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Background  In 2004, in response to high levels of treatment failure associated with sulfadoxine-pyrimethamine (SP) resistance, Benin changed its first-line malaria treatment from SP to artemisinin-based combination therapy for treatment of uncomplicated  Plasmodium falciparum  malaria. Resistance to SP is conferred by accumulation of single nucleotide polymorphisms (SNPs) in  P. falciparum  genes involved in folate metabolism,  dihydrofolate reductase (Pfdhfr)  and  dihydropteroate synthase (Pfdhps) , targeted by pyrimethamine and sulfadoxine, respectively. Because SP is still used for intermittent preventive treatment in pregnant women (IPTp) and seasonal malaria chemoprevention (SMCP) in Benin, the prevalence of  Pfdhfr  and  Pfdhps  SNPs in  P. falciparum  isolates collected in 2017 were investigated.    Methods  This study was carried out in two sites where the transmission of  P. falciparum  malaria is hyper-endemic: Klouékanmey and Djougou. Blood samples were collected from 178 febrile children 6–59 months old with confirmed uncomplicated  P. falciparum  malaria and were genotyped for SNPs associated with SP resistance.    Results  The  Pfdhfr  triple mutant  IRN  (N51 I , C59 R , and S108 N ) was the most prevalent (84.6%) haplotype and was commonly found with the  Pfdhps  single mutant A437 G  (50.5%) or with the  Pfdhps  double mutant S436 A  and A437 G  (33.7%). The quintuple mutant,  Pfdhfr   IRN / Pfdhps   GE  (A437 G  and K540 E ), was rarely observed (0.8%). The A581 G  and A613 S  mutant alleles were found in 2.6 and 3.9% of isolates, respectively. Six isolates (3.9%) were shown to harbour a mutation at codon I431 V , recently identified in West African parasites.    Conclusions  This study showed that  Pfdhfr  triple  IRN  mutants are near fixation in this population and that the highly sulfadoxine-resistant  Pfdhps  alleles are not widespread in Benin. These data support the continued use of SP for chemoprevention in these study sites, which should be complemented by periodic nationwide molecular surveillance to detect emergence of resistant genotypes.

Low prevalence of highly sulfadoxine‐resistant dihydropteroate synthase alleles in Plasmodium falciparum isolates in Benin