Risk factors for colonization with extended-spectrum cephalosporin-resistant and carbapenem-resistant Enterobacterales among hospitalized patients in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) study

Objectives

The spread of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) has resulted in increased morbidity, mortality, and health care costs worldwide. To identify the factors associated with ESCrE and CRE colonization within hospitals, we enrolled hospitalized patients at a regional hospital located in Guatemala.

Methods

Stool samples were collected from randomly selected patients using a cross-sectional study design (March-September, 2021), and samples were tested for the presence of ESCrE and CRE. Hospital-based and household variables were examined for associations with ESCrE and CRE colonization using lasso regression models, clustered by ward (n = 21).

Results

A total of 641 patients were enrolled, of whom complete data sets were available for 593. Colonization with ESCrE (72.3%, n = 429/593) was negatively associated with carbapenem administration (odds ratio [OR] 0.21, 95% confidence interval [CI] 0.11-0.42) and positively associated with ceftriaxone administration (OR 1.61, 95% CI 1.02-2.53), as was reported hospital admission within 30 days of the current hospitalization (OR 2.84, 95% CI 1.19-6.80). Colonization with CRE (34.6%, n = 205 of 593) was associated with carbapenem administration (OR 2.62, 95% CI 1.39-4.97), reported previous hospital admission within 30 days of current hospitalization (OR 2.58, 95% CI 1.17-5.72), hospitalization in wards with more patients (OR 1.05, 95% CI 1.02-1.08), hospitalization for ≥4 days (OR 3.07, 95% CI 1.72-5.46), and intubation (OR 2.51, 95% CI 1.13-5.59). No household-based variables were associated with ESCrE or CRE colonization in hospitalized patients.

Conclusion

The hospital-based risk factors identified in this study are similar to what has been reported for risk of health care-associated infections, consistent with colonization being driven by hospital settings rather than community factors. This also suggests that colonization with ESCrE and CRE could be a useful metric to evaluate the efficacy of infection and prevention control programs in clinics and hospitals.

Informal sale of antibiotics in Guatemalan convenience stores before and after implementation of federal antibiotic dispensing legislation

BACKGROUND

Convenience stores in Guatemala provide essential consumer goods in communities, but many dispense antibiotics illegally. Federal legislation, passed in August of 2019, requires prescriptions for antibiotic purchase at pharmacies but it is unclear if this legislation is enforced or if it has any impact on unlawful sales of antibiotics.

METHODS

To determine if antibiotic availability changed in convenience stores, we carried out a repeated measures study collecting antibiotic availability data before and after implementation of the dispensing regulation.

RESULTS

There was no statistical difference in the proportion of convenience stores that sold antibiotics before and after antibiotic regulations [66.6% (295/443) and 66.7% (323/484), respectively, P>0.96], nor in the number of stores selling amoxicillin [55.5% (246/443) and 52.3% (253/484), respectively, P>0.96], but fewer stores (20%) sold tetracycline capsules after regulation was passed (P<0.05). For stores visited both before and after passage of legislation (n=157), 15% stopped selling antibiotics while 25% started selling antibiotics. Antibiotics from convenience stores were reportedly sold for use in people and animals.

CONCLUSIONS

Antibiotics remain widely available in convenience stores consistent with no significant change in the informal sector after implementation of prescription requirements for pharmacies. Importantly, effects from regulatory change could have been masked by potential changes in antibiotic use during the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic.

A multimedia program for caregivers of pediatric patients with chronic kidney disease in Guatemala

OBJECTIVES

A multimedia medication training program for parents and legal guardians of children with chronic kidney disease (CKD) aimed to improve comprehension CKD and general information about medications used in pediatric patients attending The Foundation for Children with Kidney Disease (FUNDANIER, Guatemala City).

METHODS

A quasi-experimental study was carried out to measure the impact of the educational intervention on medication knowledge, at FUNDANIER from September to October 2019. Means and standard deviations was used to described test results. A Wilcoxon test was performed, to compare scores of pre and post-tests. Odds Ratio (OR) was used to determine if there was an improvement in the knowledge score before and after the intervention. Results There was significant improvement in knowledge scores knowledge before and after the intervention(27/35 versus 33/35, P < 0.005). Mestizo participants had higher odds of improvement before and after the intervention (OR 7, CI: 0.6-78). Parent-guardians with prior education, and who spoke Spanish had higher odds of improved knowledge scores (OR 3.2, CI:0.3-35; OR 1.1 CI: 0.1-14 respectively).

CONCLUSION

Caregivers who participated in the educational workshop improved and retained information related to CKD comprehension and medications used. This study provides a model for educational modules that can be used, tested, and applied in other chronic disease settings in low to middle income countries.

PRACTICE IMPLICATIONS

A culturally relevant multimedia CKD educational platform was effective in improving medication knowledge among parent/guardians of children with CKD in a low literacy setting.

Risk Factors for Colonization With Extended-Spectrum Cephalosporin-Resistant and Carbapenem-Resistant Enterobacterales Among Hospitalized Patients in Kenya: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

The spread of extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) represents a significant global public health threat. We identified putative risk factors for ESCrE and CRE colonization among patients in 1 urban and 3 rural hospitals in Kenya.

METHODS

During a January 2019 and March 2020 cross-sectional study, stool samples were collected from randomized inpatients and tested for ESCrE and CRE. The Vitek2 instrument was used for isolate confirmation and antibiotic susceptibility testing, and least absolute shrinkage and selection operator (LASSO) regression models were used to identify colonization risk factors while varying antibiotic use measures.

RESULTS

Most (76%) of the 840 enrolled participants received ≥1 antibiotic in the 14 days preceding their enrollment, primarily ceftriaxone (46%), metronidazole (28%), or benzylpenicillin-gentamycin (23%). For LASSO models that included ceftriaxone administration, ESCrE colonization odds were higher among patients hospitalized for ≥3 days (odds ratio, 2.32 [95% confidence interval, 1.6-3.37]; P < .001), intubated patients (1.73 [1.03-2.91]; P = .009), and persons living with human immunodeficiency virus (1.70 [1.03-2.8]; P = .029). CRE colonization odds were higher among patients receiving ceftriaxone (odds ratio, 2.23 [95% confidence interval, 1.14-4.38]; P = .025) and for every additional day of antibiotic use (1.08 [1.03-1.13]; P = .002).

CONCLUSIONS

While CRE colonization was strongly associated with ceftriaxone use and duration of antibiotic use, the odds of ESCrE colonization increased with exposure to the hospital setting and invasive medical devices, which may reflect nosocomial transmission. These data suggest several areas where hospitals can intervene to prevent colonization among hospitalized patients, both through robust infection prevention and control practices and antibiotic stewardship programs.

Colonization With Antibiotic-Resistant Bacteria in a Hospital and Associated Communities in Guatemala: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

We estimated the prevalence of colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) and carbapenem-resistant Enterobacterales (CRE) from a hospital and associated communities in western Guatemala.

METHODS

Randomly selected infants, children, and adults (<1, 1-17, and ≥18 years, respectively) were enrolled from the hospital (n = 641) during the coronavirus disease 2019 (COVID-19) pandemic, March to September 2021. Community participants were enrolled using a 3-stage cluster design between November 2019 and March 2020 (phase 1, n = 381) and between July 2020 and May 2021 (phase 2, with COVID-19 pandemic restrictions, n = 538). Stool samples were streaked onto selective chromogenic agar, and a Vitek 2 instrument was used to verify ESCrE or CRE classification. Prevalence estimates were weighted to account for sampling design.

RESULTS

The prevalence of colonization with ESCrE and CRE was higher among hospital patients compared to community participants (ESCrE: 67% vs 46%, P < .01; CRE: 37% vs 1%, P < .01). Hospital ESCrE colonization was higher for adults (72%) compared with children (65%) and infants (60%) (P < .05). Colonization was higher for adults (50%) than children (40%) in the community (P < .05). There was no difference in ESCrE colonization between phase 1 and 2 (45% and 47%, respectively, P > .05), although reported use of antibiotics among households declined (23% and 7%, respectively, P < .001).

CONCLUSIONS

While hospitals remain foci for ESCrE and CRE colonization, consistent with the need for infection control programs, community prevalence of ESCrE in this study was high, potentially adding to colonization pressure and transmission in healthcare settings. Better understanding of transmission dynamics and age-related factors is needed.

Risk Factors for Colonization With Multidrug-Resistant Bacteria in Urban and Rural Communities in Kenya: An Antimicrobial Resistance in Communities and Hospitals (ARCH) Study

BACKGROUND

Colonization with antimicrobial-resistant bacteria increases the risk of drug-resistant infections. We identified risk factors potentially associated with human colonization with extended-spectrum cephalosporin-resistant Enterobacterales (ESCrE) in low-income urban and rural communities in Kenya.

METHODS

Fecal specimens, demographic and socioeconomic data were collected cross-sectionally from clustered random samples of respondents in urban (Kibera, Nairobi County) and rural (Asembo, Siaya County) communities between January 2019 and March 2020. Presumptive ESCrE isolates were confirmed and tested for antibiotic susceptibility using the VITEK2 instrument. We used a path analytic model to identify potential risk factors for colonization with ESCrE. Only 1 participant was included per household to minimize household cluster effects.

RESULTS

Stool samples from 1148 adults (aged ≥18 years) and 268 children (aged <5 years) were analyzed. The likelihood of colonization increased by 12% with increasing visits to hospitals and clinics. Furthermore, individuals who kept poultry were 57% more likely to be colonized with ESCrE than those who did not. Respondents' sex, age, use of improved toilet facilities, and residence in a rural or urban community were associated with healthcare contact patterns and/or poultry keeping and may indirectly affect ESCrE colonization. Prior antibiotic use was not significantly associated with ESCrE colonization in our analysis.

CONCLUSIONS

The risk factors associated with ESCrE colonization in communities include healthcare- and community-related factors, indicating that efforts to control antimicrobial resistance in community settings must include community- and hospital-level interventions.

Self-medication and ILI etiologies among individuals presenting at pharmacies with influenza-like illness: Guatemala City, 2018 influenza season

Objectives

We aimed to characterize the proportion of clients presenting to community pharmacies with influenza-like illness (ILI) and the severity of their illness; the proportion with detectable influenza A, influenza B, and other pathogens (i.e., parainfluenza I, II, and III, adenovirus, respiratory syncytial virus, human metapneumovirus); and to describe their self-medication practices.

Methods

A cross-sectional study was conducted in six pharmacies in Guatemala City. Study personnel collected nasopharyngeal and oropharyngeal swabs from participants who met the ILI case definition and who were self-medicating for the current episode. Participants were tested for influenza A and B and other pathogens using real-time RT-PCR. Participants’ ILI-associated self-medication practices were documented using a questionnaire.

Results

Of all patients entering the pharmacy during peak hours who responded to a screening survey (n = 18,016) 6% (n = 1029) self-reported ILI symptoms, of which 45% (n = 470/1029) met the study case definition of ILI. Thirty-one percent (148/470) met inclusion criteria, of which 87% (130/148) accepted participation and were enrolled in the study. Among 130 participants, nearly half tested positive for viral infection (n = 55, 42.3%) and belonged to groups at low risk for complications from influenza. The prevalence of influenza A was 29% (n = 35). Thirteen percent of the study population (n = 17) tested positive for a respiratory virus other than influenza. Sixty-four percent of participants (n = 83) reported interest in receiving influenza vaccination if it were to become available in the pharmacy. Medications purchased included symptom-relieving multi-ingredient cold medications (n = 43/100, 43%), nonsteroidal anti-inflammatory drugs (n = 23, 23%), and antibiotics (n = 16, 16%). Antibiotic use was essentially equal among antibiotic users regardless of viral status. The broad-spectrum antibiotics ceftriaxone and azithromycin were the most common antibiotics purchased.

Conclusions

During a typical influenza season, a relatively low proportion of all pharmacy visitors were experiencing influenza symptoms. A high proportion of clients presenting to pharmacies with ILI tested positive for a respiratory virus. Programs that guide appropriate use of antibiotics in this population are needed and become increasingly important during pandemics caused by respiratory viral pathogens.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13962-8.

Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19

Continuity of key water, sanitation, and hygiene (WASH) infrastructure and WASH practices-for example, hand hygiene-are among several critical community preventive and mitigation measures to reduce transmission of infectious diseases, including COVID-19 and other respiratory diseases. WASH guidance for COVID-19 prevention may combine existing WASH standards and new COVID-19 guidance. Many existing WASH tools can also be modified for targeted WASH assessments during the COVID-19 pandemic. We partnered with local organizations to develop and deploy tools to assess WASH conditions and practices and subsequently implement, monitor, and evaluate WASH interventions to mitigate COVID-19 in low- and middle-income countries in Latin America and the Caribbean and Africa, focusing on healthcare, community institution, and household settings and hand hygiene specifically. Employing mixed-methods assessments, we observed gaps in access to hand hygiene materials specifically despite most of those settings having access to improved, often onsite, water supplies. Across countries, adherence to hand hygiene among healthcare providers was about twice as high after patient contact compared to before patient contact. Poor or non-existent management of handwashing stations and alcohol-based hand rub (ABHR) was common, especially in community institutions. Markets and points of entry (internal or external border crossings) represent congregation spaces, critical for COVID-19 mitigation, where globally-recognized WASH standards are needed. Development, evaluation, deployment, and refinement of new and existing standards can help ensure WASH aspects of community mitigation efforts that remain accessible and functional to enable inclusive preventive behaviors.

1277. Colonization Rates for Antimicrobial-resistant Bacteria in Kenya: An Antibiotic Resistance in Communities and Hospitals (ARCH) Study

Background

Characterization of antimicrobial-resistant organism (ARO) colonization is critical to understand transmission dynamics and infection risk, however data in resource-limited settings are scare. We estimated the prevalence of Enterobacterales colonization with extended-spectrum cephalosporin-resistance (ESCrE), carbapenem-resistance (CRE) and methicillin-resistant Staphylococcus aureus (MRSA) among community residents and hospitalized patients in rural (Siaya County) and urban (Kibera) Kenya.

Methods

Community-dwelling adults and children were enrolled via cluster randomized sampling. Inpatients of all ages were enrolled by simple random sampling. Stool/rectal and nasal swabs were collected and screened for ESCrE, CRE and MRSA, respectively, using HardyChrom™ media. Vitek2^® was used for isolate confirmation and antibiotic susceptibility testing. Fisher’s exact tests were used to compare prevalence of AROs.

Results

The prevalence of ESCrE was higher for the urban hospital (69.8%, 263/377) compared to rural hospitals (62.7%, 298/475, P=0.04); a similar pattern was evident for CRE (16.7%, 63/377 and 6.5%, 31/475, respectively, P< 0.01). The prevalence of MRSA was 3.2% for both urban and rural hospitals (P=0.99). For adults, the prevalence of ESCrE was higher in Kibera households (51.4%, 346/673) compared to Siaya (44.6%, 283/634, P=0.02) while the prevalence of both CRE and MRSA was < 3% for both areas and did not differ significantly (CRE, P=0.13, MRSA, P=0.14). There was no significant difference between urban and rural children for ESCrE (47.7%, 74/155 and 53.4%, 135/253, P=0.31); both CRE and MRSA were rarely detected (< 2%) with no difference across settings (CRE, P=1.0, MRSA, P=0.42). Among Enterobacteriaceae recovered, Escherichia coli and Klebsiella spp. predominated.

Conclusion

Colonization with AROs were widespread in households and hospitals in urban and rural areas. Hospitals with elevated prevalence of highly transmissible AROs should consider whether implementation of colonization screening can be incorporated as part of their infection prevention and control programs. Risk factors for ARO colonization should be elucidated to identify novel prevention strategies.

Disclosures

All Authors: No reported disclosures

120. Antimicrobial Prescribing Guidance and Communication Among Health Care Professionals in Five Guatemalan Hospitals

Background

Communication among health care professionals during antimicrobial prescribing is critical to ensure appropriate use. This is of concern in Guatemala where physicians seldom consider guidance from other professionals during antimicrobial prescribing activities.

Methods

We carried out a cross sectional questionnaire and open ended interviews with physicians from five hospitals in Guatemala to describe perceptions of communication between health care providers, and acceptance of antimicrobial guidance during prescribing.

Results

From January to April 2021 an electronic questionnaire was sent to enrolled physicians of which 74% completed participation (n=107/145). Fifty-five percent participated in open ended interviews (n=79/145). Respondents perceived high levels of communication between physicians and ID specialists (94% of respondents); 52%, and 54% perceived high levels of physician-pharmacist, and physician-nurse communication respectively. Significant differences in the perception of physician-pharmacist communication were detected when comparing responses between hospitals, and between respondent sex (chi2, p&lt; 0.05). Barriers to communication between professionals included lack of local guidelines or protocols, patient overload, COVID-19 pandemic, lack of mentorship, and little room to discuss antimicrobial therapy with higher-ranking physicians. Eighty percent and 45% of physicians were open to receiving antibiotic optimization recommendations from other physicians, and pharmacists respectively. Notable barriers to accepting recommendations from pharmacists included lack of regular communication, lack of clinical experience, and concern about evidence based recommendations.

Conclusion

Effective communication is perceived between physicians during antimicrobial prescribing activities. Marginal levels of communication and acceptance of prescribing recommendations have been detected between physicians and pharmacists.In this milieu, there is an opportunity to strengthen multidisciplinary teams to optimize antimicrobial use.

Disclosures

Mario Augusto Melgar Toledo, MD, Merck (Grant/Research Support)Pfizer (Grant/Research Support)

808. Appropriate Use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala

Background

The appropriate use of Surgical Antibiotic Prophylaxis (SAP) contributes to reducing the prevalence of Surgical Site Infections (SSI). Inappropriate use increases the risk of SSIs, hospitalization costs and potentially contributes to the emergence of antimicrobial resistance. We aimed to compare the appropriate use before and after implementing a SAP protocol in our institution

Methods

We conducted a retrospective chart review in patients older than 18 undergoing elective cardiac surgery with cardiopulmonary bypass using cephalotin as SSI prophylaxis. We excluded patients who received other antimicrobials for prophylaxis, those undergoing non-elective surgery, and patients with delayed sternal closure. We identified SSIs according to the Centers for Disease Prevention and Control criteria. We evaluated if appropriate dosing (2g-3g) and timing ( &gt;60 min.) occurred before the surgical incision, if redosing was administered, and if prophylaxis was administered &gt; 48 hours. We evaluated before and after implementation of the protocol (August 2016-July 2017; October 2017-2018)

Results

The study included 262 and 285 patients before and after protocol implementation, respectively. Patient characteristics were similar between comparator groups (Table 1). We found that 1.1% of patients vs. 63% of patients had appropriate dosing before the surgical incision, before and after protocol implementation, respectively (p &lt; 0.05). There was no difference in appropriate redosing when the duration of surgery was greater than 4 hours and no difference in inappropriate prophylaxis administration &gt; 48 hours after protocol implementation. A total of 8 SSIs were identified in each group, with no statistical difference in the incidence, length of stay, or clinical outcome between comparator groups

Table 1. Patient Characteristics and Appropriate use of Cephalotin Before and After Implementation of a Cardiac Surgery Antibiotic Prophylaxis Protocol in Guatemala

Conclusion

Based on our findings, implementing a local guideline-protocol for SAP resulted in significant improvement of pre-surgical antimicrobial dosing. We observed continual unnecessary administration of antibiotic prophylaxis in the postoperative period that needs more proactive interventional pharmacy-guided strategies such as automatic stops or audits width feedback.

Disclosures

Lourdes A. Sandoval, Master of Science in Pharmacovigilance and Pharmacoepidemiology, Abbott (Employee)

Disponibilidad de antibióticos en tiendas de Guatemala

No disponible.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala

OBJECTIVE

To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala.

METHODS

A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER's pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis.

RESULTS

The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother's education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables.

CONCLUSIONS

Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother's level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

Factors associated with chronic kidney disease of non-traditional causes among children in Guatemala

Objective. To identify factors associated with chronic kidney disease of non-traditional causes among children in Guatemala.

Methods. A cross-sectional survey was conducted. The study population was all pediatric patients with stage 5 chronic kidney disease active in FUNDANIER’s pediatric nephrology unit (N = 156). Simple random sampling led to a total of 100 participants. Data collection consisted of a questionnaire addressing individual and household characteristics, access and utilization of health care, and place of residence when the disease began. Chronic kidney disease etiology was obtained from medical records. Municipality-level secondary data were collected. Descriptive statistics were estimated. Logistic regression was used for bivariate and multivariate analysis.

Results. The odds ratio (OR) for almost all variables approached 1. Notable exceptions in household characteristics were mother’s education level up to primary school (OR 2.2727) and living in an urban setting when symptoms began (OR 0.4035). Exceptions in municipal characteristics are zones with intensive small-scale agriculture (OR 3.8923) and those with intensive large-scale agriculture (OR 0.3338). P-values and confidence intervals show that the sample was not big enough to capture statistically significant associations between variables.

Conclusions. Study findings suggest that factors associated with chronic kidney disease of non-traditional causes among children in Guatemala are intensive agricultural practices in their municipality of residence, and mother’s level of education. Future research in children could use case-control designs or population-based studies in agricultural communities. Public health interventions that involve kidney function screening among children are recommended.

Toward improved adherence: a text message intervention in an human immunodeficiency virus pediatric clinic in Guatemala City

As access to human immunodeficiency virus treatment expands in Low to Middle Income Countries, it becomes critical to develop and test strategies to improve adherence and ensure efficacy. Text messaging improves adherence to antiretroviral treatment antiretroviral treatment in some patient populations, but data surrounding the use of these tools is sparse in pediatric and adolescent patients in low to middle income countries. We evaluated if a text message intervention can improve antiretroviral treatment adherence while accounting for cell phone access, patterns of use, and willingness to receive text messages.We carried out a cross sectional study to understand willingness of receiving text message reminders, followed by a randomized controlled trial to assess effectiveness of text message intervention.Enrolled participants were randomized to receive standard care with regular clinic visits, or standard care plus short message service reminders. Adherence was measured 3 times during the study period using a 4-day Recall Questionnaire. Outcome was measured based on differences in the average adherence between the intervention and control group at each time point (baseline, 3 months, 6 months).Most respondents were willing to receive text message adherence reminders (81.1%, n = 53). Respondent literacy, travel time to clinic, cell phone access, and patterns of use were significantly associated with willingness. In the randomized trial the intervention group (n = 50) experienced a small but significant mean improvement in adherence over the six-month period (4%, P < .01) whereas the control group (n = 50) did not (mean improvement: 0.8%, P = .64).Text message interventions effectively support antiretroviral adherence in pediatric patients living with human immunodeficiency virus. Studies designed to assess the impact of text messaging interventions must examine local context for cellular phone infrastructure and use and must account for potential loss to follow up when patients miss appointments and study assessments.

Exploring the safety and efficacy of adding ketoconazole to tacrolimus in pediatric renal transplant immunosuppression

BACKGROUND

Guatemala is a developing country in Central America with limited health resources. In order to expand successful renal transplant care to children and adolescents at the lowest possible cost, our pediatric renal transplant clinic uses a post-transplant tacrolimus-sparing strategy via inhibition of CYP3A4.

AIM

To study the safety, efficacy and the associated cost reduction of ketoconazole in combination with tacrolimus in this pediatric population.

METHODS

A retrospective chart review was carried out among the cohort of pediatric renal transplant recipients treated at the Foundation for pediatric renal patients (Fundación para el Niño Enfermo Renal - FUNDANIER), a pediatric tertiary care renal transplant center in Guatemala City, Guatemala. Patient charts were reviewed to ascertain the number of transplant recipients who were transitioned from tacrolimus based immunosuppression to combination therapy with ketoconazole and tacrolimus. Twenty-five post-transplant patients that used ketoconazole combined with tacrolimus were identified. Anthropometric, clinical and laboratory data was collected from patient charts before and after the transition.

RESULTS

Of the 25 patient charts reviewed 12 (48%) patients were male and the average patient age was 13 years. Twenty-four (96%) transplants were from living donors. There was a non-significant difference between the mean tacrolimus doses six months and two months prior to ketoconazole: -0.10 ± 0.04 (95%CI: 0.007, -0.029), P = 0.23. However, the difference between the mean tacrolimus doses six months prior to ketoconazole initiation and six months after ketoconazole addition was significant: 0.06 ± 0.05 (95%CI: -0.034, -0.086) P < 0.001. All tacrolimus doses were reduced by 45% after the addition of ketoconazole. Therapeutic levels of tacrolimus ranged between 6.8-8.8 ng/mL during the study period and patients demonstrated an increase in estimated glomerular filtration rate. The combination of tacrolimus and ketoconazole resulted in a 21% reduction in cost.

CONCLUSION

Patients experienced an effective dose-reduction of tacrolimus with the administration of ketoconazole. There was no relevant variations in tacrolimus serum levels, number of rejections, or significant liver toxicity. The strategy allowed a cost reduction in pediatric immunosuppressive therapy.

Community-Acquired Antimicrobial Resistant Enterobacteriaceae in Central America: A One Health Systematic Review

Community-acquired antimicrobial resistant Enterobacteriaceae (CA-ARE) are an increasingly important issue around the world. Characterizing the distribution of regionally specific patterns of resistance is important to contextualize and develop locally relevant interventions. This systematic review adopts a One Health framework considering the health of humans, animals, and the environment to describe CA-ARE in Central America. Twenty studies were identified that focused on antimicrobial resistance (AMR) in Enterobacteriaceae. Studies on CA-ARE in Central America characterized resistance from diverse sources, including humans (n = 12), animals (n = 4), the environment (n = 2), and combinations of these categories (n = 2). A limited number of studies assessed prevalence of clinically important AMR, including carbapenem resistance (n = 3), third generation cephalosporin resistance (n = 7), colistin resistance (n = 2), extended spectrum beta-lactamase (ESBL) production (n = 4), or multidrug resistance (n = 4). This review highlights significant gaps in our current understanding of CA-ARE in Central America, most notably a general dearth of research, which requires increased investment and research on CA-ARE as well as AMR more broadly.

Availability of over-the-counter antibiotics in Guatemalan corner stores

Widespread availability of antibiotics without prescription potentially facilitates overuse and contributes to selection pressure for antimicrobial resistant bacteria. Prior to this study, anecdotal observations in Guatemala identified corner stores as primary antibiotic dispensaries, where people purchase antibiotics without prescriptions. We carried out a cross sectional study to document the number and types of antibiotics available in corner stores, in four study areas in Guatemala. A total of 443 corner stores were surveyed, of which 295 (67%) sold antibiotics. The most commonly available antibiotics were amoxicillin, found in 246/295 (83%) stores, and tetracycline, found in 195/295 (66%) stores. Over the counter sales result from laissez-faire enforcement of antibiotic dispensing regulations in Guatemala combined with patient demand. This study serves as a baseline to document changes in the availability of antibiotics in informal establishments in light of new pharmacy regulations for antibiotic dispensing, which were adopted after this study was completed.

Antibiotic use and hygiene interact to influence the distribution of antimicrobial-resistant bacteria in low-income communities in Guatemala

To examine the effects of poor sanitation and hygiene on the prevalence of antimicrobial-resistant bacteria, we surveyed households in two rural and two urban communities in Guatemala (N = 196 randomly selected households). One adult (≥ 18-years old) and, when available, one child (≤ 5 years-old) provided a stool sample. Up to 48 presumptive Escherichia coli isolates were collected from each stool sample (n = 21,256 total) and were subjected to breakpoint assays for ten antibiotics. Mixed-effects logistic models were used to identify potential factors influencing the likelihood of harboring antibiotic-resistant bacteria. For nine out of ten antibiotics, the odds of detecting resistant bacteria decreased by ~ 32% (odds ratios, OR 0.53-0.8, P < 0.001) for every unit of improvement of a hygiene scale. Hygiene differences between households had a greater impact on prevalence compared to antibiotic use differences. The likelihood of detecting resistant isolates was lower for five antibiotics among households that boiled raw milk before consumption (OR 0.31-0.69), and higher for nine antibiotics in urban households (OR > 1.89-9.6). Poor hygiene conditions likely obscure effects of individual antibiotic use, presumably due to enhanced microbial transmission. Consequently, efforts to improve antibiotic stewardship should be coupled with improving hygiene conditions.

Factors associated to acceptable treatment adherence among children with chronic kidney disease in Guatemala

Pediatric patients with Chronic Kidney Disease face several barriers to medication adherence that, if addressed, may improve clinical care outcomes. A cross sectional questionnaire was administered in the Foundation for Children with Kidney Disease (FUNDANIER, Guatemala City) from September of 2015 to April of 2016 to identify the predisposing factors, enabling factors and need factors related to medication adherence. Sample size was calculated using simple random sampling with a confidence level of 95%, confidence interval of 0.05 and a proportion of 87%. A total of 103 participants responded to the questionnaire (calculated sample size was 96). Independent variables were defined and described, and the bivariate relationship to dependent variables was determined using Odds Ratio. Multivariate analysis was carried out using logistic regression. The mean adherence of study population was 78% (SD 0.08, max = 96%, min = 55%). The mean adherence in transplant patients was 82% (SD 7.8, max 96%, min 63%), and the mean adherence in dialysis patients was 76% (SD 7.8 max 90%, min 55%). Adherence was positively associated to the mother's educational level and to higher monthly household income. Together predisposing, enabling and need factors illustrate the complexities surrounding adherence in this pediatric CKD population. Public policy strategies aimed at improving access to comprehensive treatment regimens may facilitate treatment access, alleviating economic strain on caregivers and may improve adherence outcomes.

Comparing antibiotic self-medication in two socio-economic groups in Guatemala City: a descriptive cross-sectional study

Background

Self-medication with antibiotics may result in antimicrobial resistance and its high prevalence is of particular concern in Low to Middle Income Countries (LMIC) like Guatemala. A better understanding of self-medication with antibiotics may represent an opportunity to develop interventions guiding the rational use of antibiotics. We aimed to compare the magnitude of antibiotic self-medication and the characteristics of those who self-medicate in two pharmacies serving disparate socio-economic communities in Guatemala City.

Methods

We conducted a descriptive, cross-sectional study in one Suburban pharmacy and one City Center pharmacy in Guatemala City. We used a questionnaire to gather information about frequency of self-medication, income and education of those who self-medicate. We compared proportions between the two pharmacies, using two-sample z-test as appropriate.

Results

Four hundred and eighteen respondents completed the survey (221 in the Suburban pharmacy and 197 in the City Center pharmacy). Most respondents in both pharmacies were female (70%). The reported monthly income in the suburban pharmacy was between $1,250.00-$2,500.00, the city-center pharmacy reported a monthly income between $125.00- $625.00 (p < 0.01). Twenty three percent of Suburban pharmacy respondents and 3% in the City Center pharmacy completed high school (p < 0.01). Proportion of self-medication was 79% in the Suburban pharmacy and 77% in City Center pharmacy. In both settings, amoxicillin was reported as the antibiotic most commonly used.

Conclusions

High proportions of self-medication with antibiotics were reported in two pharmacies serving disparate socio-economic groups in Guatemala City. Additionally, self-medicating respondents were most often women and most commonly self-medicated with amoxicillin. Our findings support future public health interventions centered on the regulation of antibiotic sales and on the potential role of the pharmacist in guiding prescription with antibiotics in Guatemala.

Electronic supplementary material

The online version of this article (doi:10.1186/s40360-015-0011-3) contains supplementary material, which is available to authorized users.