Infections that won’t go away

Here is why your diagnosis, treatment could be wrong

Kampala, Uganda | FLAVIA NASSAKA | Martin Muhangi often gets headache, fever, joint aches and sometimes stomach ache. He has been given medicine from hospital but the ailments persist. But the bank teller in Kampala is more frustrated because the doctors keep shifting his diagnosis.

When it started three months ago, he was diagnosed with a bacterial infection and was given a few packs of antibiotic tablets. He felt better by the next day but shortly after, the symptoms returned. Now his doctor says he has a bacterial infection and with a cannula on his wrist holds a pack of antibiotic Azithromycin and Panadol that he will have for the next five days. The doctor says his infection is at 91%.  This doesn’t make much sense to him.

After a previous test, the doctor said his reinfection could be a result of dirt and some things he keeps at home.  So he tidied up his apartment, putting away anything he thought put him at risk of infection.

Dr. Simon Kalyesubula, a scientist based at the National Public Health laboratories in Butabika says being diagnosed with one infection first and then another later could be a result of ‘secondary infection’; where a virus may initiate the process and then a bacterium follows.

He says both bacterial and viral infections tend to spread the same way and can present similar symptoms. Because of this he says doctors tend to treat them the same way yet they should be treated differently.  He says some bacteria do not need treatment because they multiply outside the body and are not harmful yet viruses multiply within the body.

Prof. Moses Joloba, the head of the Medical Microbiology Department at Makerere University College of Health Sciences says cases like Muhangi where ailments appear to fail to cure could  result from clinicians who diagnose an infection but do not know whether it is caused  by fungi, virus, or bacteria.

He says often when a patient arrives at a clinic with Muhangi’s symptoms, the first thing clinicians test for is malaria.  If treatment fails after that, they will test for typhoid, then brucella; a type of fever picked from contaminated milk or meat.

The trouble could also arise when the clinicians use crude testing methods which end up either giving a wrong result or a result that does not confirm how much disease a patient has to determine the required intervention.

He cites the widal test; a type of typhoid fever test which is still widely used in Uganda yet, according to him, it has been phased out in other countries because it is neither specific nor sensitive.

“They say its accuracy is at 75%,” says Joloba, “but just imagine if 25% of the population is given a wrong diagnosis. Do you know what can happen if they are to depend on that to treat people. Do you know how many people you will have given medicine for no good reason?” he said at a meeting held at the National Laboratories in Butabika on Aug.31. It was attended by senior physicians, microbiologists and pediatricians to discuss increasing reports of infections.

Topher Nuwagaba, a Laboratory Officer, at Ebenezer; a popular private lab in the city is familiar with wrong diagnosis based on the Widal test. He said laboratories are not fully supervised to see whether their machines are up to date.

He says many people whose treatment fails often turn up at his lab with a positive typhoid result based on the Widal test. He says, however, only 0.007% of the cases are confirmed for the disease when another test is used.

For him, while the country cannot afford up to date  technology that can offer better tests, there is need to urge those who use such methods as a widal test to always do a follow up test.

He says the timing of some tests could lead to a wrong result. He says, for example, the best time to conduct a blood culture should be around six days after the onset of the disease and 10 days for a stool culture. And even then, he says once a test is done, it is not always necessary to immediately recommend treatment.

Nuwagaba says it is easy for such misdiagnosis to go through without notice because there is no body in the country that tracks diagnostic errors.  He says the Allied Health Professionals Council that is mandated to supervise private facilities does not have capacity to oversee all of them.

He recommends that government inspects laboratories that have stool and blood culture facilities to ensure that their equipment is well maintained and calibrated.

‘Breeding resistance ‘

At the Ministry of Health, the Permanent Secretary Dr. Diana Atwiine says they are already looking for ways of curbing the increasing reports of misdiagnosed infections.

She says laboratory services in the country are underfunded to the extent that many facilities cannot do simple and accurate tests like blood culture which can easily detect infections spreading through the blood stream.

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) programme that was funding such tests at Regional Referral hospitals across the country stopped in 2016 leaving clinicians with one choice of using cheap rapid diagnosis tests.

Atwiine says microbiologists across the country have held meetings to discuss how to handle the problem; especially among children with febrile disease; an illness which appears to combine all illnesses and whose cause is unclear.  The idea is to come up with workable recommendations that can mitigate the situation.

As infections are continuously being treated unsuccessfully, she warns, doctors are also breeding antibiotic resistance as more pathogenic bacteria are now getting resistant. Recent studies done in Uganda have shown people are getting resistant to common antibiotics like Septrin, chloramphenicol, tetracycline, ampicillin, cefraxone, ciproflaxin and augumentin among others.  Atwiine says resistance is already causing a crisis in the developed world.