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Hama Diallo A, Shahid ASMSB, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Achieng C, Bourdon C, Oduol C, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort. EClinicalMedicine 2024; 73:102676. [PMID: 38933099 PMCID: PMC11200276 DOI: 10.1016/j.eclinm.2024.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia. Methods This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission. Findings Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission. Interpretation Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care. Funding The Bill & Melinda Gates Foundation (OPP1131320).
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Mogeni P, Soge OO, Tickell KD, Tornberg SN, Pascual R, Wakatake E, Diakhate MM, Rwigi D, Kariuki K, Kariuki S, Singa BO, Fang FC, Walson JL, Pavlinac PB. β-Lactamase and Macrolide Resistance Gene Carriage in Escherichia coli Isolates Among Children Discharged From Inpatient Care in Western Kenya: A Cross-sectional Study. Open Forum Infect Dis 2024; 11:ofae307. [PMID: 38938894 PMCID: PMC11210497 DOI: 10.1093/ofid/ofae307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 05/30/2024] [Indexed: 06/29/2024] Open
Abstract
Background Antimicrobial resistance (AMR) is a global threat to infectious disease control, particularly among recently hospitalized children. We sought to determine the prevalence and mitigating factors of resistance in enteric Escherichia coli among children discharged from health facilities in western Kenya. Methods Between June 2016 and November 2019, children aged 1 to 59 months were enrolled at the point of discharge from the hospital. E coli was isolated by microbiological culture from rectal swabs at baseline. β-Lactamases and macrolide resistance-conferring genes were detected by polymerase chain reaction. A modified Poisson regression model was used to assess the predictors mph(A) and CTX-M-type extended-spectrum β-lactamase (ESBL). Results Of the 238 children whose E coli isolates were tested, 91 (38.2%) and 109 (45.8%) had detectable CTX-M-type ESBL and mph(A) genes, respectively. Antibiotic treatment during hospitalization (adjusted prevalence ratio [aPR], 2.47; 95% CI, 1.12-5.43; P = .025), length of hospitalization (aPR, 1.42; 95% CI, 1.00-2.01; P = .052), and the practice of open defecation (aPR, 2.47; 95% CI, 1.40-4.36; P = .002) were independent predictors for CTX-M-type ESBL and mph(A) genes. Pneumococcal vaccination was associated with a 43% lower likelihood of CTX-M-type ESBL (aPR, 0.57; 95% CI, .38-.85; P = .005), while measles vaccination was associated with a 32% lower likelihood of mph(A) genes (aPR, 0.68; 95% CI, .49-.93; P = .017) in E coli isolates. Conclusions Among children discharged from the hospital, history of vaccination, shorter hospital stay, lack of in-hospital antibiotic exposure, and improved sanitation were associated with a lower likelihood of AMR genes. To mitigate the continued spread of AMR, AMR control programs should consider strategies beyond antimicrobial stewardship, including improvements in sanitation, increased vaccine coverage, and the development of novel vaccines.
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Affiliation(s)
- Polycarp Mogeni
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, USA
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Stephanie N Tornberg
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Rushlenne Pascual
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Erika Wakatake
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Mame M Diakhate
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Doreen Rwigi
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Kariuki
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Samuel Kariuki
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Benson O Singa
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ferric C Fang
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- Department of Microbiology, University of Washington, Seattle, Washington, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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Rwigi D, Nyerere AK, Diakhate MM, Kariuki K, Tickell KD, Mutuma T, Tornberg SN, Soge OO, Walson JL, Singa B, Kariuki S, Pavlinac PB, Mogeni P. Phenotypic and molecular characterization of β-lactamase-producing Klebsiella species among children discharged from hospital in Western Kenya. BMC Microbiol 2024; 24:135. [PMID: 38654237 PMCID: PMC11040804 DOI: 10.1186/s12866-024-03284-7] [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: 11/09/2023] [Accepted: 03/31/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND The emergence and spread of β-lactamase-producing Klebsiella spp. has been associated with a substantial healthcare burden resulting in therapeutic failures. We sought to describe the proportion of phenotypic resistance to commonly used antibiotics, characterize β-lactamase genes among isolates with antimicrobial resistance (AMR), and assess the correlates of phenotypic AMR in Klebsiella spp. isolated from stool or rectal swab samples collected from children being discharged from hospital. METHODS We conducted a cross-sectional study involving 245 children aged 1-59 months who were being discharged from hospitals in western Kenya between June 2016 and November 2019. Whole stool or rectal swab samples were collected and Klebsiella spp. isolated by standard microbiological culture. β-lactamase genes were detected by PCR whilst phenotypic antimicrobial susceptibility was determined using the disc diffusion technique following standard microbiology protocols. Descriptive analyses were used to characterize phenotypic AMR and carriage of β-lactamase-producing genes. The modified Poisson regression models were used to assess correlates of phenotypic beta-lactam resistance. RESULTS The prevalence of β-lactamase carriage among Klebsiella spp. isolates at hospital discharge was 62.9% (154/245). Antibiotic use during hospitalization (adjusted prevalence ratio [aPR] = 4.51; 95%CI: 1.79-11.4, p < 0.001), longer duration of hospitalization (aPR = 1.42; 95%CI: 1.14-1.77, p < 0.002), and access to treated water (aPR = 1.38; 95%CI: 1.12-1.71, p < 0.003), were significant predictors of phenotypically determined β-lactamase. All the 154 β-lactamase-producing Klebsiella spp. isolates had at least one genetic marker of β-lactam/third-generation cephalosporin resistance. The most prevalent genes were blaCTX-M 142/154 (92.2%,) and blaSHV 142/154 (92.2%,) followed by blaTEM 88/154 (57.1%,) and blaOXA 48/154 (31.2%,) respectively. CONCLUSION Carriage of β-lactamase producing Klebsiella spp. in stool is common among children discharged from hospital in western Kenya and is associated with longer duration of hospitalization, antibiotic use, and access to treated water. The findings emphasize the need for continued monitoring of antimicrobial susceptibility patterns to inform the development and implementation of appropriate treatment guidelines. In addition, we recommend measures beyond antimicrobial stewardship and infection control within hospitals, improved sanitation, and access to safe drinking water to mitigate the spread of β-lactamase-producing Klebsiella pathogens in these and similar settings.
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Affiliation(s)
- Doreen Rwigi
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
- Center for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.
| | - Andrew K Nyerere
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Mame M Diakhate
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Kevin Kariuki
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Center for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, USA
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Timothy Mutuma
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Center for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA
| | - Benson Singa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Samuel Kariuki
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Center for Microbiology Research (CMR), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Polycarp Mogeni
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
- Department of Global Health, University of Washington, Seattle, Washington, USA.
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Rees CA, Ideh RC, Kisenge R, Kamara J, Coleman-Nekar YJG, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP. Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool. BMJ Open 2024; 14:e079389. [PMID: 38365298 PMCID: PMC10875550 DOI: 10.1136/bmjopen-2023-079389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
INTRODUCTION The immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify neonates discharged from the neonatal ward at risk for 60-day post-discharge mortality. METHODS We conducted a prospective observational cohort study of neonates discharged from Muhimbili National Hospital in Dar es Salaam, Tanzania, and John F Kennedy Medical Centre in Monrovia, Liberia. Research staff called caregivers to ascertain vital status up to 60 days after discharge. We conducted multivariable logistic regression analyses with best subset selection to identify socioeconomic, demographic, clinical, and anthropometric factors associated with post-discharge mortality. We used adjusted log coefficients to assign points to each variable and internally validated our tool with bootstrap validation with 500 repetitions. RESULTS There were 2344 neonates discharged and 2310 (98.5%) had post-discharge outcomes available. The median (IQR) age at discharge was 8 (4, 15) days; 1238 (53.6%) were male. In total, 71 (3.1%) died during follow-up (26.8% within 7 days of discharge). Leaving against medical advice (adjusted OR [aOR] 5.62, 95% CI 2.40 to 12.10) and diagnosis of meconium aspiration (aOR 6.98, 95% CI 1.69 to 21.70) conferred the greatest risk for post-discharge mortality. The risk assessment tool included nine variables (total possible score=63) and had an optimism corrected area under the receiver operating characteristic curve of 0.77 (95% CI 0.75 to 0.80). A score of ≥6 was most optimal (sensitivity 68.3% [95% CI 64.8% to 71.5%], specificity 72.1% [95% CI 71.5% to 72.7%]). CONCLUSIONS A small number of factors predicted all-cause, 60-day mortality after discharge from neonatal wards in Tanzania and Liberia. After external validation, this risk assessment tool may facilitate clinical decision making for eligibility for discharge and the direction of resources to follow-up high risk neonates.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Readon C Ideh
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Julia Kamara
- Department of Pediatrics, John F Kennedy Medical Center, Monrovia, Liberia
| | | | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Boston, USA
- Center for Nutrition, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Oldenburg CE, Ouattara M, Bountogo M, Boudo V, Ouedraogo T, Compaoré G, Dah C, Zakane A, Coulibaly B, Bagagnan C, Hu H, O’Brien KS, Nyatigo F, Keenan JD, Doan T, Porco TC, Arnold BF, Lebas E, Sié A, Lietman TM. Mass Azithromycin Distribution to Prevent Child Mortality in Burkina Faso: The CHAT Randomized Clinical Trial. JAMA 2024; 331:482-490. [PMID: 38349371 PMCID: PMC10865159 DOI: 10.1001/jama.2023.27393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/14/2023] [Indexed: 02/15/2024]
Abstract
Importance Repeated mass distribution of azithromycin has been shown to reduce childhood mortality by 14% in sub-Saharan Africa. However, the estimated effect varied by location, suggesting that the intervention may not be effective in different geographical areas, time periods, or conditions. Objective To evaluate the efficacy of twice-yearly azithromycin to reduce mortality in children in the presence of seasonal malaria chemoprevention. Design, Setting, and Participants This cluster randomized placebo-controlled trial evaluating the efficacy of single-dose azithromycin for prevention of all-cause childhood mortality included 341 communities in the Nouna district in rural northwestern Burkina Faso. Participants were children aged 1 to 59 months living in the study communities. Interventions Communities were randomized in a 1:1 ratio to receive oral azithromycin or placebo distribution. Children aged 1 to 59 months were offered single-dose treatment twice yearly for 3 years (6 distributions) from August 2019 to February 2023. Main Outcomes and Measures The primary outcome was all-cause childhood mortality, measured during a twice-yearly enumerative census. Results A total of 34 399 children (mean [SD] age, 25.2 [18] months) in the azithromycin group and 33 847 children (mean [SD] age, 25.6 [18] months) in the placebo group were included. A mean (SD) of 90.1% (16.0%) of the censused children received the scheduled study drug in the azithromycin group and 89.8% (17.1%) received the scheduled study drug in the placebo group. In the azithromycin group, 498 deaths were recorded over 60 592 person-years (8.2 deaths/1000 person-years). In the placebo group, 588 deaths were recorded over 58 547 person-years (10.0 deaths/1000 person-years). The incidence rate ratio for mortality was 0.82 (95% CI, 0.67-1.02; P = .07) in the azithromycin group compared with the placebo group. The incidence rate ratio was 0.99 (95% CI, 0.72-1.36) in those aged 1 to 11 months, 0.92 (95% CI, 0.67-1.27) in those aged 12 to 23 months, and 0.73 (95% CI, 0.57-0.94) in those aged 24 to 59 months. Conclusions and Relevance Mortality in children (aged 1-59 months) was lower with biannual mass azithromycin distribution in a setting in which seasonal malaria chemoprevention was also being distributed, but the difference was not statistically significant. The study may have been underpowered to detect a clinically relevant difference. Trial Registration ClinicalTrials.gov Identifier: NCT03676764.
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Affiliation(s)
- Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
| | | | | | | | | | | | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | | | | | | | - Huiyu Hu
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
| | - Fanice Nyatigo
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Jeremy D. Keenan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Benjamin F. Arnold
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology & Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
- Institute for Global Health Sciences, University of California, San Francisco
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Atlas HE, Brander RL, Tickell KD, Bunyige L, Oongo S, McGrath CJ, John-Stewart GC, Richardson BA, Singa BO, Denno DM, Walson JL, Pavlinac PB. Prevalence and Correlates of Stunting among a High-Risk Population of Kenyan Children Recently Hospitalized for Acute Illnesses. Am J Trop Med Hyg 2024; 110:356-363. [PMID: 38150727 PMCID: PMC10859817 DOI: 10.4269/ajtmh.23-0050] [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: 01/20/2023] [Accepted: 09/30/2023] [Indexed: 12/29/2023] Open
Abstract
Stunting (length/height-for-age z-score < -2) is associated with significant morbidity and mortality among children under 5 years of age in sub-Saharan Africa. Children who are stunted and recently hospitalized for acute illness may be at particularly elevated risk for post-discharge mortality. In this cross-sectional analysis, we measured the prevalence of stunting at hospital discharge and identified host, caregiver, and environmental correlates of stunting among children aged 1-59 months in Western Kenya enrolled in the Toto Bora Trial. Child age- and site-adjusted prevalence ratios were estimated using Poisson regression. Of the 1,394 children included in this analysis, 23% were stunted at hospital discharge. Older children (12-23 months and 24-59 months versus 0-5 months) had a higher prevalence of stunting (adjusted prevalence ratio [aPR]: 1.58; 95% CI: 1.04-2.36 and aPR: 1.59; 95% CI: 1.08-2.34, respectively). HIV-exposed, uninfected children (aPR: 1.94; 95% CI: 1.39-2.70), children with HIV infection (aPR: 2.73; 95% CI: 1.45-5.15), and those who were never exclusively breastfed in early life (aPR 2.51; 95% CI: 1.35-4.67) were more likely to be stunted. Caregiver education (primary school or less) and unimproved sanitation (pit latrine without slab floor or open defecation) were associated with increased risk of stunting (aPR: 1.94; 95% CI: 1.54-2.44; aPR: 1.99; 95% CI: 1.20-3.31; aPR: 3.57; 95% CI: 1.77-7.21, respectively). Hospital discharge represents an important opportunity for both identifying and delivering targeted interventions for nutrition-associated poor outcomes among a high-risk population of children.
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Affiliation(s)
- Hannah E Atlas
- Department of Global Health, University of Washington, Seattle, Washington
| | - Rebecca L Brander
- International Food Policy Research Institute, Division of Poverty, Health, and Nutrition, Baltimore, Maryland
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington
- Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Lucy Bunyige
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Susan Oongo
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
- Department of Allergy and Infectious Disease, University of Washington, Seattle, Washington
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Benson O Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Donna M Denno
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
- Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington
- Department of International Health, Johns Hopkins University, Baltimore, Maryland
- Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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7
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Sié A, Ouattara M, Bountogo M, Boudo V, Ouedraogo T, Compaoré G, Dah C, Bagagnan C, Lebas E, Hu H, Rice J, Porco TC, Arnold BF, Lietman TM, Oldenburg CE. Azithromycin during Routine Well-Infant Visits to Prevent Death. N Engl J Med 2024; 390:221-229. [PMID: 38231623 DOI: 10.1056/nejmoa2309495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND Mass distribution of azithromycin to children 1 to 59 months of age has been shown to reduce childhood all-cause mortality in some sub-Saharan African regions, with the largest reduction seen among infants younger than 12 months of age. Whether the administration of azithromycin at routine health care visits for infants would be effective in preventing death is unclear. METHODS We conducted a randomized, placebo-controlled trial of a single dose of azithromycin (20 mg per kilogram of body weight) as compared with placebo, administered during infancy (5 to 12 weeks of age). The primary end point was death before 6 months of age. Infants were recruited at routine vaccination or other well-child visits in clinics and through community outreach in three regions of Burkina Faso. Vital status was assessed at 6 months of age. RESULTS Of the 32,877 infants enrolled from September 2019 through October 2022, a total of 16,416 infants were randomly assigned to azithromycin and 16,461 to placebo. Eighty-two infants in the azithromycin group and 75 infants in the placebo group died before 6 months of age (hazard ratio, 1.09; 95% confidence interval [CI], 0.80 to 1.49; P = 0.58); the absolute difference in mortality was 0.04 percentage points (95% CI, -0.10 to 0.21). There was no evidence of an effect of azithromycin on mortality in any of the prespecified subgroups, including subgroups defined according to age, sex, and baseline weight, and no evidence of a difference between the two trial groups in the incidence of adverse events. CONCLUSIONS In this trial conducted in Burkina Faso, we found that administration of azithromycin to infants through the existing health care system did not prevent death. (Funded by the Bill and Melinda Gates Foundation; CHAT ClinicalTrials.gov number, NCT03676764.).
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Affiliation(s)
- Ali Sié
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Mamadou Ouattara
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Mamadou Bountogo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Valentin Boudo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Thierry Ouedraogo
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Guillaume Compaoré
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Clarisse Dah
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Cheik Bagagnan
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Elodie Lebas
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Huiyu Hu
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Jessica Rice
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Travis C Porco
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Benjamin F Arnold
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Thomas M Lietman
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
| | - Catherine E Oldenburg
- From Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso (A.S., M.O., M.B., V.B., T.O., G.C., C.D., C.B.); and the Francis I. Proctor Foundation (E.L., H.H., T.C.P., B.F.A., T.M.L., C.E.O., J.R.), the Department of Epidemiology and Biostatistics (T.C.P., T.M.L., C.E.O.), the Department of Ophthalmology (T.C.P., B.F.A., T.M.L., C.E.O.), and the Institute for Global Health Sciences (T.M.L., C.E.O.), University of California, San Francisco, San Francisco
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Knappett M, Nguyen V, Chaudhry M, Trawin J, Kabakyenga J, Kumbakumba E, Jacob ST, Ansermino JM, Kissoon N, Mugisha NK, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102380. [PMID: 38204490 PMCID: PMC10776442 DOI: 10.1016/j.eclinm.2023.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Background Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding No specific funding was received.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Maryum Chaudhry
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Dept of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Dept of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin T. Jacob
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
- Dept of Pediatrics, BC Children’s Hospital, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
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Dhindwal P, Myziuk I, Ruzzini A. Macrolide esterases: current threats and opportunities. Trends Microbiol 2023; 31:1199-1201. [PMID: 37689489 DOI: 10.1016/j.tim.2023.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 09/11/2023]
Abstract
Antibiotics often contain ester bonds. The macrocyclic lactones of macrolides are pre-eminent examples in which ester bonds are essential to the form and function of antibiotics. Bacterial macrolide esterases that hydrolyze these macrocyclic lactones to confer antimicrobial resistance (AMR) are the topic of this forum. We provide insight into their role in agricultural systems and discuss their emergence and their potential extensibility to bioremediation efforts.
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Affiliation(s)
- Poonam Dhindwal
- Department of Veterinary Microbiology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5B4
| | - Iryna Myziuk
- Department of Biochemistry, Microbiology, and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5E5
| | - Antonio Ruzzini
- Department of Veterinary Microbiology, Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5B4; Department of Biochemistry, Microbiology, and Immunology, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada, S7N 5E5.
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10
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Ouattara M, Sié A, Bountogo M, Boudo V, Dah C, Lebas E, Hu H, Porco TC, Arnold BF, Lietman TM, Oldenburg CE. Anthropometric Differences in Community- Versus Clinic-Recruited Infants Participating in a Trial of Azithromycin for Prevention of Childhood Mortality in Burkina Faso. Am J Trop Med Hyg 2023; 109:1187-1191. [PMID: 37783457 PMCID: PMC10622465 DOI: 10.4269/ajtmh.23-0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/06/2023] [Indexed: 10/04/2023] Open
Abstract
Clinic-based recruitment for preventative interventions for child health may select for healthier populations compared with community-based outreach. Nutritional status during infancy as measured by anthropometry is predictive of mortality, growth faltering later in life, and poor cognitive development outcomes. We evaluated baseline differences in infant nutritional status among children recruited directly in their community versus clinic recruitment among infants participating in a trial of azithromycin compared with placebo for prevention of mortality in three districts of Burkina Faso. Infants between 5 and 12 weeks of age were recruited in their community of residence via vaccine outreach teams or in primary health-care clinics during vaccine clinics. Weight, height, and mid upper arm circumference were measured. We used linear and logistic regression models to compare anthropometric outcomes among community and clinic recruited infants, adjusting for age at enrollment, gender, and season. Among 32,877 infants enrolled in the trial, 21,273 (64.7%) were recruited via community outreach. Mean weight-for-age z-score (WAZ) was -0.60 ± 1.2 (SD), weight-for-length z-score (WLZ) was -0.16 ± 1.5, and length-for-age z-score was-0.53 ± 1.3. Infants enrolled in the community had lower WAZ (mean difference, -0.12; 95% CI, -0.20 to -0.04) and WLZ (mean difference, -0.21; 95% CI, -0.32 to -0.09). Community-recruited infants were more often underweight (WAZ < -2; odds ratio [OR], 1.25; 95% CI, 1.09-1.43) and wasted (WLZ < -2; OR, 1.54; 95% CI, 1.31-1.79). There was no evidence of a difference in height-based measures. Community and clinic recruitment likely reach different populations of children.
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Affiliation(s)
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | | | - Valentin Boudo
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Clarisse Dah
- Centre de Recherche en Santé de Nouna, Burkina Faso, Nouna
| | - Elodie Lebas
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Huiyu Hu
- Francis I Proctor Foundation, University of California, San Francisco, California
| | - Travis C. Porco
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Benjamin F. Arnold
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Thomas M. Lietman
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
| | - Catherine E. Oldenburg
- Francis I Proctor Foundation, University of California, San Francisco, California
- Department of Epidemiology & Biostatistics, University of California, San Francisco, California
- Department of Ophthalmology, University of California, San Francisco, California
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Rees CA, Kisenge R, Ideh RC, Kamara J, Coleman YJ, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Manji KP, Duggan CP. Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia. BMJ Paediatr Open 2023; 7:e001972. [PMID: 37385735 PMCID: PMC10314694 DOI: 10.1136/bmjpo-2023-001972] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND There are no validated clinical decision aids to identify neonates and young children at risk of hospital readmission or postdischarge mortality in sub-Saharan Africa, leaving the decision to discharge a child to a clinician's impression. Our objective was to determine the precision of clinician impression to identify neonates and young children at risk for readmission and postdischarge mortality. METHODS We conducted a survey study nested in a prospective observational cohort of neonates and children aged 1-59 months followed 60 days after hospital discharge from Muhimbili National Hospital in Dar es Salaam, Tanzania or John F. Kennedy Medical Center in Monrovia, Liberia. Clinicians who discharged each enrolled patient were surveyed to determine their perceived probability of the patient's risk of 60-day hospital readmission or postdischarge mortality. We calculated the area under the precision-recall curve (AUPRC) to determine the precision of clinician impression for both outcomes. RESULTS Of 4247 discharged patients, 3896 (91.7%) had available clinician surveys and 3847 (98.7%) had 60-day outcomes available: 187 (4.8%) were readmitted and 120 (3.1%) died within 60 days of hospital discharge. Clinician impression had poor precision in identifying neonates and young children at risk of hospital readmission (AUPRC: 0.06, 95% CI: 0.04 to 0.08) and postdischarge mortality (AUPRC: 0.05, 95% CI: 0.03 to 0.08). Patients for whom clinicians attributed inability to pay for future medical treatment as the reason for risk for unplanned hospital readmission had 4.76 times the odds hospital readmission (95% CI: 1.31 to 17.25, p=0.02). CONCLUSIONS Given the poor precision of clinician impression alone to identify neonates and young children at risk of hospital readmission and postdischarge mortality, validated clinical decision aids are needed to aid in the identification of young children at risk for these outcomes.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Ye-Jeung Coleman
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children s Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
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Kariuki K, Diakhate MM, Musembi S, Tornberg-Belanger SN, Rwigi D, Mutuma T, Mutuku E, Tickell KD, Soge OO, Singa BO, Walson JL, Pavlinac PB, Kariuki S. Plasmid-mediated quinolone resistance genes detected in Ciprofloxacin non-susceptible Escherichia coli and Klebsiella isolated from children under five years at hospital discharge, Kenya. BMC Microbiol 2023; 23:129. [PMID: 37173674 PMCID: PMC10182689 DOI: 10.1186/s12866-023-02849-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 04/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The increasing spread of fluoroquinolone resistant enteric bacteria is a global public health concern. Children recently discharged from the hospital are at high risk of carriage of antimicrobial resistance (AMR) due to frequent exposure to antimicrobials during inpatient stays. This study aimed to determine the prevalence, correlates of ciprofloxacin (CIP) non-susceptibility, and distribution of plasmid-mediated quinolone resistance (PMQR) genes in Escherichia coli (E. coli) and Klebsiella spp isolated from children under five years being discharged from two Kenyan Hospitals. METHODS E. coli and Klebsiella spp were isolated from fecal samples from children discharged from hospital and subjected to antimicrobial susceptibility testing (AST) by disc diffusion and E-test. CIP non-susceptible isolates were screened for seven PMQR genes using multiplex polymerase chain reaction (PCR). Poisson regression was used to determine the association between the carriage of CIP non-susceptible isolates and patient characteristics. RESULTS Of the 280 CIP non-susceptible isolates: 188 E. coli and 92 Klebsiella spp isolates identified among 266 discharged children, 195 (68%) were CIP-non-susceptible with minimum inhibitory concentrations (MICs) of ≥ 1 µg/mL. Among these 195 isolates, 130 (67%) had high-level CIP MIC = ≥ 32 µg/mL). Over 80% of the isolates had at least one PMQR gene identified: aac(6')lb-cr (60%), qnrB (24%), oqxAB (22%), qnrS (16%), and qepA (6%), however, qnrA was not identified in any isolates tested. Co-carriage of qnrB with acc(6')-lb-cr was the most predominant accounting for 20% of all the isolates. Ceftriaxone use during hospital admission and the presence of extended spectrum beta-lactamase (ESBL) production were significantly associated with the carriage of CIP non-susceptible E. coli and Klebsiella spp. CONCLUSION CIP non-susceptibility is common among E. coli and Klebsiella spp isolated from hospital discharged children in Kenya. Carriage and co-carriage of PMQR, including the newly identified qepA gene, were frequently observed. These findings suggest that children leaving the hospital may serve as an important reservoir for transmission of resistant E. coli and Klebsiella spp to the community. Enhanced surveillance for AMR determinants is critical to inform interventions to control antimicrobial-resistant bacteria.
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Affiliation(s)
- Kevin Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
- Department of Biochemistry, Microbiology and Biotechnology, Kenyatta University, Nairobi, Kenya.
| | | | - Susan Musembi
- Department of Biochemistry, Microbiology and Biotechnology, Kenyatta University, Nairobi, Kenya
| | | | - Doreen Rwigi
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Timothy Mutuma
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth Mutuku
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, WA, USA
- Centre for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Medicine (Allergy and Infectious Diseases), University of Washington, Seattle, WA, USA
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
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13
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Imdad A, Chen FF, François M, Sana M, Tanner-Smith E, Smith A, Tsistinas O, Das JK, Bhutta ZA. Routine antibiotics for infants less than 6 months of age with growth failure/faltering: a systematic review. BMJ Open 2023; 13:e071393. [PMID: 37164453 PMCID: PMC10174012 DOI: 10.1136/bmjopen-2022-071393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
OBJECTIVE This systematic review commissioned by WHO aimed to synthesise evidence from current literature on the effects of systematically given, routine use of antibiotics for infants under 6 months of age with growth failure/faltering. SETTINGS Low-income and middle-income countries. PARTICIPANTS The study population was infants less than 6 months of age with growth failure/faltering. INTERVENTION The intervention group was infants who received no antibiotics or antibiotics other than those recommended in 2013 guidelines by WHO to treat childhood severe acute malnutrition. The comparison group was infants who received antibiotics according to the aforementioned guidelines. PRIMARY AND SECONDARY OUTCOMES The primary outcome was all-cause mortality, and secondary outcomes: clinical deterioration, antimicrobial resistance, recovery from comorbidity, adverse events, markers of intestinal inflammation, markers of systemic inflammation, hospital-acquired infections and non-response. The Grading of Recommendations Assessment, Development and Evaluation approach was considered to report the overall evidence quality for an outcome. RESULTS We screened 5137 titles and abstracts and reviewed the full text of 157 studies. None of the studies from the literature search qualified to answer the question for this systematic review. CONCLUSIONS There is a paucity of evidence on the routine use of antibiotics for the treatment of malnutrition in infants less than 6 months of age. Future studies with adequate sample sizes are needed to assess the potential risks and benefits of antibiotics in malnourished infants under 6 months of age. PROSPERO REGISTRATION NUMBER CRD42021277073.
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Affiliation(s)
- Aamer Imdad
- Division of Gastroenterology, Department of Pediatrics, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Fanny F Chen
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Melissa François
- Norton College of Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Momal Sana
- Monash Health, Clayton, Victoria, Australia
| | | | - Abigail Smith
- Health Science Library, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Olivia Tsistinas
- Health Science Library, SUNY Upstate Medical University, Syracuse, New York, USA
| | - Jai K Das
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zulfiqar Ahmed Bhutta
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
- Global Child Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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14
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Yousafzai ADK, Bangash AH, Asghar SY, Abbas SMM, Khawaja HF, Zehra S, Khan AU, Kamil M, Ayesha N, Khan AK, Mohsin R, Ahmed O, Fatima A, Ali A, Badar AU, Abbasi MN, Ashraf M, Shah AH, Iqbal T. Clinical efficacy of Azithromycin for COVID-19 management: A systematic meta-analysis of meta-analyses. Heart Lung 2023; 60:127-132. [PMID: 36996755 PMCID: PMC10017380 DOI: 10.1016/j.hrtlng.2023.03.004] [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: 11/08/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 03/18/2023]
Abstract
Background Azithromycin has been adopted as a component of the COVID-19 management protocol throughout the global healthcare settings but with a questionable if not downright unsubstantiated evidence base. Objectives In order to amalgamate and critically appraise the conflicting evidence around the clinical efficacy of Azithromycin (AZO) vis a vis COVID-19 management outcomes, a meta-analysis of meta-analyses was carried out to establish an evidence-based holistic status of AZO vis a vis its efficacy as a component-in-use of the COVID-19 management protocol. Methods A comprehensive systematic search was carried out through PubMed/Medline, Cochrane and Epistemonikos with a subsequent appraisal of abstracts and full-texts, as required. The Quality of Reporting of Meta-analyses (QUOROM) checklist and the Assessment of Multiple Systematic Reviews (AMSTAR) methodology were adopted to assess the methodological quality of the included meta-analyses. Random-effects models were developed to calculate summarized pool Odds Ratios (with 95% confidence interval) for the afore determined primary and secondary outcomes. Results AZO, when compared with best available therapy (BAT) including or excluding Hydroxychloroquine, exhibited statistically insignificant reduction in mortality [(n= 27,204 patients) OR= 0.77 (95% CI: 0.51-1.16) (I2= 97%)], requirement of mechanical ventilation [(n= 14,908 patients) OR= 1.4 (95% CI: 0.58-3.35) (I2= 98%)], induction of arrhythmia [(n= 9,723 patients) OR= 1.21 (95% CI: 0.63-2.32) (I2= 92%)] and QTc prolongation (a surrogate for torsadogenic effect) [(n= 6,534 patients) OR= 0.62 (95% CI: 0.23-1.73) (I2= 96%)]. Conclusion The meta-analysis of meta-analyses portrays AZO as a pharmacological agent that does not appear to have a comparatively superior clinical efficacy than BAT when it comes to COVID-19 management. Secondary to a very real threat of anti-bacterial resistance, it is suggested that AZO be discontinued and removed from COVID-19 management protocols.
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Affiliation(s)
| | - Ali Haider Bangash
- Shifa International Hospital, Islamabad, Pakistan,Corresponding author: Dr Ali Haider Bangash, MBBS, Shifa International Hospital, Islamabad, Pakistan. Medical student member of the American College of Physicians (ACP), American Society of Clinical Oncology (ASCO), European Academy of Neurology (EAN), Congress of Neurological Surgeons (CNS), North American Spine Society (NASS), Society for Neuro-Oncology (SNO), Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment (ISTAART), International Parkinson and Movement Disorder Society & Spine Intervention Society
| | | | | | | | - Saiqa Zehra
- Shifa International Hospital, Islamabad, Pakistan
| | | | - Musa Kamil
- Shifa International Hospital, Islamabad, Pakistan
| | - Noor Ayesha
- Shifa International Hospital, Islamabad, Pakistan
| | | | - Rabia Mohsin
- Shifa International Hospital, Islamabad, Pakistan
| | - Osama Ahmed
- Shifa International Hospital, Islamabad, Pakistan
| | | | - Aliya Ali
- Shifa International Hospital, Islamabad, Pakistan
| | - Ain ul Badar
- Shifa International Hospital, Islamabad, Pakistan
| | | | - Mohammad Ashraf
- Rawalpindi Medical College, Rawalpindi Medical University, Rawalpindi, Pakistan
| | | | - Tahir Iqbal
- Head of Department, Department of Medicine, Shifa College of Medicine, Islamabad, Pakistan
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15
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Toledo G, Landes M, van Lettow M, Tippett Barr BA, Bailey H, Crichton S, Msungama W, Thorne C. Risk factors for stunting in children who are HIV-exposed and uninfected after Option B+ implementation in Malawi. MATERNAL & CHILD NUTRITION 2022; 19:e13451. [PMID: 36349962 PMCID: PMC9749602 DOI: 10.1111/mcn.13451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
Evidence suggests children HIV-exposed and uninfected (CHEU) experience poor growth. We analysed child anthropometrics and explored factors associated with stunting among Malawian CHEU. Mothers with HIV and their infants HIV-exposed were enroled in a nationally representative prospective cohort within the National Evaluation of Malawi's Prevention of Mother-to-Child HIV Transmission Programme after Option B+ implementation (2014-2018). Anthropometry was measured at enrolment (age 1-6 months), visit 1 (approximately 12 months), and visit 2 (approximately 24 months). Weight-for-age (WAZ) and length-for-age (LAZ) z-scores were calculated using World Health Organization Growth Standards; underweight and stunting were defined as WAZ and LAZ more than 2 standard deviations below the reference median. Multivariable logistic regression restricted to CHEU aged 24 months (±3 months) was used to identify factors associated with stunting. Among 1211 CHEU, 562/1211 attended visit 2, of which 529 were aged 24 months (±3 months) and were included. At age 24 months, 40.4% of CHEU were stunted and/or underweight, respectively. In multi-variable analysis, adjusting for child age and sex, the odds of stunting were higher among CHEU with infectious disease diagnosis compared to those with no diagnosis (adjusted odds ratio = 3.35 [95% confidence interval: 1.82-6.17]), which was modified by co-trimoxazole prophylaxis (p = 0.028). Infant low birthweight was associated with an increased odds of stunting; optimal feeding and maternal employment were correlated with reduced odds. This is one of the first studies examining CHEU growth since Option B+. Interventions to improve linear growth among CHEU should address their multi-faceted health risks, alongside maternal ART prescription, and follow-up of mother-child pairs.
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Affiliation(s)
- Gabriela Toledo
- Population, Policy, and Practice Research & Teaching Department, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
| | - Megan Landes
- Department of Family and Community MedicineUniversity of TorontoTorontoOntarioCanada,Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | - Monique van Lettow
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
| | | | - Heather Bailey
- Institute for Global Health, University College LondonLondonUK
| | - Siobhan Crichton
- Medical Research Council Clinical Trials UnitUniversity College LondonLondonUK
| | - Wezi Msungama
- Division of Global HIV and TuberculosisCenters for Disease Control and PreventionLilongweMalawi
| | - Claire Thorne
- Population, Policy, and Practice Research & Teaching Department, Great Ormond Street Institute of Child HealthUniversity College LondonLondonUK
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16
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Pavlinac PB, Singa B, Huang ML, Shrestha L, Li V, Atlas HE, Diakhate MM, Brander R, Meshak L, Bogonko G, Tickell KD, McGrath CJ, Machuara IM, Ounga DO, Berkley JA, Richardson BA, John-Stewart G, Walson JL, Slyker J. Cytomegalovirus Viremia Predicts Postdischarge Mortality in Kenyan HIV-Exposed Uninfected Children. J Infect Dis 2022; 226:1519-1527. [PMID: 35152295 PMCID: PMC9624454 DOI: 10.1093/infdis/jiac047] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/11/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) viremia is associated with mortality in severely ill immunocompetent adults and hospitalized children with HIV (CWH). We measured CMV viremia in HIV-exposed and -unexposed Kenyan children aged 1-59 months discharged from hospital and determined its relationship with postdischarge mortality. METHODS CMV DNA levels were measured in plasma from 1024 children (97 of which were HIV exposed uninfected [HEU], and 15 CWH). Poisson and Cox proportional hazards regression models were used to identify correlates of CMV viremia ≥ 1000 IU/mL
and estimate associations with 6-month mortality, respectively. RESULTS CMV viremia was detected in 31% of children, with levels ≥ 1000 IU/mL in 5.8%. HIV infection, age < 2 years, breastfeeding, and midupper arm circumference < 12.5 cm were associated with CMV viremia ≥ 1000 IU/mL. Among HEU children, CMV ≥ 1000 IU/mL (hazard ratio [HR] = 32.0; 95% confidence interval [CI], 2.9-354.0; P = .005) and each 1-log increase in CMV viral load (HR = 5.04; 95% CI, 1.7-14.6; P = .003) were associated with increased risk of mortality. CMV viremia was not significantly associated with mortality in HIV-unexposed children. CONCLUSIONS CMV levels at hospital postdischarge predict increased risk of 6-month mortality in Kenyan HEU children. CMV suppression may be a novel target to reduce mortality in HEU children. CLINICAL TRIAL REGISTRATION NCT02414399.
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Affiliation(s)
- Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Benson Singa
- Kenya Medical Research Institute, Nairobi, Kenya
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Meei-Li Huang
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Lasata Shrestha
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Vanessa Li
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Hannah E Atlas
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | - Rebecca Brander
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Liru Meshak
- Homa Bay Teaching and Referral Hospital, Homa Bay, Kenya
| | | | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | | | - James A Berkley
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Medicine, Allergy, and Infectious Disease, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Medicine, Allergy, and Infectious Disease, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Jennifer Slyker
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
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17
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Hu H, Arzika AM, Sie A, Abdou A, Maliki R, Mankara AK, Outtara M, Bountogo M, Boudo V, Yago-Wienne F, Bamba I, Knirsch C, Emerson P, Hooper PJ, Lebas E, Brogdon J, Nyatigo F, Oldenburg CE, Lietman TM, O'Brien KS. Simplified dosing of oral azithromycin for children 1-11 months old in child survival programmes: age-based and height-based dosing protocols. BMJ Glob Health 2022; 7:bmjgh-2022-009801. [PMID: 36253018 PMCID: PMC9577904 DOI: 10.1136/bmjgh-2022-009801] [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: 06/03/2022] [Accepted: 09/24/2022] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To facilitate mass distribution of azithromycin, trachoma control programmes use height instead of weight to determine dose for children 6 months to 15 years old. WHO has recommended azithromycin distribution to children 1-11 months old to reduce mortality in high mortality settings under carefully monitored conditions. Weight was used to determine dose in children 1-5 months old in studies of azithromycin distribution for child survival, but a simplified approach using age or height for all aged 1-11 months old could increase programme efficiency in real-world settings. METHODS This secondary analysis used data from two cluster randomised trials of azithromycin distribution for child mortality in Niger and Burkina Faso. An exhaustive search algorithm was developed to determine the optimal dose for different age groups, using tolerance limits of 10-20 mg/kg for children 1-2 months old and 15-30 mg/kg for children 3-11 months old. Height-based dosing was evaluated against the existing trachoma dosing pole and with a similar exhaustive search. RESULTS The optimal two-tiered age-based approach suggested a dose of 80 mg (2 mL) for children 1-2 months old and 160 mg (4 mL) for children 3-11 months old. Under this schedule, 89%-93% of children would have received doses within tolerance limits in both study populations. Accuracy was 93%-94% with a three-tiered approach, which resulted in doses of 80 mg (2 mL), 120 mg (3 mL) and 160 mg (4 mL) for children 1-2, 3-4 and 5-11 months old, respectively. For children 1-5 months old, the existing height pole would result in 70% of doses within tolerance limits. The optimisation identified height-based dosing options with 95% accuracy, although this would require changes to the existing dosing pole as well as additional training to measure infants lying flat. CONCLUSIONS Overall, an age-based approach with two age tiers resulted in high accuracy while considering both concerns about overdosing in this young population and simplicity of field operations.
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Affiliation(s)
- Huiyu Hu
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | | | - Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | - Amza Abdou
- Programme Nationale de Santé Oculaire, Niamey, Niger
| | - Ramatou Maliki
- Centre de Recherche et Interventions en Sante Publique, Niamey, Niger
| | | | | | | | - Valentin Boudo
- Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso
| | | | - Issouf Bamba
- Helen Keller International, Ouagadougou, Burkina Faso
| | | | - Paul Emerson
- International Trachoma Initiative, Decatur, Georgia, USA
| | - PJ Hooper
- International Trachoma Initiative, Decatur, Georgia, USA
| | - Elodie Lebas
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Jessica Brogdon
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Fanice Nyatigo
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA
| | - Catherine E Oldenburg
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Thomas M Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
| | - Kieran S O'Brien
- Francis I. Proctor Foundation, University of California, San Francisco, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA,Department of Ophthalmology, University of California, San Francisco, California, USA,Institute for Global Health Sciences, University of California, San Francisco, California, USA
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18
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Kwambai TK, Mori AT, Nevitt S, van Eijk AM, Samuels AM, Robberstad B, Phiri KS, Ter Kuile FO. Post-discharge morbidity and mortality in children admitted with severe anaemia and other health conditions in malaria-endemic settings in Africa: a systematic review and meta-analysis. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:474-483. [PMID: 35605629 DOI: 10.1016/s2352-4642(22)00074-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Severe anaemia is associated with high in-hospital mortality among young children. In malaria-endemic areas, surviving children also remain at increased risk of mortality for several months after hospital discharge. We aimed to compare the risks of morbidity and mortality among children discharged from hospital after recovery from severe anaemia versus other health conditions in malaria-endemic settings in Africa. METHODS Following PRISMA guidelines, we searched PubMed, Scopus, Web of Science, and Cochrane Central from inception to Nov 30, 2021, without language restrictions, for prospective or retrospective cohort studies and randomised controlled trials that followed up children younger than 15 years for defined periods after hospital discharge in malaria-endemic countries in Africa. We excluded the intervention groups in trials and studies or subgroups involving children with sickle cell anaemia, malignancies, or surgery or trauma, or those reporting follow-up data that were combined with the in-hospital period. Two independent reviewers extracted the data and assessed the quality and risk of bias using the Newcastle Ottawa Scale or the Cochrane Collaboration's tool. The coprimary outcomes were all-cause death and all-cause readmissions 6 months after discharge. This study is registered with PROSPERO, CRD42017079282. FINDINGS Of 2930 articles identified in our search, 27 studies were included. For children who were recently discharged following hospital admission with severe anaemia, all-cause mortality by 6 months was higher than during the in-hospital period (n=5 studies; Mantel-Haenszel odds ratio 1·72, 95% CI 1·22-2·44; p=0·0020; I2=51·5%) and more than two times higher than children previously admitted without severe anaemia (n=4 studies; relative risk [RR] 2·69, 95% CI 1·59-4·53; p<0·0001; I2=69·2%). Readmissions within 6 months of discharge were also more common in children admitted with severe anaemia than in children admitted with other conditions (n=1 study; RR 3·05, 1·12-8·35; p<0·0001). Children admitted with severe acute malnutrition (regardless of severe anaemia) also had a higher 6-month mortality after discharge than those admitted for other reasons (n=2 studies; RR=3·12, 2·02-4·68; p<0·0001; I2=54·7%). Other predictors of mortality after discharge included discharge against medical advice, HIV, bacteraemia, and hypoxia. INTERPRETATION In malaria-endemic settings in Africa, children admitted to hospital with severe anaemia and severe acute malnutrition are at increased risk of mortality in the first 6 months after discharge compared with children admitted with other health conditions. Improved strategies are needed for the management of these high-risk groups during the period after discharge. FUNDING Research Council of Norway and US Centers for Disease Control and Prevention.
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Affiliation(s)
- Titus K Kwambai
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya.
| | - Amani T Mori
- Section for Ethics and Health Economics and Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sarah Nevitt
- Department of Health Data Science, University of Liverpool, Liverpool, Merseyside, UK
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aaron M Samuels
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Kisumu, Kenya; Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Bjarne Robberstad
- Section for Ethics and Health Economics and Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Kamija S Phiri
- School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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19
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Ngari MM, Berkley JA. Severe anaemia and paediatric mortality after hospital discharge in Africa. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:447-449. [PMID: 35605630 PMCID: PMC7613614 DOI: 10.1016/s2352-4642(22)00103-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Moses M Ngari
- The KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - James A Berkley
- The KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya; The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya; The Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK.
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Rolfe RJ, Shaikh H, Tillekeratne LG. Mass drug administration of antibacterials: weighing the evidence regarding benefits and risks. Infect Dis Poverty 2022; 11:77. [PMID: 35773722 PMCID: PMC9243730 DOI: 10.1186/s40249-022-00998-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Mass drug administration (MDA) is a strategy to improve health at the population level through widespread delivery of medicine in a community. We surveyed the literature to summarize the benefits and potential risks associated with MDA of antibacterials, focusing predominantly on azithromycin as it has the greatest evidence base.
Main body High-quality evidence from randomized controlled trials (RCTs) indicate that MDA-azithromycin is effective in reducing the prevalence of infection due to yaws and trachoma. In addition, RCTs suggest that MDA-azithromycin reduces under-five mortality in certain low-resource settings that have high childhood mortality rates at baseline. This reduction in mortality appears to be sustained over time with twice-yearly MDA-azithromycin, with the greatest effect observed in children < 1 year of age. In addition, observational data suggest that infections such as skin and soft tissue infections, rheumatic heart disease, acute respiratory illness, diarrheal illness, and malaria may all be treated by azithromycin and thus incidentally impacted by MDA-azithromycin. However, the mechanism by which MDA-azithromycin reduces childhood mortality remains unclear. Verbal autopsies performed in MDA-azithromycin childhood mortality studies have produced conflicting data and are underpowered to answer this question. In addition to benefits, there are several important risks associated with MDA-azithromycin. Direct adverse effects potentially resulting from MDA-azithromycin include gastrointestinal side effects, idiopathic hypertrophic pyloric stenosis, cardiovascular side effects, and increase in chronic diseases such as asthma and obesity. Antibacterial resistance is also a risk associated with MDA-azithromycin and has been reported for both gram-positive and enteric organisms. Further, there is the risk for cross-resistance with other antibacterial agents, especially clindamycin. Conclusions Evidence shows that MDA-azithromycin programs may be beneficial for reducing trachoma, yaws, and mortality in children < 5 years of age in certain under-resourced settings. However, there are significant potential risks that need to be considered when deciding how, when, and where to implement these programs. Robust systems to monitor benefits as well as adverse effects and antibacterial resistance are warranted in communities where MDA-azithromycin programs are implemented. Graphical Abstract ![]()
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Affiliation(s)
- Robert J Rolfe
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Hassaan Shaikh
- Department of Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - L Gayani Tillekeratne
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Duke Global Health Institute, Duke University, Durham, NC, USA. .,Department of Medicine, Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka.
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O’Brien KS, Oldenburg CE. MDA and trial designs to evaluate the impact of azithromycin on child mortality. THE LANCET GLOBAL HEALTH 2022; 10:e183. [DOI: 10.1016/s2214-109x(21)00557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/26/2021] [Accepted: 11/19/2021] [Indexed: 11/25/2022] Open
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Does mass drug administration of azithromycin reduce child mortality? THE LANCET GLOBAL HEALTH 2021; 9:e1485-e1486. [DOI: 10.1016/s2214-109x(21)00417-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/26/2022] Open
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