Establishing Antimicrobial Resistance Surveillance & Research Network in India: Journey so far

An integrated surveillance network for antimicrobial resistance, India

OBJECTIVE

To assess the preparedness of veterinary laboratories in India to participate in an integrated antimicrobial resistance surveillance network and to address gaps in provision identified.

METHODS

The Indian Council of Medical Research and the Indian Council of Agricultural Research collaborated: (i) to select eight nationally representative veterinary microbiology laboratories whose capacity for participating in an integrated antimicrobial resistance surveillance network would be assessed using a standardized tool; (ii) to identify gaps in provision from the assessment findings; and (iii) to develop a plan, and take the necessary steps to address these gaps in consultation with participating organizations.

FINDINGS

The main gaps in provision identified were: (i) a lack of dedicated funding for antimicrobial resistance surveillance; (ii) the absence of standard guidelines for antimicrobial susceptibility testing; (iii) a shortage of reference strains for testing and quality assurance; and (iv) the absence of mechanisms for sharing data. We addressed these gaps by creating a veterinary standard operating procedure for antimicrobial susceptibility testing, by carrying out a validation exercise to identify problems with implementing the procedure and by conducting capacity-building workshops for veterinary laboratories.

CONCLUSION

Antimicrobial resistance surveillance networks depend on the availability of accurate, quality-controlled testing. The challenges identified in creating an integrated surveillance network for India can be overcome by developing a comprehensive plan for improving laboratory capacity in human, veterinary and environmental sectors that is supported by the necessary funds. The study's findings may provide guidance for other low- and middle-income countries planning to develop a similar network.

Antimicrobial resistance and the post antibiotic era: better late than never effort

Introduction: Antimicrobial resistance (AMR) is a multi-layered problem with a calamitous impact on humans, livestock, the environment, and the biosphere. Initiatives and action plan to preclude AMR remain poorly implemented in India.Area covered: This review highlights essential factors contributing to AMR, epidemiology of the resistant bacteria, current treatment options, economic impact, and regulatory efforts initiated by the Indian government to tackle AMR.Expert opinion: Health-care professionals, hospitals, and the general public must understand and cooperatively implement the 'One Health approach,' which entails judicious use of antibiotics in humans, animals, and the environment. Neglecting the AMR problem predicts the expansion of the 'Post-antibiotic era' characterized by drying antibiotic discovery pipelines, overuse of 'Watch' and 'Reserve' groups, coupled with underuse of 'Access' antibiotics, increased daily defined doses, increased healthcare cost, rise in morbidity, mortality, and environmental degradation. The Indian case study elucidates a looming international crisis that demands global attention and commitment for envisaging and implementing locally relevant solutions.

The Prevalence and Antimicrobial Susceptibility Pattern of Gram-Positive Pathogens: Three-Year Study at a Private Tertiary Care Hospital in Mumbai, India

Introduction  The growing resistance pattern of the gram-positive pathogens along with a steady increase in minimum inhibitory concentration of the currently available antibiotics have led to an increase in morbidity and mortality rates in India. This study aims to access the shifting antibiotic susceptibility paradigm of the gram-positive pathogens in various infections at a tertiary care center.

Methods  This is a 3-year retrospective observational study which was performed from January 2016 to December 2018 at a tertiary care hospital in Mumbai. All clinically significant gram-positive cocci isolated from a variety of clinical specimens were studied for their prevalence and antimicrobial susceptibility.

Results  Out of 4,428 gram-positive isolates, Staphylococcus aureus (35.3%) was the commonly encountered pathogen, followed by Enterococcus spp. (32.1%) and coagulase-negative Staphylococcus (CoNS) (25.7%). S. aureus was majorly isolated from skin and soft tissue infections (60.3%), followed by patients with respiratory tract infections (18.2%) and blood stream infections (13%). Among S. aureus , particularly methicillin-resistant S. aureus (MRSA), prevalence increased from 29.5% in 2016 to 35.1% in 2018, with an overall prevalence of 33.6%. All S. aureus isolates were 100% sensitive toward vancomycin, linezolid, tigecycline, and teicoplanin. However, the CoNS isolates showed a higher resistance rate with reduced susceptibility toward linezolid and teicoplanin. High prevalence of resistance was observed across gram-positive isolates with commonly used antibiotics such as ciprofloxacin, levofloxacin, and erythromycin. While the prevalence of linezolid-resistant enterococcus (LRE) was 3.6%, vancomycin (VRE) and teicoplanin resistance among the enterococcus species was as high as 7.7% and 7.5%, respectively.

Conclusion  Rising methicillin resistance among the Staphylococcal species (MRSA and MR-CoNS) along with reduced susceptibility toward currently available anti-MRSA agents is a matter of serious concern as it limits the therapeutic options for treating multidrug resistant (MDR) gram-positive infections.

Whole genome sequence of colistin-resistant Escherichia coli from western India

BACKGROUND

With virtually dried out new antibiotic discovery pipeline, emergence and spread of antimicrobial resistance is a cause for global concern. Colistin, a cyclic polypeptide antibiotic, often regarded as last resort for multi drug resistance gram-negative bacteria, is also rendered ineffective by horizontal transfer of resistance genes. Surveillance of colistin resistance in GNB is essential to ascertain molecular epidemiology.

METHODS

Whole genome sequencing (WGS) of an unusual colistin resistant urinary isolate of Escherichia coli was performed using Illumina MiSeq platform using 2x250bp V2 chemistry by following the manufactures protocol (Illumina Inc. USA). Multiple web-based bio-informatic tools were utilized to ascertain antibiotic resistant genes.

RESULTS

An approximate 5.4 Mb of genome of the urinary isolate AFMC_UC19 was sequenced successfully. Mobile colistin resistance gene (mcr) on the plasmid responsible for horizontal spread was absent in the isolate.

CONCLUSION

Colistin resistance has been reported previously in Klebsiella pneumoniae and it is a rare occurrence in Escherichia coli in Indian setting. Although the isolate lack mcr mediated colistin resistance, emergence and spread of colistin resistant in gram-negative bacteria pose a threat.

Microbial Profile and Antibiogram Pattern Analysis of Skin and Soft Tissue Infections at a Tertiary Care Center in South India

Skin and soft tissue infections (SSTIs) are the most common type of infection globally and also in India. Periodic evaluation of data on microbial profiling and antibiogram trend analysis is mandatory for creating a timely empirical treatment guideline and a proper antimicrobial cycling plan. In the current study, retrospective analysis of the data from 3,570 samples collected from suspected SSTI over one year was performed. Analysis was done on the clinical condition, causative agent/s identified and their antimicrobial susceptibility according to the standard guidelines. Seventy-three percent of samples yielded positive growth, with majority being unimicrobial infections. Gram-negative bacteria (GNB) were more commonly associated with infections from in-patients while Gram-positive cocci (GPC) were seen among out-patients. More than 70% of isolates among GNB were found susceptible to Carbapenems, piperacillin-tazobactam, amikacin and chloramphenicol. Among GPC, maximum sensitivity was seen to glycopeptides, linezolid followed by chloramphenicol, tetracycline, clindamycin and amikacin. Unusual resistance patterns like Penicillin resistant Ampicillin sensitive Enterococcus faecalis (PRASEF)strains, Multidrug resistance (MDR) and Extended drug resistance (XDR) were higher among Enterococci spp, MRSA, Acinetobacter spp and Klebsiella spp. Resistance to penicillin and cephalosporin drugs were high among GNB and GPC. Carbapenems, aminoglycosides, glycopeptides and broad-spectrum antibiotics are found sensitive and potential choices for empirical therapy. As prevalence of MDR and XDR strains were high and the trend analysis shows likelihood of few of the first and second line drugs becoming sensitive in future, we conclude that continued analysis of bacterial profiling and AMR pattern analysis among SSTI is essential.

Outcomes and prognostic factors in adolescents and young adults with ALL treated with a modified BFM-90 protocol

The use of pediatrics-inspired protocols in adolescent and young adult (AYA) acute lymphoblastic leukemia (ALL) results in superior survival compared with the adult protocols. Pediatrics-inspired protocols carry an increased risk of toxicity and treatment-related mortality in low resource settings, which can offset the potential benefits. We studied the outcomes and prognostic factors in the treatment of AYA ALL with a pediatrics-inspired regimen. We retrieved data regarding demographics, investigations, treatment details, and toxicities from the electronic medical records of patients diagnosed with ALL in the 15- to 25-year-old age group who were initiated on a modified Berlin-Frankfurt-Münster 90 (BFM-90) protocol between January 2013 and December 2016 at the Tata Memorial Centre. A total of 349 patients in the 15- to 25-year-old age group were treated with a modified BFM-90 protocol. The use of this pediatrics-inspired protocol resulted in a 3-year event-free survival (EFS) and overall survival (OS) of 59.4% and 61.8%, respectively. Only 15 patients underwent an allogeneic stem cell transplant. Minimal residual disease (MRD) persistence postinduction emerged as the only factor predictive of poor outcomes. A modified BFM-90 protocol is an effective and safe regimen for AYA ALL with an OS and EFS comparable to the published literature.

Design & development of customizable web API for interoperability of antimicrobial resistance data

Antimicrobial resistance (AMR) is a global health emergency. Complementary to developing new drugs, AMR can be monitored and controlled through cost-effective active surveillance of resistance. As an initiative to monitor resistance, countries all across the globe are collecting data using a variety of surveillance tools. Moreover, hospitals routinely collect the AMR data for treatment which is being stored in their Laboratory and Hospital Information systems (LIS-HIS). The generated clinical data is collected & stored in various formats, making it very difficult to analyze and generate national reports. To integrate the stored clinical data for predictive modeling and analysis, there is an immediate need for a one-stop data repository capable of importing and exporting data in simple data exchange formats (CSV/Excel). The paper highlights the design & development of i-DIA, a python-based web API to facilitate the interoperability of AMR data by automatically importing the bulk of medical data from CSV files into generic data management and analysis system. The i-DIA has been integrated and tested with the ICMR's AMR surveillance network on in-house developed software, i-AMRSS. The i-AMRSS is presently collecting data from 31 laboratories across India and i-DIA has been used to import data generated from LIS & HIS of a few hospitals directly into the system. The paper also proposes the complete web-based framework (an extension of i-DIA) integrated with peer-to-peer system architecture.

Setting up laboratory-based antimicrobial resistance surveillance in low- and middle-income countries: lessons learned from Georgia

BACKGROUND

Antimicrobial resistance (AMR) is a growing problem worldwide, with an estimated high burden in low- and middle-income countries (LMICs). In these settings, tackling the problem of AMR is often constrained by a lack of reliable surveillance data due to limited use of microbiological diagnostics in clinical practice.

OBJECTIVES

The aim of this article is to present an overview of essential elements for setting up an AMR surveillance system in LMICs, to summarize the steps taken to develop such a system in the country of Georgia, and to describe its impact on microbiology laboratories.

SOURCES

A literature review of published papers using PubMed and experiences of experts involved in setting up AMR surveillance in Georgia.

CONTENT

Basic requirements for implementing a laboratory-based surveillance system in LMICs can be captured under four pillars: (a) governmental support, (b) laboratory capacity and quality management, (c) materials and supplies, and (d) sample collection, data management, analysis and reporting. In Georgia, the World Health Organization Proof-of-Principle project helped to start the collection of AMR surveillance data on a small scale by promoting the use of microbiological diagnostics in clinics, and by providing training and materials for laboratories. Thanks to governmental support and a strong lead by the national reference laboratory, the AMR surveillance network was sustained and expanded after the project ended.

IMPLICATIONS

This review describes the Georgian approach in building and expanding a functional AMR surveillance system, considering the elements identified from the literature. The introduction of quality management systems, standardization of guidelines and training paired with targeted capacity building led to improved laboratory standards and management of patients with bloodstream infections. Reliable AMR surveillance data may inform and facilitate policy-making on AMR control. The Georgian experience can guide other countries in the process of building up their national AMR surveillance system.

Secondary Infections in Hospitalized COVID-19 Patients: Indian Experience

Purpose

Critically ill coronavirus disease 2019 (COVID-19) patients need hospitalization which increases their risk of acquiring secondary bacterial and fungal infections. The practice of empiric antimicrobial prescription, due to limited diagnostic capabilities of many hospitals, has the potential to escalate an already worrisome antimicrobial resistance (AMR) situation in India. This study reports the prevalence and profiles of secondary infections (SIs) and clinical outcomes in hospitalized COVID-19 patients in India.

Patients and Methods

A retrospective study of secondary infections in patients admitted in intensive care units (ICUs) and wards of ten hospitals of the Indian Council of Medical Research (ICMR) AMR surveillance network, between June and August 2020, was undertaken. The demographic data, time of infection after admission, microbiological and antimicrobial resistance data of secondary infections, and clinical outcome data of the admitted COVID-19 patients were collated.

Results

Out of 17,534 admitted patients, 3.6% of patients developed secondary bacterial or fungal infections. The mortality among patients who developed secondary infections was 56.7% against an overall mortality of 10.6% in total admitted COVID-19 patients. Gram-negative bacteria were isolated from 78% of patients. Klebsiella pneumoniae (29%) was the predominant pathogen, followed by Acinetobacter baumannii (21%). Thirty-five percent of patients reported polymicrobial infections, including fungal infections. High levels of carbapenem resistance was seen in A. baumannii (92.6%) followed by K. pneumoniae (72.8%).

Conclusion

Predominance of Gram-negative pathogens in COVID-19 patients coupled with high rates of resistance to higher generation antimicrobials is an alarming finding. A high rate of mortality in patients with secondary infections warrants extra caution to improve the infection control practices and practice of antimicrobial stewardship interventions not only to save patient lives but also prevent selection of drug-resistant infections, to which the current situation is very conducive.

Multidrug resistant superbugs in pyogenic infections: a study from Western Rajasthan, India

Introduction

the crude mortality rate due to infectious diseases in India is approximately 417 per one lakh persons and pyogenic infections are one of the significant contributor. Poor antimicrobial stewardship in India has led to an increase in multidrug resistant superbugs in both community as well as hospital settings. The aim of this study was to identify the bacterial etiology of pyogenic infections and to evaluate their antimicrobial resistance profile.

Methods

this is a retrospective observational study from January, 2018 to December, 2018. A total 1851 samples, collected as a part of patient care were included in this study. Specimens were subjected to culture on Blood agar and MacConkey agar and incubated at 37°C for 48 hours. Species identification was done as per standard laboratory protocol. Antimicrobial susceptibility testing was performed using Kirby-Bauer disc diffusion according to Clinical and Laboratory Standards Institute guidelines.

Results

of total 1851 samples, culture was positive in 61.54%. A total 70.59%, Gram negative organisms were isolated followed by Gram positive cocci in 45.48%, yeast in 1.05%, coryneform bacteria in 0.79% and in one case, non-tubercular mycobacteria was isolated. Staphylococcus aureus (30.9%) was the predominant organism isolated. Most common multi drug resistant isolates were Klebsiella spp. (74.79%) and Acinetobacter spp. (74.32%).

Conclusion

this study gives an insight about the prevalence and common etiology of pyogenic infections along with their antimicrobial resistance profile in north western region of India. This study will contribute in formulating antibiotic stewardship program by selecting the antibiograms of pyogenic isolates.

Antimicrobial Stewardship and Its Impact on the Changing Epidemiology of Polymyxin Use in a South Indian Healthcare Setting

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an average of 417 per year during the post-implementation period, recording a 45% reduction. The quarterly patient survival rates had a significant positive correlation with the quarterly prescription appropriateness rates (r = 0.4774, p = 0.02), right loading dose (r = 0.5228, p = 0.015) and right duration (r = 0.4361, p = 0.04). Our study on the epidemiology of polymyxin use demonstrated favorable effects on the appropriateness of prescriptions and mortality benefits after successful implementation of antimicrobial stewardship in a real-world setting.

A descriptive analysis of antimicrobial resistance patterns of WHO priority pathogens isolated in children from a tertiary care hospital in India

The World Health Organization (WHO) has articulated a priority pathogens list (PPL) to provide strategic direction to research and develop new antimicrobials. Antimicrobial resistance (AMR) patterns of WHO PPL in a tertiary health care facility in Southern India were explored to understand the local priority pathogens. Culture reports of laboratory specimens collected between 1st January 2014 and 31st October 2019 from paediatric patients were extracted. The antimicrobial susceptibility patterns for selected antimicrobials on the WHO PPL were analysed and reported. Of 12,256 culture specimens screened, 2335 (19%) showed culture positivity, of which 1556 (66.6%) were organisms from the WHO-PPL. E. coli was the most common organism isolated (37%), followed by Staphylococcus aureus (16%). Total of 72% of E. coli were extended-spectrum beta-lactamases (ESBL) producers, 55% of Enterobacteriaceae were resistant to 3rd generation cephalosporins due to ESBL, and 53% of Staph. aureus were Methicillin-resistant. The analysis showed AMR trends and prevalence patterns in the study setting and the WHO-PPL document are not fully comparable. This kind of local priority difference needs to be recognised in local policies and practices.

Knowledge, Attitude, and Practices (KAP) Survey among Veterinarians, and Risk Factors Relating to Antimicrobial Use and Treatment Failure in Dairy Herds of India

The indiscriminate usage of antimicrobials in the animal health sector contributes immensely to antimicrobial resistance (AMR). The present study aims to assess the antimicrobial usage pattern and risk factors for AMR in animal husbandry sector of India. A cross-sectional survey about Knowledge, Attitude, and Practices (KAP) among veterinarians was carried out using a questionnaire comprising of 52 parameters associated with antibiotic use and the emergence of AMR in dairy herds. Respondents’ KAP scores were estimated to rank their level of knowledge, attitude, and practice. Furthermore, risk factors associated with treatment failure were analyzed by univariable and multivariable analyses. Out of a total of 466 respondents, the majority had average knowledge (69.5%), neutral attitude (93.2%), and moderate practice (51.3%) scores toward judicious antibiotic usage. Veterinarians reported mastitis (88.0%), reproductive disorders (76.6%), and hemoprotozoan infections (49.6%) as the top three disease conditions that require antibiotic usage. Most of the veterinarians (90.6%) resorted to their “own experience” as the main criteria for antibiotic choice. The use of the highest priority critically important antimicrobials (HPCIA) listed by the World Health Organization (WHO) in animals, particularly quinolones (76.8%) and third-generation cephalosporins (47.8%), has been reported. On multivariable regression analysis of the risk factors, the lack of cooperation of the dairy farmers in the completion of a prescribed antibiotic course by the veterinarian and the demand for antibiotic use even in conditions not requiring antibiotic use were found to be significantly associated with the outcome variable “treatment failure” having respective odds of 1.8 (95%CI: 1.1–3.0) and 3.6 (95%CI: 2.3–5.8) (p < 0.05). The average KAP score of veterinarians, poor farm management practices, lack of awareness among farmers on prudent antibiotic use, and lack of antibiotic stewardship are the significant factors that need attention to combat the rising AMR in veterinary sector in India.

Extended-Spectrum β-Lactamase and Carbapenemase Producing Gram-Negative Bacilli Infections Among Patients in Intensive Care Units of Felegehiwot Referral Hospital: A Prospective Cross-Sectional Study

Background

Owing to the specific risk profile of its residents, intensive care units (ICUs) are the best place for selection pressure and the epicenter for resistance development and dissemination. Infections with β-lactamase releasing Gram-negative bacilli (GNB) at ICUs are an emerging global threat. This study dogged the magnitude of extended-spectrum β-lactamase (ESBL) and carbapenemase releasing Gram-negative bacilli infections and associated factors among patients in the ICUs of Felegehiwot Referral Hospital, Ethiopia.

Methods

A cross-sectional study was done through February to June 2020. Wound swabs, urine, blood and sputum samples were collected from patients in the ICUs symptomatic for infections while excluding those under coma and shock. Bacterial species were verified using standard microbiological methods. Carbapenemase and ESBL production were identified using modified carbapenem inactivation and combined disk diffusion methods, respectively. Multivariable analysis was calculated for factors associated with ESBL production. P-value < 0.05 was taken as cut-off for statistical significance.

Results

Out of 270 patients in the ICU, 67 (24.8%) and 14 (5.2%) had infections with ESBL and carbapenemase releasing GNB, respectively. The most frequent ESBL producing isolates were P. aeruginosa (100%), E. cloacae (100%), K. pneumoniae (82.8%) and E. coli (64%). The predominant carbapenemase producer isolates were K. pneumoniae (27.6%) and E. cloacae (33.3%). Overall, 77 (81.1%) of species were multi-drug resistant. All GNB species were 100% resistant to tetracycline and ampicillin. They are also resistant to cefuroxime, ceftazidime, sulfamethoxazole-trimethoprim and cefotaxime. Prior hospitalization (AOR = 5.5, CI = 2.63-11.46), support with medical care devices (AOR = 23.7, CI = 4.6-12) and arterial intravenous catheterization (AOR = 2.7, CI = 1.3-5.3) had significant association with β-lactamase producing GNB infection.

Conclusion

Infection with ESBL and carbapenemase producing Gram-negative bacilli linked with an alarming degree of multi-drug resistant isolates is a major healthcare threat among patients in ICUs. Hence, strict adherence to infection prevention practices and wise use of antibiotics are recommended to slow the spread of antimicrobial resistance.

Emergence of antimicrobial resistance and magnitude of Unani medicine - scope and challenges

Emergence of antimicrobial resistance, with practically all newly developed and even more potent antibiotics like carbapenem and colistin, has become a matter of great public health concern. A number of common diseases of public health importance are becoming harder and sometimes impossible to treat due to increased resistance of pathogens. These alarming threats seek prime attention of scientific community to develop newer antibiotics with long-lasting efficacy, least side effects, and low economic burden. Unani classical texts have enormous citations on different infectious diseases. Many single drugs and compound formulations are in vogue since ages for the treatment of infectious diseases. Use of Afaviya (spices), Mufarrehat (exhilarants), Tiryaqi Advia (drugs with antidote properties) and Sirka (vinegar) is highly advocated in treating various infectious diseases. Though, enormous research activities have been undertaken worldwide to explore and develop newer antibiotics from natural resources, indicating massive magnitude of natural products in treating various infectious diseases, however, the higher plants, still largely seems to be unexplored. Moreover, elaborated and well controlled clinical studies are still lacking to authenticate their clinical significance. Hence, a rigorous, well-designed & well-structured research is highly paramount to ascertain the provision of newer, relatively safe and cost effective natural antibiotics.

Molecular insights of Carbapenem resistance Klebsiella pneumoniae isolates with focus on multidrug resistance from clinical samples

BACKGROUND

Carbapenem are the last-line antibiotic, defence against Gram-negative extended spectrum ß-lactamases producers (ESBLs). Carbapenem resistance Enterobacteriaceae especially Carbapenem resistant-Klebsiella pneumoniae (CR-KP) is recognized as one of the well-known public health problem, which is increasingly being reported around the world. The present study was focused to analyse the prevalence and characterization of antibiotic resistance K. pneumoniae in centre region of Tamil Nadu, India.

METHODOLOGY

Totally 145 suspected K. pneumoniae isolates [Urine, Pus, Sputum, Blood and Biopsy] obtained from hospitals of Central South India. The isolates were subjected to biochemical and molecular identification technique, following with antibiotic resistance pattern by standard antibiotic sensitivity test. Multidrug resistance (MDR) with β-lactamase producing Carbapenem resistant K. pneumoniae (CR-KP) strains were screened by classical sensitivity method and also drug resistance encoded gene. Also, molecular typing of the MDR strains were characterized by Pulsed-Field Gel Electrophoresis (PFGE). Further, the outer membrane protein (OmpK35 and 36) related Carbapenem resistance were characterized.

RESULTS

Totally, 61% of isolates were confirmed as K. pneumoniae, 75 % of isolates were MDR including 58% carbapenem and 97% ESBL antibiotics and grouped into 17 distinct resistant patterns. The MDR KP isolates shows positive for blaCTXM-1 (92 %) gene followed by blaSHV (43 %), blaTEM (36 %), blaNDM-1 (26 %), blaGES (20 %) and blaIMP-1 (8 %). Moreover, 62 % CR-KP isolates loses OmpK36 and 33% isolates loses OmpK35.

CONCLUSIONS

Loss of OmpK36 were highly an influence the cefoxitin and carbapenem resistance. Sixteen different PFGE patterns have been observed among the 18 MDR isolates. Eventually, ESBL as well as CR-KP were diverse in genetic makeup and often associated with hyper virulence hvKP should be of serious concern.

Das MK, Mahapatra A, Pathi B, Panigrahy R, Pattnaik S, Mishra SS, Mahapatro S, Swain P, Das J, Dixit S, Sahoo SN, Pillai RN. Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study

Background

India has the largest burden of drug‑resistant organisms compared with other countries around the world, including multiresistant and extremely drug‑resistant tuberculosis and resistant Gram‑negative and Gram‑positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited.

Objective

This multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology.

Methods

This hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles.

Results

The study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of June 2020, data for 56 humans, 30 animals and birds, and fishes from 10 ponds have been collected. Data analysis is yet to be done.

Conclusions

This study will inform about the bacterial infection and resistance epidemiology among different hosts, the risk factors for infection, and resistance transmission. In addition, it will identify the potential triggers and levers for further exploration and action.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23241

A prospective, follow up study to assess guidelines compliance in uncomplicated urinary tract infection

Background and Aims:

The study was undertaken to assess the empirical antibiotic prescription in uncomplicated urinary tract infection (UTI) cases and compare them with the Indian council of medical research (ICMR) 2017 guidelines on antimicrobial use. The objective of this study was to study the compliance of prescriptions for uncomplicated UTI with respect to the guidelines recommended by ICMR and assess the success rates in terms of mean days taken to achieve symptomatic relief.

Methodology:

This study was conducted on patients (of age >16 years) presenting to the Urology, Medicine and Gynecology OPD with complaints of uncomplicated UTI over two months. Descriptive statistics were used to assess the results.

Results:

A total of 115 UTI patients were enrolled and followed up for symptomatic relief. 67 (58.26%) patients were prescribed antibiotics, the preferred ones were levofloxacin 500 mg O.D. in 24 (35.82%), nitrofurantoin 100 mg B.D. in 21 (31.34%) and levofloxacin 750 mg O.D. in 6 (8.95%) patients for a mean duration of 7.83 ± 2.37, 7.52 ± 2.68 and 4.33 ± 1.03 days respectively. Symptomatic relief was seen in 6 (25%), 15 (71.42%) and 4 (66.67%) cases within 5 ± 0.63 days, 4.2 ± 2.11 days and 4.5 ± 1 days, respectively.

Discussion:

23 (34.32%) prescriptions based on choice of empirical antibiotic and 17 (25.37%) prescriptions based on both choice of antibiotic and duration of therapy were found to be compliant with the (ICMR) -2017 guidelines. Results show decreased efficacy of co-trimoxazole and ciprofloxacin as empirical therapy for acute uncomplicated UTI.

The challenges of estimating the human global burden of disease of antimicrobial resistant bacteria

Estimating the contribution of antimicrobial resistance (AMR) to global mortality and healthcare costs enables evaluation of interventions, informs policy decisions on resource allocation, and drives research priorities. However assembling the high quality, patient-level data required for global estimates is challenging. Capacity for accurate microbiology culture and antimicrobial susceptibility testing is woefully neglected in low and middle-income countries, and further surveillance and research on community antimicrobial usage, bias in blood culture sampling, and the contribution of co-morbidities such as diabetes is essential. International collaboration between governments, policy makers, academics, microbiologists, front-line clinicians, veterinarians, the food and agriculture industry and the public is critical to understand and tackle AMR.

Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries: Progress and Challenges in Eight South Asian and Southeast Asian Countries

Antimicrobial resistance (AMR) is a serious global health threat and is predicted to cause significant health and economic impacts, particularly in low- and middle-income countries (LMICs). AMR surveillance is critical in LMICs due to high burden of bacterial infections; however, conducting AMR surveillance in resource-limited settings is constrained by poorly functioning health systems, scarce financial resources, and lack of skilled personnel. In 2015, the United Nations World Health Assembly endorsed the World Health Organization's Global Action Plan to tackle AMR; thus, several countries are striving to improve their AMR surveillance capacity, including making significant investments and establishing and expanding surveillance networks. Initial data generated from AMR surveillance networks in LMICs suggest the high prevalence of resistance, but these data exhibit several shortcomings, such as a lack of representativeness, lack of standardized laboratory practices, and underutilization of microbiology services. Despite significant progress, AMR surveillance networks in LMICs face several challenges in expansion and sustainability due to limited financial resources and technical capacity. This review summarizes the existing health infrastructure affecting the establishment of AMR surveillance programs, the burden of bacterial infections demonstrating the need for AMR surveillance, and current progress and challenges in AMR surveillance efforts in eight South and Southeast Asian countries.

Structure-based functional fitness analyses of carbapenemase variants identified among pathogenic carbapenem-resistant Gram-negative bacteria

Carbapenemase-mediated carbapenem resistance is a major public health concerns worldwide. In the present study, prevalence of circulating carbapenemases was estimated among carbapenem-resistant clinical isolates using PCR and sequencing. Diameters of zone of inhibition (ZDs) were compared for imipenem, meropenem and ertapenem among single carbapenemase producing isolates. Structure-based functional fitness of those carbapenemases was predicted through several in silico analyses. Approximately, 63.76% isolates demonstrated carbapenem resistance, of which 39.13% harboured carbapenemases like bla_NDM-1 (33.23%), bla_NDM-1-like (0.31%), bla_VIM-2 (4.35%), bla_KPC-2 (4.04%), bla_OXA-181 (6.85%), bla_OXA-23 (16.50%), bla_OXA-69 (3.88%), bla_OXA-66 (2.91%) and bla_OXA-104 (1.94%). Omega values indicated selection pressure over bla_OXA-69, bla_OXA-66 and bla_OXA-104. Protein structural dynamics predicted NDM-1 and KPC-2 to have the highest and least flexibility, indicating differences in β-lactam binding and catalytic efficiency. Increased requirement of free folding energy, improved solvent accessibility and decreased melting temperatures among NDM-1-like, OXA-181, OXA-66, OXA-69 and OXA-104 predicted functional improvement over their ancestral variants. NDM-1-like carbapenemases demonstrated improvement in binding stability, affinity and catalysis of meropenem than that of NDM-1. Catalytic activity of imipenem was predicted to improve among OXA-181, which could be correlated with more than 1.5 folds smaller ZDs around imipenem disc, than that of meropenem/ertapenem, among OXA-181 producing isolates. However, OXA-66 indicated greater binding stability and affinity for imipenem and meropenem. This study indicated structural/functional convergence as well as divergence among several carbapenemase variants and provided useful insights into carbapenemase-mediated carbapenem resistance that might help in identifying appropriate treatment regimen for bacterial infections.

Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study

Background & objectives:

The models for implementation of antibiotic stewardship programme (ASP) in the acute care settings of developing countries are lacking. In most of the hospitals, patient turnover is high and a proper system for recording antibiotic-related information and tracking hospital-acquired infections is not in place. This pilot study was conducted in a tertiary care teaching hospital in north India to assess the feasibility of implementation of an ASP in a Medicine unit and to evaluate the effect of implementation as per the criteria applicable in this set up.

Methods:

A pre-post-quasi-experimental non-randomized study was conducted in two phases. In the first phase, current practices in the Medicine wards were observed. In the second phase, the ASP was implemented in a single Medicine unit, along with prospective audit and feedback, tracking of the process, as well as outcome measures. Patient risk stratification, blood culture on day one, day 3 bundle, dose optimization, de-escalation and intravenous to oral conversion of antibiotics were the key elements focused upon.

Results:

There was a significant improvement in the appropriateness of antibiotic prescription (66 vs. 86%, P<0.001) and reduction in the mean number of antibiotics used per person (4.41 vs. 3.86, P<0.05) along with decrease in the duration of hospital stay (17 vs. 14 days, P<0.05). There was a significant improvement in sending of blood cultures on day one during the stewardship phase (P<0.001).

Interpretation & conclusions:

The ASP approach used in our pilot study may be feasible and beneficial. However, it needs further confirmation in other settings and on a large scale.