title: Increased prevalence of the pfdhfr/phdhps quintuple mutant and rapid emergence of pfdhps resistance mutations at codons 581 and 613 in Kisumu, Kenya.
abstract: BACKGROUND
  Anti-malarial drug resistance in Kenya prompted two drug policy changes within a decade: sulphadoxine-pyrimethamine (SP) replaced chloroquine (CQ) as the first-line anti-malarial in 1998 and artemether-lumefantrine (AL) replaced SP in 2004. Two cross-sectional studies were conducted to monitor changes in the prevalence of molecular markers of drug resistance over the period in which SP was used as the first-line anti-malarial. The baseline study was carried out from 1999-2000, shortly after implementation of SP, and the follow-up study occurred from 2003-2005, during the transition to AL.
  
  
  METHODS
  Blood was collected from malaria smear-positive, symptomatic patients presenting to outpatient centers in Kisumu, Kenya, during the baseline and follow-up studies. Isolates were genotyped at codons associated with SP and CQ resistance. In vitro IC50 values for antifolates and quinolones were determined for isolates from the follow-up study.
  
  
  RESULTS
  The prevalence of isolates containing the pfdhfr N51I/C59R/S108N/pfdhps A437G/K540E quintuple mutant associated with SP-resistance rose from 21% in the baseline study to 53% in the follow-up study (p < 0.001). Isolates containing the pfdhfr I164L mutation were absent from both studies. The pfdhps mutations A581G and A613S/T were absent from the baseline study but were present in 85% and 61%, respectively, of isolates from the follow-up study. At follow-up, parasites with mutations at five pfdhps codons, 436, 437, 540, 581, and 613, accounted for 39% of isolates. The CQ resistance-associated mutations pfcrt K76T and pfmdr1 N86Y rose from 82% to 97% (p = 0.001) and 44% to 76% (p < 0.001), respectively, from baseline to follow-up.
  
  
  CONCLUSIONS
  During the period in which SP was the first-line anti-malarial in Kenya, highly SP-resistant parasites emerged, including isolates harboring pfdhps mutations not previously observed there. SP continues to be widely used in Kenya; however, given the highly resistant genotypes observed in this study, its use as a first-line anti-malarial should be discouraged, particularly for populations without acquired immunity to malaria. The increase in the pfcrt K76T prevalence, despite efforts to reduce CQ use, suggests that either these efforts are not adequate to alleviate CQ pressure in Kisumu, or that drug pressure is derived from another source, such as the second-line anti-malarial amodiaquine.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
authors.forename: Maroya D
authors.initials: MD
authors.lastname: Spalding
authors.forename: Fredrick L
authors.initials: FL
authors.lastname: Eyase
authors.forename: Hoseah M
authors.initials: HM
authors.lastname: Akala
authors.forename: Sheryl A
authors.initials: SA
authors.lastname: Bedno
authors.forename: Sean T
authors.initials: ST
authors.lastname: Prigge
authors.forename: Rodney L
authors.initials: RL
authors.lastname: Coldren
authors.forename: William J
authors.initials: WJ
authors.lastname: Moss
authors.forename: Norman C
authors.initials: NC
authors.lastname: Waters
mesh_terms: D000962:Antimalarials / Q000494:pharmacology*; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins / Q000494:pharmacology / Q000627:therapeutic use; D002738:Chloroquine / Q000494:pharmacology / Q000627:therapeutic use; D003062:Codon; D003430:Cross-Sectional Studies; D004094:Dihydropteroate Synthase / Q000235:genetics*; D004338:Drug Combinations; D004351:Drug Resistance; D004983:Ethanolamines / Q000494:pharmacology / Q000627:therapeutic use; D005449:Fluorenes / Q000494:pharmacology / Q000627:therapeutic use; D005493:Folic Acid Antagonists / Q000494:pharmacology; D005838:Genotype; D006801:Humans; D020128:Inhibitory Concentration 50; D007630:Kenya; D008288:Malaria / Q000188:drug therapy / Q000469:parasitology*; D020125:Mutation, Missense; D021261:Parasitic Sensitivity Tests; D010961:Plasmodium / Q000187:drug effects / Q000235:genetics* / Q000302:isolation & purification; D015995:Prevalence; D015800:Protozoan Proteins / Q000235:genetics; D011739:Pyrimethamine / Q000494:pharmacology / Q000627:therapeutic use; D015363:Quinolones / Q000494:pharmacology; D013413:Sulfadoxine / Q000494:pharmacology / Q000627:therapeutic use; D013762:Tetrahydrofolate Dehydrogenase / Q000235:genetics*
chemical_list: D000962:Antimalarials; D000077611:Artemether, Lumefantrine Drug Combination; D037621:Artemisinins; D003062:Codon; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes; D005493:Folic Acid Antagonists; D015800:Protozoan Proteins; D015363:Quinolones; C001205:fanasil, pyrimethamine drug combination; D013413:Sulfadoxine; D002738:Chloroquine; D013762:Tetrahydrofolate Dehydrogenase; D004094:Dihydropteroate Synthase; D011739:Pyrimethamine