneumoniae is a known cause of severe invasive bacterial infection leading to morbidity and mortality among children in sub-Saharan Africa. Nasopharyngeal colonization of S. pneumoniae is a critical step towards invasive disease progression. The objective of this study was to investigate the magnitude of nasopharyngeal carriage of S. pneumoniae and its associated factors in Mwanza, Tanzania. Methods: Children underfives attending Reproductive and Child Health (RCH) clinics in Mwanza, Tanzania clinics were enrolled and investigated for nasopharyngeal carriage of S. pneumoniae. Demographic and clinical data were collected using standardized data collection tool. Nasopharyngeal swabs were taken and processed as per standard laboratory procedures. S. pneumoniae isolates were identified using conventional methods. Antimicrobial susceptibility testing was performed using the disc diffusion method as described by Clinical Laboratory Standard Institute.Results: Among 350 children enrolled in the study, 172 (49.1) were females and 309 (88.3%) were below 2 years of age. A total of 253 (72.3%) children had received at least one dose of pneumococcal vaccine (Prevanar 13) whereas 83 (23.7%) had used antibiotics at median duration of 5 days in the past 14 days. Out of 350 underfives, 43 (12.3%) were found to carry S. pneumoniae in their nasopharynx. Children with chronic diseases and those at school were 3.4 and 4.4 times more at risk to be carriers of S. pneumoniae than their counterpart group (OR; 3.4 (CI(1.0-11.6) 95%, p=0.05) and OR; 4.4 (CI (1.2-15.7) 95%, p=0.023), respectively. Number of children at home, positive HIV status and someone smoking showed association with S. pneumoniae carriage but the differences were not statistically significant. The resistance levels of S. pneumoniae to penicillin, co-trimoxazole and erythromycin were 40%, 88.2% and 41.7%, respectively. However all of the S. pneumoniae isolates were found to be 100% sensitive to ciprofloxacin.Conclusion: A high nasopharyngeal carriage of penicillin resistant S. pneumoniae is observed in Mwanza, Tanzania despite a good coverage of pneumococcal vaccination. The carriage is significantly associated with schooling and presence chronic diseases. Continuous surveillance of penicillin resistant strains coupled with serotyping of the isolates is highly recommended to determine the influence of the pneumococcal vaccination.

Streptococcus pneumoniae is a known cause of severe invasive bacterial infection leading to morbidity and mortality among children in sub-Saharan Africa. Nasopharyngeal colonization of S.pneumoniae is a critical step towards invasive disease progression. The objective of this study was to investigate the magnitude of nasopharyngeal carriage of S. pneumoniae and its associated factors in Mwanza, Tanzania. Children underfives attending Reproductive and Child Health (RCH) clinics in Mwanza, Tanzania clinics were enrolled and investigated for nasopharyngeal carriage of S. pneumoniae. Demographic and clinical data were collected using standardized data collection tool. Nasopharyngeal swabs were taken and processed as per standard laboratory procedures. S. pneumoniae isolates were identified using conventional methods. Antimicrobial susceptibility testing was performed using the disc diffusion method as described by Clinical Laboratory Standard Institute. Among 350 children enrolled in the study, 172 (49.1) were females and 309 (88.3%) were below 2 years of age. A total of 253 (72.3%) children had received at least one dose of pneumococcal vaccine (Prevanar 13) whereas 83 (23.7%) had used antibiotics at median duration of 5 days in the past 14 days. Out of 350 underfives, 43 (12.3%) were found to carry S. pneumoniae in their nasopharynx. Children with chronic diseases and those at school were 3.4 and 4.4 times more at risk to be carriers of S. pneumoniae than their counterpart group (OR; 3.4 (CI(1.0-11.6) 95%, p=0.05) and OR; 4.4 (CI (1.2-15.7) 95%, p=0.023), respectively. Number of children at home, positive HIV status and someone smoking showed association with S. pneumoniae carriage but the differences were not statistically significant. The resistance levels of S. pneumoniae to penicillin, co-trimoxazole and erythromycin were 40%, 88.2% and 41.7%, respectively. However all of the S. pneumoniae isolates were found to be 100% sensitive to ciprofloxacin. A high nasopharyngeal carriage of penicillin resistant S. pneumoniae is observed in Mwanza, Tanzania despite a good coverage of pneumococcal vaccination. The carriage is significantly associated with schooling and presence chronic diseases. Continuous surveillance of penicillin resistant strains coupled with serotyping of the isolates is highly recommended to determine the influence of the pneumococcal vaccination.