Isoniazid preventive therapy completion in children under 5 years old who are contacts of tuberculosis cases in Lima, Peru: study protocol for an open-label, cluster-randomized superiority trial

BACKGROUND

Children < 5 years old in contact with TB cases are at high risk for developing severe and fatal forms of TB. Contact investigation, BCG vaccination, and isoniazid preventive therapy (IPT) are the most effective strategies to prevent TB among children. However, the implementation of IPT faces challenges at several stages of the cascade of care of TB infection among children, particularly those less than 5 years old. In Peru, a large proportion of children do not complete IPT, which highlights the need to design effective interventions that enhance preventive therapy adherence and completion. Although the body of evidence for such interventions has grown, interventions in medium TB incidence settings are lacking. This study aims to test the effectiveness, acceptability, and feasibility of an intervention package to increase information and motivation to complete IPT among children < 5 who have been prescribed IPT.

METHODS

An open-label, cluster-randomized superiority trial will be conducted in two districts in South Lima, Peru. Thirty health facilities will be randomized as clusters, 10 to the intervention and 20 to control (standard of care). We aim to recruit 10 children from different households in each cluster. Participants will be caretakers of children aged < 5 years old who initiated IPT. The intervention consists of educational material, and short message services (SMS) reminders and motivators. The primary outcomes will be the proportion of children who picked up > 90% of the 24 weeks of IPT (22 pick-ups) and the proportion of children who picked up the 24 weeks of IPT. The standard of care is a weekly pick-up with monthly check-ups in a health facility. Feasibility and acceptability of the intervention will be assessed through an interview with the caretaker.

DISCUSSION

Unfavorable outcomes of TB in young children, high effectiveness of IPT, and low rates of IPT completion highlight the need to enhance adherence and completion of IPT among children < 5 years old. Testing of a context-adapted intervention is needed to improve IPT completion rates and therefore TB prevention in young children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03881228. Registered on March 19, 2019.

151. Molecular diversity and resistance mechanisms of Klebsiella pneumoniae bloodstream infections in Peru

Background

Klebsiella pneumoniae, a leading pathogen for mortality associated with antimicrobial resistance (AMR), was responsible for > 250,000 deaths in 2019. Genomic surveillance can guide the development of vaccines and new antibiotics against this pathogen. While AMR disproportionally affects low-and middle-income countries, limited genomic data are available from these countries. To close this gap, this study provides genomic characterization of K. pneumoniae blood isolates recovered in Peru.

Methods

Consecutive non-duplicate K. pneumoniae blood culture isolates were collected during an AMR surveillance study (VIRAPERU) from Jul 2017 to Oct 2019, from 15 tertiary hospitals from 13 regions of Peru. DNA extraction (GeneJET, Thermo Fisher Scientific), DNA library (Nextera XT, Illumina) and genome sequencing (MiSeq 500bp-V2, Illumina) were conducted. De novo assembling (SPAdes v3.13.1), quality assessment and annotation (Nullarbor v2.0), and identification of species, ST group, K/O loci, AMR (Kleborate v2.0.1) were conducted. Phylogenetic trees were built with Microreact v.192.

Results

From 119 K. pneumoniae isolates, 114 were recovered and confirmed to belong to the Klebsiella taxon. Six species were identified, the most prevalent being K. pneumoniae (106), followed by K. quasipneumoniae (3). Among carbapenem-resistant isolates (n=13), 10 (77%) carried the bla_NDM-1 gene, while other three carried bla_KPC-2 (1), bla_IMP-16 (1) or no carbapenemase (1). Phenotypic co-resistance to colistin was present in 2 isolates, both negative for mcr-1 gene. The most common mechanisms of resistance to 3^rd generation cephalosporins, quinolones and to aminoglycosides were CTX-M-15 (74.4%), qnrB (63.6%), aac(6')-Ib-cr (87.5%), respectively. Many other AMR genetic determinants were identified (Fig. 1). Sixty ST groups were identified, but only 6 ST groups carried a carbapenemase gene (Fig. 2). A wide diversity of K and O locus was also identified (54 distinct K-loci and 14 distinct O-loci). Figure 1.

Emergence of a multidrug-resistant and virulent Streptococcus pneumoniae lineage mediates serotype replacement after PCV13: an international whole-genome sequencing study

BACKGROUND

Serotype 24F is one of the emerging pneumococcal serotypes after the introduction of pneumococcal conjugate vaccine (PCV). We aimed to identify lineages driving the increase of serotype 24F in France and place these findings into a global context.

METHODS

Whole-genome sequencing was performed on a collection of serotype 24F pneumococci from asymptomatic colonisation (n=229) and invasive disease (n=190) isolates among individuals younger than 18 years in France, from 2003 to 2018. To provide a global context, we included an additional collection of 24F isolates in the Global Pneumococcal Sequencing (GPS) project database for analysis. A Global Pneumococcal Sequence Cluster (GPSC) and a clonal complex (CC) were assigned to each genome. Phylogenetic, evolutionary, and spatiotemporal analysis were conducted using the same 24F collection and supplemented with a global collection of genomes belonging to the lineage of interest from the GPS project database (n=25 590).

FINDINGS

Serotype 24F was identified in numerous countries mainly due to the clonal spread of three lineages: GPSC10 (CC230), GPSC16 (CC156), and GPSC206 (CC7701). GPSC10 was the only multidrug-resistant lineage. GPSC10 drove the increase in 24F in France and had high invasive disease potential. The international dataset of GPSC10 (n=888) revealed that this lineage expressed 16 other serotypes, with only six included in 13-valent PCV (PCV13). All serotype 24F isolates were clustered in a single clade within the GPSC10 phylogeny and long-range transmissions were detected from Europe to other continents. Spatiotemporal analysis showed GPSC10-24F took 3-5 years to spread across France and a rapid change of serotype composition from PCV13 serotype 19A to 24F during the introduction of PCV13 was observed in neighbouring country Spain.

INTERPRETATION

Our work reveals that GPSC10 alone is a challenge for serotype-based vaccine strategy. More systematic investigation to identify lineages like GPSC10 will better inform and improve next-generation preventive strategies against pneumococcal diseases.

FUNDING

Bill & Melinda Gates Foundation, Wellcome Sanger Institute, and the US Centers for Disease Control and Prevention.

Effect of bovine lactoferrin on prevention of late-onset sepsis in infants <1500 g: a pooled analysis of individual patient data from two randomized controlled trials

We previously conducted two randomized controlled trials with bovine lactoferrin (bLF) for the prevention of late-onset sepsis (LOS) in infants with a birth weight <2500 g (Study 1) and <2000 g (Study 2). The aim of this study was to determine the preventative effects of bLF on culture-proven or probable LOS in infants with a birth weight <1500 g from both studies, and to determine the effect of bLF in relation to intake of human milk. Both trial designs had similar inclusion and exclusion criteria, the same dose of bLF [200 mg·(kg body mass)^-1·day^-1], and used the same control (maltodextrin). We fitted multivariate Cox regression models to estimate the effect of bLF on the risk of development of the composite outcome, adjusting for covariates. We included 335 neonates with a mean birth weight of 1162 ± 244 g; 27.5% were <1000 g. There were 33 first episodes of LOS in the bLF treatment group and 48 in the control group (19.5% vs. 28.9%). bLF had a protective effect on the risk of development of LOS [hazard ratio (HR) = 0.64; %95 CI = 0.41-0.99; p = 0.048]; particularly among infants weighing <1000 g [HR = 0.46; %95 CI = 0.22-0.96; p = 0.039] and infants with a low intake of human milk [HR = 0.40; %95 CI = 0.19-0.84; p = 0.015]. Therefore, bLF supplementation protects infants <1500 g from LOS, particularly those infants not receiving human milk.

Characterization of ESBL-Producing Salmonella enterica Serovar Infantis Infection in Humans, Lima, Peru

Salmonella enterica serovar Infantis is causing an increasing number of infections worldwide. Our aim was to describe the characteristics of S. enterica serovar Infantis among patients attended in a hospital of Lima, Peru. Fifty cases of salmonellosis were seen during October 2015-May 2017; Salmonella Infantis was detected in 36% (n = 18) of them, displacing Enteritidis and Typhimurium (n = 13, 26%, each). Seventeen cases caused by Salmonella Infantis were presented as diarrheal illnesses; only one extraintestinal case (bacteremia) was seen in a 1-year-old infant. This serovar is resistant to multiple groups of antimicrobials, showing only fully susceptibility to carbapenems. Compared with Infantis, other serovars analyzed (mainly Enteritidis and Typhimurium) showed a lower frequency of resistance to antimicrobials such as trimethoprim-sulfamethoxazole, ampicillin, and chloramphenicol. The antibiotic with the highest frequency of resistance was ciprofloxacin. Further studies are needed to evaluate the routes of transmission and measures of control of this multidrug-resistant Salmonella.

2049. Pneumocystis jiroveci Detection by Nested PCR in HIV-Infected Peruvian Patients

Background

Pneumocystis jiroveci (PJ) is considered a common cause of pneumonia in HIV-AIDS patients. PJ detection now is facilitated by molecular techniques using non-invasive samples; however, there are few PJ colonization studies in HIV population using these techniques. The study aim was to evaluate the frequency and factors related to PJ colonization among HIV-patients with CD4 account <500 cells/mm³.

Methods

We performed a cross-sectional study evaluating HIV patients older than 18 years old with or without respiratory symptoms with CD4 account <500 cells/mm³ who attended Hospital Cayetano Heredia in Lima, Peru during May 2017–March 2018. After patients signed an inform consent, clinical information was obtained from the medical chart and a non-induced sputum sample was collected. If patient did not have cough, an oral wash sample using saline was obtained. PJ detection was based on the amplification of the mitochondrial large subunit ribosomal RNA (mtLSU rRNA) in two stages. First, single round PCR was done using external primers (pAZ102E and pAZ102H); then, PCR products were amplified (nested PCR) using internal primers (pAZ102X and pAZ102Y). If the single round PCR was positive in a patient with respiratory symptoms, it was considered a PJ infection. If only the nested PCR was positive, this was considered as PJ colonization.

Results

A total of 177 patients were included, 75 (42.4%) with respiratory symptoms. Three cases were considered PJ infections. A total of 15 cases (8.6%) were colonized by PJ, 7/72 (9.7%) cases with respiratory symptoms and 8/102 (7.8%) among asymptomatic patients. A higher proportion of colonization was seen in patients in whom an oral wash was obtained (14/156, 9.0%) compared with those in whom a non-induced sputum was analyzed (1/18, 5.5%). The frequency of PJ colonization based on CD4 account was 6.5 and 10.3% among patients with ≤200 and >200 cells/mm³, respectively.

Conclusion

PJ colonization was seen in 8.6% of HIV patients. The proportion of PJ detection was higher when oral wash was analyzed compared with non-induced sputum. Patients with lower CD4 account did not show a higher proportion of colonization.

Disclosures

All authors: No reported disclosures.

Killing of Cryptosporidium sporozoites by Lactoferrin

Intestinal infection caused by Cryptosporidium is a major contributor to diarrhea morbidity and mortality in young children around the world. Current treatments for children suffering from cryptosporidiosis are suboptimal. Lactoferrin is a glycoprotein found in breast milk. It has showed bacteriostatic and antimicrobial activity in the intestine. However, the effects of lactoferrin on the intestinal parasite Cryptosporidium have not been reported. In this study, we investigated the anticryptosporidial activity of human lactoferrin on different stages of Cryptosporidium. Physiologic concentrations of lactoferrin killed Cryptosporidium parvum sporozoites, but had no significant effect on oocysts viability or parasite intracellular development. Since sporozoites are essential for the infection process, our data reinforce the importance of breastfeeding and point to the potential of lactoferrin as a novel therapeutic agent for cryptosporidiosis.

[Effect of bovine lactoferrin biofilms in the formation of clinical strains of enteroaggregative E. coli]

OBJECTIVES

To determine the effect of bovine lactoferrin (BLF) in the formation of biofilms in clinical enteroaggregative Escherichia coli (EAEC) strains and whether this effect is independent of iron.

MATERIALS AND METHODS

Two methods were used: (a) qualitative, by direct observation of optical microscopy, and (b) quantitative readings of the absorbance values using ELISA reader in the presence of bLf in concentrations of 0.01 mg mL and 1 mg/mL, with and without iron and no bLf (control). Analysis occurred in 122 strains of EAEC (60 strains from children with diarrhea and 62 healthy children) previously collected in a previous study of passive surveillance of diarrhea in the Southern Cone Lima. 31 strains of the same method were used for the qualitative study.

RESULTS

(A) Qualitative method: 31 strains were evaluated with and without iron. Without iron biofi formation was 77% (24/31) in the control group versus 58% (14/31) with bLf of 0.01 mg/mL and 4% (1/31) with 1 mg/ml. Iron biofilm formation was 90% (28/31) in the control group versus 55% (17/31) with bLf of 0.01 mg/mL and 4% (1/31) with 1 mg/mL. (B) Quantitative method: without iron absorbance measured at OD 560 nm of the control group was 0.7 ± 0.5 versus 0.4 ± 0.3 with bLf 0.01 mg/mL and 0.3 ± 0.2 with bLf of 1 mg/mL (p<0.0001). This decrease in the presence of bLf included iron.

CONCLUSIONS

bLf tends to decrease the formation of biofilms, showing an inhibitory effect in clinical isolates of EAEC; this effect is not iron-dependent.

Cholera in ecuador: current relevance of past lessons learnt

This report analyses the trends in the cholera epidemic that hit Ecuador in 1991. The study is based on personal experiences and analysis of epidemiological databases from the Ministry of Public Health of Ecuador. The number of cases and initial attack rates in an immunologically naive population are described by province. An analysis of the Andean and coastal cholera patterns of transmission are described along with its associated risk factors. The logistical, environmental, and socio-cultural risk factors prevalent during the epidemic and the control measures implemented are also reviewed. Also, the role of the epidemic in the development of the public health and healthcare resources in Ecuador is discussed here. Current data indicate favorable conditions for another outbreak of cholera in Ecuador. In view of the existing risk factors, new strategies are proposed to prevent such an epidemic in the future.

A community randomised controlled trial evaluating a home-based environmental intervention package of improved stoves, solar water disinfection and kitchen sinks in rural Peru: rationale, trial design and baseline findings

INTRODUCTION

Pneumonia and diarrhoea are leading causes of death in children. There is a need to develop effective interventions.

OBJECTIVE

We present the design and baseline findings of a community-randomised controlled trial in rural Peru to evaluate the health impact of an Integrated Home-based Intervention Package in children aged 6 to 35 months.

METHODS

We randomised 51 communities. The intervention was developed through a community-participatory approach prior to the trial. They comprised the construction of improved stoves and kitchen sinks, the promotion of hand washing, and solar drinking water disinfection (SODIS). To reduce the potential impact of non-blinding bias, a psychomotor stimulation intervention was implemented in the control arm. The baseline survey included anthropometric and socio-economic characteristics. In a sub-sample we determined the level of faecal contamination of drinking water, hands and kitchen utensils and the prevalence of diarrhoegenic Escherichia coli in stool specimen.

RESULTS

We enrolled 534 children. At baseline all households used open fires and 77% had access to piped water supplies. E. coli was found in drinking water in 68% and 64% of the intervention and control households. Diarrhoegenic E. coli strains were isolated from 45/139 stool samples. The proportion of stunted children was 54%.

CONCLUSIONS

Randomization resulted in comparable study arms. Recently, several critical reviews raised major concerns on the reliability of open health intervention trials, because of uncertain sustainability and non-blinding bias. In this regard, the presented trial featuring objective outcome measures, a simultaneous intervention in the control communities and a 12-month follow up period will provide valuable evidence.

Enteric disease surveillance under the AFHSC-GEIS: current efforts, landscape analysis and vision forward

The mission of the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) is to support global public health and to counter infectious disease threats to the United States Armed Forces, including newly identified agents or those increasing in incidence. Enteric diseases are a growing threat to U.S. forces, which must be ready to deploy to austere environments where the risk of exposure to enteropathogens may be significant and where routine prevention efforts may be impractical. In this report, the authors review the recent activities of AFHSC-GEIS partner laboratories in regards to enteric disease surveillance, prevention and response. Each partner identified recent accomplishments, including support for regional networks. AFHSC/GEIS partners also completed a Strengths, Weaknesses, Opportunities and Threats (SWOT) survey as part of a landscape analysis of global enteric surveillance efforts. The current strengths of this network include excellent laboratory infrastructure, equipment and personnel that provide the opportunity for high-quality epidemiological studies and test platforms for point-of-care diagnostics. Weaknesses include inconsistent guidance and a splintered reporting system that hampers the comparison of data across regions or longitudinally. The newly chartered Enterics Surveillance Steering Committee (ESSC) is intended to provide clear mission guidance, a structured project review process, and central data management and analysis in support of rationally directed enteric disease surveillance efforts.

High frequency of diarrheagenic Escherichia coli in human immunodeficiency virus (HIV) patients with and without diarrhea in Lima, Peru

Diarrhea is still a prevalent health issue in HIV patients. Our objective was to characterize the different diarrheagenic E. coli (DEC) groups in stools from adult HIV patients. Cross sectional study: We enrolled HIV-positive and -negative patients with and without diarrhea from a tertiary-care center of Lima, Peru. Clinical data was recorded and a stool sample per patient was cultured. Multiplex PCR was used to detect different DECs. One hundred eighty-four participants were enrolled. The frequency of having at least one DEC was more common in HIV-positive than HIV-negative patients with diarrhea (42% versus 20%, P < 0.05). The enterotoxigenic E. coli (ETEC) was the most common DEC in patients with diarrhea, 13% in HIV patients. The diffusely adherent E. coli (DAEC) was only present in HIV positive patients with diarrhea (10.1%). Different types of DEC are frequent in stools from HIV-positive patients.

[Comparison of enteropathogenic Escherichia coli (EPEC) diagnosis by serology and by polymerase chain reaction (PCR)]

INTRODUCTION

The identification of EPEC in clinical laboratories is based on the determination of the serotypes by agglutination with O and H antiserum. Currently the proper diagnosis of EPEC should be done by the identification of the intimin gen (eaeA) by PCR.

OBJECTIVES

To compare the diagnosis of EPEC by serotyping and by PCR.

MATERIALS AND METHODS

We collected EPEC strains, identify by their O antigen, from 4 clinical laboratories in Lima from diarrheal samples in children less than 5 years of age. In those strains we have searched for virulence genes by a real time multiplex PCR for the diarrheagenic E. coli.

RESULTS

We collected 113 strains; 82% from children less than 2 years of age. Only 15 strains (13.3%) had the intimin gene and therefore a confirmatory diagnosis of EPEC. In addition we found 3 enterotoxigenic (ETEC), 3 shiga toxin-producing (STEC), 1 enteroagreggative (EAEC) and 1 enteroinvasive (EIEC) strains.

CONCLUSIONS

PCR should be use for the proper identification of EPEC. However, molecular methods are still not easily available in clinical laboratories worldwide.

Idiopathic hirsutism: an uncommon cause of hirsutism in Alabama

OBJECTIVE

To determine the prevalence of idiopathic hirsutism among a population of consecutive hirsute patients.

DESIGN

Prospective cohort study.

SETTING

University-based clinic.

PATIENT(S)

Premenopausal women with a complaint of hirsutism who were not receiving hormonal therapy.

INTERVENTION(S)

Evaluations for total and free testosterone, (T), 17-hydroxyprogesterone (17-HP), and DHEAS serum levels.

MAIN OUTCOME MEASURE(S)

Ovulatory function in women with cycles of < or =35 days in length was assessed with a basal body temperature (BBT) calendar and day 22-24 progesterone levels.

RESULT(S)

Of 132 consecutive hirsute women studied, 68 had cycles of >35 days in length. Of the remaining 64 patients, 25 also had oligo/anovulation by BBT and day 22-24 progesterone level. Of the 39 patients with hirsutism and regular ovulatory function, 22 had total and free T and DHEAS levels within normal limits.

CONCLUSION(S)

If idiopathic hirsutism is defined by the presence of hirsutism, regular ovulation, and normal androgen levels, only 17% of consecutive hirsute patients can be diagnosed with the disorder. Alternatively, if idiopathic hirsutism is based solely on the presence of hirsutism and regular ovulation, regardless of androgen levels, then 29% of the total hirsute population can be considered as having idiopathic hirsutism. Importantly, 40% of hirsute patients with a history of "regular cycles" were actually oligo/anovulatory, indicating the need to objectively assess ovulatory function in such patients.