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author:("desimone, Charles O")
1.  Adherence to treatment guidelines for uncomplicated malaria at two public health facilities in Nigeria; Implications for the ‘test and treat’ policy of malaria case management 
Adherence to treatment guidelines for uncomplicated malaria is critical to the success of malaria case management. Poor adherence has implications for increased malaria burden, in view of the risk of widespread parasite resistance and treatment failures. This study analyzed the diagnostic and prescription pattern for uncomplicated malaria at two public health facilities, south east Nigeria, to assess the current state of compliance to policy guidelines on the use of artemisinin-based combination therapy (ACT).
Retrospective audit of patients’ records, treated for uncomplicated malaria, between the months of January and March 2013, was undertaken at two public health facilities. Demographics, diagnostic information, medication and cost data were extracted. Questionnaires were distributed to providers to assess their malaria treatment intent. Data from the facilities were analyzed and compared for similarities and systematic differences, and conformity to malaria treatment policy, in terms of laboratory diagnosis, use of ACT, co-medication and cost of medication.
A total of 2,171 records of patients who had been treated for uncomplicated malaria were analyzed. Of these, 1066 (49%) were sent for laboratory confirmation of malaria using mostly microscopy, out of which 480 (45%) tested positive. 51% (1105) of the prescriptions was on the basis of presumptive treatment. 58% of slide negative results received antimalarial drugs. 93% of patients received ACT, with artemether-lumefantrin, AL (50.5%) as the most prescribed antimalarial drug. Monotherapy accounted for 7% of prescriptions, comprising mostly sulphadoxine + pyrimethamine, SP (46.5%) and monotherapy artemisinin, AS (29.2%). 97% of the prescriptions received at least one co-medication. Antibiotics were prescribed to 50% of patients. Overall, median cost of medication was N1160.00 (US$7.48 (US$0.19 - 267.87) per case, higher in tertiary than the secondary facility. There were significant variations in treatment practices between the two facilities.
Evidence suggests good compliance to policy on the use of ACT as first line treatment for uncomplicated malaria. However, there exists significant scope for improved diagnosis and rational drug use, to enhance accuracy of treatment, reduced wastages and risks of adverse drug reactions, in line with the goals of ‘test and treat’ policy of malaria case management.
PMCID: PMC4363460  PMID: 25838917
Uncomplicated malaria; Treatment guidelines; Policy adherence; Antimalarial drugs; Prescription practices; Health facility; Nigeria
2.  Efficacy and Safety Assessment of T. Angelica Herbal Tonic, a Phytomedicinal Product Popularly Used in Nigeria 
T. Angelica Herbal Tonic (TAHT) is a herbal product indicated for indigestion and constipation and highly patronized in Nigeria. In this study, the efficacy and safety of the herbal tonic in relation to the label claims were assessed. The effect on peristalsis in mice was evaluated by the charcoal meal model and in vitro using guinea pig ileum. The effects of TAHT on behavior, fertility, birth and organ weights were also determined. Teratogenic potential and reproductive toxicity were studied in pregnant rats. Acute toxicity studies showed that at doses above 5000 mg kg−1, the herbal tonic did not cause lethality and produced no signs of intoxication in mice. The study did not show any gross behavioral changes in mice treated with 1000 mg kg−1 of TAHT as compared with the negative control treatment. TAHT (400 mg kg−1) exhibited a dose-dependent enhancement in the gastrointestinal tract motility in mice when compared with the negative control. At concentrations up to 300 μg mL−1, TAHT did not cause any significant effect on acetylcholine, histamine and nicotine-evoked contractions of guinea pig ileum preparation. It took an average of 31.25 ± 4.52 days for the TAHT-treated animals to litter, which is significantly (P < .05) different from the 55 ± 4.51 days recorded for the control treatment group. TAHT exhibited a modest fertility-promoting effect and showed lack of abortifacient and teratogenic properties in the study. Generally, the results of this study showed some favorable pharmacological effects of TAHT in animals which may authenticate some of the label claims.
PMCID: PMC3094697  PMID: 19812180
3.  Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy 
Malaria Journal  2014;13:243.
Malaria treatment policy recommends regular monitoring of drug utilization to generate information for ensuring effective use of anti-malarial drugs in Nigeria. This information is currently limited in the retail sector which constitutes a major source of malaria treatment in Nigeria, but are characterized by significant inappropriate use of drugs. This study analyzed the use pattern of anti-malarial drugs in medicine outlets to assess the current state of compliance to policy on the use of artemisinin-based combination therapy (ACT).
A prospective cross-sectional survey of randomly selected medicine outlets in Enugu urban, southeast Nigeria, was conducted between May and August 2013, to determine the types, range, prices, and use pattern of anti-malarial drugs dispensed from pharmacies and patent medicine vendors (PMVs). Data were collected and analyzed for anti-malarial drugs dispensed for self-medication to patients, treatment by retail outlets and prescription from hospitals.
A total of 1,321 anti-malarial drugs prescriptions were analyzed. ACT accounted for 72.7%, while monotherapy was 27.3%. Affordable Medicines Facility-malaria (AMFm) drugs contributed 33.9% (326/961) of ACT. Artemether-lumefantrine (AL), 668 (50.6%) was the most used anti-malarial drug, followed by monotherapy sulphadoxine-pyrimethamine (SP), 248 (18.8%). Median cost of ACT at $2.91 ($0.65-7.42) per dose, is about three times the median cost of monotherapy, $0.97 ($0.19-13.55). Total cost of medication (including co-medications) with ACT averaged $3.64 (95% CI; $3.53-3.75) per prescription, about twice the mean cost of treatment with monotherapy, $1.83 (95% CI; $1.57-2.1). Highest proportion 46.5% (614), of the anti-malarial drugs was dispensed to patients for self-treatment. Treatment by retail outlets accounted for 35.8% while 17.7% of the drugs were dispensed from hospital prescriptions. Self-medication, 82%, accounted for the highest source of monotherapy and a majority of prescriptions, 85.6%, was adults.
Findings suggest vastly improved use of ACT in the retail sector after eight years of policy change, with significant contributions from AMFm drugs. However the use of monotherapy, particularly through self-medication remains significant with increasing risk of undermining treatment policy, suggesting additional measures to directly target consumers and providers in the sector for improved use of anti-malarial drugs in Nigeria.
PMCID: PMC4079827  PMID: 24961280
Anti-malarial drugs; Utilization pattern; Artemisinin-based combination therapy; Private retail sector; Affordable Medicines Facility-malaria
4.  The utility of self-emulsifying oil formulation to improve the poor solubility of the anti HIV drug CSIC 
CSIC (5-chloro-3-phenylsulfonylindole-2-carboxamide), a non-nucleoside reverse transcriptase inhibitor (NNRTI) has not been advanced as a therapeutic anti-HIV candidate drug due to its low aqueous solubility and poor bioavailability.
The objective of this work was to formulate CSIC into self-emulsifying oil formulations for the purpose of improving its aqueous solubility and evaluating in vitro antiretroviral activity.
CSIC self-emulsifying oil formulations (SEFs) were formulated and evaluated for droplet size, zeta potential, polydispersity index (PDI), viscosity, emulsification time, stability and bioactivity.
Results showed significantly improved solubility of CSIC in the SEFs.The concentration of co-surfactant affected the droplet size, zeta potential and polydispersity index. In vitro bioactivity studies showed that the CSIC SEFs retained full anti-HIV activity.
The in vitro data from this first attempt to formulate CSIC SEFs suggest that improvement on the aqueous solubility of CSIC through this delivery system may accentuate its antiretroviral effectiveness in vivo via bioavailability enhancement. The formulation is therefore intended as an oral anti-HIV agent for prophylactic and therapeutic uses.
PMCID: PMC3680009  PMID: 23721408
Anti-HIV; Poorly soluble; Self-emulsification; CSIC; Bioactivity; Anhydrous emulsion
5.  First description of Escherichia coli producing CTX-M-15- extended spectrum beta lactamase (ESBL) in out-patients from south eastern Nigeria 
We studied the presence of extended spectrum beta lactamases (ESBLs) in 44 clinical isolates of Escherichia coli collected from out-patients in two university teaching hospitals in South-Eastern Nigeria. Species identification was performed by standard microbiology methods and re-confirmed by MALDI-TOF technology. Phenotypic characterization of ESBL enzymes was done by double disc synergy test and presence of ESBL genes was determined by specific PCR followed by sequencing. Transfer of plasmid DNA was carried out by transformation using E. coli DH5 as recipient strain. Phenotypic characterization identified all isolates to be ESBL positive. 77% of strains were from urine, 13.6% from vaginal swabs and 9.0% from wound swabs. 63.6% were from female patients, 68% were from outpatients and 95.5% from patients younger than 30 years. All ESBL producers were positive in a PCR for blaCTX-M-1 cluster, in exemplary strains blaCTX-M-15 was found by sequencing. In all strains ISEcp1 was found upstream and ORF477 downstream of blaCTX-M. PCR for blaTEM and blaOXA-1 was positive in 93.1% of strains, whereas blaSHV was not detected, aac(6′)-Ib-cr was found in 97.7% of strains. RAPD analysis revealed seven different clonal groups named A through G with the majority of the strains (65.9%) belonging to clone A. Transfer of an ESBL plasmid with co-resistance to gentamicin, kanamycin, tobramycin, doxycycline and trimethropim-sulfamethoxazole was successful in 19 (43.2%) strains. This study showed a high rate of CTX-M-1 cluster - ESBLs in South-Eastern Nigeria and further confirms the worldwide spread of CTX-M ESBL in clinical isolates.
PMCID: PMC3473344  PMID: 22824236
Outpatients; ESBL; CTX-M; Escherichia coli
6.  Antimicrobial resistance status and prevalence rates of extended spectrum beta-lactamase producers isolated from a mixed human population 
Owing to the increasing epidemiological and therapeutic challenges associated with infections due to ESBL producers, ESBL prevalence rate among some bacteria isolates from healthy and non-healthy human population in a metropolitan Nigerian setting was evaluated.
A total of one hundred and forty-five (145) bacteria strains were isolated from a total of four hundred and sixty (460) samples collected from urine, wound, throat and anal swabs of 220 healthy volunteers in the community and from 240 patients in 2 secondary and 2 tertiary hospitals (altogether, 4) in Enugu metropolis. The presumptive confirmatory test used for ESBL detection was the Double Disc Synergy Test (DDST) method. Conjugation and plasmid curing studies were also done for resistance factor determination.
Of the 145 isolates, 20 were ESBL producers with 35% of these ESBL producers being of community origin and 65% from hospitals. This translates to 4.8% and 9% incidences (comparably higher than established prevalence of 4.4% and 7.5 respectively) for community and hospital infections respectively. The ESBL isolates showed high resistance to tetracycline, gentamicin, pefloxacin, ceftriaxone, cefuroxime, ciprofloxacin and Augmentin® (Amoxicilin and clavulanic acid combination). Conjugation studies for Resistance plasmid transfer showed non-transference of resistance determinants between the ESBL transconjugants and recipient strains. Correspondingly, the plasmid curing studies revealed that the acridine orange could not effect a cure on the isolates as they still retained high resistance to the antibiotics after the treatment.
This study confirms the growing incidences/pool of ESBL strains in Nigeria and call for widespread and continuous monitoring towards an effective management of the potential therapeutic hurdle posed by this trend.
PMCID: PMC4362596  PMID: 21619555
Enterobacteriaceae; Pseudomonas aeruginosa; extended spectrum beta lactamase (ESBL); antibiotics; resistance plasmid; conjugation

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