51
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Solomon AW, Hooper PJ, Bangert M, Mwingira UJ, Bakhtiari A, Brady MA, Fitzpatrick C, Jones I, Kabona G, Kello AB, Millar T, Mosher AW, Ngondi JM, Nshala A, Renneker K, Rotondo LA, Stelmach R, Harding-Esch EM, Malecela MN. The Importance of Failure: How Doing Impact Surveys That Fail Saves Trachoma Programs Money. Am J Trop Med Hyg 2020; 103:2481-2487. [PMID: 33025878 PMCID: PMC7695084 DOI: 10.4269/ajtmh.20-0686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Trachoma programs use annual antibiotic mass drug administration (MDA) in evaluation units (EUs) that generally encompass 100,000–250,000 people. After one, three, or five MDA rounds, programs undertake impact surveys. Where impact survey prevalence of trachomatous inflammation—follicular (TF) in 1- to 9-year-olds is ≥ 5%, ≥ 1 additional MDA rounds are recommended before resurvey. Impact survey costs, and the proportion of impact surveys returning TF prevalence ≥ 5% (the failure rate or, less pejoratively, the MDA continuation rate), therefore influence the cost of eliminating trachoma. We modeled, for illustrative EU sizes, the financial cost of undertaking MDA with and without conducting impact surveys. As an example, we retrospectively assessed how conducting impact surveys affected costs in the United Republic of Tanzania for 2017–2018. For EUs containing 100,000 people, the median (interquartile range) cost of continuing MDA without doing impact surveys is USD 28,957 (17,581–36,197) per EU per year, whereas continuing MDA solely where indicated by impact survey results costs USD 17,564 (12,158–21,694). If the mean EU population is 100,000, then continuing MDA without impact surveys becomes advantageous in financial cost terms only when the continuation rate exceeds 71%. For the United Republic of Tanzania in 2017–2018, doing impact surveys saved enough money to provide MDA for > 1,000,000 people. Although trachoma impact surveys have a nontrivial cost, they generally save money, providing EUs have > 50,000 inhabitants, the continuation rate is not excessive, and they generate reliable data. If all EUs pass their impact surveys, then we have waited too long to do them.
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Affiliation(s)
- Anthony W Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Pamela J Hooper
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | - Mathieu Bangert
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Upendo J Mwingira
- Neglected Tropical Disease Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - Ana Bakhtiari
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | | | - Christopher Fitzpatrick
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Iain Jones
- Sightsavers, Haywards Heath, United Kingdom
| | - George Kabona
- Neglected Tropical Disease Control Program, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, United Republic of Tanzania
| | - Amir B Kello
- Expanded Special Project for Elimination of Neglected Tropical Diseases, World Health Organization Regional Office for Africa, Brazzaville, Congo
| | - Tom Millar
- Sightsavers, Haywards Heath, United Kingdom
| | - Aryc W Mosher
- United States Agency for International Development, Washington, District of Columbia
| | | | - Andreas Nshala
- Department of International Maternal and Child Health, Faculty of Medicine and Pharmacy, University of Uppsala, Uppsala, Sweden.,IMA World Health, Dar es Salaam, United Republic of Tanzania
| | - Kristen Renneker
- Task Force for Global Health, International Trachoma Initiative, Atlanta, Georgia
| | | | | | - Emma M Harding-Esch
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mwelecele N Malecela
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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52
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Varghese GM. The Search for Effective Empiric Therapy for Acute Undifferentiated Febrile Illness. Clin Infect Dis 2020; 73:e1487-e1488. [PMID: 32991696 DOI: 10.1093/cid/ciaa1490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- George M Varghese
- Department of Infectious Diseases, Christian Medical College, Vellore, India
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53
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Schwartz DJ, Langdon AE, Dantas G. Understanding the impact of antibiotic perturbation on the human microbiome. Genome Med 2020; 12:82. [PMID: 32988391 PMCID: PMC7523053 DOI: 10.1186/s13073-020-00782-x] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 09/11/2020] [Indexed: 02/08/2023] Open
Abstract
The human gut microbiome is a dynamic collection of bacteria, archaea, fungi, and viruses that performs essential functions for immune development, pathogen colonization resistance, and food metabolism. Perturbation of the gut microbiome's ecological balance, commonly by antibiotics, can cause and exacerbate diseases. To predict and successfully rescue such perturbations, first, we must understand the underlying taxonomic and functional dynamics of the microbiome as it changes throughout infancy, childhood, and adulthood. We offer an overview of the healthy gut bacterial architecture over these life stages and comment on vulnerability to short and long courses of antibiotics. Second, the resilience of the microbiome after antibiotic perturbation depends on key characteristics, such as the nature, timing, duration, and spectrum of a course of antibiotics, as well as microbiome modulatory factors such as age, travel, underlying illness, antibiotic resistance pattern, and diet. In this review, we discuss acute and chronic antibiotic perturbations to the microbiome and resistome in the context of microbiome stability and dynamics. We specifically discuss key taxonomic and resistance gene changes that accompany antibiotic treatment of neonates, children, and adults. Restoration of a healthy gut microbial ecosystem after routine antibiotics will require rationally managed exposure to specific antibiotics and microbes. To that end, we review the use of fecal microbiota transplantation and probiotics to direct recolonization of the gut ecosystem. We conclude with our perspectives on how best to assess, predict, and aid recovery of the microbiome after antibiotic perturbation.
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Affiliation(s)
- D. J. Schwartz
- Department of Pediatrics, Division of Infectious Diseases, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - A. E. Langdon
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
| | - G. Dantas
- The Edison Family Center for Genome Sciences & Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63110 USA
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110 USA
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54
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O’Brien KS, Arzika AM, Maliki R, Manzo F, Mamkara AK, Lebas E, Cook C, Bailey RL, West SK, Oldenburg CE, Porco TC, Arnold B, Keenan JD, Lietman TM. Biannual azithromycin distribution and child mortality among malnourished children: A subgroup analysis of the MORDOR cluster-randomized trial in Niger. PLoS Med 2020; 17:e1003285. [PMID: 32931496 PMCID: PMC7491708 DOI: 10.1371/journal.pmed.1003285] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status. METHODS AND FINDINGS A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level. CONCLUSIONS Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted. TRIAL REGISTRATION The MORDOR trial is registered at clinicaltrials.gov NCT02047981.
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Affiliation(s)
- Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Division of Epidemiology, School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
| | | | | | | | | | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Catherine Cook
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Robin L. Bailey
- Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheila K. West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
| | - Benjamin Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California, United States of America
- Department of Ophthalmology, University of California, San Francisco, California, United States of America
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
- Institute for Global Health Sciences, University of California, San Francisco, California, United States of America
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55
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Gladstone RA, Bojang E, Hart J, Harding-Esch EM, Mabey D, Sillah A, Bailey RL, Burr SE, Roca A, Bentley SD, Holland MJ. Mass drug administration with azithromycin for trachoma elimination and the population structure of Streptococcus pneumoniae in the nasopharynx. Clin Microbiol Infect 2020; 27:864-870. [PMID: 32750538 PMCID: PMC8203556 DOI: 10.1016/j.cmi.2020.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/23/2020] [Accepted: 07/25/2020] [Indexed: 11/18/2022]
Abstract
Objective Mass drug administration (MDA) with azithromycin for trachoma elimination reduces nasopharyngeal carriage of Streptococcus pneumoniae in the short term. We evaluated S. pneumoniae carried in the nasopharynx before and after a round of azithromycin MDA to determine whether MDA was associated with changes in pneumococcal population structure and resistance. Methods We analysed 514 pneumococcal whole genomes randomly selected from nasopharyngeal samples collected in two Gambian villages that received three annual rounds of MDA for trachoma elimination. The 514 samples represented 293 participants, of which 75% were children aged 0–9 years, isolated during three cross-sectional surveys (CSSs) conducted before the third round of MDA (CSS-1) and at 1 (CSS-2) and 6 (CSS-3) months after MDA. Bayesian Analysis of Population Structure (BAPS) was used to cluster related isolates by capturing variation in the core genome. Serotype and multilocus sequence type were inferred from the genotype. Antimicrobial resistance determinants were identified from assemblies, including known macrolide resistance genes. Results Twenty-seven BAPS clusters were assigned. These consisted of 81 sequence types (STs). Two BAPS clusters not observed in CSS-1 (n = 109) or CSS-2 (n = 69), increased in frequency in CSS-3 (n = 126); BAPS20 (8.73%, p 0.016) and BAPS22 (7.14%, p 0.032) but were not associated with antimicrobial resistance. Macrolide resistance within BAPS17 increased after treatment (CSS-1 n = 0/6, CSS-2/3 n = 5/5, p 0.002) and was carried on a mobile transposable element that also conferred resistance to tetracycline. Discussion Limited changes in pneumococcal population structure were observed after the third round of MDA, suggesting treatment had little effect on the circulating lineages. An increase in macrolide resistance within one BAPS highlights the need for antimicrobial resistance surveillance in treated villages.
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Affiliation(s)
| | - Ebrima Bojang
- Medical Research Council Unit The Gambia at LSHTM, Fajara, Banjul, Gambia
| | - John Hart
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | | | - David Mabey
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Ansumana Sillah
- National Eye Health Programme, Ministry of Health and Social Welfare, Kanifing, Gambia
| | - Robin L Bailey
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Sarah E Burr
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Anna Roca
- Medical Research Council Unit The Gambia at LSHTM, Fajara, Banjul, Gambia; London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | | | - Martin J Holland
- London School of Hygiene & Tropical Medicine, Keppel Street, London, UK.
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56
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Coulibaly B, Sié A, Kiemde D, Dembélé N, Compaore A, Dabo O, Dah C, Ouermi L, Cevallos V, Lebas E, Brogdon JM, Keenan JD, Oldenburg CE. Pneumococcal Carriage and Antibiotic Resistance in Children Younger than 5 Years in Nouna District, Burkina Faso. Am J Trop Med Hyg 2020; 103:684-688. [PMID: 32458778 DOI: 10.4269/ajtmh.20-0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Increasing antibiotic consumption has been shown to lead to increased antibiotic resistance selection. We evaluated the prevalence of antibiotic resistance in Streptococcus pneumoniae to commonly used antibiotic classes as well as correlations between resistance and antibiotic consumption at the individual and community levels in children aged 0-59 months in Nouna district, Burkina Faso. A population-based sample of 300 children aged 0-59 months was randomly selected from the most recent census in 18 communities in the Nouna Health and Demographic Surveillance Site. Caregivers were interviewed about children's recent antibiotic use, and a nasopharyngeal swab was collected from each child. Nasopharyngeal swabs were processed using standard microbiological methods to determine pneumococcal carriage and resistance. Community-level antibiotic consumption was determined by record review from primary healthcare facilities, which routinely collect prescription data for children aged 0-59 months. Streptococcus pneumoniae was isolated from 101 (35.7%) nasopharyngeal samples. Among positive isolates, co-trimoxazole (75.6%) and tetracycline (69.3%) resistance was the most common, followed by oxacillin (26.7%) and azithromycin (9.9%). Recent antibiotic use was associated with decreased pneumococcal carriage (odds ratio 0.56, 95% CI: 0.33-0.93) at the individual level. There was no statistically significant relationship between antibiotic use and antibiotic resistance at the individual or community levels, although CIs were generally wide. The prevalence of antibiotic resistance to commonly used antibiotics was high in the study area. Expanding antimicrobial resistance surveillance in areas with little population-based data will be important for informing policy related to antibiotic use.
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Affiliation(s)
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Dramane Kiemde
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Nestor Dembélé
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Adama Compaore
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Ousmane Dabo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Vicky Cevallos
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Jessica M Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Jeremy D Keenan
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California.,Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Department of Ophthalmology, University of California, San Francisco, San Francisco, California
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57
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Doster E, Lakin SM, Dean CJ, Wolfe C, Young JG, Boucher C, Belk KE, Noyes NR, Morley PS. MEGARes 2.0: a database for classification of antimicrobial drug, biocide and metal resistance determinants in metagenomic sequence data. Nucleic Acids Res 2020; 48:D561-D569. [PMID: 31722416 PMCID: PMC7145535 DOI: 10.1093/nar/gkz1010] [Citation(s) in RCA: 179] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/09/2019] [Accepted: 11/06/2019] [Indexed: 11/12/2022] Open
Abstract
Antimicrobial resistance (AMR) is a threat to global public health and the identification of genetic determinants of AMR is a critical component to epidemiological investigations. High-throughput sequencing (HTS) provides opportunities for investigation of AMR across all microbial genomes in a sample (i.e. the metagenome). Previously, we presented MEGARes, a hand-curated AMR database and annotation structure developed to facilitate the analysis of AMR within metagenomic samples (i.e. the resistome). Along with MEGARes, we released AmrPlusPlus, a bioinformatics pipeline that interfaces with MEGARes to identify and quantify AMR gene accessions contained within a metagenomic sequence dataset. Here, we present MEGARes 2.0 (https://megares.meglab.org), which incorporates previously published resistance sequences for antimicrobial drugs, while also expanding to include published sequences for metal and biocide resistance determinants. In MEGARes 2.0, the nodes of the acyclic hierarchical ontology include four antimicrobial compound types, 57 classes, 220 mechanisms of resistance, and 1,345 gene groups that classify the 7,868 accessions. In addition, we present an updated version of AmrPlusPlus (AMR ++ version 2.0), which improves accuracy of classifications, as well as expanding scalability and usability.
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Affiliation(s)
- Enrique Doster
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Steven M Lakin
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Christopher J Dean
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
| | - Cory Wolfe
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Jared G Young
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
| | - Christina Boucher
- Department of Computer and Information Science and Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Keith E Belk
- Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Noelle R Noyes
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
| | - Paul S Morley
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
- To whom correspondence should be addressed. Tel: +1 970 219 6089;
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58
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Micek ST, Simmons J, Hampton N, Kollef MH. Characteristics and outcomes among a hospitalized patient cohort with Streptococcus pneumoniae infection. Medicine (Baltimore) 2020; 99:e20145. [PMID: 32358404 PMCID: PMC7440058 DOI: 10.1097/md.0000000000020145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Infection due to Streptococcus pneumoniae (SP) requiring hospitalization is common. However, recent clinical studies describing patient characteristics and outcomes for SP infection in adults requiring hospitalization are lacking. Our goal was to evaluate patient characteristics, contemporary antibiotic resistance, and clinical outcomes among hospitalized adults with SP infections.A retrospective cohort study was conducted at Barnes-Jewish Hospital (1350 beds) in St. Louis, Missouri, USA for years 2012 through 2016. During the study period, 358 hospitalized adults, excluding those with meningitis, were identified with SP infection. Forty-four patients (12.3%) died within 30 days of the identification of their infection. Among these infections, 99 (27.7%) were assessed to be hospital-acquired and 259 (72.3%) were community-onset infections. The majority of infections involved the respiratory tract (88.5%). Azithromycin resistance was the most common antibiotic resistance at 51.4%, followed by enteral penicillin resistance (45.3%), trimethoprim-sulfamethoxazole (34.1%), second-generation cephalosporin (cefuroxime) (30.7%), and meropenem (22.6%). There were 70 isolates (19.6%) classified as multidrug resistant. Independent predictors of hospital mortality included increasing weight in 1-kilogram increments (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01 - 1.02; P = .048), increasing Charlson Comorbidity Index scores (AOR, 1.31; 95% CI, 1.21 - 1.42; P = .001), and the presence of septic shock (AOR, 3.89; 95% CI, 2.31 - 6.57; P = .009). The median [interquartile range] hospital length of stay was 8.1 days [4.5 days, 16.8 days].Hospitalized patients with infection attributed to SP have significant 30-day mortality and use of hospital resources. Antibiotic resistance is common among isolates associated with infection. Determinants of mortality are primarily severity of illness, underlying comorbidities and increasing patient weight. Efforts to improve the treatment and prevention of SP infections are needed.
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Affiliation(s)
- Scott T. Micek
- Department of Pharmacy Practice, St. Louis College of Pharmacy
| | - James Simmons
- Department of Pharmacy Practice, St. Louis College of Pharmacy
| | | | - Marin H. Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
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59
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Hart JD, Kalua K, Keenan JD, Lietman TM, Bailey RL. Cost-Effectiveness of Mass Treatment with Azithromycin for Reducing Child Mortality in Malawi: Secondary Analysis from the MORDOR Trial. Am J Trop Med Hyg 2020; 103:1283-1290. [PMID: 32342840 PMCID: PMC7470598 DOI: 10.4269/ajtmh.19-0622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The recent Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance (MORDOR) trial reported a reduction in child mortality following biannual azithromycin mass drug administration (MDA). Here, we investigate the financial costs and cost-effectiveness from the health provider perspective of azithromycin MDA at the MORDOR-Malawi study site. During MORDOR, a cluster-randomized trial involving biannual azithromycin MDA or placebo to children aged 1–59 months, fieldwork-related costs were collected, including personnel, transport, consumables, overheads, training, and supervision. Mortality rates in azithromycin- and placebo-treated clusters were calculated overall and for the five health zones of Mangochi district. These were used to estimate the number needed to treat to avert one death and the costs per death and disability-adjusted life year (DALY) averted. The cost per dose of MDA was $0.74 overall, varying between $0.63 and $0.94 in the five zones. Overall, the number needed to treat to avert one death was 1,213 children; the cost per death averted was $898.47, and the cost per DALY averted was $9.98. In the three zones where mortality was lower in azithromycin-treated clusters, the number needed to treat to avert one death, cost per death averted, and cost per DALY averted, respectively, were as follows: 3,070, $2,899.24, and $32.31 in Monkey Bay zone; 1,530, $1,214.42, and $13.49 in Chilipa zone; and 344, $217.98, and $2.42 in Namwera zone. This study is a preliminary cost-effectiveness analysis that indicates azithromycin MDA for reducing child mortality has the potential to be highly cost-effective in some settings in Malawi, but the reasons for geographical variation in effectiveness require further investigation.
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Affiliation(s)
- John D Hart
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Khumbo Kalua
- Blantyre Institute for Community Outreach, Blantyre, Malawi
| | - Jeremy D Keenan
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, Califorina
| | - Thomas M Lietman
- Francis I Proctor Foundation and Department of Ophthalmology, University of California, San Francisco, San Francisco, Califorina
| | - Robin L Bailey
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Doster E, Lakin SM, Dean CJ, Wolfe C, Young JG, Boucher C, Belk KE, Noyes NR, Morley PS. MEGARes 2.0: a database for classification of antimicrobial drug, biocide and metal resistance determinants in metagenomic sequence data. Nucleic Acids Res 2020. [PMID: 31722416 DOI: 10.1590/10.1093/nar/gkz1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
Antimicrobial resistance (AMR) is a threat to global public health and the identification of genetic determinants of AMR is a critical component to epidemiological investigations. High-throughput sequencing (HTS) provides opportunities for investigation of AMR across all microbial genomes in a sample (i.e. the metagenome). Previously, we presented MEGARes, a hand-curated AMR database and annotation structure developed to facilitate the analysis of AMR within metagenomic samples (i.e. the resistome). Along with MEGARes, we released AmrPlusPlus, a bioinformatics pipeline that interfaces with MEGARes to identify and quantify AMR gene accessions contained within a metagenomic sequence dataset. Here, we present MEGARes 2.0 (https://megares.meglab.org), which incorporates previously published resistance sequences for antimicrobial drugs, while also expanding to include published sequences for metal and biocide resistance determinants. In MEGARes 2.0, the nodes of the acyclic hierarchical ontology include four antimicrobial compound types, 57 classes, 220 mechanisms of resistance, and 1,345 gene groups that classify the 7,868 accessions. In addition, we present an updated version of AmrPlusPlus (AMR ++ version 2.0), which improves accuracy of classifications, as well as expanding scalability and usability.
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Affiliation(s)
- Enrique Doster
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Steven M Lakin
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Christopher J Dean
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
| | - Cory Wolfe
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Jared G Young
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
| | - Christina Boucher
- Department of Computer and Information Science and Engineering, University of Florida, Gainesville, FL 32611, USA
| | - Keith E Belk
- Department of Animal Sciences, Colorado State University, Fort Collins, CO 80523, USA
| | - Noelle R Noyes
- Department of Veterinary Population Medicine, University of Minnesota, St. Paul, MN 55455, USA
| | - Paul S Morley
- Veterinary Education, Research, and Outreach (VERO) Program, Texas A&M University and West Texas A&M University, Canyon, TX 79016, USA
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Brander RL, Weaver MR, Pavlinac PB, John-Stewart GC, Hawes SE, Walson JL. Projected impact and cost-effectiveness of community-based versus targeted azithromycin administration strategies for reducing child mortality in sub-Saharan Africa. Clin Infect Dis 2020; 74:ciz1220. [PMID: 31905386 PMCID: PMC8834658 DOI: 10.1093/cid/ciz1220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/02/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Trials of mass drug administration (MDA) of azithromycin (AZM) report reductions in child mortality in sub-Saharan Africa (SSA). AZM targeted to high-risk children may preserve benefit while minimizing antibiotic exposure. We modeled the cost-effectiveness of MDA to children 1-59 months of age, MDA to children 1-5 months of age, AZM administered at hospital discharge, and the combination of MDA and post-discharge AZM. METHODS AND FINDINGS Models employed a payer perspective with a 1-year time horizon. Cost-effectiveness was presented as cost per DALY averted and death averted, with probabilistic sensitivity analyses. The model included parameters for macrolide resistance, adverse events, hospitalization, and mortality sourced from published data. Assuming a base-case 1.64% mortality risk among children 1-59 months old, 3.1% among children 1-5 months old, 4.4% mortality risk post-discharge, and 13.5% mortality reduction per trial data, post-discharge AZM would avert ~45,000 deaths, at a cost of $2.84/DALY (95% uncertainty interval [UI]: 1.71-5.57) averted. MDA to only children 1-5 months old would avert ~186,000 deaths at a cost of $4.89/DALY averted (95% UI: 2.88-11.42), MDA to all under-5 children would avert ~267,000 deaths a cost of $14.26/DALY averted (95% UI: 8.72-27.08). Cost-effectiveness decreased with presumed diminished efficacy due to macrolide resistance. CONCLUSIONS Targeting AZM to children at highest risk of death may be an antibiotic-sparing and cost-effective, or even cost-saving, strategy to reduce child mortality. However, targeted AZM averts fewer absolute deaths and may not reach all children who would benefit. Any AZM administration decision must consider implications for antibiotic resistance.
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Affiliation(s)
- Rebecca L Brander
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Marcia R Weaver
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Health Services, University of Washington, Seattle, Washington, USA
- Department of Health Metrics Sciences, University of Washington, Seattle, Washington, USA
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - Judd L Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, University of Washington, Seattle, Washington, USA
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62
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Sié A, Ouattara M, Bountogo M, Bagagnan C, Coulibaly B, Boudo V, Lebas E, Brogdon JM, Lin Y, Bärnighausen T, Porco TC, Doan T, Lietman TM, Oldenburg CE. A double-masked placebo-controlled trial of azithromycin to prevent child mortality in Burkina Faso, West Africa: Community Health with Azithromycin Trial (CHAT) study protocol. Trials 2019; 20:675. [PMID: 31801563 PMCID: PMC6894235 DOI: 10.1186/s13063-019-3855-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/25/2019] [Indexed: 01/20/2023] Open
Abstract
Background Biannual, mass azithromycin distribution has previously been shown to reduce all-cause child mortality in sub-Saharan Africa. Subgroup analysis suggested that the strongest effects were in the youngest children, leading to the hypothesis that targeting younger age groups might be an effective strategy to prevent mortality. We present the methods of two randomized controlled trials designed to evaluate mass and targeted azithromycin distribution for the prevention of child mortality in Burkina Faso, West Africa. Methods/design The Child Health with Azithromycin Treatment (CHAT) study consists of two nested, randomized controlled trials. In the first, communities are randomized in a 1:1 fashion to biannual, mass azithromycin distribution or placebo. The primary outcome is under-5 all-cause mortality measured at the community level. In the second, children attending primary healthcare facilities during the first 5–12 weeks of life for a healthy child visit (e.g., for vaccination) are randomized in a 1:1 fashion to a single orally administered dose of azithromycin or placebo. The primary outcome is all-cause mortality measured at 6 months of age. The trial commenced enrollment in August 2019. Discussion This study is expected to provide evidence on two health systems delivery approaches (mass and targeted treatment) for azithromycin to prevent all-cause child mortality. The results will inform global and national policies related to azithromycin for the prevention of child mortality. Trial registration ClinicalTrials.gov, ID: NCT03676764. Registered on 19 September 2018; prospectively registered pre results.
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Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | | | - Cheik Bagagnan
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Jessica M Brogdon
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Ying Lin
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg, Germany.,Africa Health Research Institute (AHRI), Somkhele, South Africa.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Travis C Porco
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA.,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, 513 Parnassus Ave, Room S334, San Francisco, CA, USA. .,Department of Ophthalmology, University of California, San Francisco, CA, USA. .,Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
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63
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Lietman TM, Doan T, Keenan JD. Macrolide Resistance and Longer-Term Assessment of Azithromycin in MORDOR I. Reply. N Engl J Med 2019; 381:2184-2185. [PMID: 31774979 DOI: 10.1056/nejmc1910014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Thuy Doan
- Francis I. Proctor Foundation, San Francisco, CA
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65
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Sie A, Bountogo M, Nebie E, Ouattara M, Coulibaly B, Bagagnan C, Zabre P, Lebas E, Brogdon J, Godwin WW, Lin Y, Porco T, Doan T, Lietman TM, Oldenburg CE. Neonatal azithromycin administration to prevent infant mortality: study protocol for a randomised controlled trial. BMJ Open 2019; 9:e031162. [PMID: 31488494 PMCID: PMC6731835 DOI: 10.1136/bmjopen-2019-031162] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Biannual mass azithromycin distribution to children aged 1-59 months has been shown to reduce all-cause mortality. Children under 28 days of age were not treated in studies evaluating mass azithromycin distribution for child mortality due to concerns related to infantile hypertrophic pyloric stenosis (IHPS). Here, we report the design of a randomised controlled trial to evaluate the efficacy and safety of administration of a single dose of oral azithromycin during the neonatal period. METHODS AND ANALYSIS The Nouveaux-nés et Azithromycine: une Innovation dans le Traitement des Enfants (NAITRE) study is a double-masked randomised placebo-controlled trial designed to evaluate the efficacy of a single dose of azithromycin (20 mg/kg) for the prevention of child mortality. Newborns (n=21 712) aged 8-27 days weighing at least 2500 g are 1:1 randomised to a single, directly observed, oral dose of azithromycin or matching placebo. Participants are followed weekly for 3 weeks after treatment to screen for adverse events, including IHPS. The primary outcome is all-cause mortality at the 6-month study visit. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Boards at the University of California, San Francisco in San Francisco, USA (Protocol #18-25027) and the Comité National d'Ethique pour la Recherche in Ouagadougou, Burkina Faso (Protocol #2018-10-123). The findings of this trial will be presented at local, regional and international meetings and published in open access peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03682653; Pre-results.
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Affiliation(s)
- Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Eric Nebie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | | | - Cheik Bagagnan
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Pascal Zabre
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Jessica Brogdon
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - William W Godwin
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Ying Lin
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
| | - Travis Porco
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Thuy Doan
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Catherine E Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California, USA
- Department of Ophthalmology, University of California, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
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Doan T, Hinterwirth A, Worden L, Arzika AM, Maliki R, Abdou A, Kane S, Zhong L, Cummings ME, Sakar S, Chen C, Cook C, Lebas E, Chow ED, Nachamkin I, Porco TC, Keenan JD, Lietman TM. Gut microbiome alteration in MORDOR I: a community-randomized trial of mass azithromycin distribution. Nat Med 2019; 25:1370-1376. [PMID: 31406349 DOI: 10.1038/s41591-019-0533-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/25/2019] [Indexed: 01/25/2023]
Abstract
The MORDOR I trial1, conducted in Niger, Malawi and Tanzania, demonstrated that mass azithromycin distribution to preschool children reduced childhood mortality1. However, the large but simple trial design precluded determination of the mechanisms involved. Here we examined the gut microbiome of preschool children from 30 Nigerien communities randomized to either biannual azithromycin or placebo. Gut microbiome γ-diversity was not significantly altered (P = 0.08), but the relative abundances of two Campylobacter species, along with another 33 gut bacteria, were significantly reduced in children treated with azithromycin at the 24-month follow-up. Metagenomic analysis revealed functional differences in gut bacteria between treatment groups. Resistome analysis showed an increase in macrolide resistance gene expression in gut microbiota in communities treated with azithromycin (P = 0.004). These results suggest that prolonged mass azithromycin distribution to reduce childhood mortality reduces certain gut bacteria, including known pathogens, while selecting for antibiotic resistance.
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Affiliation(s)
- T Doan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
| | - A Hinterwirth
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - L Worden
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | | | - R Maliki
- The Carter Center, Niamey, Niger
| | - A Abdou
- Ministry of Public Health, Niamey, Niger
- Programme National de Soins Oculaires, Niamey, Niger
| | - S Kane
- The Carter Center, Niamey, Niger
| | - L Zhong
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - M E Cummings
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - S Sakar
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - C Chen
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - C Cook
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - E Lebas
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
| | - E D Chow
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA, USA
| | - I Nachamkin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - T C Porco
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - J D Keenan
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
| | - T M Lietman
- Francis I Proctor Foundation, University of California, San Francisco, CA, USA
- Department of Ophthalmology, University of California, San Francisco, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
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Keenan JD, Arzika AM, Maliki R, Boubacar N, Elh Adamou S, Moussa Ali M, Cook C, Lebas E, Lin Y, Ray KJ, O’Brien KS, Doan T, Oldenburg CE, Callahan EK, Emerson PM, Porco TC, Lietman TM. Longer-Term Assessment of Azithromycin for Reducing Childhood Mortality in Africa. N Engl J Med 2019; 380:2207-2214. [PMID: 31167050 PMCID: PMC6512890 DOI: 10.1056/nejmoa1817213] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The MORDOR I trial (Macrolides Oraux pour Réduire les Décès avec un Oeil sur la Résistance) showed that in Niger, mass administration of azithromycin twice a year for 2 years resulted in 18% lower postneonatal childhood mortality than administration of placebo. Whether this benefit could increase with each administration or wane owing to antibiotic resistance was unknown. METHODS In the Niger component of the MORDOR I trial, we randomly assigned 594 communities to four twice-yearly distributions of either azithromycin or placebo to children 1 to 59 months of age. In MORDOR II, all these communities received two additional open-label azithromycin distributions. All-cause mortality was assessed twice yearly by census workers who were unaware of participants' original assignments. RESULTS In the MORDOR II trial, the mean (±SD) azithromycin coverage was 91.3±7.2% in the communities that received twice-yearly azithromycin for the first time (i.e., had received placebo for 2 years in MORDOR I) and 92.0±6.6% in communities that received azithromycin for the third year (i.e., had received azithromycin for 2 years in MORDOR I). In MORDOR II, mortality was 24.0 per 1000 person-years (95% confidence interval [CI], 22.1 to 26.3) in communities that had originally received placebo in the first year and 23.3 per 1000 person-years (95% CI, 21.4 to 25.5) in those that had originally received azithromycin in the first year, with no significant difference between groups (P = 0.55). In communities that had originally received placebo, mortality decreased by 13.3% (95% CI, 5.8 to 20.2) when the communities received azithromycin (P = 0.007). In communities that had originally received azithromycin and continued receiving it for an additional year, the difference in mortality between the third year and the first 2 years was not significant (-3.6%; 95% CI, -12.3 to 4.5; P = 0.50). CONCLUSIONS We found no evidence that the effect of mass administration of azithromycin on childhood mortality in Niger waned in the third year of treatment. Childhood mortality decreased when communities that had originally received placebo received azithromycin. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT02047981.).
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Affiliation(s)
- Jeremy D. Keenan
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF
| | | | | | | | | | | | | | | | - Ying Lin
- Francis I Proctor Foundation, UCSF
| | - Kathryn J. Ray
- Francis I Proctor Foundation, UCSF; Department of Epidemiology and
Biostatistics, UCSF
| | - Kieran S. O’Brien
- Francis I Proctor Foundation, UCSF; The University of California, Berkeley
School of Public Health
| | - Thuy Doan
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF;
Department of Epidemiology and Biostatistics, UCSF; Institute for Global
Health Sciences, UCSF
| | | | | | - Travis C. Porco
- Francis I Proctor Foundation, UCSF; Department of Ophthalmology, UCSF;
Department of Epidemiology and Biostatistics, UCSF
| | - Thomas M. Lietman
- Corresponding Author Thomas M. Lietman, , 513 Parnassus Ave.,
Medical Sciences Building, Room S309, UCSF, San Francisco, CA 94143-0944
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Affiliation(s)
- Naor Bar-Zeev
- From the International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore
| | - William J Moss
- From the International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore
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