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Background  Regular monitoring of the levels of anti-malarial resistance of  Plasmodium falciparum  is an essential policy to adapt therapy and improve malaria control. This monitoring can be facilitated by using molecular tools, which are easier to implement than the classical determination of the resistance phenotype. In Cameroon, chloroquine (CQ), previously the first-line therapy for uncomplicated malaria was officially withdrawn in 2002 and replaced initially by amodiaquine (AQ) monotherapy. Then, artemisinin-based combination therapy (ACT), notably artesunate-amodiaquine (AS-AQ) or artemether-lumefantrine (AL), was gradually introduced in 2004. This situation raised the question of the evolution of  P. falciparum  resistance molecular markers in Yaoundé, a highly urbanized Cameroonian city.    Methods  The genotype of  pfcrt  72 and 76 and  pfmdr1  86 alleles and  pfmdr1  copy number were determined using real-time PCR in 447  P. falciparum  samples collected between 2005 and 2009.    Results  This study showed a high prevalence of parasites with mutant  pfcrt  76 (83%) and  pfmdr1  86 (93%) codons. On the contrary, no mutations in the  pfcrt  72 codon and no samples with duplication of the  pfmdr1  gene were observed.    Conclusion  The high prevalence of mutant  pfcrt  76T and  pfmdr1  86Y alleles might be due to the choice of alternative drugs (AQ and AS-AQ) known to select such genotypes. Mutant  pfcrt  72 codon was not detected despite the prolonged use of AQ either as monotherapy or combined with artesunate. The absence of  pfmdr1  multicopies suggests that AL would still remain efficient. The limited use of mefloquine or the predominance of mutant  pfmdr1  86Y codon could explain the lack of  pfmdr1  amplification. Indeed, this mutant codon is rarely associated with duplication of  pfmdr1  gene. In Cameroon, the changes of therapeutic strategies and the simultaneous use of several formulations of ACT or other anti-malarials that are not officially recommended result in a complex selective pressure, rendering the prediction of the evolution of  P. falciparum  resistance difficult. This public health problem should lead to increased vigilance and regular monitoring.

malaria journal

Molecular monitoring of plasmodium falciparum drug susceptibility at the time of the introduction of artemisinin-based combination therapy in Yaoundé, Cameroon: Implications for the future