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Kamara IF, Fofanah BD, Nuwagira I, Kamara KN, Tengbe SM, Abiri O, Kamara RZ, Lakoh S, Farma L, Kamara AK, Hailu B, Dove D, Squire JS, D'Almeida SA, Sheriff B, Mustapha A, Bawa N, Lagesse H, Koroma AT, Kanu JS. Assessment of antimicrobial stewardship programmes and antibiotic use among children admitted to two hospitals in Sierra Leone: a cross-sectional study. Antimicrob Resist Infect Control 2024; 13:80. [PMID: 39039593 PMCID: PMC11265072 DOI: 10.1186/s13756-024-01425-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 06/14/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a global public health concern and irrational use of antibiotics in hospitals is a key driver of AMR. Even though it is not preventable, antimicrobial stewardship (AMS) programmes will reduce or slow it down. Research evidence from Sierra Leone has demonstrated the high use of antibiotics in hospitals, but no study has assessed hospital AMS programmes and antibiotic use specifically among children. We conducted the first-ever study to assess the AMS programmes and antibiotics use in two tertiary hospitals in Sierra Leone. METHODS This was a hospital-based cross-sectional survey using the World Health Organization (WHO) point prevalence survey (PPS) methodology. Data was collected from the medical records of eligible patients at the Ola During Children's Hospital (ODCH) and Makeni Regional Hospital (MRH) using the WHO PPS hospital questionnaire; and required data collection forms. The prescribed antibiotics were classified according to the WHO Access, Watch, and Reserve (AWaRe) classification. Ethics approval was obtained from the Sierra Leone Ethics and Scientific Review Committee. Statistical analysis was conducted using the SPSS version 22. RESULTS Both ODCH and MRH did not have the required AMS infrastructure; policy and practice; and monitoring and feedback mechanisms to ensure rational antibiotic prescribing. Of the 150 patients included in the survey, 116 (77.3%) were admitted at ODCH and 34 (22.7%) to MRH, 77 (51.3%) were males and 73 (48.7%) were females. The mean age was 2 years (SD=3.5). The overall prevalence of antibiotic use was 84.7% (95% CI: 77.9% - 90.0%) and 77 (83.8%) of the children aged less than one year received an antibiotic. The proportion of males that received antibiotics was higher than that of females. Most (58, 47.2 %) of the patients received at least two antibiotics. The top five antibiotics prescribed were gentamycin (100, 27.4%), ceftriaxone (76, 20.3%), ampicillin (71, 19.5%), metronidazole (44, 12.1%), and cefotaxime (31, 8.5%). Community-acquired infections were the primary diagnoses for antibiotic prescription. CONCLUSION The non-existence of AMS programmes might have contributed to the high use of antibiotics at ODCH and MRH. This has the potential to increase antibiotic selection pressure and in turn the AMR burden in the country. There is need to establish hospital AMS teams and train health workers on the rational use of antibiotics.
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Affiliation(s)
- Ibrahim Franklyn Kamara
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone.
- Reproductive maternal newborn child and adolescent health unit, Universal Health Coverage, Life Course Cluster, WHO Country Office in Sierra Leone, Freetown, Sierra Leone.
| | - Bobson Derrick Fofanah
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Innocent Nuwagira
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Kadijatu Nabie Kamara
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
| | - Sia Morenike Tengbe
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
| | - Onome Abiri
- Pharmacy Board Sierra Leone, New England Ville, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Rugiatu Z Kamara
- United States Centers for Disease Control and Prevention Country Office, Emergency Operation Centre, Wilkinson Road, Freetown, Sierra Leone
| | - Sulaiman Lakoh
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Lynda Farma
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
| | - Abibatu Kollia Kamara
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Binyam Hailu
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Djossaya Dove
- Department of Demographic and Social Statistics, National Institute of Statistics, Yaoundé, Cameroon
| | | | - Selassi A D'Almeida
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Bockarie Sheriff
- Reproductive Maternal Newborn Child and Adolescent Unit, Universal Health Coverage, Life Course Cluster, World Health Organization Country Office, 21 A-B Riverside Off Kingharman Road, Freetown, Sierra Leone
| | - Ayeshatu Mustapha
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
| | - Najima Bawa
- Momentum Country and Global Leadership, Sir Samuel Lewis Road, Freetown, Sierra Leone
| | - Hailemariam Lagesse
- United Nation Children's Fund, Jomo Kenyatta Road, New England Ville, Freetown, Sierra Leone
| | | | - Joseph Sam Kanu
- Ministry of Health, Fourth Floor, Youyi Building, Brookfields, Freetown, Sierra Leone
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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Amábile-Cuevas CF, Lund-Zaina S. Non-Canonical Aspects of Antibiotics and Antibiotic Resistance. Antibiotics (Basel) 2024; 13:565. [PMID: 38927231 PMCID: PMC11200725 DOI: 10.3390/antibiotics13060565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/09/2024] [Accepted: 05/29/2024] [Indexed: 06/28/2024] Open
Abstract
The understanding of antibiotic resistance, one of the major health threats of our time, is mostly based on dated and incomplete notions, especially in clinical contexts. The "canonical" mechanisms of action and pharmacodynamics of antibiotics, as well as the methods used to assess their activity upon bacteria, have not changed in decades; the same applies to the definition, acquisition, selective pressures, and drivers of resistance. As a consequence, the strategies to improve antibiotic usage and overcome resistance have ultimately failed. This review gathers most of the "non-canonical" notions on antibiotics and resistance: from the alternative mechanisms of action of antibiotics and the limitations of susceptibility testing to the wide variety of selective pressures, lateral gene transfer mechanisms, ubiquity, and societal factors maintaining resistance. Only by having a "big picture" view of the problem can adequate strategies to harness resistance be devised. These strategies must be global, addressing the many aspects that drive the increasing prevalence of resistant bacteria aside from the clinical use of antibiotics.
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Affiliation(s)
| | - Sofia Lund-Zaina
- Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
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Denyer Willis L, Kayendeke M, Chandler CIR. The politics of irrationality. Med Anthropol Q 2023; 37:382-395. [PMID: 37703403 PMCID: PMC10947286 DOI: 10.1111/maq.12809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 07/16/2023] [Indexed: 09/15/2023]
Abstract
In siloed discussions of antimicrobial resistance, antibiotic use on farms in the Global South has emerged as a key site for intervention. The antibiotic consumption targeted is not all consumption, but "irrational" consumption. This concept of irrationality is neither new, nor true, but rather is a long-standing form of maintenance work within global health systems. Via an attention to chickens and the antibiotics farmers use to raise them in the suburbs of Kampala, we suggest that claims of irrationality are a central part of constituting what Tania Li has called the 'deficient subject'. In other words, irrationality, like the chicken and the antibiotic, is itself a humanitarian device that maintains a certain condition of governance where 'Africans' are imagined as being in deficit of rationality and good behavior. Claims of irrationality justify (and mask the political nature of) intervention.
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Affiliation(s)
| | | | - Clare IR Chandler
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
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Olaru ID, Walther B, Schaumburg F. Zoonotic sources and the spread of antimicrobial resistance from the perspective of low and middle-income countries. Infect Dis Poverty 2023; 12:59. [PMID: 37316938 DOI: 10.1186/s40249-023-01113-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Antimicrobial resistance is an increasing challenge in low and middle-income countries as it is widespread in these countries and is linked to an increased mortality. Apart from human and environmental factors, animal-related drivers of antimicrobial resistance in low- and middle-income countries have special features that differ from high-income countries. The aim of this narrative review is to address the zoonotic sources and the spread of antimicrobial resistance from the perspective of low- and middle-income countries. MAIN BODY Contamination with extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli is highest in poultry (Africa: 8.9-60%, Asia: 53-93%) and there is a risk to import ESBL-producing E. coli through poultry meat in Africa. In aquacultures, the proportion of ESBL-producers among E. coli can be high (27%) but the overall low quality of published studies limit the general conclusion on the impact of aquacultures on human health. ESBL-producing E. coli colonization of wildlife is 1-9% in bats or 2.5-63% birds. Since most of them are migratory animals, they can disperse antimicrobial resistant bacteria over large distances. So-called 'filth flies' are a relevant vector not only of enteric pathogens but also of antimicrobial resistant bacteria in settings where sanitary systems are poor. In Africa, up to 72.5% of 'filth flies' are colonized with ESBL-producing E. coli, mostly conferred by CTX-M (24.4-100%). While methicillin-resistant Staphylococcus aureus plays a minor role in livestock in Africa, it is frequently found in South America in poultry (27%) or pork (37.5-56.5%) but less common in Asia (poultry: 3%, pork: 1-16%). CONCLUSIONS Interventions to contain the spread of AMR should be tailored to the needs of low- and middle-income countries. These comprise capacity building of diagnostic facilities, surveillance, infection prevention and control in small-scale farming.
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Affiliation(s)
- Ioana D Olaru
- Institute of Medical Microbiology, University of Münster, Münster, Germany.
| | - Birgit Walther
- Advanced Light and Electron Microscopy, Robert Koch-Institute, Berlin, Germany
- Department of Environmental Hygiene, German Environment Agency, Berlin, Germany
| | - Frieder Schaumburg
- Institute of Medical Microbiology, University of Münster, Münster, Germany
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Zeng Y, Li W, Zhao M, Li J, Liu X, Shi L, Yang X, Xia H, Yang S, Yang L. The association between ambient temperature and antimicrobial resistance of Klebsiella pneumoniae in China: a difference-in-differences analysis. Front Public Health 2023; 11:1158762. [PMID: 37361142 PMCID: PMC10285064 DOI: 10.3389/fpubh.2023.1158762] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/19/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction Antimicrobial resistance (AMR) of Klebsiella pneumoniae (K. pneumoniae) poses a significant global public health threat and is responsible for a high prevalence of infections and mortality. However, knowledge about how ambient temperature influences the AMR of K. pneumoniae is limited in the context of global warming. Methods AMR data of 31 Chinese provinces was collected from the China Antimicrobial Resistance Surveillance System (CARSS) between 2014 and 2020. Socioeconomic and meteorological data were collected from the China Statistical Yearbook during the same period. A modified difference-in-differences (DID) approach was applied to estimate the association between ambient temperature and third-generation cephalosporin-resistant K. pneumoniae (3GCRKP) and carbapenem-resistant K. pneumoniae (CRKP). Furthermore, moderating effects of socioeconomic factors were also evaluated. Results Every 1°C increase in annual average temperature was associated with a 4.7% (relative risk (RR):1.047, 95% confidence intervals (CI): 1.031-1.082) increase in the detection rate of 3GCRKP, and a 10.7% (RR:1.107, 95% CI: 1.011-1.211) increase in the detection rate of CRKP. The relationships between ambient temperature and 3GCRKP and CRKP were found to be moderated by socioeconomic status (GDP per capita, income per capita, and consumption per capita; the interaction p-values <0.05), where higher economic status was found to strengthen the effects of temperature on the detection rate of 3GCRKP and weaken the effects on the detection rate of CRKP. Discussion Ambient temperature was found to be positively associated with AMR of K. pneumoniae, and this association was moderated by socioeconomic status. Policymakers should consider the impact of global warming and high temperatures on the spread of 3GCRKP and CRKP when developing strategies for the containment of AMR.
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Affiliation(s)
- Yingchao Zeng
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Weibin Li
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Manzhi Zhao
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University. Guangzhou, Guangdong, China
| | - Jia Li
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xu Liu
- Department of Infectious Disease, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Lin Shi
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Xinyi Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Haohai Xia
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Shifang Yang
- Department of Pulmonary and Critical Care Medicine, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University. Guangzhou, Guangdong, China
| | - Lianping Yang
- School of Public Health, Sun Yat-sen University, Guangzhou, China
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Allel K, Day L, Hamilton A, Lin L, Furuya-Kanamori L, Moore CE, Van Boeckel T, Laxminarayan R, Yakob L. Global antimicrobial-resistance drivers: an ecological country-level study at the human-animal interface. Lancet Planet Health 2023; 7:e291-e303. [PMID: 37019570 DOI: 10.1016/s2542-5196(23)00026-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 01/20/2023] [Accepted: 02/01/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a pressing, holistic, and multisectoral challenge facing contemporary global health. In this study we assessed the associations between socioeconomic, anthropogenic, and environmental indicators and country-level rates of AMR in humans and food-producing animals. METHODS In this modelling study, we obtained data on Carbapenem-resistant Acinetobacter baumanii and Pseudomonas aeruginosa, third generation cephalosporins-resistant Escherichia coli and Klebsiella pneumoniae, oxacillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecium AMR in humans and food-producing animals from publicly available sources, including WHO, World Bank, and Center for Disease Dynamics Economics and Policy. AMR in food-producing animals presented a combined prevalence of AMR exposure in cattle, pigs, and chickens. We used multivariable β regression models to determine the adjusted association between human and food-producing animal AMR rates and an array of ecological country-level indicators. Human AMR rates were classified according to the WHO priority pathogens list and antibiotic-bacterium pairs. FINDINGS Significant associations were identified between animal antimicrobial consumption and AMR in food-producing animals (OR 1·05 [95% CI 1·01-1·10]; p=0·013), and between human antimicrobial consumption and AMR specifically in WHO critical priority (1·06 [1·00-1·12]; p=0·035) and high priority (1·22 [1·09-1·37]; p<0·0001) pathogens. Bidirectional associations were also found: animal antibiotic consumption was positively linked with resistance in critical priority human pathogens (1·07 [1·01-1·13]; p=0·020) and human antibiotic consumption was positively linked with animal AMR (1·05 [1·01-1·09]; p=0·010). Carbapenem-resistant Acinetobacter baumanii, third generation cephalosporins-resistant Escherichia coli, and oxacillin-resistant Staphylococcus aureus all had significant associations with animal antibiotic consumption. Analyses also suggested significant roles of socioeconomics, including governance on AMR rates in humans and animals. INTERPRETATION Reduced rates of antibiotic consumption alone will not be sufficient to combat the rising worldwide prevalence of AMR. Control methods should focus on poverty reduction and aim to prevent AMR transmission across different One Health domains while accounting for domain-specific risk factors. The levelling up of livestock surveillance systems to better match those reporting on human AMR, and, strengthening all surveillance efforts, particularly in low-income and middle-income countries, are pressing priorities. FUNDING None.
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Affiliation(s)
- Kasim Allel
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK; Institute for Global Health, University College London, London, UK.
| | - Lucy Day
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Leesa Lin
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong Special Administrative Region, China; The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Luis Furuya-Kanamori
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Catrin E Moore
- The Centre for Neonatal and Paediatric Infection, Infection and Immunity Institute, St George's, University of London, UK
| | - Thomas Van Boeckel
- Eidgenössische Technische Hochschule, Zurich, Health Geography and Policy Group, Zurich, Switzerland
| | - Ramanan Laxminarayan
- The One Health Trust, Washington DC, USA; The High Meadows Environmental Institute, Princeton University, Princeton, NJ, USA
| | - Laith Yakob
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Antimicrobial Resistance Centre, London School of Hygiene & Tropical Medicine, London, UK
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Legenza L, Coetzee R, Rose WE, Esack T, Crombie K, Mina M, Safdar N, Barnett SG. Application of consolidated framework for implementation research to improve Clostridioides difficile infection management in district hospitals. Res Social Adm Pharm 2022; 18:4100-4111. [PMID: 35981939 PMCID: PMC9891768 DOI: 10.1016/j.sapharm.2022.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 06/08/2022] [Accepted: 07/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Clostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed. OBJECTIVES to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process. METHODS A CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake. RESULTS One of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship. CONCLUSIONS This research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.
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Affiliation(s)
- Laurel Legenza
- University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, United States; University of the Western Cape School of Pharmacy, Robert Sobukwe, Cape Town, 7535, South Africa.
| | - Renier Coetzee
- University of the Western Cape School of Pharmacy, Robert Sobukwe, Cape Town, 7535, South Africa; University of the Western Cape School of Public Health, Robert Sobukwe, Cape Town, 7535, South Africa
| | - Warren E Rose
- University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, United States
| | - Tasneem Esack
- Victoria Hospital, Wynberg, Cape Town, 7800, South Africa
| | - Kenneth Crombie
- University of Cape Town, Rondebosch, Cape Town, 7700, South Africa
| | - Megan Mina
- University of Cape Town, Rondebosch, Cape Town, 7700, South Africa; General Justice Gizenga Mpanza Regional Hospital, KwaDukuza, KwaZulu-Natal, 4450, South Africa
| | - Nasia Safdar
- University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI, 53726, United States
| | - Susanne G Barnett
- University of Wisconsin-Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, United States
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King T, Schindler R, Chavda S, Conly J. Dimensions of poverty as risk factors for antimicrobial resistant organisms in Canada: a structured narrative review. Antimicrob Resist Infect Control 2022; 11:18. [PMID: 35074013 PMCID: PMC8785485 DOI: 10.1186/s13756-022-01059-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background Few studies have assessed the relationship between poverty and the risk of infection with antimicrobial resistant organisms (AROs). We sought to identify, appraise, and synthesize the available published Canadian literature that analyzes living in poverty and risk of AROs. Methods A structured narrative review methodology was used, including a systematic search of three databases: MedLINE, EMBASE and Web of Science for articles pertaining to poverty, and infection with AROs in Canada between 1990 and 2020. Poverty was broadly defined to include economic measures and associated social determinants of health. Based on inclusion and exclusion criteria, there were 889 initial articles, and 43 included in the final review. The final articles were extracted using a standard format and appraised using the Joanna Briggs Institute Levels of Evidence framework. Results Of 43 studies, 15 (35%) related to methicillin-resistant Staphylococcus aureus (MRSA). One study found a 73% risk reduction (RR 0.27, 95%CI 0.19–0.39, p = < 0.0001) in community-acquired MRSA (CA-MRSA) infection for each $100,000 income increase. Results pertaining to homelessness and MRSA suggested transmission was related to patterns of frequent drug use, skin-to-skin contact and sexual contact more than shelter contact. Indigenous persons have high rates of CA-MRSA, with more rooms in the house being a significant protective factor (OR 0.86, p = 0.023). One study found household income over $60,000 (OR 0.83, p = 0.039) in univariate analysis and higher maternal education (OR 0.76, 95%CI 0.63–0.92, p = 0.005) in multivariate analysis were protective for otitis media due to an ARO among children. Twenty of 43 (46.5%) articles pertained to tuberculosis (TB). Foreign-born persons were four times more likely to have resistant TB compared to Canadian-born persons. None of the 20 studies used income in their analyses. Conclusions There is an association between higher income and protection from CA-MRSA. Mixed results exist regarding the impact of homelessness and MRSA, demonstrating a nuanced relationship with behavioural risk factors. Higher income and maternal education were associated with reduced ARO-associated acute otitis media in children in one study. We do not have a robust understanding of the social measures of marginalization related to being foreign-born that contribute to higher rates of resistant TB infection. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-022-01059-1.
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Bumbangi FN, Llarena AK, Skjerve E, Hang’ombe BM, Mpundu P, Mudenda S, Mutombo PB, Muma JB. Evidence of Community-Wide Spread of Multi-Drug Resistant Escherichia coli in Young Children in Lusaka and Ndola Districts, Zambia. Microorganisms 2022; 10:1684. [PMID: 36014101 PMCID: PMC9416312 DOI: 10.3390/microorganisms10081684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 12/23/2022] Open
Abstract
Increased antimicrobial resistance (AMR) has been reported for pathogenic and commensal Escherichia coli (E. coli), hampering the treatment, and increasing the burden of infectious diarrhoeal diseases in children in developing countries. This study focused on exploring the occurrence, patterns, and possible drivers of AMR E. coli isolated from children under-five years in Zambia. A hospital-based cross-sectional study was conducted in the Lusaka and Ndola districts. Rectal swabs were collected from 565 and 455 diarrhoeic and healthy children, respectively, from which 1020 E. coli were cultured and subjected to antibiotic susceptibility testing. Nearly all E. coli (96.9%) were resistant to at least one antimicrobial agent tested. Further, 700 isolates were Multi-Drug Resistant, 136 were possibly Extensively-Drug Resistant and nine were Pan-Drug-Resistant. Forty percent of the isolates were imipenem-resistant, mostly from healthy children. A questionnaire survey documented a complex pattern of associations between and within the subgroups of the levels of MDR and socio-demographic characteristics, antibiotic stewardship, and guardians' knowledge of AMR. This study has revealed the severity of AMR in children and the need for a community-specific-risk-based approach to implementing measures to curb the problem.
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Affiliation(s)
- Flavien Nsoni Bumbangi
- School of Medicine, Eden University, Lusaka P.O. Box 37727, Zambia
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia
| | - Ann-Katrin Llarena
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, 1432 Ås, Norway
| | - Eystein Skjerve
- Faculty of Veterinary Medicine, Norwegian University of Life Sciences, 1432 Ås, Norway
| | - Bernard Mudenda Hang’ombe
- Department of Paraclinical Studies, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia
| | - Prudence Mpundu
- Department of Environmental and Occupational Health, Levy Mwanawasa Medical University, Lusaka P.O. Box 33991, Zambia
| | - Steward Mudenda
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka P.O. Box 50110, Zambia
| | - Paulin Beya Mutombo
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa 834, Congo
| | - John Bwalya Muma
- Department of Disease Control, School of Veterinary Medicine, University of Zambia, Lusaka P.O. Box 32379, Zambia
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Tornberg-Belanger SN, Rwigi D, Mugo M, Kitheka L, Onamu N, Ounga D, Diakhate MM, Atlas HE, Wald A, McClelland RS, Soge OO, Tickell KD, Kariuki S, Singa BO, Walson JL, Pavlinac PB. Antimicrobial resistance including Extended Spectrum Beta Lactamases (ESBL) among E. coli isolated from kenyan children at hospital discharge. PLoS Negl Trop Dis 2022; 16:e0010283. [PMID: 35358186 PMCID: PMC9015121 DOI: 10.1371/journal.pntd.0010283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 04/18/2022] [Accepted: 02/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background Children who have been discharged from hospital in sub-Saharan Africa remain at substantial risk of mortality in the post-discharge period. Antimicrobial resistance (AMR) may be an important factor. We sought to determine the prevalence and risk factors associated with AMR in commensal Escherichia coli(E. coli) from Kenyan children at the time of discharge. Methodology/Principle findings Fecal samples were collected from 406 children aged 1–59 months in western Kenya at the time of discharge from hospital and cultured for E. coli. Susceptibility to ampicillin, ceftriaxone, cefotaxime, ceftazidime, cefoxitin, imipenem, ciprofloxacin, gentamicin, combined amoxicillin/clavulanic acid, trimethoprim-sulfamethoxazole, azithromycin, and chloramphenicol was determined by disc diffusion according to guidelines from the Clinical and Laboratory Standards Institute (CLSI). Poisson regression was used to determine associations between participant characteristics and the presence of extended-spectrum beta-lactamases (ESBL) producing E. coli. Non-susceptibility to ampicillin (95%), gentamicin (44%), ceftriaxone (46%), and the presence of ESBL (44%) was high. Receipt of antibiotics during the hospitalization was associated with the presence of ESBL (aPR = 2.23; 95% CI: 1.29–3.83) as was being hospitalized within the prior year (aPR = 1.32 [1.07–1.69]). Open defecation (aPR = 2.02; 95% CI: 1.39–2.94), having a toilet shared with other households (aPR = 1.49; 95% CI: 1.17–1.89), and being female (aPR = 1.42; 95% CI: 1.15–1.76) were associated with carriage of ESBL E. coli Conclusions/Significance AMR is common among isolates of E. coli from children at hospital discharge in Kenya, including nearly half having detectable ESBL. Children who have been hospitalized in sub-Saharan Africa remain at a high risk of death and morbidity for at least 6 months following discharge. These children may harbor AMR in commensal bacteria following hospitalization, which may be associated with poor outcomes. There are limited data describing AMR and risk factors that are associated with AMR carriage at hospital discharge. In this cross-sectional study of Kenyan children under 5 years of age discharged from hospitals, we found AMR to be high. Children who received antibiotics in the hospital, had limited access to improved sanitation, and who were female had the highest prevalence of ESBL-producing E. coli.
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Affiliation(s)
- Stephanie N. Tornberg-Belanger
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- * E-mail: (STB); (PBP)
| | - Doreen Rwigi
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Michael Mugo
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Lynnete Kitheka
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Nancy Onamu
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Derrick Ounga
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mame M. Diakhate
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Hannah E. Atlas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Anna Wald
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Olusegun O. Soge
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States of America
| | - Kirkby D. Tickell
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Samuel Kariuki
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Benson O. Singa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Judd L. Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Medicine (Allergy and Infectious Diseases), University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Patricia B. Pavlinac
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail: (STB); (PBP)
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11
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A comparative assessment of action plans on antimicrobial resistance from OECD and G20 countries using natural language processing. Health Policy 2022; 126:522-533. [DOI: 10.1016/j.healthpol.2022.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/13/2022] [Accepted: 03/22/2022] [Indexed: 11/18/2022]
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12
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Booth A, Wester AL. A multivariable analysis of the contribution of socioeconomic and environmental factors to blood culture Escherichia Coli resistant to fluoroquinolones in high- and middle-income countries. BMC Public Health 2022; 22:354. [PMID: 35183144 PMCID: PMC8857829 DOI: 10.1186/s12889-022-12776-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 02/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a public health concern. We wanted to determine if various environmental and socioeconomic variables as well as markers of antimicrobial use impacted on the level of AMR in countries of different income levels. METHODS We performed cross-national univariate and multivariable analyses using the national proportion of quinolone-resistant Escherichia coli (QREC) in blood culture as the dependent variable. Access to safe water and sanitation, other socioeconomic variables, and human and animal antimicrobial consumption were analysed. RESULTS In middle-income countries, unsafely managed sanitation, corruption and healthcare access and quality were significantly associated with the national proportion of blood culture QREC (%) in univariate analyses, whereas no variables remained significant in the multivariable models. For the multivariable high-income country model, corruption and healthcare access and quality were significantly associated with blood culture QREC (%) levels. For the model including all countries, human fluoroquinolone use, corruption level, livestock and crop production index were significantly associated with blood culture QREC (%) levels in the univariate analyses. CONCLUSION Corruption is a strong predictor of AMR, likely reflecting a multitude of socioeconomic factors. Sanitation quality contributed to increased blood culture QREC (%) levels in middle-income countries, although was not an independent factor, highlighting the need to also focus on infrastructure such as sanitation services in the context of AMR.
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Affiliation(s)
- Amy Booth
- Faculty of Health Sciences, University of Cape Town, Rondebosch, Cape Town, 7700, South Africa.
| | - Astrid Louise Wester
- Centre for Antimicrobial Resistance Research, and Division of Infection Control, Norwegian Institute of Public Health, Lovisenberggata 8, 0456, Oslo, Norway
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13
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Berman D, Chandy SJ, Cansdell O, Moodley K, Veeraraghavan B, Essack SY. Global access to existing and future antimicrobials and diagnostics: antimicrobial subscription and pooled procurement. Lancet Glob Health 2022; 10:e293-e297. [PMID: 34914900 PMCID: PMC8765761 DOI: 10.1016/s2214-109x(21)00463-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/18/2021] [Accepted: 09/24/2021] [Indexed: 02/08/2023]
Abstract
The COVID-19 pandemic has underlined the importance of an efficient and equitable supply of and access to essential health products. These factors are equally pertinent to the antimicrobial resistance pandemic, in which access to a portfolio of existing and pipeline antimicrobials plus complementary diagnostics is crucial. This Viewpoint focuses on market shaping in low-income and middle-income countries (LMICs), where the need for effective antimicrobials and complementary diagnostics is most acute. We propose the creation of a subscription and pooled procurement model that consolidates the growing demand for a portfolio of antimicrobials and diagnostics in LMICs. Anchored by regional market leaders, these pooling mechanisms would guarantee consistent private-sector and public-sector access in participating countries, while creating conditions for long-term best practice in stewardship. Supported by data from South Africa and India, this proposal sets out an innovative approach to tackle the antimicrobial resistance crisis in LMICs.
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Affiliation(s)
- Daniel Berman
- Nesta Challenges, London, UK,Correspondence to: Daniel Berman, Nesta Challenges, London, EC4Y 0DS, UK
| | - Sujith J Chandy
- Department of Pharmacology and Clinical Pharmacology, Christian Medical College, Vellore, India
| | | | - Krishnee Moodley
- Antimicrobial Research Unit, University of KwaZulu-Natal, Durban, South Africa
| | | | - Sabiha Y Essack
- Antimicrobial Research Unit, University of KwaZulu-Natal, Durban, South Africa
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14
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The influence of social and economic environment on health. One Health 2022. [DOI: 10.1016/b978-0-12-822794-7.00005-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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15
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Castro RAD, Borrell S, Gagneux S. The within-host evolution of antimicrobial resistance in Mycobacterium tuberculosis. FEMS Microbiol Rev 2021; 45:fuaa071. [PMID: 33320947 PMCID: PMC8371278 DOI: 10.1093/femsre/fuaa071] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/11/2020] [Indexed: 12/12/2022] Open
Abstract
Tuberculosis (TB) has been responsible for the greatest number of human deaths due to an infectious disease in general, and due to antimicrobial resistance (AMR) in particular. The etiological agents of human TB are a closely-related group of human-adapted bacteria that belong to the Mycobacterium tuberculosis complex (MTBC). Understanding how MTBC populations evolve within-host may allow for improved TB treatment and control strategies. In this review, we highlight recent works that have shed light on how AMR evolves in MTBC populations within individual patients. We discuss the role of heteroresistance in AMR evolution, and review the bacterial, patient and environmental factors that likely modulate the magnitude of heteroresistance within-host. We further highlight recent works on the dynamics of MTBC genetic diversity within-host, and discuss how spatial substructures in patients' lungs, spatiotemporal heterogeneity in antimicrobial concentrations and phenotypic drug tolerance likely modulates the dynamics of MTBC genetic diversity in patients during treatment. We note the general characteristics that are shared between how the MTBC and other bacterial pathogens evolve in humans, and highlight the characteristics unique to the MTBC.
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Affiliation(s)
- Rhastin A D Castro
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051 Basel, Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Basel, Switzerland
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16
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Zhen X, Chen J, Sun X, Sun Q, Guo S, Stålsby Lundborg C. Socioeconomic Factors Contributing to Antibiotic Resistance in China: A Panel Data Analysis. Antibiotics (Basel) 2021; 10:antibiotics10080994. [PMID: 34439044 PMCID: PMC8388882 DOI: 10.3390/antibiotics10080994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 11/16/2022] Open
Abstract
The relationship between socioeconomic factors and antibiotic resistance (ABR) prevalence remains a knowledge gap in China. In this study, our aim was to examine the association between ABR prevalence and socioeconomic factors across 30 provinces in mainland China. We used two measures of level of ABR: the proportion of methicillin-resistant Staphylococcus aureus (MRSA), third-generation cephalosporin-resistant Escherichia coli (3GCREC), and third-generation cephalosporin-resistant Klebsiella pneumoniae (3GCRKP), and the aggregate resistance. The data of ABR prevalence, education, gross domestic product (GDP) per capita, out-of-pocket (OOP) health expenditure, physician density, hospital bed density, and public toilet density during 2014 and 2018 in 30 provinces in mainland China were included. We examined the association between ABR prevalence and potential contributing socioeconomic factors using panel data modeling. In addition, we explored this relationship in the eastern, central, and western economic zones. Our results indicated that GDP per capita was significantly positively correlated with ABR in mainland China and the eastern economic zone; however, significantly positive associations did not exist in the central and western economic zones. Surprisingly, both higher GDP per capita and higher OOP health expenditure were associated with a higher level of MRSA, but a lower level of 3GCREC; higher physician density was associated with a lower level of MRSA, but a higher level of 3GCREC. In addition, ABR prevalence presented a decline trend during 2014 and 2018. Our study showed the potential associ-ations between resistance and GDP per capita, OOP health expenditure, physician density. It high-lights that the social and economic determinants can be of importance in tacking the development and spread of ABR in mainland China.
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Affiliation(s)
- Xuemei Zhen
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine (NHC Key Laboratory of Health Economics and Policy Research), Shandong University, Jinan 250012, China; (X.Z.); (S.G.)
| | - Jingchunyu Chen
- Department of Prosthodontics, School of Tomatology, Cheeloo College of Medicine, Shandong University, Jinan 250012, China;
| | - Xueshan Sun
- Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, Hangzhou 310058, China;
| | - Qiang Sun
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine (NHC Key Laboratory of Health Economics and Policy Research), Shandong University, Jinan 250012, China; (X.Z.); (S.G.)
- Correspondence: ; Tel.: +86-531-8838-2526
| | - Shasha Guo
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine (NHC Key Laboratory of Health Economics and Policy Research), Shandong University, Jinan 250012, China; (X.Z.); (S.G.)
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17
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Cama J, Leszczynski R, Tang PK, Khalid A, Lok V, Dowson CG, Ebata A. To Push or To Pull? In a Post-COVID World, Supporting and Incentivizing Antimicrobial Drug Development Must Become a Governmental Priority. ACS Infect Dis 2021; 7:2029-2042. [PMID: 33606496 PMCID: PMC7931625 DOI: 10.1021/acsinfecdis.0c00681] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The COVID-19 pandemic has refocused attention worldwide on the dangers of infectious diseases, in terms of both global health and the effects on the world economy. Even in high income countries, health systems have been found wanting in dealing with the new infectious agent. However, the even greater long-term danger of antimicrobial resistance in pathogenic bacteria and fungi is still under-appreciated, especially among the general public. Although antimicrobial drug development faces significant scientific challenges, the gravest challenge at the moment appears to be economic, where the lack of a viable market has led to a collapse in drug development pipelines. There is therefore a critical need for governments across the world to further incentivize the development of antimicrobials. Most incentive strategies over the past decade have focused on so-called "push" incentives that bridge the costs of antimicrobial research and development, but these have been insufficient for reviving the pipeline. In this Perspective, we analyze the current incentive strategies in place for antimicrobial drug development, and focus on "pull" incentives, which instead aim to improve revenue generation and thereby resolve the antimicrobial market failure challenge. We further analyze these incentives in a broader "One Health" context and stress the importance of developing and enforcing strict protocols to ensure appropriate manufacturing practices and responsible use. Our analysis reiterates the importance of international cooperation, coordination across antimicrobial research, and sustained funding in tackling this significant global challenge. A failure to invest wisely and continuously to incentivize antimicrobial pipelines will have catastrophic consequences for global health and wellbeing in the years to come.
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Affiliation(s)
- J. Cama
- Living
Systems Institute, University of Exeter, Stocker Road, Exeter EX4 4QD, U.K.
- College
of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter EX4 4QF, U.K.
- ,
| | - R. Leszczynski
- Polygeia,
Global Health Student Think Tank, London, U.K.https://www.polygeia.com/
| | - P. K. Tang
- Polygeia,
Global Health Student Think Tank, London, U.K.https://www.polygeia.com/
- Faculty
of Life Sciences and Medicine, King’s
College London, Great
Maze Pond, London SE1 1UK, U.K.
| | - A. Khalid
- Polygeia,
Global Health Student Think Tank, London, U.K.https://www.polygeia.com/
- School
of Clinical Medicine, University of Cambridge, Cambridge CB2 0SP, U.K.
| | - V. Lok
- Polygeia,
Global Health Student Think Tank, London, U.K.https://www.polygeia.com/
- School of
Biological and Chemical Sciences, Queen
Mary University of London, Mile End Road, London E1 4NS, U.K.
| | - C. G. Dowson
- School
of Life Sciences, Gibbet Hill Campus, University
of Warwick, Coventry CV4 7AL, U.K.
- Antibiotic
Research U.K., Genesis 5, York Science Park, Heslington, York YO10 5DQ, U.K.
| | - A. Ebata
- Institute
of Development Studies, Library Road, Brighton BN1 9RE, U.K.
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18
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Iwu CD, Patrick SM. An insight into the implementation of the global action plan on antimicrobial resistance in the WHO African region: A roadmap for action. Int J Antimicrob Agents 2021; 58:106411. [PMID: 34371112 DOI: 10.1016/j.ijantimicag.2021.106411] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/13/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The Global Action Plan (GAP) on antimicrobial resistance (AMR) delivers a 'One Health' strategy for the development of the national action plan. It encourages the optimal use of antimicrobials and strengthens the evidence base through surveillance and research. METHODS This study evaluated the current status of implementation of the GAP on AMR in World Health Organization (WHO) African countries via a retrospective, cross-sectional analysis of routinely collected data on AMR. A SWOT analysis was used to identify the strengths, weaknesses, opportunities and threats involved in the GAP implementation. A roadmap for action was proposed. RESULTS The overall mean GAP performance score across all the countries that were assessed was 32% ± SD12 (95% CI 27-36%). The mean thematic scores were 59% ± 12 (53-65%) for multi-sector and One Health collaboration; 50% ± 22 (42-58%) for developing national AMR action plans; 38% ± 12 (33-42%) for awareness and training; 18% ± 13 (13-23%) for surveillance; 33% ± 13 (29-38%) for infection prevention and control; and 28% ± 23 (20-37%) for optimal use of antimicrobial medicines in human, animal and plant health. The difference in GAP performance scores between African sub-regions and between income categories was not statistically significant (P > 0.05). While seven countries exhibited strengths in two themes, 25 countries exhibited weaknesses across all themes. Six threats and six opportunities were identified to inform a practical roadmap for AMR action. CONCLUSION The findings from this study indicate that the overall GAP implementation on AMR in the WHO African region is inadequate. Some thematic GAP scores appeared to be relatively good, but on closer inspection, individual indicators revealed a lack of progress and implementation, requiring action.
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Affiliation(s)
- Chidozie Declan Iwu
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.
| | - Sean Mark Patrick
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; Environmental Chemical Pollution and Health (ECPH) Research Unit, University of Pretoria, Pretoria, South Africa
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19
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Kalanxhi E, Osena G, Kapoor G, Klein E. Confidence interval methods for antimicrobial resistance surveillance data. Antimicrob Resist Infect Control 2021; 10:91. [PMID: 34108041 PMCID: PMC8191092 DOI: 10.1186/s13756-021-00960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background Antimicrobial resistance (AMR) is one of the greatest global health challenges today, but burden assessment is hindered by uncertainty of AMR prevalence estimates. Geographical representation of AMR estimates typically pools data collected from several laboratories; however, these aggregations may introduce bias by not accounting for the heterogeneity of the population that each laboratory represents. Methods We used AMR data from up to 381 laboratories in the United States from The Surveillance Network to evaluate methods for estimating uncertainty of AMR prevalence estimates. We constructed confidence intervals for the proportion of resistant isolates using (1) methods that account for the clustered structure of the data, and (2) standard methods that assume data independence. Using samples of the full dataset with increasing facility coverage levels, we examined how likely the estimated confidence intervals were to include the population mean. Results Methods constructing 95% confidence intervals while accounting for possible within-cluster correlations (Survey and standard methods adjusted to employ cluster-robust errors), were more likely to include the sample mean than standard methods (Logit, Wilson score and Jeffreys interval) operating under the assumption of independence. While increased geographical coverage improved the probability of encompassing the mean for all methods, large samples still did not compensate for the bias introduced from the violation of the data independence assumption. Conclusion General methods for estimating the confidence intervals of AMR rates that assume data are independent, are likely to produce biased results. When feasible, the clustered structure of the data and any possible intra-cluster variation should be accounted for when calculating confidence intervals around AMR estimates, in order to better capture the uncertainty of prevalence estimates. Supplementary Information The online version contains supplementary material available at 10.1186/s13756-021-00960-5.
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Affiliation(s)
- Erta Kalanxhi
- Center for Disease Dynamics, Economics and Policy (CDDEP), Washington, DC, USA
| | - Gilbert Osena
- Center for Disease Dynamics, Economics and Policy (CDDEP), Washington, DC, USA
| | - Geetanjali Kapoor
- Center for Disease Dynamics, Economics and Policy (CDDEP), Washington, DC, USA
| | - Eili Klein
- Center for Disease Dynamics, Economics and Policy (CDDEP), Washington, DC, USA. .,Johns Hopkins University, Baltimore, MD, USA.
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20
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Abstract
Surveillance is critical in containing globally increasing antimicrobial resistance (AMR). Affordable methodologies to prioritize AMR surveillance efforts are urgently needed, especially in low- and middle-income countries (LMICs), where resources are limited. While socioeconomic characteristics correlate with clinical AMR prevalence, this correlation has not yet been used to estimate AMR prevalence in countries lacking surveillance. We captured the statistical relationship between AMR prevalence and socioeconomic characteristics in a suite of beta-binomial principal component regression models for nine pathogens resistant to 19 (classes of) antibiotics. Prevalence data from ResistanceMap were combined with socioeconomic profiles constructed from 5,595 World Bank indicators. Cross-validated models were used to estimate clinical AMR prevalence and temporal trends for countries lacking data. Our approach provides robust estimates of clinical AMR prevalence in LMICs for most priority pathogens (cross-validated q 2 > 0.78 for six out of nine pathogens). By supplementing surveillance data, 87% of all countries worldwide, which represent 99% of the global population, are now informed. Depending on priority pathogen, our estimates benefit 2.1 to 4.9 billion people living in countries with currently insufficient diagnostic capacity. By estimating AMR prevalence worldwide, our approach allows for a data-driven prioritization of surveillance efforts. For carbapenem-resistant Acinetobacter baumannii and third-generation cephalosporin-resistant Escherichia coli, specific countries of interest are located in the Middle East, based on the magnitude of estimates; sub-Saharan Africa, based on the relative prevalence increase over 1998 to 2017; and the Pacific Islands, based on improving overall model coverage and performance.
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21
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Gottesman BS, Low M, Almog R, Chowers M. Quinolone Consumption by Mothers Increases Their Children's Risk of Acquiring Quinolone-Resistant Bacteriuria. Clin Infect Dis 2021; 71:532-538. [PMID: 31504346 DOI: 10.1093/cid/ciz858] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 08/28/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Quinolone resistance has been documented in the pediatric population, although their use is limited in children. This study investigated the effect of maternal quinolone use on gram-negative bacterial resistance to quinolones in their offspring. METHODS We conducted a population-based, unmatched case-control study during 2010-2017. Cases were all children aged 0.5-17 years with community acquired, gram-negative quinolone-resistant bacteriuria. Controls were similar children with quinolone-sensitive bacteriuria. Only the first positive urine cultures for each child were included. Data on quinolones dispensed to the mother, any antibiotics dispensed to the children, age, sex, ethnicity, and prior hospitalizations were collected. Children with previous quinolone use were excluded. RESULTS The study population consisted of 40 204 children. Quinolone resistance was detected in 2182 (5.3%) urine cultures. The median age was 5 years, with 93.7% females and 77.6% Jewish. A total of 26 937 (65%) of the children received any antibiotic and 1359 (3.2%) of the mothers received quinolones in the 6 months preceding bacteriuria. Independent risk factors were quinolone dispensed to the mothers (odds ratio [OR], 1.50 [95% confidence interval {CI}, 1.22-1.85]), Arab ethnicity (OR, 1.99 [95% CI, 1.81-2.19]), and antibiotic dispensed to the child (OR, 1.54 [95% CI, 1.38-1.71]). Compared with children aged 12-17 years, younger children had 1.33-1.43 increased odds for quinolone-resistant bacteriuria. CONCLUSIONS Quinolone prescription to mothers was linked to increased risk of community-acquired, quinolone-resistant bacteria in their offspring, by about 50%. This is another example of the deleterious ecological effects of antibiotic use and should be considered when prescribing antibiotics.
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Affiliation(s)
- Bat-Sheva Gottesman
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel.,Department of Family Medicine, Sharon-Shomron District, Clalit Health Services, Kfar Saba, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Marcelo Low
- Clalit Health Services, Chief Physician's Office, Tel Aviv, Israel.,School of Public Health, University of Haifa, Haifa, Israel
| | - Ronit Almog
- School of Public Health, University of Haifa, Haifa, Israel.,Epidemiology Department and Biobank, Rambam Healthcare Campus, Haifa, Israel
| | - Michal Chowers
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel.,Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
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Brandl M, Hoffmann A, Willrich N, Reuss A, Reichert F, Walter J, Eckmanns T, Haller S. Bugs That Can Resist Antibiotics but Not Men: Gender-Specific Differences in Notified Infections and Colonisations in Germany, 2010-2019. Microorganisms 2021; 9:894. [PMID: 33922011 PMCID: PMC8143559 DOI: 10.3390/microorganisms9050894] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/15/2022] Open
Abstract
Data from surveillance networks show that men have a higher incidence rate of infections with anti-microbial-resistant (AMR) pathogens than women. We systematically analysed data of infections and colonisations with AMR pathogens under mandatory surveillance in Germany to quantify gender-specific differences. We calculated incidence-rates (IR) per 100,000 person-years for invasive infections with Methicillin-resistant Staphylococcus aureus (MRSA), and for infections or colonisations with carbapenem-non-susceptible Acinetobacter spp. (CRA), and Enterobacterales (CRE), using the entire German population as a denominator. We limited the study periods to years with complete notification data (MRSA: 2010-2019, CRA/CRE: 2017-2019). We used Poisson regression to adjust for gender, age group, federal state, and year of notification. In the study periods, IR for all notifications were 4.2 for MRSA, 0.90 for CRA, and 4.8 for CRE per 100,000 person--years. The adjusted IR ratio for infections of men compared to women was 2.3 (95% confidence interval [CI]: 2.2-2.3) for MRSA, 2.2 (95%CI: 1.9-2.7) for CRA, and 1.7 (95%CI: 1.6-1.8) for CRE. Men in Germany show about double the risk for infection with AMR pathogens than women. This was also true for colonisations, where data were available. Screening procedures and associated hygiene measures may profit from a gender-stratified approach.
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Affiliation(s)
- Michael Brandl
- Postgraduate Training for Applied Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (F.R.); (J.W.)
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), 17183 Stockholm, Sweden
| | - Alexandra Hoffmann
- Unit for Healthcare-Associated Infections, Surveillance of Antibiotic Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (A.H.); (N.W.); (A.R.); (T.E.); (S.H.)
| | - Niklas Willrich
- Unit for Healthcare-Associated Infections, Surveillance of Antibiotic Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (A.H.); (N.W.); (A.R.); (T.E.); (S.H.)
| | - Annicka Reuss
- Unit for Healthcare-Associated Infections, Surveillance of Antibiotic Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (A.H.); (N.W.); (A.R.); (T.E.); (S.H.)
| | - Felix Reichert
- Postgraduate Training for Applied Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (F.R.); (J.W.)
- European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), 17183 Stockholm, Sweden
| | - Jan Walter
- Postgraduate Training for Applied Epidemiology, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (F.R.); (J.W.)
| | - Tim Eckmanns
- Unit for Healthcare-Associated Infections, Surveillance of Antibiotic Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (A.H.); (N.W.); (A.R.); (T.E.); (S.H.)
| | - Sebastian Haller
- Unit for Healthcare-Associated Infections, Surveillance of Antibiotic Resistance and Consumption, Department of Infectious Disease Epidemiology, Robert Koch Institute, 10113 Berlin, Germany; (A.H.); (N.W.); (A.R.); (T.E.); (S.H.)
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23
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Shinga Wembulua B, Lakhe A, Diallo Mbaye K, Ndikou Aw N, Cisse Diallo V, Ka D, Fortes L, Seydi M. [Antibacterial Susceptibility Patterns of Bloodstream Isolates in 74 HIV-Infected Patients Hospitalized at the Clinic of Infectious and Tropical Diseases of Fann University Hospital, Dakar from 2013 to 2016]. MEDECINE TROPICALE ET SANTE INTERNATIONALE 2021; 1:mtsibulletin.n1.2021.88. [PMID: 35586586 PMCID: PMC9022763 DOI: 10.48327/mtsibulletin.n1.2021.88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 04/03/2021] [Indexed: 11/18/2022]
Abstract
Introduction Bacteremia is associated with high lethality in HIV-infected patients. The widespread use of cotrimoxazole prophylaxis and misuse of antibiotics promote antibacterial resistance. Only few studies have considered this issue in HIV-infected patients. Thus, the objective of this study was to describe the etiology and antibacterial susceptibility patterns of bloodstream isolates in patient living with HIV. Material and methods This is a retrospective cross-sectional and descriptive study conducted at the clinic of Infectious and Tropical Diseases of Fann university hospital from March 2013 to December 2016. Data were collected from patients' files according to a pre-establish survey form made of demographic, clinical, bacteriological and biological parameters. Results Seventy-four cases of bacteremia were registered, 51.4% of which in women. Participants' median age was 45 years old [18-73 years old] and average CD4 count 83.3 cells/μl. The most commonly isolated bacteria were coagulase negative staphylococci (14%) followed by Escherichia coli (10%) and Klebsiella pneumoniae (10%). Rates of methicillin resistance for coagulase negative staphylococci and Staphylococcus aureus were 35.7% (5/14) and 22% (2/9), respectively. The most frequent ESBL producing germs were Escherichia coli 50% (5/10), Klebsiella pneumoniae 40% (4/10) and Enterobacter sp 25% (2/8). Pseudomonas sp were the most (22.2%) germs resistant to carbapenems. Conclusion The result of this study advocates the need for ongoing surveillance of antibacterial resistance in HIV-infected patients and empirical antibiotic therapy based on surveillance data.
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24
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Knoll RL, Dennebaum MS. [Fever in pediatric returning travellers]. Monatsschr Kinderheilkd 2021; 169:426-431. [PMID: 33727732 PMCID: PMC7952080 DOI: 10.1007/s00112-021-01147-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2021] [Indexed: 11/24/2022]
Abstract
Management and treatment of the febrile pediatric patient returning from a tropical country is often challenging. Detailed medical and travel history with an emphasis on possible exposure (e.g. fresh water exposure, animal contact etc.) as well as a complete physical examination are essential. Considering the possible incubation period and travel destination, the number of potential differential diagnoses can often be greatly reduced. While most infections are self-limiting and run an uncomplicated course, it is crucial to recognize potentially life-threatening infections and to treat them appropriately.This article provides guidance for a rational approach and diagnostics with respect to fever in the context of differential diagnoses in tropical medicine in the pediatric patient collective.
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Affiliation(s)
- Rebecca L Knoll
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin, Mainz, Deutschland
| | - Martin S Dennebaum
- Institut für Mikrobiologie und Hygiene, Abteilung Infektionsmedizin, Universitätsmedizin, Langenbeckstr. 1, 55131 Mainz, Deutschland
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25
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Salinas L, Loayza F, Cárdenas P, Saraiva C, Johnson TJ, Amato H, Graham JP, Trueba G. Environmental Spread of Extended Spectrum Beta-Lactamase (ESBL) Producing Escherichia coli and ESBL Genes among Children and Domestic Animals in Ecuador. ENVIRONMENTAL HEALTH PERSPECTIVES 2021; 129:27007. [PMID: 33617318 PMCID: PMC7899495 DOI: 10.1289/ehp7729] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 05/24/2023]
Abstract
BACKGROUND There is a significant gap in our understanding of the sources of multidrug-resistant bacteria and resistance genes in community settings where human-animal interfaces exist. OBJECTIVES This study characterized the relationship of third-generation cephalosporin-resistant Escherichia coli (3GCR-EC) isolated from animal feces in the environment and child feces based on phenotypic antimicrobial resistance (AMR) and whole genome sequencing (WGS). METHODS We examined 3GCR-EC isolated from environmental fecal samples of domestic animals and child fecal samples in Ecuador. We analyzed phenotypic and genotypic AMR, as well as clonal relationships (CRs) based on pairwise single-nucleotide polymorphisms (SNPs) analysis of 3GCR-EC core genomes. CRs were defined as isolates with fewer than 100 different SNPs. RESULTS A total of 264 3GCR-EC isolates from children (n=21), dogs (n=20), and chickens (n=18) living in the same region of Quito, Ecuador, were identified. We detected 16 CRs total, which were found between 7 children and 5 domestic animals (5 CRs) and between 19 domestic animals (11 CRs). We observed that several clonally related 3GCR-EC isolates had acquired different plasmids and AMR genes. Most CRs were observed in different homes (n=14) at relatively large distances. Isolates from children and domestic animals shared the same blaCTX-M allelic variants, and the most prevalent were blaCTX-M-55 and blaCTX-M-65, which were found in isolates from children, dogs, and chickens. DISCUSSION This study provides evidence of highly dynamic horizontal transfer of AMR genes and mobile genetic elements (MGEs) in the E. coli community and shows that some 3GCR-EC and (extended-spectrum β-lactamase) ESBL genes may have moved relatively large distances among domestic animals and children in semirural communities near Quito, Ecuador. Child-animal contact and the presence of domestic animal feces in the environment potentially serve as important sources of drug-resistant bacteria and ESBL genes. https://doi.org/10.1289/EHP7729.
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Affiliation(s)
- Liseth Salinas
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Fernanda Loayza
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Paúl Cárdenas
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Carlos Saraiva
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
| | - Timothy J. Johnson
- Department of Veterinary and Biomedical Sciences, University of Minnesota, Saint Paul, Minnesota, USA
- Mid Central Research & Outreach Center, Willmar, Minnesota, USA
| | - Heather Amato
- Environmental Health Sciences Division, University of California, Berkeley, California, USA
| | - Jay P. Graham
- Environmental Health Sciences Division, University of California, Berkeley, California, USA
| | - Gabriel Trueba
- Instituto de Microbiología, Colegio de Ciencias Biológicas y Ambientales, Universidad San Francisco de Quito, Quito, Pichincha, Ecuador
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26
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Antimicrobial Resistance in the Context of the Sustainable Development Goals: A Brief Review. Eur J Investig Health Psychol Educ 2021; 11:71-82. [PMID: 34542450 PMCID: PMC8314330 DOI: 10.3390/ejihpe11010006] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 12/15/2022] Open
Abstract
The reduction in infectious disease morbidity and mortality may be attributed to a variety of factors; however, improved sanitation and public health, and the introduction of vaccines and antibiotics are among the most significant. The development of antimicrobial resistance (AMR) in bacterial pathogens is an expected consequence of evolutionary adaptation to these noxious agents and the widespread use of these drugs has significantly sped up this process. Infections caused by multidrug resistant pathogens are directly associated with worse clinical outcomes, longer hospital stays, excess mortality in the affected patients and an increasing burden and costs on the healthcare infrastructure. The Sustainable Development Goals (SDGs) were published in 2015 by the United Nations to serve as a global blueprint for a better, more equitable, more sustainable life on our planet. The SDGs contextualize AMR as a global public health and societal issue; in addition, the continuing emergence of AMR may limit the attainment on many SDGs. The aim of this mini-review is to provide insight on the interface between attainment of SDGs and the clinical problem of drug resistance in bacteria.
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27
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Whole-genome sequencing as part of national and international surveillance programmes for antimicrobial resistance: a roadmap. BMJ Glob Health 2020; 5:e002244. [PMID: 33239336 PMCID: PMC7689591 DOI: 10.1136/bmjgh-2019-002244] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/18/2020] [Accepted: 03/27/2020] [Indexed: 12/26/2022] Open
Abstract
The global spread of antimicrobial resistance (AMR) and lack of novel alternative treatments have been declared a global public health emergency by WHO. The greatest impact of AMR is experienced in resource-poor settings, because of lack of access to alternative antibiotics and because the prevalence of multidrug-resistant bacterial strains may be higher in low-income and middle-income countries (LMICs). Intelligent surveillance of AMR infections is key to informed policy decisions and public health interventions to counter AMR. Molecular surveillance using whole-genome sequencing (WGS) can be a valuable addition to phenotypic surveillance of AMR. WGS provides insights into the genetic basis of resistance mechanisms, as well as pathogen evolution and population dynamics at different spatial and temporal scales. Due to its high cost and complexity, WGS is currently mainly carried out in high-income countries. However, given its potential to inform national and international action plans against AMR, establishing WGS as a surveillance tool in LMICs will be important in order to produce a truly global picture. Here, we describe a roadmap for incorporating WGS into existing AMR surveillance frameworks, including WHO Global Antimicrobial Resistance Surveillance System, informed by our ongoing, practical experiences developing WGS surveillance systems in national reference laboratories in Colombia, India, Nigeria and the Philippines. Challenges and barriers to WGS in LMICs will be discussed together with a roadmap to possible solutions.
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28
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Dunachie SJ, Day NP, Dolecek C. The challenges of estimating the human global burden of disease of antimicrobial resistant bacteria. Curr Opin Microbiol 2020; 57:95-101. [PMID: 33147565 PMCID: PMC7763986 DOI: 10.1016/j.mib.2020.09.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/29/2022]
Abstract
Estimating the contribution of antimicrobial resistance (AMR) to global mortality and healthcare costs enables evaluation of interventions, informs policy decisions on resource allocation, and drives research priorities. However assembling the high quality, patient-level data required for global estimates is challenging. Capacity for accurate microbiology culture and antimicrobial susceptibility testing is woefully neglected in low and middle-income countries, and further surveillance and research on community antimicrobial usage, bias in blood culture sampling, and the contribution of co-morbidities such as diabetes is essential. International collaboration between governments, policy makers, academics, microbiologists, front-line clinicians, veterinarians, the food and agriculture industry and the public is critical to understand and tackle AMR.
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Affiliation(s)
- Susanna J Dunachie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | - Nicholas Pj Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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29
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Savoldi A, Carrara E, Gladstone BP, Azzini AM, Göpel S, Tacconelli E. Gross national income and antibiotic resistance in invasive isolates: analysis of the top-ranked antibiotic-resistant bacteria on the 2017 WHO priority list. J Antimicrob Chemother 2020; 74:3619-3625. [PMID: 31730162 DOI: 10.1093/jac/dkz381] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To assess the association between country income status and national prevalence of invasive infections caused by the top-ranked bacteria on the WHO priority list: carbapenem-resistant (CR) Acinetobacter spp., Klebsiella spp. and Pseudomonas aeruginosa; third-generation cephalosporin-resistant (3GCR) Escherichia coli and Klebsiella spp.; and MRSA and vancomycin-resistant Enterococcus faecium (VR E. faecium). METHODS Active surveillance systems providing yearly prevalence data from 2012 onwards for the selected bacteria were included. The gross national income (GNI) per capita was used as the indicator for income status of each country and was log transformed to account for non-linearity. The association between antibiotic prevalence data and GNI per capita was investigated individually for each bacterium through linear regression. RESULTS Surveillance data were available from 67 countries: 38 (57%) were high income, 16 (24%) upper-middle income, 11 (16%) lower-middle income and two (3%) low income countries. The regression showed significant inverse association (P<0.0001) between resistance prevalence of invasive infections and GNI per capita. The highest rate of increase per unit decrease in log GNI per capita was observed in 3GCR Klebsiella spp. (22.5%, 95% CI 18.2%-26.7%), CR Acinetobacter spp. (19.2% 95% CI 11.3%-27.1%) and 3GCR E. coli (15.3%, 95% CI 11.6%-19.1%). The rate of increase per unit decrease in log GNI per capita was lower in MRSA (9.5%, 95% CI 5.2%-13.7%). CONCLUSIONS The prevalence of invasive infections caused by the WHO top-ranked antibiotic-resistant bacteria is inversely associated with GNI per capita at the global level. Public health interventions designed to limit the burden of antimicrobial resistance should also consider determinants of poverty and inequality, especially in lower-middle income and low income countries.
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Affiliation(s)
- Alessia Savoldi
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany.,Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Beryl Primrose Gladstone
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany
| | - Anna Maria Azzini
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Siri Göpel
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany.,Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
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Castro RAD, Ross A, Kamwela L, Reinhard M, Loiseau C, Feldmann J, Borrell S, Trauner A, Gagneux S. The Genetic Background Modulates the Evolution of Fluoroquinolone-Resistance in Mycobacterium tuberculosis. Mol Biol Evol 2020; 37:195-207. [PMID: 31532481 PMCID: PMC6984360 DOI: 10.1093/molbev/msz214] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Fluoroquinolones (FQ) form the backbone in experimental treatment regimens against drug-susceptible tuberculosis. However, little is known on whether the genetic variation present in natural populations of Mycobacterium tuberculosis (Mtb) affects the evolution of FQ-resistance (FQ-R). To investigate this question, we used nine genetically distinct drug-susceptible clinical isolates of Mtb and measured their frequency of resistance to the FQ ofloxacin (OFX) in vitro. We found that the Mtb genetic background led to differences in the frequency of OFX-resistance (OFX-R) that spanned two orders of magnitude and substantially modulated the observed mutational profiles for OFX-R. Further, in vitro assays showed that the genetic background also influenced the minimum inhibitory concentration and the fitness effect conferred by a given OFX-R mutation. To test the clinical relevance of our in vitro work, we surveyed the mutational profile for FQ-R in publicly available genomic sequences from clinical Mtb isolates, and found substantial Mtb lineage-dependent variability. Comparison of the clinical and the in vitro mutational profiles for FQ-R showed that 51% and 39% of the variability in the clinical frequency of FQ-R gyrA mutation events in Lineage 2 and Lineage 4 strains, respectively, can be attributed to how Mtb evolves FQ-R in vitro. As the Mtb genetic background strongly influenced the evolution of FQ-R in vitro, we conclude that the genetic background of Mtb also impacts the evolution of FQ-R in the clinic.
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Affiliation(s)
- Rhastin A D Castro
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Amanda Ross
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Lujeko Kamwela
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Miriam Reinhard
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Chloé Loiseau
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Julia Feldmann
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Andrej Trauner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Tackling antimicrobial resistance in Bangladesh: A scoping review of policy and practice in human, animal and environment sectors. PLoS One 2020; 15:e0227947. [PMID: 31986167 PMCID: PMC6984725 DOI: 10.1371/journal.pone.0227947] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 01/04/2020] [Indexed: 11/29/2022] Open
Abstract
Background Antimicrobial resistance (AMR) has become an emerging issue in the developing countries as well as in Bangladesh. AMR is aggravated by irrational use of antimicrobials in a largely unregulated pluralistic health system. This review presents a ‘snap shot’ of the current situation including existing policies and practices to address AMR, and the challenges and barriers associated with their implementation. Methods A systematic approach was adopted for identifying, screening, and selecting relevant literature on AMR situation in Bangladesh. We used Google Scholar, Pubmed, and Biomed Central databases for searching peer-reviewed literature in human, animal and environment sectors during January 2010-August 2019, and Google for grey materials from the institutional and journal websites. Two members of the study team independently reviewed these documents for inclusion in the analysis. We used a ‘mixed studies review’ method for synthesizing evidences from different studies. Result Of the final 47 articles, 35 were primary research, nine laboratory-based research, two review papers and one situation analysis report. Nineteen articles on human health dealt with prescribing and/or use of antimicrobials, five on self-medication, two on non-compliance of dosage, and 10 on the sensitivity and resistance patterns of antibiotics. Four papers focused on the use of antimicrobials in food animals and seven on environmental contamination. Findings reveal widespread availability of antimicrobials without prescription in the country including rise in its irrational use across sectors and consequent contamination of environment and spread of resistance. The development and transmission of AMR is deep-rooted in various supply and demand side factors. Implementation of existing policies and strategies remains a challenge due to poor awareness, inadequate resources and absence of national surveillance. Conclusion AMR is a multi-dimensional problem involving different sectors, disciplines and stakeholders requiring a One Health comprehensive approach for containment.
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Montealegre MC, Talavera Rodríguez A, Roy S, Hossain MI, Islam MA, Lanza VF, Julian TR. High Genomic Diversity and Heterogenous Origins of Pathogenic and Antibiotic-Resistant Escherichia coli in Household Settings Represent a Challenge to Reducing Transmission in Low-Income Settings. mSphere 2020; 5:e00704-19. [PMID: 31941809 PMCID: PMC6968650 DOI: 10.1128/msphere.00704-19] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 12/14/2019] [Indexed: 11/25/2022] Open
Abstract
Escherichia coli is present in multiple hosts and environmental compartments as a normal inhabitant, temporary or persistent colonizer, and as a pathogen. Transmission of E. coli between hosts and with the environment is considered to occur more often in areas with poor sanitation. We performed whole-genome comparative analyses on 60 E. coli isolates from soils and fecal sources (cattle, chickens, and humans) in households in rural Bangladesh. Isolates from household soils were in multiple branches of the reconstructed phylogeny, intermixed with isolates from fecal sources. Pairwise differences between all strain pairs were large (minimum, 189 single nucleotide polymorphisms [SNPs]), suggesting high diversity and heterogeneous origins of the isolates. The presence of multiple virulence and antibiotic resistance genes is indicative of the risk that E. coli from soil and feces represent for the transmission of variants that pose potential harm to people. Analysis of the accessory genomes of the Bangladeshi E. coli relative to E. coli genomes available in NCBI identified a common pool of accessory genes shared among E. coli isolates in this geographic area. Together, these findings indicate that in rural Bangladesh, a high level of E. coli in soil is likely driven by contributions from multiple and diverse E. coli sources (human and animal) that share an accessory gene pool relatively unique to previously published E. coli genomes. Thus, interventions to reduce environmental pathogen or antimicrobial resistance transmission should adopt integrated One Health approaches that consider heterogeneous origins and high diversity to improve effectiveness and reduce prevalence and transmission.IMPORTANCEEscherichia coli is reported in high levels in household soil in low-income settings. When E. coli reaches a soil environment, different mechanisms, including survival, clonal expansion, and genetic exchange, have the potential to either maintain or generate E. coli variants with capabilities of causing harm to people. In this study, we used whole-genome sequencing to identify that E. coli isolates collected from rural Bangladeshi household soils, including pathogenic and antibiotic-resistant variants, are diverse and likely originated from multiple diverse sources. In addition, we observed specialization of the accessory genome of this Bangladeshi E. coli compared to E. coli genomes available in current sequence databases. Thus, to address the high level of pathogenic and antibiotic-resistant E. coli transmission in low-income settings, interventions should focus on addressing the heterogeneous origins and high diversity.
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Affiliation(s)
| | | | - Subarna Roy
- Food Microbiology Laboratory, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Muhammed Iqbal Hossain
- Food Microbiology Laboratory, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mohammad Aminul Islam
- Food Microbiology Laboratory, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Paul G. Allen School for Global Animal Health, Washington State University, Pullman, Washington, USA
| | - Val F Lanza
- Servicio de Microbiología, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Timothy R Julian
- Eawag, Swiss Federal Institute of Science and Technology, Dübendorf, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Lakoh S, Adekanmbi O, Jiba DF, Deen GF, Gashau W, Sevalie S, Klein EY. Antibiotic use among hospitalized adult patients in a setting with limited laboratory infrastructure in Freetown Sierra Leone, 2017-2018. Int J Infect Dis 2019; 90:71-76. [PMID: 31655112 DOI: 10.1016/j.ijid.2019.10.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/16/2019] [Accepted: 10/18/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Our study aimed to assess antibiotic use in adult inpatients in the context of limited laboratory services at the main tertiary hospital in Sierra Leone. DESIGN A cross-sectional study of consecutive adult inpatients (≥18 years) between October 2017 and February 2018 at Connaught Hospital in Freetown. RESULTS A total of 920 patients were interviewed, of which 753 (81.8%) had at least one antibiotic. Complete data was captured for 688 (91.0%) patients. The median age was 41 years and 52.8% were male. Fever was reported in 41.5% of patients, though 85.1% had no leukocyte count prior to antibiotic use and none had a bacterial culture. Indications for prescribing were surgical prophylaxis (15.7%), pneumonia (15.1%), and trauma (5.8%). Cephalosporins (25.9%), penicillins (23.2%), and imidazoles (20.8%) were commonly prescribed. CONCLUSION We found high rates of antibiotic use, of which most was not based on laboratory evidence. Lack of oversight and microbiological support are drivers of poor prescribing in many developing countries, which lack financial resources and serve a sicker population. Greater investments are needed to establish antimicrobial stewardship programs and provide clinicians with diagnostic support to enable improvements in patient outcomes and curb the spread of antibiotic resistance.
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Affiliation(s)
- Sulaiman Lakoh
- Department of Internal Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone; Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Sierra Leone; Sustainable Health Systems, Freetown, Sierra Leone.
| | | | - Darlinda F Jiba
- Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Sierra Leone
| | - Gibrilla F Deen
- Department of Internal Medicine, College of Medicine and Allied Health Sciences, University of Sierra Leone, Sierra Leone; Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Sierra Leone
| | - Wadzani Gashau
- Department of Medicine, University of Sierra Leone Teaching Hospitals Complex, Sierra Leone
| | - Stephen Sevalie
- 34 Military Hospital Freetown, Sierra Leone, Sierra Leone; Sustainable Health Systems, Freetown, Sierra Leone
| | - Eili Y Klein
- Center for Disease Dynamics, Economics & Policy, Washington, DC 20005, United States; Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21209, United States; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States
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Kaba HEJ, Kuhlmann E, Scheithauer S. Thinking outside the box: Association of antimicrobial resistance with climate warming in Europe - A 30 country observational study. Int J Hyg Environ Health 2019; 223:151-158. [PMID: 31648934 DOI: 10.1016/j.ijheh.2019.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 11/28/2022]
Abstract
The association of antimicrobial resistance (AMR) with climatic factors gained higher attention since resistance increased with increasing local temperatures in the USA. We aimed to investigate whether the explanatory strength of climatic factors holds true in a region encompassing diverse healthcare systems, like Europe. In particular, we determined whether exposure to temporal climate warming is associated with an increase in AMR prevalence for clinically relevant pathogens. A 30-country cross-sectional study was conducted. The six-year prevalence of carbapenem-resistant Pseudomonas aeruginosa (CRPA), Klebsiella pneumoniae (CRKP), Multiresistant Escherichia coli (MREC), and Methicillin-resistant Staphylococcus aureus (MRSA) was determined based on > 900 k clinical isolates. Bi- and multivariate analysis were performed to identify associations with climatic variables using healthcare and socio-economic confounders. CRPA was significantly associated with the warm-season change in temperature, which, alongside corruption perception, explained 78% of total CRPA variance. Accordingly, a 0.5 °C increase of year-wise temperature change (exposition) resulted in a 1.02-fold increase (p = 0.035) in CRPA prevalence (outcome). For a given country, exposition status doubled the odds of outcome attainment compared to non-exposition (OR = 2.03, 95%-CI [1.03-3.99]). Moreover, we found significant associations of CRKP, MREC, and MRSA with the warm-season mean temperature, which had a higher contribution to MRSA variance explanation than outpatient antimicrobial drug use. We identified a novel association between AMR and climatic factors in Europe, which reveals two aspects: climatic factors significantly contribute to the explanation of AMR in different types of healthcare systems, while climate change (i.e. warming) might increase AMR transmission, in particular CRPA.
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Affiliation(s)
- Hani E J Kaba
- Institute of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany
| | - Ellen Kuhlmann
- Institute of Epidemiology, Social Medicine and Health System Research, Hannover Medical School (MHH), Germany
| | - Simone Scheithauer
- Institute of Infection Control and Infectious Diseases, University Medical Center Göttingen (UMG), Georg-August University Göttingen, Germany.
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Denyer Willis L, Chandler C. Quick fix for care, productivity, hygiene and inequality: reframing the entrenched problem of antibiotic overuse. BMJ Glob Health 2019; 4:e001590. [PMID: 31497315 PMCID: PMC6703303 DOI: 10.1136/bmjgh-2019-001590] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/05/2019] [Accepted: 07/12/2019] [Indexed: 11/04/2022] Open
Abstract
Antimicrobial resistance (AMR) is a major challenge of our time. A key global objective is to reduce antibiotic use (ABU), in order to reduce resistance caused by antimicrobial pressure. This is often set as a 'behaviour change' issue, locating intervention efforts in the knowledge and attitudes of individual prescribers and users of medicines. Such approaches have had limited impact and fall short of addressing wider drivers of antibiotic use. To address the magnitude of antibiotic overuse requires a wider lens to view our relationships with these medicines. This article draws on ethnographic research from East Africa to answer the question of what roles antibiotics play beyond their immediate curative effects. We carried out interviews, participant observation and documentary analysis over a decade in northeast Tanzania and eastern and central Uganda. Our findings suggest that antibiotics have become a 'quick fix' in our modern societies. They are a quick fix for care in fractured health systems; a quick fix for productivity at local and global scales, for humans, animals and crops; a quick fix for hygiene in settings of minimised resources; and a quick fix for inequality in landscapes scarred by political and economic violence. Conceptualising antibiotic use as a 'quick fix' infrastructure shifts attention to the structural dimensions of AMR and antimicrobial use (AMU) and raises our line of sight into the longer term, generating more systemic solutions that have greater chance of achieving equitable impact.
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Affiliation(s)
- Laurie Denyer Willis
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Clare Chandler
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Malik B, Bhattacharyya S. Antibiotic drug-resistance as a complex system driven by socio-economic growth and antibiotic misuse. Sci Rep 2019; 9:9788. [PMID: 31278344 PMCID: PMC6611849 DOI: 10.1038/s41598-019-46078-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/17/2019] [Indexed: 01/21/2023] Open
Abstract
Overwhelming antibiotic use poses a serious challenge today to the public-health policymakers worldwide. Many empirical studies pointed out this ever-increasing antibiotic consumption as primary driver of the community-acquired antibiotic drug-resistance, especially in the middle- and lower-income countries. The association is well documented across spatio-temporal gradients in many parts of the world, but there is rarely any study that emphasizes the mechanism of the association, which is important for combating drug-resistance. Formulating a mathematical model of emergence and transmission of drug-resistance, we in this paper, present how amalgamating three components: socio-economic growth, population ecology of infectious disease, and antibiotic misuse can instinctively incite proliferation of resistance in the society. We show that combined impact of economy, infections, and self-medication yield synergistic interactions through feedbacks on each other, presenting the emergence of drug-resistance as a self-reinforcing cycle in the population. Analysis of our model not only determines the threshold of antibiotic use beyond which the emergence of resistance may occur, but also characterizes how fast it develops depending on economic growth, and lack of education and awareness of the population. Our model illustrates that proper and timely government aid in population health can break the self-reinforcing process and reduce the burden of drug-resistance in the community.
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Affiliation(s)
- Bhawna Malik
- Disease Modelling Lab, Department of Mathematics, School of Natural Sciences, Shiv Nadar University, Gautan Buddha Nagar, India.
| | - Samit Bhattacharyya
- Disease Modelling Lab, Department of Mathematics, School of Natural Sciences, Shiv Nadar University, Gautan Buddha Nagar, India.
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Diverse Commensal Escherichia coli Clones and Plasmids Disseminate Antimicrobial Resistance Genes in Domestic Animals and Children in a Semirural Community in Ecuador. mSphere 2019; 4:4/3/e00316-19. [PMID: 31118304 PMCID: PMC6531886 DOI: 10.1128/msphere.00316-19] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The increased prevalence of antimicrobial resistance (AMR) among Enterobacteriaceae has had major clinical and economic impacts on human medicine. Many of the multidrug-resistant (multiresistant) Enterobacteriaceae found in humans are community acquired, and some of them are possibly linked to food animals (i.e., livestock raised for meat and dairy products). In this study, we examined whether numerically dominant commensal Escherichia coli strains from humans (n = 63 isolates) and domestic animals (n = 174 isolates) in the same community and with matching phenotypic AMR patterns were clonally related or shared the same plasmids. We identified 25 multiresistant isolates (i.e., isolates resistant to more than one antimicrobial) that shared identical phenotypic resistance patterns. We then investigated the diversity of E. coli clones, AMR genes, and plasmids carrying the AMR genes using conjugation, replicon typing, and whole-genome sequencing. All of the multiresistant E. coli isolates (from children and domestic animals) analyzed had at least 90 or more whole-genome SNP differences between one another, suggesting that none of the strains was recently transferred. While the majority of isolates shared the same antimicrobial resistance genes and replicons, DNA sequencing indicated that these genes and replicons were found on different plasmid structures. We did not find evidence of the clonal spread of AMR in this community: instead, AMR genes were carried on diverse clones and plasmids. This presents a significant challenge for understanding the movement of AMR in a community.IMPORTANCE Even though Escherichia coli strains may share nearly identical phenotypic AMR profiles and AMR genes and overlap in space and time, the diversity of clones and plasmids challenges research that aims to identify sources of AMR. Horizontal gene transfer appears to play a more significant role than clonal expansion in the spread of AMR in this community.
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Volpi C, Shehadeh F, Mylonakis E. Correlation of antimicrobial prescription rate and county income in medicare part D. Medicine (Baltimore) 2019; 98:e15914. [PMID: 31145355 PMCID: PMC6709292 DOI: 10.1097/md.0000000000015914] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/24/2019] [Accepted: 05/09/2019] [Indexed: 11/26/2022] Open
Abstract
The objective of this study was to examine whether patient income has an impact on likelihood of being prescribed an antimicrobial agent at the county level. A better understanding of factors that influence antimicrobial prescription is needed to efficiently mitigate rates of antimicrobial agents prescribed.This cross-sectional study used data from two publicly available datasets. The 2015 Medicare Part D PUF data quantifies the antimicrobial prescription rate at the county level and data from US Census Bureau provides information on socioeconomic status at the county level.At the county level, we explained 48% of the variation in antimicrobial prescriptions by socioeconomic status, age, gender, and race. More specifically, socioeconomic status accounted for 26% of the variation in antimicrobial rate and as income increased, correlation with antimicrobial prescription rate trended down.We determined patient income and other sociodemographics to influence the prescription of antimicrobial agents. Interventions should consider these factors to effectively evaluate antimicrobial prescription methods. Findings from this study can help guide intervention efforts which aim to minimize the number of inappropriate antimicrobials prescribed, such as antimicrobial stewardship programs. Effective interventions have the capability of decreasing levels of inappropriate antimicrobials prescribed and prevent future cases of resistance.
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Affiliation(s)
- Connor Volpi
- Brown University School of Public Health, 121 South Main Street
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Fadi Shehadeh
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
| | - Eleftherios Mylonakis
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI 02903
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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. THE LANCET. INFECTIOUS DISEASES 2019; 19:601-610. [PMID: 31047852 DOI: 10.1016/s1473-3099(18)30792-8] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 11/15/2018] [Accepted: 12/07/2018] [Indexed: 11/20/2022]
Abstract
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.
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40
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Lim WW, Wu P, Bond HS, Wong JY, Ni K, Seto WH, Jit M, Cowling BJ. Determinants of methicillin-resistant Staphylococcus aureus (MRSA) prevalence in the Asia-Pacific region: A systematic review and meta-analysis. J Glob Antimicrob Resist 2018; 16:17-27. [PMID: 30145271 DOI: 10.1016/j.jgar.2018.08.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/11/2018] [Accepted: 08/17/2018] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Published literature on methicillin-resistant Staphylococcus aureus (MRSA) in the Asia-Pacific region was reviewed to document the prevalence of MRSA in the region and to examine the impact of variability in study design on the reported MRSA prevalence data. METHODS This review included studies reporting MRSA prevalence between 2000 and 2016. Studies were excluded if they did not contain complete information on antimicrobial susceptibility testing (AST) methods. Primary outcomes were the proportion of MRSA among S. aureus isolates (resistance proportion) or among individual samples (prevalence). RESULTS A total of 229 studies in 19 countries/territories were included in the study. There was substantial heterogeneity in both outcomes (resistance proportion, I2=99.59%; prevalence, I2=99.83%), precluding pooled averages, and meta-regression analyses revealed that these variations were explained by country income status and participant characteristics but not by methodological differences in AST. Also, no significant secular changes in MRSA prevalence or resistance proportions in Asia-Pacific were found. CONCLUSION The resistance proportions and prevalence of MRSA infections in Asia-Pacific are comparable with those reported in other regions with no significant secular changes in the past decade. Country income status and characteristics of the sample population explained more variation in the reported resistance proportions and prevalence of MRSA than methodological differences in AST across locations in the region.
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Affiliation(s)
- Wey Wen Lim
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Peng Wu
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Helen S Bond
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jessica Y Wong
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kaiwen Ni
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wing Hong Seto
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Mark Jit
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; Modelling and Economics Unit, Public Health England, London, UK; Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Benjamin J Cowling
- World Health Organization Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Alividza V, Mariano V, Ahmad R, Charani E, Rawson TM, Holmes AH, Castro-Sánchez E. Investigating the impact of poverty on colonization and infection with drug-resistant organisms in humans: a systematic review. Infect Dis Poverty 2018; 7:76. [PMID: 30115132 PMCID: PMC6097281 DOI: 10.1186/s40249-018-0459-7] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 07/09/2018] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Vivian Alividza
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Victor Mariano
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Raheelah Ahmad
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
- Health Group, Management Department, Imperial College Business School, Exhibition Road, London, UK
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Timothy M. Rawson
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Alison H. Holmes
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
| | - Enrique Castro-Sánchez
- NIHR Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK
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Årdal C, Røttingen JA, Opalska A, Van Hengel AJ, Larsen J. Pull Incentives for Antibacterial Drug Development: An Analysis by the Transatlantic Task Force on Antimicrobial Resistance. Clin Infect Dis 2018; 65:1378-1382. [PMID: 29017240 DOI: 10.1093/cid/cix526] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 06/06/2017] [Indexed: 11/14/2022] Open
Abstract
New alternative market models are needed to incentivize companies to invest in developing new antibacterial drugs. In a previous publication, the Transatlantic Task Force on Antimicrobial Resistance (TATFAR) summarized the key areas of consensus for economic incentives for antibacterial drug development. That work determined that there was substantial agreement on the need for a mixture of push and pull incentives and particularly those that served to delink the revenues from the volumes sold. Pull incentives reward successful development by increasing or ensuring future revenue. Several pull incentives have been proposed that could substantially reward the development of new antibacterial drugs. In this second article authored by representatives of TATFAR, we examine the advantages and disadvantages of different pull incentives for antibacterial drug development. It is TATFAR's hope that this analysis, combined with other related analyses, will provide actionable information that will shape policy makers' thinking on this important issue.
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Affiliation(s)
| | - John-Arne Røttingen
- Norwegian Institute of Public Health, Oslo, Norway.,Institute of Health and Society, University of Oslo, Norway
| | - Aleksandra Opalska
- Directorate - General for Health and Food Safety, European Commission, Brussels, Belgium
| | - Arjon J Van Hengel
- Directorate Health, Directorate-General for Research and Innovation, European Commission, Brussels, Belgium
| | - Joseph Larsen
- Division of Chemical, Biological, Radiological, and Nuclear Medical Countermeasures, Biomedical Advanced Research and Development Authority, Office of Assistant Secretary for Preparedness and Response, US Department of Health and Human Services, Washington DC
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Asaduzzaman M. Antimicrobial resistance: an urgent need for a planetary and ecosystem approach. Lancet Planet Health 2018; 2:e99-e100. [PMID: 29615230 DOI: 10.1016/s2542-5196(18)30019-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 01/29/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Muhammad Asaduzzaman
- Planetary Health Alliance, Harvard University, Cambridge, MA 02138, USA; Healthcare Information for all, Charlbury, OX7 3PN, UK.
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Alvarez-Uria G, Gandra S, Mandal S, Laxminarayan R. Global forecast of antimicrobial resistance in invasive isolates of Escherichia coli and Klebsiella pneumoniae. Int J Infect Dis 2018; 68:50-53. [PMID: 29410253 PMCID: PMC5889426 DOI: 10.1016/j.ijid.2018.01.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 01/13/2018] [Accepted: 01/15/2018] [Indexed: 12/27/2022] Open
Abstract
We aimed to estimate global trends of antimicrobial resistance of E. coli and K. pneumoniae invasive isolates. By 2030, over half of E. coli and K. pneumoniae invasive isolates could become resistant to third generation cephalosporins. Carbapenem resistance is increasing rapidly among K. pneumoniae invasive isolates.
Objectives To project future antimicrobial resistance (AMR) in Escherichia coli and Klebsiella pneumoniae. Methods Mixed linear models were constructed from a sample of countries with AMR data in the ResistanceMap database. Inverse probability weighting methods were used to account for countries without AMR data. Results The estimated prevalence of AMR in 2015 was 64.5% (95% confidence interval (CI) 42–87%) for third-generation cephalosporin-resistant (3GCR) Escherichia coli, 5.8% (95% CI 1.8–9.7%) for carbapenem-resistant (CR) E. coli, 66.9% (95% CI 47.1–86.8%) for 3GCR Klebsiella pneumoniae, and 23.4% (95% CI 7.4–39.4%) for CR K. pneumoniae. The projected AMR prevalence in 2030 was 77% (95% CI 55–99.1%) for 3GCR E. coli, 11.8% (95% CI 3.7–19.9%) for CR E. coli, 58.2% (95% CI 50.2–66.1%) for 3GCR K. pneumoniae, and 52.8% (95% CI 16.3–89.3%) for CR K. pneumoniae. Conclusions The models suggest that third-generation cephalosporins and carbapenems could be ineffective against a sizeable proportion of infections by E. coli and K. pneumoniae in most parts of the world by 2030, supporting both the need to enhance stewardship efforts and to prioritize research and development of new antibiotics for resistant Enterobacteriaceae.
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Affiliation(s)
- Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, AP, India
| | - Sumanth Gandra
- Center for Disease Dynamics, Economics & Policy, New Delhi, India; Department of Management Science, University of Strathclyde, Glasgow, UK
| | | | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, New Delhi, India; Department of Management Science, University of Strathclyde, Glasgow, UK; Princeton Environmental Institute, Princeton, NJ, USA.
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Pires D, de Kraker MEA, Tartari E, Abbas M, Pittet D. ‘Fight Antibiotic Resistance—It’s in Your Hands’: Call From the World Health Organization for 5th May 2017. Clin Infect Dis 2017. [DOI: 10.1093/cid/cix226] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Daniela Pires
- Infection Control Programme and WHO Collaborating Centre on Patient Safety - Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
- Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal; and
| | - Marlieke Elizabeth Adriana de Kraker
- Infection Control Programme and WHO Collaborating Centre on Patient Safety - Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Ermira Tartari
- Infection Control Programme and WHO Collaborating Centre on Patient Safety - Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
- Infection Control Unit, Mater Dei Hospital, Msida, Malta
| | - Mohamed Abbas
- Infection Control Programme and WHO Collaborating Centre on Patient Safety - Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Didier Pittet
- Infection Control Programme and WHO Collaborating Centre on Patient Safety - Infection Control & Improving Practices, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland
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