Muhimbili National Hospital Research Articles

Drug resistant epilepsy and associated factors among children with epilepsies in tanzania: a cross-sectional study

BackgroundEpilepsy contributes to high morbidity among children and adolescents in developing countries. A quarter of all children with epilepsy will be resistant to anti-seizure medications (ASMs), with associated neurocognitive impairments and risk of higher mortality. This study aimed to estimate and characterize drug-resistant epilepsy (DRE) (defined as failure to achieve sustained remission after adequate trials of two tolerated and appropriately chosen ASMs) and its associated factors among children and adolescents with epilepsies attending the pediatric neurology clinic at Muhimbili National Hospital (MNH), Dar es Salaam Tanzania.MethodsThis cross-sectional study was conducted from June 2020 to June 2021. Children with epilepsies and who had been treated with ASMs for at least 3 months were eligible for inclusion. Exclusion criteria included children whose caregivers denied consent and those who exhibited acute medical conditions necessitating admission on the scheduled visit day. Data on demographic characteristics, perinatal history, detailed history of the seizures semiology, drug history, magnetic resonance imaging (MRI), and electroencephalography (EEG) results were obtained from caregivers and medical records available during recruitment. Seizures and epilepsies were classified using the 2017 International League Against Epilepsy (ILAE) classification. Logistic regression was used to determine factors associated with DRE.ResultsA total of 236 children and adolescents aged between 4 months and 15 years (Median age 72 months (IQR = 42–78)) were enrolled in this study. We found the proportion of DRE to be 14.8% in this cohort. Of the thirty-five patients with DRE, 60% had generalized epilepsy and almost 25% had a diagnosis of an epilepsy syndrome, the most common being Lennox-Gastaut syndrome (LGS). Structural abnormalities on brain MRI were seen in almost 80% of all patients with DRE, the most prevalent being cystic encephalomalacia, which was observed in 34% of patients. Patients using both ASMs and alternative therapies accounted for 9% of this cohort. The onset of seizures during the first month of life (aOR = 1.99; 95%CI 1.7–4.6; p = 0.031) and high initial seizure frequency (aOR = 3.6; 95%CI 1.6-8;p = 0.002) were found to be independently associated with DRE.ConclusionThe proportion of DRE in Tanzania is high. Patients with neonatal onset seizures and high initial seizure frequency should be followed up closely to ensure early diagnosis of DRE.

Predictors of Colorectal Resection and Primary Anastomosis outcome at Muhimbili National Hospital.

Anastomotic leakage is among the most common complications after bowel resection and primary anastomosis, causing considerable morbidity and mortality. As a result it tends to affect the quality of life and increase burden to the patients and caretakers. This study focused on the assessment of the predictors and outcome of anastomotic leakage among patients who underwent large bowel surgery that involved resection and primary anastomosis. Hospital based prospective observational study at Muhimbili National Hospital. Data of the patients who underwent colorectal resection and primary anastomosis were collected by using a structured questionnaire. Consecutive recruitment sampling technique was applied to get the required sample size and followed for 30 days. Subjects' information including age, sex, perioperative information was documented and analyzed by using Statistical Package for the Social Sciences (SPSS) version 23 software. The study included 141 participants. Among those operated, 23 (16.3%) developed anastomotic leakage with a mortality rate of 30.4%. Predictors which were statistically significantly associated with anastomotic leakage were hypertension, body mass index > 30kg/m2, history of radiation therapy, female sex, high American Society of Anesthesiologists (ASA) grade III-IV score and peritonitis. Increased length of hospital stay, re-admission and re-operation rate together with high mortality are among the outcomes of anastomotic leakage found in this study. No loss to follow up event occurred. Anastomotic leakage remains a considerable problem among patients undergoing large bowel surgery at Muhimbili National Hospital. From the study site, factors such as peritonitis, HIV/AIDS, hypertension, history of radiation, obesity, high ASA score (III-IV) and female sex were found to be independent predictors of anastomotic leakage. Optimization of co-morbidities conditions before surgery, choosing best surgical option such as creating temporary stoma versus primary anastomosis in dirty wound may help to reduce the rate of anastomotic leakage.

Trends in mortality and associated factors among neonates hospitalized at Muhimbili national hospital, Tanzania: A three-year retrospective study.

Tanzania is amongst the countries with high neonatal mortality in Sub-Saharan Africa (SSA), and estimates vary widely among regions. Various interventions are being implemented at Muhimbili National Hospital (MNH), a tertiary and teaching facility, to contribute towards the reduction of neonatal mortality. This study aimed to detail the magnitude, trends and factors associated with neonatal mortality at MNH. A hospital-based retrospective cohort study was conducted from January 2018 to December 2020. Records of all neonates admitted during the study period were extracted from neonatal registers and the electronic medical record system and recorded in a pretested data collection form. Data cleaning and analysis were done using SPSS version 23. Poisson regression was used to determine adjusted relative risk (aRR) with a 95% confidence interval (CI) to test association. A p-value of <0.05 was considered significant. Of the 17,021 neonates admitted, 11,552 (67.9%) were inborn. During the three years reviewed, 1,814 (10.7%) neonates died. The mortality rates were 5.9% for inborn neonates, 24.1% for outborn neonates, and 4.8% for readmitted neonates. Mortality trends declined quarterly at an average of 0.15%. Factors associated with neonatal mortality included; birth weight < 2500g [{aRR = 1.14; 95% CI (1.01-1.29)}], GA < 37 weeks[{aRR = 1.17; 95% CI (1.03-1.33)}], fifth-minute Apgar score <7[{aRR = 2.53; 95% CI (2.32-2.77)}], vaginal delivery[{aRR = 1.39; 95% CI (1.24-1.55)}], out-born[{aRR = 2.85; 95% CI (2.58-3.14)}], positive maternal HIV status[{aRR = 1.18; 95% CI (1.02-1.36)}] and maternal age ≥35years [{aRR = 1.12; 95% CI (1.01-1.25)}]. Despite a declining trend, in-hospital neonatal mortality at MNH is still high. Ongoing quality improvement strategies should prioritize the identification of neonates with risk factors for poor outcomes. Specifically, the high proportion of mortality among out-born neonates requires more attention and further investigation.

Postoperative Complications and Factors Associated with Surgical Site Infection at Muhimbili National Hospital, Dar es Salaam, Tanzania: A cross-Sectional study.

Postoperative complications are a leading cause of morbidity and mortality to surgical patients. Different complications are encountered in clinical practice, however surgical site infection (SSI) appears to be the most common. To date, limited published information is known pertaining to the patterns of postoperative complications and factors associated with SSI among patients operated on in other hospitals in Tanzania and referred to Muhimbili national hospital for further management. Therefore, the purpose of this study was to identify patterns of postoperative complications and factors associated with SSI among the study participants. This was a hospital based cross-sectional study conducted at Muhimbili national hospital from August 2022 to January 2023, which included 181 patients. Obtained data was analysed using frequency tables, Pearson Chi-squared test and binary logistic regression model, at a level of significance of <0.05. One hundred eighty one (181) patients were included in this study, of whom 113(62.4%) were females; median age was 39 years. Cigarette smokers and alcohol consumers were 42(23.2%) and 90(49.7%) respectively. Diabetic patients were 8(4.4%), 35(19.3%) were HIV positive and 52(28.7%) had hypertension. Patients whose diagnosis was related to general surgery accounted for 50.2%, whereas 30.9% were obstetric cases. Patients who had undergone Caesarean section were 45(24.9%), whereas 20(11%) patients had undergone total abdominal hysterectomy. Bowel resection and primary anastomosis included 16(8.8%) patients and perforated peptic ulcer repair 8(4.4%) patients. Patients with infected peritoneal collection were 34(18.8%), postpartum haemorrhage 18(9.9%) and bowel perforation 10(5.5%). Patients who had undergone relaparotomy as part of treatment were 70(38.7%), whereas 30(16.6%) patients with SSIs were treated by serial wound dressing and 26(14.4%) patients were admitted and nursed in intensive care unit. None of the factors was found to have a statistically significant association with SSI. There is a large proportion of patients suffering from postoperative complications after gastroenterology and obstetric surgeries; and of all complications encountered in this study; SSI was the most common contributing 52%, followed by gastrointestinal complications at 31%. Despite the fact that multiple factors were associated with SSI, none of them was found to be statistically significant.

A study protocol for predictors of post-discharge mortality among children aged 5-14 years admitted to tertiary hospitals in Tanzania: A prospective observational cohort study.

Globally, millions of children and adolescents die every year from treatable and preventable causes. Sub-Saharan Africa accounted for 55% of deaths of children aged 5-14 years in 2017. Despite this high burden, minimal effort has been directed toward reducing mortality among older children and adolescents in comparison to under-fives. Mortality rates of children post-discharge vary between 1-18% in limited-resource countries and are reported to exceed in-hospital mortality. In Tanzania, there is limited data regarding post-discharge mortality and its predictors among children aged 5-14 years. This study aims to determine the post-discharge mortality rate and its predictors among children aged 5-14 years admitted to pediatric wards at MNH, MOI, and JKCI. This will be a prospective observational cohort study that will be conducted among children aged 5-14 years admitted to pediatric wards at Muhimbili National Hospital, Jakaya Kikwete Cardiac Institue, and Muhimbili Orthopedic Institue in Dar-Es-Salaam, Tanzania. Data will be collected using a structured questionnaire and will include socio-demographic characteristics, clinical factors, and patients' outcomes. Post-discharge follow-up will be done at months 1, 2, and 3 after discharge via phone call. Data will be analyzed using SPSS version 23. The association of demographic, social economic, and clinical factors with the outcome of all causes, 3 months post-discharge mortality will be determined by Cox regression, and survival rates will be displayed through Kaplan-Meier curves. This study will determine post-discharge mortality among children aged 5-14 years and its predictors in Tanzania. This information is expected to provide baseline data that will be useful for raising awareness of clinicians on how to prioritize and plan a proper follow-up of children following hospital discharge. These data may also be used to guide policy development to address and reduce the high burden of older children and adolescent mortality and may be used for future studies including those aiming to develop prediction models for post-discharge mortality among older children and adolescents.

Clinical profile and outcomes of paediatric patients with acute seizures: a prospective cohort study at an urban emergency department of a tertiary hospital in Tanzania

ObjectiveChildren with seizures require immediate and appropriate intervention in the emergency department (ED). This study describes the clinical profile and outcome of paediatric patients with seizures at the ED in...

"Establishing a Multi-disciplinary Adult Oncology Unit at Muhimbili National Hospital: Lessons Learned, Challenges, and Opportunities Amidst Tanzania's Growing Cancer Burden"

The escalating cancer burden, particularly in low- and middle-income countries such as Tanzania, necessitates innovative strategies. One strategy is to increase access to cancer services through the establishment of treatment in existing referral hospitals that offer multidisciplinary care, as was the case in the opening of the adult oncology unit at Muhimbili National Hospital (MNH) in Tanzania. A comprehensive facility assessment served as the foundation for this expansion, encompassing assessments of the spatial requirements of human resources, equipment, and drug availability. Aiming to ensure optimal resource allocation and effective implementation by capitalizing on existing systems. The main objective of opening the MNH adult oncology unit was to increase coverage and accessibility to comprehensive cancer care services. This initiative has substantially improved patient outcomes, with reduced wait times for oncology care initiation, facilitating seamless care coordination that capitalizes on multidisciplinary treatment planning. The unit has provided benefits to MNH by fostering collaborative efforts, serving as a revenue generation point, and expanding care that aligns with institutional goals. Nonetheless, challenges persist, including space constraints and an inadequate number of trained human resources for oncology care. The successful establishment of the MNH's adult oncology unit exemplifies the significance of stakeholder engagement, adaptability, and collaboration. A comprehensive approach that emphasizes workforce development, community awareness, and infrastructure enhancement offers promise in confronting Tanzania's mounting cancer burden.

Prevalence and Factors Associated with Self-Reported Substance Use among Patients with Mental Illness in Dar es Salaam, Tanzania: A Cross-Sectional Analytical Study

Background. Substance use is prevalent among patients with mental illness in low- and middle-income countries, including Tanzania. This heightened prevalence not only increases the risk of developing mental disorders and substance use disorders but also contributes to poor treatment outcomes for these patients. Despite these concerns, the current prevalence of substance use and its associated factors in this population remains unclear in Tanzania. Therefore, this study is aimed at determining the 12-month period prevalence of self-reported substance use and associated factors among patients with mental illness. Methods. We conducted a cross-sectional analytical study among patients with mental illness at Muhimbili National Hospital in Dar es Salaam, Tanzania. Respondents were selected using a systematic random sampling technique. Data on self-reported substance use were collected using the World Health Organization’s (WHO) alcohol, smoking, and substance involvement screening test (ASSIST) V3.0. IBM SPSS version 25 was employed for data analysis, utilizing frequencies and percentages to determine the prevalence of self-reported substance use. The study employed bivariate and multiple logistic regression analyses to investigate the association between patient characteristics and self-reported substance use, with statistical significance set at a p value of &lt; 0.05. Results. A total of 364 patients were enrolled in the study, with 215 (59.1%) being male and a mean (SD) age of 35.57 (±9.01) years. Among the participants, 119 (32.7%) reported substance use. The most commonly used substances were alcohol (21.7%), tobacco (19.8%), and cannabis (12.9%). Factors significantly associated with self-reported substance use included younger age (AOR: 1.829; 95% CI: 1.112, 3.010; p=0.017), male gender (AOR: 2.346; 95% CI: 1.397, 3.939; p=0.001), positive family history of mental illness (AOR: 2.247; 95% CI: 1.364, 3.701; p=0.001), and a family history of substance use (AOR: 3.804; 95% CI: 2.305, 6.276; p&lt;0.001). Conclusions. A significant proportion, amounting to one-third of patients, reported substance use, highlighting the imperative need for targeted measures within this population. The implementation of routine substance use screening programs for patients with mental illness is crucial, alongside gender-sensitive and age-specific interventions. Consideration of patients’ family history of mental illness and substance use should be an integral part of these measures.

Implementation of the Adult Oncology Unit at Muhimbili National Hospital (MNH)

The escalating cancer burden, particularly in low- and middle-income countries such as Tanzania, necessitates innovative strategies. One such strategy is increasing access to cancer services through the establishment of treatment in existing referral hospitals that offer multidisciplinary care, as was the case in the opening of the adult oncology unit at Muhimbili National Hospital (MNH) in Tanzania to address the burgeoning cancer crisis. A comprehensive facility assessment served as the foundation for this transformation, ensuring optimal resource allocation and effective implementation. The rising cancer burden in Tanzania is dominated by cervical, breast, and prostate cancers. However, reported figures might underestimate the issue due to the lack of a centralized national cancer registry and limited access to diagnostic and treatment facilities throughout the country. The MNH oncology unit's creation aimed to decentralize care from the Ocean Road Cancer Institute (ORCI); as the cancer burden increased over the years, the center was getting strained by demand. The MNH facility assessment encompassed assessments of spatial requirements for human resources, equipment, and drug availability. This unit adopts a multidisciplinary approach, enabling personalized treatment plans and collaborative decision-making, aimed at expanding capacity and promoting inter-departmental cooperation. A "train-the-trainer" model empowered nursing staff in chemotherapy administration, and pharmacist involvement ensured accurate medication management. This initiative has substantially improved patient outcomes, with reduced wait times for oncology care initiation, facilitating seamless care coordination that capitalizes on multidisciplinary treatment planning. The opening of the oncology unit has given benefits to MNH through fostering multidisciplinary collaboration, an increase in revenue generation, and the expansion of care that aligns with institutional goals. Nonetheless, challenges, including space constraints and an inadequate number of trained human resources for oncology care, persist. The successful establishment of MNH's adult oncology unit exemplifies stakeholder engagement, adaptability, and the significance of collaboration. A comprehensive approach, emphasizing workforce development, community awareness, and infrastructure enhancement, offers promise in confronting Tanzania's mounting cancer burden.

An alarming prevalence of multidrug-resistant (MDR) ESKAPE pathogens and other drug-resistant bacteria isolated from patients with bloodstream infections hospitalized at Muhimbili National Hospital in Dar es Salaam, Tanzania

This study was conducted between April and May 2023 at the Muhimbili National Hospital in Tanzania to determine the prevalence of multidrug-resistant (MDR) ESKAPE, and other drug-resistant bacteria isolated from 856 patients with bloodstream infections (BSIs). The prevalence of BSIs was 37.3% (319/856), with 5% (17/319) of the patients having polymicrobial infections. The prevalence of BSIs was slightly greater among males (38.3%, 162/423) than females (36.3%, 157/433) (p= 0.585. Most of the infections occurred in children aged &lt;1 year (45.3%, 149/329) or adults aged ≥61 years (45.7%, 37/81) (p= 0.001). Patients admitted to the intensive care unit (ICU) had significantly greater BSIs (44%; 113/258) than those admitted to other wards (34.4%; 206/599) (p= 0.006). The ESKAPE pathogens accounted for 43.28% of all the isolates, predominantly Staphylococcus aureus (16.4%), followed by Klebsiella pneumoniae (9.25%), Acinetobacter spp. (6.86%), and Pseudomonas aeruginosa (4.77%). The overall proportion of MDR bacteria was 83.8%, and 63.64% were resistant to more than four classes of antibiotics. Among the remaining strains, 23.4% of the ESKAPE pathogens and 10% of the MDR Enterobacterales were resistant to eight different classes of the tested antibiotics and were regarded as extensively drug-resistant (XDR). Resistance to 3rd generation cephalosporins was observed in 91% of the Klebsiella pneumoniae isolates and all the Enterobacter spp. The proportion of methicillin-resistant S. aureus (MRSA) was 71.4%. Based on these results, we strongly discourage empiric treatment of BSIs and recommend that laboratory results guide all prescriptions. Immediate action is undoubtedly needed to introduce rapid drug resistance tests and review the existing management guidelines.

Investigating bothersome lower urinary tract symptoms among people living with HIV on antiretroviral therapy: prevalence, influencing factors, and quality-of-life implications

BackgroundUrological complications are not uncommon among people living with HIV and are often the initial clinical manifestation of HIV and AIDS. These complications, when presenting with bothersome lower urinary tract symptoms (LUTS), can significantly impact the Quality of life (QoL) of affected individuals. We, therefore, conducted a study aiming at determining the prevalence of bothersome LUTS, identifying factors influencing the severity of these symptoms, and examining their influence on the QoL among people living with HIV on antiretroviral treatment (ART).MethodsA cross-sectional study was conducted among randomly selected adult HIV-positive patients who attended the Care and Treatment Center at Muhimbili National Hospital, located in Dar es Salaam, Tanzania, from September 2021 to February 2022. Data was collected using a questionnaire that incorporated the American version of the International Prostate Symptom Score (IPSS). The IPSS was utilized to assess the severity of LUTS and their influence on the QoL. Descriptive statistics were used to summarize the results, and ordinal regression analysis was employed to assess the factors influencing the severity of LUTS.ResultsThe prevalence of LUTS in the study population was 57.8%, with mild symptoms (mean IPSS 3.92 ± 1.92) being the most common manifestation. The mean age of the study participants who presented with LUTS was 47.89 ± 12.05 years, and the majority were females (55.6%). Factors that were significantly associated with increased severity of LUTS included male sex (OR 2.75; 95% CI 1.59–4.75; p < 0.001), age above 49 years (OR 3.02; 95% CI 1.49–6.16; p = 0.002), ART use for over 10 years (OR 3.03; 95% CI 0.9–6.10; p = 0.021), and HIV stage IV (OR 2.42; 95% CI 0.9–3.4; p = 0.047). The majority of the study participants reported an above-average QoL, with only 9.7% of them reporting unhappy-terrible experiences with urinary symptoms. However, a statistically significant (p < 0.001) inverse correlation between QoL and the severity of LUTS was observed.ConclusionsIn light of these findings, policymakers and healthcare providers should integrate routine assessment and management of LUTS into the care protocols tailored for these high-risk groups. This proactive approach holds the potential to enhance the QoL and overall welfare of people living with HIV.

The Influence of Redcap in Improving the Quality of Data in Sickle Cell Medical Research Program: The Case of Sickle Cell Program at Muhimbili National Hospital

The study examined the influence of REDCap in improving the quality of data in sickle cell medical research program. The study used descriptive research design whereas both qualitative and quantitative approaches were used where a cross-sectional design was employed to collect information at one time in particular point. A total of 52 questionnaires with closed-ended questions were distributed. Primary data were collected through survey and in-depth interviews. Data were analyzed by using SPSS which simplified process of data analysis; the program identified the position of the variables and multiple regression analysis. The study found that there is effectiveness of REDCap in improving the quality of data in sickle cell medical research program in the sense that REDCap has effectively facilitated the collection of all necessary variables and essential information for research purposes. The study concluded that REDCap plays a significant role in improving the overall data quality in the context of sickle cell medical research programs. The study suggests that stringent quality control procedures should be implemented to ensure the accuracy and reliability of data input into the REDCap system. This recommendation underscores the importance of maintaining high standards in data management processes to enhance the credibility and validity of research outcomes in the field of sickle cell medical research.

Prevalence of methicillin and clindamycin resistant Staphylococcus species at a tertiary hospital in Tanzania: Implications for antibiotic stewardship and infection management

Methicillin and clindamycin resistance (constitutive and inducible) pose a common clinical challenge in treating Staphylococcal infections. This cross-sectional study, conducted at Muhimbili National Hospital (MNH) in Tanzania from April to June 2023, to assess the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and clindamycin-resistant Staphylococcus (S.) species by using a cefoxitin disk (30 μg) and the D-test method as per CLSI 2022 guidelines. Of the 361 clinical samples, 125 (34.6%) were culture-positive. Among Staphylococcus spp., S. aureus was 6% (12/125), while 33.6% (42/125) were coagulase-negative staphylococci (CoNS). Among the isolated S. aureus, 75% were resistant to methicillin, while 66.7% of the CoNS were resistant to methicillin. Further, 92% (11/12) of the S. aureus isolates were resistant to erythromycin, and 50% (6/12) were resistant to clindamycin. Among the CoNS, 83% (35/42) were resistant to erythromycin, and 52% (22/42) were resistant to clindamycin. The proportion of inducible macrolides lincosamide streptogramin B resistance (iMLSB), constitutive macrolides lincosamide streptogramin B resistance (cMLSB), and macrolides lincosamide streptgramin B methicillin susceptible (MS) phenotypes among S. aureus isolates was 16.7%, 41.7%, and 33.3%, respectively, and among CoNS was 19%, 35.7%, and 28.6%, respectively. The overall prevalence of iMLSB and cMLSB phenotypes was 18.5% (10/54) and 37% (20/54), respectively. Comparatively, MRSA had more resistance to ciprofloxacin than methicillin-susceptible S. aureus (MSSA) (88.9% vs. 33.3% p = 0.027), while methicillin-resistant coagulase-negative staphylococci (MR-CoNS) had significantly higher resistance to gentamicin (35.7% vs. 7.1% p= 0.005), and trimethoprim-sulfamethoxazole (78.6% vs. 50% p=0.007) than methicillin-susceptible coagulase-negative staphylococci (MS-CoNS). The high prevalence of methicillin and inducible clindamycin resistance in this study points out a potential rise in treatment failures, prolonged hospitalization, and limited treatment options. Thus, emphasizes the importance of antibiotic stewardship and laboratory-guided antibiotic decisions. To address the growing challenge of antibiotic resistance in Tanzania, it is advisable to implement stringent public health measures, including monitoring antibiotic usage, conducting educational initiatives, and raising awareness among patients and healthcare professionals.

Decision to delivery interval, maternal and fetal outcomes in emergency caesarean sections in a tertiary teaching hospital, Dar es salaam, Tanzania.

Emergency caesarean section (CS) answers the question on how soon the procedure should be performed. Maternal and fetal outcomes deteriorate when decision to delivery interval (DDI) exceeds 75 min. This study aimed at determining the DDI, Maternal and fetal outcomes in CS categories at Muhimbili National Hospital (MNH). A descriptive cross-sectional study involving 427 emergency CS at MNH was conducted from September to November, 2017. Data was extracted and analysed using SPSS version 23.0 where frequency, means, chi-square test and DDI were calculated to determine its association with categories of CS. The mean DDI for category one, two and three CS were 126.73, 133.57 and 160.08 min respectively. Only two (0.5%) and 54 (12.6%) of category one and two emergency CS met the recommended DDI of 30 and 75 min respectively. Maternal and fetal adverse outcome were increasing with increase in DDI. There was no significant association between DDI and adverse maternal outcome (OR: 1.2; 95% CI 0.49-2.83) and fetal outcome (OR: 1.7; 95% CI 0.91-3.38). The proportions of adverse maternal and fetal outcome were high when DDI was ≥ 75 min. Improving triage of the patients according to their urgency is crucial in reducing prolonged DDI.

Antibiotic use at a tertiary hospital in Tanzania: findings from a point prevalence survey

BackgroundIn Tanzania, data on antibiotic use at the patient level is scarce, and intervention measures to optimize antibiotic use and reduce antimicrobial resistance are rarely performed.ObjectivesTo describe antibiotic use at Muhimbili National Hospital.MethodsThis was a point prevalence survey on antibiotic use conducted at Muhimbili National Hospital in August-September 2022. The World Health Organization point prevalence survey data collection tool was used to collect patients’ information from the files. All patients admitted to the wards on the day of the survey were included.ResultsOverall, 47% (185/397) of admitted patients were on at least one antibiotic during the survey. All antibiotics prescribed were for empirical treatment and guideline compliance was low, at 45%. Of 185 patients who received antibiotics, the most common indication was community acquired infection (55%) and 36% had no documentation of the reasons for prescribing antibiotics. Almost 75% of the antibiotics were administered parenterally, with only 2% switching to oral route. Microbiological tests were performed in only 9 (5%) patients out of 185 and results were available for only one patient. Of all participants, 52% received two or more antibiotic in combination, with the combination ceftriaxone-metronidazole being most frequently prescribed, followed by the combination of ampicillin, cloxacillin, and gentamicin. For individual antibiotics, ceftriaxone was the most frequently prescribed antibiotic accounting for 28% (79/283), followed by metronidazole (24%) and amoxicillin-clavulanic acid (11%).ConclusionThe findings of a high prevalence of antibiotic use, inadequate use of bacterial culture, and frequent empiric antibiotic treatment suggests the need for strengthening diagnostic and antimicrobial stewardship programs. Furthermore, this study has identified areas for quality improvement, including education programs focusing on prescription practice.

Experience of nurses in the prevention of Ventilator-Associated Pneumonia among critically ill patients at Muhimbili National Hospital in Dar Es Salaam

Background: Ventilator-associated pneumonia (VAP) is one of the most common nosocomial infections that occur more than 48 hours after intubation and initiation of mechanical ventilation. It is associated with morbidity and mortality, increased health costs, and prolonged hospital stays. The estimated incidence of VAP globally is about 5-40% whereby in low and middle-income countries is about 47.9 per 1000 ventilator days. However, there is limited literature about VAP prevention in hospitals in Tanzania. Therefore this study aimed to explore nurses’ experience in the prevention of VAP. Methods: An exploratory descriptive study design was conducted with 15 nurses who were purposefully recruited from medical and surgical ICUs. A semi-structured interview guide consisting of main questions and probes was used to collect data. All interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic analytical approach. Results: Four main themes emerged; nurses’ roles in the prevention of VAP, nurses’ challenges toward care provision, nurses’ competency in implementing VAP prevention strategies, and enablers toward the implementation of VAP. The revealed prevention strategies were suctioning, early weaning, head of bed elevation of 30-45°, oral care, administration of medication, and implementation of IPC measures. The study has also revealed important barriers such are inadequate equipment, lack of VAP prevention protocols, shortage of staff, and inadequate knowledge. However, the major facilitators were responsible leadership, a quality control team, the availability of IPC guidelines, and individual motivation. Conclusion: This study provides insights into the experience of nurses in the prevention of VAP. Nurses face several challenges including a shortage of staff, shortage of equipment and supplies, lack of training, lack of VAP prevention protocols, and inadequate knowledge of VAP prevention. Despite these challenges nurses in their capacity are involved in VAP preventive measures. Keywords: Ventilator-associated pneumonia, strategies, experience, nurses, critically ill patients.

Critical illness at the emergency department of a Tanzanian national hospital in a three-year period 2019–2021

BackgroundCritically ill patients have life-threatening conditions requiring immediate vital organ function intervention. But, critical illness in the emergency department (ED) has not been comprehensively described in resource-limited settings. Understanding the characteristics and dynamics of critical illness can help hospitals prepare for and ensure the continuum of care for critically ill patients. This study aimed to describe the pattern and outcomes of critically ill patients at the ED of the National Hospital in Tanzania from 2019 to 2021.MethodologyThis hospital-records-based retrospective cohort study analyzed records of all patients who attended the ED of Muhimbili National Hospital between January 2019 and December 2021. Data extracted from the ED electronic database included clinical and demographic information, diagnoses, and outcome status at the ED. Critical illness in this study was defined as either a severe derangement of one or more vital signs measured at triage or the provision of critical care intervention. Data were analyzed using Stata 17 to examine critical illnesses’ burden, characteristics, first-listed diagnosis, and outcomes at the ED.ResultsAmong the 158,445 patients who visited the ED in the study period, 16,893 (10.7%) were critically ill. The burden of critical illness was 6,346 (10.3%) in 2019, 5,148 (10.9%) in 2020, and 5,400 (11.0%) in 2021. Respiratory (18.8%), cardiovascular (12.6%), infectious diseases (10.2%), and trauma (10.2%) were the leading causes of critical illness. Most (81.6%) of the critically ill patients presenting at the ED were admitted or transferred, of which 11% were admitted to the ICUs and 89% to general wards. Of the critically ill, 4.8% died at the ED.ConclusionMore than one in ten patients attending the Tanzanian National Hospital emergency department was critically ill. The number of critically ill patients did not increase during the pandemic. The majority were admitted to general hospital wards, and about one in twenty died at the ED. This study highlights the burden of critical illness faced by hospitals and the need to ensure the availability and quality of emergency and critical care throughout hospitals.

Evaluation of Dose Adjustment in Patients With Renal Impairment at Muhimbili National Hospital in Tanzania.

Background: The burden of renal diseases is increasing in developing countries like Tanzania. Drug accumulation exposes patients with renal impairment to drug toxicity that may lead to adverse drug reactions, poor adherence to treatment, and increased healthcare costs. There is limited information on the appropriateness of dosage regimen adjustment for patients with renal impairment, particularly in developing countries such as Tanzania. This study aimed to investigate the appropriateness of drug dosing in hospitalized patients with renal impairment in Tanzania. Methods: This was a retrospective cross-sectional study. It was conducted between November 2019 and April 2020 amongst hospitalized patients at Muhimbili National Hospital. All enrolled patients had serum creatinine levels ≥1.2 mg/dL and taking at least one drug requiring dosage regimen adjustment. Creatinine clearance was calculated from patient serum creatinine using the Cockcroft-Gault equation. Drug dosing appropriateness was determined by comparing the current practice with tertiary references. The relationship between the patient's baseline characteristics and the rate of dosage regimen adjustment was determined using the X2 test. Univariate and multivariate logistic regression analysis evaluated the predictors of dosing adjustment. Results: Most of the enrolled patients, 269 (98.9%) had comorbidities. Of the medication orders included in the final analysis, 372 (27%) needed dosage regimen adjustment. Out of the 372 medication orders, not adjusted were 168 (45.2%), inappropriately adjusted 105 (28.2%), and appropriately adjusted were only 99 (26.6%). In this study, 212 (77.9%) patients received at least one drug with an incorrect dosage regimen. Females and those with level 4 renal impairment patients were more likely to have their doses appropriately adjusted compared to their counterparts. Conclusions: In this study, about three-quarters of the patients received at least one drug with an incorrect dosage regimen. Thus, appropriate measures such as the availability of national guidelines and clinical decision support systems for drug dosing adjustment in patients' renal impairment should be in place.

Antenatal corticosteroid and early neonatal outcomes among preterm neonates delivered at a tertiary hospital in Tanzania.

Antenatal corticosteroids (ACS) have been proven to reduce prematurity-related neonatal complications and deaths. Tanzania introduced national ACS guidelines in 2015 with immediate adoption in tertiary facilities. This study aimed to assess the effect of ACS exposure among preterm neonates delivered at Muhimbili National Hospital. A cross-sectional study was conducted between August 2017 and January 2018, where 160 preterm neonates with their mothers were recruited and their data was collected. We used univariate and bivariate logistic regression analysis to determine associations between ACS exposure and adverse neonatal outcomes. ACS exposure significantly reduced the risk of respiratory distress syndrome (RDS) by 58% (COR=0.42, 95%, CI, 0.2-0.8, p <0.01) and neonatal death by 75%, (COR=0.25, 95%, CI, 0.1-0.8, p=0.01). There was no effect on neonatal sepsis or necrotizing enterocolitis. We conclude that exposure to ACS was significantly associated with reduced RDS and mortality among preterm neonates.

Factors influencing career preference in mental health among nursing students and intern nurses in Dar es Salaam, Tanzania.

Worldwide, the prevalence of mental health, neurological, and substance use (MNS) disorders has been on the rise and remains a significant leading cause of disease burden. Sub-Saharan Africa (SSA) shares a fair burden of MNS with depressive disorders being the most prevalent in this region. A huge treatment gap for MNS exists, with lack of appropriate human resources and expertise for service delivery being one of the key barriers. Pre-service and in-service training plays a vital role in developing human resource for mental health. However, low or lack of career interests in mental health has been documented among students. A cross-sectional study was conducted between April and May 2021 to determine factors influencing career preference in mental health among nursing students and intern nurses at Muhimbili University of Health and Allied Sciences (MUHAS) and Muhimbili National Hospital (MNH) respectively in Dar es Salaam, Tanzania. Sixty-eight (68) nursing students at MUHAS who had covered the mental health nursing course and 83 intern nurses who had rotated at the MNH Psychiatry and Mental Health department participated in the study using consecutive sampling. A pre-tested structured self-administered questionnaire was used to collect data, followed by analysis with version 25 of the Statistical Package for the Social Sciences. The Chi-square test and logistic regression were performed to determine factors associated with career preference. One third (33.1%; n = 50) of participants had career preference in mental health nursing. Living with a person with mental illness (adjusted odds ratio [AOR]: 4.350; 95% CI: 1.958, 9.664; p <0.001), awareness of possible career advancement in mental health (AOR: 16.193; 95% CI: 2.022, 129.653; p = 0.009), awareness of possible income generation in mental health career (AOR: 6.783; 95% CI: 2.295, 20.047; p = 0.001), and satisfaction with psychiatric working environment (AOR: 6.753; 95% CI: 2.900, 15.726; p <0.001), were significantly associated with career preference in mental health. Low mental health career preference among university nursing students and intern nurses jeopardizes the future of the mental health nursing profession and may complicate the already existing shortage of human resource for mental health. The higher learning institutions, health facilities, and the Ministry of Health may need to take deliberate actions to ensure that interest to pursue a career in mental health is built among students and interns. Further research is needed to provide more insight into how the psychiatric working environment affects career preference in mental health.