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Kakaraskoska Boceska B, Vilken T, Xavier BB, Kostyanev T, Lin Q, Lammens C, Ellis S, O'Brien S, da Costa RMA, Cook A, Russell N, Bielicki J, Riddell A, Stohr W, Walker AS, Berezin EN, Roilides E, De Luca M, Romani L, Ballot D, Dramowski A, Wadula J, Lochindarat S, Boonkasidecha S, Namiiro F, Ngoc HTB, Tran MD, Cressey TR, Preedisripipat K, Berkley JA, Musyimi R, Zarras C, Nana T, Whitelaw A, da Silva CB, Jaglal P, Ssengooba W, Saha SK, Islam MS, Mussi-Pinhata MM, Carvalheiro CG, Piddock LJV, Heath PT, Malhotra-Kumar S, Sharland M, Glupczynski Y, Goossens H. Assessment of three antibiotic combination regimens against Gram-negative bacteria causing neonatal sepsis in low- and middle-income countries. Nat Commun 2024; 15:3947. [PMID: 38729951 PMCID: PMC11087563 DOI: 10.1038/s41467-024-48296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Gram-negative bacteria (GNB) are a major cause of neonatal sepsis in low- and middle-income countries (LMICs). Although the World Health Organization (WHO) reports that over 80% of these sepsis deaths could be prevented through improved treatment, the efficacy of the currently recommended first- and second-line treatment regimens for this condition is increasingly affected by high rates of drug resistance. Here we assess three well known antibiotics, fosfomycin, flomoxef and amikacin, in combination as potential antibiotic treatment regimens by investigating the drug resistance and genetic profiles of commonly isolated GNB causing neonatal sepsis in LMICs. The five most prevalent bacterial isolates in the NeoOBS study (NCT03721302) are Klebsiella pneumoniae, Acinetobacter baumannii, E. coli, Serratia marcescens and Enterobacter cloacae complex. Among these isolates, high levels of ESBL and carbapenemase encoding genes are detected along with resistance to ampicillin, gentamicin and cefotaxime, the current WHO recommended empiric regimens. The three new combinations show excellent in vitro activity against ESBL-producing K. pneumoniae and E. coli isolates. Our data should further inform and support the clinical evaluation of these three antibiotic combinations for the treatment of neonatal sepsis in areas with high rates of multidrug-resistant Gram-negative bacteria.
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Affiliation(s)
- Biljana Kakaraskoska Boceska
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium.
| | - Tuba Vilken
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Basil Britto Xavier
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Department of Medical Microbiology and Infection Control, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
- Research Group for Global Capacity Building, National Food Institute, Technical University of Denmark, Kgs, Lyngby, Denmark
| | - Qiang Lin
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Christine Lammens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Seamus O'Brien
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | | | - Aislinn Cook
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
| | - Neal Russell
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
| | - Julia Bielicki
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
- Paediatric Research Centre, University of Basel Children's Hospital, Basel, Switzerland
| | - Amy Riddell
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
| | - Wolfgang Stohr
- MRC Clinical Trials Unit, University College London, London, UK
| | | | | | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Dept Paediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Daynia Ballot
- Department of Pediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jeannette Wadula
- Department of Clinical Microbiology & Infectious Diseases, National Health Laboratory Services, CH Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Flavia Namiiro
- Mulago Specialized Women's and Neonatal Hospital, Kampala, Uganda
| | | | | | - Tim R Cressey
- AMS-PHPT Research Collaboration, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | | | - James A Berkley
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Robert Musyimi
- Department of Microbiology, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Charalampos Zarras
- Microbiology Department, Hippokration General Hospital, Thessaloniki, Greece
| | - Trusha Nana
- Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Microbiology Laboratory, National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Cely Barreto da Silva
- Infection Control and Prevention Service, Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Prenika Jaglal
- Department of Clinical Microbiology & Infectious Diseases, National Health Laboratory Services, CH Baragwanath Academic Hospital, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Willy Ssengooba
- Makerere University, Department of Medical Microbiology, Kampala, Uganda
| | - Samir K Saha
- Child Health Research Foundation (CHRF), Dhaka, Bangladesh
| | | | | | | | - Laura J V Piddock
- Global Antibiotic Research and Development Partnership (GARDP), Geneva, Switzerland
| | - Paul T Heath
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
| | - Surbhi Malhotra-Kumar
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Michael Sharland
- Centre for Neonatal and Pediatric Infection, Institute for Infection & Immunity, St. George's University of London, London, UK
| | - Youri Glupczynski
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium.
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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Baltogianni M, Dermitzaki N, Kosmeri C, Serbis A, Balomenou F, Giapros V. Reintroduction of Legacy Antibiotics in Neonatal Sepsis: The Special Role of Fosfomycin and Colistin. Antibiotics (Basel) 2024; 13:333. [PMID: 38667009 PMCID: PMC11047481 DOI: 10.3390/antibiotics13040333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/29/2024] Open
Abstract
Neonatal sepsis is a leading cause of morbidity and mortality in neonates, particularly in low- and middle-income countries. The emergence of antimicrobial resistance is a rapidly growing global problem. A significant proportion of the pathogens that commonly cause neonatal sepsis are resistant to multiple antibiotics. Therefore, for the empirical treatment of neonatal sepsis, the repurposing of older antibiotics that are effective against multidrug-resistant pathogens is being investigated. This review aims to provide an overview of current research and experience using the repurposed antibiotics colistin and fosfomycin for the empirical treatment of neonatal sepsis. Based on current knowledge, colistin and fosfomycin may be potentially helpful for the empirical treatment of sepsis in neonates due to their efficacy against a wide range of pathogens and acceptable safety profile.
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Affiliation(s)
- Maria Baltogianni
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Niki Dermitzaki
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Chrysoula Kosmeri
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (C.K.); (A.S.)
| | - Anastasios Serbis
- Department of Paediatrics, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (C.K.); (A.S.)
| | - Foteini Balomenou
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
| | - Vasileios Giapros
- Neonatal Intensive Care Unit, School of Medicine, University of Ioannina, 451 10 Ioannina, Greece; (M.B.); (N.D.); (F.B.)
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Styczynski A, Amin MB, Hoque KI, Parveen S, Md Pervez AF, Zeba D, Akhter A, Pitchik H, Islam MA, Hossain MI, Saha SR, Gurley ES, Luby S. Perinatal colonization with extended-spectrum beta-lactamase-producing and carbapenem-resistant Gram-negative bacteria: a hospital-based cohort study. Antimicrob Resist Infect Control 2024; 13:13. [PMID: 38281974 PMCID: PMC10823664 DOI: 10.1186/s13756-024-01366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a growing global health threat that contributes to substantial neonatal mortality. Bangladesh has reported some of the highest rates of AMR among bacteria causing neonatal sepsis. As AMR colonization among newborns can predispose to infection with these bacteria, we aimed to characterize the frequency of and risk factors for colonization of mothers and newborns during hospitalization for delivery. METHODS We enrolled pregnant women presenting for delivery to a tertiary care hospital in Faridpur, Bangladesh. We collected vaginal and rectal swabs from mothers pre- and post-delivery, rectal swabs from newborns, and swabs from the hospital environment. Swabs were plated on agars selective for extended-spectrum-beta-lactamase producing bacteria (ESBL-PB) and carbapenem-resistant bacteria (CRB). We performed logistic regression to determine factors associated with ESBL-PB/CRB colonization. RESULTS We enrolled 177 women and their newborns during February-October 2020. Prior to delivery, 77% of mothers were colonized with ESBL-PB and 15% with CRB. 79% of women underwent cesarean deliveries (C-section). 98% of women received antibiotics. Following delivery, 98% of mothers and 89% of newborns were colonized with ESBL-PB and 89% of mothers and 72% of newborns with CRB. Of 290 environmental samples, 77% were positive for ESBL-PB and 69% for CRB. Maternal pre-delivery colonization was associated with hospitalization during pregnancy (RR for ESBL-PB 1.24, 95% CI 1.10-1.40; CRB 2.46, 95% CI 1.39-4.37). Maternal post-delivery and newborn colonization were associated with C-section (RR for maternal CRB 1.31, 95% CI 1.08-1.59; newborn ESBL-PB 1.34, 95% CI 1.09-1.64; newborn CRB 1.73, 95% CI 1.20-2.47). CONCLUSIONS In this study, we observed high rates of colonization with ESBL-PB/CRB among mothers and newborns, with pre-delivery colonization linked to prior healthcare exposure. Our results demonstrate this trend may be driven by intense use of antibiotics, frequent C-sections, and a contaminated hospital environment. These findings highlight that greater attention should be given to the use of perinatal antibiotics, improved surgical stewardship for C-sections, and infection prevention practices in healthcare settings to reduce the high prevalence of colonization with AMR organisms.
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Affiliation(s)
- Ashley Styczynski
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, USA.
| | - Mohammed Badrul Amin
- Laboratory of Food Safety and One Health, Laboratory Sciences and Services Division, icddr,b, Dhaka, Bangladesh
| | - Kazi Injamamul Hoque
- Laboratory of Food Safety and One Health, Laboratory Sciences and Services Division, icddr,b, Dhaka, Bangladesh
| | - Shahana Parveen
- Programme on Emerging Infections, icddr,b, Dhaka, Bangladesh
| | - Abu Faisal Md Pervez
- Department of Pediatrics, Bangabandhu Sheikh Mujib Medical College, Faridpur, Bangladesh
| | - Dilruba Zeba
- Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical College, Faridpur, Bangladesh
| | - Akhi Akhter
- Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical College, Faridpur, Bangladesh
| | - Helen Pitchik
- Division of Epidemiology, School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Mohammad Aminul Islam
- Paul G. Allen School for Global Health, Washington State University, Pullman, WA, USA
| | - Muhammed Iqbal Hossain
- Laboratory of Food Safety and One Health, Laboratory Sciences and Services Division, icddr,b, Dhaka, Bangladesh
| | - Sumita Rani Saha
- Laboratory of Food Safety and One Health, Laboratory Sciences and Services Division, icddr,b, Dhaka, Bangladesh
| | - Emily S Gurley
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Stephen Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, USA
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Kumar J, Soni PK, Angrup A, Saini SS, Sundaram V, Mukhopadhyay K, Dutta S, Kumar P. Antimicrobial Resistance Patterns Among Neonates Referred to Pediatric Emergency in North India: A Prospective Cohort Study. Pediatr Infect Dis J 2023; 42:1007-1011. [PMID: 37523584 DOI: 10.1097/inf.0000000000004056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
BACKGROUND Sepsis is a leading cause of neonatal mortality worldwide, with a disproportionately high burden in low-income and middle-income countries. There is limited prospective data on microorganism profiles and antimicrobial resistance (AMR) in outborn newborns referred to pediatric emergency in developing countries. We aimed to assess the pathogen profile and AMR patterns in outborn neonates referred to the pediatric emergency at a tertiary care center. METHODS In this prospective cohort study, we enrolled neonates with suspected sepsis and sent blood or cerebrospinal fluid cultures. Neonates were followed up daily until discharge or death. The isolated organisms were identified and tested for antimicrobial susceptibility. Standard definitions were used to define multidrug resistance. RESULTS Between January 1, 2020, and December 31, 2020, 1072 outborn neonates with suspected sepsis were enrolled. The rate of proven sepsis was 223.6 (95% CI:198.7-248.4) per 1000 infants. Gram-negative sepsis was the most common (n = 107,10%), followed by gram-positive sepsis (n = 81,7.6%) and fungal sepsis (n = 67,6.3%). Coagulase-negative staphylococci (n = 69), Candida spp. (n = 68), Klebsiella spp. (n = 55), Acinetobacter spp . (n = 31) and Escherichia coli (n = 9) were the most common pathogens. Over two-thirds (68.6%) of pathogens were multidrug resistance, with an alarming prevalence in Klebsiella spp. (33/53, 62%), Acinetobacter spp. (25/30, 83%) and coagulase-negative staphylococci (54/66, 82%). In total, 124 (11.6%) neonates died in the hospital (13.3% of proven cases and 11.1% of culture-negative sepsis cases). CONCLUSIONS High sepsis burden and alarming AMR among neonates referred to tertiary care centers warrant urgent attention toward coordinated implementation of rigorous sepsis prevention measures and antimicrobial stewardship across all healthcare levels.
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Affiliation(s)
| | | | - Archana Angrup
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Singhal T, Shah S, Thakkar P, Ladi S. Candida auris as the Predominant Species Causing Invasive Candidiasis in Neonates and Children. Indian J Pediatr 2023; 90:946. [PMID: 37256449 DOI: 10.1007/s12098-023-04672-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Tanu Singhal
- Department of Pediatrics, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Sweta Shah
- Department of Microbiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Pooja Thakkar
- Department of Microbiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
| | - Shweta Ladi
- Department of Microbiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India
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Riddell A, Cook A, Khavessian N, Ellis S, Bilardi D, Correia E, Kostyanev T, Nardone A, Russell N, Vilken T, Stohr W, Adhisivam B, de Moraes IRA, Ahmed NU, Bekker A, Berezin EN, Boonkasidecha S, Carvalheiro CG, Chauhan P, Chiurchiù S, Chorafa E, Dramowski A, DS M, Feng J, Jia S, Kong Y, Kyohere M, Kontou A, Lochindarat S, De Luca M, Mphaphuli A, Mussi-Pinhata MM, Murunga S, Nakwa FL, Nangia S, Nassolo E, Hoang NTB, Obiero CW, Olson L, Ping W, Plakkal N, Prasad P, Preedisripipat K, Rahman SW, Seef T, Sukrakanchana PO, Thomas R, Yu Z, Zhang Q, Walker AS, Bielicki J, Heath PT, Sharland M, Munera-Huertas T. Challenges in the Implementation of the NeoOBS Study, a Global Pragmatic Observational Cohort Study, to Investigate the Aetiology and Management of Neonatal Sepsis in the Hospital Setting. Antibiotics (Basel) 2023; 12:923. [PMID: 37237826 PMCID: PMC10215156 DOI: 10.3390/antibiotics12050923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/21/2023] [Accepted: 04/26/2023] [Indexed: 05/28/2023] Open
Abstract
Neonatal sepsis is a significant cause of mortality and morbidity in low- and middle-income countries. To deliver high-quality data studies and inform future trials, it is crucial to understand the challenges encountered when managing global multi-centre research studies and to identify solutions that can feasibly be implemented in these settings. This paper provides an overview of the complexities faced by diverse research teams in different countries and regions, together with actions implemented to achieve pragmatic study management of a large multi-centre observational study of neonatal sepsis. We discuss specific considerations for enrolling sites with different approval processes and varied research experience, structures, and training. Implementing a flexible recruitment strategy and providing ongoing training were necessary to overcome these challenges. We emphasize the attention that must be given to designing the database and monitoring plans. Extensive data collection tools, complex databases, tight timelines, and stringent monitoring arrangements can be problematic and might put the study at risk. Finally, we discuss the complexities added when collecting and shipping isolates and the importance of having a robust central management team and interdisciplinary collaborators able to adapt easily and make swift decisions to deliver the study on time and to target. With pragmatic approaches, appropriate training, and good communication, these challenges can be overcome to deliver high-quality data from a complex study in challenging settings through a collaborative research network.
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Affiliation(s)
- Amy Riddell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | | | | | | | | | - Tomislav Kostyanev
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | | | - Neal Russell
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tuba Vilken
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerpen, Belgium
| | - Wolfgang Stohr
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | | | | | - Adrie Bekker
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | | | | | - Cristina G. Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Prachi Chauhan
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Sara Chiurchiù
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Elisavet Chorafa
- Infectious Diseases Unit, 3rd Dept Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, 546 43 Thessaloniki, Greece
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 8000, South Africa
| | - Madhusudhan DS
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | - Jinxing Feng
- Department of Neonatology, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Shengnan Jia
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - Yuan Kong
- Clinical Laboratory, Shenzhen Children’s Hospital, Shenzhen 518048, China
| | - Mary Kyohere
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Angeliki Kontou
- 1st Neonatology Department and Neonatal Intensive Care Unit, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Hippokration General Hospital, 546 42 Thessaloniki, Greece
| | | | - Maia De Luca
- Academic Department of Pediatrics (DPUO), Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Aripfani Mphaphuli
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | - Marisa M. Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto 14049-900, Brazil
| | - Sheila Murunga
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
| | - Firdose Lambey Nakwa
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children’s Hospital, New Delhi 110001, India
| | - Erinah Nassolo
- MUJHU Research Collaboration, Kampala P.O. Box 23491, Uganda
| | - Ngoc Thi Bin Hoang
- Department of Microbiology, Vietnam National Children’s Hospital, Hanoi 100000, Vietnam
| | - Christina W. Obiero
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi P.O. Box 230, Kenya
- Amsterdam UMC, University of Amsterdam, Emma Children’s Hospital, Department of Global Health, 1081 Amsterdam, The Netherlands
| | - Linus Olson
- Department of Women’s and Children’s Health, Karolinska institutet, Stockholm, Sweden and Department of Global Public Health, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Wang Ping
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Nishad Plakkal
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry 605006, India
| | - Priyanka Prasad
- Seth G. S. Medical College & KEM Hospital, Mumbai 400012, India
| | | | | | - Tiffany Seef
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa AND Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, South Africa
| | | | - Reenu Thomas
- Department of Paediatrics and Child Health, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 1864, South Africa
| | - Zhang Yu
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
- Beijing Maternal and Child Health Care Hospital, Beijing 100026, China
| | - Qiaoru Zhang
- Department of Neonatology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100051, China
| | - A. Sarah Walker
- MRC Clinical Trials Unit, University College London, London WC1V 6LJ, UK
| | - Julia Bielicki
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Paul T. Heath
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Michael Sharland
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
| | - Tatiana Munera-Huertas
- Centre for Neonatal and Paediatric Infection, St. George’s University of London, London SW17 0RE, UK
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Sharma M, Jain M, Veeraraghavan B, Rodrigues C, Bansal N, Nambi PS, Nangia S, Singhal T, Walia K. Target product profiles for diagnosis of sepsis: Proposing a new approach for diagnostic innovation. Indian J Med Res 2023; 157:395-402. [PMID: 37322632 PMCID: PMC10443725 DOI: 10.4103/ijmr.ijmr_1936_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Indexed: 06/17/2023] Open
Abstract
Background & objectives Sepsis, including neonatal sepsis, remains a prevalent cause of morbidity and mortality in low- and middle-income countries such as India, representing 85 per cent of all sepsis-related deaths globally. Early diagnosis and timely initiation of treatment is challenging due to non-specific clinical manifestations and non-availability of rapid diagnostic tests. There is an urgent need for affordable diagnostics with fast turnaround time catering to the needs of end-users. Target product profiles (TPPs) have been found instrumental in developing 'fit-for-use' diagnostics, thus reducing the time taken to facilitate development and improving diagnosis. Hitherto, no such guidance or criteria has been defined for rapid diagnostics for sepsis/neonatal sepsis. We propose an innovative approach for developing the diagnostics for sepsis screening and diagnosis which can be utilized by diagnostic developers in the country. Methods Thr@ee-round Delphi method, including two online surveys and one virtual consultation, was adopted to define criteria for minimum and optimum attributes of TPPs and build consensus on characteristics. Expert panel (n=23) included infectious disease physicians, public health specialists, clinical microbiologists, virologists, researchers/scientists and technology experts/innovators. Results We present a three-component product profile for sepsis diagnosis, (i) screening with high sensitivity, (ii) detection of aetiological agent, and (iii) profiling of antimicrobial susceptibility/resistance, in adults and neonates with an option of testing different considerations. An agreement of >75 per cent was achieved for all TPP characteristics by Delphi. These TPPs are tailored to the Indian healthcare settings and can also be extrapolated to other resource-constraint and high-disease burden settings. Interpretation & conclusions Diagnostics developed using these TPPs will facilitate utilization of invested resources leading to development of the products that have potential to ease the economic burden on patient and save lives.
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Affiliation(s)
- Monica Sharma
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | - Meenu Jain
- Deaprtment of Microbiology, Viral Research and Diagnostic Laboratory, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Camilla Rodrigues
- Department of Microbiology, P.D. Hinduja Hospital & Medical Research Centre & Medical Research Institute, Mumbai, Maharashtra, India
| | - Nitin Bansal
- Department of Infectious Diseases, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
| | - P. Senthur Nambi
- Department of Infectious Diseases, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College & Kalawati Saran Children’s Hospital, New Delhi, India
| | - Tanu Singhal
- Department of Pediatrics & Infectious Disease, Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute, Mumbai, Maharashtra, India
| | - Kamini Walia
- Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi, India
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8
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Soni PK, Kumar J, Angrup A, Kumar P, Saini SS, Sundaram V, Mukhopadhyay K, Dutta S. Meningitis Among Neonates with Suspected Sepsis Presenting to Pediatric Emergency. Pediatr Infect Dis J 2023; 42:e124-e127. [PMID: 36728654 DOI: 10.1097/inf.0000000000003816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We aimed to assess the risk factors, clinical features and microbial profiles of meningitis in neonates with suspected sepsis referred to a pediatric emergency. Over 13 months, 191 neonates were enrolled, of whom 64 (33.5%) had meningitis. There were no significant differences in risk factors or clinical features between infants with and without meningitis. Ninety-three neonates (49%) had culture-positive sepsis (109 isolates). Candida spp. (n = 29), coagulase-negative staphylococci (n = 28) and Klebsiella pneumoniae (n = 23) were the most common pathogens. Forty-one (53%) bacteria were multidrug resistant.
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Affiliation(s)
| | | | - Archana Angrup
- Department of Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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9
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Cook A, Ferreras-Antolin L, Adhisivam B, Ballot D, Berkley JA, Bernaschi P, Carvalheiro CG, Chaikittisuk N, Chen Y, Chibabhai V, Chitkara S, Chiurchiu S, Chorafa E, Dien TM, Dramowski A, de Matos SF, Feng J, Jarovsky D, Kaur R, Khamjakkaew W, Laoyookhong P, Machanja E, Mussi-Pinhata MM, Namiiro F, Natraj G, Naziat H, Ngoc HTB, Ondongo-Ezhet C, Preedisripipat K, Rahman H, Riddell A, Roilides E, Russell N, Sastry AS, Tasimwa HB, Tongzhen J, Wadula J, Wang Y, Whitelaw A, Wu D, Yadav V, Yang G, Stohr W, Bielicki JA, Ellis S, Warris A, Heath PT, Sharland M. Neonatal invasive candidiasis in low- and middle-income countries: Data from the NeoOBS study. Med Mycol 2023; 61:myad010. [PMID: 36881725 PMCID: PMC10026246 DOI: 10.1093/mmy/myad010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/11/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023] Open
Abstract
Neonatal invasive candidiasis (NIC) has significant morbidity and mortality. Reports have shown a different profile of those neonates affected with NIC and of fluconazole-resistant Candida spp. isolates in low- and middle-income countries (LMICs) compared to high-income countries (HICs). We describe the epidemiology, Candida spp. distribution, treatment, and outcomes of neonates with NIC from LMICs enrolled in a global, prospective, longitudinal, observational cohort study (NeoOBS) of hospitalized infants <60 days postnatal age with sepsis (August 2018-February 2021). A total of 127 neonates from 14 hospitals in 8 countries with Candida spp. isolated from blood culture were included. Median gestational age of affected neonates was 30 weeks (IQR: 28-34), and median birth weight was 1270 gr (interquartile range [IQR]: 990-1692). Only a minority had high-risk criteria, such as being born <28 weeks, 19% (24/127), or birth weight <1000 gr, 27% (34/127). The most common Candida species were C. albicans (n = 45, 35%), C. parapsilosis (n = 38, 30%), and Candida auris (n = 18, 14%). The majority of C. albicans isolates were fluconazole susceptible, whereas 59% of C. parapsilosis isolates were fluconazole-resistant. Amphotericin B was the most common antifungal used [74% (78/105)], followed by fluconazole [22% (23/105)]. Death by day 28 post-enrollment was 22% (28/127). To our knowledge, this is the largest multi-country cohort of NIC in LMICs. Most of the neonates would not have been considered at high risk for NIC in HICs. A substantial proportion of isolates was resistant to first choice fluconazole. Understanding the burden of NIC in LMIC is essential to guide future research and treatment guidelines.
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Affiliation(s)
- Aislinn Cook
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
| | - Laura Ferreras-Antolin
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Bethou Adhisivam
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | - Daynia Ballot
- School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - James A Berkley
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Paola Bernaschi
- Microbiology Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cristina G Carvalheiro
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Yunsheng Chen
- Clinical Laboratory, Shenzhen Children's Hospital, Shenzhen, China
| | - Vindana Chibabhai
- Department of Clinical Microbiology & Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- NHLS Microbiology Laboratory, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Shweta Chitkara
- Lady Hardinge Medical College & Associated SSK & KSC Hospitals, New Delhi, India
| | - Sara Chiurchiu
- Academic Hospital Paediatric Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisavet Chorafa
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Tran Minh Dien
- Vice Director Vietnam National Children's Hospital, Hanoi, Vietnam
- Department of Surgery, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Angela Dramowski
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Jinxing Feng
- Department of Neonatology, Shenzhen Children's Hospital, Shenzhen, China
| | | | - Ravinder Kaur
- Lady Hardinge Medical College & Associated SSK & KSC Hospitals, New Delhi, India
| | | | | | - Edwin Machanja
- Department of Microbiology, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Marisa M Mussi-Pinhata
- Department of Pediatrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Flavia Namiiro
- Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | - Gita Natraj
- Seth G. S. Medical College & KEM Hospital, Mumbai, India
| | - Hakka Naziat
- Child Health Research Foundation, Dhaka, Bangladesh
| | - Hoang Thi Bich Ngoc
- Department of Microbiology, Vietnam National Children's Hospital, Hanoi, Vietnam
| | - Claude Ondongo-Ezhet
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Amy Riddell
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Neal Russell
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
| | - Apurba S Sastry
- Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India
| | | | - Ji Tongzhen
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University,Beijing, China
- Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Jeannette Wadula
- National Health Laboratory Services, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yajuan Wang
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, 2# Yabao Road, Chaoyang District, Beijing, China
- Department of Neonatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Andrew Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Dan Wu
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, 2# Yabao Road, Chaoyang District, Beijing, China
| | - Varsha Yadav
- Seth G. S. Medical College & KEM Hospital, Mumbai, India
| | - Gao Yang
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University,Beijing, China
- National Health Laboratory Services, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wolfgang Stohr
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Julia Anna Bielicki
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
| | - Sally Ellis
- Global Antibiotic Research & Development Partnership (GARDP), Geneva, Switzerland
| | - Adilia Warris
- MRC Centre for Medical Mycology, University of Exeter, Exeter, UK
| | - Paul T Heath
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
| | - Michael Sharland
- Centre for Neonatal and Paediatric Infection, St. George's University of London, London, UK
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10
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Cefiderocol as Salvage Therapy for Carbapenem-Resistant Klebsiella pneumoniae Sepsis in an Extremely Preterm Neonate. Indian J Pediatr 2023; 90:310. [PMID: 36637637 DOI: 10.1007/s12098-022-04468-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023]
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11
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Panda SK, Pugalia R. Colistin Resistance in Gram Negative Bacteria in a Tertiary Care Neonatal Intensive Unit in Odisha. Indian Pediatr 2023. [DOI: 10.1007/s13312-023-2819-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
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12
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Saha AK, Saha B. Profile of neonatal candidiasis in tertiary neonatal intensive care unit: A report from a developing country. J Neonatal Perinatal Med 2023; 16:501-506. [PMID: 37718871 DOI: 10.3233/npm-231204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND Systemic candidiasis is an important nosocomial infection in neonatal intensive care units. The objective of this study was to identify the change in the profile of neonatal candidiasis in a tertiary neonatal intensive care unit (NICU) in eastern India in recent times. METHODS It was a retrospective review of case records from 2014 to 2019 from a tertiary NICU of eastern India. Data of the fungal sepsis, demographic details, risk factors of fungal sepsis and mortality were collected from 103 neonates. RESULTS One hundred and three neonates had blood culture positive for fungal species of which 91 (88.3%) infants weighed ≥1500 g and 66 (64%) infants were term. There was significant higher incidence of candidiasis among outborn (Relative risk of outborn 18.84, 95% CI 10.74-33.05). Prolonged antibiotic usage (>14 days), meropenem usage (>5 days), central catheterization (>5 days), invasive mechanical ventilation (>5 days), surgical intervention were found in 64 (62.1%), 46 (44.6%), 31(30.0%), 40 (38.8%) and 39 (37.8%) infants. Non albicans candida (NAC) was isolated as the predominant species (82/103, 79.6%). Resistance to both of fluconazole and amphotericin B were found in 19 (18.4%) babies. Presence of NAC infection and resistance to both amphotericin B and fluconazole were independent predictors of candida associated mortality in NICU. CONCLUSION Neonatal candidiasis is found among outborn infants with higher birth weight and gestational age. NAC species are predominant organisms with resistance to common antifungal drugs.
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Affiliation(s)
- A K Saha
- Department of Neonatology, Institute of Post-Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
| | - B Saha
- Department of Neonatology, Institute of Post-Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
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13
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Unmet needs for management of drug-resistant infections: low- and middle-income countries' viewpoint. Drug Target Insights 2022; 16:78-80. [PMID: 36644017 PMCID: PMC9823287 DOI: 10.33393/dti.2022.2532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/26/2022] [Indexed: 12/30/2022] Open
Abstract
Drug-resistant infections are a serious threat globally which demands cost-effective solutions to meet the unmet needs in their diagnosis and treatment. Gram-negative pathogens, drug-resistant tuberculosis, and multidrug-resistant Salmonella typhi have been reported as cause of resistant infections in developing countries. Here, we discuss the priority pathogens and conditions for which feasible solutions adaptable to low-resource settings are required to address the antimicrobial resistance in pathogens. These solutions will be helpful in containing the spread of antimicrobial resistance and better patient outcomes.
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14
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Mukherjee M, Poddar S, Mukherjee A, Bathia JN. Covid-period-associated changes in organism profile of neonatal sepsis in a tertiary center from East India. J Trop Pediatr 2022; 69:6965016. [PMID: 36579931 DOI: 10.1093/tropej/fmac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal sepsis is a major cause of morbidity and mortality with a higher burden from the low- and middle-income countries. The coronavirus disease 2019 (Covid 19) pandemic has impacted healthcare in various ways including healthcare-associated infections (HAI). The objective of the present study was to determine changes in organism profile and incidence rates of HAI in neonates admitted to the index hospital during the pandemic and compared it with the data from the pre-pandemic period. MATERIALS AND METHODS The study design was a retrospective, observational analysis of data from neonates with culture-positive sepsis, in a tertiary care children's hospital, between January 2018 and December 2021. Pre-Covid (January 2018 to December 2019) and Covid period data (January 2020 to December 2021) were analyzed for the significance of change. RESULTS The prevalence of culture-positive sepsis, in pre-Covid and Covid periods, was 19.55% [95% confidence interval (95% CI) 17.13-21.52)] and 18.36% (CI 16.05-20.74), respectively. HAI rates/1000 patient days increased slightly during the Covid pandemic [7.2% (95% CI 6.98-10.08) to 9.8% (95% CI 9.78-13.67)] mainly due to an increase in fungal HAI (26% pre- vs. 41.5% Covid period). However, the proportion of Gram-negative (GN) infections fell significantly (70.5% vs. 48.6%) during the same period. In the pre-Covid period, Klebsiella followed by Burkholderia cepacia, Acinetobacter spp and Pseudomonas, were the major HAI isolates. During the Covid period, there was a decline in these isolates and Burkholderia spp was not detected. All fungal isolates were Candida species. The case fatality ratio (CFR) from HAI decreased significantly from 38% to 15.45%, mainly due to a decrease in GN HAI. CONCLUSION During Covid pandemic, there was a significant decline in GN HAI and CFR from HAI, due to improved compliance with infection control measures in the neonatal intensive care unit (NICU). At the same time, there was a rise in the fungal HAI, possibly because of a higher proportion of premature, and sick neonates with longer hospital stay and more invasive procedures. Consolidations of gains in infection control and restriction of invasive procedures could help to minimize HAI in NICUs.
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Affiliation(s)
- Mausumi Mukherjee
- Assistant Professor, Department of Paediatrics, Institute of Child Health, Kolkata 700017, India
| | - Sumon Poddar
- Associate Professor, Department of Clinical Microbiology, Institute of Child Health, Kolkata 700017, India
| | - Amrita Mukherjee
- 4th Semester UG, Department of Economics, St Stephen's College, University of Delhi, Delhi 110007, India
| | - Jigna N Bathia
- Senior Registrar, Department of Paediatrics, Institute of Child Health, Kolkata 700017, India
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15
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Darlow CA, McEntee L, Johnson A, Farrington N, Unsworth J, Jimenez-Valverde A, Jagota B, Kolamunnage-Dona R, Da Costa RMA, Ellis S, Franceschi F, Sharland M, Neely M, Piddock L, Das S, Hope W. Assessment of flomoxef combined with amikacin in a hollow-fibre infection model for the treatment of neonatal sepsis in low- and middle-income healthcare settings. J Antimicrob Chemother 2022; 77:3349-3357. [PMID: 36177766 PMCID: PMC9704437 DOI: 10.1093/jac/dkac323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/27/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Annual mortality from neonatal sepsis is an estimated 430 000-680 000 infants globally, most of which occur in low- and middle-income countries (LMICs). The WHO currently recommends a narrow-spectrum β-lactam (e.g. ampicillin) and gentamicin as first-line empirical therapy. However, available epidemiological data demonstrate high rates of resistance to both agents. Alternative empirical regimens are needed. Flomoxef and amikacin are two off-patent antibiotics with potential for use in this setting. OBJECTIVES To assess the pharmacodynamics of flomoxef and amikacin in combination. METHODS The pharmacodynamic interaction of flomoxef and amikacin was assessed in chequerboard assays and a 16-arm dose-ranged hollow-fibre infection model (HFIM) experiment. The combination was further assessed in HFIM experiments mimicking neonatal plasma exposures of clinically relevant doses of both drugs against five Enterobacterales isolates with a range of flomoxef/amikacin MICs. RESULTS Flomoxef and amikacin in combination were synergistic in bacterial killing in both assays and prevention of emergence of amikacin resistance in the HFIM. In the HFIM assessing neonatal-like drug exposures, the combination killed 3/5 strains to sterility, (including 2/5 that monotherapy with either drug failed to kill) and failed to kill the 2/5 strains with flomoxef MICs of 32 mg/L. CONCLUSIONS We conclude that the combination of flomoxef and amikacin is synergistic and is a potentially clinically effective regimen for the empirical treatment of neonatal sepsis in LMIC settings and is therefore suitable for further assessment in a clinical trial.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Laura McEntee
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Nicola Farrington
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Jennifer Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Bhavana Jagota
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - Ruwanthi Kolamunnage-Dona
- Department of Health Data Science, University of Liverpool, Liverpool Health Partners, Liverpool L69 3GF, UK
| | - Renata M A Da Costa
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, Geneva 1202, Switzerland
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, Geneva 1202, Switzerland
| | - François Franceschi
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, Geneva 1202, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London SW17 0QT, UK
| | - Michael Neely
- Department of Infectious Diseases, Children's Hospital Los Angeles and the Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA
| | - Laura Piddock
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, Geneva 1202, Switzerland
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, Liverpool L69 7BE, UK
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16
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Kitt E, Hayes M, Congdon M, Ballester L, Sewawa KB, Mulale U, Mazhani L, Arscott-Mills T, Steenhoff A, Coffin S. Risk factors for mortality in a hospitalised neonatal cohort in Botswana. BMJ Open 2022; 12:e062776. [PMID: 36691117 PMCID: PMC9454043 DOI: 10.1136/bmjopen-2022-062776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/24/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES A disproportionate number of neonatal deaths occur in low/middle-income countries, with sepsis a leading contributor of mortality. In this study, we investigate risk factors for mortality in a cohort of high-risk hospitalised neonates in Botswana. Independent predictors for mortality for infants experiencing either a sepsis or a non-sepsis-related death are described. METHODS This is a prospective observational cohort study with infants enrolled from July to October 2018 at the neonatal unit (NNU) of Princess Marina Hospital (PMH) in Gaborone, Botswana. Data on demographic, clinical and unit-specific variables were obtained. Neonates were followed to death or discharge, including transfer to another hospital. Death was determined to be infectious versus non-infectious based on primary diagnosis listed on day of death by lead clinician on duty. RESULTS Our full cohort consisted of 229 patients. The overall death rate was 227 per 1000 live births, with cumulative proportion of deaths of 22.7% (n=47). Univariate analysis revealed that sepsis, extremely low birth weight (ELBW) status, hypoxic ischaemic encephalopathy, critical illness and infants born at home were associated with an increased risk of all-cause mortality. Our multivariate model revealed that critical illness (HR 3.07, 95% CI 1.56 to 6.03) and being born at home (HR 4.82, 95% CI 1.76 to 13.19) were independently associated with all-cause mortality. Low birth weight status was independently associated with a decreased risk of mortality (HR 0.24, 95% CI 0.11 to 0.53). There was a high burden of infection in the cohort with more than half of infants (140, 61.14%) diagnosed with sepsis at least once during their NNU admission. Approximately 20% (n=25) of infants with sepsis died before discharge. Our univariate subanalysis of the sepsis cohort revealed that ELBW and critical illness were associated with an increased risk of death. These findings persisted in the multivariate model with HR 3.60 (95% CI 1.11 to 11.71) and HR 2.39 (95% CI 1 to 5.77), respectively. CONCLUSIONS High rates of neonatal mortality were noted. Urgent interventions are needed to improve survival rates at PMH NNU and to prioritise care for critically ill infants at time of NNU admission, particularly those born at home and/or of ELBW.
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Affiliation(s)
- Eimear Kitt
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Molly Hayes
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Morgan Congdon
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Section of Hospital Medicine, CHOP, Philadelphia, Pennsylvania, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kgotlaetsile B Sewawa
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Unami Mulale
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Loeto Mazhani
- Department of Paediatric & Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, South-East District, Botswana
| | - Tonya Arscott-Mills
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew Steenhoff
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan Coffin
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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17
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Turton JF, Perry C, Claxton A. Do plasmids containing heavy metal resistance genes play a role in neonatal sepsis and invasive disease caused by Klebsiella pneumoniae and Klebsiella variicola? J Med Microbiol 2022; 71. [PMID: 35972879 DOI: 10.1099/jmm.0.001486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
Introduction. Klebsiella species are some of those most implicated in neonatal sepsis. However, many isolates from infections appear unremarkable; they are generally susceptible to antibiotics and often of sporadic types not associated with virulence.Hypothesis/Gap Statement. Investigation is needed to identify if such isolates have virulence characteristics.Aim. To sequence multiple isolates of a range of types from cases of neonatal invasive disease to identify elements that may explain their virulence, and to determine if such elements are more common among these isolates than generally.Methodology. In total, 14 isolates of K. pneumoniae/K. variicola belonging to 13 distinct types from blood or CSF from neonatal infections were sequenced using long-read nanopore technology. PCR assays were used to screen a general set of isolates for heavy metal resistance genes arsC, silS and merR.Results. Overall, 12/14 isolates carried one or more plasmids. Ten carried a large plasmid (186 to 310 kb) containing heavy metal resistance genes associated with hypervirulence plasmids, with most (nine) carrying genes for resistance to copper, silver and one other heavy metal (arsenic, tellurite or mercury), but lacking the genes encoding capsule-upregulation and siderophores. Most isolates (9/14) lacked any additional antibiotic resistance genes other than those intrinsic in the species. However, a representative of an outbreak strain carried a plasmid containing bla CTX-M-15, qnrS1, aac3_IIa, dfrA17, sul1, mph(A), tet(A), bla TEM1B and aadA5, but no heavy metal resistance genes. arsC, silS and merR were widely found among 100 further isolates screened, with most carbapenemase-gene-positive isolates (20/27) carrying at least one.Conclusion. Plasmids containing heavy metal resistance genes were a striking feature of isolates from neonatal sepsis but are widely found. They share elements in common with virulence and antibiotic resistance plasmids, perhaps providing a basis from which such plasmids evolve.
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Affiliation(s)
- Jane F Turton
- HCAI, Fungal, AMR, AMU & Sepsis Division, UK Health Security Agency, London, UK
| | - Claire Perry
- Reference Services Division, UK Health Security Agency, London, UK
| | - Alleyna Claxton
- Homerton University Hospital NHS Foundation Trust, London, UK
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Mondain V, Retur N, Bertrand B, Lieutier-Colas F, Carenco P, Diamantis S. Advocacy for Responsible Antibiotic Production and Use. Antibiotics (Basel) 2022; 11:antibiotics11070980. [PMID: 35884234 PMCID: PMC9311909 DOI: 10.3390/antibiotics11070980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 11/26/2022] Open
Abstract
Antibiotic-resistant bacteria have become one of humankind’s major challenges, as testified by the UN’s Call to Action on Antimicrobial Resistance in 2021. Our knowledge of the underlying processes of antibiotic resistance is steadily improving. Beyond the inappropriate use of antimicrobials in human medicine, other causes have been identified, raising ethical issues and requiring an approach to the problem from a “One Health” perspective. Indeed, it is now clear that the two main issues regarding the subject of antibiotics are their misuse in the global food industry and their method of production, both leading to the emergence and spread of bacterial resistance.
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Affiliation(s)
- Véronique Mondain
- Centre Hospitalo-Universitaire de Nice, Service des Maladies Infectieuses et Tropicales, Hôpital Archet 1, 06202 Nice, France
- Correspondence:
| | - Nicolas Retur
- Centre Hospitalo-Universitaire de Nice, Pharmacie, Hôpital Archet 1, 06202 Nice, France;
| | | | - Florence Lieutier-Colas
- AntibioEst, Regional Antibiotic Therapy Centre, Nancy University Hospital, Brabois Hospital, 54511 Vandoeuvre-les-Nancy, France;
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Shah MH, McAleese S, Kadam S, Parikh T, Vaidya U, Sanghavi S, Johnson J. Emerging Antibiotic Resistance Patterns in a Neonatal Intensive Care Unit in Pune, India: A 2-Year Retrospective Study. Front Pediatr 2022; 10:864115. [PMID: 35757124 PMCID: PMC9226713 DOI: 10.3389/fped.2022.864115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/11/2022] [Indexed: 11/27/2022] Open
Abstract
Objective Treating neonatal bloodstream infections and meningitis in South Asia remains difficult given high rates of antimicrobial resistance (AMR). To evaluate changing epidemiology of neonatal infections, we assessed pathogen-specific and clinical features of culture-proven infections in neonates admitted to a neonatal intensive care unit (NICU) in Pune, India. Materials and Methods This retrospective cohort study was performed in the King Edward Memorial Hospital and Research Center NICU over 2 years between January 1, 2017 and December 31, 2018. We included all neonates admitted to the NICU with positive blood or cerebrospinal fluid cultures. Demographic, clinical, and microbiologic data were collected from the medical record. We reviewed antimicrobial susceptibility testing (AST) of all isolates. Results There were 93 culture-positive infections in 83 neonates, including 11 cases of meningitis. Fifteen (18%) neonates died. Gram-negative pathogens predominated (85%) and AST showed 74% resistance to aminoglycosides, 95% resistance to third/fourth generation cephalosporins, and 56% resistance to carbapenems. Resistance to colistin was present in 30% of Klebsiella pneumoniae isolates. Birth weight <1,000 g [odds ratio (OR) 6.0, p < 0.002], invasive respiratory support (OR 7.7, p = 0.001), and antibiotics at the time of culture (OR 4.2, p = 0.019) were associated with increased risk of mortality. Rates of AMR to all major antibiotic classes were similar between early onset and late onset infections. There was no association between carbapenem resistance and mortality. Conclusion In our NICU in India, there are high rates of AMR among Gram-negative pathogens that are predominantly responsible for infections. Given higher colistin resistance in this cohort than previously reported, hospitals should consider routinely testing for colistin resistance.
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Affiliation(s)
| | - Samuel McAleese
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sandeep Kadam
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital & Research Centre, Pune, India
| | - Tushar Parikh
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital & Research Centre, Pune, India
| | - Umesh Vaidya
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital & Research Centre, Pune, India
| | - Sonali Sanghavi
- Department of Microbiology, King Edward Memorial Hospital & Research Centre, Pune, India
| | - Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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20
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Gan MY, Lee WL, Yap BJ, Seethor STT, Greenberg RG, Pek JH, Tan B, Hornik CPV, Lee JH, Chong SL. Contemporary Trends in Global Mortality of Sepsis Among Young Infants Less Than 90 Days: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:890767. [PMID: 35722477 PMCID: PMC9204066 DOI: 10.3389/fped.2022.890767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Current knowledge on the global burden of infant sepsis is limited to population-level data. We aimed to summarize global case fatality rates (CFRs) of young infants with sepsis, stratified by gross national income (GNI) status and patient-level risk factors. Methods We performed a systematic review and meta-analysis on CFRs among young infants < 90 days with sepsis. We searched PubMed, Cochrane Central, Embase, and Web of Science for studies published between January 2010 and September 2019. We obtained pooled CFRs estimates using the random effects model. We performed a univariate analysis at patient-level and a meta-regression to study the associations of gestational age, birth weight, onset of sepsis, GNI, age group and culture-proven sepsis with CFRs. Results The search yielded 6314 publications, of which 240 studies (N = 437,796 patients) from 77 countries were included. Of 240 studies, 99 were conducted in high-income countries, 44 in upper-middle-income countries, 82 in lower-middle-income countries, 6 in low-income countries and 9 in multiple income-level countries. Overall pooled CFR was 18% (95% CI, 17-19%). The CFR was highest for low-income countries [25% (95% CI, 7-43%)], followed by lower-middle [25% (95% CI, 7-43%)], upper-middle [21% (95% CI, 18-24%)] and lowest for high-income countries [12% (95% CI, 11-13%)]. Factors associated with high CFRs included prematurity, low birth weight, age less than 28 days, early onset sepsis, hospital acquired infections and sepsis in middle- and low-income countries. Study setting in middle-income countries was an independent predictor of high CFRs. We found a widening disparity in CFRs between countries of different GNI over time. Conclusion Young infant sepsis remains a major global health challenge. The widening disparity in young infant sepsis CFRs between GNI groups underscore the need to channel greater resources especially to the lower income regions. Systematic Review Registration [www.crd.york.ac.uk/prospero], identifier [CRD42020164321].
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Affiliation(s)
- Ming Ying Gan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wen Li Lee
- Duke-NUS Medical School, Singapore, Singapore
| | - Bei Jun Yap
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Rachel G Greenberg
- Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jen Heng Pek
- Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Bobby Tan
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Christoph Paul Vincent Hornik
- Division of Critical Care Medicine, Department of Paediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Jan Hau Lee
- Duke-NUS Medical School, Singapore, Singapore
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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Singhal T. Antimicrobial Resistance: The 'Other' Pandemic! : Based on 9th Dr. I. C. Verma Excellence Award for Young Pediatricians Delivered as Oration on 19th Sept. 2021. Indian J Pediatr 2022; 89:600-606. [PMID: 35064528 PMCID: PMC8782680 DOI: 10.1007/s12098-021-04008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
Antimicrobial resistance is projected to kill 10 million people by 2050. The biggest driver of antimicrobial resistance is excessive/unrestricted use of antimicrobials in humans and animals. Antimicrobial resistance is a problem in all types of pathogens including bacteria, mycobacteria, viruses, fungi, and parasites both globally and India and in both adults and children. The areas of greatest concern for India is the epidemic of MDR and XDR tuberculosis and resistance in gram-negative pathogens. The alarming rate of extended spectrum beta lactamase (ESBL) production in Enterobacteriales in both community and health care-associated infections is driving carbapenem use. Rates of carbapenem resistance are now significantly high in health care-associated gram negative pathogens with associated high mortality rates. The key solution to this antimicrobial resistance crisis needs participation of all stakeholders and lies in promoting rational antimicrobial therapy.
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Affiliation(s)
- Tanu Singhal
- Department of Pediatrics and Infectious Disease, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, 400053, India.
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22
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Mohakud NK, Mishra JP, Nayak MK, Mishra J, Pradhan L, Panda SS, Bahera MR, Pugulia R. Bacteriological Profile and Outcome of Culture-Positive Neonatal Sepsis in a Special Newborn Care Unit Setting, Odisha. Cureus 2022; 14:e25539. [PMID: 35800816 PMCID: PMC9246319 DOI: 10.7759/cureus.25539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction: Nearly one-third of neonatal mortality in India is due to neonatal sepsis and death occurs in 30% of culture-positive neonates. Pathogens such as Klebsiella pneumoniae and Escherichia coli are the most common bacteria responsible for neonatal sepsis in India and South Asia. Materials and Methods: It was an observational study, conducted in special newborn care units (SNCUs) of Capital Hospital in Bhubaneswar, Odisha from May 2017 to October 2019. All neonates (<28 days of life) with blood culture-positive sepsis were included in this study. Blood cultures were sent in all the babies with features of clinical sepsis. The demographic profile of neonates, clinical presentations, isolated organisms, and their sensitive patterns was recorded for analysis. Results: Blood culture was sent in 445 suspected neonates with clinical sepsis out of which 115 blood culture positive organisms were isolated. Among the isolated organisms, 42 (35.6%) cases were Staphylococcus aureus followed by Coagulase negative Staphylococcus (CONS) (20.8%), E. coli (19.1%), K. pneumoniae (10.4%), Acinetobacter baumannii (2.7%), Enterobacter spp.(4.3%), Enterococcus spp. (4.3%), and Pseudomonas aeruginosa (2.7%). S. aureus was the predominant organism found in both early and late-onset sepsis. All Gram-negative bacilli (GNB) are resistant to ampicillin whereas cephalosporin resistance was found in 68% of cases. Mortality due to sepsis was 8%. Conclusion: S. aureus followed by CONS was found to be the most common cause of sepsis in SNCU. A high degree of resistance of organisms to penicillins and cephalosporins calls for a re-evaluation of antibiotic policy and protocols for empirical treatment in neonatal sepsis.
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Rani U, Lewis LE, Chawla K, Naha A. Preventable contributors to the neonatal healthcare-associated infections: a uni-center analytical study from South India. F1000Res 2022; 11:454. [PMID: 35903417 PMCID: PMC9280113 DOI: 10.12688/f1000research.111101.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Globally, neonatal healthcare-associated infections (HAIs) are known to cause high mortality. HAIs is a preventable condition related to the healthcare environment. The current study explored the contributors to neonatal HAIs in one of the largest tertiary care referral hospitals in South India. Methods: Neonates from December 2016 to June 2018 were observed for the occurrence of healthcare-associated infections and compared with the matched control group. Various observations on neonatal demography, maternal contributors, and medical procedures were made and recorded to explore and analyse the contributors to neonatal HAIs. Univariate and multivariate analysis was carried out to find the contributors. The Odds ratio with 95% CI was also computed and reported. Results: Bloodstream infection (83%) was prevalent among neonates; the maternal contributor was only preterm labor (Odds ratio of 11.93; 95% CI; 6.47-21.98; p<.05) to acquire HAIs. On univariate analysis, mechanical ventilation for > 3days duration, NIV for > five days, and PICC line insertion procedure were significant (p<0.05) contributors to neonatal HAIs. IV cannulation for more than three times in four consecutive days was found in 100(85%) neonates considered being associated with neonatal HAIs. On multivariate analysis, NIV, PICC line, preterm labor, and low birth weight were significant (p<0.05) contributors to neonatal HAIs. Conclusion: The increased duration of invasive and non-invasive therapeutic devices and catheters contributes to neonatal HAIs. Neonates are acquiring bloodstream infections; low birth weight (LBW) neonates are more susceptible to acquiring HAIs.
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Affiliation(s)
- Usha Rani
- Department of Social and Health Innovation, Prasanna School of Public Health, Manipal academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Leslie E. Lewis
- Department of Pediatrics, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Kiran Chawla
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Anup Naha
- Department of Pharmaceutics, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
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Panda SK, Nayak MK, Jena P, Rath S, Gudu R, Pugulia R, Panda SS. Nonfermenting, Gram-Negative Bacilli Causing Neonatal Sepsis in Odisha, India: Four-Year Surveillance. Cureus 2022; 14:e22219. [PMID: 35340522 PMCID: PMC8927856 DOI: 10.7759/cureus.22219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 12/27/2022] Open
Abstract
Introduction In India, blood culture-positive sepsis results in mortality in 33%-35% of affected neonates. Nonfermenting Gram-negative bacilli (NFGNB), particularly Acinetobacter baumannii and Burkholderia cepacia commonly cause hospital-acquired infection. Materials and methods We performed a subgroup analysis as part of a prospective study conducted in a neonatal intensive care unit in a tertiary care hospital in Odisha, India, between January 2017 and December 2020. Neonates with blood culture-positive sepsis caused by NFGNB were enrolled in this study. Demographic characteristics of the neonates, clinical features of sepsis, complications, need for supportive care, and blood culture sensitivity patterns were recorded and analyzed. Results A total of 168 organisms were isolated in blood cultures during our study period, of which 48 (29%) were NFGNB species. Among these 48 species, A. baumannii (37.5%) and B. cepacia (33.3%) were the most common NFGNB in our study. Neonates with sepsis commonly exhibited feeding intolerance (64.5%), circulatory insufficiency that necessitated vasopressor treatment (54.1%), disseminated intravascular coagulopathy (35.4%), seizures (33.3%), and the need for respiratory support (56.2%). NFGNB were multidrug-resistant (MDR) in 70.8% of cases, and 93.7% of B. cepacia and 55.5% of A. baumannii were MDR. Conclusions A. baumannii and B. cepacia are NFGNB commonly isolated in neonatal cases of blood culture-positive sepsis. The prevalence of MDR NFGNB sepsis is gradually increasing, which poses a threat to neonates. Strict aseptic precautions and antibiotic stewardship are thus mandatory in perinatal practice.
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25
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Darlow CA, Farrington N, Johnson A, McEntee L, Unsworth J, Jimenez-Valverde A, Kolamunnage-Dona R, Da Costa RMA, Ellis S, Franceschi F, Sharland M, Neely M, Piddock LJV, Das S, Hope W. OUP accepted manuscript. J Antimicrob Chemother 2022; 77:1334-1343. [PMID: 35170719 PMCID: PMC9047679 DOI: 10.1093/jac/dkac038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Neonatal sepsis is a serious bacterial infection of neonates, globally killing up to 680 000 babies annually. It is frequently complicated by antimicrobial resistance, particularly in low- and middle-income country (LMIC) settings with widespread resistance to the WHO’s recommended empirical regimen of ampicillin and gentamicin. Objectives We assessed the utility of flomoxef and fosfomycin as a potential alternative empirical regimen for neonatal sepsis in these settings. Methods We studied the combination in a 16-arm dose-ranged hollow-fibre infection model (HFIM) experiment and chequerboard assays. We further assessed the combination using clinically relevant regimens in the HFIM with six Enterobacterales strains with a range of flomoxef/fosfomycin MICs. Results Pharmacokinetic/pharmacodynamic modelling of the HFIM experimental output, along with data from chequerboard assays, indicated synergy of this regimen in terms of bacterial killing and prevention of emergence of fosfomycin resistance. Flomoxef monotherapy was sufficient to kill 3/3 strains with flomoxef MICs ≤0.5 mg/L to sterility. Three of three strains with flomoxef MICs ≥8 mg/L were not killed by fosfomycin or flomoxef monotherapy; 2/3 of these were killed with the combination of the two agents. Conclusions These data suggest that flomoxef/fosfomycin could be an efficacious and synergistic regimen for the empirical treatment of neonatal sepsis in LMIC settings with prevalent antimicrobial resistance. Our HFIM results warrant further assessment of the flomoxef/fosfomycin combination in clinical trials.
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Affiliation(s)
- Christopher A. Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
- Corresponding author: E-mail:
| | - Nicola Farrington
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | - Adam Johnson
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | - Laura McEntee
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | - Jennifer Unsworth
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | - Ana Jimenez-Valverde
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | | | - Renata M A Da Costa
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, 1202 Geneva, Switzerland
| | - Sally Ellis
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, 1202 Geneva, Switzerland
| | - François Franceschi
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, 1202 Geneva, Switzerland
| | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George’s, University of London, UK
| | - Michael Neely
- Children’s Hospital Los Angeles and the Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Laura J. V. Piddock
- Global Antibiotic Research and Development Partnership, 15 Chemin Camille-Vidart, 1202 Geneva, Switzerland
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool Health Partners, UK
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DING H, SHI Z, ZHANG L, GAO N, CHENG X, LIN H, ZHANG Z, ZHANG G. Progranulin (PGRN) is serves as an inflammation-response biomarker and promotes lung damage in burn-induced Sepsis via the SIRT1 Pathways by ROS. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.36720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Hui DING
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Zhaoling SHI
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Lu ZHANG
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Nairong GAO
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Xiaoning CHENG
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Haibo LIN
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Zhihong ZHANG
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
| | - Guocheng ZHANG
- The Second Hospital Affiated Shaanxi University of Chinese Medicine, China
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27
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Darlow CA, Hope W. Flomoxef for neonates: extending options for treatment of neonatal sepsis caused by ESBL-producing Enterobacterales. J Antimicrob Chemother 2021; 77:711-718. [PMID: 34969066 PMCID: PMC8864998 DOI: 10.1093/jac/dkab468] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/19/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a serious and frequently lethal infection, often complicated by antimicrobial resistance (including ESBLs) in low- and middle-income countries (LMICs). Flomoxef is an off-patent oxacephem β-lactam with stability against non-AmpC ESBLs, with potential for utility in these settings. To date, there has been no published flomoxef neonatal population pharmacokinetic (PopPK) model. OBJECTIVES To summarize the clinical data available for flomoxef, build a neonatal PopPK model and assess the adequacy of different neonatal flomoxef regimens. METHODS A systematic literature search returned all available clinical or pharmacokinetic data of flomoxef use in neonates. Pharmacokinetic data were used to construct a PopPK model, with progressive incorporation of covariates into the final model. Monte Carlo simulations were performed using this final model to simulate drug exposures of different flomoxef regimens to calculate PTAs. RESULTS Individual-level clinical and pharmacokinetic data were extracted for 313 and 146 neonates, respectively, with population clinical data extracted for a further 199 neonates. Clinical and microbiological success rates were 89.71% and 82.8%, respectively, with minimal side effects. The final PopPK model incorporated body weight and postnatal age as covariates. PTA analyses predicted that IV regimens of 20 mg/kg q12h, 20 mg/kg q6-8h and 40 mg/kg q6-8h are adequate for neonates aged 0-7, 7-14 and 14-28 days, respectively. CONCLUSIONS To the best of our knowledge, this is the first published neonatal PopPK model for flomoxef. Given the high treatment success rates, low toxicity rates and off-patent status, this drug has potential for use in the treatment of neonatal sepsis in ESBL-prevalent LMIC settings.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, University of Liverpool, Liverpool, UK
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Akselsen AB, Sheth CC, Veses V. Efficacy of empiric antibiotic treatment of late-onset neonatal sepsis caused by Enterobacteriaceae: A Systematic Review. Lett Appl Microbiol 2021; 75:500-510. [PMID: 34951709 DOI: 10.1111/lam.13640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/30/2022]
Abstract
Neonatal sepsis is a serious condition, where an adequate empiric antibiotic treatment is crucial. The objective of this systematic review is to assess whether the World Health Organisation's recommended treatment regime remains applicable for late-onset neonatal sepsis caused by Enterobacteriaceae, in the time of increased antimicrobial resistance. PubMed was searched for articles from 2009 to 2020. A total of 49 articles were eligible for inclusion. The review was carried out in accordance with PRISMA guidelines. For Klebsiella spp. 100%, 68%, and 63% of the studies found sensitivity to ampicillin, gentamicin, and third generation cephalosporin in <50% of the isolates. For Escherichia coli the corresponding values were 88%, 50%, and 42% respectively, whilst for Enterobacter spp. 100%, 70% and 94% of the studies found <50% sensitivity to these antibiotics. Overall, there is low sensitivity to all agents in the WHO's recommended empiric treatment regimes (WHO recommends ampicillin plus gentamicin as first line treatment and third generation cephalosporin as second line treatment). A revised guideline for empiric antibiotic treatment of neonatal sepsis is urgently needed due to increased threat of antimicrobial resistant Enterobacteriaceae causing neonatal sepsis.
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Affiliation(s)
- Alice B Akselsen
- Department of Medicine, Faculty of Health Sciences, Universidad CEU Cardenal Herrera, CEU Universities, Alfara del Patriarca 46115, Valencia, Spain
| | - Chirag C Sheth
- Department of Medicine, Faculty of Health Sciences, Universidad CEU Cardenal Herrera, CEU Universities, Alfara del Patriarca 46115, Valencia, Spain
| | - Veronica Veses
- Department of Biomedical Sciences, Faculty of Health Sciences, Universidad CEU Cardenal Herrera, CEU Universities, Alfara del Patriarca 46115, Valencia, Spain
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Mitchell J, Purohit M, Jewell CP, Read JM, Marrone G, Diwan V, Stålsby Lundborg C. Trends, relationships and case attribution of antibiotic resistance between children and environmental sources in rural India. Sci Rep 2021; 11:22599. [PMID: 34799577 PMCID: PMC8604955 DOI: 10.1038/s41598-021-01174-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/21/2021] [Indexed: 12/29/2022] Open
Abstract
Bacterial antibiotic resistance is an important global health threat and the interfaces of antibiotic resistance between humans, animals and the environment are complex. We aimed to determine the associations and overtime trends of antibiotic resistance between humans, animals and water sources from the same area and time and estimate attribution of the other sources to cases of human antibiotic resistance. A total of 125 children (aged 1-3 years old) had stool samples analysed for antibiotic-resistant bacteria at seven time points over two years, with simultaneous collection of samples of animal stools and water sources in a rural Indian community. Newey-West regression models were used to calculate temporal associations, the source with the most statistically significant relationships was household drinking water. This is supported by use of SourceR attribution modelling, that estimated the mean attribution of cases of antibiotic resistance in the children from animals, household drinking water and wastewater, at each time point and location, to be 12.6% (95% CI 4.4-20.9%), 12.1% (CI 3.4-20.7%) and 10.3% (CI 3.2-17.3%) respectively. This underlines the importance of the 'one health' concept and requires further research. Also, most of the significant trends over time were negative, suggesting a possible generalised improvement locally.
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Affiliation(s)
- Joseph Mitchell
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Manju Purohit
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, 171 77, Stockholm, Sweden.
- Department of Pathology, R.D. Gardi Medical College, Ujjain, 456006, India.
| | - Chris P Jewell
- Faculty of Health and Medicine, Lancaster Medical School, Lancaster University, Lancaster, England, UK
| | - Jonathan M Read
- Faculty of Health and Medicine, Lancaster Medical School, Lancaster University, Lancaster, England, UK
| | - Gaetano Marrone
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Vishal Diwan
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, 171 77, Stockholm, Sweden
- Division of Environmental Monitoring and Exposure Assessment (Water and Soil), ICMR - National Institute for Research in Environmental Health, Bhopal, 462030, India
| | - Cecilia Stålsby Lundborg
- Department of Global Public Health, Health Systems and Policy (HSP): Improving Use of Medicines, Karolinska Institutet, 171 77, Stockholm, Sweden
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30
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Pu Z, Zhang W, Wang M, Xu M, Xie H, Zhao J. Schisandrin B Attenuates Colitis-Associated Colorectal Cancer through SIRT1 Linked SMURF2 Signaling. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2021; 49:1773-1789. [PMID: 34632965 DOI: 10.1142/s0192415x21500841] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Colon cancer, a common type of malignant tumor, seriously endangers human health. However, due to the relatively slow progress in diagnosis and treatment, the clinical therapeutic technology of colon cancer has not been substantially improved in the past three decades. The present study was designed to investigate the effects and involved mechanisms of schisandrin B in cell growth and metastasis of colon cancer. C57BL/6 mice received AOM and dextran sulfate sodium. Mice in treatment groups were gavaged with 3.75-30 mg/kg/day of schisandrin B. Transwell chamber migration, enzyme-linked immunosorbent assay (ELISA), Western blot analysis, immunoprecipitation (IP) and immunofluorescence were conducted, and HCT116 cell line was employed in this study. Data showed that schisandrin B inhibited tumor number and tumor size in the AOD+DSS-induced colon cancer mouse model. Schisandrin B also inhibited cell proliferation and metastasis of colon cancer cells. We observed that schisandrin B induced SMURF2 protein expression and affected SIRT1 in vitro and in vivo. SMURF2 interacted with SIRT1 protein, and there was a negative correlation between SIRT1 and SMURF2 expressions in human colorectal cancer. The regulation of SMURF2 was involved in the anticancer effects of schisandrin B in both in vitro and in vivo models. In conclusion, the present study revealed that schisandrin B suppressed SIRT1 protein expression, and SIRT1 is negatively correlated with the induction of SMURF2, which inhibited cell growth and metastasis of colon cancer. Schisandrin B could be a leading compound, which will contribute to finding novel potential agents and therapeutic targets for colon cancer.
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Affiliation(s)
- Zhichen Pu
- Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China.,Key Laboratory of Non-Coding RNA Transformation Research of Anhui Higher Education Institution, Wannan Medical College, Wuhu 241001, P. R. China.,State Key Laboratory of Natural Medicines, Key Lab of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing 210009, P. R. China
| | - Weiwei Zhang
- Department of Pharmacy, Second affiliated hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China
| | - Minhui Wang
- Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China
| | - Maodi Xu
- Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China
| | - Haitang Xie
- Drug Clinical Evaluation, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China
| | - Jun Zhao
- Department of Pharmacy, Second affiliated hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China.,Department of Gastrointestinal Surgery, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P. R. China
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31
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Darlow CA, da Costa RMA, Ellis S, Franceschi F, Sharland M, Piddock L, Das S, Hope W. Potential Antibiotics for the Treatment of Neonatal Sepsis Caused by Multidrug-Resistant Bacteria. Paediatr Drugs 2021; 23:465-484. [PMID: 34435316 PMCID: PMC8418595 DOI: 10.1007/s40272-021-00465-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 01/26/2023]
Abstract
Neonatal sepsis causes up to an estimated 680,000 deaths annually worldwide, predominantly in low- and middle-income countries (LMICs). A significant and growing proportion of bacteria causing neonatal sepsis are resistant to multiple antibiotics, including the World Health Organization-recommended empiric neonatal sepsis regimen of ampicillin/gentamicin. The Global Antibiotic Research and Development Partnership is aiming to develop alternative empiric antibiotic regimens that fulfil several criteria: (1) affordable in LMIC settings; (2) activity against neonatal bacterial pathogens, including extended-spectrum β-lactamase producers, gentamicin-resistant Gram-negative bacteria, and methicillin-resistant Staphylococcus aureus (MRSA); (3) a licence for neonatal use or extensive experience of use in neonates; and (4) minimal toxicities. In this review, we identify five antibiotics that fulfil these criteria: amikacin, tobramycin, fosfomycin, flomoxef, and cefepime. We describe the available characteristics of each in terms of mechanism of action, resistance mechanisms, clinical pharmacokinetics, pharmacodynamics, and toxicity profile. We also identify some knowledge gaps: (1) the neonatal pharmacokinetics of cefepime is reliant on relatively small and limited datasets, and the pharmacokinetics of flomoxef are also reliant on data from a limited demographic range and (2) for all reviewed agents, the pharmacodynamic index and target has not been definitively established for both bactericidal effect and emergence of resistance, with many assumed to have an identical index/target to similar class molecules. These five agents have the potential to be used in novel combination empiric regimens for neonatal sepsis. However, the data gaps need addressing by pharmacokinetic trials and pharmacodynamic characterisation.
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Affiliation(s)
- Christopher A Darlow
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
| | | | - Sally Ellis
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
| | | | - Mike Sharland
- Paediatric Infectious Diseases Research Group, St George's University of London, London, UK
| | - Laura Piddock
- Global Antibiotic Research and Development Partnership, Geneva, Switzerland
- Antimicrobials Research Group, Institute for Microbiology and Infection, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Shampa Das
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
| | - William Hope
- Antimicrobial Pharmacodynamics and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool Health Partners, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
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Wen SCH, Ezure Y, Rolley L, Spurling G, Lau CL, Riaz S, Paterson DL, Irwin AD. Gram-negative neonatal sepsis in low- and lower-middle-income countries and WHO empirical antibiotic recommendations: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003787. [PMID: 34582466 PMCID: PMC8478175 DOI: 10.1371/journal.pmed.1003787] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 09/01/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Neonatal sepsis is a significant global health issue associated with marked regional disparities in mortality. Antimicrobial resistance (AMR) is a growing concern in Gram-negative organisms, which increasingly predominate in neonatal sepsis, and existing WHO empirical antibiotic recommendations may no longer be appropriate. Previous systematic reviews have been limited to specific low- and middle-income countries. We therefore completed a systematic review and meta-analysis of available data from all low- and lower-middle-income countries (LLMICs) since 2010, with a focus on regional differences in Gram-negative infections and AMR. METHODS AND FINDINGS All studies published from 1 January 2010 to 21 April 2021 about microbiologically confirmed bloodstream infections or meningitis in neonates and AMR in LLMICs were assessed for eligibility. Small case series, studies with a small number of Gram-negative isolates (<10), and studies with a majority of isolates prior to 2010 were excluded. Main outcomes were pooled proportions of Escherichia coli, Klebsiella, Enterobacter, Pseudomonas, Acinetobacter and AMR. We included 88 studies (4 cohort studies, 3 randomised controlled studies, and 81 cross-sectional studies) comprising 10,458 Gram-negative isolates from 19 LLMICs. No studies were identified outside of Africa and Asia. The estimated pooled proportion of neonatal sepsis caused by Gram-negative organisms was 60% (95% CI 55% to 65%). Klebsiella spp. was the most common, with a pooled proportion of 38% of Gram-negative sepsis (95% CI 33% to 43%). Regional differences were observed, with higher proportions of Acinetobacter spp. in Asia and Klebsiella spp. in Africa. Resistance to aminoglycosides and third-generation cephalosporins ranged from 42% to 69% and from 59% to 84%, respectively. Study limitations include significant heterogeneity among included studies, exclusion of upper-middle-income countries, and potential sampling bias, with the majority of studies from tertiary hospital settings, which may overestimate the burden caused by Gram-negative bacteria. CONCLUSIONS Gram-negative bacteria are an important cause of neonatal sepsis in LLMICs and are associated with significant rates of resistance to WHO-recommended first- and second-line empirical antibiotics. AMR surveillance should underpin region-specific empirical treatment recommendations. Meanwhile, a significant global commitment to accessible and effective antimicrobials for neonates is required.
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Affiliation(s)
- Sophie C. H. Wen
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- * E-mail:
| | - Yukiko Ezure
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
| | - Lauren Rolley
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
| | - Geoff Spurling
- Primary Care Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Colleen L. Lau
- School of Public Health, University of Queensland, Brisbane, Queensland, Australia
- Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Saba Riaz
- Institute of Microbiology and Molecular Genetics, University of the Punjab, Lahore, Pakistan
| | - David L. Paterson
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Adam D. Irwin
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
- Infection Management Prevention Service, Queensland Children’s Hospital, Brisbane, Queensland, Australia
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Johnson J, Robinson ML, Rajput UC, Valvi C, Kinikar A, Parikh TB, Vaidya U, Malwade S, Agarkhedkar S, Randive B, Kadam A, Smith RM, Westercamp M, Mave V, Gupta A, Milstone AM, Manabe YC. High Burden of Bloodstream Infections Associated With Antimicrobial Resistance and Mortality in the Neonatal Intensive Care Unit in Pune, India. Clin Infect Dis 2021; 73:271-280. [PMID: 32421763 PMCID: PMC8282256 DOI: 10.1093/cid/ciaa554] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) is a growing threat to newborns in low- and middle-income countries (LMIC). METHODS We performed a prospective cohort study in 3 tertiary neonatal intensive care units (NICUs) in Pune, India, to describe the epidemiology of neonatal bloodstream infections (BSIs). All neonates admitted to the NICU were enrolled. The primary outcome was BSI, defined as positive blood culture. Early-onset BSI was defined as BSI on day of life (DOL) 0-2 and late-onset BSI on DOL 3 or later. RESULTS From 1 May 2017 until 30 April 2018, 4073 neonates were enrolled. Among at-risk neonates, 55 (1.6%) developed early-onset BSI and 176 (5.5%) developed late-onset BSI. The majority of BSIs were caused by gram-negative bacteria (GNB; 58%); among GNB, 61 (45%) were resistant to carbapenems. Klebsiella spp. (n = 53, 23%) were the most common cause of BSI. Compared with neonates without BSI, all-cause mortality was higher among neonates with early-onset BSI (31% vs 10%, P < .001) and late-onset BSI (24% vs 7%, P < .001). Non-low-birth-weight neonates with late-onset BSI had the greatest excess in mortality (22% vs 3%, P < .001). CONCLUSIONS In our cohort, neonatal BSIs were most commonly caused by GNB, with a high prevalence of AMR, and were associated with high mortality, even in term neonates. Effective interventions are urgently needed to reduce the burden of BSI and death due to AMR GNB in hospitalized neonates in LMIC.
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Affiliation(s)
- Julia Johnson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Matthew L Robinson
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Uday C Rajput
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Chhaya Valvi
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Aarti Kinikar
- Department of Pediatrics, Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Tushar B Parikh
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Umesh Vaidya
- Division of Neonatology, Department of Pediatrics, King Edward Memorial Hospital, Pune, India
| | - Sudhir Malwade
- Department of Pediatrics, Dr D. Y. Patil Medical College, Pune, India
| | | | - Bharat Randive
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Abhay Kadam
- Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Rachel M Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Vidya Mave
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Byramjee Jeejeebhoy Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aaron M Milstone
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yukari C Manabe
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Dhir SK, Sundaram V, Gautam V, Munda VS, Tiewsoh JBA, Angurana SK, Kumar J, Saini SS, Dutta S, Kumar P. Microorganisms Profile and Antimicrobial Resistance Pattern in Outborn Neonates in Northern India: A Hospital-Based Observational Study. J Trop Pediatr 2021; 67:6354690. [PMID: 34410001 DOI: 10.1093/tropej/fmab068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neonates born somewhere else (outborn) and treated in a referral centre have different microbiological profile. We report the microorganism's profile and antimicrobial resistance (AMR) in blood culture proven sepsis in outborn neonates. METHODS Culture positive neonatal sepsis from a neonatal unit of a referral institute catering to outborn neonates was studied over an 18 months duration. Data from the hospital information system were used to analyse the culture positivity rates, the spectrum of the microorganisms isolated and AMR pattern. RESULTS Out of 5258 admitted neonates, 3687 blood samples were sent for suspect sepsis. The blood cultures were positive in 537 (14.6%) samples from 514 neonates. Gram-positive cocci (GPC) were the most common [240 (45%)] followed by gram-negative bacilli (GNB) [233 (43.4%)] and fungi [64 (11.9%)]. Coagulase negative staphylococcus (CONS) contributed to two-thirds of GPC followed by Klebsiella [93 (17.3%)] and Acinetobacter species [52 (9.7%)]. In 403 (75%) neonates, organisms grew in the samples sent at or within 24 h of admission. The case fatality rate was significantly higher in those with culture positive sepsis. The resistance to meropenem and imipenem was documented in 57.1% and 49.7%, respectively and 48% of the GNB was multidrug resistant. CONCLUSIONS CONS followed by Klebsiella species were the most common organisms isolated. Three-fourths of the neonates had organisms grown at or within 24 h from admission. More than half of the GNB were multidrug resistant. The case fatality rate was significantly higher in those with culture positive sepsis.
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Affiliation(s)
- Shashi Kant Dhir
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Vimal Singh Munda
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jutang Babat Ain Tiewsoh
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Suresh Kumar Angurana
- Pediatric Critical Care Unit, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jogender Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Shiv Sajan Saini
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Sourabh Dutta
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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Osei Sekyere J, Reta MA, Bernard Fourie P. Risk factors for, and molecular epidemiology and clinical outcomes of, carbapenem- and polymyxin-resistant Gram-negative bacterial infections in pregnant women, infants, and toddlers: a systematic review and meta-analyses. Ann N Y Acad Sci 2021; 1502:54-71. [PMID: 34212401 DOI: 10.1111/nyas.14650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/19/2021] [Accepted: 05/28/2021] [Indexed: 12/13/2022]
Abstract
In the following systematic review and meta-analyses, we report several conclusions about resistance to carbapenem and polymyxin last-resort antibiotics for treating multidrug-resistant bacterial infections among pregnant women and infants. Resistance to carbapenems and polymyxins is increasing, even in otherwise vulnerable groups such as pregnant women, toddlers, and infants, for whom therapeutic options are limited. In almost all countries, carbapenem-/polymyxin-resistant Klebsiella pneumoniae, Escherichia coli, and Acinetobacter baumannii infect and/or colonize neonates and pregnant women, causing periodic outbreaks with very high infant mortalities. Downregulation of plasmid-borne blaNDM , blaKPC , blaOXA-48 , blaIMP, blaVIM , blaGES-5 , and ompK35/36 in clonal strains accelerates the horizontal and vertical transmissions of carbapenem resistance among these pathogens. New Delhi metallo-β-lactamase (NDM)-positive isolates in infants/neonates have been mainly detected in China and India, while OXA-48-positive isolates in infants/neonates have been mainly detected in Africa. NDM-positive isolates in pregnant women have been found only in Madagascar. Antibiotic therapy, prolonged hospitalization, invasive procedures, mechanical ventilation, low birth weight, and preterm delivery have been common risk factors associated with carbapenem/polymyxin resistance. The use of polymyxins to treat carbapenem-resistant infections may be selecting for resistance to both agents, restricting therapeutic options for infected infants and pregnant women. Currently, low- and middle-income countries have the highest burden of these pathogens. Antibiotic stewardship, periodic rectal and vaginal screening, and strict infection control practices in neonatal ICUs are necessary to forestall future outbreaks and deaths.
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Affiliation(s)
- John Osei Sekyere
- Molecular Mycobacteriology Laboratory, Department of Medical Microbiology, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Melese Abate Reta
- Molecular Mycobacteriology Laboratory, Department of Medical Microbiology, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, Gauteng, South Africa
| | - Petrus Bernard Fourie
- Molecular Mycobacteriology Laboratory, Department of Medical Microbiology, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, Gauteng, South Africa
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Mahich S, Angurana SK, Sundaram V, Gautam V. Epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary hospital in Northern India. J Matern Fetal Neonatal Med 2021; 35:7948-7956. [PMID: 34180351 DOI: 10.1080/14767058.2021.1939300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS AND OBJECTIVES To study the epidemiology, microbiological profile, and outcome of culture positive sepsis among outborn neonates at a tertiary care teaching hospital in Northern India. MATERIALS AND METHODS Neonates (n = 406) with blood culture positive sepsis were enrolled prospectively over a period of 1 year (February 2018-January 2019). Demographic details, clinical features, microbiological profile, antibiotic sensitivity pattern, treatment, and outcome were recorded. RESULTS The mean (±SD) age at presentation was 2.4 (±0.6) days and 2/3rd were males. The mean (±SD) gestation was 35.5 (±3.4) weeks, birth weight was 2215 (±219) g, and 42.4% were preterm. The proportion of neonates with early and late onset sepsis were 69% and 31%, respectively. Predominant isolates were Gram-negative (46.5%), Gram-positive (27.6%) organisms, and yeast (25.9%). Klebsiella pneumoniae (46.5%), Acinetobacter baumannii (17.5%), and Escherichia coli (8%) were common Gram-negative; and coagulase negative Staphylococcus (CONS) (70%), Staphylococcus aureus (13.4%), and Enterococcus (12.5%) were common Gram-positive organisms. Among Gram-negative organisms, the antibiotic sensitivity pattern was ciprofloxacin 45%, cephalosporins 15-40%, aminoglycosides 20-42%, piperacillin-tazobactam 49%, carbapenems 34-51%, tetracyclines 55-70%, doxycycline 55%, chloramphenicol 42%, and colistin 98%; and among Gram-positive organisms were methicillin 30%, clindamycin 52%, vancomycin 100%, teicoplanin 98%, and linezolid 99%. The survival rate was 60.3%. The neonates with Gram-negative sepsis had higher requirement of oxygen, mechanical ventilation, and vasoactive drugs; had more complications; and lower survival (50.3% vs. 72.3%, p= .003) when compared to Gram-positive sepsis. CONCLUSIONS Gram-negative organisms were commonest cause of neonatal sepsis, had low sensitivity to commonly used antibiotics, and associated with poor outcome.
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Affiliation(s)
- Swati Mahich
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Suresh Kumar Angurana
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Amikacin Combined with Fosfomycin for Treatment of Neonatal Sepsis in the Setting of Highly Prevalent Antimicrobial Resistance. Antimicrob Agents Chemother 2021; 65:e0029321. [PMID: 33972238 PMCID: PMC8373250 DOI: 10.1128/aac.00293-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Antimicrobial resistance (particularly through extended-spectrum β-lactamase and aminoglycoside-modifying enzyme production) in neonatal sepsis is a global problem, particularly in low- and middle-income countries, with significant mortality rates. High rates of resistance are reported for the current WHO-recommended first-line antibiotic regimen for neonatal sepsis, i.e., ampicillin and gentamicin. We assessed the utility of fosfomycin and amikacin as a potential alternative regimen to be used in settings of increasingly prevalent antimicrobial resistance. The combination was studied in a 16-arm dose-ranged hollow-fiber infection model (HFIM) experiment. The combination of amikacin and fosfomycin enhanced bactericidal activity and prevented the emergence of resistance, compared to monotherapy with either antibiotic. Modeling of the experimental quantitative outputs and data from checkerboard assays indicated synergy. We further assessed the combination regimen at clinically relevant doses in the HFIM with nine Enterobacterales strains with high fosfomycin and amikacin MICs and demonstrated successful kill to sterilization for 6/9 strains. From these data, we propose a novel combination breakpoint threshold for microbiological success for this antimicrobial combination against Enterobacterales strains, i.e., MICF × MICA < 256 (where MICF and MICA are the fosfomycin and amikacin MICs, respectively). Monte Carlo simulations predict that a standard fosfomycin-amikacin neonatal regimen would achieve >99% probability of pharmacodynamic success for strains with MICs below this threshold. We conclude that the combination of fosfomycin with amikacin is a viable regimen for the empirical treatment of neonatal sepsis and is suitable for further clinical assessment in a randomized controlled trial.
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Pelegrin AC, Palmieri M, Mirande C, Oliver A, Moons P, Goossens H, van Belkum A. Pseudomonas aeruginosa: a clinical and genomics update. FEMS Microbiol Rev 2021; 45:6273131. [PMID: 33970247 DOI: 10.1093/femsre/fuab026] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 05/07/2021] [Indexed: 12/13/2022] Open
Abstract
Antimicrobial resistance (AMR) has become a global medical priority that needs urgent resolution. Pseudomonas aeruginosa is a versatile, adaptable bacterial species with widespread environmental occurrence, strong medical relevance, a diverse set of virulence genes and a multitude of intrinsic and possibly acquired antibiotic resistance traits. P. aeruginosa causes a wide variety of infections and has an epidemic-clonal population structure. Several of its dominant global clones have collected a wide variety of resistance genes rendering them multi-drug resistant (MDR) and particularly threatening groups of vulnerable individuals including surgical patients, immunocompromised patients, Caucasians suffering from cystic fibrosis (CF) and more. AMR and MDR especially are particularly problematic in P. aeruginosa significantly complicating successful antibiotic treatment. In addition, antimicrobial susceptibility testing (AST) of P. aeruginosa can be cumbersome due to its slow growth or the massive production of exopolysaccharides and other extracellular compounds. For that reason, phenotypic AST is progressively challenged by genotypic methods using whole genome sequences (WGS) and large-scale phenotype databases as a framework of reference. We here summarize the state of affairs and the quality level of WGS-based AST for P. aeruginosa mostly from clinical origin.
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Affiliation(s)
- Andreu Coello Pelegrin
- bioMérieux, Data Analytics Unit, 3 Route du Port Michaud, 38390 La Balme les Grottes, France
| | - Mattia Palmieri
- bioMérieux, Data Analytics Unit, 3 Route du Port Michaud, 38390 La Balme les Grottes, France
| | - Caroline Mirande
- bioMérieux, R&D Microbiology, Route du Port Michaud, 38390 La Balme-les-Grottes, France
| | - Antonio Oliver
- Servicio de Microbiología, Módulo J, segundo piso, Hospital Universitario Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Ctra. Valldemossa, 79, 07120 Palma de Mallorca, Spain
| | - Pieter Moons
- Laboratory of Medical Microbiology, University of Antwerp, Universiteitsplein 1, building S, 2610 Wilrijk, Antwerp, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Alex van Belkum
- bioMérieux, Open Innovation and Partnerships, 3 Route du Port Michaud, 38390 La Balme Les Grottes, France
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Azam M, Gaind R, Yadav G, Sharma A, Upmanyu K, Jain M, Singh R. Colistin Resistance Among Multiple Sequence Types of Klebsiella pneumoniae Is Associated With Diverse Resistance Mechanisms: A Report From India. Front Microbiol 2021; 12:609840. [PMID: 33692764 PMCID: PMC7937630 DOI: 10.3389/fmicb.2021.609840] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 01/22/2021] [Indexed: 12/25/2022] Open
Abstract
Background: The resistance to colistin and carbapenems in Klebsiella pneumoniae infections have been associated with increased morbidity and mortality worldwide. A retrospective observational study was conducted to determine the prevalence and molecular events contributing to colistin resistance. Methods: Clinical samples were screened for colistin resistance and underlying mechanisms were studied by PCR-based amplification and sequence analysis of genes of two-component regulatory system (phoPQ and pmrAB), regulatory transmembrane protein-coding mgrB, and mobilized colistin resistance genes (mcr-1-8). Gene expression of pmrC and pmrK was analyzed by qRT-PCR, and the genetic relationship was assessed by MLST. The putative effect of amino-acid substitutions was predicted by a combination of bioinformatics tools. Results: Of 335 Klebsiella spp. screened, 11 (3.2%) were identified as colistin-resistant (MIC range, 8 to >128 μg/ml). K. pneumoniae isolates belonged to clonal complex-11 (CC11) with sequence types (STs): 14, 16, 43, 54, 147 and 395, whereby four isolates conferred three novel STs (3986, 3987 and 3988) profiles. Sequence analysis revealed non-synonymous potentially deleterious mutations in phoP (T151A), phoQ (del87–90, del263–264, L30Q, and A351D), pmrA (G53S), pmrB (D150V, T157P, L237R, G250C, A252G, R315P, and Q331H), and mgrB (C28G) genes. The mgrB gene in three strains was disrupted by insertion sequences encoding IS1-like and IS5/IS1182 family-like transposase genes. All 11 isolates showed an elevation in the transcription level of pmrC gene. Mobilized colistin-resistance (mcr) genes were not detected. All but one of the colistin-resistant isolates was also resistant to carbapenems; β-lactamase genes blaNDM-1-like, blaOXA-48-like, and blaCTX-M-like were detected in eight, five, and nine isolates, respectively. Conclusion: All the studied colistin- and carbapenem-resistant K. pneumoniae isolates were genetically distinct, and various mechanisms of colistin resistance were detected, indicating its spontaneous emergence in this bacterial species.
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Affiliation(s)
- Mudsser Azam
- ICMR-National Institute of Pathology, New Delhi, India
| | - Rajni Gaind
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Gulshan Yadav
- ICMR-National Institute of Pathology, New Delhi, India
| | - Amit Sharma
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Kirti Upmanyu
- ICMR-National Institute of Pathology, New Delhi, India
| | - Manisha Jain
- Department of Microbiology, VMMC and Safdarjung Hospital, New Delhi, India
| | - Ruchi Singh
- ICMR-National Institute of Pathology, New Delhi, India
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Singh S, Charani E, Devi S, Sharma A, Edathadathil F, Kumar A, Warrier A, Shareek PS, Jaykrishnan AV, Ellangovan K. A road-map for addressing antimicrobial resistance in low- and middle-income countries: lessons learnt from the public private participation and co-designed antimicrobial stewardship programme in the State of Kerala, India. Antimicrob Resist Infect Control 2021; 10:32. [PMID: 33573697 PMCID: PMC7878026 DOI: 10.1186/s13756-020-00873-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The global concern over antimicrobial resistance (AMR) is gathering pace. Low- and middle-income countries (LMICs) are at the epicentre of this growing public health threat and governmental and healthcare organizations are at different stages of implementing action plans to tackle AMR. The South Indian state of Kerala was one of the first in India to implement strategies and prioritize activities to address this public health threat. STRATEGIES Through a committed and collaborative effort from all healthcare related disciplines and its professional societies from both public and private sector, the Kerala Public Private Partnership (PPP) has been able to deliver a state-wide strategy to tackle AMR A multilevel strategic leadership model and a multilevel implementation approach that included developing state-wide antibiotic clinical guidelines, a revision of post-graduate and undergraduate medical curriculum, and a training program covering all general practitioners within the state the PPP proved to be a successful model for ensuring state-wide implementation of an AMR action plan. Collaborative work of multi-professional groups ensured co-design and development of disease based clinical treatment guidelines and state-wide infection prevention policy. Knowledge exchange though international and national platforms in the form of workshops for sharing of best practices is critical to success. Capacity building at both public and private institutions included addressing practical and local solutions to the barriers e.g. good antibiotic prescription practices from primary to tertiary care facility and infection prevention at all levels. CONCLUSION Through 7 years of stakeholder engagement, lobbying with government, and driving change through co-development and implementation, the PPP successfully delivered an antimicrobial stewardship plan across the state. The roadmap for the implementation of the Kerala PPP strategic AMR plan can provide learning for other states and countries aiming to implement action plans for AMR.
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Affiliation(s)
- Sanjeev Singh
- Amrita Institute of Medical Sciences, Amrita Vishwavidyapeetham, Kochi, India.
| | - Esmita Charani
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College, London, UK
| | - Sarada Devi
- Trivandrum Medical College, Trivandrum, India
| | - Anuj Sharma
- Technical Focal Point, Antimicrobial Resistance, Laboratory and Infection Prevention and Control, WHO Country Office, Delhi, India
| | - Fabia Edathadathil
- Amrita Institute of Medical Sciences, Amrita Vishwavidyapeetham, Kochi, India
| | - Anil Kumar
- Amrita Institute of Medical Sciences, Amrita Vishwavidyapeetham, Kochi, India
| | | | - P S Shareek
- Sree Uthradom Thirunal Hospital, Trivandrum, India
| | | | - K Ellangovan
- Ministry of Health and Family Welfare, Government of Kerala, Trivandrum, India
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Mahich S, Angurana SK, Suthar R, Sundaram V, Munda VS, Gautam V. Acinetobacter Sepsis Among Out-born Neonates Admitted to Neonatal Unit in Pediatric Emergency of a Tertiary Care Hospital in North India. Indian J Pediatr 2021; 88:127-133. [PMID: 32767194 PMCID: PMC7410966 DOI: 10.1007/s12098-020-03460-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To study the clinical profile, complications, antibiotic resistance pattern, treatment, and outcome of out-born neonates with Acinetobacter spp. sepsis admitted in Pediatric emergency of a tertiary care hospital in North India. METHODS In this subgroup analysis of a prospective study (conducted over 1 y, February 2018 through January 2019), neonates with Acinetobacter spp. sepsis were included. The data collection included demographic details, clinical features, pre-referral treatment, complications, antibiotic resistance pattern, treatment, and final outcome. RESULTS Acinetobacter spp. accounted for 10.6% (43/406) of all isolates and 22.7% (43/189) of Gram-negative isolates. The median (IQR) age at presentation was 1 (1-2) d, 2/3rd were male, and 46.5% were preterm. All were admitted in peripheral hospitals before referral to authors' centre and all received intravenous antibiotics and fluids. The resistance to different antibiotics was: Ciprofloxacin 82%, cephalosporins 78-100%, amikacin 75%, pipercillin-tazobactum 62%, carbapenems 50-85%, chloramphenicol 83%, and tetracycline 50-60%. All isolates were sensitive to colistin. The survival rate was 37.2% (n = 16) and 62.8% (n = 27) had poor outcome [death and Left against medical advice (LAMA)]. Higher proportion of neonates with Acinetobacter sepsis had septic shock, multi-organ dysfunctional syndrome (MODS), and disseminated intravascular coagulation (DIC); and higher proportion required mechanical ventilation, vasoactive drugs, and had poor outcome compared to those with sepsis due to other organisms. CONCLUSIONS Acinetobacter spp. accounts for high burden of sepsis among out-born neonates and is associated with alarmingly high resistance to cephalosporins, fluroquinolones, aminoglycosides, pipercillin-tazobactum, tetracyclines, and carbapenems. Neonates with Acinetobacter spp. sepsis had higher rates of complications, requirement of mechanical ventilation and vasoactive drugs, and poor survival.
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Affiliation(s)
- Swati Mahich
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Suresh Kumar Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Renu Suthar
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Venkataseshan Sundaram
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Vimal Singh Munda
- Department of Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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43
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Luo N, Jiang S, McNamara PJ, Li X, Guo Y, Wang Y, Han J, Deng Y, Yang Y, Lee SK, Cao Y. Cardiovascular Pharmacological Support Among Preterm Infants in Chinese Referral Center Neonatal Intensive Care Units. Front Pediatr 2021; 9:638540. [PMID: 33968845 PMCID: PMC8100183 DOI: 10.3389/fped.2021.638540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To describe cardiovascular pharmacological support in infants born at <34 weeks' gestation within the first postnatal week in Chinese neonatal intensive care units (NICUs). Design: A secondary analysis of data from a multicenter randomized controlled study (REIN-EPIQ). A questionnaire regarding cardiovascular support practices was also completed by all participating NICUs. Setting: Twenty-five tertiary hospitals from 19 provinces in China. Patients: All infants born at <34 weeks' gestation and admitted to participating NICUs within the first postnatal week from May 2015 to April 2018 were included. Infants who were discharged against medical advice were excluded. Measures and Main Results: Among the 26,212 preterm infants <34 weeks, 16.1% received cardiovascular pharmacological support. The use rates increased with decreasing gestational age and birth weight, with 32.5% among infants <28 weeks and 35.9% among infants <1,000 g. Cardiovascular pharmacological support was independently associated with higher risks of death (aOR 2.8; 95% CI 2.4-3.3), severe intraventricular hemorrhage (IVH) (aOR 2.1; 95% CI 1.8-2.5) and bronchopulmonary dysplasia (BPD) (aOR 2.2; 95% CI 2.0-2.5). Overall 63.1% courses of cardiovascular pharmacological support were >3 days. Prolonged cardiovascular pharmacological support (>3 days) was independently associated with lower rates of survival without morbidity in very-low-birth-weight infants, compared with infants with shorter durations. Dopamine was the most commonly used cardiovascular agent. The cardiovascular pharmacological support rates varied from 1.9 to 65.8% among the participating NICUs. Conclusions: The rate of cardiovascular pharmacological support within the first postnatal week was high with prolonged durations in Chinese NICUs. Marked variation in cardiovascular support existed among participating NICUs. Cardiovascular pharmacological support during the early postnatal period, especially prolonged, may be associated with adverse neonatal outcomes. Clinical Trial Registration: The original trial was registered as "Reduction of Infection in Neonatal Intensive Care Units using the Evidence-based Practice for Improving Quality" (ID: NCT02600195) on clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/NCT02600195?term=NCT02600195&draw=2&rank=1.
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Affiliation(s)
- Ningxin Luo
- Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- Children's Hospital of Fudan University, Shanghai, China
| | - Patrick J McNamara
- Department of Pediatrics and Internal Medicine, University of Iowa, Iowa City, IA, United States
| | - Xiaoying Li
- Qilu Children's Hospital of Shandong University, Jinan, China
| | - Yan Guo
- Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Yang Wang
- The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Junyan Han
- Children's Hospital of Fudan University, Shanghai, China
| | - Yingping Deng
- Children's Hospital of Fudan University, Shanghai, China
| | - Yi Yang
- National Health Commision (NHC) Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre and Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,Department of Obstetrics and Gynecology, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Yun Cao
- Children's Hospital of Fudan University, Shanghai, China
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Singhal T. "Rationalization of Empiric Antibiotic Therapy" - A Move Towards Preventing Emergence of Resistant Infections. Indian J Pediatr 2020; 87:945-950. [PMID: 31912460 DOI: 10.1007/s12098-019-03144-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 12/24/2022]
Abstract
Antimicrobial resistance is a key factor leading to emerging/ re-emerging infections. Rational antimicrobial therapy or antimicrobial stewardship is one of the important interventions to prevent emergence of resistance. Choosing correct empiric therapy is crucial not only to prevent antimicrobial resistance but also to achieve good treatment outcomes. Antimicrobial therapy can be broadly classified as empiric, definitive/ targeted and preventive. It is in choice of empiric therapy that the largest margin of error exists. Paradoxically, empiric therapy is the most commonly employed therapy since microbiologic results are either not available at initiation of treatment or cannot be sent due to logistic reasons or are negative. In the Indian setting, where penetration of microbiologic diagnostic methods in small cities, towns and rural areas is still fairly low, therapy is largely empiric. Choice of empiric therapy is governed by various factors including likely pathogens, antimicrobial resistance, degree of sickness, site of infection and host co-morbidities. These principles can be applied to any clinical syndrome whether it is fever without focus, infections of the respiratory tract, gastrointestinal tract, abdomen, central nervous system, bone and joint, skin and soft tissue, urinary tract as well as neonatal sepsis and healthcare associated infections. Adherence to published guidelines for syndromic management such as that by the Indian Academy of Pediatrics and Indian Council of Medical Research is strongly recommended. One can tailor these guidelines and suggestions made in this article to an individual setting.
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Affiliation(s)
- Tanu Singhal
- Department of Pediatrics and Infectious Disease, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India.
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45
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Bandick RG, Mousavi S, Bereswill S, Heimesaat MM. Review of therapeutic options for infections with carbapenem-resistant Klebsiella pneumoniae. Eur J Microbiol Immunol (Bp) 2020; 10:115-124. [PMID: 32946421 PMCID: PMC7592515 DOI: 10.1556/1886.2020.00022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022] Open
Abstract
Infections with multi-drug resistant (MDR) bacteria including carbapenem-resistant Klebsiella pneumoniae are emerging worldwide but are difficult to treat with the currently available antibiotic compounds and therefore constitute serious threats to human health. This prompted us to perform a literature survey applying the MEDLINE database and Cochrane Register of Controlled Trials including clinical trials comparing different treatment regimens for infections caused by carbapenem-resistant K. pneumoniae. Our survey revealed that a combined application of antibiotic compounds such as meropenem plus vaborbactam, meropenem plus colistin and carbapenem plus carbapenem, resulted in significantly increased clinical cure and decreased mortality rates as compared to respective control treatment. However, further research on novel antibiotic compounds, but also on antibiotic-independent molecules providing synergistic or at least resistance-modifying properties needs to be undertaken in vitro as well as in large clinical trials to provide future options in the combat of emerging life-threatening infections caused by MDR bacteria.
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Affiliation(s)
- Rasmus G Bandick
- Institute of Microbiology, Infectious Diseases and Immunology, Gastrointestinal Microbiology Research Group, Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Soraya Mousavi
- Institute of Microbiology, Infectious Diseases and Immunology, Gastrointestinal Microbiology Research Group, Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Stefan Bereswill
- Institute of Microbiology, Infectious Diseases and Immunology, Gastrointestinal Microbiology Research Group, Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Markus M Heimesaat
- Institute of Microbiology, Infectious Diseases and Immunology, Gastrointestinal Microbiology Research Group, Charité - University Medicine Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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Popescu CR, Cavanagh MMM, Tembo B, Chiume M, Lufesi N, Goldfarb DM, Kissoon N, Lavoie PM. Neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. Expert Rev Anti Infect Ther 2020; 18:443-452. [PMID: 32070161 DOI: 10.1080/14787210.2020.1732818] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction: Sepsis accounts for up to one-third of neonatal deaths in the world each year. The World Health Organization acknowledges neonatal sepsis as a major global health concern, and that the highest burden occurs in low- and middle-income countries (LMICs). Despite major research and clinical progress in this area, we still lack accurate diagnostic tools for neonatal sepsis, complicating the management of this condition.Areas covered: The purpose here is to review the latest data on the incidence, diagnosis, prevention, and management of neonatal sepsis in LMIC. We discuss the limitations of current diagnostic tests - including their lack of availability - and how this may influence global estimates of cases. We review the benefits of antenatal, intrapartum, and post-natal preventive measures. We briefly discuss the management, highlighting the emergence of antimicrobial resistance. Finally, we expose some high priority areas.Expert opinion: Neonatal sepsis is a challenging condition requiring a multifaceted approach to address the major diagnostic issues, but also the underlying socio-economic causes that nourish epidemic cases in LMIC. Focusing on antibiotics as a main pillar of intervention is likely to engender antimicrobial resistance, eventually hindering the appreciable gains LMICs have achieved in neonatal health outcomes.
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Affiliation(s)
- Constantin Radu Popescu
- Department of Pediatrics, Division of Neonatology, Université Laval, Québec, QC, Canada.,BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Miranda M M Cavanagh
- Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | - Bentry Tembo
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Msandeni Chiume
- Department of Pediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Norman Lufesi
- Directorate of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, BC, Canada
| | - Niranjan Kissoon
- BC Children's Hospital Research Institute, Vancouver, BC, Canada
| | - Pascal M Lavoie
- BC Children's Hospital Research Institute, Vancouver, BC, Canada.,Division of Neonatology, BC Women's Hospital and Health Centre, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Carbapenem-Resistant Gram-Negative Bacterial Infections in Children. Antimicrob Agents Chemother 2020; 64:AAC.02183-19. [PMID: 31844014 DOI: 10.1128/aac.02183-19] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Carbapenem-resistant organisms (CRO) are a major global public health threat. Enterobacterales hydrolyze almost all β-lactams through carbapenemase production. Infections caused by CRO are challenging to treat due to the limited number of antimicrobial options. This leads to significant morbidity and mortality. Over the last few years, several new antibiotics effective against CRO have been approved. Some of them (e.g., plazomicin or imipenem-cilastatin-relebactam) are currently approved for use only by adults; others (e.g., ceftazidime-avibactam) have recently been approved for use by children. Recommendations for antibiotic therapy of CRO infections in pediatric patients are based on evidence mainly from adult studies. The availability of pediatric pharmacokinetic and safety data is the cornerstone to broaden the use of proposed agents in adults to the pediatric population. This article provides a comprehensive review of the current knowledge regarding infections caused by CRO with a focus on children, which includes epidemiology, risk factors, outcomes, and antimicrobial therapy management, with particular attention being given to new antibiotics.
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Wattal C, Kler N, Oberoi JK, Fursule A, Kumar A, Thakur A. Neonatal Sepsis: Mortality and Morbidity in Neonatal Sepsis due to Multidrug-Resistant (MDR) Organisms: Part 1. Indian J Pediatr 2020; 87:117-121. [PMID: 31828600 PMCID: PMC6974503 DOI: 10.1007/s12098-019-03106-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 10/22/2019] [Indexed: 01/23/2023]
Abstract
The major causes of emergence of multidrug-resistant organisms (MDRO) in neonatal sepsis include empiric antibiotic prescriptions, unregulated use of over-the-counter drugs, high incidence of healthcare associated infections (HAI), lack of awareness about antibiotic stewardship program and under staffing of neonatal intensive care units. In general, mortality due to MDRO sepsis is significantly higher as compared to non MDRO sepsis. Reported morbidities include prolonged use of total parenteral nutrition, need for central venous catheter, invasive ventilation, increased duration of hospital stay and neurologic sequelae.
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Affiliation(s)
- Chand Wattal
- Department of Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India.
| | - Neelam Kler
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - J K Oberoi
- Department of Clinical Microbiology & Immunology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anurag Fursule
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anup Kumar
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Anup Thakur
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
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Wyres KL, Nguyen TNT, Lam MMC, Judd LM, van Vinh Chau N, Dance DAB, Ip M, Karkey A, Ling CL, Miliya T, Newton PN, Lan NPH, Sengduangphachanh A, Turner P, Veeraraghavan B, Vinh PV, Vongsouvath M, Thomson NR, Baker S, Holt KE. Genomic surveillance for hypervirulence and multi-drug resistance in invasive Klebsiella pneumoniae from South and Southeast Asia. Genome Med 2020; 12:11. [PMID: 31948471 DOI: 10.1101/557785v1.full] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/12/2019] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a leading cause of bloodstream infection (BSI). Strains producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases are considered global priority pathogens for which new treatment and prevention strategies are urgently required, due to severely limited therapeutic options. South and Southeast Asia are major hubs for antimicrobial-resistant (AMR) K. pneumoniae and also for the characteristically antimicrobial-sensitive, community-acquired "hypervirulent" strains. The emergence of hypervirulent AMR strains and lack of data on exopolysaccharide diversity pose a challenge for K. pneumoniae BSI control strategies worldwide. METHODS We conducted a retrospective genomic epidemiology study of 365 BSI K. pneumoniae from seven major healthcare facilities across South and Southeast Asia, extracting clinically relevant information (AMR, virulence, K and O antigen loci) using Kleborate, a K. pneumoniae-specific genomic typing tool. RESULTS K. pneumoniae BSI isolates were highly diverse, comprising 120 multi-locus sequence types (STs) and 63 K-loci. ESBL and carbapenemase gene frequencies were 47% and 17%, respectively. The aerobactin synthesis locus (iuc), associated with hypervirulence, was detected in 28% of isolates. Importantly, 7% of isolates harboured iuc plus ESBL and/or carbapenemase genes. The latter represent genotypic AMR-virulence convergence, which is generally considered a rare phenomenon but was particularly common among South Asian BSI (17%). Of greatest concern, we identified seven novel plasmids carrying both iuc and AMR genes, raising the prospect of co-transfer of these phenotypes among K. pneumoniae. CONCLUSIONS K. pneumoniae BSI in South and Southeast Asia are caused by different STs from those predominating in other regions, and with higher frequency of acquired virulence determinants. K. pneumoniae carrying both iuc and AMR genes were also detected at higher rates than have been reported elsewhere. The study demonstrates how genomics-based surveillance-reporting full molecular profiles including STs, AMR, virulence and serotype locus information-can help standardise comparisons between sites and identify regional differences in pathogen populations.
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Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - To N T Nguyen
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Margaret M C Lam
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | | | - David A B Dance
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Abhilasha Karkey
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Clare L Ling
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Amphone Sengduangphachanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Phat Voong Vinh
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Nicholas R Thomson
- London School of Hygiene and Tropical Medicine, London, UK
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID) Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0AW, UK.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
- London School of Hygiene and Tropical Medicine, London, UK
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Wyres KL, Nguyen TNT, Lam MMC, Judd LM, van Vinh Chau N, Dance DAB, Ip M, Karkey A, Ling CL, Miliya T, Newton PN, Lan NPH, Sengduangphachanh A, Turner P, Veeraraghavan B, Vinh PV, Vongsouvath M, Thomson NR, Baker S, Holt KE. Genomic surveillance for hypervirulence and multi-drug resistance in invasive Klebsiella pneumoniae from South and Southeast Asia. Genome Med 2020; 12:11. [PMID: 31948471 PMCID: PMC6966826 DOI: 10.1186/s13073-019-0706-y] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/12/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Klebsiella pneumoniae is a leading cause of bloodstream infection (BSI). Strains producing extended-spectrum beta-lactamases (ESBLs) or carbapenemases are considered global priority pathogens for which new treatment and prevention strategies are urgently required, due to severely limited therapeutic options. South and Southeast Asia are major hubs for antimicrobial-resistant (AMR) K. pneumoniae and also for the characteristically antimicrobial-sensitive, community-acquired "hypervirulent" strains. The emergence of hypervirulent AMR strains and lack of data on exopolysaccharide diversity pose a challenge for K. pneumoniae BSI control strategies worldwide. METHODS We conducted a retrospective genomic epidemiology study of 365 BSI K. pneumoniae from seven major healthcare facilities across South and Southeast Asia, extracting clinically relevant information (AMR, virulence, K and O antigen loci) using Kleborate, a K. pneumoniae-specific genomic typing tool. RESULTS K. pneumoniae BSI isolates were highly diverse, comprising 120 multi-locus sequence types (STs) and 63 K-loci. ESBL and carbapenemase gene frequencies were 47% and 17%, respectively. The aerobactin synthesis locus (iuc), associated with hypervirulence, was detected in 28% of isolates. Importantly, 7% of isolates harboured iuc plus ESBL and/or carbapenemase genes. The latter represent genotypic AMR-virulence convergence, which is generally considered a rare phenomenon but was particularly common among South Asian BSI (17%). Of greatest concern, we identified seven novel plasmids carrying both iuc and AMR genes, raising the prospect of co-transfer of these phenotypes among K. pneumoniae. CONCLUSIONS K. pneumoniae BSI in South and Southeast Asia are caused by different STs from those predominating in other regions, and with higher frequency of acquired virulence determinants. K. pneumoniae carrying both iuc and AMR genes were also detected at higher rates than have been reported elsewhere. The study demonstrates how genomics-based surveillance-reporting full molecular profiles including STs, AMR, virulence and serotype locus information-can help standardise comparisons between sites and identify regional differences in pathogen populations.
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Affiliation(s)
- Kelly L Wyres
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - To N T Nguyen
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Margaret M C Lam
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | - Louise M Judd
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
| | | | - David A B Dance
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Abhilasha Karkey
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Clare L Ling
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, 63110, Thailand
| | - Thyl Miliya
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Amphone Sengduangphachanh
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Balaji Veeraraghavan
- Department of Clinical Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Phat Voong Vinh
- Hospital of Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Manivanh Vongsouvath
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | - Nicholas R Thomson
- London School of Hygiene and Tropical Medicine, London, UK
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID) Department of Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0AW, UK.
| | - Kathryn E Holt
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Victoria, 3004, Australia
- London School of Hygiene and Tropical Medicine, London, UK
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