WHO/INRUD prescribing indicators among tertiary regional referral hospitals in Dar es Salaam, Tanzania: a call to strengthen antibiotic stewardship programmes.

Background: Antibiotic prescribing should be guided by national essential medicines lists (NEMLs) and treatment guidelines; however, there are inadequate data on antibiotic utilization patterns in tertiary hospitals in Tanzania. This study aimed to determine antibiotic prescribing patterns in tertiary hospitals in Dar es Salaam, Tanzania. Methods: A retrospective cross-sectional study was conducted in three regional referral hospitals. About 200 prescription records from 2020 to 2022 were analysed at each hospital for prescribing patterns using WHO/ International Network of Rational Use of Drugs (INRUD) indicators (1993) and the AWaRe 2021 classification. Factors associated with receiving an antibiotic prescription were assessed using a logistic regression model. Facilities were ranked on prescribing practices using the index of rational drug prescribing (IRDP). Results: A total of 2239 drugs were prescribed, of which 920 (41.1%) were antibiotics. An average of 3.7 ±â€Š1.5 (optimal: 1.6-1.8) total medicines and 1.53 ±â€Š0.78 antibiotics were prescribed per patient. About 88.0% (528) of the prescriptions contained antibiotics (optimal: 20.0%-26.8%), while 78.2% (413) of all antibiotic prescriptions contained injections (optimal: 13.4%-24.1%). Furthermore, 87.5% (462) of the antibiotics were prescribed in generic names (optimal: 100%), while 98.7% (521) conformed to the NEML (optimal: 100%). Metronidazole was the most frequently prescribed antibiotic (39.2%; n = 134), followed by ceftriaxone (37.1%, n = 127) and amoxicillin/clavulanic acid (8.5%, n = 29). Conclusions: We found substantial empirical prescribing and overuse of antibiotics exceeding WHO recommendations. Antibiotic overuse varied across the hospitals. Being male, having underlying conditions such as diabetes mellitus, and/or being treated at Temeke hospital were associated with receiving an antibiotic prescription. We recommend strengthening antibiotic stewardship programmes in the studied facilities.

Profiling of antimicrobial dispensing practices in accredited drug dispensing outlets in Tanzania: a mixed-method cross-sectional study focusing on pediatric patients.

BACKGROUND: The emergency of antimicrobial resistance due to irrational antimicrobial use has put public health under threat. Accredited Drug Dispensing Outlets (ADDOs) play an important role in enhancing availability and accessibility of antimicrobials, however, there is a scarcity of studies assessing antimicrobial dispensing practices in these outlets, focusing on children in Tanzania. OBJECTIVE: This study was conducted to assess the antimicrobial dispensing practices among ADDO dispensers and explore the factors influencing the use of antimicrobials for children in Tanzania. METHODS: A community-based cross-sectional study utilizing both qualitative (interviews) and quantitative (simulated clients) methods was conducted between June and September 2020 in seven zones and 14 regions in Tanzania. RESULTS: The study found inappropriate dispensing and use of antimicrobials for children, influenced by multiple factors such as patient's and dispenser's knowledge and attitude, financial constraints, and product-related factors. Only 8% (62/773) of dispensers asked for prescriptions, while the majority (90%) were willing to dispense without prescriptions. Most dispensers, 83% (426/513), supplied incomplete doses of antimicrobials and only 60.5% (345/570) of the dispensers gave proper instructions for antimicrobial use to clients. Over 75% of ADDO dispensers displayed poor practice in taking patient history. CONCLUSION: ADDO dispensers demonstrated poor practices in dispensing and promoting rational antimicrobial use for children. Training, support, and regulatory interventions are required to improve antimicrobial dispensing practices in community drug outlets.

Implementation of antibiotic stewardship programmes in paediatric patients in regional referral hospitals in Tanzania: experience from prescribers and dispensers.

Background: In 2017, Tanzania launched the National Action Plan for Antimicrobial Resistance (NAPAR), 2017-2022 and implementation of antibiotic stewardship programmes (ASPs) was one of the agendas. Since the launch of the National Action Plan, no study has been done to assess its implementation. Objectives: To explore the experiences of prescribers and dispensers on implementing ASPs among paediatric patients attending Regional Referral Hospitals (RRHs) in Tanzania. Methods: An exploratory qualitative study was conducted among key informants, in 14 RRHs in Tanzania between July and August 2020. A total of 28 key informants, 14 dispensers in charge of pharmacies and 14 medical doctors in charge of paediatric departments (prescribers), were interviewed. A hybrid thematic analysis was conducted on the gathered information. Results: Most of the study participants were not conversant with the term 'antibiotic stewardship'. Some had heard about the programmes but were not aware of the activities involved in the programme. Those who were knowledgeable on ASPs mentioned the lack of existence of such programmes in their settings. They further added that absence or limited knowledge of the stewardship concepts may have influenced the current poor practices. Barriers to the implementation of ASPs mentioned were lack of laboratory facilities to support culture and susceptibility tests, lack of materials and reagents, management pressure to prevent loss or to generate income, patients' influence and limited training opportunities. Conclusions: Despite launching the NAPAR in 2017, we found limited implementation of ASPs in the management of paediatric patients. This study highlighted some barriers and identified possible intervention points.

Barriers and Facilitators of Availability of Hydroxyurea for Sickle Cell Disease in Tanzania; A Qualitative Study of Pharmaceutical Manufacturers, Importers, and Regulators.

Despite three decades of proven safety and effectiveness of hydroxyurea in modifying sickle cell disease (SCD), its accessibility is limited in Sub-Saharan Africa, which shares 75% of the world's SCD burden. Therefore, it is time to explore the barriers and facilitators for manufacturing and importation of hydroxyurea for SCD in Tanzania. This was qualitative research that employed a case study approach. Purposive sampling followed by an in-depth interview (IDI) using a semi-structured questionnaire aspired by data saturation enabled us to gather data from 10 participants. The study participants were people with more than three years of experience in pharmaceuticals importation, manufacturing, and regulation. The audio-recorded data were verbatim transcribed and analyzed using thematic analysis. Two themes were generated. The first comprised barriers for importation and manufacturing of hydroxyurea with sub-themes such as inadequate awareness of SCD and hydroxyurea, limited market, and investment viability. The second comprised opportunities for importation and manufacturing of hydroxyurea with sub-themes such as awareness of activities performed by medicines regulatory authority and basic knowledge on SCD and hydroxyurea. Inadequate understanding of SCD, hydroxyurea, and orphan drug regulation are major issues that aggravate the concern for limited market and investment viability. Existing opportunities are a starting point towards increasing the availability of hydroxyurea.

Drivers of irrational use of antibiotics among children: a mixed-method study among prescribers and dispensers in Tanzania.

BACKGROUND: Misuse of antibiotics has been associated with poor knowledge, attitude and practice (KAP). Therefore, this study aimed to assess if KAP of prescribers and dispensers could drive irrational use of antibiotics among children in Tanzania. METHODS: A convergent parallel mixed-methods study design that employed quantitative and qualitative approaches was conducted in 14 regional referral hospitals (RRHs). A total of 108 participants, prescribers [54] and dispensers [54] working with the pediatric population in the respective regions participated in a quantitative survey, by filling the standard questionnaire while 28 key informant interviews were conducted with in-charges of units from the pharmacy and pediatric departments. Two key informants (prescriber and dispenser) were selected from each RRH. RESULTS: Overall, among prescribers and dispensers, there was adequate knowledge; 81.5% and 79.6%, p = 0.53, those with positive attitudes were 31.5% and 81.5%, p < 0.001 and poor practices were among 70.4% and 48% p = 0.0312 respectively. Among prescribers, 14.8% agreed and strongly agreed that prescribing antibiotics that a patient did not need does not contribute to resistance. Moreover 19% disagreed to prescribe antibiotics according to local guidelines. Among dispensers, a-quarter of the dispensers thought individual efforts to implement antibiotic stewardship would not make a difference, 17% agreed and strongly agreed that antibiotics can treat viral infection and 7% agreed and strongly agreed antibiotics can be stopped upon resolution of symptoms. From qualitative interviews, both participants displayed an adequate understanding of multi-contributors of antibiotic resistance (AR) including polypharmacy, community self-medication, among others. Regardless, both professions declared to prescribed and dispensed antibiotics according to the antibiotics available in stock at the facility. Furthermore, prescribers perceived laboratory investigation took a long time, hence wasting their time. On the other hand, Dispensers reported not to provide adequate instruction to the patients, after dispensing antibiotics. CONCLUSIONS: Both prescribers and dispensers had adequate knowledge, few prescribers had positive attitudes and the majority had poor practices. Few dispensers had poor attitude and practice. These findings highlight the need to provide adequate training on antimicrobial stewardship and enforce regulation that foster appropriate medical practice.

The Effects of Sickle Cell Disease on the Quality of Life: A Focus on the Untold Experiences of Parents in Tanzania.

Tanzania is among the top five countries with a high burden of sickle cell disease (SCD) in the world. Even though the effects of SCD on quality of life have been documented in other countries including Nigeria and the United States of America, few are known from Tanzania. Therefore, this study focused on evaluating the effects of SCD on the quality of life among children living with SCD and their parents. The study employed a qualitative approach to interview purposively selected parents of children who have lived with SCD and have used hydroxyurea (HU) for more than 3 years. The in-depth interviews were conducted with 11 parents of children with SCD at the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar-es-salaam, Tanzania. A semi-structured interview guide was used. Interviews were audio-recorded, transcribed, and thematically analyzed. Three themes were generated including psycho-social effects: family conflicts and divorce, limited access to education, stress and fear; financial effects: Employment limitation, reduced efficiency and productivity, loss of job and lack of self-keeping expenses; and physical effects: physical disability and dependence, and burden of the frequent crisis. Children living with SCD and their parents suffer psycho-social, financial, and physical impacts of the disease. Appropriate interventions should be introduced to minimize the observed effects as ways of improving the quality of life of the individuals living with SCD and their caregivers.

Microbiological Quality of Selected Local and Imported Non-Sterile Pharmaceutical Products in Dar es Salaam, Tanzania.

Background: Pathogenic and non-pathogenic microbial contaminants can cause physical-chemical alterations of pharmaceuticals and medicine-related infections. This study aimed to examine the microbiological quality of selected local and imported non-sterile pharmaceutical products in the Dar es Salaam market and the antibiogram of the isolated microorganisms. Methods: Samples were collected between April and June 2021 and analysed for microbial content as per the harmonised methods of the European Pharmacopoeia (EP). Antibiotic susceptibility of the microbial isolates was studied using Kirby-Bauer disc diffusion method. Results: Fifty percent (50%) of the samples failed both bacterial and fungal enumeration tests. In this study, local products recorded lower microbial counts than imported products. Major bacterial contaminants isolated were P. aeruginosa (45.5%), S. epidermidis, (45.5%) and K. pneumoniae, while major fungal contaminants were A. flavus (58.3%), followed by A. fumigatus (25%) and Penicillium spp (16.7%). The isolated bacterial contaminants recorded high resistance levels to commonly used antibiotics. Conclusion: The tested products were contaminated with microorganisms at different levels, most of them exceeding the maximum acceptable colony counts. Syrups or suspensions were more contaminated than tablets and capsules. The isolated bacterial contaminants were highly resistant to commonly used antibiotics. Recommendations: We recommend that pharmaceutical manufacturers abide by good manufacturing, distribution and storage practices to limit contamination and cross-contamination of products. Responsible drug regulatory authorities should heighten the frequency of inspection of manufacturing facilities and regularly conduct post-marketing surveillance (PMS) of registered products to assess continued conformity to GMP guidelines. Future studies should involve samples collected directly from manufacturing sites.

Determinants of misuse of antibiotics among parents of children attending clinics in regional referral hospitals in Tanzania.

Parents are the important implementers on appropriate/inappropriate use of antibiotics, especially in the pediatric population. Limited studies have associated poor knowledge, attitude, and practice (KAP) among parents with antibiotics misuse. Therefore, this study was conducted to determine the parents' KAP and factors associated with inappropriate use of antibiotics among Tanzanian children. A hospital-based cross-sectional study was conducted in 14 regional referral hospitals (RRHs) in Tanzania between June and September 2020. KAP was estimated using a Likert scale, whereas KAP factors were determined using logistic regression models. A total of 2802 parents were enrolled in the study. The median age (interquartile range) of parents was 30.0 (25-36) years where 82.4% (n = 2305) were female parents. The majority of the parents had primary education, 56.1% (n = 1567). Of 2802 parents, only 10.9% (n = 298) had good knowledge about antibiotics, 16.4% (n = 455) had positive attitude whereas 82.0% (n = 2275) had poor practice on the appropriate use of antibiotics. Parents' education level, i.e., having a university degree (aOR: 3.27 95% CI 1.62-6.63, p = 0.001), good knowledge (aOR: 1.70, 95% CI 1.19-2.23, p = 0.003) and positive attitudes (aOR: 5.56, 95% CI 4.09-7.56, p < 0.001) were significantly associated with the appropriate use of antibiotics in children. Most parents had poor knowledge, negative attitude, and poor practice towards antibiotics use in children. Parents' education level, employment status, knowledge on antibiotic use, and good attitude contributed to the appropriate use of antibiotics in children attending clinics at RRHs.

WHO/INRUD core prescribing indicators and antibiotic utilization patterns among primary health care facilities in Ilala district, Tanzania.

BACKGROUND: Antibiotic use requires regular monitoring to prevent emergence of antibiotic resistance. OBJECTIVES: To assess antibiotic prescribing patterns at health care facilities (HCF) in Ilala district, Tanzania. METHODS: A 1 year retrospective study was conducted in four HCFs using WHO/International Network of Rational Use of Drugs (INRUD) core prescribing indicators. Factors associated with antibiotic prescription were analysed using logistic regression model. RESULTS: A total of 604 prescriptions were reviewed. Patients had median age (IQR) of 15 (4-31) years with majority having upper respiratory tract infection 33.3% (n = 201), urinary tract infection 31.1% (n = 188) or diarrhoea 21.2% (n = 128). Out of 624 prescribed antibiotics, amoxicillin was the most common (22.7%), followed by ciprofloxacin (13.6%) and metronidazole (11.6%). The studied HCFs had an average of 1.99 medicines prescribed per consultation (reference: 1.6-1.8). Of 1203 medicines prescribed, 51.9% (n = 624) were antibiotics (reference: 20.0%-26.8%). Additionally, 97.6% (n = 609) of the antibiotics appeared on the national essential medicines list, whereby 84.4% (n = 510) were prescribed by generic names (reference: 100%). Patients with peptic ulcers had a 4.4-fold higher chance of receiving antibiotics [adjusted odds ratio (aOR) = 4.4, 95% CI = 1.918-10.13, P = 0.0001] while patients with diarrhoea had a 2.6-fold higher chance of receiving at least one antibiotic (aOR = 2.6, 95% CI = 1.206-5.491, P = 0.015). CONCLUSIONS: We found inappropriate use of antibiotics in the studied primary HCFs. Antibiotic stewardship programmes should be extended to primary HCFs found in Ilala district.

Premarital genetic screening and care of Tanzanian children with sickle cell disease: a qualitative study on parents' views and experiences.

Genetic testing and counselling is one of the approaches to reduce the high birth rate of individuals with sickle cell disease (SCD). A descriptive phenomenological approach was used to explore parents' views on premarital genetic screening for sickle cell trait and their experiences in the care of Tanzanian children with SCD using a face-to-face in-depth interview. The study was conducted at sickle cell clinic at tertiary hospital in Dar es Salaam region between June and August 2020. The study found that most of the parents with SCD children knew about genetic testing and counselling after the diagnosis of their children's SCD status. Major approaches employed in managing SCD crises were supportive, preventive, and symptomatic. Parents expressed a heavy burden related to caretaking due to the lack of financial support and stigmatization. These affected their children's quality of care and management. In conclusion, participants expressed a preference for premarital genetic testing, where others insisted it becomes compulsory. In addition, there should be an adequate clinic for early screening, accessible therapeutic support and long-term follow up for children with SCD. Support to poor families with individual with SCD through national health assurance scheme and free provision of preventive medications such as hydroxyurea, is recommended.

Clinical characteristics and treatment outcomes of patients with MDR tuberculosis in Dar Es Salaam region, Tanzania.

BACKGROUND: In Tanzania more than 28% of all multi-drug resistant tuberculosis (MDR-TB) cases occur in Dar es Salaam. However, information about management and clinical outcomes of patients with MDR-TB in the region is scarce, and hence the need for this study. METHODS: A 5-year retrospective cohort study was conducted in six centres in Dar es Salaam. Descriptive statistics were used to summarize social demographics and clinical characteristics. Associations between occurrence of adverse events, regimen change and cure were determined using the Chi-square test whereas factors associated with mortality were determined using the Log-ranking test and Cox regression model. RESULTS: Three-hundred patient files were found and reviewed. The majority were male 199 (66.3%), aged 25-44 years [176 (58.7%)] and 89 (30.1%) were HIV co-infected. 186 (62%) completed their treatment, 68 (22.0%) were on treatment and 9 (3.3%) were lost to follow-up. The majority, 152 (51.0%) were managed using long MDR-TB regimens. The overall mortality rate was 5.7 per 1000 MDR-TB patients. A higher mortality rate was associated with being ≥45 years [adjusted hazard ratio (AHR): 10.82, 95% CI: 1.14-102.74, P = 0.038), female (AHR: 5.92, 95% CI: 1.75-20.08, P = 0.004), on a short anti-TB regimen (AHR: 4.34, 95% CI: 1.41-13.35, P = 0.010), HIV co-infected [crude hazard ratio (CHR): 2.56, 95% CI: 1.01-6.50, P = 0.048), on concomitant long-term medication use (CHR: 2.99, 95% CI: 1.17-7.64, P = 0.022) and having other co-morbidities (CHR: 3.45, 95% CI: 1.32-9.02, P = 0.011). CONCLUSIONS: MDR-TB mortality was associated with short anti-TB regimens, sex, age, concomitant long-term medication use and HIV coinfection. In this population, use of long and individualized regimens is recommended.