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Hornuss D, Göpel S, Walker SV, Tobys D, Häcker G, Seifert H, Higgins PG, Xanthopoulou K, Gladstone BP, Cattaneo C, Mischnik A, Rohde AM, Imirzalioglu C, Trauth J, Fritzenwanker M, Falgenhauer J, Gastmeier P, Behnke M, Kramme E, Käding N, Rupp J, Peter S, Schmauder K, Eisenbeis S, Kern WV, Tacconelli E, Rieg S. Epidemiological trends and susceptibility patterns of bloodstream infections caused by Enterococcus spp. in six German university hospitals: a prospectively evaluated multicentre cohort study from 2016 to 2020 of the R-Net study group. Infection 2024:10.1007/s15010-024-02249-2. [PMID: 38684586 DOI: 10.1007/s15010-024-02249-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/25/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE To analyse recent epidemiological trends of bloodstream infections (BSI) caused by Enterococcus spp. In adult patients admitted to tertiary care centres in Germany. METHODS Epidemiological data from the multicentre R-NET study was analysed. Patients presenting with E. faecium or E. faecalis in blood cultures in six German tertiary care university hospitals between October 2016 and June 2020 were prospectively evaluated. In vancomycin-resistant enterococci (VRE), the presence of vanA/vanB was confirmed via molecular methods. RESULTS In the 4-year study period, 3001 patients with BSI due to Enterococcus spp. were identified. E. faecium was detected in 1830 patients (61%) and E. faecalis in 1229 patients (41%). Most BSI occurred in (sub-) specialties of internal medicine. The pooled incidence density of enterococcal BSI increased significantly (4.0-4.5 cases per 10,000 patient days), which was primarily driven by VRE BSI (0.5 to 1.0 cases per 10,000 patient days). In 2020, the proportion of VRE BSI was > 12% in all study sites (range, 12.8-32.2%). Molecular detection of resistance in 363 VRE isolates showed a predominance of the vanB gene (77.1%). CONCLUSION This large multicentre study highlights an increase of BSI due to E. faecium, which was primarily driven by VRE. The high rates of hospital- and ICU-acquired VRE BSI point towards an important role of prior antibiotic exposure and invasive procedures as risk factors. Due to limited treatment options and high mortality rates of VRE BSI, the increasing incidence of VRE BSI is of major concern.
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Affiliation(s)
- Daniel Hornuss
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, 79106, Freiburg, Germany.
- DZIF German Centre for Infection Research, Brunswick, Germany.
| | - Siri Göpel
- DZIF German Centre for Infection Research, Brunswick, Germany
- Division of Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Sarah V Walker
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Institute Für Clinical Microbiology and Hospital Hygiene, RKH Regionale Kliniken Holding Und Services GmbH, Ludwigsburg, Germany
| | - David Tobys
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Georg Häcker
- Institute for Medical Microbiology and Hygiene, University Medical Centre Freiburg, Freiburg, Germany
| | - Harald Seifert
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Institute of Translational Research, CECAD Cluster of Excellence, University of Cologne, Cologne, Germany
| | - Paul G Higgins
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kyriaki Xanthopoulou
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Beryl Primrose Gladstone
- DZIF German Centre for Infection Research, Brunswick, Germany
- Division of Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Chiara Cattaneo
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, 79106, Freiburg, Germany
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Neonatology and Pediatric Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, University Children's Hospital, Hamburg, Germany
| | - Alexander Mischnik
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Infectious Diseases and Microbiology, University of Lübeck and University Hospital Schleswig-Holstein, Campus Lübeck, 23538, Lübeck, Germany
| | - Anna M Rohde
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of Nosocomial Infections, Charité-University Hospital, Berlin, Germany
| | - Can Imirzalioglu
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute of Medical Microbiology, Justus Liebig University Giessen, Giessen, Germany
| | - Janina Trauth
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Internal Medicine (Infectious Diseases), Uniklinikum Giessen, Justus Liebig University Giessen, Giessen, Germany
| | - Moritz Fritzenwanker
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute of Medical Microbiology, Justus Liebig University Giessen, Giessen, Germany
| | - Jane Falgenhauer
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute of Medical Microbiology, Justus Liebig University Giessen, Giessen, Germany
| | - Petra Gastmeier
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of Nosocomial Infections, Charité-University Hospital, Berlin, Germany
| | - Michael Behnke
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute for Hygiene and Environmental Medicine, National Reference Centre for the Surveillance of Nosocomial Infections, Charité-University Hospital, Berlin, Germany
| | - Evelyn Kramme
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Infectious Diseases and Microbiology, University of Lübeck and University Hospital Schleswig-Holstein, Campus Lübeck, 23538, Lübeck, Germany
| | - Nadja Käding
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Infectious Diseases and Microbiology, University of Lübeck and University Hospital Schleswig-Holstein, Campus Lübeck, 23538, Lübeck, Germany
| | - Jan Rupp
- DZIF German Centre for Infection Research, Brunswick, Germany
- Department of Infectious Diseases and Microbiology, University of Lübeck and University Hospital Schleswig-Holstein, Campus Lübeck, 23538, Lübeck, Germany
| | - Silke Peter
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - Kristina Schmauder
- DZIF German Centre for Infection Research, Brunswick, Germany
- Institute of Medical Microbiology and Hygiene, University of Tübingen, Tübingen, Germany
| | - Simone Eisenbeis
- DZIF German Centre for Infection Research, Brunswick, Germany
- Division of Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, 79106, Freiburg, Germany
| | - Evelina Tacconelli
- DZIF German Centre for Infection Research, Brunswick, Germany
- Division of Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, 79106, Freiburg, Germany
- DZIF German Centre for Infection Research, Brunswick, Germany
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2
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Kingston R, Vella V, Pouwels KB, Schmidt JE, Abdelatif El-Abasiri RA, Reyna-Villasmil E, Hassoun-Kheir N, Harbarth S, Rodríguez-Baño J, Tacconelli E, Arieti F, Gladstone BP, de Kraker MEA, Naylor NR, Robotham JV. Excess resource use and cost of drug-resistant infections for six key pathogens in Europe: a systematic review and Bayesian meta-analysis. Clin Microbiol Infect 2024; 30 Suppl 1:S26-S36. [PMID: 38128781 DOI: 10.1016/j.cmi.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/05/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Quantifying the resource use and cost of antimicrobial resistance establishes the magnitude of the problem and drives action. OBJECTIVES Assessment of resource use and cost associated with infections with six key drug-resistant pathogens in Europe. METHODS A systematic review and Bayesian meta-analysis. DATA SOURCES MEDLINE (Ovid), Embase (Ovid), Econlit databases, and grey literature for the period 1 January 1990, to 21 June 2022. STUDY ELIGIBILITY CRITERIA Resource use and cost outcomes (including excess length of stay, overall costs, and other excess in or outpatient costs) were compared between patients with defined antibiotic-resistant infections caused by carbapenem-resistant (CR) Pseudomonas aeruginosa and Acinetobacter baumannii, CR or third-generation cephalosporin Escherichia coli (3GCREC) and Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant Enterococcus faecium, and patients with drug-susceptible or no infection. PARTICIPANTS All patients diagnosed with drug-resistant bloodstream infections (BSIs). INTERVENTIONS NA. ASSESSMENT OF RISK OF BIAS An adapted version of the Joanna Briggs Institute assessment tool, incorporating case-control, cohort, and economic assessment frameworks. METHODS OF DATA SYNTHESIS Hierarchical Bayesian meta-analyses were used to assess pathogen-specific resource use estimates. RESULTS Of 5969 screened publications, 37 were included in the review. Data were sparse and heterogeneous. Most studies estimated the attributable burden by, comparing resistant and susceptible pathogens (32/37). Four studies analysed the excess cost of hospitalization attributable to 3GCREC BSIs, ranging from -€ 2465.50 to € 6402.81. Eight studies presented adjusted excess length of hospital stay estimates for methicillin-resistant S. aureus and 3GCREC BSIs (4 each) allowing for Bayesian hierarchical analysis, estimating means of 1.26 (95% credible interval [CrI], -0.72 to 4.17) and 1.78 (95% CrI, -0.02 to 3.38) days, respectively. CONCLUSIONS Evidence on most cost and resource use outcomes and across most pathogen-resistance combinations was severely lacking. Given the importance of this evidence for rational policymaking, further research is urgently needed.
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Affiliation(s)
- Rhys Kingston
- Field Service Data Science Team, UK Health Security Agency, London, UK
| | | | - Koen B Pouwels
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | | | | | - Eduardo Reyna-Villasmil
- Infectious Diseases and Microbiology Division, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Department of Medicine, University of Sevilla/CSIC, Sevilla, Spain
| | - Nasreen Hassoun-Kheir
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Geneva, Switzerland
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Geneva, Switzerland
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Microbiology Division, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen Macarena, Department of Medicine, University of Sevilla/CSIC, Sevilla, Spain
| | - Evelina Tacconelli
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Fabiana Arieti
- Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Beryl Primrose Gladstone
- Department of Internal Medicine, DZIF-Clinical Research Unit, Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Marlieke E A de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, WHO Collaborating Center, Geneva, Switzerland
| | - Nichola R Naylor
- HCAI, Fungal, AMR, AMU, & Sepsis Division, UK Health Security Agency, London, UK
| | - Julie V Robotham
- HCAI, Fungal, AMR, AMU, & Sepsis Division, UK Health Security Agency, London, UK.
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3
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Pezzani MD, Arieti F, Rajendran NB, Barana B, Cappelli E, De Rui ME, Galia L, Hassoun-Kheir N, Argante L, Schmidt J, Rodriguez-Bano J, Harbarth S, de Kraker M, Gladstone BP, Tacconelli E. Frequency of bloodstream infections caused by six key antibiotic-resistant pathogens for prioritization of research and discovery of new therapies in Europe: a systematic review. Clin Microbiol Infect 2024; 30 Suppl 1:S4-S13. [PMID: 38007387 DOI: 10.1016/j.cmi.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND To prioritize healthcare investments, ranking of infections caused by antibiotic-resistant bacteria should be based on accurate incidence data. OBJECTIVES We performed a systematic review to estimate frequency measures of antimicrobial resistance for six key bacteria causing bloodstream infections (BSI) in European countries. DATA SOURCES We searched PubMed, Web of Science, Embase databases, and the ECRAID-Base Epidemiological-Network platform. STUDY ELIGIBILITY CRITERIA We included studies and surveillance systems assessing resistance-percentage, prevalence, or incidence-density of BSI because of carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Klebsiella pneumoniae, and Escherichia coli, third-generation cephalosporins-resistant E. coli and K. pneumoniae, vancomycin-resistant Enterococcus faecium, and methicillin-resistant Staphylococcus aureus. METHODS Reviewers independently assessed published data and evaluated study quality with the modified Joanna Briggs Institute critical appraisal tool. Pooled estimates were determined using random effects meta-analysis. Consistency of data was assessed using random effects meta-regression (Wald test, p > 0.05). RESULTS We identified 271 studies and 52 surveillance systems from 32 European countries. Forty-five studies (16%) reported on BSI, including 180 frequency measures most commonly as resistance-percentage (88, 48.9%). Among 309 frequency measures extracted from 24 (46%) surveillance systems, 278 (89%) were resistance-percentages. Frequency measures of methicillin-resistant S. aureus and vancomycin-resistant E. faecium BSI were more frequently reported from Southern Europe and Western Europe (80%), whereas carbapenem-resistant P. aeruginosa BSI from Northern Europe and Western Europe (88%). Highest resistance-percentages were detected for carbapenem-resistant A. baumannii (66% in Central Eastern Europe) and carbapenem-resistant K. pneumoniae (62.8% in Southern Europe). Pooled estimates showed lower resistance-percentages in community versus healthcare-associated infections and in children versus adults. Estimates from studies and surveillance systems were mostly consistent among European regions. The included data was of medium quality. DISCUSSION Pathogen-specific frequency measures of antimicrobial resistance in BSI are insufficient to inform antibiotic stewardship and research and development strategies. Improving data collection and standardization of frequency measures is urgently needed.
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Affiliation(s)
- Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nithya Babu Rajendran
- Infectious Diseases, Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Benedetta Barana
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Eva Cappelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maria Elena De Rui
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Nasreen Hassoun-Kheir
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Lorenzo Argante
- Department of Bacterial Vaccine Epidemiology, GSK, Siena, Italy
| | | | - Jesus Rodriguez-Bano
- Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain; Infectious Diseases and Microbiology Division, Hospital Universitario Virgen Macarena, Seville, Spain; Department of Medicine, University of Sevilla/CSIC, Seville, Spain; CIBERINFEC, Madrid, Spain
| | - Stephan Harbarth
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marlieke de Kraker
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Beryl Primrose Gladstone
- Infectious Diseases, Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany; DZIF-Clinical Research Unit, Infectious Diseases, Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; DZIF-Clinical Research Unit, Infectious Diseases, Department of Internal Medicine, University Hospital Tübingen, Tübingen, Germany
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4
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Babu Rajendran N, Arieti F, Mena-Benítez CA, Galia L, Tebon M, Alvarez J, Gladstone BP, Collineau L, De Angelis G, Duro R, Gaze W, Göpel S, Kanj SS, Käsbohrer A, Limmathurotsakul D, Lopez de Abechuco E, Mazzolini E, Mutters NT, Pezzani MD, Presterl E, Renk H, Rodríguez-Baño J, Săndulescu O, Scali F, Skov R, Velavan TP, Vuong C, Tacconelli E, Avery L, Bonten M, Cassini A, Chauvin C, Compri M, Damborg P, De Greeff S, Del Toro MD, Filter M, Franklin A, Gonzalez-Zorn B, Grave K, Hocquet D, Hoelzle LE, Kalanxhi E, Laxminarayan R, Leibovici L, Malhotra-Kumar S, Mendelson M, Paul M, Muñoz Madero C, Murri R, Piddock LJ, Ruesen C, Sanguinetti M, Schilling T, Schrijver R, Schwaber MJ, Scudeller L, Torumkuney D, Van Boeckel T, Vanderhaeghen W, Voss A, Wozniak T. EPI-Net One Health reporting guideline for antimicrobial consumption and resistance surveillance data: a Delphi approach. Lancet Reg Health Eur 2023; 26:100563. [PMID: 36895445 PMCID: PMC9989632 DOI: 10.1016/j.lanepe.2022.100563] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Strategic and standardised approaches to analysis and reporting of surveillance data are essential to inform antimicrobial resistance (AMR) mitigation measures, including antibiotic policies. Targeted guidance on linking full-scale AMR and antimicrobial consumption (AMC)/antimicrobial residues (AR) surveillance data from the human, animal, and environmental sectors is currently needed. This paper describes the initiative whereby a multidisciplinary panel of experts (56 from 20 countries-52 high income, 4 upper middle or lower income), representing all three sectors, elaborated proposals for structuring and reporting full-scale AMR and AMC/AR surveillance data across the three sectors. An evidence-supported, modified Delphi approach was adopted to reach consensus among the experts for dissemination frequency, language, and overall structure of reporting; core elements and metrics for AMC/AR data; core elements and metrics for AMR data. The recommendations can support multisectoral national and regional plans on antimicrobials policy to reduce resistance rates applying a One Health approach.
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Affiliation(s)
- Nithya Babu Rajendran
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany
| | - Fabiana Arieti
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Liliana Galia
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Maela Tebon
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Julio Alvarez
- VISAVET Health Surveillance Center and Department of Animal Health, Faculty of Veterinary Medicine, Complutense University, Madrid, Spain
| | - Beryl Primrose Gladstone
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany.,German Centre for Infection Research (DZIF) Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, Tübingen, Germany
| | - Lucie Collineau
- French Agency for Food, Environmental and Occupational Health and Safety, ANSES, Maisons-Alfort, France
| | - Giulia De Angelis
- Dipartimento di Scienze Biotecnologiche di base, Cliniche Intensivologiche e Perioperatorie, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Raquel Duro
- Unit for the Prevention and Control of Infection and Antimicrobial Resistance, Centro Hospitalar do Tâmega e Sousa, Penafiel, Porto, Portugal
| | - William Gaze
- The European Centre for Environment and Human Health, University of Exeter Medical School, University of Exeter, Penryn, Cornwall, UK
| | - Siri Göpel
- Infectious Diseases, Department of Internal Medicine I, University Hospital Tübingen, Tübingen, Germany.,German Centre for Infection Research (DZIF) Clinical Research Unit for Healthcare Associated and Antibiotic Resistant Bacterial Infections, Tübingen, Germany
| | - Souha S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, Infection Control Program, Antimicrobial Stewardship Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Annemarie Käsbohrer
- German Federal Institute for Risk Assessment (BfR), Department 4 - Biological Safety, Berlin, Germany
| | - Direk Limmathurotsakul
- Mahidol Oxford Tropical Medicine Research Unit and Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, UK
| | | | - Elena Mazzolini
- Department of Epidemiology, Istituto Zooprofilattico Sperimentale delle Venezie, Udine-Padova, Padua, Italy
| | - Nico T Mutters
- Institute for Hygiene and Public Health, Bonn University Hospital, Bonn, Germany.,European Committee on Infection Control, Basel, Switzerland
| | - Maria Diletta Pezzani
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elisabeth Presterl
- European Committee on Infection Control, Basel, Switzerland.,Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria.,ESCMID Study Group for Nosocomial Infections, Basel, Switzerland
| | - Hanna Renk
- Department of Paediatric Cardiology, Pulmology and Intensive Care Medicine, University Children's Hospital Tübingen, Tübingen, Germany
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Microbiology Division, Hospital Universitario Virgen Macarena/Department of Medicine, School of Medicine, University of Seville/Biomedicine Institute of Seville (IBiS)/CSIC, Seville, Spain.,CIBERINFEC, Instituto de Salud Carlos III, Madrid, Spain
| | - Oana Săndulescu
- Department of Infectious Diseases I, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,National Institute for Infectious Diseases "Prof. Dr. Matei Balș", Bucharest, Romania
| | - Federico Scali
- Istituto Zooprofilattico Sperimentale della Lombardia e Dell'Emilia Romagna, Brescia, Italy
| | - Robert Skov
- Epidemiological Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Thirumalaisamy P Velavan
- Institute of Tropical Medicine, Universitätsklinikum Tübingen, Tübingen, Germany.,Vietnamese - German Center for Medical Research, Hanoi, Vietnam
| | - Cuong Vuong
- AiCuris Anti-infective Cures GmbH, Wuppertal, Germany.,Jansen Pharmaceuticals, Beerse, Belgium
| | - Evelina Tacconelli
- Infectious Diseases Section, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.,European Committee on Infection Control, Basel, Switzerland
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5
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Häger L, Wendland P, Biergans S, Lederer S, de Arruda Botelho Herr M, Erhardt C, Schmauder K, Kschischo M, Malek NP, Bunk S, Bitzer M, Gladstone BP, Göpel S. External Validation of COVID-19 Risk Scores during Three Waves of Pandemic in a German Cohort-A Retrospective Study. J Pers Med 2022; 12:jpm12111775. [PMID: 36579493 PMCID: PMC9693591 DOI: 10.3390/jpm12111775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 01/01/2023] Open
Abstract
Several risk scores were developed during the COVID-19 pandemic to identify patients at risk for critical illness as a basic step to personalizing medicine even in pandemic circumstances. However, the generalizability of these scores with regard to different populations, clinical settings, healthcare systems, and new epidemiological circumstances is unknown. The aim of our study was to compare the predictive validity of qSOFA, CRB65, NEWS, COVID-GRAM, and 4C-Mortality score. In a monocentric retrospective cohort, consecutively hospitalized adults with COVID-19 from February 2020 to June 2021 were included; risk scores at admission were calculated. The area under the receiver operating characteristic curve and the area under the precision-recall curve were compared using DeLong's method and a bootstrapping approach. A total of 347 patients were included; 23.6% were admitted to the ICU, and 9.2% died in a hospital. NEWS and 4C-Score performed best for the outcomes ICU admission and in-hospital mortality. The easy-to-use bedside score NEWS has proven to identify patients at risk for critical illness, whereas the more complex COVID-19-specific scores 4C and COVID-GRAM were not superior. Decreasing mortality and ICU-admission rates affected the discriminatory ability of all scores. A further evaluation of risk assessment is needed in view of new and rapidly changing epidemiological evolution.
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Affiliation(s)
- Lukas Häger
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
| | - Philipp Wendland
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Stephanie Biergans
- Medical Data Integration Center (meDIC), University Hospital Tübingen, Schaffhausenstraße 77, 72072 Tubingen, Germany
| | - Simone Lederer
- Medical Data Integration Center (meDIC), University Hospital Tübingen, Schaffhausenstraße 77, 72072 Tubingen, Germany
| | - Marius de Arruda Botelho Herr
- Medical Data Integration Center (meDIC), University Hospital Tübingen, Schaffhausenstraße 77, 72072 Tubingen, Germany
| | - Christian Erhardt
- Medical Data Integration Center (meDIC), University Hospital Tübingen, Schaffhausenstraße 77, 72072 Tubingen, Germany
| | - Kristina Schmauder
- Institute of Medical Microbiology and Hospital Hygiene, University Hospital Tübingen, Elfriede-Aulhorn-Str. 6, 72076 Tubingen, Germany
| | - Maik Kschischo
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, Joseph-Rovan-Allee 2, 53424 Remagen, Germany
| | - Nisar Peter Malek
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
| | - Stefanie Bunk
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
| | - Michael Bitzer
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
| | - Beryl Primrose Gladstone
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
- Clinical Research Unit for Health Care Associated Infections, German Center for Infection Research (DZIF), Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
| | - Siri Göpel
- Department of Internal Medicine 1, University Hospital Tübingen, Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
- Clinical Research Unit for Health Care Associated Infections, German Center for Infection Research (DZIF), Otfried-Müllerstrasse 10, 72076 Tubingen, Germany
- Correspondence:
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Savoldi A, Carrara E, Gladstone BP, Azzini AM, Göpel S, Tacconelli E. Gross national income and antibiotic resistance in invasive isolates: analysis of the top-ranked antibiotic-resistant bacteria on the 2017 WHO priority list. J Antimicrob Chemother 2020; 74:3619-3625. [PMID: 31730162 DOI: 10.1093/jac/dkz381] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To assess the association between country income status and national prevalence of invasive infections caused by the top-ranked bacteria on the WHO priority list: carbapenem-resistant (CR) Acinetobacter spp., Klebsiella spp. and Pseudomonas aeruginosa; third-generation cephalosporin-resistant (3GCR) Escherichia coli and Klebsiella spp.; and MRSA and vancomycin-resistant Enterococcus faecium (VR E. faecium). METHODS Active surveillance systems providing yearly prevalence data from 2012 onwards for the selected bacteria were included. The gross national income (GNI) per capita was used as the indicator for income status of each country and was log transformed to account for non-linearity. The association between antibiotic prevalence data and GNI per capita was investigated individually for each bacterium through linear regression. RESULTS Surveillance data were available from 67 countries: 38 (57%) were high income, 16 (24%) upper-middle income, 11 (16%) lower-middle income and two (3%) low income countries. The regression showed significant inverse association (P<0.0001) between resistance prevalence of invasive infections and GNI per capita. The highest rate of increase per unit decrease in log GNI per capita was observed in 3GCR Klebsiella spp. (22.5%, 95% CI 18.2%-26.7%), CR Acinetobacter spp. (19.2% 95% CI 11.3%-27.1%) and 3GCR E. coli (15.3%, 95% CI 11.6%-19.1%). The rate of increase per unit decrease in log GNI per capita was lower in MRSA (9.5%, 95% CI 5.2%-13.7%). CONCLUSIONS The prevalence of invasive infections caused by the WHO top-ranked antibiotic-resistant bacteria is inversely associated with GNI per capita at the global level. Public health interventions designed to limit the burden of antimicrobial resistance should also consider determinants of poverty and inequality, especially in lower-middle income and low income countries.
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Affiliation(s)
- Alessia Savoldi
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany.,Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Elena Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Beryl Primrose Gladstone
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany
| | - Anna Maria Azzini
- Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
| | - Siri Göpel
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine I, German Center for Infection Research, University of Tübingen, Otfried Müller Straße 12, 72074 Tübingen, Germany.,Division of Infectious Diseases, Department of Diagnostic and Public Health, G. B. Rossi University Hospital, University of Verona, P.le L.A. Scuro 10, 37100 Verona, Italy
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Shamsrizi P, Gladstone BP, Carrara E, Luise D, Cona A, Bovo C, Tacconelli E. Variation of effect estimates in the analysis of mortality and length of hospital stay in patients with infections caused by bacteria-producing extended-spectrum beta-lactamases: a systematic review and meta-analysis. BMJ Open 2020; 10:e030266. [PMID: 31964661 PMCID: PMC7044956 DOI: 10.1136/bmjopen-2019-030266] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess the variation of effect estimates in the analysis of mortality and length of stay (LOS) in patients with infections caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. DESIGN Systematic review and meta-analysis METHODS: Literature search for clinical studies from 1 January 1960 to 1 October 2018 was conducted in PubMed. Primary outcomes were risk ratios (RRs) of all-cause and attributable mortality and weighted mean differences (WMDs) in LOS in patients with bloodstream infections (BSIs) and non-invasive infections. Any change in the effect estimates was assessed by grouping studies according to design, setting, economy-based country classification, reporting period, microbiological aetiology, infection type and adjustment for appropriateness of empirical treatment. The impact of ESBL production was calculated using random-effect meta-analysis and heterogeneity was evaluated by I2 statistics and metaregression. RESULTS Eighty-four studies including 22 030 patients and 149 outcome measures were included in the meta-analysis. Most studies were retrospective cohorts from high-income countries, providing unadjusted estimates. ESBL production in patients with BSIs (56 studies) increased the RR for all-cause mortality by a factor of 1.70 (95% CI 1.52 to 1.90; p<0.001), attributable mortality (16 studies) by 1.75 (95% CI 1.448 to 2.108; p<0.001) and WMD in the intensive care unit by 3.07 days (95% CI 1.61 to 4.54; p<0.001). WMD in hospital LOS was significantly higher in BSIs (4.41 days; 95% CI 3.37 to 5.46; p<0.001) and non-invasive (2.19 days; 95% CI 1.56 to 2.81; p<0.001). Subgroup analyses showed variation of estimates by study design, population, strain and assessment of appropriateness of empiric treatment. High heterogeneity was observed in all analyses. CONCLUSIONS Current evidence of the clinical burden of infections caused by ESBL-producing bacteria is highly heterogeneous and based mainly on unadjusted estimates derived from retrospective studies. Despite these limitations, ESBL production in strains causing BSIs seems associated with higher all-cause and attributable mortality and longer hospitalisation.
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Affiliation(s)
- Parichehr Shamsrizi
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
| | - Beryl Primrose Gladstone
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
| | - Elena Carrara
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Dora Luise
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
| | - Andrea Cona
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, ASST Santi Paolo e Carlo, Milano, Italy
| | - Chiara Bovo
- Medical Direction, Integrated University Hospital of Verona, Verona, Italy
| | - Evelina Tacconelli
- Division of Infectious Disease, Department of Internal Medicine I Gastroenterology Hepatology and Infectious Diseases, University Hospital Tubingen, Tubingen, Germany
- Division of Infectious Disease, Department of Diagnostic and Public Health, Integrated University Hospital of Verona, Verona, Italy
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Tacconelli E, Górska A, De Angelis G, Lammens C, Restuccia G, Schrenzel J, Huson DH, Carević B, Preoţescu L, Carmeli Y, Kazma M, Spanu T, Carrara E, Malhotra-Kumar S, Gladstone BP. Estimating the association between antibiotic exposure and colonization with extended-spectrum β-lactamase-producing Gram-negative bacteria using machine learning methods: a multicentre, prospective cohort study. Clin Microbiol Infect 2019; 26:87-94. [PMID: 31128285 DOI: 10.1016/j.cmi.2019.05.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/20/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The aim of the study was to measure the impact of antibiotic exposure on the acquisition of colonization with extended-spectrum β-lactamase-producing Gram-negative bacteria (ESBL-GNB) accounting for individual- and group-level confounding using machine-learning methods. METHODS Patients hospitalized between September 2010 and June 2013 at six medical and six surgical wards in Italy, Serbia and Romania were screened for ESBL-GNB at hospital admission, discharge, antibiotic start, and after 3, 7, 15 and 30 days. Primary outcomes were the incidence rate and predictive factors of new ESBL-GNB colonization. Random forest algorithm was used to rank antibiotics according to the risk of selection of ESBL-GNB colonization in patients not colonized before starting antibiotics. RESULTS We screened 10 034 patients collecting 28 322 rectal swab samples. New ESBL-GNB colonization incidence with and without antibiotic treatment was 22/1000 and 9/1000 exposure-days, respectively. In the adjusted regression analyses, antibiotic exposure (hazard ratio (HR) 2.38; 95% CI 1.29-4.40), age 60-69 years (HR 1.19; 95% CI 1.05-1.34), and spring season (HR 1.25; 95% CI 1.14-1.38) were independently associated with new colonization. Monotherapy ranked higher als combination therapy in promoting ESBL-GNB colonization. Among monotherapy, cephalosporins ranked first followed by tetracycline (second), macrolide (fourth) and cotrimoxazole (seventh). Overall the ranking of cephalosporins was lower when used in combination. Among combinations not including cephalosporins, quinolones plus carbapenems ranked highest (eighth). Among sequential therapies, quinolones ranked highest (tenth) when prescribed within 30 days of therapy with cephalosporins. CONCLUSIONS Impact of antibiotics on selecting ESBL-GNB at intestinal level varies if used in monotherapy or combination and according to previous antibiotic exposure. These finding should be explored in future clinical trials on antibiotic stewardship interventions. CLINICAL TRIAL REGISTRATION NCT01208519.
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Affiliation(s)
- E Tacconelli
- Division of Infectious Disease, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany; Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Italy.
| | - A Górska
- Algorithms in Bioinformatics, University of Tübingen and International Max Planck Research School, Tübingen, Germany
| | - G De Angelis
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - G Restuccia
- Department of Anaesthesiology and Intensive Care Medicine, University of Catania, Catania, Italy
| | - J Schrenzel
- Bacteriology Laboratory, Service of Infectious Diseases, University of Geneva Hospitals and Medical Faculty, Geneva, Switzerland
| | - D H Huson
- Algorithms in Bioinformatics, University of Tübingen and International Max Planck Research School, Tübingen, Germany
| | - B Carević
- Department for Hospital Epidemiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - L Preoţescu
- National Institute for Infectious Diseases, University of Medicine 'Carol Davila', Bucharest, Romania
| | - Y Carmeli
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - M Kazma
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; National Centre for Infection Control, Israel Ministry of Health, Tel Aviv, Israel
| | - T Spanu
- Institute of Microbiology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - E Carrara
- Division of Infectious Diseases, Department of Diagnostic and Public Health, University of Verona, Italy
| | - S Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - B P Gladstone
- Division of Infectious Disease, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany
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Temkin E, Fallach N, Almagor J, Gladstone BP, Tacconelli E, Carmeli Y. Estimating the number of infections caused by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae in 2014: a modelling study. Lancet Glob Health 2019; 6:e969-e979. [PMID: 30103998 DOI: 10.1016/s2214-109x(18)30278-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/25/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The number of infections caused by resistant organisms is largely unknown. We estimated the number of infections worldwide that are caused by the WHO priority pathogens third-generation cephalosporin-resistant and carbapenem-resistant Escherichia coli and Klebsiella pneumoniae. METHODS We calculated a uniform weighted mean incidence of serious infections caused by antibiotic-susceptible E coli and K pneumoniae using data from 17 countries. Using this uniform incidence, as well as population sizes and country-specific resistance levels, we estimated the number of infections caused by third-generation cephalosporin-resistant and carbapenem-resistant E coli and K pneumoniae in 193 countries in 2014. We also calculated interval estimates derived from changing the fixed incidence of susceptible infections to 1 SD below and above the weighted mean. We compared an additive model with combination models in which resistant infections were replaced by susceptible infections. We distinguished between higher-certainty regions (those with good-quality data sources for resistance levels and resistance ≤30%), moderate-certainty regions (those with good-quality data sources for resistance levels and including some countries with resistance >30%), and low-certainty regions (those in which good-quality data sources for resistance levels were unavailable for countries comprising at least 20% of the region's population, regardless of resistance level). FINDINGS Using the additive model, we estimated that third-generation cephalosporin-resistant E coli and K pneumoniae caused 6·4 million (interval estimate 3·5-9·2) bloodstream infections and 50·1 million (27·5-72·8) serious infections in 2014; estimates were 5·5 million (3·0-7·9) bloodstream infections and 43·1 million (23·6-62·2) serious infections in the 25% replacement model, 4·6 million (2·5-6·6) bloodstream infections and 36·0 million (19·7-52·2) serious infections in the 50% replacement model, and 3·7 million (2·0-5·3) bloodstream infections and 28·9 million (15·8-41·9) serious infections in the 75% replacement model. Carbapenem-resistant strains caused 0·5 million (0·3-0·7) bloodstream infections and 3·1 million (1·8-4·5) serious infections based on the additive model, 0·5 million (0·3-0·7) bloodstream infections and 3·0 million (1·7-4·3) serious infections based on the 25% replacement model, 0·4 million (0·2-0·6) bloodstream infections and 2·8 million (1·6-4·1) serious infections based on the 50% replacement model, and 0·4 million (0·2-0·6) bloodstream infections and 2·7 million (1·5-3·8) serious infections based on the 75% replacement model. INTERPRETATION To our knowledge, this study is the first to report estimates of the global number of infections caused by antibiotic-resistant priority pathogens. Uncertainty stems from scant data on resistance levels from low-income and middle-income countries and insufficient knowledge regarding resistance dynamics when resistance is high. FUNDING Innovative Medicines Initiative.
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Affiliation(s)
- Elizabeth Temkin
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Noga Fallach
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Jonatan Almagor
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Beryl Primrose Gladstone
- Division of Infectious Diseases, Department of Internal Medicine 1, German Center for Infection Research, University Hospital Tuebingen, Tuebingen, Germany
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine 1, German Center for Infection Research, University Hospital Tuebingen, Tuebingen, Germany
| | - Yehuda Carmeli
- Department of Epidemiology and Preventive Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Vach W, Gladstone BP. Design and Interpretation of Noninferiority Trials. J Gen Intern Med 2018; 33:1216. [PMID: 29845471 PMCID: PMC6082190 DOI: 10.1007/s11606-018-4503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- Werner Vach
- Institute of Medical Biometry and Statistics, Medical Faculty & Medical Center, University of Freiburg, Freiburg, Germany.,Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Beryl Primrose Gladstone
- Division of Infectious Disease, Department of Internal Medicine I, Tübingen University Hospital, Tübingen, Germany.
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Tacconelli E, Sifakis F, Harbarth S, Schrijver R, van Mourik M, Voss A, Sharland M, Rajendran NB, Rodríguez-Baño J, Bielicki J, de Kraker M, Gandra S, Gastmeier P, Gilchrist K, Gikas A, Gladstone BP, Goossens H, Jafri H, Kahlmeter G, Leus F, Luxemburger C, Malhotra-Kumar S, Marasca G, McCarthy M, Navarro MD, Nuñez-Nuñez M, Oualim A, Price J, Robert J, Sommer H, von Cube M, Vuong C, Wiegand I, Witschi AT, Wolkewitz M. Surveillance for control of antimicrobial resistance. The Lancet Infectious Diseases 2018; 18:e99-e106. [DOI: 10.1016/s1473-3099(17)30485-1] [Citation(s) in RCA: 166] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 12/11/2022]
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Tacconelli E, Gladstone BP. Hospital antimicrobial stewardship: the way forward - Authors' reply. Lancet Infect Dis 2017; 17:1120-1121. [PMID: 29115259 DOI: 10.1016/s1473-3099(17)30581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 09/29/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Evelina Tacconelli
- Division of Infectious Disease, Department of Internal Medicine I, Tübingen University Hospital, 72076 Tübingen, Germany.
| | - Beryl Primrose Gladstone
- Division of Infectious Disease, Department of Internal Medicine I, Tübingen University Hospital, 72076 Tübingen, Germany
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Gladstone BP, Cona A, Shamsrizi P, Vilken T, Kern WV, Malek N, Tacconelli E. Antimicrobial resistance rates in gram-positive bacteria do not drive glycopeptides use. PLoS One 2017; 12:e0181358. [PMID: 28727741 PMCID: PMC5519079 DOI: 10.1371/journal.pone.0181358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/15/2017] [Indexed: 11/25/2022] Open
Abstract
Surveillance data are considered essential to appropriate empiric antibiotic therapy and stewardship. The objective of this study was to determine if a change in the rates of antibiotic resistance impacts antibiotic use in European hospitals. Glycopeptides use was selected to study the correlation between resistance rates and antibiotic use because of the restricted spectrum against resistant gram positive bacteria. PubMed, ECDC databases and national/regional surveillance systems were searched to identify glycopeptides´ consumption in defined daily dose per 1000 inhabitant-days (DID) and rate of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase negative staphylococci (MRCoNS), and vancomycin-resistant enterococci (VRE) in bloodstream infections (BSIs) in European countries between 1997 and 2015. Time trends were studied and associations between DID and BSI resistance rates were tested using multi-level mixed effect models. To account for the gap in the publication and dissemination of the yearly resistance data, a 2-year lag in the resistance rates was applied. Data on glycopeptides´ DID and resistance rates of target microorganisms in blood cultures were identified among 31 countries over a 19-year period. Glycopeptides use significantly increased (p<0·0001) while rates of MRSA BSIs decreased in majority of the countries (p<0·0001) and MRCoNS and VRE BSIs remained stable. Variation in glycopeptides’ DID was not associated with variation in BSIs due to MRSA (p = 0·136) and VRE (p = 0·613). After adjusting for MRCoNS and VRE resistance rates, among 21 countries, 11 (52%) had a concordant and 10 (48%) a discordant trend in yearly glycopeptides´ DID and MRSA BSI rates. No correlation was found between resistance rates and DID data even among 8 countries with more than 5% decrease in MRSA rates over time. (RC -0·009, p = 0·059). Resistance rate of MRSA, MRCoNS, and VRE BSIs does not impact DID of glycopeptides in European hospitals. This finding is key to redefining the role and structure of antimicrobial surveillance and stewardship programmes.
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Affiliation(s)
- Beryl Primrose Gladstone
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
| | - Andrea Cona
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
- Infectious Diseases and Tropical Medicine, San Paolo Hospital, University of Milan, Milan, Italy
| | - Parichehr Shamsrizi
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
| | - Tuba Vilken
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
| | - Winfred V. Kern
- Infectious Diseases, Department of Medicine, University Hospital and Medical Center and Albert-Ludwigs-University Faculty of Medicine, Freiburg, Germany
| | - Nisar Malek
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
| | - Evelina Tacconelli
- Infectious Diseases, Department of Internal Medicine I, DZIF Partner, Tübingen University Hospital, Tübingen, Germany
- * E-mail:
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Sarkar R, Gladstone BP, Warier JP, Sharma SL, Raman U, Muliyil J, Kang G. Rotavirus and other Diarrheal Disease in a Birth Cohort from Southern Indian Community. Indian Pediatr 2017; 53:583-8. [PMID: 27508534 DOI: 10.1007/s13312-016-0892-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the incidence, severity and etiology of diarrheal disease in infants and young children residing in an urban slum community in Southern India. SETTING Three contiguous urban slums in Vellore, Tamil Nadu. PARTICIPANTS 452 children participating in a birth cohort study on diarrheal disease; 373 completed three years of follow-up. OUTCOME MEASURES Diarrheal incidence (obtained by twice-weekly home visits) and severity (assessed by the Vesikari scoring system), and etiological agents associated with diarrhea (through examination of stool specimens by bacteriologic culture, rotavirus enzyme immunoassay, PCR for norovirus and microscopy for parasites). RESULTS A total of 1856 diarrheal episodes were reported in 373 children. The overall incidence rate of diarrhea was 1.66 episodes per child year for three years, with 2.76 episodes per child year in infancy. The incidence peaked during the months of July and August. Severe diarrhea formed 8% of the total episodes. Rotavirus was the most common pathogen detected, being identified in 18% of episodes. Good hygiene status resulted in 33% protection against moderate-to-severe diarrhea. CONCLUSIONS This study highlights the burden of diarrheal disease and the important etiological agents of childhood diarrhea in Southern India. Promotion of hygienic behavior through health education may help reduce diarrheal incidence in this and similar communities.
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Affiliation(s)
- R Sarkar
- Division of Gastrointestinal Sciences, and *Community Health Department, Christian Medical College, Vellore, Tamil Nadu, India. Correspondence to: Dr Gagandeep Kang, Division of Gastrointestinal Sciences, Christian Medical College, Vellore 632 004, Tamil Nadu, India.
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Nithya BR, Gladstone BP, Rodríguez-Baño J, Sifakis F, Voss A, Carmeli Y, Burkert FR, Gkolia P, Tacconelli E. EpideMiology and control measures of outBreaks due to Antibiotic-Resistant orGanisms in EurOpe (EMBARGO): a systematic review protocol. BMJ Open 2017; 7:e013634. [PMID: 28057656 PMCID: PMC5223682 DOI: 10.1136/bmjopen-2016-013634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Improving our understanding of outbreaks due to antibiotic-resistant bacteria (ARB) and their control is critical in the current public health scenario. The threat of outbreaks due to ARB requires multifaceted efforts. However, a global overview of epidemiological characteristics of outbreaks due to ARB and effective infection control measures is missing. In this paper, we describe the protocol of a systematic review aimed at mapping and characterising the epidemiological aspects of outbreaks due to ARB and infection control measures in European countries. METHODS AND ANALYSIS The databases MEDLINE, Web of Knowledge and Cochrane library will be searched using a 3-step search strategy. Selection of articles for inclusion will be performed by 2 reviewers using predefined eligibility criteria. All study designs will be included if they report an outbreak and define the microbiological methods used for microorganism identification. The target bacteria will be methicillin-resistant and vancomycin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, ceftazidime-resistant and carbapenem-resistant Acinetobacter baumannii, ceftazidime-resistant and carbapenem-resistant Pseudomonas aeruginosa, ciprofloxacin-resistant Escherichia coli, extended-spectrum β-lactamase-producing E. coli and Klebsiella pneumoniae, carbapenem-resistant and carbapenamase-producing Enterobacteriaceae. Data will be extracted using a tailored pilot tested form and the quality of reporting will be assessed using the ORION (Outbreak Reports and Intervention Studies Of Nosocomial infections) tool. Data will be synthesised and reported by the type of ARB, setting and country. Infection control measures and bundles of measures will be described. The effectiveness will be reported as defined by the authors. Regression analysis will be used to define independent factors associated with outbreaks' control. Heterogeneity between studies will be assessed by forest plots and I² statistics. ETHICS AND DISSEMINATION Ethical approval is not applicable for this study. Findings will be disseminated through journal publication and conference presentations and talks.
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Affiliation(s)
- Babu Rajendran Nithya
- Division of Infectious Diseases, Department of Internal Medicine 1, DZIF Partner Centre, University Hospital Tuebingen, Tuebingen, Germany
| | - Beryl Primrose Gladstone
- Division of Infectious Diseases, Department of Internal Medicine 1, DZIF Partner Centre, University Hospital Tuebingen, Tuebingen, Germany
| | - Jesús Rodríguez-Baño
- Department of Infectious Diseases and Clinical Microbiology, Hospital Universitario Virgen Macarena, Servicio Andaluz de Salud, Sevilla, Spain
| | | | - Andreas Voss
- Department of Clinical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
- Department of Medical Microbiology, Radboud University Medical Center Nijmegen, The Netherlands
| | - Yehuda Carmeli
- National Center for Antibiotic Resistance and Infection Control, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Francesco Robert Burkert
- Division of Infectious Diseases, Department of Internal Medicine 1, DZIF Partner Centre, University Hospital Tuebingen, Tuebingen, Germany
| | - Panagiota Gkolia
- Division of Infectious Diseases, Department of Internal Medicine 1, DZIF Partner Centre, University Hospital Tuebingen, Tuebingen, Germany
| | - Evelina Tacconelli
- Division of Infectious Diseases, Department of Internal Medicine 1, DZIF Partner Centre, University Hospital Tuebingen, Tuebingen, Germany
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Wehrum T, Guenther F, Vach W, Gladstone BP, Wendel S, Fuchs A, Wu K, Maurer CJ, Harloff A. Aortic Atherosclerosis Determines Increased Retrograde Blood Flow as a Potential Mechanism of Retrograde Embolic Stroke. Cerebrovasc Dis 2017; 43:132-138. [PMID: 28049202 DOI: 10.1159/000455053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Retrograde brain embolization from complex plaques of the proximal descending aorta (DAo) has been identified as a new potential mechanism of stroke. Our purpose was to identify predictors of increased retrograde aortic blood flow indicating an elevated risk of brain embolization from the DAo. METHODS A total of 485 patients with acute ischemic stroke were prospectively included and underwent transesophageal echocardiography. Blood flow velocities in the proximal DAo were studied using 2D pulse-wave Doppler ultrasound. Velocity-time integrals (VTI) were calculated for antegrade and retrograde velocity directions. The ratio (VTIretrograde/VTIantegrade) was used to estimate retrograde flow extent. Associations between patient demographics, cardiovascular risk factors, echocardiographic parameters, and VTIratio were analyzed using multivariate linear regression. RESULTS Retrograde blood flow in the DAo occurred in all patients. Velocity profiles in the proximal DAo were as follows (mean ± SD): VTIantegrade = 21.1 ± 6.5, VTIretrograde = 11.0 ± 3.6, and VTIratio = 0.54 ± 0.16. Diameter (r = 0.25, p < 0.001), presence of complex plaques (r = 0.12, p = 0.007), and reduced strain of the DAo (r = -0.23, p < 0.001) had significant partial effects in a predictor model based on predefined variables, which predicted 26% (adjusted R2 = 0.26) of the variance in VTIratio. A unit increase in the DAo diameter was associated with a 2% increase in VTIratio (95% CI 1-2.8%, p < 0.001). Presence of complex plaques increased VTIratio by 7% (95% CI 2-13%, p = 0.007) and an increase in strain by 0.1 indicated a decrease in VTIratio by about 11% (95% CI 6.2-15.5%, p < 0.001). Complex atheroma was found in the proximal DAo of 79 subjects, of which 40 (50.6%) had a VTIratio above average (VTIratio ≥0.54) compared to 87 of 261 (33.3%) patients without any complex plaques (p < 0.001). Twenty-five of 79 (31.7%) patients with complex DAo plaques had a VTIratio ≥0.60, which indicates a high likelihood of retrograde pathline length of ≥3 cm and thus increased risk of retrograde cerebral embolization. Stroke etiology of those 25 patients was determined in 13 and cryptogenic in 12 cases. CONCLUSIONS Retrograde blood flow in the DAo was found in all stroke patients. However, it increased further in patients with concomitant complex plaques, low strain, and/or large aortic diameter, that is, in those with atherosclerosis of the DAo. Accordingly, such patients may be predisposed to retrograde embolization in case of occurrence of a complex plaque in proximity to a brain-supplying artery.
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Affiliation(s)
- Thomas Wehrum
- Department of Neurology, University Medical Center Freiburg, Freiburg, Germany
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Schröder W, Sommer H, Gladstone BP, Foschi F, Hellman J, Evengard B, Tacconelli E. Gender differences in antibiotic prescribing in the community: a systematic review and meta-analysis. J Antimicrob Chemother 2016; 71:1800-6. [DOI: 10.1093/jac/dkw054] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 02/10/2016] [Indexed: 01/24/2023] Open
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Vach W, Gladstone BP. A framework to assess the value of application of formal criteria to check clinical relevance in RCTs as part of a benefit assessment strategy. Biom J 2015; 58:59-75. [PMID: 26272793 DOI: 10.1002/bimj.201300246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 06/14/2015] [Accepted: 06/17/2015] [Indexed: 01/28/2023]
Abstract
Recently, the topic of assessing clinical relevance on top of statistical significance in the analysis of randomized control trials (RCTs) has got increasing attention, in particular as part of benefit assessments. Several formal criteria to serve this purpose have been published. In this paper, we present a framework to assess the value of the application of such criteria. We propose to quantify the need for the assessment of clinical relevance by the actual risk of having accepted a benefit for a treatment with an irrelevant effect in a successful RCT. We then study how this risk can be controlled by two popular criteria based on comparing the effect estimate or the lower bound of the confidence interval with a given threshold. We further propose to quantify the impact of using formal criteria by considering the expected costs when specifying error-specific costs for each of the three possible types of errors: A benefit may be accepted for a treatment, which is actually inferior, or which is not inferior, but only implies an irrelevant improvement, or a benefit may be rejected for a treatment implying a relevant improvement. This way we can demonstrate that the impact depends on parameters which are typically not explicitly defined in the frame of benefit assessments. Depending on the values of these parameters, formal checks of clinical relevance may imply better decisions on average, but they may also imply more harm than good on average.
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Affiliation(s)
- Werner Vach
- Clinical Epidemiology, Center of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Stefan Meier Str. 26, D-79104, Freiburg, Germany
| | - Beryl Primrose Gladstone
- Division of Infectious Diseases, Tübingen University Hospital, Otfried-Müller-Strae 12, D-72076, Tübingen, Germany
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Lindekilde N, Gladstone BP, Lübeck M, Nielsen J, Clausen L, Vach W, Jones A. The impact of bariatric surgery on quality of life: a systematic review and meta-analysis. Obes Rev 2015; 16:639-51. [PMID: 26094664 DOI: 10.1111/obr.12294] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/28/2015] [Accepted: 04/30/2015] [Indexed: 12/13/2022]
Abstract
This study aims to review the obesity literature in order to assess the impact of bariatric surgery on quality of life and the between-study variation by examining the standardized mean magnitude of effect in change in the levels of quality of life. The following databases EMBASE, PubMed, PsycINFO, CINAHL, the Cochrane Library and Web of Science were systematically searched for studies examining change in quality of life in adults receiving bariatric surgery for obesity. Seventy-two studies were included with a total of 9,433 participants treated for obesity with bariatric surgery. The average impact of bariatric surgery on quality of life corresponded to an effect size of 0.88 (95% CI: 0.80-0.96), indicating that bariatric surgery has a significant positive influence on quality of life in general. The impact varied considerably across studies with bariatric surgery showing a significantly greater positive influence on physical quality of life compared to mental quality of life. Bariatric surgery is effective in improving quality of life, especially when looking at physical well-being. Greater focus on the psychological well-being of the person undergoing surgery for obesity may lead to a better post-surgery prognosis for more people.
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Affiliation(s)
- N Lindekilde
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
| | - B P Gladstone
- Institute of Medical Biometry and Medical Informatics, University Medical Centre Freiburg, Freiburg im Breisgau, Germany
| | - M Lübeck
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
| | - J Nielsen
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
| | - L Clausen
- Centre of Child- and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark
| | - W Vach
- Institute of Medical Biometry and Medical Informatics, University Medical Centre Freiburg, Freiburg im Breisgau, Germany
| | - A Jones
- Institute of Psychology, University of Southern Denmark, Odense, Denmark
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20
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Gladstone BP, Vach W. Analyzing noninferiority trials: it is time for advantage deficit assessment – an observational study of published noninferiority trials. OAJCT 2015. [DOI: 10.2147/oajct.s74821] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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21
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Gladstone BP, Vach W. Choice of non-inferiority (NI) margins does not protect against degradation of treatment effects on an average--an observational study of registered and published NI trials. PLoS One 2014; 9:e103616. [PMID: 25080093 PMCID: PMC4117500 DOI: 10.1371/journal.pone.0103616] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 07/01/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE NI margins have to be chosen appropriately to control the risk of degradation of treatment effects in non-inferiority (NI) trials. We aimed to study whether the current choice of NI margins protects sufficiently against a degradation of treatment effect on an average. STUDY DESIGN AND SETTING NI trials reflecting current practice were assembled and for each trial, the NI margin was translated into a likelihood of degradation. The likelihood of degradation was calculated as the conditional probability of a treatment being harmful given that it is declared non-inferior in the trial, using simulation. Its distribution among the NI trials was then studied to assess the potential risk of degradation. RESULTS The median (lower/upper quartile) NI margin among 112 binary outcome NI trials corresponded to an odds ratio of 0.57(0.45, 0.66), while among 38 NI trials with continuous outcome, to a Cohen's d of -0.42(-0.54, -0.31) and a hazard ratio of 0.82(0.73, 0.86) among 24 survival outcome NI trials. Overall, the median likelihood of degradation was 56% (45%, 62%). CONCLUSION Only two fifths of the current NI trials had a likelihood of degradation lower than 50%, suggesting that, in majority of the NI trials, there is no sufficient protection against degradation on an average. We suggest a third hurdle for the choice of NI margins, thus contributing a sufficient degree of protection.
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Affiliation(s)
- Beryl Primrose Gladstone
- Clinical Epidemiology Group, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany
| | - Werner Vach
- Clinical Epidemiology Group, Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Freiburg, Germany
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Jones A, Gladstone BP, Lübeck M, Lindekilde N, Upton D, Vach W. Motivational interventions in the management of HbA1c levels: a systematic review and meta-analysis. Prim Care Diabetes 2014; 8:91-100. [PMID: 24525286 DOI: 10.1016/j.pcd.2014.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 01/15/2014] [Accepted: 01/18/2014] [Indexed: 11/28/2022]
Abstract
AIMS To review the diabetes literature in order to examine the effect of motivational interventions on treatment outcome as measured by changes in glycated haemoglobin. METHODS Relevant databases were systematically searched for randomised controlled trials in which motivational interventions were examined in relation to treatment outcome in people with type 1 and type 2 diabetes mellitus. RESULTS The 13 studies identified for review included 1223 participants diagnosed with type 1 diabetes and 1895 participants diagnosed with type 2 diabetes. The analysis showed a 0.17% (95% CI: -0.09, 0.43%) improvement in glycemic control in people who received a motivational intervention compared to a control group, however, the effect was not statistically significant. CONCLUSIONS The impact of motivational interventions in the management of blood glucose levels appears to be limited. However, due to the small number of studies and issues of heterogeneity caution in interpreting the present findings is advised. Moreover, the unique contribution of motivational interventions may be better assessed by outcomes such as behaviour change and other intermediate outcomes. Further research examining the delivery and focus of motivational interventions in helping people manage their diabetes is recommended. The clinical implications of the present findings are therefore uncertain pending further research.
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MESH Headings
- Biomarkers/blood
- Blood Glucose/metabolism
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/diagnosis
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/diagnosis
- Diabetes Mellitus, Type 2/psychology
- Diabetes Mellitus, Type 2/therapy
- Glycated Hemoglobin/metabolism
- Health Behavior
- Health Knowledge, Attitudes, Practice
- Humans
- Motivation
- Motivational Interviewing
- Patients/psychology
- Treatment Outcome
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Affiliation(s)
- Allan Jones
- Institute of Psychology, University of Southern Denmark, Denmark.
| | - Beryl Primrose Gladstone
- Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Germany
| | - Marlene Lübeck
- Institute of Psychology, University of Southern Denmark, Denmark
| | - Nanna Lindekilde
- Institute of Psychology, University of Southern Denmark, Denmark
| | - Dominic Upton
- Institute of Health and Society, University of Worcester, UK
| | - Werner Vach
- Institute of Medical Biometry and Medical Informatics, University Medical Center Freiburg, Germany
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Vach W, Gladstone BP. A framework to assess the impact of applying formal criteria to check clinical relevance on top of statistical significance. Trials 2013. [PMCID: PMC3980969 DOI: 10.1186/1745-6215-14-s1-o101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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24
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Gladstone BP, Vach W. About half of the noninferiority trials tested superior treatments: a trial-register based study. J Clin Epidemiol 2013; 66:386-96. [PMID: 23337782 DOI: 10.1016/j.jclinepi.2012.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 10/15/2012] [Accepted: 10/24/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES A concern that noninferiority (NI) trials pose a risk of degradation of the treatment effects is prevalent. Thus, we aimed to determine the fraction of positive true effects (superiority rate) and the average true effect of current NI trials based on data from registered NI trials. STUDY DESIGN AND SETTING All NI trials carried out between 2000 and 2007 analyzing the NI of efficacy as the primary objective and registered in one of the two major clinical trials registers were studied. Having retrieved results from these trials, random effects modeling of the effect estimates was performed to determine the distribution of true effects. RESULTS Effect estimates were available for 79 of 99 eligible trials identified. For trials with binary outcome, we estimated a superiority rate of 49% (95% confidence interval = 27-70%) and a mean true log odds ratio of -0.005 (-0.112, 0.102). For trials with continuous outcome, the superiority rate was 58% (41-74%) and the mean true effect as Cohen's d of 0.06 (-0.064, 0.192). CONCLUSIONS The unanticipated finding of a positive average true effect and superiority of the new treatment in most NI trials suggest that the current practice of choosing NI designs in clinical trials makes degradation on average unlikely. However, the distribution of true treatment effects demonstrates that, in some NI trials, the new treatment is distinctly inferior.
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Affiliation(s)
- Beryl Primrose Gladstone
- Clinical Epidemiology Group, Department of Medical Biometry and Statistics, University Medical Center Freiburg Stefan-Meier-Str. 26, D-79104 Freiburg, Germany.
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25
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Markl M, Wallis W, Strecker C, Gladstone BP, Vach W, Harloff A. Analysis of pulse wave velocity in the thoracic aorta by flow-sensitive four-dimensional MRI: reproducibility and correlation with characteristics in patients with aortic atherosclerosis. J Magn Reson Imaging 2012; 35:1162-8. [PMID: 22271330 DOI: 10.1002/jmri.22856] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 09/27/2011] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To measure aortic pulse wave velocity (PWV) using flow-sensitive four-dimensional (4D) MRI and to evaluate test-retest reliability, inter- and intra-observer variability in volunteers and correlation with characteristics in patients with aortic atherosclerosis. MATERIALS AND METHODS Flow-sensitive 4D MRI was performed in 12 volunteers (24 ± 3 years) and 86 acute stroke patients (68 ± 9 years) with aortic atherosclerosis. Retrospectively positioned 28 ± 4 analysis planes along the entire aorta (inter-slice-distance = 10 mm) and frame wise lumen segmentation yielded flow-time-curves for each plane. Global aortic PWV was calculated from time-shifts and distances between the upslope portions of all available flow-time curves. RESULTS Inter- and intra-observer variability of PWV measurements in volunteers (7% and 8%) was low while test-retest reliability (22%) was moderate. PWV in patients was significantly higher compared with volunteers (5.8 ± 2.9 versus 3.8 ± 0.8 m/s; P = 0.02). Among 17 patient characteristics considered, statistical analysis revealed significant (P < 0.05) but low correlation of PWV with age (r = 0.25), aortic valve insufficiency (r = 0.29), and pulse pressure (r = 0.28). Multivariate modeling indicated that aortic valve insufficiency and elevated pulse pressure were significantly associated with higher PWV (adjusted R(2) = 0.13). CONCLUSION Flow-sensitive 4D MRI allows for estimating aortic PWV with low observer dependence and moderate test-retest reliability. PWV in patients correlated with age, aortic valve insufficiency, and pulse pressure.
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Affiliation(s)
- Michael Markl
- Department of Radiology, Medical Physics, University Medical Center Freiburg, Germany.
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Banerjee I, Primrose Gladstone B, Iturriza-Gomara M, Gray JJ, Brown DW, Kang G. Evidence of intrafamilial transmission of rotavirus in a birth cohort in South India. J Med Virol 2008; 80:1858-63. [PMID: 18712810 DOI: 10.1002/jmv.21263] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Transmission of rotavirus infection was studied in a birth cohort of children based in an urban slum in Vellore and their familial contacts. Contemporaneous samples from index patients and their familial contacts were collected for analysis in three different settings. Firstly, samples were collected from familial contacts during a period of rotavirus infection in children from the cohort. Secondly, on occasions when a family member had rotavirus diarrhea, samples from the cohort child were taken for analysis. Lastly, asymptomatic surveillance samples collected at predetermined time points from both the cohort child and familial contacts were analyzed. From 560 samples collected from family members during symptomatic and asymptomatic rotavirus infections in these children, three rotavirus transmissions were identified, accounting for a secondary attack rate of 0.54%. In four instances of rotavirus diarrhea in a family member, one infection was transmitted to the cohort child. Nucleotide sequence and phylogenetic analysis demonstrated a high degree of similarity in all these pairs ranging between 99% and 100% at both the nucleotide and the deduced amino acid levels, highly suggestive of person-to-person transmission of rotavirus infection. There was complete concordance of rotavirus genotyping between these pairs. No transmission events were noted from 14 asymptomatic rotavirus infections identified during routine surveillance of family members. This study is the first to use phylogenetic analysis to study the intrafamilial spread of rotavirus infection.
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Affiliation(s)
- Indrani Banerjee
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
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Sowmyanarayanan TV, Mukhopadhya A, Gladstone BP, Sarkar R, Kang G. Investigation of a hepatitis A outbreak in children in an urban slum in Vellore, Tamil Nadu, using geographic information systems. Indian J Med Res 2008; 128:32-7. [PMID: 18820356 PMCID: PMC3855648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND & OBJECTIVE An outbreak of symptomatic viral hepatitis in children less than 10 yr of age in Vellore, south India, was investigated and the disease pattern studied using serological and epidemiological methods, supplemented by geographic information systems (GIS) mapping. METHODS Three cases of hepatitis A were identified during routine surveillance in a birth cohort House-to-house visits were undertaken to identify other symptomatic cases and samples collected for anti- HAV IgM, ELISA testing. All cases and controls were mapped and geo-referenced using Arc View GIS 3.3. Spatial clustering was investigated using SaTScan 7.0.1 software. Drinking water sources were tested for coliform counts with the most probable number technique. RESULTS Of the 965 children surveyed, 26 (2.78%) had jaundice between February to July 2006. From the 26 patients, 11 (42.3%) blood samples were obtained and tested for anti-HAV IgM; 10 (90.9%) were found to be positive. Water analysis showed high coliform counts in all samples. No spatial clustering of cases could be detected. INTERPRETATION & CONCLUSION The outbreak was identified because of the symptomatic presentation of the cases. Our study highlighted the increasing detection of symptomatic children with hepatitis A virus infection. Water sources in the area were contaminated and may have served as the source of infection. The lack of clustering in GIS analysis could be due to the common water source.
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Gladstone BP, Muliyil JP, Jaffar S, Wheeler JG, Le Fevre A, Iturriza-Gomara M, Gray JJ, Bose A, Estes MK, Brown DW, Kang G. Infant morbidity in an Indian slum birth cohort. Arch Dis Child 2008; 93:479-84. [PMID: 17916587 PMCID: PMC2682775 DOI: 10.1136/adc.2006.114546] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To establish incidence rates, clinic referrals, hospitalisations, mortality rates and baseline determinants of morbidity among infants in an Indian slum. DESIGN A community-based birth cohort with twice-weekly surveillance. SETTING Vellore, South India. SUBJECTS 452 newborns recruited over 18 months, followed through infancy. MAIN OUTCOME MEASURES Incidence rates of gastrointestinal illness, respiratory illness, undifferentiated fever, other infections and non-infectious morbidity; rates of community-based diagnoses, clinic visits and hospitalisation; and rate ratios of baseline factors for morbidity. RESULTS Infants experienced 12 episodes (95% confidence interval (CI) 11 to 13) of illness, spending about one fifth of their infancy with an illness. Respiratory and gastrointestinal symptoms were most common with incidence rates (95% CI) of 7.4 (6.9 to 7.9) and 3.6 (3.3 to 3.9) episodes per child-year. Factors independently associated with a higher incidence of respiratory and gastrointestinal illness were age (3-5 months), male sex, cold/wet season and household involved in beedi work. The rate (95% CI) of hospitalisation, mainly for respiratory and gastrointestinal illness, was 0.28 (0.22 to 0.35) per child-year. CONCLUSIONS The morbidity burden due to respiratory and gastrointestinal illness is high in a South Indian urban slum, with children ill for approximately one fifth of infancy, mainly with respiratory and gastrointestinal illnesses. The risk factors identified were younger age, male sex, cold/wet season and household involvement in beedi work.
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Affiliation(s)
- B P Gladstone
- Department of Community Health, Christian Medical College, Vellore, India
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Ramani S, Arumugam R, Gopalarathinam N, Mohanty I, Mathew S, Gladstone BP, Jana AK, Kuruvilla KA, Kang G. Investigation of the environment and of mothers in transmission of rotavirus infections in the neonatal nursery. J Med Virol 2008; 80:1099-105. [DOI: 10.1002/jmv.21177] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Rao Ajjampur SS, Asirvatham JR, Muthusamy D, Gladstone BP, Abraham OCM, Mathai D, Ward H, Wanke C, Kang G. Clinical features & risk factors associated with cryptosporidiosis in HIV infected adults in India. Indian J Med Res 2007; 126:553-557. [PMID: 18219083 PMCID: PMC2673507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND & OBJECTIVE Cryptosporidiosis is a leading cause of protracted, life threatening diarrhoea in HIV infected patients. Although data on prevalence are available for Indian patients, no information on risk factors for transmission exists. We therefore undertook this study to identify risk factors for transmission of cryptosporidiosis in HIV infected adults. METHODS Both symptomatic (diarrhoeal) and asymptomatic HIV infected patients were screened for cryptosporidiosis. All Cryptosporidium spp. positive cases were enrolled in the study and interviewed to record socio-demographic information, water supply and animal contact. Data were analysed to study clinical features and potential association with species and genotype. RESULTS Of the 28 cryptosporidial infections identified on screening 111 HIV positive patients with diarrhoea, 10 (35.7%) had chronic diarrhoea, 14 (50%) had associated fever and 8 (28.6%) had nausea. Symptomatic patients had a significantly higher number of co-infections with other enteric parasites (P=0.04) than 20 asymptomatics of 423 HIV positive individuals screened. Eleven of 17 (64%) patients with potentially zoonotic infections had diarrhoea. Patients with zoonotic species (64%) also tended to have fever more frequently than those infected with C. hominis (58%). Association between area of residence, rural or urban, water source and contact with animals and acquisition of cryptosporidiosis was not statistically significant. INTERPRETATION & CONCLUSION Cryptosporidiosis is an important cause of morbidity in HIV infected individuals in India, resulting in chronic diarrhoea. Risk factors for potentially zoonotic transmission of cryptosporidiosis were described in this study, but larger studies need to be done for a clearer understanding of the transmission dynamics of different cryptosporidial species in developing countries.
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Affiliation(s)
- S S Rao Ajjampur
- Department of Gastrointestinal Sciences, Christian Medical College Vellore,India
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Ajjampur SSR, Gladstone BP, Selvapandian D, Muliyil JP, Ward H, Kang G. Molecular and spatial epidemiology of cryptosporidiosis in children in a semiurban community in South India. J Clin Microbiol 2007; 45:915-20. [PMID: 17251402 PMCID: PMC1829120 DOI: 10.1128/jcm.01590-06] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cryptosporidium spp. are a leading cause of diarrhea in Indian children, but there are no data for prevalent species or subgenotypes. Genetic characterization of Cryptosporidium spp. by PCR-restriction fragment length polymorphism and spatial analysis of cases using Geographical Information Systems technology was carried out for 53 children with cryptosporidial diarrhea in an urban slum. The two most common species were C. hominis (81%) and C. parvum (12%). Other species identified were C. felis and C. parvum (mouse genotype). Five subgenotypes were identified at the Cpgp40/15 locus. Subgenotype Ia predominated among C. hominis isolates, and all C. parvum isolates were subgenotype Ic. C. hominis infection was associated with a greater severity of diarrhea. Sequencing of the Cpgp40/15 alleles of C. felis and C. parvum (mouse genotype) revealed similarities to subgenotype IIa and C. meleagridis, respectively. Space-time analysis revealed two clusters of infection due to C. hominis Ia, with a peak in February 2005. This is the first study to demonstrate space-time clustering of a single subgenotype of C. hominis in a setting where cryptosporidiosis is endemic. Molecular characterization and spatial analysis have the potential to further the understanding of disease and transmission in the community.
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Banerjee I, Gladstone BP, Le Fevre AM, Ramani S, Iturriza-Gomara M, Gray JJ, Brown DW, Estes MK, Muliyil JP, Jaffar S, Kang G. Neonatal infection with G10P[11] rotavirus did not confer protection against subsequent rotavirus infection in a community cohort in Vellore, South India. J Infect Dis 2007; 195:625-32. [PMID: 17262703 PMCID: PMC2483790 DOI: 10.1086/510853] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Accepted: 08/01/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Various observational studies have suggested that neonatal rotavirus infection confers protection against diarrhea due to subsequent rotavirus infection. We examined the incidence of rotavirus infection and diarrhea during the first 2 years of life among children infected with the G10P[11] rotavirus strain during the neonatal period and those not infected with rotavirus. METHODS Children were recruited at birth and were followed up at least twice weekly. Stool samples, collected every 2 weeks for surveillance and at each episode of diarrhea, were screened by enzyme-linked immunosorbent assay and were genotyped by polymerase chain reaction. RESULTS Among 33 children infected neonatally with G10P[11] and 300 children not infected with rotavirus, there was no significant difference in the rates of rotavirus-positive diarrhea (rate ratio [RR], 1.05 [95% confidence interval [CI], 0.61-1.79]), moderate or severe rotavirus-positive diarrhea (RR, 1.42 [95% CI, 0.73-2.78]), or asymptomatic rotavirus shedding (RR, 1.25 [95% CI, 0.85-1.83]). CONCLUSION Neonatal G10P[11] infection with a strain resembling a vaccine candidate did not confer protection against subsequent rotavirus infection or diarrhea of any severity in this setting.
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Affiliation(s)
- Indrani Banerjee
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | | | - Andrea M. Le Fevre
- Infectious Diseases Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sasirekha Ramani
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Miren Iturriza-Gomara
- Enteric Virus Unit, Virus Reference Department, Centre for Infection, Health Protection Agency, London, United Kingdom
| | - James J. Gray
- Enteric Virus Unit, Virus Reference Department, Centre for Infection, Health Protection Agency, London, United Kingdom
| | - David W. Brown
- Enteric Virus Unit, Virus Reference Department, Centre for Infection, Health Protection Agency, London, United Kingdom
| | - Mary K. Estes
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston
| | | | - Shabbar Jaffar
- Infectious Diseases Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gagandeep Kang
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
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Ramani S, Banerjee I, Gladstone BP, Sarkar R, Selvapandian D, Le Fevre AM, Jaffar S, Iturriza-Gomara M, Gray JJ, Estes MK, Brown DW, Kang G. Geographic information systems and genotyping in identification of rotavirus G12 infections in residents of an urban slum with subsequent detection in hospitalized children: emergence of G12 genotype in South India. J Clin Microbiol 2006; 45:432-7. [PMID: 17135437 PMCID: PMC1829045 DOI: 10.1128/jcm.01710-06] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rotavirus infections by G12 strains in several countries have recently been described. In this study, we report the emergence of G12 strains in south India. Fourteen cases of G12 infection were identified between June and September 2005. G12 was seen in combination with P[6], P[8], or nontypeable P type. Nine cases, including five symptomatic infections and four asymptomatic infections, were identified as part of routine surveillance for rotavirus infections in a birth cohort in the community between June and July 2005. Significant temporal and time-space clustering of eight of these cases represents a possible recent introduction of a new rotavirus VP7 genotype. Previous rotavirus infections had been documented for six of the nine children in the community. In the following 2 months, five cases of G12 infection were identified among children presenting to a referral hospital with diarrhea. This is the first description of symptomatic and asymptomatic G12 infections in children in the community. The detection of G12 strains from different parts of the world in recent years suggests the possibility of its emergence as an important global genotype. Monitoring of cocirculating rotavirus strains and detection of emerging strains is important in the context of the availability of rotavirus vaccines.
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Affiliation(s)
- Sasirekha Ramani
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
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