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Kariuki K, Diakhate MM, Musembi S, Tornberg-Belanger SN, Rwigi D, Mutuma T, Mutuku E, Tickell KD, Soge OO, Singa BO, Walson JL, Pavlinac PB, Kariuki S. Plasmid-mediated quinolone resistance genes detected in Ciprofloxacin non-susceptible Escherichia coli and Klebsiella isolated from children under five years at hospital discharge, Kenya. BMC Microbiol 2023; 23:129. [PMID: 37173674 PMCID: PMC10182689 DOI: 10.1186/s12866-023-02849-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 04/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The increasing spread of fluoroquinolone resistant enteric bacteria is a global public health concern. Children recently discharged from the hospital are at high risk of carriage of antimicrobial resistance (AMR) due to frequent exposure to antimicrobials during inpatient stays. This study aimed to determine the prevalence, correlates of ciprofloxacin (CIP) non-susceptibility, and distribution of plasmid-mediated quinolone resistance (PMQR) genes in Escherichia coli (E. coli) and Klebsiella spp isolated from children under five years being discharged from two Kenyan Hospitals. METHODS E. coli and Klebsiella spp were isolated from fecal samples from children discharged from hospital and subjected to antimicrobial susceptibility testing (AST) by disc diffusion and E-test. CIP non-susceptible isolates were screened for seven PMQR genes using multiplex polymerase chain reaction (PCR). Poisson regression was used to determine the association between the carriage of CIP non-susceptible isolates and patient characteristics. RESULTS Of the 280 CIP non-susceptible isolates: 188 E. coli and 92 Klebsiella spp isolates identified among 266 discharged children, 195 (68%) were CIP-non-susceptible with minimum inhibitory concentrations (MICs) of ≥ 1 µg/mL. Among these 195 isolates, 130 (67%) had high-level CIP MIC = ≥ 32 µg/mL). Over 80% of the isolates had at least one PMQR gene identified: aac(6')lb-cr (60%), qnrB (24%), oqxAB (22%), qnrS (16%), and qepA (6%), however, qnrA was not identified in any isolates tested. Co-carriage of qnrB with acc(6')-lb-cr was the most predominant accounting for 20% of all the isolates. Ceftriaxone use during hospital admission and the presence of extended spectrum beta-lactamase (ESBL) production were significantly associated with the carriage of CIP non-susceptible E. coli and Klebsiella spp. CONCLUSION CIP non-susceptibility is common among E. coli and Klebsiella spp isolated from hospital discharged children in Kenya. Carriage and co-carriage of PMQR, including the newly identified qepA gene, were frequently observed. These findings suggest that children leaving the hospital may serve as an important reservoir for transmission of resistant E. coli and Klebsiella spp to the community. Enhanced surveillance for AMR determinants is critical to inform interventions to control antimicrobial-resistant bacteria.
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Affiliation(s)
- Kevin Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
- Department of Biochemistry, Microbiology and Biotechnology, Kenyatta University, Nairobi, Kenya.
| | | | - Susan Musembi
- Department of Biochemistry, Microbiology and Biotechnology, Kenyatta University, Nairobi, Kenya
| | | | - Doreen Rwigi
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Timothy Mutuma
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Elizabeth Mutuku
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Olusegun O Soge
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, WA, USA
- Centre for Clinical Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Pediatrics and Medicine (Allergy and Infectious Diseases), University of Washington, Seattle, WA, USA
| | - Patricia B Pavlinac
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
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Tornberg-Belanger SN, Rwigi D, Mugo M, Kitheka L, Onamu N, Ounga D, Diakhate MM, Atlas HE, Wald A, McClelland RS, Soge OO, Tickell KD, Kariuki S, Singa BO, Walson JL, Pavlinac PB. Antimicrobial resistance including Extended Spectrum Beta Lactamases (ESBL) among E. coli isolated from kenyan children at hospital discharge. PLoS Negl Trop Dis 2022; 16:e0010283. [PMID: 35358186 PMCID: PMC9015121 DOI: 10.1371/journal.pntd.0010283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [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: 07/08/2021] [Revised: 04/18/2022] [Accepted: 02/27/2022] [Indexed: 12/04/2022] Open
Abstract
Background Children who have been discharged from hospital in sub-Saharan Africa remain at substantial risk of mortality in the post-discharge period. Antimicrobial resistance (AMR) may be an important factor. We sought to determine the prevalence and risk factors associated with AMR in commensal Escherichia coli(E. coli) from Kenyan children at the time of discharge. Methodology/Principle findings Fecal samples were collected from 406 children aged 1–59 months in western Kenya at the time of discharge from hospital and cultured for E. coli. Susceptibility to ampicillin, ceftriaxone, cefotaxime, ceftazidime, cefoxitin, imipenem, ciprofloxacin, gentamicin, combined amoxicillin/clavulanic acid, trimethoprim-sulfamethoxazole, azithromycin, and chloramphenicol was determined by disc diffusion according to guidelines from the Clinical and Laboratory Standards Institute (CLSI). Poisson regression was used to determine associations between participant characteristics and the presence of extended-spectrum beta-lactamases (ESBL) producing E. coli. Non-susceptibility to ampicillin (95%), gentamicin (44%), ceftriaxone (46%), and the presence of ESBL (44%) was high. Receipt of antibiotics during the hospitalization was associated with the presence of ESBL (aPR = 2.23; 95% CI: 1.29–3.83) as was being hospitalized within the prior year (aPR = 1.32 [1.07–1.69]). Open defecation (aPR = 2.02; 95% CI: 1.39–2.94), having a toilet shared with other households (aPR = 1.49; 95% CI: 1.17–1.89), and being female (aPR = 1.42; 95% CI: 1.15–1.76) were associated with carriage of ESBL E. coli Conclusions/Significance AMR is common among isolates of E. coli from children at hospital discharge in Kenya, including nearly half having detectable ESBL. Children who have been hospitalized in sub-Saharan Africa remain at a high risk of death and morbidity for at least 6 months following discharge. These children may harbor AMR in commensal bacteria following hospitalization, which may be associated with poor outcomes. There are limited data describing AMR and risk factors that are associated with AMR carriage at hospital discharge. In this cross-sectional study of Kenyan children under 5 years of age discharged from hospitals, we found AMR to be high. Children who received antibiotics in the hospital, had limited access to improved sanitation, and who were female had the highest prevalence of ESBL-producing E. coli.
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Affiliation(s)
- Stephanie N. Tornberg-Belanger
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- * E-mail: (STB); (PBP)
| | - Doreen Rwigi
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Michael Mugo
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Lynnete Kitheka
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Nancy Onamu
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Derrick Ounga
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mame M. Diakhate
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Hannah E. Atlas
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Anna Wald
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - R. Scott McClelland
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
| | - Olusegun O. Soge
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States of America
| | - Kirkby D. Tickell
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Samuel Kariuki
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Benson O. Singa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Judd L. Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, United States of America
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Medicine (Allergy and Infectious Diseases), University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Patricia B. Pavlinac
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail: (STB); (PBP)
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Ahmed T, Chisti MJ, Rahman MW, Alam T, Ahmed D, Parvin I, Kabir MF, Sazawal S, Dhingra P, Dutta A, Deb S, Chouhan A, Sharma AK, Jaiswal VK, Dhingra U, Walson JL, Singa BO, Pavlinac PB, McGrath CJ, Nyabinda C, Deichsel EL, Anyango M, Kariuki KM, Rwigi D, Tornberg-Belanger SN, Kotloff KL, Sow SO, Tapia MD, Haidara FC, Mehta A, Coulibaly F, Badji H, Permala-Booth J, Tennant SM, Malle D, Bar-Zeev N, Dube Q, Freyne B, Cunliffe N, Ndeketa L, Witte D, Ndamala C, Cornick J, Qamar FN, Yousafzai MT, Qureshi S, Shakoor S, Thobani R, Hotwani A, Kabir F, Mohammed J, Manji K, Duggan CP, Kisenge R, Sudfeld CR, Kibwana U, Somji S, Bakari M, Msemwa C, Samma A, Bahl R, De Costa A, Simon J, Ashorn P. Effect of 3 Days of Oral Azithromycin on Young Children With Acute Diarrhea in Low-Resource Settings: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2136726. [PMID: 34913980 PMCID: PMC8678692 DOI: 10.1001/jamanetworkopen.2021.36726] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/21/2021] [Indexed: 12/25/2022] Open
Abstract
Importance World Health Organization (WHO) guidelines do not recommend routine antibiotic use for children with acute watery diarrhea. However, recent studies suggest that a significant proportion of such episodes have a bacterial cause and are associated with mortality and growth impairment, especially among children at high risk of diarrhea-associated mortality. Expanding antibiotic use among dehydrated or undernourished children may reduce diarrhea-associated mortality and improve growth. Objective To determine whether the addition of azithromycin to standard case management of acute nonbloody watery diarrhea for children aged 2 to 23 months who are dehydrated or undernourished could reduce mortality and improve linear growth. Design, Setting, and Participants The Antibiotics for Children with Diarrhea (ABCD) trial was a multicountry, randomized, double-blind, clinical trial among 8266 high-risk children aged 2 to 23 months presenting with acute nonbloody diarrhea. Participants were recruited between July 1, 2017, and July 10, 2019, from 36 outpatient hospital departments or community health centers in a mixture of urban and rural settings in Bangladesh, India, Kenya, Malawi, Mali, Pakistan, and Tanzania. Each participant was followed up for 180 days. Primary analysis included all randomized participants by intention to treat. Interventions Enrolled children were randomly assigned to receive either oral azithromycin, 10 mg/kg, or placebo once daily for 3 days in addition to standard WHO case management protocols for the management of acute watery diarrhea. Main Outcomes and Measures Primary outcomes included all-cause mortality up to 180 days after enrollment and linear growth faltering 90 days after enrollment. Results A total of 8266 children (4463 boys [54.0%]; mean [SD] age, 11.6 [5.3] months) were randomized. A total of 20 of 4133 children in the azithromycin group (0.5%) and 28 of 4135 children in the placebo group (0.7%) died (relative risk, 0.72; 95% CI, 0.40-1.27). The mean (SD) change in length-for-age z scores 90 days after enrollment was -0.16 (0.59) in the azithromycin group and -0.19 (0.60) in the placebo group (risk difference, 0.03; 95% CI, 0.01-0.06). Overall mortality was much lower than anticipated, and the trial was stopped for futility at the prespecified interim analysis. Conclusions and Relevance The study did not detect a survival benefit for children from the addition of azithromycin to standard WHO case management of acute watery diarrhea in low-resource settings. There was a small reduction in linear growth faltering in the azithromycin group, although the magnitude of this effect was not likely to be clinically significant. In low-resource settings, expansion of antibiotic use is not warranted. Adherence to current WHO case management protocols for watery diarrhea remains appropriate and should be encouraged. Trial Registration ClinicalTrials.gov Identifier: NCT03130114.
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Affiliation(s)
- Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Muhammad Waliur Rahman
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmina Alam
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Dilruba Ahmed
- Laboratory Sciences and Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Irin Parvin
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Farhad Kabir
- Nutrition and Clinical Services Division, International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Sunil Sazawal
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | - Arup Dutta
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Saikat Deb
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | | | | | | | - Usha Dhingra
- Center for Public Health Kinetics, New Delhi, Delhi, India
| | - Judd L Walson
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle
- Department of Pediatrics, University of Washington, Seattle
- Department of Medicine (Allergy and Infectious Diseases), University of Washington, Seattle
| | - Benson O Singa
- Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Emily L Deichsel
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | | | | | - Doreen Rwigi
- Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Samba O Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Milagritos D Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Fadima Cheick Haidara
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Ashka Mehta
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Flanon Coulibaly
- Division of Advanced Primary Health Care Research and Clinical Trials, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Henry Badji
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Jasnehta Permala-Booth
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Sharon M Tennant
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Dramane Malle
- Division of Clinical Microbiology and Molecular Biology, Centre pour le Développement des Vaccins, Bamako, Mali
| | - Naor Bar-Zeev
- International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Queen Dube
- Department of Pediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Bridget Freyne
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Nigel Cunliffe
- National Institutes of Health Research Health Protection Research Unit in Gastrointestinal Infections, University of Liverpool, Liverpool, United Kingdom
| | - Latif Ndeketa
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Liverpool School of Tropical Medicine, Blantyre, Malawi
| | - Desiree Witte
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Chifundo Ndamala
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jennifer Cornick
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Institute of Infection, Veterinary and Ecological Sciences, The University of Liverpool, Blantyre, Malawi
| | - Farah Naz Qamar
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | | | - Shahida Qureshi
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
| | - Rozina Thobani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Aneeta Hotwani
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Furqan Kabir
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Jan Mohammed
- Department of Pediatrics and Child Heath, Aga Khan University, Karachi, Pakistan
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Upendo Kibwana
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Cecylia Msemwa
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abraham Samma
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rajiv Bahl
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Ayesha De Costa
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Jonathon Simon
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
| | - Per Ashorn
- Department of Maternal, Child, and Adolescent Health and Aging, World Health Organization, Geneva, Switzerland
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Ryan D, Tornberg-Belanger SN, Perez G, Maurer S, Price C, Rao D, Chan KCG, Ornelas IJ. Stress, social support and their relationship to depression and anxiety among Latina immigrant women. J Psychosom Res 2021; 149:110588. [PMID: 34371256 PMCID: PMC8453089 DOI: 10.1016/j.jpsychores.2021.110588] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Latina immigrant women in the United States are at increased risk of adverse mental health outcomes due to economic, political, cultural and social stressors related to migration and resettlement. However, few studies have described how stress and social supports are related to depression and anxiety symptoms among Latina immigrant women. METHOD This cross-sectional study used survey data collected from a community-based sample as part of the Amigas Latinas Motivando el Alma (ALMA) study to describe levels of stress, social support, depression and anxiety among Latina immigrant women (N=153). We also estimated associations between stressors, social supports and mental health. RESULTS At baseline, 29% of participants reported moderate to severe depressive symptoms and 32% of participants reported moderate to severe anxiety symptoms. In adjusted regression models, stressors including social isolation (β=0.2, p<0.001), perceived stress (β=0.6, p<.0001), and law/immigration enforcement stress (β=0.3, p=0.04) were associated with higher levels of depression symptoms. Perceived stress (β=0.6, p<0.001) and stress associated with meeting basic needs (β=0.6, p<0.001) were associated with higher levels of anxiety symptoms, while social support received through positive social interactions was associated with fewer anxiety symptoms (β=-0.8, p=0.03). CONCLUSIONS Latina immigrant women experience a number of stressors associated with immigration and their social position, which in turn are associated with increased symptoms of depression and anxiety. Future research should examine how social support, along with programs and policies that reduce stress, can improve mental health outcomes in this population.
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Affiliation(s)
- Daron Ryan
- Department of Health Systems and Population Health, University of Washington, United States of America
| | - Stephanie N Tornberg-Belanger
- Department of Health Systems and Population Health, University of Washington, United States of America; Department of Epidemiology, University of Washington, United States of America
| | - Georgina Perez
- Department of Health Systems and Population Health, University of Washington, United States of America
| | - Serena Maurer
- Department of Health Systems and Population Health, University of Washington, United States of America
| | - Cynthia Price
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, United States of America
| | - Deepa Rao
- Department of Global Health, University of Washington, United States of America; Department of Psychiatry and Behavioral Services, University of Washington, United States of America
| | - Kwun C G Chan
- Department of Health Systems and Population Health, University of Washington, United States of America; Department of Biostatistics, University of Washington, United States of America
| | - India J Ornelas
- Department of Health Systems and Population Health, University of Washington, United States of America.
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5
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Pavlinac PB, Singa BO, Tickell KD, Brander RL, McGrath CJ, Amondi M, Otieno J, Akinyi E, Rwigi D, Carreon JD, Tornberg-Belanger SN, Nduati R, Babigumira JB, Meshak L, Bogonko G, Kariuki S, Richardson BA, John-Stewart GC, Walson JL. Azithromycin for the prevention of rehospitalisation and death among Kenyan children being discharged from hospital: a double-blind, placebo-controlled, randomised controlled trial. Lancet Glob Health 2021; 9:e1569-e1578. [PMID: 34559992 PMCID: PMC8638697 DOI: 10.1016/s2214-109x(21)00347-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/23/2021] [Accepted: 07/21/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Mass drug administration of azithromycin to children in sub-Saharan Africa has been shown to improve survival in high-mortality settings. The period after hospital discharge is a time of elevated risk unaddressed by current interventions and might provide an opportunity for targeting empirical azithromycin administration. We aimed to assess the efficacy of azithromycin administered at hospital discharge on risk of death and rehospitalisation in Kenyan children younger than 5 years. METHODS In this double-blind, placebo-controlled randomised trial, children were randomly assigned (1:1) to receive a 5-day course of azithromycin (oral suspension 10 mg/kg on day 1, followed by 5mg/kg per day on days 2-5) or identically appearing and tasting placebo at discharge from four hospitals in western Kenya. Children were eligible if they were aged 1-59 months at hospital discharge, weighed at least 2 kg, and had been admitted to hospital for any medical reason other than trauma, poisoning, or congenital anomaly. The primary outcome was death or rehospitalisation in the subsequent 6-month period in a modified intention-to-treat population, compared by randomisation group with Cox proportional hazards regression and Kaplan-Meier. Azithromycin resistance in Escherichia coli isolates from a random subset of children was compared by randomisation group with generalised estimating equations. This trial is registered with ClinicalTrials.gov, NCT02414399. FINDINGS Between June 28, 2016, and Nov 4, 2019, 1400 children were enrolled in the trial at discharge from hospital, with 703 (50·2%) randomly assigned to azithromycin and 697 (49·8%) to placebo. Among the 1398 children included in the modified intention-to-treat analysis (702 in the azithromycin group and 696 in the placebo group), the incidence of death or rehospitalisation was 20·4 per 100 child-years in the azithromycin group and 22·5 per 100 child-years in the placebo group (adjusted hazard ratio 0·91, 95·5% CI 0·64-1·29, p=0·58). Azithromycin resistance was common in commensal E coli isolates from enrolled children before randomisation (37·7% of 406 isolates) despite only 3·7% of children having received a macrolide antibiotic during the hospitalisation. Azithromycin resistance was slightly higher at 3 months after randomisation in the azithromycin group (26·9%) than in the placebo group (19·1%; adjusted prevalence ratio 1·41, 95% CI 0·95-2·09, p=0·088), with no difference observed at 6 months (1·17, 0·78-1·76, p=0·44). INTERPRETATION We did not observe a significant benefit of a 5-day course of azithromycin delivered to children younger than 5 years at hospital discharge despite the overall high risk of mortality and rehospitalisation. These findings highlight the need for more research into mechanisms and interventions for prevention of morbidity and mortality in the post-discharge period. FUNDING Eunice Kennedy Shriver National Institute of Child Health & Human Development.
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Affiliation(s)
| | - Benson O Singa
- Department of Global Health, University of Washington, Seattle, WA, USA; Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | | | - Christine J McGrath
- Department of Global Health, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
| | - Mary Amondi
- International AIDS Vaccine Initiative, Nairobi, Kenya
| | - Joyce Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Elizabeth Akinyi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Doreen Rwigi
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | - Ruth Nduati
- Department of Pediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Liru Meshak
- Homa Bay Teaching and Referral Hospital, Homa Bay, Kenya
| | | | - Samuel Kariuki
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Departments of Pediatrics and Medicine-Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
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Balkus JE, Hajat A, Rowhani-Rahbar A, Tornberg-Belanger SN. RE: "ASSESSING REPRESENTATION AND PERCEIVED INCLUSION AMONG MEMBERS OF THE SOCIETY FOR EPIDEMIOLOGIC RESEARCH". Am J Epidemiol 2020; 189:1211. [PMID: 32602535 DOI: 10.1093/aje/kwaa116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 11/13/2022] Open
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Tickell KD, Mangale DI, Tornberg-Belanger SN, Bourdon C, Thitiri J, Timbwa M, Njirammadzi J, Voskuijl W, Chisti MJ, Ahmed T, Shahid ASMSB, Diallo AH, Ouédrago I, Khan AF, Saleem AF, Arif F, Kazi Z, Mupere E, Mukisa J, Sukhtankar P, Berkley JA, Walson JL, Denno DM. A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines. PLoS One 2019; 14:e0212395. [PMID: 30908499 PMCID: PMC6433255 DOI: 10.1371/journal.pone.0212395] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 08/06/2018] [Accepted: 01/27/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children–including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. Methods Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2–23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. Results All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. Conclusion Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.
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Affiliation(s)
- Kirkby D. Tickell
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Dorothy I. Mangale
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Stephanie N. Tornberg-Belanger
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Celine Bourdon
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Jenala Njirammadzi
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Mohammod J. Chisti
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | | | - Abdoulaye H. Diallo
- Department of Public Health, Centre MURAZ Research Institute, Ministry of Health, Bobo-Dioulasso, Burkina Faso
- Department of Public Health, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Issaka Ouédrago
- Department of Paediatrics, Banfora Regional Referral Hospital, Banfora, Burkina Faso
| | - Al Fazal Khan
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Ali F. Saleem
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fehmina Arif
- Department of Paediatrics, Civil Hospital Karachi, Karachi, Pakistan
| | - Zaubina Kazi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Mukisa
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Judd L. Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Department of Health Services, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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