Correlations between Income inequality and antimicrobial resistance

Acute Respiratory Infection Hubs: A Service Model with Potential to Optimise Infection Management

Patients with acute respiratory infections (ARI)-including those with upper and lower respiratory infections from both bacterial and viral pathogens-are one of the most common reasons for acute deterioration, with large numbers of potentially avoidable hospital admissions. The acute respiratory infection hubs model was developed to improve healthcare access and quality of care for these patients. This article outlines the implementation of this model and its potential impacts in a number of areas. Firstly, by improving healthcare access for patients with respiratory infections by increasing the capacity for assessment in community and non-emergency department settings and also by providing flexible response to surges in demand and reducing primary and secondary care demand. Secondly, by optimising infection management (including the use of point-of-care diagnostics and standardised best practise guidance to improve appropriate antimicrobial usage) and reducing nosocomial transmission by cohorting those with suspected ARI away from those with non-infective presentations. Thirdly, by addressing healthcare inequalities; in areas of greatest deprivation, acute respiratory infection is strongly linked with increased emergency department attendance. Fourthly, by reducing the National Health Service's (NHS) carbon footprint. Finally, by providing a wonderful opportunity to gather community infection management data to enable large-scale evaluation and research.

Tracheostomized children tracheal colonization and antibiotic resistance profile - A STROBE analysis

AIMS

To verify the prevalence of Potentially pathogenic bacteria (PPB) and their antimicrobial resistance profile in tracheal aspirates of children with tracheostomy and compare it to clinical data.

METHODS

A cross-sectional study was conducted in patients aged 0-18 years who all underwent tracheostomy cannula change (TCC) performed by the Otolaryngology Unit at Hospital de Clínicas de Porto Alegre, Brazil, between October, 2017 and December, 2018. Patients were submitted, at the time of TCC, to a tracheal aspirate through the tracheostomy and secretion was sent to microbiological analysis and antimicrobial susceptibility testing. Clinical data were evaluated through available patients' electronic medical records.

RESULTS

Forty-four patients had their tracheostomy aspirate cultured and all but one presented PPB growth (97.7%). Median age was 3 years-old. Pseudomonas aeruginosa was the most prevalent bacteria (56.9%) and it was resistant to gentamycin, amikacin and cefepime in 36%, 28% and 12% of the culture tests, respectively. P. aeruginosa resistance to gentamycin and to cefepime suggested an association with the number of antibiotic classes used in the 12 months before enrollment (both p=0.04) and with 2 or more hospital admissions in the same period (p=0.03 and p=0.02, respectively). Staphylococcus aureus was isolated in 9.1% and there was no MRSA.

CONCLUSION

It was found a 97.7% prevalence of PPB in the cultured aspirates; the most prevalent bacterium was P. aeruginosa and there was no MRSA identification. Data suggest an association between P. aeruginosa antimicrobial resistance with previous use of antibiotic therapy.

Effectiveness of front line and emerging fungal disease prevention and control interventions and opportunities to address appropriate eco-sustainable solutions

Fungal pathogens contribute to significant disease burden globally; however, the fact that fungi are eukaryotes has greatly complicated their role in fungal-mediated infections and alleviation. Antifungal drugs are often toxic to host cells and there is increasing evidence of adaptive resistance in animals and humans. Existing fungal diagnostic and treatment regimens have limitations that has contributed to the alarming high mortality rates and prolonged morbidity seen in immunocompromised cohorts caused by opportunistic invasive infections as evidenced during HIV and COVID-19 pandemics. There is a need to develop real-time monitoring and diagnostic methods for fungal pathogens and to create a greater awareness as to the contribution of fungal pathogens in disease causation. Greater information is required on the appropriate selection and dose of antifungal drugs including factors governing resistance where there is commensurate need to discover more appropriate and effective solutions. Popular azole fungal drugs are widely detected in surface water and sediment due to incomplete removal in wastewater treatment plants where they are resistant to microbial degradation and may cause toxic effects on aquatic organisms such as algae and fish. UV has limited effectiveness in destruction of anti-fungal drugs where there is increased interest in the combination approaches such as novel use of pulsed-plasma gas-discharge technologies for environmental waste management. There is growing interest in developing alternative and complementary green eco-biocides and disinfection innovation. Fungi present challenges for cleaning, disinfection and sterilization of reusable medical devices such as endoscopes where they (example, Aspergillus and Candida species) can be protected when harboured in build-up biofilm from lethal processing. Information on the efficacy of established disinfection and sterilization technologies to address fungal pathogens including bottleneck areas that present high risk to patients is lacking. There is a need to address risk mitigation and modelling to inform efficacy of appropriate intervention technologies that must consider all contributing factors where there is potential to adopt digital technologies to enable real-time analysis of big data, such as use of artificial intelligence and machine learning. International consensus on standardised protocols for developing and reporting on appropriate alternative eco-solutions must be reached, particularly in order to address fungi with increasing drug resistance where research and innovation can be enabled using a One Health approach.

High prevalence and risk factors of multiple antibiotic resistance in patients who fail first-line Helicobacter pylori therapy in southern China: a municipality-wide, multicentre, prospective cohort study

BACKGROUND

We aimed to study the prevalence of secondary antibiotic resistance of Helicobacter pylori in southern China and its risk factors, particularly geographical and socio-economic factors.

METHODS

This was a municipality-wide, multicentre, prospective cohort study involving five major hospitals. Patients aged ≥18 years who failed first-line bismuth-based quadruple anti-H. pylori therapy between September 2016 and February 2018 were recruited. Participants underwent upper gastrointestinal endoscopy with biopsy from the antrum and body for H. pylori culture and antimicrobial susceptibility testing for six antibiotics (clarithromycin, levofloxacin, metronidazole, amoxicillin, tetracycline and furazolidone). Patients with failure of H. pylori culture were excluded. Participants completed a questionnaire profiling 22 potential risk factors of H. pylori infection and antibiotic resistance, including medical, social, household and birthplace factors.

RESULTS

A total of 1113 patients failed first-line therapy, with successful H. pylori culture in 791 (71.1%) [male = 433 (54.7%); median age = 43 years]. Secondary resistance rates of dual antibiotics (clarithromycin + metronidazole and levofloxacin + metronidazole) and triple antibiotics (clarithromycin + levofloxacin + metronidazole) were 34.0%, 38.7% and 17.8%, respectively. Risk factors for clarithromycin + metronidazole resistance were history of ≥2 courses of H. pylori therapies [adjusted OR (aOR) = 1.71; 95% CI = 1.17-2.54], ≥3 household members (aOR = 2.00; 95% CI = 1.07-3.90) and family history of gastric cancer (aOR = 1.85; 95% CI = 1.18-2.85). Risk factors for levofloxacin + metronidazole resistance were age ≥40 years (aOR = 1.94; 95% CI = 1.37-2.75), lower gross domestic product per capita (aOR = 0.29; 95% CI = 0.10-0.80) and higher number of doctors/10 000 population (aOR = 1.59; 95% CI = 1.07-2.39). A higher human development index was of borderline significance (aOR = 2.79; 95% CI = 0.97-8.70).

CONCLUSIONS

The rates of secondary resistance of H. pylori to multiple antibiotics were high in southern China. Certain population-level risk factors were associated with levofloxacin + metronidazole resistance.

Antibiotic-Resistant Acinetobacter baumannii in Low-Income Countries (2000-2020): Twenty-One Years and Still below the Radar, Is It Not There or Can They Not Afford to Look for It?

Acinetobacter baumannii is an emerging pathogen, and over the last three decades it has proven to be particularly difficult to treat by healthcare services. It is now regarded as a formidable infectious agent with a genetic setup for prompt development of resistance to most of the available antimicrobial agents. Yet, it is noticed that there is a gap in the literature covering this pathogen especially in countries with limited resources. In this review, we provide a comprehensive updated overview of the available data about A. baumannii, the multi-drug resistant (MDR) phenotype spread, carbapenem-resistance, and the associated genetic resistance determinants in low-income countries (LIICs) since the beginning of the 21st century. The coverage included three major databases; PubMed, Scopus, and Web of Science. Only 52 studies were found to be relevant covering only 18 out of the 29 countries included in the LIC group. Studies about two countries, Syria and Ethiopia, contributed ~40% of the studies. Overall, the survey revealed a wide spread of MDR and alarming carbapenem-resistance profiles. Yet, the total number of studies is still very low compared to those reported about countries with larger economies. Accordingly, a discussion about possible reasons and recommendations to address the issue is presented. In conclusion, our analyses indicated that the reported studies of A. baumannii in the LICs is far below the expected numbers based on the prevailing circumstances in these countries. Lack of proper surveillance systems due to inadequate financial resources could be a major contributor to these findings.

Gross national income and antibiotic resistance in invasive isolates: analysis of the top-ranked antibiotic-resistant bacteria on the 2017 WHO priority list

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.

The Antimicrobial Resistance Crisis: How Neoliberalism Helps Microbes Dodge Our Drugs

The urgent public health threat of antimicrobial resistance (AMR) has received much attention from the world's most important health agencies and national governmental organizations. However, despite large investments being allocated to strategizing national and international plans for addressing this public health problem, the incidence of untreatable, antimicrobial-resistant diseases continues to rise in many nations. To avoid returning to a society in which common infections once again become deadly, one must consider the often-ignored root causes driving inappropriate behaviors relating to antimicrobial use, such as the history of antimicrobial drug development, the effects of commodifying health-related services, and the rise in social inequalities. By employing the lens of political economy to analyze the phenomenon of AMR on national and international scales, it is found that the acceptance of neoliberalism as a governing ideology by authorities is hindering our ability to globally combat AMR through the depoliticization of issues that require political intervention to stimulate change. Differences in level of AMR and approaches to pharmaceutical governance between social democratic and liberal welfare states provide validity to this hypothesis.

A Capability Perspective on Antibiotic Resistance, Inequality, and Child Development

Nussbaum’s capability theory by drawing attention to multiple determinants of wellbeing provides a rich and relevant evaluative space for framing antibiotic resistance. I consider the implications of antibiotic resistance for child development and adult capabilities. There are common risk factors for childhood growth stunting and the spread of infectious diseases in both antibiotic sensitive and resistant forms. The interaction between infectious diseases, antibiotic resistance and growth stunting illustrates a clustering of disadvantage. The control of antibiotic resistance requires wide-ranging cooperative action. Cooperation is predicated on an expectation of equitable access to effective antibiotics. This expectation is confounded by inequality both in access to antibiotics, and in the risk that available antibiotics will be ineffective. Securing child development (and adult capabilities) requires that inequalities both in access to antibiotics and in risk factors for the dissemination and transmission of antibiotic resistance are addressed. Inequality undermines the cooperative activity that is control of infectious diseases and compounds the threat to the securing of capabilities that arises from antibiotic resistance.

Who is willing to stay sick for the collective? - Individual characteristics, experience, and trust

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We study attitudes towards antibiotics and antibiotic resistance.

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We analyze results from a novel web-survey of Swedish citizens (n = 1906).

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Acceptability of doctor's decision not to prescribe antibiotics was found to be large.

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Trust in the healthcare sector is linked to acceptability of doctor's decision.

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Concern about antibiotic resistance is linked to willingness to limit antibiotic use.

Correlation of antimicrobial prescription rate and county income in medicare part D

The objective of this study was to examine whether patient income has an impact on likelihood of being prescribed an antimicrobial agent at the county level. A better understanding of factors that influence antimicrobial prescription is needed to efficiently mitigate rates of antimicrobial agents prescribed.This cross-sectional study used data from two publicly available datasets. The 2015 Medicare Part D PUF data quantifies the antimicrobial prescription rate at the county level and data from US Census Bureau provides information on socioeconomic status at the county level.At the county level, we explained 48% of the variation in antimicrobial prescriptions by socioeconomic status, age, gender, and race. More specifically, socioeconomic status accounted for 26% of the variation in antimicrobial rate and as income increased, correlation with antimicrobial prescription rate trended down.We determined patient income and other sociodemographics to influence the prescription of antimicrobial agents. Interventions should consider these factors to effectively evaluate antimicrobial prescription methods. Findings from this study can help guide intervention efforts which aim to minimize the number of inappropriate antimicrobials prescribed, such as antimicrobial stewardship programs. Effective interventions have the capability of decreasing levels of inappropriate antimicrobials prescribed and prevent future cases of resistance.

Predictors and trajectories of antibiotic consumption in 22 EU countries: Findings from a time series analysis (2000-2014)

BACKGROUND

This study analyzes the trajectories of antibiotic consumption using different indicators of patients' socioeconomic status, category and age-group of physicians.

METHODS

This study uses a pooled, cross-sectional, time series analysis. The data focus on 22 European countries from 2000 to 2014 and were obtained from the European Center for Disease and Control, Organization for Economic Co-operation and Development, Eurostat and Global Economic Monitor.

RESULTS

There are large variations in community and hospital use of antibiotics in European countries, and the consumption of antibiotics has remained stable over the years. This applies to the community (b = 0.07, p = 0.267, 95% -0.06, 0.19, b-squared <0.01, p = 0.813, 95% = -0.01, 0.02) as well as the hospital sector (b = -0.02; p = 0.450; CI 95% = -0.06, 0.03; b-squared <0.01; p = 0.396; CI95% = > -0.01, <0.01). Some socioeconomic variables, such as level of education, income, Gini index and unemployment, are not related to the rate of antibiotic use. The age-group of physicians and general practitioners is associated with the use of antibiotics in the hospital. An increase in the proportion of young doctors (<45 years old) leads to a significant increase in antibiotics consumption, and as the percentage of generalist practitioners increases, there use of antibiotics in hospitals decreases by 0.04 DDD/1000 inhabitants.

CONCLUSIONS

Understanding that age-groups and categories (general/specialist practitioners) of physicians may predict antibiotic consumption is potentially useful in defining more effective health care policies to reduce the inappropriate antibiotic use while promoting rational use.

Antibiotic Resistance of Helicobacter pylori Among Male United States Veterans

BACKGROUND & AIMS

The most recent information published on resistance of Helicobacter pylori to antibiotics in a large population in the United States is more than 10 years old. We assessed the susceptibility of H pylori to antibiotics among patients in a large metropolitan hospital, as well as demographic, clinical, and lifestyle factors associated with antimicrobial resistance.

METHODS

We performed a cross-sectional study of a random sample of 656 patients (90.2% men) from a cohort of 1559 undergoing esophagogastroduodenoscopy with collection of gastric biopsies from 2009 through 2013 at the Houston Veterans Affairs Medical Center. We performed culture analyses of gastric tissues to detect H pylori. The minimum inhibitory concentrations of amoxicillin, clarithromycin, metronidazole, levofloxacin, and tetracycline were determined by the Epsilometer test. Logistic regression analysis was performed to estimate the association between risk factors and antimicrobial resistance.

RESULTS

Biopsies from 135 subjects (20.6%) tested positive for H pylori; 128 of these were from men (94.8%). Only 65 strains were susceptible to all 5 antibiotics. The prevalence of resistance to levofloxacin was 31.3% (95% confidence interval [CI], 23.1%-39.4%), to metronidazole it was 20.3% (95% CI, 13.2%-27.4%), to clarithromycin it was 16.4% (95% CI, 9.9%-22.9%), and to tetracycline it was 0.8% (95% CI, 0.0%-2.3%). No isolate was resistant to amoxicillin. Clarithromycin resistance increased from 9.1% in 2009-2010 to 24.2% in 2011-2013. In multivariate analysis, prior treatment of H pylori infection and use of fluoroquinolones were significantly associated with clarithromycin and levofloxacin resistance, respectively.

CONCLUSIONS

H pylori resistance to clarithromycin increased between 2009 and 2013; resistance to metronidazole remains high in infected men in the United States. The high frequency of resistance to levofloxacin is a new and concerning finding.

Living conditions are associated with increased antibiotic resistance in community isolates of Escherichia coli

OBJECTIVES

The objective of this study was to measure the associations between domains of deprivation and antibiotic resistance of Escherichia coli.

METHODS

Routine surveillance data for antibiotic susceptibility of E. coli isolates were obtained from urine specimens taken from patients presenting with suspected urinary tract infection in 2010-12 to healthcare practitioners based in the community in Leeds and Bradford. Eight antibiotics were included in the analyses. Postcodes were linked to lower super output areas (average populations of 1500). The 2010 Indices of Deprivation were used as neighbourhood characteristics for each lower super output area. Multilevel logistic regression models were used to estimate the independent effect of structural components on the odds of resistance to each antibiotic.

RESULTS

With respect to living conditions, residence in the most-deprived areas compared with the least-deprived areas was associated with increased odds of antibiotic resistance for all eight antibiotics analysed. The magnitude of these associations included an OR of 2.04 (95% CI 1.03-3.07) for cefalexin, 2.16 (95% CI 1.16-4.05) for ciprofloxacin, 2.47 (95% CI 1.08-5.66) for nitrofurantoin and 1.33 (95% CI 1.07-1.75) for trimethoprim.

CONCLUSIONS

Social deprivation in the form of living conditions is associated with increased antibiotic resistance for E. coli. This evidence suggests there is a need for further individual-level studies to explore the potential mechanism for these associations.

Risk factors for and impact of carbapenem-resistant Acinetobacter baumannii colonization and infection: matched case-control study

The objective of this investigation was to identify risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) and its association with mortality. A population-based matched case-control study using the computerized database of Clalit Health Services (CHS) in the period between 2007 and 2012 was conducted. Hospitalized patients with CRAB colonization or infection were compared to hospitalized patients without evidence of A. baumannii, matched by age, ward of hospitalization, season, Charlson score, and length of hospitalization. Risk factors for CRAB isolation were searched for using multivariate analysis. Association of CRAB and other risk factors with mortality were assessed in the cohort. A total of 1190 patients with CRAB were matched to 1190 patients without CRAB. Low socioeconomic status was independently associated with CRAB isolation and CRAB bacteremia [odds ratio 2.18, 95% confidence interval (CI) 1.02-5]. Other risk factors were invasive procedures and bacteremia with other pathogens prior to CRAB isolation, and various comorbidities. Among all patients, CRAB isolation was independently associated with increased mortality (hazard ratio 2.33, 95% CI 2.08-2.6). Socioeconomic status is associated with health outcomes. Our population-based study revealed an almost doubled risk for CRAB in patients at lower socioeconomic status and an association with healthcare exposure. CRAB was associated with mortality and might become a risk indicator for complex morbidity and mortality.

Antimicrobial resistance: risk associated with antibiotic overuse and initiatives to reduce the problem

Antimicrobial resistance is a global public health challenge, which has accelerated by the overuse of antibiotics worldwide. Increased antimicrobial resistance is the cause of severe infections, complications, longer hospital stays and increased mortality. Overprescribing of antibiotics is associated with an increased risk of adverse effects, more frequent re-attendance and increased medicalization of self-limiting conditions. Antibiotic overprescribing is a particular problem in primary care, where viruses cause most infections. About 90% of all antibiotic prescriptions are issued by general practitioners, and respiratory tract infections are the leading reason for prescribing. Multifaceted interventions to reduce overuse of antibiotics have been found to be effective and better than single initiatives. Interventions should encompass the enforcement of the policy of prohibiting the over-the-counter sale of antibiotics, the use of antimicrobial stewardship programmes, the active participation of clinicians in audits, the utilization of valid rapid point-of-care tests, the promotion of delayed antibiotic prescribing strategies, the enhancement of communication skills with patients with the aid of information brochures and the performance of more pragmatic studies in primary care with outcomes that are of clinicians' interest, such as complications and clinical outcomes.

High prevalence of Staphylococcus aureus and methicillin-resistant S. aureus colonization among healthy children attending public daycare centers in informal settlements in a large urban center in Brazil

BACKGROUND

In the past decade methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly prevalent in community settings. Attending a daycare center (DCC) is a known risk factor for colonization with MRSA. Brazil operates free, public DCCs for low-income families, some of which are located in census tracts defined by the Brazilian Census Bureau as informal settlements (aglomerados subnormais, AGSN). Physical and demographic characteristics of AGSNs suggest that S. aureus colonization prevalence would be higher, but little is known about the prevalence of MRSA in these settings.

METHODS

We conducted a cross-sectional study to assess risk factors for S. aureus and MRSA colonization among children attending DCCs located in AGSN vs non-AGSN. Nasal swabs were collected from children aged three months to six years in 23 public DCCs in Niterói, Brazil between August 2011 and October 2012.

RESULTS

Of 500 children enrolled in the study, 240 (48%) were colonized with S. aureus and 31 (6.2%) were colonized with MRSA. Children attending DCCs in AGSNs were 2.32 times more likely to be colonized with S. aureus (95% CI: 1.32, 4.08), and 3.27 times more likely to be colonized with MRSA than children attending non-AGSN DCCs (95% CI: 1.52, 7.01), adjusted for confounding variables.

CONCLUSION

S. aureus and MRSA colonization prevalence among children attending DCCs in informal settlement census tracts was higher than previously reported in healthy pre-school children in Latin America. Our data suggest that transmission may occur more frequently in DCCs rather than at home, highlighting the importance of DCCs in AGSNs as potential MRSA reservoirs. This finding underscores the importance of local epidemiologic surveillance in vulnerable AGSN communities.