In sub-Saharan Africa, the burden of typhoid fever, caused by Salmonella enterica serovar Typhi, remains largely unknown, in part because of a lack of blood or bone marrow culture facilities. We characterized a total of 323 S. Typhi isolates from outbreaks in Kenya over the period 1988 to 2008 for antimicrobial susceptibilities and phylogenetic relationships using single-nucleotide polymorphism (SNP) analysis. There was a dramatic increase in the number and percentage of multidrug-resistant (MDR) S. Typhi isolates over the study period. Overall, only 54 (16.7%) S. Typhi isolates were fully sensitive, while the majority, 195 (60.4%), were multiply resistant to most commonly available drugs-ampicillin, chloramphenicol, tetracycline, and cotrimoxazole; 74 (22.9%) isolates were resistant to a single antimicrobial, usually ampicillin, cotrimoxazole, or tetracycline. Resistance to these antibiotics was encoded on self-transferrable IncHI1 plasmids of the ST6 sequence type. Of the 94 representative S. Typhi isolates selected for genome-wide haplotype analysis, sensitive isolates fell into several phylogenetically different groups, whereas MDR isolates all belonged to a single haplotype, H58, associated with MDR and decreased ciprofloxacin susceptibility, which is also dominant in many parts of Southeast Asia. Derivatives of the same S. Typhi lineage, H58, are responsible for multidrug resistance in Kenya and parts of Southeast Asia, suggesting intercontinental spread of a single MDR clone. Given the emergence of this aggressive MDR haplotype, careful selection and monitoring of antibiotic usage will be required in Kenya, and potentially other regions of sub-Saharan Africa.

BackgroundKenya has implemented the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme to facilitate quality improvement in medical laboratories and to support national accreditation goals. Continuous quality improvement after SLMTA completion is needed to ensure sustainability and continue progress toward accreditation.MethodsAudits were conducted by qualified, independent auditors to assess the performance of five enrolled laboratories using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. End-of-programme (exit) and one year post-programme (surveillance) audits were compared for overall score, star level (from zero to five, based on scores) and scores for each of the 12 Quality System Essential (QSE) areas that make up the SLIPTA checklist.ResultsAll laboratories improved from exit to surveillance audit (median improvement 38 percentage points, range 5–45 percentage points). Two laboratories improved from zero to one star, two improved from zero to three stars and one laboratory improved from three to four stars. The lowest median QSE scores at exit were: internal audit; corrective action; and occurrence management and process improvement (< 20%). Each of the 12 QSEs improved substantially at surveillance audit, with the greatest improvement in client management and customer service, internal audit and information management (≥ 50 percentage points). The two laboratories with the greatest overall improvement focused heavily on the internal audit and corrective action QSEs.ConclusionWhilst all laboratories improved from exit to surveillance audit, those that focused on the internal audit and corrective action QSEs improved substantially more than those that did not; internal audits and corrective actions may have acted as catalysts, leading to improvements in other QSEs. Systematic identification of core areas and best practices to address them is a critical step toward strengthening public medical laboratories.

Background: Typhoid fever is a global health problem. The World Health Organization (WHO) estimates that the current annual global burden of typhoid is approximately 22 million new cases, 5% of which are fatal. Methodology: To assess the trends in antibiotic resistance in 100 Salmonella enterica serovar Typhi strains were isolated from the blood of patients in Nairobi, Kenya, from 2004 to 2006. All isolates were tested against ampicilin, chloramphenic, nalidixic acid, ciprofloxacin, cotrimoxazole, cefuroxime, cefriaxone, amoxycillin/clavulanic acid, tetracycline and gentamycin. Susceptibility and resistance were determined using MIC and disk diffusion tests. Results: From 2004 to 2006 a total of 100 strains were studied; 70% of the isolates were multidrug resistant (MDR) while 15% of the isolates were sensitive to all drugs tested. Of 13 isolates that were resistant to ciprofloxacin and nalidixic acid by disk diffusion, 11 had an MIC of 0. 25 µg/ml while two isolates had an MIC of 1.00 µg,/ml. Resistance in ampicillin decreased from  88% in 2004 to 64% in 2005; this increased to 76% in 2006. Similar trends were observed for four other antibiotics tested. Conclusion: The prescription of first-line antibiotics used in the treatment of S. Typhi should be stopped temporarily. Drugs such as cipfloxacin would be useful in the treatment of typhoid caused by MDR S. Typhi. There is need to monitor the resistance in flouroquinolones as resistance to these drugs has been observed and they are the current drugs used to treat typhoid.