Tackling antibiotic resistance in India

Molecular characterization of enteropathogenic Escherichia coli isolated from patients with gastroenteritis in a tertiary referral hospital of northeast India

PURPOSE

Diarrhoeal illness accounts for a high morbidity and mortality both in paediatric as well as adult groups and diarrhoeagenic Escherichia coli occupies a top position as a causative agent of infectious diarrhoeal illness worldwide. The aim of the current investigation was to determine the virulence and pattern of antibiotic resistance of enteropathogenic, enterotoxigenic, and shiga toxigenic Escherichia coli that are linked to diarrhoea in patients of both adult and paediatric age groups.

METHODS

A total of 50 consecutive, nonduplicate Escherichia coli isolates were collected from patients with gastro-enteritis who were admitted to different clinical wards Silchar Medical College and Hospital, Silchar, India. PCR was used to identify the virulence genes of EPEC (eaeA and bfpA), STEC (stx1, stx2, and eae) and ETEC (eltA, eltB, estA1 and estA2) in the isolates of E. coli. The antibiotic susceptibility pattern of virulent E. coli isolates were checked using disc diffusion method. Molecular typing of the virulent E. coli detected in the study based on enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR) was also done.

RESULT

Out of 50 E. coli isolates, 13 (26%) were found to carry atleast one virulence gene. 11 isolates harboured eae gene and were characterized as EPEC and two isolates carried stx1 gene of STEC. These virulent isolates showed different antibiotic susceptibility pattern and harboured single or multiple antibiotic resistance genes. ERIC PCR established 12 different clonal patterns of the virulent study isolates of E. coli harbouring.

CONCLUSION

EPEC pathotypes were found to be the most detected pathotype in the stool samples. Majority of the virulent isolates were also resistant to multiple antibiotics which is a serious public health concern and therefore requires a proper surveillance and studies to track their reservoirs to contain their spread.

Correlation Between Individual Child-Level Antibiotic Consumption and Antibiotic-Resistant Among Commensal Escherichia coli: Results from a Cohort of Children Aged 1-3 Years in Rural Ujjain India

Background

The global expansion of antibiotic-resistant bacteria is a serious concern and is increasing worldwide in both pathogenic and commensal bacteria. The study determined the correlation between individual child-level antibiotic consumption and antibiotic resistance among the commensal Escherichia coli (E.coli) in a cohort of 125 children in rural Ujjain, India.

Methods

During a two-year period between August 2014 and September 2016, stool samples were collected at seven-time points from a cohort of 125 children; aged 1–3. A total of six colonies of E.coli per stool sample were collected for antibiotic susceptibility testing. Antibiotic consumption data was collected during the healthcare-seeking follow–up done during the same period. At each of the seven-time points correlation between antibiotic consumption (Defined Daily Dose-DDD/100 patient-days) and antibiotic resistance (number of resistant isolates) was analyzed independently using the Spearman correlation coefficient. Further, mixed-effects logistic regression models were built to study correlation between child-level consumption of penicillin with the number of E.coli isolates resistant to ampicillin, consumption of cephalosporin with resistance to cefotaxime and ceftazidime, consumption of fluoroquinolones with resistance to nalidixic acid and consumption of cotrimoxazole with resistance to cotrimoxazole.

Results

Out of 756 illness episodes reported in 125 children 42% were with antibiotic prescriptions and reported a total antibiotic consumption of 55DDD/100 patient-days. The most common antibiotics used were cefixime (J01DD08;72 DDD/100patient/days) followed by ofloxacin (J01MA01;51DDD/100patient-days), cefpodoxime (J01DD13;38DDD/100patient-days) and amoxicillin (J01CA04;28DDD/100patient-days). The highest percentage of resistance was found to the ampicillin (67%) followed by nalidixic acid (52%) and cefotaxime (44%) and when summarized, more than 90% were resistant to cefotaxime, ceftazidime, and co-trimoxazole in commensal E.coli isolates. The consumption of cephalosporins showed weak positive correlation with the resistance to cefotaxime (Coefficient±SE=0.13 ± 0.09,p<0.001).

Conclusion

Our findings showed no correlation between individual-level antibiotic consumption and resistance development in commensal E.coli in a rural community environment.

Determinants and pathways of healthcare-seeking behaviours in under-5 children for common childhood illnesses and antibiotic prescribing: a cohort study in rural India

OBJECTIVES

To explore the healthcare-seeking pathways, antibiotic prescribing and determine the sociodemographic factors associated with healthcare-seeking behaviour (HSB) of caregivers for common illnesses in under-5 (U-5) children in rural Ujjain, India.

STUDY DESIGN

Prospective cohort study.

STUDY SETTING AND STUDY SAMPLE

The cohort included 270 U-5 children from selected six villages in rural demographic surveillance site, of the R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India. A community-based cohort was visited two times weekly for over 113 weeks (August 2014 to October 2016) to record the HSB of caregivers using HSB diaries. Sociodemographic information was also solicited.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes: first point of care, healthcare-seeking pathway and quantify antibiotic prescribing for the common acute illnesses.

SECONDARY OUTCOME

HSB risk factors were determined using mixed-effects multinomial logistic regression.

RESULTS

A total of 60 228 HSB follow-up time points for 270 children were recorded with a total of 2161 acute illness episodes. The most common illnesses found were respiratory tract infections (RTI) (69%) and gastrointestinal tract infections (8%). No healthcare was sought in 33% of illness episodes, mostly for RTIs. The most common healthcare-seeking pathway was to informal healthcare providers (IHCPs, 49% of illness episodes). The adjusted relative risk for obtaining no treatment, home treatment and treatment by IHCPs was higher for RTIs (aRR=11.54, 1.82 and 1.29, respectively), illiterate mothers (aRR=2.86, 2.38 and 1.93, respectively), and mothers who were homemakers (aRR=2.90, 4.17 and 2.10, respectively). Socioeconomic status was associated with HSB, with the highest aRR for no treatment in the lowest two socioeconomic quintiles (aRR=6.59 and 6.39, respectively). Antibiotics were prescribed in 46% (n=670/1450) illness episodes and the majority (85%, n=572/670) were broad spectrum.

CONCLUSION

In our rural cohort for many acute episodes of illnesses, no treatment or home treatment was done, which resulted in overall reduced antibiotic prescribing. The most common healthcare-seeking pathway was to visit IHCPs, which indicates that they are major healthcare providers in rural areas. Most of the antibiotics were prescribed by IHCPs and were commonly prescribed for illnesses where they were not indicated.

Trends, relationships and case attribution of antibiotic resistance between children and environmental sources in rural India

Bacterial antibiotic resistance is an important global health threat and the interfaces of antibiotic resistance between humans, animals and the environment are complex. We aimed to determine the associations and overtime trends of antibiotic resistance between humans, animals and water sources from the same area and time and estimate attribution of the other sources to cases of human antibiotic resistance. A total of 125 children (aged 1-3 years old) had stool samples analysed for antibiotic-resistant bacteria at seven time points over two years, with simultaneous collection of samples of animal stools and water sources in a rural Indian community. Newey-West regression models were used to calculate temporal associations, the source with the most statistically significant relationships was household drinking water. This is supported by use of SourceR attribution modelling, that estimated the mean attribution of cases of antibiotic resistance in the children from animals, household drinking water and wastewater, at each time point and location, to be 12.6% (95% CI 4.4-20.9%), 12.1% (CI 3.4-20.7%) and 10.3% (CI 3.2-17.3%) respectively. This underlines the importance of the 'one health' concept and requires further research. Also, most of the significant trends over time were negative, suggesting a possible generalised improvement locally.

Antibiotics Use in Food Animal Production: Escalation of Antimicrobial Resistance: Where Are We Now in Combating AMR?

The use of antibiotics has been very beneficial to human health, animal wellbeing, and food production, however, there are no alternatives to antimicrobials in treating infectious diseases. Their use can contribute to the development of antimicrobial resistance, but the world has realized the need to combat antimicrobial resistance in recent decades due to the continued escalation of the problem jeopardizing human and veterinary medicine and food and environmental safety. Understanding the AMR and judicious use of antimicrobials are critical, and one health approach involving several sectors and multiple disciplines is important to tackle the problem. National, regional, and global action plans have been instigated to tackle the escalation of AMR. Antimicrobials are frequently used in food animal production. Therefore, food animal producers are important participants to prevent overuse and misuse of antimicrobials. Recent regulations to address the challenges have not been perceived well in animal farming communities. More awareness regarding these action plans and understanding the impact of AMR are needed. A nationwide survey of perceptions of food animal producers regarding AMR mitigation approaches should be conducted to evaluate the effectiveness of the current policies regarding antibiotics use and AMR. These outcomes should be incorporated in future policies and awareness campaigns targeting food animal producers.

High levels of drug resistance in commensal E. coli in a cohort of children from rural central India

The world is experiencing crisis of antibiotic resistance not only in pathogenic but also in commensal bacteria. We determine the prevalence of antibiotic resistance in commensal Escherichia coli in young children in rural setting of central India and search for its correlations with demographic and behavioral factors. At seven time points during a period of 2 years we collected stool samples from 125 children; aged 1–3 in a rural area of Madhya Pradesh. We isolated six isolates of E. coli per stool sample and subjected them to antibiotic susceptibility testing. We found resistance to ampicillin, quinolones, cephalosporins, sulfamethoxazole, co-trimoxazole, in at least one isolate from 89% to 100% of children. Extended spectrum beta lactamase producing E. coli were identified in all but one child and multidrug resistance was identified in isolates from all children. Female gender (p = 0.04) and higher wealth (p = 0.03) was significantly correlated with less antibiotic resistance. Thus, the high prevalence of antibiotic resistance in commensal E. coli in rural community from India needs urgent measures to control the growing antibiotic resistance crisis.

A study of antimicrobial use in children admitted to pediatric medicine ward of a tertiary care hospital

OBJECTIVES

Antimicrobials are frequently used in tertiary care hospitals. We conducted an observational study on children admitted to a teaching hospital in Eastern India, to generate a profile of antimicrobial use and suspected adverse drug reactions (ADRs) attributable to them.

MATERIALS AND METHODS

Hospitalized children of either sex, aged between 1 month and 12 years, were studied. Baseline demographic and clinical features, duration of hospital stay, antimicrobials received in hospital along with dosing and indications and details of suspected ADRs attributable to their use were recorded. Every patient was followed up till discharge, admission to the Pediatric Intensive Care Unit, or death.

RESULTS

Over the 1 year study period, 332 admissions were screened. The prevalence of antimicrobial use was 79.82%. The majority of the 265 children who received antimicrobials were males (61.10%) and hailed from rural and low socioeconomic background. Median age was 36 months. Six children died, 43 were transferred out, and the rest discharged. In most instances, either 2 (40%) or a single antibiotic (39.6%) was used. Ceftriaxone, co-amoxiclav, amikacin, vancomycin, and ampicillin were predominantly used. Antivirals, antimalarials, and antiprotozoals were used occasionally. Average number of antimicrobials per patient was 2.0 ± 1.27; the majority (84.1%) were by parenteral route and initial choice was usually empirical. Prescriptions were usually in generic name. The antimicrobial treatment ranged between 1 and 34 days, with a median of 7 days. Six ADRs were noted of which half were skin rash and the rest loose stools.

CONCLUSIONS

The profile of antimicrobial use is broadly similar to earlier Indian studies. Apparent overuse of multiple antimicrobials per prescription and the parenteral route requires exploration. Antimicrobials are being used empirically in the absence of policy. ADRs to antimicrobials are occasional and usually mild. The baseline data can serve in situation analysis for antibiotic prescribing guidelines.