Local Surveillance Data Research Articles

Development of high titer anti-drug antibodies in a Phase 1b/2a infant clesrovimab trial are associated with RSV exposure beyond day 150.

Clesrovimab is a human half-life extended mAb in phase 3 evaluation for the prevention of RSV disease in infants. ADA were observed at late time points in a phase 1b/2a study where clesrovimab was well tolerated with an extended half-life of ∼45 days. Serum samples at days 150, 365 and 545 post-dose were assayed for ADA titers. Samples with high ADA titers were characterized for their binding specificity to the Fab or the YTE portion of clesrovimab. RSV serum neutralization (SNA) titers were also measured on ADA+ and ADA- infants. Additionally, a D25 (site Ø) competitive ELISA was performed on ADA+ available samples to determine RSV exposure. Local surveillance data was used to ascertain RSV circulation during the trial. High ADA titers were observed in a minority of infants at days 365 and 545 for all doses tested. Additionally, all high titer ADA+ infants had ADA directed towards the YTE epitope of clesrovimab. Moreover, these infants demonstrated robust RSV-SNA and had D25 competitive antibodies suggesting an RSV exposure after day 150, coinciding with the epidemiological data. RSV exposure in infants beyond day 150 after dosing is associated with ADA development and high RSV-SNA titers with no impact on pharmacokinetics.

Epidemiology of Chronic Hepatitis B Virus Infection, Alameda County, California, 2017-2021.

In the United States, chronic hepatitis B (CHB) virus infection predominantly affects ethnic minorities and vulnerable populations. We analyzed surveillance data to describe CHB epidemiology to guide hepatitis B virus (HBV) elimination efforts in Alameda County. Persons with CHB during 2017-2021 were identified by ≥2 positive HBV tests (ie, HBsAg, HbeAg, and HBV DNA) ≥180days apart using data from California Reportable Disease Information Exchange. Persons with CHB were stratified by age, race/ethnicity, zip code-based Healthy Places Index (HPI), and federally designated Medically Underserved Areas (MUA). Comparisons of reported CHB prevalence between groups utilized z test; comparisons between MUA regions utilized chi-square testing. A total of 8122 persons with CHB were identified; reported 5-year CHB prevalence was 0.53% (95% confidence interval: 0.52%-0.54%). Reported CHB 5-year prevalence was significantly higher among persons aged 50 to 69years old than persons aged 30 to 49years old (0.99%, 0.78%; P <.001) and Asians, Native Hawaiian/Pacific Islanders, African Americans compared to Whites (1.22%, 0.56%, 0.18%, 0.06%; P <.001). Reported CHB 5-year prevalence in the 2 lowest and most disadvantaged HPI quartiles was significantly higher than the 2 highest quartiles (0.55%, 0.68%, 0.37%, 0.42%; P <.001). The 1918 persons with CHB in MUA, compared to 5859 non-MUA persons, were significantly more likely to be African American (7%, 3%; P <.001) and from the lowest HPI quartile (79%, 19%; P <.001). Reported CHB 5-year prevalence in Alameda County was 1.5 times the national prevalence estimates, and reported prevalence was highest among Asians and persons in more disadvantaged areas. Analysis of local CHB surveillance data can guide public health efforts toward HBV elimination.

One Health Landscape of Antimicrobial Resistance in Bacteria Isolated from Virginia between 2007-2021.

The emergence of antimicrobial-resistant (AMR) bacteria has become a critical global One Health issue, mainly attributed to the extensive use of antimicrobial agents in human and agricultural settings. Regional and local AMR surveillance data is essential for implementing awareness and mitigation strategies. This article assesses AMR frequency in 1604 bacterial isolates consisting of Escherichia coli (E. coli) and Salmonella spp. isolated from diverse sources in Virginia, including farm animals, wildlife, environment, and food samples from 2007 to 2021. The results are based on the Kirby-Bauer disc diffusion assessment method of susceptibility to select antimicrobial agents, spanning nine distinct categories approved by the US Food and Drug Administration for clinical use. Streptomycin (STR) and tetracycline (TCY) exhibited the highest frequency of resistance in E. coli (39.1%) and Salmonella (25.2%), respectively. Multidrug resistance (MDR) was evident in 6.6% of E. coli and 10.9% of Salmonella isolates. Notably, 51% of E. coli and 36% of Salmonella isolates demonstrated resistance to more than one antimicrobial. None of the tested antimicrobials guaranteed effectiveness against the bacteria isolated from the surveyed sources and regions. The study found heightened MDR and distinct AMR patterns in bacteria isolated from food products compared to other sampled sources. These findings are vital for comprehending the current AMR landscape, prompting the development of strategies to mitigate the emergence of AMR bacteria, and advocating prudent antimicrobial use from a One Health perspective.

Antimicrobial susceptibility patterns of aerobic bacteria isolated from canine urinary samples in South East Queensland, 2013 to 2018.

Urinary tract infections are a common diagnosis in dogs presenting to veterinary practice. Veterinarians often treat suspected infections empirically, either in the absence of culture and susceptibility testing results or whilst waiting for them. This study aimed to identify the bacteria most frequently isolated from canine urinary samples and their antimicrobial susceptibility patterns in South East Queensland (SEQ) to help guide responsible empirical antimicrobial prescription by the veterinary community in this geographical location. Cumulative antibiograms were generated from the results of 1284 culture-positive urinary samples in SEQ, obtained from a commercial veterinary laboratory over a 5-year period. Escherichia coli was the most commonly isolated bacterial species (43%), followed by Staphylococcus spp. (23%), Proteus spp. (21%) and Enterococcus spp. (10%). Of the six most common isolates, 97% had susceptibility to at least one low-importance antimicrobial. Susceptibility to the low-importance and first-line antimicrobial recommendation, amoxicillin, was 81% for E. coli and 24% for Staphylococcus spp. Susceptibility of both E. coli and Staphylococcus spp. to medium-importance and commonly recommended empirical antimicrobials, trimethoprim sulphonamides and amoxicillin-clavulanic acid was ≥85% and >92% for high-importance antimicrobials enrofloxacin and ceftiofur. Of the E. coli and Staphylococcus spp. isolates, 8.8% and 4%, respectively, were considered multidrug resistant. There was no increase in resistance to antimicrobials detected over the study period. Susceptibilities suggest low- and medium-importance antimicrobials remain acceptable first-line empirical treatments. However, this should be continually assessed and updated using local surveillance data.

Data Sharing in a Decentralized Public Health System: Lessons From COVID-19 Syndromic Surveillance.

The COVID-19 pandemic revealed that data sharing challenges persist across public health information systems. We examine the specific challenges in sharing syndromic surveillance data between state, local, and federal partners. These challenges are complicated by US federalism, which decentralizes public health response and creates friction between different government units. The current policies restrict federal access to state and local syndromic surveillance data without each jurisdiction's consent. These policies frustrate legitimate federal governmental interests and are contrary to ethical guidelines for public health data sharing. Nevertheless, state and local public health agencies must continue to play a central role as there are important risks in interpreting syndromic surveillance data without understanding local contexts. Policies establishing a collaborative framework will be needed to support data sharing between federal, state, and local partners. A collaborative framework would be enhanced by a governance group with robust state and local involvement and policy guardrails to ensure the use of data is appropriate. These policy and relational challenges must be addressed to actualize a truly national public health information system.

Assessment of Antibiotics Resistance pattern of Pseudomonas aeruginosa Isolated from Patients Admitted in selected Hospitals in Kebbi State, Nigeria

Pseudomonas aeruginosa is one of the ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp) that induce a dignified healthcare aggravation among hospital admitted patients. This results in prolonged hospital stays, which increase costs for healthcare providers and patients' families. Therefore, this study aimed to isolate Pseudomonas aeruginosa and evaluate its resistance patterns from patients admitted to selected hospitals in Kebbi State. A total of 185 clinical samples, including nasal intubation, urine catheters, and wound swabs, were obtained. The bacteria were isolated and identified following standard microbiological methods. Modified Kirby Bauer techniques was used to determine the susceptibility status of the isolates. Out of 185 clinical samples collected, 43 (23.2%) bacterial isolates yield positive and 13 (30.2%) of which were P. aeruginosa from the studied hospitals. Prevalence of P. aeruginosa was found to be higher among females 08 (61.5%). The age groups 6-11 years had the highest prevalence P. aeruginosa 07 (53.8%). P. aeruginosa was isolated most from wound swab samples, 07 (24.1%). The Pseudomonas aeruginosa isolates exhibit high level resistance (100%) to Amoxicillin/Clavulanic acid, Cefpodoxime, Cefepime, Cepotaxime and Meropenem and showed least resistant to Imepenem 05 (38.4%). The increasing resistance of Pseudomonas aeruginosa isolates to multiple antimicrobial agents that are currently considered as first- line agents for the treatment of Pseudomonas aeruginosa infections, this highlights the need for careful use of these agents and also suggests the need for careful and up-to-date monitoring of multidrug- resistant strains diffusion in the various health care facilities of the country. Treatment options should be guided by medical laboratory scientist via microscopy culture and sensitivity testing, as well as local epidemiological surveillance data.

Modelling the Potential Public Health Impact of Different COVID-19 Vaccination Strategies with an Adapted Vaccine in Singapore

ABSTRACT Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing COVID-19 has been a dynamically changing virus, requiring the development of adapted vaccines. This study estimated the potential public health impact alternative vaccination strategies for COVID-19 in Singapore. Research Design and Methods The outcomes of alternative vaccination strategies with a future adapted vaccine were estimated using a combined Markov decision tree model. The population was stratified by high- and standard-risk. Using age-specific inputs informed by local surveillance data and published sources, the model estimated health (case numbers, hospitalizations, and deaths) and economic (medical costs and productivity losses) outcomes in different age and risk subpopulations. Results Booster vaccination in only the elderly and high-risk subpopulation was estimated to avert 278,614 cases 21,558 hospitalizations, 239 deaths, Singapore dollars (SGD) 277 million in direct medical costs, and SGD 684 million in indirect medical costs. These benefits increased as vaccination was expanded to other subpopulations. Increasing the booster vaccination coverage to 75% of the standard-risk population averted more deaths (3%), hospitalizations (29%), infections (145%), direct costs (90%), and indirect costs (192%) compared to the base case. Conclusions Broader vaccination strategies using an adapted booster vaccine could have substantial public health and economic impact in Singapore.

Population-level effectiveness of pre-exposure prophylaxis for HIV prevention among men who have sex with men in Montréal (Canada): a modelling study of surveillance and survey data.

HIV pre-exposure prophylaxis (PrEP) has been recommended and partly subsidized in Québec, Canada, since 2013. We evaluated the population-level impact of PrEP on HIV transmission among men who have sex with men (MSM) in Montréal, Québec's largest city, over 2013-2021. We used an agent-based mathematical model of sexual HIV transmission to estimate the fraction of HIV acquisitions averted by PrEP compared to a counterfactual scenario without PrEP. The model was calibrated to local MSM survey, surveillance, and cohort data and accounted for COVID-19 pandemic impacts on sexual activity, HIV prevention, and care. PrEP was modelled from 2013 onwards, assuming 86% individual-level effectiveness. The PrEP eligibility criteria were: any anal sex unprotected by condoms (past 6 months) and either multiple partnerships (past 6 months) or multiple uses of post-exposure prophylaxis (lifetime). To assess potential optimization strategies, we modelled hypothetical scenarios prioritizing PrEP to MSM with high sexual activity (≥11 anal sex partners annually) or aged ⩽45 years, increasing coverage to levels achieved in Vancouver, Canada (where PrEP is free-of-charge), and improving retention. Over 2013-2021, the estimated annual HIV incidence decreased from 0.4 (90% credible interval [CrI]: 0.3-0.6) to 0.2 (90% CrI: 0.1-0.2) per 100 person-years. PrEP coverage among HIV-negative MSM remained low until 2015 (<1%). Afterwards, coverage increased to a maximum of 10% of all HIV-negative MSM, or about 16% of the 62% PrEP-eligible HIV-negative MSM in 2020. Over 2015-2021, PrEP averted an estimated 20% (90% CrI: 11%-30%) of cumulative HIV acquisitions. The hypothetical scenarios modelled showed that, at the same coverage level, prioritizing PrEP to high sexual activity MSM could have averted 30% (90% CrI: 19%-42%) of HIV acquisitions from 2015-2021. Even larger impacts could have resulted from higher coverage. Under the provincial eligibility criteria, reaching 10% coverage among HIV-negative MSM in 2015 and 30% in 2019, like attained in Vancouver, could have averted up to 63% (90% CrI: 54%-70%) of HIV acquisitions from 2015 to 2021. PrEP reduced population-level HIV transmission among Montréal MSM. However, our study suggests missed prevention opportunities and adds support for public policies that reduce PrEP barriers, financial or otherwise, to MSM at risk of HIV acquisition.

Comprehensive testing and rapid dissemination of local drug supply surveillance data in Rhode Island.

The North American overdose crisis has continued at unprecedented rates with more than 100,000 overdose deaths estimated to have occurred in the United States in 2022. Regional variations in overdose rates signify differences in local drug supplies. State-level drug supply surveillance systems have been limited in their ability to document and communicate the rapidly changing drug supplies which can hinder harm reduction efforts at the community level. We sought to address by piloting a two-year, community-engaged local drug supply surveillance program in Rhode Island (RI). The first set of samples (n=125) were collected from May 2022 to January 2023 across RI and included used paraphernalia (e.g., cookers), refuse (e.g., baggies), and product. Samples were tested using comprehensive toxicology testing approaches via liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). Results were disseminated to participants and the broader public across platforms. Fentanyl was detected in 67.2% of all samples tested. 39.2% (n=49) of samples were expected to be fentanyl. Xylazine was detected in 41.6% of all samples-always in combination with fentanyl-and no samples were expected to contain xylazine. In expected stimulant samples (n=39), 10% contained fentanyl and/or analogues as major substances and 30.8% contained trace amounts of fentanyl and/or analogues. In expected stimulant samples, 15.4% contained xylazine with fentanyl. No opioids or benzodiazepines were detected in expected hallucinogen or dissociative samples (n=7). In expected benzodiazepine samples (n=8), no opioids were detected. Our results describe part of the local drug supply in Rhode Island, including a presence of NPS and adulterants (e.g., designer benzodiazepines, xylazine). Importantly, our findings underscore the feasibility of developing a community-driven drug supply surveillance database. Expanding drug supply surveillance initiatives is imperative for improving the health and safety of people who use drugs and informing public health approaches to addressing the overdose crisis.

Provision of Microbiology, Infection Services and Antimicrobial Stewardship in Intensive Care: A Survey across the Critical Care Networks in England and Wales.

Infection rounds in Intensive Care Units (ICU) can impact antimicrobial stewardship (AMS). The aim of this survey was to assess the availability of microbiology, infection, AMS services, and antimicrobial prescribing practices in the UK ICUs. An online questionnaire was sent to clinical leads for ICUs in each region listed in the Critical Care Network for the UK. Out of 217 ICUs, 87 deduplicated responses from England and Wales were analyzed. Three-quarters of those who responded had a dedicated microbiologist, and 50% had a dedicated infection control prevention nurse. Infection rounds varied in their frequency, with 10% providing phone advice only. Antibiotic guidance was available in 99% of the units; only 8% of those were ICU-specific. There were variations in the availability of biomarkers & the duration of antibiotics prescribed for pneumonia (community, hospital, or ventilator), urinary, intra-abdominal, and line infections/sepsis. Antibiotic consumption data were not routinely discussed in a multi-disciplinary meeting. The electronic prescription was available in ~60% and local antibiotic surveillance data in only 47% of ICUs. The survey highlights variations in practice and AMS services and may offer the opportunity to further collaborations and share learnings to support the safe use of antimicrobials in the ICU.

Arthropod-borne diseases among travellers arriving in Europe from Africa, 2015 to 2019.

BackgroundTravellers are generally considered good sentinels for infectious disease surveillance.AimTo investigate whether health data from travellers arriving from Africa to Europe could provide evidence to support surveillance systems in Africa.MethodsWe examined disease occurrence and estimated risk of infection among travellers arriving from Africa to Europe from 2015 to 2019 using surveillance data of arthropod-borne disease cases collected through The European Surveillance System (TESSy) and flight passenger volumes from the International Air Transport Association.ResultsMalaria was the most common arthropod-borne disease reported among travellers from Africa, with 34,235 cases. The malaria travellers' infection rate (TIR) was 28.8 cases per 100,000 travellers, which is 36 and 144 times higher than the TIR for dengue and chikungunya, respectively. The malaria TIR was highest among travellers arriving from Central and Western Africa. There were 956 and 161 diagnosed imported cases of dengue and chikungunya, respectively. The highest TIR was among travellers arriving from Central, Eastern and Western Africa for dengue and from Central Africa for chikungunya in this period. Limited numbers of cases of Zika virus disease, West Nile virus infection, Rift Valley fever and yellow fever were reported.ConclusionsDespite some limitations, travellers' health data can efficiently complement local surveillance data in Africa, particularly when the country or region has a sub-optimal surveillance system. The sharing of anonymised traveller health data between regions/continents should be encouraged.

Components of Existing National Surgical Site Infection Surveillance Programs Based on a Case Series of Low- and Middle-Income Countries: Building Blocks for Success and Opportunities for Improvement.

Background: Surgical site infection (SSI) surveillance programs are recommended to be included in national infection prevention and control (IPC) programs, yet few exist in low- or middle-income countries (LMICs). Our goal was to identify components of surveillance in existing programs that could be replicated elsewhere and note opportunities for improvement to build awareness for other countries in the process of developing their own national surgical site infection surveillance (nSSIS) programs. Methods: We administered a survey built upon the U.S. Centers for Disease Control and Prevention's framework for surveillance system evaluation to systematically deconstruct logistical infrastructure of existing nSSIS programs in LMICs. Qualitative analyses of survey responses by thematic elements were used to identify successful surveillance system components and recognize opportunities for improvement. Results: Three respondents representing countries in Europe and Central Asia, sub-Saharan Africa, and South Asia designated as upper middle-income, lower middle-income, and low-income responded. Notable strengths described by respondents included use of local paper documentation, staggered data entry, and limited data entry fields. Opportunities for improvement included outpatient data capture, broader coverage of healthcare centers within a nation, improved audit processes, defining the denominator of number of surgical procedures, and presence of an easily accessible, free SSI surveillance training program for healthcare workers. Conclusions: Outpatient post-surgery surveillance, national coverage of healthcare facilities, and training on how to take local SSI surveillance data and integrate it within a broader nSSIS program at the national level remain areas of opportunities for countries looking to implement a nSSIS program.

Association between mobility, non-pharmaceutical interventions, and COVID-19 transmission in Ghana: A modelling study using mobile phone data.

Governments around the world have implemented non-pharmaceutical interventions to limit the transmission of COVID-19. Here we assess if increasing NPI stringency was associated with a reduction in COVID-19 cases in Ghana. While lockdowns and physical distancing have proven effective for reducing COVID-19 transmission, there is still limited understanding of how NPI measures are reflected in indicators of human mobility. Further, there is a lack of understanding about how findings from high-income settings correspond to low and middle-income contexts. In this study, we assess the relationship between indicators of human mobility, NPIs, and estimates of Rt, a real-time measure of the intensity of COVID-19 transmission. We construct a multilevel generalised linear mixed model, combining local disease surveillance data from subnational districts of Ghana with the timing of NPIs and indicators of human mobility from Google and Vodafone Ghana. We observe a relationship between reductions in human mobility and decreases in Rt during the early stages of the COVID-19 epidemic in Ghana. We find that the strength of this relationship varies through time, decreasing after the most stringent period of interventions in the early epidemic. Our findings demonstrate how the association of NPI and mobility indicators with COVID-19 transmission may vary through time. Further, we demonstrate the utility of combining local disease surveillance data with large scale human mobility data to augment existing surveillance capacity to monitor the impact of NPI policies.

Country data on AMR in India in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BackgroundAntimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.ObjectivesTo review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes.MethodsNational AMR initiatives, antibiotic use and prescribing in India, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information.ConclusionsMany initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Country data on AMR in Pakistan in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BackgroundAntimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.ObjectivesTo review the current situation with respect to AMR in Pakistan and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR and improve patient outcomes.MethodsNational AMR initiatives, antibiotic use and prescribing in Pakistan, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information.ConclusionsPakistan is active in developing initiatives to address AMR such as compiling a National Action Plan. However, antibiotic consumption is high and although there is legislation in place prohibiting over-the-counter purchase of antibiotics, this is still possible. Healthcare professionals use local and international antibiotic prescribing guidelines for CA-RTIs when managing patients. As highlighted by the clinical microbiologist’s expert comments, surveillance of AMR in locally prevalent microorganisms is lacking. A more standardized inclusive approach in developing local guidelines, using up-to-date local surveillance data of isolates from community-acquired infections, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.

Country data on AMR in Mexico in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BackgroundAntimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.ObjectivesTo review AMR in Mexico and initiatives addressing it. Identifying any areas where more information is required will provide a call to action to minimize any further rises in AMR and to improve patient outcomes.MethodsNational AMR initiatives in Mexico, antibiotic use and prescribing, and availability of susceptibility data, particularly the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used in Mexico for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, along with local antibiotic availability. Insights from a local clinician were sought to contextualize this information.ConclusionsThe Mexican national AMR strategy was published in 2018. This comprised similar objectives to the Global Action Plan from the World Health Assembly (2015) and was compulsory, requiring full compliance from members of the National Health System. Historically, antibiotic consumption in Mexico has been high, however, between 2000 and 2015, consumption fell, in sharp contrast to the majority of countries. Mexico lacks a national surveillance network for AMR, however there are several ongoing global surveillance studies providing local antibiotic susceptibility data. International and local antibiotic prescribing guidelines for CA-RTIs are used. A more standardized inclusive approach in developing local guidelines, using up-to-date local surveillance data of isolates from community-acquired infections, could make guideline use more locally relevant. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development in Mexico and improve patient outcomes.

Role of Multidrug-resistant Pathogens in Ventilator-Associated Pneumonia in a Tertiary Care Hospital in India

Aim: Ventilator-associated pneumonia (VAP) is the second most common infection acquired in the intensive care unit (ICU). Bacteriological profiles cause VAP and their susceptibility patterns vary in different institutions. Methods: A prospective study was conducted from June 2017 to May 2018 in a tertiary care hospital as per the recent NHSN guidelines in finding the incidence of VAP and further determining the etiological agents by both conventional and automated methods. The combination disk method (Phenotypic confirmatory test), ampicillin C (AmpC) disk test, modified carbapenem inactivation method, imipenem/ethylenediamine tetraacetic acid combined disc test, and cefoxitin disk test were performed for the detection of extended-spectrum beta-lactamases (ESBL), AmpC β-lactamases, carbapenemases, metallo-beta-lactamases (MBL), and methicillin-resistant Staphylococcus aureus, respectively. Results: Among 104 patients, 31 cases developed PVAP (possible VAP) during their ICU stay; of these cases, two patients had two episodes of VAP each, and the incidence of VAP was 32%. The most common isolate was Acinetobacter baumannii (38%), followed by Pseudomonas aeruginosa (22%), Klebsiella pneumoniae (16%), and Escherichia coli (13.51%). Twenty (54%) of the 37 VAP pathogens were multidrug resistant. ESBL was produced by 40% and 67% of E. coli and K. pneumoniae, respectively. MBL was produced by 25% of P. aeruginosa. In addition, AmpC beta-lactamases were produced by 18% each of the Enterobacteriaceae and non-fermenters, respectively. One of the two S. aureus isolates was methicillin-resistant. Conclusion: The majority of VAP cases in our setting were caused by highly resistant strains. The frequency of specific multidrug resistance pathogens causing VAP may vary due to hospital, patient population, exposure to antibiotics, type of ICU patients, and changes over time, emphasizing the need for timely local surveillance data.

In Vitro Activity of Ceftazidime-avibactam and Colistin Against Carbapenem-Resistant Klebsiella pneumoniae Clinical Isolates

Infections caused by multi drug-resistant gram-negative bacilli are increasingly reported worldwide. Colistin, tigecycline and aminoglycosides are almost the only and last choice antibiotics in the treatment of infections caused by carbapenem-resistant Enterobacterales members. Ceftazidime-avibactam is a novel antibiotic combination consisting of a broad-spectrum cephalosporin and avibactam with good antimicrobial activity against carbapenem-resistant Enterobacterales members. The aim of this study was to assess the in vitro activity of ceftazidime-avibactam and colistin against carbapenem-resistant Klebsiella pneumoniae isolates and to obtain local antimicrobial surveillance data. A total of 150 carbapenem-resistant K.pneumoniae isolates obtained from various clinical samples of the patients hospitalized in our hospital between 2018-2021 were included in the study. Duplicate isolates were excluded from the study. The isolates were recovered from blood (n= 72), tracheal aspirate (n= 40), wound (n= 20), biopsy and abscess (n= 10), steril body fluid (n= 5), and peripheral venous catheter (n= 3) samples. Isolates were identified by matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS, Bruker Daltonics, Germany). The minimum inhibitory concentration (MIC) values of the isolates for meropenem, colistin, ceftazidime, and ceftazidime-avibactam were determined by broth microdilution method. Susceptibility of the isolates to the tested antibiotics was evaluated by the European Committee of Antimicrobial Susceptibility Testing (EUCAST) criteria. The presence of carbapenemases (VIM, IMP, NDM, KPC, and OXA-48) was investigated by polymerase chain reaction (PCR) using specific primers. The mcr-1, mcr-2, mcr-3, mcr-4, and mcr-5 genes were evaluated by PCR for plasmid-mediated colistin resistance. All K.pneumoniae isolates were found to be positive for at least one of the carbapenemase genes evaluated in the study. The blaOXA-48 gene was detected in 107 (71.3%), blaKPC gene in 25 (16.7%); blaNDM gene in 7 (4.7%), co-production of blaOXA-48 and blaKPC genes in 10 (6.7%), co-production of blaOXA-48 and blaNDM genes in 1 (0.6%) isolate. None of the isolates harbored the blaVIM and blaIMP genes. None of the mcr genes screened in the study were detected among the isolates. The susceptibility of the isolates to ceftazidime-avibactam and colistin was 92.7% (139/150) and 48% (72/150), respectively. The MIC50 and MIC90 values for meropenem, ceftazidime, ceftazidime-avibactam, and colistin of the isolates were determined as 32/256, > 128/> 128, 1/8, and 4/16 µg/ml, respectively. Of the ceftazidimeavibactam resistant isolates, seven were positive for blaNDM, three for blaKPC, and one for both blaOXA-48 and blaNDM genes. High ceftazidime-avibactam MIC levels (> 128 µg/ml) were detected in metallo-betalactamase producing isolates. Consequently, our data suggested that ceftazidime-avibactam exhibited as a good alternative therapeutic choice for carbapenem-resistant K.pneumoniae isolates. It is noteworthy that high rate of colistin resistance was detected in K.pneumoniae isolates. Another notable finding of this study is the increase in K.pneumoniae isolates producing blaKPC for our country. To prevent the development of resistance which is observed even in last-choice therapeutic antibiotics, the principles of rational antibiotic use should be followed. The appropriate antimicrobial susceptibility testing should be routinely performed for surveillance of ceftazidime-avibactam and colistin.

Using the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program Data to Monitor Trends in US Emergency Department Visits for Firearm Injuries, 2018 to 2019

We describe trends in emergency department (ED) visits for initial firearm injury encounters in the United States. Using data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program, we analyzed monthly and yearly trends in ED visit rates involving a firearm injury (calculated as the number of firearm injury-related ED visits divided by the total number of ED visits for each month and multiplied by 100,000) by sex-specific age group and US region from 2018 to 2019 and conducted Joinpoint regression to detect trend significance. Among approximately 215 million ED visits captured in the National Syndromic Surveillance Program from January 2018 to December 2019, 132,767 involved a firearm injury (61.6 per 100,000 ED visits). Among males, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 64 years during the study period. Among females, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 54 years during the study period. By region, rates significantly changed in the northeast, southeast, and southwest for males and females during the study period. These analyses highlight a novel data source for monitoring trends in ED visits for firearm injuries. With increased and effective use of state and local syndromic surveillance data, in addition to improvements to firearm injury syndrome definitions by intent, public health professionals could better detect unusual patterns of firearm injuries across the United States for improved prevention and tailored response efforts.

Aetiological Agents in Neonatal Nosocomial Sepsis and their Sensitivity Pattern from a Tertiary Care Hospital, Odisha, India: A Cross-sectional Study

Introduction: Nosocomial infections are a major problem for hospitalised neonates due to increase in morbidity, mortality, duration of hospitalisation and costs of treatment. The magnitude of this problem varies from place to place and is unique to each place as per the organisms and their resistance pattern is concerned. There is need to develop local level surveillance data on incidence of nosocomial sepsis, causative organisms, their sensitivity pattern and periodically review antibiotic policy based on this information. Aim: To determine the aetiological agents of nosocomial sepsis and their antibiotic sensitivity and resistance pattern. Materials and Methods: This was a cross-sectional study in which the cases of nosocomial infections in neonates of &gt; 35 weeks were studied from November 2018-October 2019 at Sriram Chandra Bhanja Medical College and Hospital (S.C.B.M.C.H) and Sardar Vallabh Bhai Patel Postgraduate Institute of Paediatrics (S.V.P.P.G.I.P) based on clinical findings, sepsis screen and blood culture. Blood culture is considered as gold standard for diagnosis of sepsis. Blood sample (1 mL) was collected under strict asepsis in Becton Dickinson and Company (BACTEC) and was sent for performing blood culture. The data was processed and arranged into distribution tables and cross tables using Statistical Package for the Social Sciences (SPSS) version 21.0. Results: Out of total 100 suspected cases of nosocomial sepsis, blood culture was positive in 46 (46%) of cases. Candida spp. was the most common obtained organism 9 (19.5%) followed by Klebsiella pneumoniae 8 (17.3%) and Staphylococcus aureus 8 (17.3%) each respectively. There was increased incidence of bacterial resistance to commonly used antibiotics and combinations of it, like ampicillin, gentamicin, cefotaxime, amikacin and piperacillin+ tazobactam among these bacterial isolates. Among the possible new combinations deduced from the observation, the combination of vancomycin+amikacin had sensitivity of 67.6% and can be considered as initial antibiotic combination of choice while combination with colistin and tigecycline should be reserved only for culture proven resistant cases or babies who continue to be deteriorating and critically sick while on previous combination. Conclusion: Candida spp. is the leading cause of nosocomial sepsis. Among bacterial organisms, Klebsiella pneumoniae and Staphylococcus aureus are most common. Most isolates are resistant to traditional antibiotics, hence new combination like vancomycin+amikacin are more appropriate empiric choice in present context and combination with colistin and tigecycline are reserved only for culture proven resistant sepsis.