A spatial approach for the epidemiology of antibiotic use and resistance in community-based studies: the emergence of urban clusters of Escherichia coli quinolone resistance in Sao Paulo, Brasil

Sociodemographic disparities in antibiotic-resistant outpatient urine cultures in a Boston hospital, 2015-2020: a cross-sectional analysis

BACKGROUND

Antibiotic resistance in uropathogens has rapidly escalated over time, complicating treatment and increasing morbidity and mortality. Few studies have explored how the social determinants of health may be associated with patients' risks for acquiring antibiotic-resistant (AR) uropathogens.

METHODS

We identified urine cultures collected from outpatients presenting to Tufts Medical Center Primary Care Practices between 2015 and 2020. Specimens were included if patients' age, sex, and residential address were recorded in the electronic medical record (EMR) and if their urine culture yielded Enterococcus spp. or one or more gram-negative bacterial organism(s) or for which antibiotic susceptibility profiling and species identification was conducted. We abstracted patients' sociodemographic characteristics from the EMR and used US Census Bureau data to identify characteristics about patients' census tracts of residence. We evaluated associations between individual- and neighborhood-level characteristics and patients' risk of having a urine culture resistant to (1) three or more antibiotic classes (i.e., multidrug resistant [MDR]), (2) first-line treatments, (3) fluoroquinolones, (4) aminoglycosides, or (5) ceftriaxone using logistic regression models and a Bonferroni correction to account for multiple hypothesis testing.

RESULTS

We included urine cultures from 1,306 unique outpatients, most of whom were female (89%). Patients largely self-identified as Non-Hispanic White (36%), Asian (15%), or Non-Hispanic Black (11%). Over 60% lived in an environmental justice-designated census tract. Most included isolates were Escherichia coli (76%) or Klebsiella pneumoniae (7%). Using public insurance increased patients' odds of having a uropathogen resistant to first-line antibiotics, but living in a limited-income neighborhood reduced patients' odds of having a MDR uropathogen by 47%. We noted a strong but non-significant positive trend between speaking a language other than English and having an aminoglycoside-resistant uropathogen (p-value = 0.02). Most notably, after controlling for other factors, we observed no statistically significant associations between race or ethnicity and AR uropathogens.

CONCLUSION

The social determinants of health may play important and intersecting roles in determining a patient's risk of having a resistant uropathogens that is more challenging or expensive to treat. It is crucial to acknowledge how race is likely to be a proxy for other factors affecting health, and to consider that some groups may be disproportionately impacted by antibiotic resistance.

Spatial clusters of extended-spectrum beta-lactamase-producing Escherichia coli causing community-onset bacteriuria due to repeat infections: cluster analysis from a large urban medical center, San Francisco, 2014-2020

BACKGROUND

Urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) may occur as outbreaks due to common-source exposures. Yet, it is currently unknown if they cluster geographically as would be expected as part of an outbreak.

METHODS

We collected electronic health record data on all patients living in San Francisco with culture-documented community-onset E. coli bacteriuria in a safety-net public healthcare system from January 2014 to March 2020 (diagnosed < 48 h after hospital admission or in outpatient clinical settings without a hospitalization in the past 90 days). We assessed the presence of spatial clusters of (1) ESBL-E. coli bacteriuria episodes, and (2) individuals with any ESBL-E. coli bacteriuria episode, with Global and Local Moran's I. We evaluated differences in prevalence of bacteriuria recurrence by ESBL-production by Poisson regression.

RESULTS

Out of 4,304 unique individuals, we identified spatial clusters of ESBL-E. coli bacteriuria episodes (n = 461) compared to non-ESBL-E. coli bacteriuria episodes (n = 5477; Global Moran's p < 0.001). Spatial clusters of individuals with any bacteriuria caused by ESBL-E. coli were not identified (p = 0.43). Bacteriuria recurrence was more likely to occur with ESBL-E. coli (odds ratio [OR] 2.78, 95% confidence interval [95% CI] 2.10, 3.66, p < 0.001), particularly after an initial ESBL-E. coli bacteriuria episode (OR 2.27, 95% CI 1.82, 2.83, p < 0.001).

CONCLUSION

We found spatial clusters of ESBL-E. coli bacteriuria episodes. However, this was partly explained by clustering within individuals more than between individuals, as having an ESBL-E. coli bacteriuria was associated with recurrence with ESBL-E. coli. These findings may help better tailor clinical treatment of patients with recurrent urinary tract infections after an initial episode caused by ESBL-E. coli.

Spatial clusters of extended-spectrum beta-lactamase-producing Escherichia coli causing community-onset bacteriuria due to repeat infections: cluster analysis from a large urban medical center, San Francisco, 2014-2020

Background

Urinary tract infections caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (ESBL-E. coli) may occur as outbreaks due to common-source exposures. Yet, it is currently unknown if they cluster geographically as would be expected as part of an outbreak.

Methods

We collected electronic health record data on all patients living in San Francisco with culture-documented community-onset E. coli bacteriuria in a safety-net public healthcare system from January 2014 to March 2020 (diagnosed < 48 hours after hospital admission or in outpatient clinical settings without a hospitalization in the past 90 days). We assessed the presence of spatial clusters of (1) ESBL-E. coli bacteriuria episodes, and (2) individuals with any ESBL-E. coli bacteriuria episode, with Global and Local Moran's I. We evaluated differences in prevalence of bacteriuria recurrence by ESBL-production by Poisson regression.

Results

Out of 4,304 unique individuals, we identified spatial clusters of ESBL-E. coli bacteriuria episodes (n = 461) compared to non-ESBL-E. coli bacteriuria episodes (n = 5477; Global Moran's p < 0.001). Spatial clusters of individuals with any bacteriuria caused by ESBL-E. coli were not identified (p = 0.43). Bacteriuria recurrence was more likely to occur with ESBL-E. coli (odds ratio [OR] 2.78, 95% confidence interval [95% CI] 2.10, 3.66, p < 0.001), particularly after an initial ESBL-E. coli bacteriuria episode (OR 2.27, 95% CI 1.82, 2.83, p < 0.001).

Conclusion

We found spatial clusters of ESBL-E. coli bacteriuria episodes. However, this was partly explained by clustering within individuals more than between individuals, as having an ESBL-E. coli bacteriuria was associated with recurrence with ESBL-E. coli.

A geospatial approach to identify patterns of antibiotic susceptibility at a neighborhood level in Wisconsin, United States

The global threat of antimicrobial resistance (AMR) varies regionally. This study explores whether geospatial analysis and data visualization methods detect both clinically and statistically significant variations in antibiotic susceptibility rates at a neighborhood level. This observational multicenter geospatial study collected 10 years of patient-level antibiotic susceptibility data and patient addresses from three regionally distinct Wisconsin health systems (UW Health, Fort HealthCare, Marshfield Clinic Health System [MCHS]). We included the initial Escherichia coli isolate per patient per year per sample source with a patient address in Wisconsin (N = 100,176). Isolates from U.S. Census Block Groups with less than 30 isolates were excluded (n = 13,709), resulting in 86,467 E. coli isolates. The primary study outcomes were the results of Moran's I spatial autocorrelation analyses to quantify antibiotic susceptibility as spatially dispersed, randomly distributed, or clustered by a range of - 1 to + 1, and the detection of statistically significant local hot (high susceptibility) and cold spots (low susceptibility) for variations in antibiotic susceptibility by U.S. Census Block Group. UW Health isolates collected represented greater isolate geographic density (n = 36,279 E. coli, 389 = blocks, 2009-2018), compared to Fort HealthCare (n = 5110 isolates, 48 = blocks, 2012-2018) and MCHS (45,078 isolates, 480 blocks, 2009-2018). Choropleth maps enabled a spatial AMR data visualization. A positive spatially-clustered pattern was identified from the UW Health data for ciprofloxacin (Moran's I = 0.096, p = 0.005) and trimethoprim/sulfamethoxazole susceptibility (Moran's I = 0.180, p < 0.001). Fort HealthCare and MCHS distributions were likely random. At the local level, we identified hot and cold spots at all three health systems (90%, 95%, and 99% CIs). AMR spatial clustering was observed in urban areas but not rural areas. Unique identification of AMR hot spots at the Block Group level provides a foundation for future analyses and hypotheses. Clinically meaningful differences in AMR could inform clinical decision support tools and warrants further investigation for informing therapy options.

Geographic distribution of the major clone of extended-spectrum beta-lactamase-producing Escherichia coli infection in a pediatric community in southern Taiwan

BACKGROUND

The geographic distribution of the major clone of sequence type 131 (ST131) in extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) infections is not known. We analyzed the clinical features, resistance mechanisms, and geographic distribution of ESBL-producing E. coli clones in 120 children.

METHODS

We studied the 120 ESBL-producing E. coli strains from children younger than 18 years. A VITEK 2 automated system was used to determine bacterial identification and ESBL production. Sequence type was determined by multi-locus sequence typing (MLST). The genetic relationship of the ESBL-producing strains was studied using pulsed-field gel electrophoresis (PFGE). Phylogenetic group and blaCTX-M group was performed using polymerase chain reaction (PCR). Multiplex PCR for detecting the common group 9 variant, CTX-M-14, and group 1 variant, CTX-M-15, was also performed. The addresses of the 120 children were collected, and plotted on the Taiwan map.

RESULTS

The groups in the center of Kaohsiung City lived mainly in urban areas with a population density of over 10,000 people per square kilometer, and the majority of the Kaohsiung groups on the outskirts of the city center lived in suburban areas with a population density of under 6000 people per square kilometer. There was no statistically significant difference between the city center and outskirt groups in terms of clinical presentation, laboratory, and imaging data. However, more ST131 clones, major pulsotype groups, and phylogenetic group B2 strains were found in the center of Kaohsiung than on the outskirts.

CONCLUSION

ESBL-producing E. coli clones may be more challenging to treat clinically. Most infections were community-acquired, and there appeared to be major pulsotype clones, mainly in urban areas. This reinforces the necessity of environmental surveillance and sanitary procedures for ESBL-producing E. coli.

Global trend of antimicrobial resistance in common bacterial pathogens in response to antibiotic consumption

The emergence of antimicrobial resistance (AMR) is a growing public health threat worldwide and antibiotic consumption is being increasingly recognized as the main selective pressure driving this resistance. However, global trend in antibiotic resistance in response to antibiotic consumption is not fully understood. In this study, we collected national resistance data on specific resistant pathogens considered by the World Health Organization (WHO) as priority and antibiotic consumption data for 61 countries to assess the global trends in antibiotic resistance of those common bacterial pathogens and their association with antibiotic consumption. The low- and middle-income countries (LMICs) represented the largest hotspots of resistance, which presented relatively higher resistance rates in common bacterial pathogens but lower antibiotic consumption rates compared to high-income countries (HICs). Specifically, we developed the Normalized Antibiotic Resistance/Consumption Index (NARCI) and produced global maps of NARCI to roughly assess the appropriateness of antibiotic consumption across countries and to indicate the potentially inappropriate antibiotic consumption in LMICs compared with HICs. Additionally, we linked antibiotic consumption rates and resistance rates of target pathogens, in conjunction with NARCI and the correlation analysis between antibiotic use and resistance, to inform strategies to alleviate the threat of antibiotic resistance worldwide.

Geospatial analysis of Helicobacter pylori infection in South Australia: Should location influence eradication therapy?

BACKGROUND AND AIM

Rates of antimicrobial-resistant Helicobacter pylori infection are rising globally; however, geospatial location and its interaction with risk factors for infection have not been closely examined.

METHODS

Gastric biopsy specimens were collected to detect H. pylori infection at multiple centers in Adelaide, South Australia, between 1998 and 2017. The geospatial distribution of antibiotic-resistant H. pylori in the Greater Adelaide region was plotted using choropleth maps. Moran's I was used to assess geospatial correlation, and multivariate linear regression (MLR) was used to examine associations between migration status, socioeconomic status, age, gender, and rates of H. pylori positivity and antibiotic resistance. Geographically weighted regression (GWR) was used to determine the extent to which the associations varied according to geospatial location.

RESULTS

Of 20 108 biopsies across 136 postcodes within the Greater Adelaide region, 1901 (9.45%) were H. pylori positive. Of these, 797 (41.9%) displayed clarithromycin, tetracycline, metronidazole, or amoxicillin resistance. In MLR, migration status was associated with the rate of H. pylori positivity (β = 3.85% per 10% increase in a postcode's migrant population; P < 0.001). H. pylori positivity and resistance to any antibiotic were geospatially clustered (Moran's I = 0.571 and 0.280, respectively; P < 0.001 for both). In GWR, there was significant geospatial variation in the strength of the migrant association for both H. pylori positivity and antibiotic resistance.

CONCLUSION

Our study demonstrates the heterogeneous geospatial distribution of H. pylori positivity and antibiotic resistance, as well as its interaction with migrant status. Geographic location and migrant status are important factors to consider for H. pylori eradication therapy.

Influence of Change of Full-Time Equivalents on Post-prescription Review with Feedback Interventions in an Antimicrobial Stewardship

Few studies have investigated the influence of more full-time equivalents (FTEs) of infectious disease (ID) pharmacists on the likelihood of a post-prescription review with feedback (PPRF) intervention. This study focused on this in community hospitals before and after the Japanese medical reimbursement system was revised to introduce antimicrobial stewardship (AS) fees. We collected data for two periods: before (April 2017 to March 2018) and after (April 2018 to March 2019) AS fee implementation. The efficacy of the PPRF by the ID pharmacist was assessed based on the usage of broad-spectrum antimicrobials in days of therapy (DOT) per 100 patient-days. Further, we generated the susceptibility rate for antimicrobial-resistant organisms. The number of PPRF drugs was 2336 (2596 cases) before AS fee implementation and 2136 (1912 cases) after implementation. The overall monthly FTE for AS for an ID pharmacist increased from [median (interquartile range; IQR)] 0.34 (0.33-0.36) to 0.63 (0.61-0.63) after AS fee implementation. The DOT of the broad-spectrum antibiotics decreased from 10.46 (9.61-12.48) to 8.68 (8.14-9.18). The DOT of carbapenems and quinolones decreased significantly from 4.11 (3.69-4.41) to 3.07 (2.79-3.22) and 0.96 (0.61-1.14) to 0.37 (0.19-0.46), respectively (p < 0.05). Furthermore, the rate of levofloxacin (LVFX)-susceptible Pseudomonas (P.) aeruginosa improved from 71.5 to 84.8% (p < 0.01). We observed that increasing the FTE of ID pharmacists influences the DOTs of broad-spectrum antibiotics; a higher FTE contributes to fewer DOTs. Further, the susceptibility of P. aeruginosa to meropenem and LVFX increased as the FTE increased.

Spatial, Ecologic, and Clinical Epidemiology of Community-Onset, Ceftriaxone-Resistant Enterobacteriaceae, Cook County, Illinois, USA

We performed a spatial and mixed ecologic study of community-onset Enterobacteriaceae isolates collected from a public healthcare system in Cook County, Illinois, USA. Individual-level data were collected from the electronic medical record and census tract–level data from the US Census Bureau. Associations between individual- and population-level characteristics and presence of ceftriaxone resistance were determined by logistic regression analysis. Spatial analysis confirmed nonrandom distribution of ceftriaxone resistance across census tracts, which was associated with higher percentages of Hispanic, foreign-born, and uninsured residents. Individual-level analysis showed that ceftriaxone resistance was associated with male sex, an age range of 35–85 years, race or ethnicity other than non-Hispanic Black, inpatient encounter, and percentage of foreign-born residents in the census tract of isolate provenance. Our findings suggest that the likelihood of community-onset ceftriaxone resistance in Enterobacteriaceae is influenced by geographic and population-level variables. The development of effective mitigation strategies might depend on better accounting for these factors.

The sociospatial factors of death: Analyzing effects of geospatially-distributed variables in a Bayesian mortality model for Hong Kong

Human mortality is in part a function of multiple socioeconomic factors that differ both spatially and temporally. Adjusting for other covariates, the human lifespan is positively associated with household wealth. However, the extent to which mortality in a geographical region is a function of socioeconomic factors in both that region and its neighbors is unclear. There is also little information on the temporal components of this relationship. Using the districts of Hong Kong over multiple census years as a case study, we demonstrate that there are differences in how wealth indicator variables are associated with longevity in (a) areas that are affluent but neighbored by socially deprived districts versus (b) wealthy areas surrounded by similarly wealthy districts. We also show that the inclusion of spatially-distributed variables reduces uncertainty in mortality rate predictions in each census year when compared with a baseline model. Our results suggest that geographic mortality models should incorporate nonlocal information (e.g., spatial neighbors) to lower the variance of their mortality estimates, and point to a more in-depth analysis of sociospatial spillover effects on mortality rates.

Geographic mapping of Enterobacteriaceae with extended-spectrum β-lactamase (ESBL) phenotype in Pereira, Colombia

Background

Antimicrobial resistance is an ecological and multicausal problem. Infections caused by extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-E) can be acquired and transmitted in the community. Data on community-associated ESBL-E infections/colonizations in Colombia are scarce. Georeferencing tools can be used to study the dynamics of antimicrobial resistance at the community level.

Methods

We conducted a study of geographic mapping using modern tools based on geographic information systems (GIS). Two study centers from the city of Pereira, Colombia were involved. The records of patients who had ESBL-producing Enterobacteriaceae were reviewed. Antimicrobial susceptibility testing and phenotypic detection of ESBL was done according to CLSI standards.

Results

A population of 415 patients with community-acquired infections/colonizations and 77 hospital discharges were obtained. Geographic distribution was established and heat maps were created. Several hotspots were evidenced in some geographical areas of the south-west and north-east of the city. Many of the affected areas were near tertiary hospitals, rivers, and poultry industry areas.

Conclusions

There are foci of antimicrobial resistance at the community level. This was demonstrated in the case of antimicrobial resistance caused by ESBL in a city in Colombia. Causality with tertiary hospitals in the city, some rivers and the poultry industry is proposed as an explanation of the evidenced phenomenon. Geographic mapping tools are useful for monitoring antimicrobial resistance in the community.

Employment of Mapping Technology in Antimicrobial Resistance Reporting in Saudi Arabia

Although Antimicrobial Resistance (AMR) is a worldwide threat, local AMR databases do not exist. Unlike other health disasters, developing containment strategies for AMR cannot be started without a representative, local, updated AMR data. However, Geographical Information Systems (GIS) mapping technology is capable of visualizing AMR data integrated with geographical regions. Due to the absence of AMR databases in Saudi Arabia, we searched Medline and Embase databases from inception until May 28, 2018, including literature that reported AMR data on the most prevalent gram-negative bacterial strains in Saudi Arabia. These data were extracted into Microsoft Excel file and inserted into STATA software, version 13 and ArcMap 10.6 software platform for mapping. We found particularly high levels of AMR in Makkah (Mecca), possibly due to high antibiotic consumption because of the influx of pilgrims, with Pseudomonas aeruginosa isolates showing the highest resistance rate against amikacin, aztreonam, cefepime, ceftazidime, ciprolfloxacin, gentamicin, imipenem, meropenem and pipracillin/tazobactam, and Enterobacteriaceae isolates against cefuroxime, ciprofloxacin, ampicillin, imipenem and ertapenem. The cause is, however, multifactorial since Acinetobacter baumannii isolates showed a variable resistance rate throughout the country. The employment of mapping technology in displaying AMR data extracted from published literature is a practically useful approach, and advanced GIS analyses should help stakeholders create containment strategies and allocate resources to slow down the emergence of AMR.

Surveillance of antibiotic resistance among uropathogens in Aljouf region northern Saudi Arabia

BACKGROUND AND OBJECTIVES

Urinary tract infections are common health problem affecting millions worldwide. Antibiotic resistance among uropathogens (Ups) is prevalent in many countries. In the absence of any available data in the region, this hospital-based study investigated the pattern, frequency and susceptibility of Ups at Prince Mutaib Bin Abdulaziz Hospital, Aljouf Region, Saudi Arabia.

MATERIALS AND METHODS

A retrospective assessment of UPs and their antibiotics susceptibility was conducted from January 2017 to December 2017 using the fully automated Vitek2 system (BioMérieux, France).

RESULTS

Among the 415 uropathogens isolates, the most prevalent bacteria were Gram-negatives comprising 137 (51%) E. coli; 46 (17.2%) Klebsiella spp.; 30 (11.2%) Pseudomonas spp.; 25 (9.3%) Proteus spp.; 14 (5.2%) Acinetobacter baumanii and 16 (5.9%) others. On the other hand, Enterococcus spp. were predominant among Gram-positive isolates representing 54 (36.7%), 47 (32.0%) Staphylococcus spp., 22 (15.1%) Streptococcus spp., and 13 (8.8%) S. aureus, and 11 (7.5%) others. Gram-negative Ups showed multidrug resistance towards the majority of the tested antimicrobials (ampicillins, cephalosporins, fluoroquinolones, trimethoprim-sulfamethoxazole, fosfomycin, aztreonam, and nitrofurantoin). While high resistance patterns by Gram-positives was also seen against cephalosporins, penicillins, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole, clindamycin, erythromycin and tetracycline.

CONCLUSION

The observed widespread multidrug resistance clearly warrant implementing stricter control measures, local guidelines of antimicrobials usage, and continuous epidemiological surveys at hospitals and communities.

Spatial relationships between small-holder farms coupled with livestock management practices are correlated with the distribution of antibiotic resistant bacteria in northern Tanzania

We examined the spatial distribution of antibiotic-resistant coliform bacteria amongst livestock from three distinct cultural groups, where group-level differences in practices (e.g., antibiotic use) may influence the magnitude of antibiotic resistance, while livestock interactions (e.g., mixing herds, shared markets) between these locations may reduce heterogeneity in the distribution of antibiotic resistant bacteria. Data was collected as part of a larger study of antibiotic-resistance in northern Tanzania. Simple regression and generalized linear regression were used to assess livestock management and care practices in relation to the prevalence of multidrug-resistant (MDR) coliform bacteria. Simple and multivariable logistic regression were then used to identify how different management practices affected the odds of households being found within MDR "hotspots." Households that had a higher median neighbourhood value within a 3000 m radius showed a significant positive correlation with livestock MDR prevalence (β = 4.33, 95% CI: 2.41-6.32). Households were more likely to be found within hotspots if they had taken measures to avoid disease (Adjusted Odds Ratio (AOR) 1.53, CI: 1.08-2.18), and if they reported traveling less than a day to reach the market (AOR 2.66, CI: 1.18-6.01). Hotspot membership was less likely when a greater number of livestock were kept at home (AOR 0.81, CI: 0.69-0.95), if livestock were vaccinated (AOR 0.32, CI: 0.21-0.51), or if distance to nearest village was greater (AOR 0.46, CI: 0.36-0.59). The probability of MDR increases when herds are mixed, consistent with evidence for passive transmission of resistant bacteria between animals. Reduced MDR with vaccination is consistent with many studies showing reduced antibiotic use with less disease burden. The neighbourhood effect has implications for design of intervention studies.

Antimicrobial Resistance Surveillance in Typhoidal Salmonella in Ahmedabad in an Era of Global Antimicrobial Resistance Surveillance Systems

INTRODUCTION

India possibly carries the highest burden of antimicrobial resistant typhoidal salmonellae in the world. We report on the health-care ecosystem that produces data on antimicrobial resistance (AMR) testing and the resistance patterns of typhoidal Salmonella isolates in the city of Ahmedabad.

MATERIALS AND METHODS

Through municipality records and internet searches, we identified 1696 private and 83 public laboratories in the city; 4 medical colleges, 4 health-care institution attached laboratories, and 4 corporate laboratories (CLs) were performing culture and antibiotic sensitivity testing (AST), but only 2 medical colleges and 1 CL shared their data with us. There was considerable variation in culturing and sensitivity testing methodology across laboratories.

RESULTS

Out of 51,260 blood cultures, Salmonella isolates were detected in only 146 (0.28%). AST was conducted on 124 isolates, of which 67 (54%) were found resistant. Multidrug resistance was absent. Concurrent resistance to more than one antibiotic was very high, 88%, among the 67 resistant isolates. Ciprofloxacin resistance varied widely between the private and public sector laboratories. Notably, isolates from the private sector laboratory showed complete resistance to azithromycin.

CONCLUSIONS

High resistance to ciprofloxacin and azithromycin observed in Ahmedabad may be due to the increased use of these two antibiotics in the public and private sectors, respectively. The need of the hour is to identify a representative sample of laboratories from both the public and the private sectors and encourage them to participate in the national AMR surveillance network.

Fluoroquinolone consumption and Escherichia coli resistance in Japan: an ecological study

BACKGROUND

The frequency of antimicrobial resistance has steadily increased worldwide, induced by inappropriate use of antibiotics in a variety of settings. We analyzed the ecological correlation between fluoroquinolone consumption and levofloxacin resistance in Escherichia coli in Japan.

METHODS

We collected information on cases of E. coli resistant to levofloxacin in 2015-2016 in all 47 prefectures from the Japan Nosocomial Infections Surveillance system. Information on fluoroquinolone consumption was obtained from pharmaceutical sales data. To address potential confounding, we also collected information on the number of physicians, nurses, and medical facilities per 100,000 individuals.

RESULTS

We identified higher fluoroquinolone consumption and higher resistance in western prefectures, and lower consumption and resistance in eastern prefectures. Multivariate analysis identified a positive correlation between fluoroquinolone consumption and levofloxacin resistance in both 2015 and 2016.

CONCLUSIONS

Fluoroquinolone consumption and levofloxacin-resistant E. coli are potentially associated on a nationwide scale. The relationship between the two must be elucidated using additional studies with different epidemiological designs, so that any possible counter-measures, including alternative prescription, can be considered in the future.

A nonlinear time-series analysis approach to identify thresholds in associations between population antibiotic use and rates of resistance

Balancing access to antibiotics with the control of antibiotic resistance is a global public health priority. At present, antibiotic stewardship is informed by a 'use it and lose it' principle, in which antibiotic use by the population is linearly related to resistance rates. However, theoretical and mathematical models suggest that use-resistance relationships are nonlinear. One explanation for this is that resistance genes are commonly associated with 'fitness costs' that impair the replication or transmissibility of the pathogen. Therefore, resistant genes and pathogens may only gain a survival advantage where antibiotic selection pressures exceed critical thresholds. These thresholds may provide quantitative targets for stewardship-optimizing the control of resistance while avoiding over-restriction of antibiotics. Here, we evaluated the generalizability of a nonlinear time-series analysis approach for identifying thresholds using historical prescribing and microbiological data from five populations in Europe. We identified minimum thresholds in temporal relationships between the use of selected antibiotics and incidence rates of carbapenem-resistant Acinetobacter baumannii (Hungary), extended-spectrum β-lactamase-producing Escherichia coli (Spain), cefepime-resistant E. coli (Spain), gentamicin-resistant Pseudomonas aeruginosa (France) and methicillin-resistant Staphylococcus aureus (Northern Ireland) in different epidemiological phases. Using routinely generated data, our approach can identify context-specific quantitative targets for rationalizing population antibiotic use and controlling resistance. Prospective intervention studies that restrict antibiotic consumption are needed to validate these thresholds.

Mapping and Analysing Potential Sources and Transmission Routes of Antimicrobial Resistant Organisms in the Environment using Geographic Information Systems-An Exploratory Study

Antimicrobial resistance (AMR) is one of the leading threats to human health worldwide. The identification of potential sources of antimicrobial resistant organisms (AROs) and their transmission routes in the environment is important for improving our understanding of AMR and to inform and improve policy and monitoring systems, as well as the identification of suitable sampling locations and potential intervention points. This exploratory study uses geographic information systems (GIS) to analyse the spatial distribution of likely ARO sources and transmission routes in four local authority areas (LAAs) in Ireland. A review of relevant spatial data in each LAA, grouped into themes, and categorised into sources and transmission routes, was undertaken. A range of GIS techniques was used to extract, organise, and collate the spatial data into final products in the form of thematic maps for visual and spatial analysis. The results highlight the location of 'clusters' at increased risk of harbouring AMR in each LAA. They also demonstrate the relevance of aquatic transmission routes for ARO mobility and risk of human exposure. The integration of a GIS approach with expert knowledge of AMR is shown to be a useful tool to gain insights into the spatial dimension of AMR and to guide sampling campaigns and intervention points.

Can hydrophilic coated catheters be beneficial for the public healthcare system in Brazil? - A cost-effectiveness analysis in patients with spinal cord injuries

INTRODUCTION

Detrusor sphincter dyssynergia affects 70% to 80% of all spinal cord injury patients, resulting in increased risk of urinary tract infections (UTIs) and potential exposure to antimicrobial resistance. In Brazil, local guidelines recommend intermittent catheterization as the best method for bladder emptying, and two catheter types are available: the conventional uncoated PVC and the hydrophilic coated catheters.

OBJECTIVE

To evaluate the cost-effectiveness of two types of catheters for intermittent catheterization from the perspective of the Brazilian public healthcare system.

MATERIALS AND METHODS

A Markov model was used to evaluate cost-effectiveness in those with spinal cord injuries. A primary analysis was conducted on all possible adverse events, and a secondary analysis was performed with urinary tract infections as the only relevant parameter. The results were presented as cost per life years gained (LYG), per quality-adjusted life years (QALY) and per number of urinary tract infections (UTIs) avoided.

RESULTS

The base scenario of all adverse events shows a cost-effective result of hydrophilic coated catheters compared to uncoated PVC catheters at 57,432 BRL (Brazilian Reais) per LYG and 122,330 BRL per QALY. The secondary scenario showed that the use of hydrophilic coated catheters reduces the total number of UTIs, indicating that an additional cost of hydrophilic coated catheters of 31,240 BRL over a lifetime will reduce lifetime UTIs by 6%.

CONCLUSIONS

Despite the higher unit value, the use of hydrophilic coated catheters is a cost-effective treatment from the perspective of the Brazilian public healthcare system.

Tetracycline use in the community may promote decreased susceptibility to quinolones in Escherichia coli isolates

We previously found that the hospital use of tetracyclines is associated with quinolone resistance in hospital isolates of Enterobacteriaceae. Tetracyclines are heavily used in the community. Our aim was to assess whether their use in the community favors quinolone resistance in community isolates of Escherichia coli. Monthly data of community antibiotics use and E. coli quinolone resistance in a 1.3 million inhabitant French area were obtained from 2009 to 2014, and were analyzed with autoregressive integrated moving average (ARIMA) models. Quinolone use decreased from 10.1% of the total antibiotic use in 2009 to 9.3% in 2014 (trend, - 0.016; p-value < 0.0001), while tetracycline use increased from 16.5% in 2009 to 17.1% in 2014 (trend, 0.016; p < 0.0001). The mean (95% confidence interval) monthly proportions of isolates that were non-susceptible to nalidixic acid and ciprofloxacin were 14.8% (14.2%-15.5%) and 9.5% (8.8%-10.1%), respectively, with no significant temporal trend. After adjusting on quinolone use, tetracycline use in the preceding month was significantly associated with nalidixic acid non-susceptibility (estimate [SD], 0.01 [0.007]; p-value, 0.04), but not with ciprofloxacin non-susceptibility (estimate [SD], 0.01 [0.009]; p-value, 0.23). Tetracycline use in the community may promote quinolone non-susceptibility in E. coli. Decreasing both tetracycline and quinolone use may be necessary to fight against the worldwide growth of quinolone resistance.

Socioeconomic Determinants of Antibiotic Consumption in the State of São Paulo, Brazil: The Effect of Restricting Over-The-Counter Sales

BACKGROUND

Improper antibiotic use is one of the main drivers of bacterial resistance to antibiotics, increasing infectious diseases morbidity and mortality and raising costs of healthcare. The level of antibiotic consumption has been shown to vary according to socioeconomic determinants (SED) such as income and access to education. In many Latin American countries, antibiotics could be easily purchased without a medical prescription in private pharmacies before enforcement of restrictions on over-the-counter (OTC) sales in recent years. Brazil issued a law abolishing OTC sales in October 2010. This study seeks to find SED of antibiotic consumption in the Brazilian state of São Paulo (SSP) and to estimate the impact of the 2010 law.

METHODS

Data on all oral antibiotic sales having occurred in the private sector in SSP from 2008 to 2012 were pooled into the 645 municipalities of SSP. Linear regression was performed to estimate consumption levels that would have occurred in 2011 and 2012 if no law regulating OTC sales had been issued in 2010. These values were compared to actual observed levels, estimating the effect of this law. Linear regression was performed to find association of antibiotic consumption levels and of a greater effect of the law with municipality level data on SED obtained from a nationwide census.

RESULTS

Oral antibiotic consumption in SSP rose from 8.44 defined daily doses per 1,000 inhabitants per day (DID) in 2008 to 9.95 in 2010, and fell to 8.06 DID in 2012. Determinants of a higher consumption were higher human development index, percentage of urban population, density of private health establishments, life expectancy and percentage of females; lower illiteracy levels and lower percentage of population between 5 and 15 years old. A higher percentage of females was associated with a stronger effect of the law.

CONCLUSIONS

SSP had similar antibiotic consumption levels as the whole country of Brazil, and they were effectively reduced by the policy.

Infecções comunitárias do trato urinário: prevalência e susceptibilidade aos antimicrobianos na cidade de Florianópolis

Objetivo: Determinar a frequência de isolamento dos uropatógenos e avaliar o perfil de sensibilidade antimicrobiana in vitro das bactérias isoladas em uroculturas de pacientes ambulatoriais atendidos em Florianópolis no ano de 2014, correlacionando tais dados com sexo e idade do paciente. Métodos: Estudo observacional, descritivo do tipo transversal, que incluiu uroculturas positivas de pacientes ambulatoriais realizadas em um único laboratório seguindo a mesma metodologia. Realizaram-se análises de estatísticas descritivas e testes de associação entre as variáveis classificatórias: sexo, idade, agente etiológico e sensibilidade aos antimicrobianos. Resultados: Foram registradas 1035 uroculturas positivas, das quais 89,66% de pacientes femininas. Microrganismos Gram-negativos foram os patógenos mais isolados, com destaque para a Escherichia coli (77,10%), principal agente causal. Proteus mirabilis foi significativamente mais prevalente no sexo masculino e o principal microrganismo isolado nas uroculturas dos meninos de 1 a 5 anos. A E. coli foi significativamente mais prevalente no sexo feminino e apresentou o perfil mais amplo de resistência. Evidenciaram-se diferenças estatisticamente significativas nas resistências às fluoroquinolonas entre os gêneros, com maiores prevalências de resistência em homens e entre as faixas etárias, com maior resistência entre idosos. Conclusões: Idade e sexo são variáveis determinantes na frequência de isolamento dos uropatógenos e na prevalência da susceptibilidade antimicrobiana; e os microrganismos mais prevalentes já não respondem satisfatoriamente a parte dos antimicrobianos amplamente utilizados. É fundamental que o médico considere tais informações no momento da decisão terapêutica e preze pelo uso racional dos antimicrobianos, sobretudo aqueles de largo espectro como as fluoroquinolonas.

Prevalence of antibiotic susceptibility and resistance of Escherichia coli in acute uncomplicated cystitis in Korea: Systematic review and meta-analysis

BACKGROUND

The aim of this study is to determine the prevalence of antibiotic susceptibility and resistance of Escherichia coli Escherichia coli (E coli) in female uncomplicated cystitis in Korea using meta-analysis.

METHODS

A cross-search of the literature was performed with MEDLINE for all relevant data published before October 2015 and EMBASE from 1980 to 2015, the Cochrane Library, KoreaMed, RISS, KISS, and DBPia were also searched. Observational or prospective studies that reported the prevalence of antimicrobial susceptibility and resistance of E coli were selected for inclusion. No language or time restrictions were applied. We performed a meta-analysis using a random effects model to quantify the prevalence of antimicrobial susceptibility and resistance of E coli.

RESULTS

Ten studies were eligible for the meta-analysis, which together included a total of 2305 women with uncomplicated cystitis. The overall resistance rate to antibiotics was 0.28 (95% confidence interval [CI]: 0.25, 0.32). The pooled resistance rates were 0.08 (95% CI: 0.06, 0.11) for cephalosporin, 0.22 (95% CI: 0.18, 0.25) for fluoroquinolone (FQ), and 0.43 (95% CI: 0.35, 0.51) for trimethoprim/sulfamethoxazole (TMP/SMX). Regression analysis showed that resistance to FQ is increasing (P = 0.014) and resistance to TMP/SMX is decreasing (P = 0.043) by year. The generation of cephalosporin was not a significant moderator of differences in resistance rate.

CONCLUSION

The resistance rate of FQ in Korea is over 20% and is gradually increasing. Although the resistance rate of TMP/SMX is over 40%, its tendency is in decreasing state. Antibiotic strategies used for the treatment of uncomplicated cystitis in Korea have to be modified.

City-Specific Spatiotemporal Infant and Neonatal Mortality Clusters: Links with Socioeconomic and Air Pollution Spatial Patterns in France

Infant and neonatal mortality indicators are known to vary geographically, possibly as a result of socioeconomic and environmental inequalities. To better understand how these factors contribute to spatial and temporal patterns, we conducted a French ecological study comparing two time periods between 2002 and 2009 for three (purposefully distinct) Metropolitan Areas (MAs) and the city of Paris, using the French census block of parental residence as the geographic unit of analysis. We identified areas of excess risk and assessed the role of neighborhood deprivation and average nitrogen dioxide concentrations using generalized additive models to generate maps smoothed on longitude and latitude. Comparison of the two time periods indicated that statistically significant areas of elevated infant and neonatal mortality shifted northwards for the city of Paris, are present only in the earlier time period for Lille MA, only in the later time period for Lyon MA, and decrease over time for Marseille MA. These city-specific geographic patterns in neonatal and infant mortality are largely explained by socioeconomic and environmental inequalities. Spatial analysis can be a useful tool for understanding how risk factors contribute to disparities in health outcomes ranging from infant mortality to infectious disease-a leading cause of infant mortality.

ANTIBIOTIC RESISTANCE PATTERNS OF URINARY TRACT INFECTIONS IN A NORTHEASTERN BRAZILIAN CAPITAL

Urinary tract infection is a common problem worldwide. Its clinical characteristics and susceptibility rates of bacteria are important in determining the treatment of choice and its duration. This study assessed the frequency and susceptibility to antimicrobials of uropathogens isolated from community-acquired urinary tract infections in the city of Natal, Rio Grande do Norte State capital, northeastern Brazil, from 2007 to 2010. A total of 1,082 positive samples were evaluated; E. coli was the most prevalent pathogen (60.4%). With respect to the uropathogens susceptibility rates, the resistance of enterobacteria to ciprofloxacin and sulfamethoxazole-trimethoprim was 24.4% and 50.6%, respectively. Susceptibility was over 90% for nitrofurantoin, aminoglycosides and third-generation cephalosporins. High resistance rates of uropathogens to quinolones and sulfamethoxazole-trimethoprim draws attention to the choice of these drugs on empirical treatments, especially in patients with pyelonephritis. Given the increased resistance of community bacteria to antimicrobials, local knowledge of susceptibility rates of uropathogens is essential for therapeutic decision making regarding patients with urinary tract infections.

Short-term prophylaxis with ciprofloxacin in extended 16-core prostate biopsy

Objective

To evaluate the safety, efficacy and possible complications of 16-core transrectal prostate biopsies using two doses of ciprofloxacin for prophylaxis of infectious complications.

Materials and Methods

Sixteen-core prostate biopsies were performed on a number of patients with different signs of potential prostate cancer. Complications were assessed both during the procedure and one week later. After the procedure, urine samples were collected for culture. The rate of post-biopsy complications, hospital visits and hospitalizations were also analyzed. Ciprofloxacin (500 mg) was administered two hours before, and eight hours after the procedure.

Results

The overall rate of post-biopsy complications was 87.32%, being 5.4% of those considered major complications due to hemorrhage, or to urinary retention. Eight patients required hospital treatment post-biopsy. Fever occurred in just one patient (0.29%). There was no incidence of orchitis, epididymitis, prostatitis, septicemia, hospitalization, or death. The urine culture showed positive results in five patients (2.15%).

Conclusion

One-day prophylaxis with ciprofloxacin proved to be safe and effective in the prevention of infectious complications following 16-core prostate biopsies.

Susceptibility to antibiotics in urinary tract infections in a secondary care setting from 2005-2006 and 2010-2011, in São Paulo, Brazil: data from 11,943 urine cultures

INTRODUCTION

Urinary tract infection (UTI) has a high incidence and recurrence, therefore, treatment is empirical in the majority of cases.

OBJECTIVES

The aim of this study was to analyze the urine cultures performed at a secondary hospital, during two periods, 2005-2006 and 2010-2011, and to estimate the microbial resistance.

PATIENTS AND METHODS

We analyzed 11,943 aerobic urine cultures according to basic demographic data and susceptibility to antibiotics in accordance with the Clinical and Laboratory Standards Institute (CLSI) for Vitek 1 and 2.

RESULTS

Most of our cohort consisted of young adult females that were seen at the Emergency Department. E. coli was the most frequent (70.2%) among the 75 species isolated. Resistance of all isolates was ≥ 20% for trimethoprim/sulfamethoxazole (TMP/SMX), norfloxacin, nitrofurantoin, cefazolin and nalidixic acid. Although E. coli was more susceptible (resistance ≥ 20% for TMP/SMX and nalidixic acid) among all of the isolates, when classified by the number and percentage of antibiotic resistance. Global resistance to fluoroquinolones was approximately 12%. Risk factors for E. coli were female gender and an age less than 65 years. Men and patients older than 65 years of age, presented more resistant isolates. Extended spectrum beta-lactamases (ESBL) were identified in 173 out of 5,722 Gram-negative isolates (3.0%) between 2010 and 2011.

CONCLUSION

E. coli was the most frequent microbe isolated in the urine cultures analyzed in this study. There was a significant evolution of bacterial resistance between the two periods studied. In particular, the rise of bacterial resistance to fluoroquinolones was concerning.

Air quality and social deprivation in four French metropolitan areas--a localized spatio-temporal environmental inequality analysis

Several studies have documented that more deprived populations tend to live in areas characterized by higher levels of environmental pollution. Yet, time trends and geographic patterns of this disproportionate distribution of environmental burden remain poorly assessed, especially in Europe. We investigated the spatial and temporal relationship between ambient air nitrogen dioxide (NO2) concentrations and socioeconomic and demographic data in four French metropolitan areas (Lille in the North, Lyon in the center, Marseille in the South, and Paris) during two different time periods. The geographical unit used was the census block. The dependent variable was the NO2 annual average concentration (μg/m(3)) per census block, and the explanatory variables were a neighborhood deprivation index and socioeconomic and demographic data derived from the national census. Generalized additive models were used to account for spatial autocorrelation. We found that the strength and direction of the association between deprivation and NO2 estimates varied between cities. In Paris, census blocks with the higher social categories are exposed to higher mean concentrations of NO2. However, in Lille and Marseille, the most deprived census blocks are the most exposed to NO2. In Lyon, the census blocks in the middle social categories were more likely to have higher concentrations than in the lower social categories. Despite a general reduction in NO2 concentrations over the study period in the four metropolitan areas, we found contrasting results in the temporal trend of environmental inequalities. There is clear evidence of city-specific spatial and temporal environmental inequalities that relate to the historical socioeconomic make-up of the cities and its evolution. Hence, general statements about environmental and social inequalities can be made.

Air quality and social deprivation in four French metropolitan areas--a localized spatio-temporal environmental inequality analysis

Several studies have documented that more deprived populations tend to live in areas characterized by higher levels of environmental pollution. Yet, time trends and geographic patterns of this disproportionate distribution of environmental burden remain poorly assessed, especially in Europe. We investigated the spatial and temporal relationship between ambient air nitrogen dioxide (NO2) concentrations and socioeconomic and demographic data in four French metropolitan areas (Lille in the North, Lyon in the center, Marseille in the South, and Paris) during two different time periods. The geographical unit used was the census block. The dependent variable was the NO2 annual average concentration (μg/m(3)) per census block, and the explanatory variables were a neighborhood deprivation index and socioeconomic and demographic data derived from the national census. Generalized additive models were used to account for spatial autocorrelation. We found that the strength and direction of the association between deprivation and NO2 estimates varied between cities. In Paris, census blocks with the higher social categories are exposed to higher mean concentrations of NO2. However, in Lille and Marseille, the most deprived census blocks are the most exposed to NO2. In Lyon, the census blocks in the middle social categories were more likely to have higher concentrations than in the lower social categories. Despite a general reduction in NO2 concentrations over the study period in the four metropolitan areas, we found contrasting results in the temporal trend of environmental inequalities. There is clear evidence of city-specific spatial and temporal environmental inequalities that relate to the historical socioeconomic make-up of the cities and its evolution. Hence, general statements about environmental and social inequalities can be made.

Exploratory Spatial Mapping of the Occurrence of Antimicrobial Resistance in E. coli in the Community

The use of antimicrobials over the past six decades has been associated with the emergence and dissemination of antimicrobial-resistant bacteria. To explore local geographical patterns in the occurrence of acquired antimicrobial resistance (AMR), AMR of E. coli causing urinary tract infections (UTI) in the community in the West of Ireland was mapped. All adult patients consulting with a suspected UTI in 22 general practices in the West of Ireland over a nine-month study period were requested to supply a urine sample. Those with a laboratory confirmed E. coli infection were included (n = 752) in the study. Antimicrobial susceptibility testing was performed by standardized disc diffusion. Patient addresses were geocoded. The diameters of the zone of inhibition of growth for trimethoprim (5 μg) and ciprofloxacin (5 μg) for the relevant isolate was mapped against the patient address using ArcGIS software. A series of maps illustrating spatial distribution of AMR in the West of Ireland were generated. The spatial data demonstrated a higher proportion of isolates with AMR from urban areas. Some rural areas also showed high levels of resistant E. coli. Our study is the first to demonstrate the feasibility of using a geographical information system (GIS) platform for routine visual geographical analysis of AMR data in Ireland. Routine presentation of AMR data in this format may be valuable in understanding AMR trends at a local level.

Empirical mode decomposition and k-nearest embedding vectors for timely analyses of antibiotic resistance trends

Background

Antibiotic resistance is a major worldwide public health concern. In clinical settings, timely antibiotic resistance information is key for care providers as it allows appropriate targeted treatment or improved empirical treatment when the specific results of the patient are not yet available.

Objective

To improve antibiotic resistance trend analysis algorithms by building a novel, fully data-driven forecasting method from the combination of trend extraction and machine learning models for enhanced biosurveillance systems.

Methods

We investigate a robust model for extraction and forecasting of antibiotic resistance trends using a decade of microbiology data. Our method consists of breaking down the resistance time series into independent oscillatory components via the empirical mode decomposition technique. The resulting waveforms describing intrinsic resistance trends serve as the input for the forecasting algorithm. The algorithm applies the delay coordinate embedding theorem together with the k-nearest neighbor framework to project mappings from past events into the future dimension and estimate the resistance levels.

Results

The algorithms that decompose the resistance time series and filter out high frequency components showed statistically significant performance improvements in comparison with a benchmark random walk model. We present further qualitative use-cases of antibiotic resistance trend extraction, where empirical mode decomposition was applied to highlight the specificities of the resistance trends.

Conclusion

The decomposition of the raw signal was found not only to yield valuable insight into the resistance evolution, but also to produce novel models of resistance forecasters with boosted prediction performance, which could be utilized as a complementary method in the analysis of antibiotic resistance trends.

Trends in outpatient antibiotic use in Israel during the years 2000-2010: setting targets for an intervention

PURPOSE

The abundant use of antibiotics (Abs) in the community plays a major role in inducing Ab resistance, but the literature concerning patterns in outpatient Ab use is limited. This study aims to lay the foundations for future policy and interventional programs to address the rise in Ab resistance by looking at long-term trends in Ab usage in Israel.

METHODS

Defined daily doses per 1,000 inhabitants per day (DID) of total Ab use, consumption in different age groups, and of different Ab preparations were calculated for the years 2000, 2005, and 2010 in the eight districts of Israel. Data were collected from the pharmacy registries of "Clalit Health Services", the largest Health Maintenance Organization (HMO) in Israel, covering 4 million patients, representing 53 % of the population. Trends in use over time were analyzed.

RESULTS

The overall Ab usage in Israel has remained constant in the last decade. Three significant trends were identified in this study: an increase in the consumption of expensive, broad-spectrum Abs, paralleled by a reduction in narrow-spectrum Abs; an increase in Ab consumption among the elderly, counteracted by reduced usage among children; large regional variations in the overall and specific use of Ab agents.

CONCLUSIONS

Our main findings of increased broad-spectrum Ab consumption, primarily among the adult population in Israel, and a wide variability in Ab use between the regions in Israel, can focus our future studies on searching for the factors behind these trends to aid in constructing interventional methods for decreasing outpatient Ab overuse.

Spatial exploration of Streptococcus pneumoniae clonal clustering in São Paulo, Brazil

OBJECTIVES

To examine the spatial distribution of Streptococcus pneumoniae and its clonal patterns collected between 2002 and 2006 in São Paulo, Brazil.

METHODS

As part of an observational study in São Paulo city, Brazil, S. pneumoniae isolates routinely cultured from blood, respiratory specimens, or cerebrospinal and other profound fluids were selected. Additionally, only isolates with either penicillin (PEN) intermediate (I) or resistant (R) status on routine antibiogram were included, in order to obtain a higher probability of clonal isolates. A single I/R S. pneumoniae isolate per patient was included and submitted to genotypic determination by pulsed field gel electrophoresis (PFGE). Minimum inhibitory concentrations (MICs) were determined for the isolates by Etest® to PEN and other antimicrobials. Each isolate was geocoded in a digital map. The Kernel function and ratio methods between total isolates vs. clones were used in order to explore possible cluster formations.

RESULTS

Seventy-eight (78) S. pneumoniae community isolates from two major outpatient centers in São Paulo, Brazil, were selected from the databank according to their penicillin susceptibility profile, i.e. R or I to penicillin assessed by oxacillin disc diffusion. Of these, 69 were submitted to PFGE, 65 to MIC determination, and 48 to spatial analytical procedures. Preliminary spatial analysis method showed two possible cluster formation located in southwest and southeast regions of the city.

CONCLUSION

Further analyses are required for precisely determining the existence of S. pneumoniae clusters and their related risk factors. Apparently there is a specific transmission pattern of S. pneumoniae clones within certain regions and populations. GIS and spatial methods can be applied to better understand epidemiological patterns and to identify target areas for public health interventions.

Proposta sobre uso de dados de receitas de antimicrobianos retidas: a experiência EUREQA

A presente nota pesquisa demonstra que o uso das informações de receituário ou prescrição médica tem fundamental valor para a compreensão das correlações da dinâmica da resistência bacteriana comunitária. Além disso, a análise dos dados gerada pode ajudar a estabelecer medidas e políticas de saúde pública mais adequadas para o controle e a otimização do consumo de antimicrobianos. Para isso, o artigo usa como base o modelo lógico desenvolvido pelo Projeto EUREQA voltado para aquisição, classificação, interpretação e análise das informações relacionadas à prescrição dos antimicrobianos de uso oral.

Development of spatial density maps based on geoprocessing web services: application to tuberculosis incidence in Barcelona, Spain

Background

Health professionals and authorities strive to cope with heterogeneous data, services, and statistical models to support decision making on public health. Sophisticated analysis and distributed processing capabilities over geocoded epidemiological data are seen as driving factors to speed up control and decision making in these health risk situations. In this context, recent Web technologies and standards-based web services deployed on geospatial information infrastructures have rapidly become an efficient way to access, share, process, and visualize geocoded health-related information.

Methods

Data used on this study is based on Tuberculosis (TB) cases registered in Barcelona city during 2009. Residential addresses are geocoded and loaded into a spatial database that acts as a backend database. The web-based application architecture and geoprocessing web services are designed according to the Representational State Transfer (REST) principles. These web processing services produce spatial density maps against the backend database.

Results

The results are focused on the use of the proposed web-based application to the analysis of TB cases in Barcelona. The application produces spatial density maps to ease the monitoring and decision making process by health professionals. We also include a discussion of how spatial density maps may be useful for health practitioners in such contexts.

Conclusions

In this paper, we developed web-based client application and a set of geoprocessing web services to support specific health-spatial requirements. Spatial density maps of TB incidence were generated to help health professionals in analysis and decision-making tasks. The combined use of geographic information tools, map viewers, and geoprocessing services leads to interesting possibilities in handling health data in a spatial manner. In particular, the use of spatial density maps has been effective to identify the most affected areas and its spatial impact. This study is an attempt to demonstrate how web processing services together with web-based mapping capabilities suit the needs of health practitioners in epidemiological analysis scenarios.