Antimicrobial resistance in developing countries. Part I: recent trends and current status

Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review

BACKGROUND

Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses.

METHODS

Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs.

RESULTS

In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used.

CONCLUSIONS

The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact.

Field level interventions on subclinical mastitis and detection of Staphylococcus in crossbred dairy cows

Mastitis has emerged as one of the major managemental diseases of economic importance of high yielding dairy cows. A cross sectional study was carried out on 116 cross-bred dairy cows of small scale dairy farms; subclinical mastitis (SCM) was detected in 22 animals (cow-wise prevalence, 18.96%). Of the 88 individual quarter’s milk tested using California mastitis test (CMT) and somatic cell count (SCC) tests, 51 quarters showed SCM (quarterwise prevalence, 57.9%). Quarter-wise prevalence of SCM was 29.4, 31.4, 23.5 and 15.7% in right-fore (RF), right-hind (RH), left-fore (LF) and left-hind (LH) quarters, respectively. Fore-(52.9%) and right-(60.8%) quarters showed higher prevalence of SCM than hind-(47.1%) and left-(39.2%) quarters. All 4 quarters were found affected with SCM in 47% cows followed by 3-(23.5%), 1-(17.6%) and 2-(11.8%) quarters. Staphylococci were isolated and confirmed using 16S rRNA gene based genus-specific PCR in 39.2% of SCM affected quarters. Virulence associated nuc gene was detected in 75% of Staphylococcus isolates indicating their potential pathogenicity. Antibiogram showed multiple drug resistance (≥3 antimicrobial category) in 63.6% of Staphylococci. Multiple antimicrobial resistance (MAR) was recorded in 31.8% isolates. However, none of the isolate carried mecA gene. Interventions, viz. clean milk production practices, antimicrobial therapy and non-specific supportive treatments resulted in 77.7, 50 and 38.8% reductions in SCM compared to the untreated control (37.5%). This study accentuated higher prevalence of SCM among dairy cattle and predominance of Staphylococcus as the major mastitogen. Early detection and management of SCM among dairy cattle is recommended so as to prevent its progression to clinical illness and curtail potential economic loss to farmers.

Prevalence of enteric bacteria and their antimicrobial susceptibility patterns among food handlers in Gondar town, Northwest Ethiopia

Background

Enteric bacterial pathogens are the major causes of food-borne gastroenteritis in humans and remain important public health problems worldwide. The emergence of antimicrobial resistance is a global concern, particularly in developing countries. The aim of this study was to determine the prevalence of enteric bacteria pathogens and their antimicrobial susceptibility patterns among food handlers in Gondar town, Northwest Ethiopia.

Methods

A cross-sectional study was conducted from February 4 to April 16, 2018. A total of 257 food handlers were selected using a multistage sampling technique. Data on socio-demographic characteristics were collected using a structured questionnaire. Stool samples were collected and inoculated into appropriate media. Enteric bacterial pathogens were identified using standard microbiological methods. Antimicrobial susceptibility tests were performed using the disk diffusion technique as per the standard Kirby-Bauer method. Data were entered and analyzed using SPSS version 20 software.

Results

The overall prevalence of enteric bacteria was 34/257 (13. 2%, [95% CI, 8.9-17.5%]). Shigella species was the leading isolate that accounted for 26/257 (10.1%) followed by Enterohemorrhagic Escherichia coli (EHEC) O157: H7 5/257 (1.9%) and Salmonella species 3/257 (1.2%). Shigella spp. was susceptible to ciprofloxacin 26 (100%), ceftriaxone 25 (96.1%), chloramphenicol 24 (92.3%), nalidixic acid 24 (92.3%), and gentamicin 20 (76.9%). Escherichia coli O157: H7 and Salmonella spp. showed the maximum (100%) susceptibility results to ceftriaxone, chloramphenicol, ciprofloxacin, and gentamicin. The overall prevalence of Multidrug resistance (MDR) in the current study was 14/34 (41.2%).

Conclusion

Our study showed high prevalence of enteric bacterial pathogens among food handlers. All isolates were susceptible to ciprofloxacin. However, a substential number of isolates were resistant to commonly prescribed antibiotics and the prevalence of MDR was high.

Opportunities and Challenges for the Sustainability of Lakes and Reservoirs in Relation to the Sustainable Development Goals (SDGs)

Emerging global threats, such as biological invasions, climate change, land use intensification, and water depletion, endanger the sustainable future of lakes and reservoirs. To deal with these threats, a multidimensional view on the protection and exploitation of lakes and reservoirs is needed. The holistic approach needs to contain not just the development of economy and society but also take into account the negative impacts of this growth on the environment, from that, the balance between the three dimensions can be sustained to reach a sustainable future. As such, this paper provides a comprehensive review on future opportunities and challenges for the sustainable development of lakes and reservoirs via a critical analysis on their contribution to individual and subsets of the Sustainable Development Goals (SDGs). Currently, lakes and reservoirs are key freshwater resources. They play crucial roles in human societies for drinking water provision, food production (via fisheries, aquaculture, and the irrigation of agricultural lands), recreation, energy provision (via hydropower dams), wastewater treatment, and flood and drought control. Because of the (mostly) recent intensive exploitations, many lakes and reservoirs are severely deteriorated. In recent years, physical (habitat) degradation has become very important while eutrophication remains the main issue for many lakes and ponds worldwide. Besides constant threats from anthropogenic activities, such as urbanization, industry, aquaculture, and watercourse alterations, climate change and emerging contaminants, such as microplastics and antimicrobial resistance, can generate a global problem for the sustainability of lakes and reservoirs. In relation to the SDGs, the actions for achieving the sustainability of lakes and reservoirs have positive links with the SDGs related to environmental dimensions (Goals 6, 13, 14, and 15) as they are mutually reinforcing each other. On the other hand, these actions have direct potential conflicts with the SDGs related to social and economic dimensions (Goals 1, 2, 3 and 8). From these interlinkages, we propose 22 indicators that can be used by decision makers for monitoring and assessing the sustainable development of lakes and reservoirs.

Investing in Food Safety for Developing Countries: Opportunities and Challenges in Applying Whole-Genome Sequencing for Food Safety Management

Whole-genome sequencing (WGS) has become a significant tool in investigating foodborne disease outbreaks and some countries have incorporated WGS into national food control systems. However, WGS poses technical challenges that deter developing countries from incorporating it into their food safety management system. A rapid scoping review was conducted, followed by a focus group session, to understand the current situation regarding the use of WGS for foodborne disease surveillance and food monitoring at the global level and identify key limiting factors for developing countries in adopting WGS for their food control systems. The results showed that some developed nations routinely use WGS in their food surveillance systems resulting in more precise understanding of the causes of outbreaks. In developing nations, knowledge of WGS exists in the academic/research sectors; however, there is limited understanding at the government level regarding the usefulness of WGS for food safety regulatory activities. Thus, incorporation of WGS is extremely limited in most developing nations. While some countries lack the capacity to collect and analyze the data generated from WGS, the most significant technical gap in most developing countries is in data interpretation using bioinformatics. The gaps in knowledge and capacities between developed and developing nations regarding use of WGS likely introduce an inequality in international food trade, and thus, relevant international organizations, as well as the countries that are already proficient in the use of WGS, have significant roles in assisting developing nations to be able to fully benefit from the technology and its applications in food safety management.

Human, animal and environmental contributors to antibiotic resistance in low-resource settings: integrating behavioural, epidemiological and One Health approaches

Antibiotic resistance (ABR) is recognized as a One Health challenge because of the rapid emergence and dissemination of resistant bacteria and genes among humans, animals and the environment on a global scale. However, there is a paucity of research assessing ABR contemporaneously in humans, animals and the environment in low-resource settings. This critical review seeks to identify the extent of One Health research on ABR in low- and middle-income countries (LMICs). Existing research has highlighted hotspots for environmental contamination; food-animal production systems that are likely to harbour reservoirs or promote transmission of ABR as well as high and increasing human rates of colonization with ABR commensal bacteria such as Escherichia coli However, very few studies have integrated all three components of the One Health spectrum to understand the dynamics of transmission and the prevalence of community-acquired resistance in humans and animals. Microbiological, epidemiological and social science research is needed at community and population levels across the One Health spectrum in order to fill the large gaps in knowledge of ABR in low-resource settings.

Using WGS to identify antibiotic resistance genes and predict antimicrobial resistance phenotypes in MDR Acinetobacter baumannii in Tanzania

BACKGROUND

Reliable phenotypic antimicrobial susceptibility testing can be a challenge in clinical settings in low- and middle-income countries. WGS is a promising approach to enhance current capabilities.

AIM

To study diversity and resistance determinants and to predict and compare resistance patterns from WGS data of Acinetobacter baumannii with phenotypic results from classical microbiological testing at a tertiary care hospital in Tanzania.

METHODS AND RESULTS

MLST using Pasteur/Oxford schemes yielded eight different STs from each scheme. Of the eight, two STs were identified to be global clones 1 (n = 4) and 2 (n = 1) as per the Pasteur scheme. Resistance testing using classical microbiology determined between 50% and 92.9% resistance across all drugs. Percentage agreement between phenotypic and genotypic prediction of resistance ranged between 57.1% and 100%, with coefficient of agreement (κ) between 0.05 and 1. Seven isolates harboured mutations at significant loci (S81L in gyrA and S84L in parC). A number of novel plasmids were detected, including pKCRI-309C-1 (219000 bp) carrying 10 resistance genes, pKCRI-43-1 (34935 bp) carrying two resistance genes and pKCRI-49-1 (11681 bp) and pKCRI-28-1 (29606 bp), each carrying three resistance genes. New ampC alleles detected included ampC-69, ampC-70 and ampC-71. Global clone 1 and 2 isolates were found to harbour ISAba1 directly upstream of the ampC gene. Finally, SNP-based phylogenetic analysis of the A. baumannii isolates revealed closely related isolates in three clusters.

CONCLUSIONS

The validity of the use of WGS in the prediction of phenotypic resistance can be appreciated, but at this stage is not sufficient for it to replace conventional antimicrobial susceptibility testing in our setting.

Effect of carbapenem resistance on outcomes of bloodstream infection caused by Enterobacteriaceae in low-income and middle-income countries (PANORAMA): a multinational prospective cohort study

BACKGROUND

Low-income and middle-income countries (LMICs) are under-represented in reports on the burden of antimicrobial resistance. We aimed to quantify the clinical effect of carbapenem resistance on mortality and length of hospital stay among inpatients in LMICs with a bloodstream infection due to Enterobacteriaceae.

METHODS

The PANORAMA study was a multinational prospective cohort study at tertiary hospitals in Bangladesh, Colombia, Egypt, Ghana, India, Lebanon, Nepal, Nigeria, Pakistan, and Vietnam, recruiting consecutively diagnosed patients with carbapenem-susceptible Enterobacteriaceae (CSE) and carbapenem-resistant Entero-bacteriaceae (CRE) bloodstream infections. We excluded patients who had previously been enrolled in the study and those not treated with curative intent at the time of bloodstream infection onset. There were no age restrictions. Central laboratories in India and the UK did confirmatory testing and molecular characterisation, including strain typing. We applied proportional subdistribution hazard models with inverse probability weighting to estimate the effect of carbapenem resistance on probability of discharge alive and in-hospital death, and multistate modelling for excess length of stay in hospital. All patients were included in the analysis.

FINDINGS

Between Aug 1, 2014, and June 30, 2015, we recruited 297 patients from 16 sites in ten countries: 174 with CSE bloodstream infection and 123 with CRE bloodstream infection. Median age was 46 years (IQR 15-61). Crude mortality was 20% (35 of 174 patients) for patients with CSE bloodstream infection and 35% (43 of 123 patients) for patients with CRE bloodstream infection. Carbapenem resistance was associated with an increased length of hospital stay (3·7 days, 95% CI 0·3-6·9), increased probability of in-hospital mortality (adjusted subdistribution hazard ratio 1·75, 95% CI 1·04-2·94), and decreased probability of discharge alive (0·61, 0·45-0·83). Multilocus sequence typing showed various clades, with marginal overlap between strains in the CRE and CSE clades.

INTERPRETATION

Carbapenem resistance is associated with increased length of hospital stay and mortality in patients with bloodstream infections in LMICs. These data will inform global estimates of the burden of antimicrobial resistance and reinforce the need for better strategies to prevent, diagnose, and treat CRE infections in LMICs.

FUNDING

bioMérieux.

Over the Counter Sale of Antibiotics at Drug Stores Found in Mizan-Aman Town, Southwest Ethiopia: A Cross-Sectional Simulated Client Visit Study

Background

Antibiotics are crucial drugs, particularly in the developing world, where infectious diseases are a common cause of death. Misuse and overuse of antibiotics have driven the emergency of antibiotic-resistant bacteria, which in turn leads to a loss of efficacy of these drugs. This study aimed to assess the professional practice on OTC sale of antibiotics at community drug retail outlets found in Mizan-Aman town.

Methods

A cross-sectional simulated client visit study was conducted among community drug retail outlets found in Mizan-Aman town, Southwest Ethiopia, from 14 to 28 March, 2018. Currently, there are 18 commercially licensed community drug retail outlets in Mizan-Aman town and the study was undertaken on all drug retail outlets. Each drug retail outlet was visited once by investigators who simulated inflicting clinical scenario according to simulated client method pharmacy surveys. Three different clinical scenarios were chosen and, in each of the three cases, three levels of demand were used to obtain the antibiotic. The findings of the study were entered, cleared, coded, and stored into Epi Info version 3.5.1 and exported to Statistical Package for Social Sciences (Windows version 21) and the collected data were compiled and presented as descriptive statistics using tables and figures.

Results

Most, 17 (94.4%), of drug stores out of the total 18 in which all three clinical scenarios were allotted were issued antibiotics without a need of medical prescription with three different levels of demands. Antibiotics were sold without a prescription in most (94.4%) of drug stores in which a urinary tract infection clinical scenario was presented. Similarly, antibiotics were obtained without a prescription for acute diarrhea from 16 (88.9%) drug stores. With respect to sore throat simulation, antimicrobial drugs were obtained without a prescription from 14 (77.8%) drug stores. Commonly dispensed antibiotics were Metronidazole (50.0%), Ciprofloxacin (38.9%), and Amoxicillin (71.4%) for acute diarrhea, urinary tract infection, and sore throat case scenarios, respectively. Only 1 drug store (5.5%) refused to dispense any kind of antibiotics.

Conclusion

The results of this study demonstrate that nonprescription sales of antibiotics were highly pronounced in contrary to national guidelines regarding this practice. Most of antibiotics were dispensed without a prescription when the simulator asked any medication to alleviate his/her symptoms.

Poverty and Community-Acquired Antimicrobial Resistance with Extended-Spectrum β-Lactamase-Producing Organisms, Hyderabad, India

The decreasing effectiveness of antimicrobial agents is a global public health threat, yet risk factors for community-acquired antimicrobial resistance (CA-AMR) in low-income settings have not been clearly elucidated. Our aim was to identify risk factors for CA-AMR with extended-spectrum β-lactamase (ESBL)–producing organisms among urban-dwelling women in India. We collected microbiological and survey data in an observational study of primigravidae women in a public hospital in Hyderabad, India. We analyzed the data using multivariate logistic and linear regression and found that 7% of 1,836 women had bacteriuria; 48% of isolates were ESBL-producing organisms. Women in the bottom 50th percentile of income distribution were more likely to have bacteriuria (adjusted odds ratio 1.44, 95% CI 0.99–2.10) and significantly more likely to have bacteriuria with ESBL-producing organisms (adjusted odds ratio 2.04, 95% CI 1.17–3.54). Nonparametric analyses demonstrated a negative relationship between the prevalence of ESBL and income.

Pediatric bloodstream infections in metropolitan Australia

BACKGROUND

Bloodstream infections (BSIs) cause significant morbidity and mortality of children worldwide. The aim of this study was to investigate BSI in children and determine the identity of causative organism and their susceptibility patterns in a metropolitan public hospital in Australia.

METHODS

We retrospectively reviewed children aged 0-16 years admitted to a public hospital from January 1, 2010 to August 31, 2014 inclusive, and whose blood cultures revealed bacteraemia. Data were collected regarding patient demographics, species of bacteria isolated, antimicrobial susceptibility of these isolates, and clinical outcomes.

RESULTS

Out of 96 patients with BSI, 55 (57.3%) were males. The median age was 3.35 years (IQR 0.44-7.46), and there were 2 mortalities. Common sites of infection were the respiratory tract (16.6%, n = 16), bone and joints (15.6%, n = 15) and the urinary tract (11.5%, n = 11). The most frequent isolates were Staphylococcus aureus (27.0%), Escherichia coli (14.0%) and Streptococcus pneumoniae (12.0%). Whilst most bacterial isolates displayed susceptibility (> 90%) to common antimicrobial agents, only 57.1% (8/14) of Escherichia coli isolates were susceptible to ampicillin and 58.3% (7/12) were susceptible to co-trimoxazole.

CONCLUSIONS

Gram-positive bacteria accounted for the majority of pediatric BSIs, of which invasive pneumococcal disease remains a noteworthy cause. The majority of isolates, except Escherichia coli, were susceptible to commonly used antimicrobials. This study confirms the knowledge of high rates of resistance of Escherichia coli to ampicillin. Therefore, empirical treatment should still include gentamicin. Monitoring of resistance patterns is warranted to ensure that antibiotic therapy remains appropriate.

Community pharmacy staff's response to symptoms of common infections: a pseudo-patient study

Background

Inappropriate over-the-counter supply of antibiotics in pharmacies for common infections is recognised as a source of antibiotic misuse that can worsen the global burden of antibiotic resistance.

Objectives

To assess responses of community pharmacy staff to pseudo-patients presenting with symptoms of common infections and factors associated with such behaviour.

Methods

A cross-sectional pseudo-patient study was conducted from Jan-Sept 2017 among 242 community pharmacies in Sri Lanka. Each pharmacy was visited by one trained pseudo-patient who pretended to have a relative with clinical symptoms of one of four randomly selected clinical scenarios of common infections (three viral infections: acute sore throat, common cold, acute diarrhoea) and a bacterial uncomplicated urinary tract infection. Pseudo-patients requested an unspecified medicine for their condition. Interactions between the attending pharmacy staff and the pseudo-patients were audio recorded (with prior permission). Interaction data were also entered into a data collection form immediately after each visit.

Results

In 41% (99/242) of the interactions, an antibiotic was supplied illegally without a prescription. Of these, 66% (n = 65) were inappropriately given for the viral infections. Antibiotics were provided for 55% of the urinary tract infections, 50% of the acute diarrhoea, 42% of the sore throat and 15% of the common cold cases. Patient history was obtained in less than a quarter of the interactions. In 18% (44/242) of the interactions staff recommended the pseudo-patient to visit a physician, however, in 25% (11/44) of these interactions an antibiotic was still dispensed. Pharmacy staff advised the pseudo-patient on how to take (in 60% of the interactions where an antibiotic was supplied), when to take (47%) and when to stop (22%) the antibiotics supplied. Availability of a pharmacist reduced the likelihood of unlawful antibiotic supply (OR = 0.53, 95% CI: 0.31-0.89; P = 0.016) but not appropriate practice.

Conclusions

Illegal and inappropriate dispensing of antibiotics was evident in the participating community pharmacies. This may be a public health threat to Sri Lanka and beyond. Strategies to improve the appropriate dispensing practice of antibiotics among community pharmacies should be considered seriously.

Antibiotic Resistance in Pacific Island Countries and Territories: A Systematic Scoping Review

Several studies have investigated antimicrobial resistance in low- and middle-income countries, but to date little attention has been paid to the Pacific Islands Countries and Territories (PICTs). This study aims to review the literature on antibiotic resistance (ABR) in healthcare settings in PICTs to inform further research and future policy development for the region. Following the PRISMA-ScR checklist health databases and grey literature sources were searched. Three reviewers independently screened the literature for inclusion, data was extracted using a charting tool and the results were described and synthesised. Sixty-five studies about ABR in PICTs were identified and these are primarily about New Caledonia, Fiji and Papua New Guinea. Ten PICTs contributed the remaining 21 studies and nine PICTs were not represented. The predominant gram-positive pathogen reported was community-acquired methicillin resistant S. aureus and the rates of resistance ranged widely (>50% to <20%). Resistance reported in gram-negative pathogens was mainly associated with healthcare-associated infections (HCAIs). Extended spectrum beta-lactamase (ESBL) producing K. pneumoniae isolates were reported in New Caledonia (3.4%) and Fiji (22%) and carbapenem resistant A. baumannii (CR-ab) isolates in the French Territories (24.8%). ABR is a problem in the PICTs, but the epidemiology requires further characterisation. Action on strengthening surveillance in PICTs needs to be prioritised so strategies to contain ABR can be fully realised.

Antibacterial Activities of Crude Secondary Metabolite Extracts from Pantoea Species Obtained from the Stem of Solanum mauritianum and Their Effects on Two Cancer Cell Lines

Endophytes are microorganisms that are perceived as non-pathogenic symbionts found inside plants since they cause no symptoms of disease on the host plant. Soil conditions and geography among other factors contribute to the type(s) of endophytes isolated from plants. Our research interest is the antibacterial activity of secondary metabolite crude extracts from the medicinal plant Solanum mauritianum and its bacterial endophytes. Fresh, healthy stems of S. mauritianum were collected, washed, surface sterilized, macerated in PBS, inoculated in the nutrient agar plates, and incubated for 5 days at 30 °C. Amplification and sequencing of the 16S rRNA gene was applied to identify the isolated bacterial endophytes. These endophytes were then grown in nutrient broth for 7⁻14 days, after which sterilized Amberlite® XAD7HP 20⁻60 mesh (Merck KGaA, Darmstadt, Germany) resin was added to each culture to adsorb the secondary metabolites, which were later extracted using ethyl acetate. Concentrated crude extracts from each bacterial endophyte were tested for antibacterial activity against 11 pathogenic bacteria and two human cancer cell lines. In this study, a total of three bacterial endophytes of the Pantoea genus were identified from the stem of S. mauritianum. The antibacterial test showed that crude secondary metabolites of the endophytes and stem of S. mauritianum possessed antibacterial properties against pathogenic microbes such as Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa, with concentrations showing inhibition ranging from 0.0625 to 8.0000 mg/mL. The anticancer analysis showed an increase in cell proliferation when A549 lung carcinoma and UMG87 glioblastoma cell lines were treated with both the plant and endophytes' crude extracts. As far as we know, this is the first study of its kind on Solanum mauritianum in South Africa showing S. mauritianum endophytes having activity against some of the common human pathogenic organisms.

Bacterial Infections in Neonates, Madagascar, 2012-2014

Severe bacterial infections are a leading cause of death among neonates in low-income countries, which harbor several factors leading to emergence and spread of multidrug-resistant bacteria. Low-income countries should prioritize interventions to decrease neonatal infections; however, data are scarce, specifically from the community. To assess incidence, etiologies, and antimicrobial drug–resistance patterns of neonatal infections, during 2012–2014, we conducted a community-based prospective investigation of 981 newborns in rural and urban areas of Madagascar. The incidence of culture-confirmed severe neonatal infections was high: 17.7 cases/1,000 live births. Most (75%) occurred during the first week of life. The most common (81%) bacteria isolated were gram-negative. The incidence rate for multidrug-resistant neonatal infection was 7.7 cases/1,000 live births. In Madagascar, interventions to improve prevention, early diagnosis, and management of bacterial infections in neonates should be prioritized.

Treating Surgical Infections in Low- and Middle-Income Countries: Source Control, Then What?

Surgical infections present a significant burden of disease globally. Management focuses on source control and appropriate antibiotic therapy. This remains a challenge in low- and middle-income settings, where access to surgical care and antibiotics is limited. This paper discusses the complex challenges facing the management of surgical infections in low- and middle-income countries.

Analysis of research intensity on infectious disease by disease burden reveals which infectious diseases are neglected by researchers

Infectious diseases are associated with considerable morbidity and mortality worldwide. Although human, financial, substantial, and time resources are limited, it is unknown whether such resources are used effectively in research to manage diseases. The correlation between the disability-adjusted life years to represent disease burden and number of publications as a surrogate for research activity was investigated to measure burden-adjusted research intensity for 52 infectious diseases at global and country levels. There was significantly low research intensity for paratyphoid fever and high intensity for influenza, HIV/acquired immunodeficiency syndrome, hepatitis C, and tuberculosis considering their disease burden. We identified the infectious diseases that have received the most attention from researchers and those that have been relatively disregarded. Interestingly, not all so-called neglected tropical diseases were subject to low burden-adjusted research intensity. Analysis of the intensity of infectious disease research at a country level revealed characteristic patterns. These findings provided a basis for further discussion of the more appropriate allocation of resources for research into infectious diseases.

Assessing the Potential Deployment of Biosensors for Point-of-Care Diagnostics in Developing Countries: Technological, Economic and Regulatory Aspects

Infectious diseases and antimicrobial resistance are major burdens in developing countries, where very specific conditions impede the deployment of established medical infrastructures. Since biosensing devices are nowadays very common in developed countries, particularly in the field of diagnostics, they are at a stage of maturity at which other potential outcomes can be explored, especially on their possibilities for multiplexing and automation to reduce the time-to-results. However, the translation is far from being trivial. In order to understand the factors and barriers that can facilitate or hinder the application of biosensors in resource-limited settings, we analyze the context from several angles. First, the technology of the devices themselves has to be rethought to take into account the specific needs and the available means of these countries. For this, we describe the partition of a biosensor into its functional shells, which define the information flow from the analyte to the end-user, and by following this partition we assess the strengths and weaknesses of biosensing devices in view of their specific technological development and challenging deployment in low-resource environments. Then, we discuss the problem of cost reduction by pointing out transversal factors, such as throughput and cost of mistreatment, that need to be re-considered when analyzing the cost-effectiveness of biosensing devices. Beyond the technical landscape, the compliance with regulations is also a major aspect that is described with its link to the validation of the devices and to the acceptance from the local medical personnel. Finally, to learn from a successful case, we analyze a breakthrough inexpensive biosensor that is showing high potential with respect to many of the described aspects. We conclude by mentioning both some transversal benefits of deploying biosensors in developing countries, and the key factors that can drive such applications.

Relation between flomoxef minimum inhibitory concentrations and clinical outcomes of patients treated with flomoxef for Enterobacteriaceae bacteremia

Background

Flomoxef is potentially effective against β-lactamase-producing Enterobacteriaceae because limited clinical data demonstrate its effectiveness against Enterobacteriaceae bloodstream infections (BSIs) based on its minimum inhibitory concentrations (MICs). This study was conducted to determine the optimal breakpoints based on the survival of patients with Enterobacteriaceae BSIs treated with flomoxef.

Methods

The 30-day crude mortality rate was analyzed among 224 adults who initiated flomoxef monotherapy for Enterobacteriaceae BSIs at a medical center over a 3-year period, according to the flomoxef MICs of the initial isolates. The outcome was evaluated by classification and regression tree modeling and by logistic regression analysis.

Results

The 30-day crude mortality was approximately two fold greater in patients whose isolates had flomoxef MICs of ≥2 mg/L (54.9% [62/113]) than in those with isolates with MICs of ≤1 mg/L (26.1% [29/111]); the differences were significant in bivariate analysis (P<0.01) and in survival analysis (log-rank test; P<0.001). The classification and regression tree analysis revealed a split between MICs of 1 and 2 mg/L and predicted the same difference in mortality, with a P-value of <0.001. Flomoxef for Enterobacteriaceae BSIs caused by isolates with flomoxef MICs of ≥2 mg/L was an independent predictor of 30-day crude mortality (adjusted OR 3.76, 95% CI 1.94–7.29).

Conclusion

Patients with Enterobacteriaceae bacteremia who received flomoxef had a lower 30-day crude mortality when the flomoxef MICs of the isolates were ≤1 mg/L than those with MICs ≥2 mg/L.

Antibiotic misuse among university students in developed and less developed regions of China: a cross-sectional survey

Background: Antimicrobial resistance (AMR) is a great threat to public health. The primary cause of AMR is human antibiotic misuse. Little is known about regional differences of antibiotic misuse behaviours in China.

Objectives: To explore the antibiotic misuse behaviours among university students in western and eastern China and find out the regional differences.

Methods: Participants were recruited from universities in less developed Guizhou Province and developed Zhejiang Province using a cluster random sampling method. A self-administered questionnaire was designed to collect data, and the χ² test and logistic regression were adopted to assess the associations between region and antibiotic misuse behaviours.

Results: A total of 2073 university students from Guizhou and 1922 from Zhejiang completed questionnaires. Students in Guizhou had lower household income, parents’ education, and urban residence proportion than those in Zhejiang. Compared with those in Zhejiang, students in Guizhou had higher antibiotic use prescribed by doctors (79.8% vs 56.2%) and self-medication with antibiotics (33.0% vs 16.1%). Students in Guizhou were more likely to buy over-the-counter antibiotics without prescriptions (73.9% vs 63.4%), ask for antibiotics from doctors (21.4% vs 15.6%), and use antibiotics prophylactically (29.9% vs 15.7%). Adjusted models showed that the less developed region was significantly associated with higher antibiotic misuse behaviours.

Conclusions: Misuse of antibiotics by well-educated young adults was very high in two regions but most serious in the less developed one. Campaigns are urgently needed to promote appropriate antibiotic use especially in less developed regions.

Presence of fluoroquinolone resistance with persistent occurrence of gyrA gene mutations in a municipal wastewater treatment plant in India

Municipal wastewater treatment plants (WWTP) have been cited as the reservoirs of antibiotic resistance, as they provide suitable conditions for the selection of antibiotic resistant bacteria over the antibiotic-sensitive ones. This study is an attempt to investigate the occurrence of fluoroquinolone (FQ) antibiotics, FQ-resistant bacteria in a WWTP located in India. The results indicated that the concentrations of FQ resistant bacteria ranged from 5.10 × 10³ to 5.76 × 10³ CFU/mL in the influent stream and 2.66 × 10² to 4 × 10² CFU/mL in the effluent stream. An increase in the fraction of FQ resistant bacteria over the total bacteria is observed at the bio-outlet indicating there is a selection pressure within the biological treatment unit of the treatment plant. The mean concentrations of the FQ antibiotics, namely ciprofloxacin, norfloxacin and ofloxacin in the influent ranged from 6 to 16.4 μg/L with 60-90% of removal in the biological treatment unit. Chlorine-based disinfection process was able to eliminate 96% of the FQ-resistant bacteria from the treated water being discharged into the river Ganges. However, the risk of horizontal gene transformation of resistance was found to be negligible as the resistant mutations occurred at Quinolone resistant determining region (QRDR) of Gyrase A gene. It is observed that 75% of the isolated bacteria showed two point mutations at S83L and D87N positions of the QRDR region of gyrA gene.

Using machine learning to guide targeted and locally-tailored empiric antibiotic prescribing in a children's hospital in Cambodia

Background: Early and appropriate empiric antibiotic treatment of patients suspected of having sepsis is associated with reduced mortality. The increasing prevalence of antimicrobial resistance reduces the efficacy of empiric therapy guidelines derived from population data. This problem is particularly severe for children in developing country settings. We hypothesized that by applying machine learning approaches to readily collect patient data, it would be possible to obtain individualized predictions for targeted empiric antibiotic choices. Methods and Findings: We analysed blood culture data collected from a 100-bed children's hospital in North-West Cambodia between February 2013 and January 2016. Clinical, demographic and living condition information was captured with 35 independent variables. Using these variables, we used a suite of machine learning algorithms to predict Gram stains and whether bacterial pathogens could be treated with common empiric antibiotic regimens: i) ampicillin and gentamicin; ii) ceftriaxone; iii) none of the above. 243 patients with bloodstream infections were available for analysis. We found that the random forest method had the best predictive performance overall as assessed by the area under the receiver operating characteristic curve (AUC). The random forest method gave an AUC of 0.80 (95%CI 0.66-0.94) for predicting susceptibility to ceftriaxone, 0.74 (0.59-0.89) for susceptibility to ampicillin and gentamicin, 0.85 (0.70-1.00) for susceptibility to neither, and 0.71 (0.57-0.86) for Gram stain result. Most important variables for predicting susceptibility were time from admission to blood culture, patient age, hospital versus community-acquired infection, and age-adjusted weight score. Conclusions: Applying machine learning algorithms to patient data that are readily available even in resource-limited hospital settings can provide highly informative predictions on antibiotic susceptibilities to guide appropriate empiric antibiotic therapy. When used as a decision support tool, such approaches have the potential to improve targeting of empiric therapy, patient outcomes and reduce the burden of antimicrobial resistance.

Antimicrobial use by WHO methodology at primary health care centers: a cross sectional study in Punjab, Pakistan

BACKGROUND

To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan.

METHODS

A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS.

RESULTS

Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1-19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1-39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1-1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9-89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3-6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6-4.3). The PHCCs prescribed a median of 5 (range = 3-9) types of AMs, including 10 (range = 5-15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs.

CONCLUSIONS

In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Comparative evaluation of cytotoxic, antimicrobial and antioxidant activities of the crude extracts of three Plectranthus species grown in Saudi Arabia

Natural products from medicinal plants represent major resource of novel therapeutic substances for combating serious diseases including cancers and microbial infections. The genus Plectranthus (Family: Labiatae) represents a large and widespread group of species with a diversity of traditional uses in treatment of various ailments. Therefore, this research study aimed to evaluate the cytotoxic, antimicrobial and antioxidant activities of three Plectranthus species growing in Saudi Arabia namely P. cylindraceus Hocst. ex Benth., P. asirensis JRI Wood and P. barbatus Andrews. Moreover, this work focused on the isolation of the active constituents responsible for the activities from the most active Plectranthus species.

The extracts were tested for their cytotoxic activity against three cancer cell lines (Hela, HepG2 and HT-29), using MTT-test, antimicrobial activity against Gram positive, Gram negative bacterial and fungal strains using broth micro-dilution assay for minimum inhibitory and bactericidal concentrations (MIC and MBC) and antioxidant activity using scavenging activity of DPPH radical and β-carotene-linoleic acid methods. The ethanolic extracts of the Plectranthus species showed remarkable cytotoxic activity against all cancer cell lines with IC₅₀ values ranging between 10.1 ± 0.33 to 102.6 ± 8.66 μg/mL and a great and antimicrobial activity with MIC values between 62.5 and 250 µg/mL. In addition, the three Plectranthus species showed almost moderate antioxidant activity. The most interesting cytotoxic and antimicrobial results were observed with the extract of P. barbatus. Consequently, this extract was partitioned between water and n-hexane, chloroform and n-butanol and tested. The cytotoxic activity resided predominantly in the n-hexane and chloroform fractions. The analysis of the chloroform fraction led to the isolation of four diterpenoid compounds, two of labdane- and two of abietane-type, which were identified as coleonol B, forskolin, sugiol and 5,6-dehydrosugiol. Purification of the n-hexane fraction led to isolation of a major abietane-type diterpene, which was identified as ferruginol. Sugiol, 5,6-dehydrosugiol and ferruginol were isolated for the first time from P. barbatus in this study. The isolated diterpenoids showed variable cytotoxic effects with IC₅₀ values between 15.1 ± 2.03 and 242 ± 13.3 µg/mL, a great antimicrobial activity with MIC values between 15.6 and 129 µg/mL and a total antioxidant activity ranging from 23.1 ± 2.9 to 69.2 ± 3.8%.

Antibiotic prescribing and dispensing for acute respiratory infections in children: effectiveness of a multi-faceted intervention for health-care providers in Vietnam

Background: Appropriate antibiotic use is vital to effectively contain antibiotic resistance and improve global health. Acute respiratory infections (ARIs) remain the leading cause of disease and death in children under five in low-income countries.

Objective: To evaluate a multi-faceted intervention targeting health-care-providers’ (HCPs) knowledge, practical competences and practices regarding antibiotic use for ARIs.

Methods: A multi-faceted educational intervention with a two-armed randomised controlled design targeting HCPs treating ARIs in children was conducted in Bavi district, a rural district in Northern Vietnam in 2010–2011. Thirty-two communes of the district were randomized into two arms, with 144 HCPs in the intervention arm and 160 in the control arm. The intervention, conducted over seven months, comprised: (i) education regarding appropriate-antibiotic use, (ii) case scenario discussion and (iii) poster distribution. Questionnaires to assess knowledge and dispensing/prescribing forms to assess practice were completed before-and after interventions. The main outcome measures were differences in improvement in knowledge and practice in the intervention and control group, respectively.

Results: Knowledge improved in the intervention group for ARI aetiology by 28% (Δ_{Decrement control arm} 10%), antibiotic use for mild ARIs by 15% (Δ_{Decrement control arm} 13%) and for severe ARIs by 14% (Δ_{Improvement control arm} 29%). Practical competence for a mild ARI case scenario improved in the intervention and control groups by 20% and 11%, respectively. Total knowledge score increased statistically in the intervention group (Δ_{mean improvement} 1.17); less so in the control group (Δ_{mean improvement} 0.48). Practice regarding antibiotics for mild ARIs improved by 28% in the intervention group (Δ_{Decrement control arm} 3%).

Conclusions: The intervention significantly improved HCPs’ knowledge of ARIs and practice of antibiotic use in treatment of ARIs. We suggest mixed method assessment and long-term follow-up of these interventions to enable better appreciation of the effects and effect sizes of our interventions.

Antibiotic Stewardship in Community Pharmacies: A Scoping Review

The increase in antibiotic resistance has frequently been linked to unrestrained antibiotic dispensing. This review was conducted to mainly assess the perception and attitudes of community pharmacists towards antibiotic dispensing. This scoping review was performed between June 2016 and September 2016 to identify published studies related to the perception and attitudes of community pharmacists towards antibiotic dispensing. The combination of terms such as 'antibiotic dispensing', 'antimicrobial resistance', 'community pharmacy', and 'community pharmacists' were searched in electronic databases such as PubMed, ProQuest, Google Scholar, and Science Direct. Only published articles within the last 12 years were included. A total of 13 studies were identified. In general, community pharmacists have good awareness and knowledge of antibiotic dispensing. However, the majority of them are still selling antibiotics to their customers and/or patients for unjustified reasons. The community pharmacists seem well aware of the antimicrobial resistance crisis and considered it a significant health issue. However, many embraced the concept that dispensing antibiotics without medical prescription (DAwMP) can be one of the key features in the dissemination of multidrug resistant bacteria.

Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review

BACKGROUND

Poverty increases the risk of contracting infectious diseases and therefore exposure to antibiotics. Yet there is lacking evidence on the relationship between income and non-income dimensions of poverty and antimicrobial resistance. Investigating such relationship would strengthen antimicrobial stewardship interventions.

METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Ovid, MEDLINE, EMBASE, Scopus, CINAHL, PsychINFO, EBSCO, HMIC, and Web of Science databases were searched in October 2016. Prospective and retrospective studies reporting on income or non-income dimensions of poverty and their influence on colonisation or infection with antimicrobial-resistant organisms were retrieved. Study quality was assessed with the Integrated quality criteria for review of multiple study designs (ICROMS) tool.

RESULTS

Nineteen articles were reviewed. Crowding and homelessness were associated with antimicrobial resistance in community and hospital patients. In high-income countries, low income was associated with Streptococcus pneumoniae and Acinetobacter baumannii resistance and a seven-fold higher infection rate. In low-income countries the findings on this relation were contradictory. Lack of education was linked to resistant S. pneumoniae and Escherichia coli. Two papers explored the relation between water and sanitation and antimicrobial resistance in low-income settings.

CONCLUSIONS

Despite methodological limitations, the results suggest that addressing social determinants of poverty worldwide remains a crucial yet neglected step towards preventing antimicrobial resistance.

Antibiotic Resistance in Syria: A Local Problem Turns Into a Global Threat

Pharmaceutical sector of Syrian Arab Republic before the war was characterized by bold and successful development since the late 1980s. With the beginning of war in the country back in March 2011, momentum has changed significantly. Traumatism, communicable diseases related to morbidity and mortality as well as wound infections became particularly hot public health concern. This relates not only to the direct victims of military conflict but also to the displaced civilians, refugees, and ordinary citizens alike. Evolving legislative framework in Syria since 1980s tolerated dispensing of antibiotics without appropriate prescription. Such practice led to spreading of antibiotic resistance among the local bacteria frequently causing both community-acquired and nosocomial infections. Laboratory findings of resistant bacteria strains among the Syrian refugees in some European countries serve as evidence of concern spreading far beyond Middle East. Practice of self-diagnosis and self-medication with antibiotics by patients themselves and restraint to pharmacist advice is widespread. A number of recommendations is presented to stakeholders to compact antibiotic resistance after the peace is established in the country. The successful implementation of such recommendations is the way to preserve shrinking golden reserve of highly potent antibiotics as it is the last defense line against resistant bacterial strains causing severe life—threatening infections.

Antimicrobial Drug Resistance in Blood Culture Isolates at a Tertiary Hospital, Uganda

We summarize antimicrobial drug resistance (AMR) patterns from blood cultures at a tertiary hospital in Uganda. High rates of resistance to first-line antibiotic drugs were observed among Staphylococcus aureus and gram-negative organisms. Microbiology services with susceptibility testing should be strengthened to support standardized reporting of AMR data in sub-Saharan Africa.

Prevalence and antibiotic susceptibility patterns of Shigella and Salmonella among children aged below five years with Diarrhoea attending Nigist Eleni Mohammed memorial hospital, South Ethiopia

BACKGROUND

Diarrhoeal disease is the second leading cause of death among children aged below 5 years. Even though, both preventable and treatable diseases, globally there are nearly 1.7 billion cases of childhood diarrhoeal disease and responsible for killing around 525,000 children every year. Shigella and Salmonella species were the leading cause of etiologic agents for diarrhoea associated deaths. The aim of this study was to determine the prevalence and antibiotic susceptibility patterns of Shigella and Salmonella isolated from children aged below 5 years with diarrhoea attending Nigist Eleni Mohammed Memorial Hospital, Hossana, South Ethiopia.

METHODS

A cross sectional study was conducted from June 02 to September 24, 2017. Two hundred four children aged below 5 years with diarrhoea were enrolled consecutively using convenience sampling technique. Stool specimens were processed in accordance with the standard bacteriological methods and antibiotic susceptibility pattern of the isolates was determined using disc diffusion method. Data were analyzed using SPSS version 20.

RESULTS

Out of the 204 children aged below 5 years with diarrhoeal disease 19/204 (9.3%, [95%CI, 5.7-13.7%]) of them were positive for bacterial growth, of which 17/204(8.3%) were Shigella species and 2/204(1%) were Salmonella species. Both Shigella and Salmonella isolates were 100% susceptible to norfloxacin, nalidixic acid and kanamycin. However, isolates of Shigella showed 100, 76.5 and 64.7% resistance to ampicillin, gentamicin and cotrimoxazole respectively while Salmonella species were highly resistant to ampicillin and gentamicin (100% each).

CONCLUSIONS

Salmonella and Shigella species is prevalent in the current study area. Among the tested antibiotics, norfloxacin, nalidixic acid and kanamycin were found to be most effective for both isolates. Both species are developing resistance to the commonly prescribed antibiotic. Therefore, culture based bacterial species identification and antimicrobial susceptibility testing services are strongly recommended to avoid empirical treatment in the study area.

Using risk adjustment to improve the interpretation of global inpatient pediatric antibiotic prescribing

Objectives

Assessment of regional pediatric last-resort antibiotic utilization patterns is hampered by potential confounding from population differences. We developed a risk-adjustment model from readily available, internationally used survey data and a simple patient classification to aid such comparisons.

Design

We investigated the association between pediatric conserve antibiotic (pCA) exposure and patient / treatment characteristics derived from global point prevalence surveys of antibiotic prescribing, and developed a risk-adjustment model using multivariable logistic regression. The performance of a simple patient classification of groups with different expected pCA exposure levels was compared to the risk model.

Setting

226 centers in 41 countries across 5 continents.

Participants

Neonatal and pediatric inpatient antibiotic prescriptions for sepsis/bloodstream infection for 1281 patients.

Results

Overall pCA exposure was high (35%), strongly associated with each variable (patient age, ward, underlying disease, community acquisition or nosocomial infection and empiric or targeted treatment), and all were included in the final risk-adjustment model. The model demonstrated good discrimination (c-statistic = 0.83) and calibration (p = 0.38). The simple classification model demonstrated similar discrimination and calibration to the risk model. The crude regional pCA exposure rates ranged from 10.3% (Africa) to 67.4% (Latin America). Risk adjustment substantially reduced the regional variation, the adjusted rates ranging from 17.1% (Africa) to 42.8% (Latin America).

Conclusions

Greater comparability of pCA exposure rates can be achieved by using a few easily collected variables to produce risk-adjusted rates.

Epidemiology and molecular characterization of multidrug-resistant Escherichia coli isolates harboring blaCTX-M group 1 extended-spectrum β-lactamases causing bacteremia and urinary tract infection in Manhiça, Mozambique

Background

The emergence and spread of extended-spectrum β-lactamases (ESBLs), especially CTX-M, is an important public health problem with serious implications for low-income countries where second-line treatment is often unavailable. Knowledge of the local prevalence of ESBL is critical to define appropriate empirical therapeutic strategies for multidrug-resistant (MDR) organisms. This study aimed to assess and characterize the presence of ESBL and especially CTX-M-producing Escherichia coli MDR isolates from patients with urinary tract infections (UTIs) and bacteremia in a rural hospital in Mozambique.

Materials and methods

One hundred and fifty-one E. coli isolates from bacteremia and UTI in children were screened for CTX-M, TEM, SHV and OXA β-lactamases by polymerase chain reaction and sequencing. Isolates carrying CTX-M group 1 β-lactamases were further studied. The resistance to other antibiotic families was determined by phenotypic and genotypic methods, the location of the bla_CTX-M gene and the epidemiology of the isolates were studied, and extensive plasmid characterization was performed.

Results

Approximately 11% (17/151) of E. coli isolates causing bacteremia and UTI were ESBL producers. CTX-M-15 was the most frequently detected ESBL, accounting for 75% of the total isolates characterized. The bla_CTX-M gene is located in different plasmids belonging to different incompatibility groups and can be found in non-epidemiologically related isolates, indicating the high capacity of this resistance determinant to spread widely.

Conclusion

Our data suggest the presence of a co-selection of third-generation cephalosporin-resistant determinants in the study area despite limited access to these antibiotics. This highlights the importance of continuous surveillance of antimicrobial resistance of both genetic elements of resistance and resistant isolates in order to monitor the emergence and trends of ESBL-producing isolates to promote adequate therapeutic strategies for the management of MDR bacterial infections.

Pattern of Antimicrobial Resistance among Bacterial Isolates from Urogenital Clinical Specimens: A Descriptive Study from the Buea Health District, Cameroon

INTRODUCTION

Antimicrobial resistance has become a global concern and is particularly affecting developing countries where infectious diseases and poverty are endemic. The effectiveness of currently available antimicrobials is decreasing as a result of increasing resistant strains among clinical isolates.

OBJECTIVES

The aim of this study was to determine the resistance pattern of bacterial isolates from different clinical urogenital specimens at different hospitals in the Buea Health District, Cameroon.

METHODS

A retrospective study was conducted in three hospital laboratories in the Buea Health District, Cameroon, from June to August 2017. All culture and antimicrobial susceptibility test results of patients who presented at each of the laboratories for urine, vaginal swab or urethral swab cultures from January 2012 to December 2016 were included in the study. Data were analysed using SPSS Windows version 20.0. The comparisons between different isolates' resistance to antimicrobials were performed using the chi-square test. The difference in the resistance of urogenital isolates to various antimicrobials within different years was also compared by the chi-square test.

RESULTS

A total of 423 bacterial isolates were obtained from clinical urogenital specimens such as: urine 93 (21.9%), vaginal swab 175 (41.4%) and urethral swab cultures 155 (36.6%). The predominant bacterial isolates were Staphylococcus spp. 320 (75.5%), Escherichia coli 37 (8.7%) and Enterococcus spp. 24 (5.7%). All the isolates showed significantly high resistance rates to amoxicillin/clavulanic acid (67.6% resistant rate, p = 0.025), but most isolates, except those of Staphylococcus, were relatively more susceptible to nitrofurantoin (82.6% susceptibility rate, p = 0.045). However, Staphylococcus spp. was more susceptible to ceftriaxone (91.0% susceptibility rate, p < 0.0001) and cefotaxime (74.4% susceptibility rate, p = 0.034). Generally, most of the isolates showed significantly rising rates of resistance to the majority of the antimicrobials tested from 2012 to 2017.

CONCLUSION

Our findings showed a progressively rising rate of antimicrobial resistance in urogenital bacterial isolates over the last 5 years in the Buea Health District. Thus, uncontrolled and irrational use or prescription of these drugs should be avoided to maintain low resistance of highly susceptible antimicrobials.

Electro-peroxone pretreatment for enhanced simulated hospital wastewater treatment and antibiotic resistance genes reduction

Hospital wastewater is one of the possible sources responsible for antibiotic resistant bacteria spread into the environment. This study proposed a promising strategy, electro-peroxone (E-peroxone) pretreatment followed by a sequencing batch reactor (SBR) for simulated hospital wastewater treatment, aiming to enhance the wastewater treatment performance and to reduce antibiotic resistance genes production simultaneously. The highest chemical oxygen demand (COD) and total organic carbon (TOC) removal efficiency of 94.3% and 92.8% were obtained using the E-peroxone-SBR process. The microbial community analysis through high-throughput sequencing showed that E-peroxone pretreatment could guarantee microbial richness and diversity in SBR, as well as reduce the microbial inhibitions caused by antibiotic and raise the amount of nitrification and denitrification genera. Specially, quantitative real-time PCRs revealed that E-peroxone pretreatment could largely reduce the numbers and contents of antibiotic resistance genes (ARGs) production in the following biological treatment unit. It was indicated that E-peroxone-SBR process may provide an effective way for hospital wastewater treatment and possible ARGs reduction.

How effective and cost-effective are behaviour change interventions in improving the prescription and use of antibiotics in low-income and middle-income countries? A protocol for a systematic review

INTRODUCTION

Antibiotic resistance endangers effective prevention and treatment of infections, and places significant burden on patients, families, communities and healthcare systems. Low-income and middle-income countries (LMICs) are especially vulnerable to antibiotic resistance, owing to high infectious disease burden, and limited resources for treatment. High prevalence of antibiotic prescription and use due to lack of provider's knowledge, prescriber's habits and perceived patient needs further exacerbate the situation. Interventions implemented to address the inappropriate prescription and use of antibiotics in LMICs must address different determinants of antibiotic resistance through sustainable and scalable interventions. The aim of this protocol is to provide a comprehensive overview of the methods that will be used to identify and appraise evidence on the effectiveness and cost-effectiveness of behaviour change interventions implemented in LMICs to improve the prescription and use of antibiotics.

METHODS AND ANALYSIS

Two databases (Web of Science and PubMed) will be searched based on a strategy developed in consultation with an essential medicines and health systems researcher. Additional studies will be identified using the same search strategy in Google Scholar. To be included, a study must describe a behaviour change intervention and use an experimental design to estimate effectiveness and/or cost-effectiveness in an LMIC. Following systematic screening of titles, abstracts and keywords, and full-text appraisal, data will be extracted using a customised extraction form. Studies will be categorised by type of behaviour change intervention and experimental design. A meta-analysis or narrative synthesis will be conducted as appropriate, along with an appraisal of quality of studies using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) checklist.

ETHICS AND DISSEMINATION

No individual patient data are used, so ethical approval is not required. The systematic review will be disseminated in a peer-reviewed journal and presented at a relevant international conference.

PROSPERO REGISTRATION NUMBER

CRD42017075596.

Enhancing pharmacists' role in developing countries to overcome the challenge of antimicrobial resistance: a narrative review

Background

Antimicrobial resistance (AMR) is a global health challenge and developing countries are more vulnerable to the adverse health impacts of AMR. Health care workers including pharmacists can play a key role to support the appropriate use of antimicrobials in developing countries and reduce AMR.

Objective

The aim of this review is to investigate the role of pharmacists in the appropriate use of antibiotics and to identify how the pharmacists’ role can be enhanced to combat AMR in developing countries.

Method

The databases MEDLINE, EMBASE, Web of Science and Google Scholar were searched for articles published between 2000 and the end of August 2017 that involved studies on the role of pharmacists in developing countries, the expanded services of pharmacists in patient care in developed countries and pharmacists’ contributions in antimicrobial use in both developed and developing nations.

Key findings

In developing countries pharmacists role in patient care are relatively limited. However, in developed nations, the pharmacists’ role has expanded to provide multifaceted services in patient care resulting in improved health outcomes from clinical services and reduced health care costs. Success stories of pharmacist-led programs in combating AMR demonstrates that appropriately trained pharmacists can be part of the solution to overcome the global challenge of AMR. Pharmacists can provide education to patients enabling them to use antibiotics appropriately. They can also provide guidance to their healthcare colleagues on appropriate antibiotic prescribing.

Conclusions

This review highlights that appropriately trained pharmacists integrated into the health care system can make a significant impact in minimising inappropriate antibiotic use in developing countries. Strengthening and enhancing the pharmacists’ role in developing countries has the potential to positively impact the global issue of AMR.

Synergistic Effect of Diallyl Sulfide With Zinc Oxide Nanorods: A Novel and Effective Approach for Treatment of Acute Dermatitis in Model Animals

Besides inciting persistent and recurrent nosocomial afflictions, Staphylococcus aureus (S. aureus), a biofilm forming pathogen, poses an increased risk of several skin as well as respiratory tract infections as well. Emerging antimicrobial resistance trend asks to search for an alternate non-antibiotic based option to combat S. aureus pathogen. In the present study, we evaluated synergistic antimicrobial potential of Zinc oxide nanorods (ZnO-NRs) and diallyl sulphide (DAS) emulsion against methicillin resistant Staphylococcus aureus (MRSA). The antimicrobial assessment study suggests that the ZnO-NR and DAS emulsion effectively suppressed both sensitive S. aureus as well as MRSA isolates. The combination treatment showed enhanced activity even at a lower concentration as compared to the single treatment based on ZnO-NRs and DAS emulsion alone. The ZnO-NRs-DAS combination showed significant inhibition of MRSA biofilm as well. The data suggest that a combination therapy, comprising of ZnO-NRs and DAS emulsion, successfully treated experimental dermatitis infection caused by MRSA in mice model.

Antimicrobials usage assessments in commercial poultry and local birds in North-central Nigeria: Associated pathways and factors for resistance emergence and spread

The World Health Organization's Global Action Plan on antimicrobial resistance (AMR) recommended monitoring of antimicrobial use (AMU) through surveillance and research to help mitigate AMR. This survey was aimed at assessing poultry owners' knowledge/awareness and practices regarding AMU, identified pathways for AMR emergence and spread in small-scale commercial poultry farms and free-range local bird flocks in North-central Nigeria. An interview questionnaire-based cross-sectional study was conducted on commercial poultry farmers and local bird flock keepers in 2017. Also, a Traffic Light system model was used assess risk status of AMU in farms and flocks. All the 384 recruited poultry farmers/keepers participated in the survey. Female respondents were the majority (67.2%). Low proportion of poultry farmers (46.4%, 89/192) and very low proportion of bird keepers (6.8%, 13/192) knew antimicrobials misuse to be when administered under dose. About 48% (93/192) of farmers and 93% (179/192) of keepers arbitrary determined antimicrobial dosage before administration. Respondents used antimicrobials for therapeutic, prophylactic, and growth promotion in birds. Also, participants significantly identified contaminated poultry products, infected poultry or contaminated formites, and discharged contaminated faeces into environment as pathways for transmission of antimicrobial resistant pathogens to humans. Traffic Light system model revealed 88.5% of small-scale commercial poultry farms to frequently used antimicrobials without veterinarians' consultations thereby attaining Class 1 (Red risk) status. The model showed that 92.1% of free-range local bird flocks rarely used antimicrobials thereby attaining Class 3 (Green risk) status. Improper antimicrobial dosage in poultry (OR: 7.23; 95% CI: 2.74, 19.21), non-enforcement of AMU regulating laws in poultry (OR: 4.12; 95% CI: 2.39, 7.10), weak financial status of poultry owners (OR: 3.00; 95% CI: 2.39, 7.10), and management system (OR: 8.94; 95% CI: 5.62, 14.24) were more likely to satisfactorily influenced antimicrobials misuse in poultry farms and local bird flocks. The survey revealed low knowledge level regarding AMU in the poultry. Antimicrobials were rarely used in local bird flocks, making them likely organic and safe from AMR. It is imperative to educate farmers on judicious AMU, enforce existing veterinary legislation on antimicrobials, establish antimicrobials surveillance system, and sensitize farmers on adequate biosecurity measures and routine vaccination of farms, so as to assure food safety, food security, and public health.

A Comparison of Patients' Local Conceptions of Illness and Medicines in the Context of C-Reactive Protein Biomarker Testing in Chiang Rai and Yangon

Antibiotic resistance is not solely a medical but also a social problem, influenced partly by patients' treatment-seeking behavior and their conceptions of illness and medicines. Situated within the context of a clinical trial of C-reactive protein (CRP) biomarker testing to reduce antibiotic over-prescription at the primary care level, our study explores and compares the narratives of 58 fever patients in Chiang Rai (Thailand) and Yangon (Myanmar). Our objectives are to 1) compare local conceptions of illness and medicines in relation to health-care seeking and antibiotic demand; and to 2) understand how these conceptions could influence CRP point-of-care testing (POCT) at the primary care level in low- and middle-income country settings. We thereby go beyond the current knowledge about antimicrobial resistance and CRP POCT, which consists primarily of clinical research and quantitative data. We find that CRP POCT in Chiang Rai and Yangon interacted with fever patients' preexisting conceptions of illness and medicines, their treatment-seeking behavior, and their health-care experiences, which has led to new interpretations of the test, potentially unforeseen exclusion patterns, implications for patients' self-assessed illness severity, and an increase in the status of the formal health-care facilities that provide the test. Although we expected that local conceptions of illness diverge from inbuilt assumptions of clinical interventions, we conclude that this mismatch can undermine the intervention and potentially reproduce problematic equity patterns among CRP POCT users and nonusers. As a partial solution, implementers may consider applying the test after clinical examination to validate rather than direct prescription processes.

Toxicity against Drosophila melanogaster and antiedematogenic and antimicrobial activities of Alternanthera brasiliana (L.) Kuntze (Amaranthaceae)

Bioactive phytocompounds are studied by several bioactivities demonstrated, as their cytotoxic effects. The aim of this work was to evaluate the phytochemical profile, the toxic effect using the Drosophila melanogaster animal model and the anti-inflammatory and antimicrobial effect of the Alternanthera brasiliana (EEAB) ethanol extract. The phytochemical profile was performed using HPLC. The cytotoxic effect was evaluated in vivo using D. melanogaster. The anti-inflammatory effect was determined by neurogenic and antiedematogenic assays, and the antimicrobial activity was assayed using a microdilution method to determine the minimum inhibitory concentration (MIC) of the EEAB alone and in association with antibiotics. The main compound identified on the EEAB was luteolin (1.93%). Its cytotoxic effect was demonstrated after 24 h in the concentrations of 10, 20 and 40 mg/mL. The extract demonstrated an antiedematogenic effect, with a reduction of the edema between 35.57 and 64.17%. The MIC of the extract was ≥1.024 μg/mL, thus being considered clinically irrelevant. However, when the EEAB was associated with gentamicin, a synergism against all bacterial strains assayed was observed: Staphylococcus aureus (SA10), Escherichia coli (EC06) and Pseudomonas aeruginosa (PA24). Due to these results, the EEAB demonstrated a low toxicity in vivo and anti-inflammatory and synergistic activities. These are promising results, mainly against microbial pathogens, and the compounds identified can be a source of carbon backbones for the discovery and creation of new drugs.

Expression of the Fluoroquinolones Efflux Pump Genes acrA and mdfA in Urinary Escherichia coli Isolates

Escherichia coli is one of the most frequent causes of urinary tract infections. Efflux system overexpression is reported to contribute to E. coli resistance to several antibiotics. Our aim in this study was to investigate the relation between antibiotic resistance and the expression of the efflux pump genes acrA and mdfA in E. coli by real-time reverse transcription-PCR. We tested the in vitro susceptibilities to 12 antibiotics in 28 clinical isolates of E. coli obtained from urine samples. We also determined the minimum inhibitory concentrations of levofloxacin to these samples. We then revealed significant correlations between the overexpression of both mdfA and acrA and MICs of levofloxacin. In conclusion, we demonstrated that the increased expression of efflux pump genes such as mdfA and acrA can lead to levofloxacin resistance in E. coli. These findings contribute to further understanding of the molecular mechanisms of efflux pump systems and how they contribute to antibiotic resistance.

Epidemiology of antibiotic-resistant wound infections from six countries in Africa

Introduction

Little is known about the antimicrobial susceptibility of common bacteria responsible for wound infections from many countries in sub-Saharan Africa.

Methods

We performed a retrospective review of microbial isolates collected based on clinical suspicion of wound infection between 2004 and 2016 from Mercy Ships, a non-governmental organisation operating a single mobile surgical unit in Benin, Congo, Liberia, Madagascar, Sierra Leone and Togo. Antimicrobial resistant organisms of interest were defined as methicillin-resistant Staphylococcus aureus (MRSA) or Enterobacteriaceae resistant to third-generation cephalosporins. Generalised mixed-effects models accounting for repeated isolates in a patient, potential clustering by case mix for each field service, age, gender and country were used to test the hypothesis that rates of antimicrobial resistance differed between countries.

Results

3145 isolates from repeated field services in six countries were reviewed. In univariate analyses, the highest proportion of MRSA was found in Benin (34.6%) and Congo (31.9%), while the lowest proportion was found in Togo (14.3%) and Madagascar (14.5%); country remained a significant predictor in multivariate analyses (P=0.002). In univariate analyses, the highest proportion of third-generation cephalosporin-resistant Enterobacteriaceae was found in Benin (35.8%) and lowest in Togo (14.3%) and Madagascar (16.3%). Country remained a significant predictor for antimicrobial-resistant isolates in multivariate analyses (P=0.009).

Conclusion

A significant proportion of isolates from wound cultures were resistant to first-line antimicrobials in each country. Though antimicrobial resistance isolates were not verified in a reference laboratory and these data may not be representative of all regions of the countries studied, differences in the proportion of antimicrobial-resistant isolates and resistance profiles between countries suggest site-specific surveillance should be a priority and local antimicrobial resistance profiles should be used to guide empiric antibiotic selection.

Acquisition of extended spectrum beta-lactamase-producing enterobacteriaceae in neonates: A community based cohort in Madagascar

In low and middle income countries (LMICs), where the burden of neonatal sepsis is the highest, the spread of extended spectrum beta-lactamase-producing enterobacteriaceae (ESBL-PE) in the community, potentially contributing to the neonatal mortality, is a public health concern. Data regarding the acquisition of ESBL-PE during the neonatal period are scarce. The routes of transmission are not well defined and particularly the possible key role played by pregnant women. This study aimed to understand the neonatal acquisition of ESBL-PE in the community in Madagascar. The study was conducted in urban and semi-rural areas. Newborns were included at birth and followed-up during their first month of life. Maternal stool samples at delivery and six stool samples in each infant were collected to screen for ESBL-PE. A Cox proportional hazards model was performed to identify factors associated with the first ESBL-PE acquisition. The incidence rate of ESBL-PE acquisition was 10.4 cases/1000 newborn-days [95% CI: 8.0–13.4 cases per 1000 newborn-days]. Of the 83 ESBL-PE isolates identified, Escherichia coli was the most frequent species (n = 28, 34.1%), followed by Klebsiella pneumoniae (n = 20, 24.4%). Cox multivariate analysis showed that independent risk factors for ESBL-PE acquisition were low birth weight (adjusted Hazard-ratio (aHR) = 2.7, 95% CI [1.2; 5.9]), cesarean-section, (aHR = 3.4, 95% CI [1.7; 7.1]) and maternal use of antibiotics at delivery (aHR = 2.2, 95% CI [1.1; 4.5]). Our results confirm that mothers play a significant role in the neonatal acquisition of ESBL-PE. In LMICs, public health interventions during pregnancy should be reinforced to avoid unnecessary caesarean section, unnecessary antibiotic use at delivery and low birth weight newborns.

Frequent Community Use of Antibiotics among a Low-Economic Status Population in Manila, the Philippines: A Prospective Assessment Using a Urine Antibiotic Bioassay

The widespread unregulated use of antibiotics without medical consultation contributes to the burden of antibiotic resistance in Southeast Asian countries. This study investigated antibiotic use before hospital consultation. In a prospective observational study from February 2, 2015, to July 2, 2015, we enrolled febrile patients attending the emergency room in San Lazaro Hospital, Manila, the Philippines. A urine sample was collected and a bioassay was used to detect antibiotic activity in urine using Bacillus stearothermophilus (ATCC7953), Escherichia coli (ATCC25922), and Streptococcus pyogenes (ATCC19615). Patients or caregivers reported their medication history, clinical information, and socioeconomic status. During the study period, 410 patients were enrolled. The median (interquartile range) age was 14 (7-23) years and 158 (39%) reported prior antibiotic use, predominantly a beta-lactam antibiotic. A total of 164 (40%, 95% confidence interval [CI]: 35-45) patients were urine bioassay positive with any of three organisms. The Bacillus assay was the most sensitive, detecting 162 (99%, 95% CI: 96-100) cases. Among bioassay positive patients, dengue (N = 91, 55%, 95% CI: 48-63) was the most frequent diagnosis, followed by other viral infections, including measles, rubella, and mumps (N = 17, 10%, 95% CI: 6-16). Patients with a positive bioassay were significantly more likely to be from the lowest-income group (adjusted odds ratio [AOR]: 1.7; 95% CI: 1.1-2.6) and required hospital admission (AOR: 2.1; 95% CI: 1.3-3.5). Unnecessary antibiotic use for febrile illnesses before hospital consultation is common in a low-income, highly populated urban community in Manila. Education targeting this group should be implemented to reduce unnecessary antibiotic use.

Molecular analysis of integrons and antimicrobial resistance profile in Shigella spp. isolated from acute pediatric diarrhea patients

Introduction:Shigella spp. is a growing global health concern due to increasing multiple drug resistance, commonly resulting in therapeutic failure. Integrons are gene expression systems run by integrase genes. The aims of this study were detection of class I, II and III integrons and assessment of antimicrobial resistance in Shigella spp. isolated from acute pediatric diarrhea patients. Materials and methods: From January to December 2015, 16 Shigella spp. were isolated from 310 non-duplicative diarrheal stool samples in Children's Medical Center, Tehran, Iran. The isolates were analyzed for their antibiotic susceptibility using CLSI guidelines M100-S14. Multiplex PCR was used for amplification of I, II and III integron-associated integrase (intl) genes. Results: Of 310 stool samples, 16 (5.2%) were positive for Shigella spp., in 7 of them S. sonnei and in 9 of them S. flexneri were identified. Results of the antimicrobial susceptibility test showed that 6.2%, 50%, 31.2%, 6.2%, 81.2%, 56.2% and 31.2% of the isolates were resistant to gentamicin, chloramphenicol, nalidixic acid, ciprofloxacin, tetracycline, ampicillin and trimethoprim-sulfamethoxazole, respectively. Multiplex PCR results revealed that 6.2% (1/16), 31.2% (5/16), 50% (8/16) of Shigella isolates carried intlI, intlII and both intlI/intllI genes. No class 3 integrons were detected. Discussion: In this study, multidrug resistance was seen in Shigella isolates similar to that in isolates from other geographical areas. This is possible due to inappropriate use of antimicrobials. Furthermore, prevalence of multidrug resistance was significantly linked to the presence of integrin genes. Conclusion: A class 2 integron plays a role in presence of multidrug resistance in Shigella spp. It is vital to prevent the spread of antibiotic resistance through continuous monitoring.