Keywords
Aspergillus spp, Histoplasma , Antifungal Resistance , Prison inmates
-
Views
-
Downloads
How to cite this article
Afundi Jackson L, Njerawana S, Chebon S and Bii C. Spectrum and Antifungal Drug Resistance among Fungal Pathogens Isolated from Prison Inmates in Nairobi, Kenya [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1301 (https://doi.org/10.12688/f1000research.156469.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
Export Citation
Sciwheel
EndNote
Ref. Manager
Bibtex
ProCite
Sente
▬
✚
Research Article
Spectrum and Antifungal Drug Resistance among Fungal Pathogens Isolated from Prison Inmates in Nairobi, Kenya
[version 1; peer review: awaiting peer review]
PUBLISHED 30 Oct 2024
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
Larry Afundi Jackson
Competing interests:
No competing interests were disclosed.
Grant information:
The author(s) declared that no grants were involved in supporting this work.
Copyright:
© 2024 Afundi Jackson L et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Afundi Jackson L, Njerawana S, Chebon S and Bii C. Spectrum and Antifungal Drug Resistance among Fungal Pathogens Isolated from Prison Inmates in Nairobi, Kenya [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1301 (https://doi.org/10.12688/f1000research.156469.1)
First published: 30 Oct 2024, 13:1301 (https://doi.org/10.12688/f1000research.156469.1)
Latest published: 30 Oct 2024, 13:1301 (https://doi.org/10.12688/f1000research.156469.1)
Introduction
Human fungal infections are increasingly causing health and economic burdens at different echelons, including personal, community, national, and global levels.1–4 Despite growing concerns, fungal infections receive very little attention and resources, leading to a scarcity of quality data on fungal disease distribution and antifungal resistance patterns. Similarly, the exact burden of fungal diseases and antifungal resistance is limited; therefore, the response is undermined.5 Arising from this health concern, 19 fungal pathogens are grouped into three priority categories: critical, high-risk, and medium. The criteria for categorization are based on the average case fatality, number of new cases annually, complications and sequelae, and antifungal resistance. Among the species in the critical group and high category were Cryptococcus neoformans, Aspergllus fumigatus and Candida albicans in the critical group, and Histoplasma spp., Fusarium spp., and Candida glabrata in the high group species.5
Studies on the prevalence of fungal diseases affecting the pulmonary and urogenital systems of inmates in Kenyan prisons have rarely been documented. However, the prevalence of other infections has also been widely reported. Studies on the prevalence of respiratory diseases caused by fungal pathogens in Kenya’s prison system remain limited. Besides a study at Kamiti Maximum Prison on the prevalence of active pulmonary TB and another on modifiable factors associated with pulmonary TB in inmates from Nakuru Maximum prisons no study has been undertaken on fungal pathogens afflicting inmates in prisons.6,7
Histoplasma capsulatum and Cryptococcocus neoformans can cause pulmonary and urogenital infections.8,9 The two pathogens have not been elucidated in the two prisons, despite their unique and paradoxically neglected yet highly pathogenic nature. Histoplasma species are not endemic to tropical regions, such as Kenya. The prison microenvironment offers favorable conditions for the proliferation of fungal pathogens missed during routine microbiological diagnosis. Misdiagnosis and inappropriate prescription practices not only prolong illness, but also drive antimicrobial resistance. Furthermore, the management of fungal infections is still highly constrained by the narrow spectrum of antifungal classes of antifungal drugs and the pharmacological toxicity associated with some of these drugs.10 It is necessary to establish the spectrum and antifungal susceptibility of respiratory and urogenital fungal pathogens among prison inmates.
Urinary tract infections have been studied extensively in diverse communities and among different age groups, but they have not been fully explored in prison inmates, whose health is often neglected.1 Transmission of respiratory and urogenital infections is enhanced in crowded environments, such as schools, offices, hospitals, and prisons. Prisons worldwide often experience overcrowding, and Kenya is no exception. This situation, coupled with other factors such as delayed diagnosis, often makes prisons a prime area for the spread of respiratory and urogenital infections among inmates.11 The prison population has a high prevalence of serious, often life-threatening, infections. When prisoners are released back into the community, they carry back new and untreated infectious diseases that pose a threat to community health and add to the burden of disease in the community. Thus, there is compelling interest in society that this vulnerable group receives health protection and treatment for any ill health.12
Resistance to currently available antifungal agents can develop via acquired mechanisms following exposure to antifungal drugs. The findings of this study highlight the significance of fungal infections in prison that will guide relevant institutions in planning and policy development in such confined settings.
Study site
The study was conducted at a male maximum and female prison institution in Nairobi County. The Maximum prison has a capacity of 1400 prisoners but now houses 1800 and 2500 prisoners. Women’s prison is the largest in Kenya, with a capacity of 700 inmates. The two maximum prisons were selected purposely as the research site because of their geographical location, capacity, and proximity to the prison headquarters, allowing access to records as well as some key informants to participate in the study.
Study design
This was a cross-sectional study with laboratory investigation. Through purposive sampling, inmates with clinical symptoms of respiratory tract infections and UTI were recruited between January 2023 and March 2023. Sputum and urine samples were collected and shipped to the Mycology Division, Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI) for fungal investigations using standard protocols. The isolates were identified using macro-and microscopic features. Antifungal susceptibility was determined using the broth microdilution method. Sociodemographic information, diagnosis, and intervention were sought using the data collection tool from consenting prison inmates. The study population consisted of adolescent and adult men and women aged 18-76 years old who were crime suspects or convicts at the prison and presented with clinical manifestations of respiratory and urogenital infections.
Laboratory procedures
Fungal culture and identification
Sputum and urine samples were subjected to direct microscopy and cultured on Sabouraud dextrose agar supplemented with chloramphenicol (16 mg/ml). The inoculated SDA plates were incubated at 35°C for four weeks and examined daily for growth. Yeast isolates were differentiated using the CHROMagar® Candida and Dalmau techniques. Morphological features, such as hyphae, pseudohyphae, blastospores, chlamydospores, basidiospores, and sporangia, were noted.
Mold identification was performed using standard macroscopic features, such as colony growth rate, surface color, and reverse, texture, and diffusing pigments. Microscopic features of lactophenol cotton blue stain at ×40 magnification such as conidia, shape, and arrangement of phialides, were used. Clarus Histoplasma GM Enzyme Immunoassay (IMMY, Norman Oklahoma) was used to detect Histoplasma antigens in urine samples according to the manufacturer’s instructions.13 Titres of 1.0 EIA units were interpreted as positive for histoplasma antigen, whereas values less than 1.0 were interpreted as negative.
Antifungal resistance testing
The minimum inhibitory concentrations of fluconazole, itraconazole, and voriconazole were determined using the broth microdilution method.14 Briefly, 9.6 mg of azoles (Fluconazole, Itraconazole and Voriconazole) was dissolved in 3.0 ml of DMSO to get 1600 μg/ml (Sigma chemicals, USA) stock drug concentration while the required concentration was achieved with further dilution with RPMI. Briefly, the final dilution was achieved by serial dilution where 4.9 ml of RPMI was added to each of the ten tubes. Two hundred microlitres of the test concentration was dispensed into microtiter plates and inoculated with 10 μl of the 0.2 MacFarland concentration of inoculum. The plates were then incubated at 30°C for 72 h. The MIC values of all the drugs were determined visually as the lowest concentrations with no visible growth. The European Committee on Antimicrobial Susceptibility (EUCAST) drug-susceptible control strain ATCC 46645 was used for QC. Antifungal susceptibility was interpreted based on the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The results were interpreted based on the EUCAST breakpoints for itraconazole (resistant isolates: MIC > 1 mg/L) and voriconazole (resistant isolates: MIC > 2 mg/L). Eucast has no set break points for fluconazole; therefore, in this study, susceptibility testing to fluconazole was based on the Clinical and Laboratory Standard Institute M38-A2 protocol.15
Data management and analysis
Data were analyzed using SPSS software version 26. Chi-square test and multivariate logistic regression analysis were performed to investigate the correlation between the independent variables and the isolation of fungal isolates. Chi-square test analysis was applied to determine sociodemographic factors and variables associated with fungal infections in patients with respiratory and urogenital-like symptoms. Logistic regression was used to calculate the odds ratios (ORs) with 95% confidence. Statistical significance was set at p<0.05.
Ethics approval
The study’s Ethical approval was obtained from Institutional Ethics and Review Committee at Jomo Kenyatta University of Agriculture and Technology (Ref No: JKU/ISERC/02316/0735, 22nd September 2022), National Commission for Science Tech & Innovation (Ref No: 659559, 19th October 2022), Kenyatta National Hospital University of Nairobi Ethical Review Committee (Ref No: KNH-ERC/RR/14, 9th February 2023) and Kenya Prison Service (PRIS19/26 VOLII/167, 3rd October 2022).
Results
Prevalence of fungal etiological agents in the two prisons facilities
Of 162 samples investigated from the two prisons, 86 were sputa and 76 were urine samples. A total of 94 (58%) samples were positive for fungi, 19 (20%) for molds, and 75 (80%) for yeasts (Table 1). Of the 94 positive fungi, 7 (7.4%) tested positive for Aspergillus flavus and 5 (5.3%) were Aspergillus fumigatus. Histoplasma antibodies were detected in 5.3% of the samples. Aspergillus flavus was the predominant filamentous fungus isolated, as shown in Figure 1.
Table 1. Social demographic and clinical data of inmates who participated.
| Variable | Number examined N=162 | Positive fungal isolates N=94 | p value | ||
|---|---|---|---|---|---|
| Mould | Yeast | ||||
| Gender | Male | 94 | 12(13%) | 46(50%) | 1.00 |
| Female | 68 | 7(7%) | 75(79%) | ||
| Sample | Sputum | 86 | 19(20%) | 41(44%) | <0.001 |
| Urine | 76 | 0 | 34(36%) | ||
Figure 1. The spectrum of fungi isolated from prison institutions.
Antifungal susceptibility pattern of fungal isolates
Twelve isolates of Aspergillus fumigatus and Aspergillus flavus obtained from 162 patients were subjected to antifungal susceptibility testing. Only three (43%) Aspergillus flavus were resistant to itraconazole. Two (40%) isolates of Aspergillus fumigatus were resistant to itraconazole. All Aspergillus fumigatus and Aspergillus flavus isolates were susceptible to voriconazole (Table 2). Susceptibility to fluconazole indicated that all Aspergillus species were resistant to fluconazole.
Discussion
Findings from this study revealed an overall fungal prevalence among prison inmates of 58%, while the prevalence of Aspergillus flavus and Aspergillus fumigatus, was 7.4% and 5.3%, respectively. This finding indicates the significance of aspergillosis in confined settings, which may increase the burden of communicable diseases in the general population. These findings agree with a previous study reporting Aspergillus spp as the leading fungal pathogen among prisoners.16
Aspergillus flavus has been reported as an invasive Aspergillus species associated with clinical manifestations, such as cough, chest pain, fever, hemoptysis, weight loss, and dyspnea, observed in the participants enrolled in this study. These symptoms are consistent with those of previous studies and suggest further investigation of chronic pulmonary aspergillosis and co-infection with TB, bacteria, or other pathogens in confined settings.
Five (3.1%) samples tested positive for histoplasma antigen among the prison inmates, confirming the existence of histoplasmosis in Kenya and highlighting its possible role in pulmonary infections. Being the first study to report histoplasmosis infection among Kenyan prisons, this calls for lookout for this priority pathogen in confined settings. Previous studies in Nigeria reported a prevalence of histoplasmosis infection of 8.5%17 while in Uganda, the prevalence of histoplasma antigens was 1.2%.18 The distribution of fungal isolates based on sex and anatomical sites showed a significant difference between fungal pathogens and anatomical sites (P< 0.001). There was no association between fungal infections and sex. More fungal pathogens were likely to be isolated from respiratory sites than from urogenital sites. This finding is supported by previous studies that reported an association between fungal isolates and pulmonary related disease.19
Based on the EUCAST Antifungal Clinical Breakpoint for Aspergillus spp, voriconazole had the lowest MIC against all tested isolates. Aspergillus fumigatus and Aspergillus flavus showed susceptibility to voriconazole, with MICs<2.0 mg/L. A similar study by Sani et al.20 indicated that all fungal isolates were sensitive to voriconazole.
Some Aspergillus flavus (43%) and Aspergillus fumigatus (29%) isolates were resistant to itraconazole. However, the majority of the patients were susceptible to itraconazole. All Aspergillus species tested were resistant to fluconazole.
These findings are consistent with those of Sriramajayam et al.,21 who reported similar widespread antifungal resistance to itraconazole but good antifungal susceptibility to voriconazole.
The findings of this study clearly indicate the need for routine fungal culture and antifungal drug resistance surveillance to improve fungal diagnosis and treatment, particularly in confined settings.
Conclusion
This study highlights the presence of Histoplasma and other fungal infections associated with respiratory and urogenital infections in prison settings in Kenya. This study also demonstrated that voriconazole was the best antimycotic agent against fungal isolates, but with emerging resistance to itraconazole. We recommend investigation of all presumptive pulmonary TB patients to avoid misdiagnosis and inappropriate use of antibiotics. This calls for diagnostic capacity for fungal infections in prisons and the general population to reduce the burden of infections and antimicrobial resistance.
Ethics approval
The study’s Ethical approval was obtained from Institutional Ethics and Review Committee at Jomo Kenyatta University of Agriculture and Technology (Ref No: JKU/ISERC/02316/0735, 22nd September 2022),National Commission for Science Tech & Innovation (Ref No: 659559, 19th October 2022) Kenyatta National Hospital University of Nairobi Ethical Review Committee (Ref No: KNH-ERC/RR/14, 9th February 2023) and Kenya Prison Service (PRIS19/26 VOLII/167, 3rd October 2022).
Download
Export To
metrics
| Views | Downloads | |
|---|---|---|
| F1000Research | - | - |
|
PubMed Central
Data from PMC are received and updated monthly.
|
- | - |
Citations
CITE
how to cite this article
Afundi Jackson L, Njerawana S, Chebon S and Bii C. Spectrum and Antifungal Drug Resistance among Fungal Pathogens Isolated from Prison Inmates in Nairobi, Kenya [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:1301 (https://doi.org/10.12688/f1000research.156469.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.
Open Peer Review
Current Reviewer Status:
AWAITING PEER REVIEW
AWAITING PEER REVIEW
Key to Reviewer Statuses
VIEW
HIDE
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Comments on this article Comments (0)