Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru

BACKGROUND: Misuse of antimicrobials (AMs) and antimicrobial resistance (AMR) are global concerns. The present study evaluated knowledge, attitudes and practices about AMR and AM prescribing among medical doctors in two large public hospitals in Lima, Peru, a middle-income country. METHODS: Cross-sectional study using a self-administered questionnaire RESULTS: A total of 256 participants completed the questionnaire (response rate 82%). Theoretical knowledge was good (mean score of 6 +/- 1.3 on 7 questions) in contrast to poor awareness (< 33%) of local AMR rates of key-pathogens. Participants strongly agreed that AMR is a problem worldwide (70%) and in Peru (65%), but less in their own practice (22%). AM overuse was perceived both for the community (96%) and the hospital settings (90%). Patients' pressure to prescribing AMs was considered as contributing to AM overuse in the community (72%) more than in the hospital setting (50%). Confidence among AM prescribing was higher among attending physicians (82%) compared to residents (30%, p < 0.001%). Sources of information considered as very useful/useful included pocket-based AM prescribing guidelines (69%) and internet sources (62%). Fifty seven percent of participants regarded AMs in their hospitals to be of poor quality. Participants requested more AM prescribing educational programs (96%) and local AM guidelines (92%). CONCLUSIONS: This survey revealed topics to address during future AM prescribing interventions such as dissemination of information about local AMR rates, promoting confidence in the quality of locally available AMs, redaction and dissemination of local AM guidelines and addressing the general public, and exploring the possibilities of internet-based training

Effects of Point Mutations in Plasmodium falciparum Dihydrofolate Reductase and Dihydropterate Synthase Genes on Clinical Outcomes and In Vitro Susceptibility to Sulfadoxine and Pyrimethamine

Sulfadoxine-pyrimethamine was a common first line drug therapy to treat uncomplicated falciparum malaria, but increasing therapeutic failures associated with the development of significant levels of resistance worldwide has prompted change to alternative treatment regimes in many national malaria control programs. METHODOLOGY AND FINDING: We conducted an in vivo therapeutic efficacy trial of sulfadoxine-pyrimethamine at two locations in the Peruvian Amazon enrolling 99 patients of which, 86 patients completed the protocol specified 28 day follow up. Our objective was to correlate the presence of polymorphisms in P. falciparum dihydrofolate reductase and dihydropteroate synthase to in vitro parasite susceptibility to sulfadoxine and pyrimethamine and to in vivo treatment outcomes. Inhibitory concentration 50 values of isolates increased with numbers of mutations (single [108N], sextuplet [BR/51I/108N/164L and 437G/581G]) and septuplet (BR/51I/108N/164L and 437G/540E/581G) with geometric means of 76 nM (35-166 nM), 582 nM (49-6890- nM) and 4909 (3575-6741 nM) nM for sulfadoxine and 33 nM (22-51 nM), 81 nM (19-345 nM), and 215 nM (176-262 nM) for pyrimethamine. A single mutation present in the isolate obtained at the time of enrollment from either dihydrofolate reductase (164L) or dihydropteroate synthase (540E) predicted treatment failure as well as any other single gene alone or in combination. Patients with the dihydrofolate reductase 164L mutation were 3.6 times as likely to be treatment failures [failures 85.4% (164L) vs 23.7% (I164); relative risk = 3.61; 95% CI: 2.14 - 6.64] while patients with the dihydropteroate synthase 540E were 2.6 times as likely to fail treatment (96.7% (540E) vs 37.5% (K540); relative risk = 2.58; 95% CI: 1.88 - 3.73). Patients with both dihydrofolate reductase 164L and dihydropteroate synthase 540E mutations were 4.1 times as likely to be treatment failures [96.7% vs 23.7%; RR = 4.08; 95% CI: 2.45 - 7.46] compared to patients having both wild forms (I164 and K540).In this part of the Amazon basin, it may be possible to predict treatment failure with sulfadoxine-pyrimethamine equally well by determination of either of the single mutations dihydrofolate reductase 164L or dihydropteroate synthase 540E.ClinicalTrials.gov NCT00951106

The burden of antimicrobial resistance in the Americas in 2019: a cross-country systematic analysis

Background Antimicrobial resistance (AMR) is an urgent global health challenge and a critical threat to modern health care. Quantifying its burden in the WHO Region of the Americas has been elusive—despite the region’s long history of resistance surveillance. This study provides comprehensive estimates of AMR burden in the Americas to assess this growing health threat. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen–drug combinations for countries in the WHO Region of the Americas in 2019. We obtained data from mortality registries, surveillance systems, hospital systems, systematic literature reviews, and other sources, and applied predictive statistical modelling to produce estimates of AMR burden for all countries in the Americas. Five broad components were the backbone of our approach: the number of deaths where infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of pathogens resistant to an antibiotic class, and the excess risk of mortality (or duration of an infection) associated with this resistance. We then used these components to estimate the disease burden by applying two counterfactual scenarios: deaths attributable to AMR (compared to an alternative scenario where resistant infections are replaced with susceptible ones), and deaths associated with AMR (compared to an alternative scenario where resistant infections would not occur at all). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Findings We estimated 569,000 deaths (95% UI 406,000–771,000) associated with bacterial AMR and 141,000 deaths (99,900–196,000) attributable to bacterial AMR among the 35 countries in the WHO Region of the Americas in 2019. Lower respiratory and thorax infections, as a syndrome, were responsible for the largest fatal burden of AMR in the region, with 189,000 deaths (149,000–241,000) associated with resistance, followed by bloodstream infections (169,000 deaths [94,200–278,000]) and peritoneal/intra-abdominal infections (118,000 deaths [78,600–168,000]). The six leading pathogens (by order of number of deaths associated with resistance) were Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. Together, these pathogens were responsible for 452,000 deaths (326,000–608,000) associated with AMR. Methicillin-resistant S. aureus predominated as the leading pathogen–drug combination in 34 countries for deaths attributable to AMR, while aminopenicillin-resistant E. coli was the leading pathogen–drug combination in 15 countries for deaths associated with AMR. Interpretation Given the burden across different countries, infectious syndromes, and pathogen–drug combinations, AMR represents a substantial health threat in the Americas. Countries with low access to antibiotics and basic health-care services often face the largest age-standardised mortality rates associated with and attributable to AMR in the region, implicating specific policy interventions. Evidence from this study can guide mitigation efforts that are tailored to the needs of each country in the region while informing decisions regarding funding and resource allocation. Multisectoral and joint cooperative efforts among countries will be a key to success in tackling AMR in the Americas.publishedVersio

Antimicrobial resistance in Peruvian hospital settings

Antimicrobial resistance and antimicrobial misuse are of global concern but affect more the resource-constrained settings. Limited research has been done in Peru in order to address these topics. We interviewed 256 physicians of two hospitals of Lima in order to assess the knowledge, attitudes, and practices about antimicrobial resistance and antimicrobials use. Most of them agreed that antimicrobial resistance is a problem worldwide and within Peru, but only 20% correctly estimated the level of resistance of Klebsiella pneumoniae to third generation cephalosporins. We also developed a network of nine hospitals in Lima to perform a resistance surveillance of key isolates causing bacteremia. We found during a one-year period that Staphylococcus aureus was the most frequently Gram positive isolated (22%). K. pneumoniae and Escherichia coli were the most frequent Gram-negative bacilli, >75% of both produced extended-spectrum β-lactamases (ESBLs). ESBL-producers microorganisms had also higher level of co-resistance to ciprofloxacin and gentamicin. Finally, to explore the antimicrobial resistance and molecular characteristics of methicillin-resistant S. aureus, we analyzed isolates from patients and healthcare workers (HCWs). Fifty percent of 338 blood isolates were methicillin-resistant (MRSA); one predominant multidrug-resistant MRSA strain was found in all hospitals (ST 5 spa t149-SCCmec I-, the Cordobes-Chilean clone. MRSA nasal carriage rate of 8.7%, was found among HCWs. The two most common clones circulating among HCWs were also the two predominant among patients with bacteremia. There is a need to implement cost-effective infection control policies to reduce the transmission of multidrug resistant microorganisms in these settings.La résistance aux antibiotiques et leur utilisation inappropriée constituent un problème majeur de santé publique qui affecte particulièrement les pays à revenus faibles et intermédiaires. Les données concernant cette problématique sont très limitées au Pérou. Nous avons interrogé 256 médecins de deux hôpitaux à Lima afin d’évaluer leurs connaissances et leurs pratiques vis-à-vis de l’utilisation des antibiotiques et de la résistance aux antibiotiques. La plupart des médecins étaient conscientisés à la problématique de la multirésistance chez les entérobactéries, mais seulement 20% d’entre eux estimaient correctement le taux résistance de Klebsiella pneumoniae aux céphalosporines à large spectre au sein de leurs institutions. Au cours de ce travail, un réseau entre neuf hôpitaux de Lima a été implémenté afin de suivre la résistance aux antimicrobiens des souches isolées d’hémocultures. Au cours des années 2008-2009, le Staphylococcus aureus était la bactérie Gram-positive la plus fréquente (22%) ;K. pneumoniae et Escherichia coli représentaient les bactéries Gram-négatives les plus souvent isolées d’hémocultures. Parmi ces dernières entérobactéries, 75% produisaient des β-lactamases à spectre étendu (BLSE) avec un taux élevé de co- résistance à la ciprofloxacine et à la gentamicine. Les souches de S. aureus isolées d’hémocultures chez les patients hospitalisés et de dépistage chez les professionnels de santé (PS) ont été caractérisées pour leur profil de résistance aux antibiotiques et génotypées par biologie moléculaire. La moitié des 338 souches isolées d’hémocultures étaient résistantes à la méticilline (« MRSA ») et appartenaient à un clone prédominant disséminés dans ces différents hôpitaux, appelé le ST 5- spa t149-SCCmec I, ou le clone Cordobes-Chilien. Le taux de portage nasal de MRSA parmi les PS était à 8,7% ;les deux génotypes les plus fréquemment observés chez les PS appartenaient aux mêmes clones que ceux retrouvés majoritairement chez les patients hospitalisés. Cette observation suggère une transmission horizontale. L’implémentation de politiques de contrôle de l'infection est primordiale dans les établissements de santé au Pérou afin de réduire la transmission de micro-organismes multi-résistants.Doctorat en Sciences biomédicales et pharmaceutiques (Médecine)info:eu-repo/semantics/nonPublishe

Bacteremia por Staphylococcus epidermidis y abceso de partes blandas en un paciente postoperado: Reporte de un caso.

We report a case of an 11 year old male who presented with bacteremia by S. epidermidis and soft tissue abscesses after a bone autograft procedure. The patient received only medical treatment, resolving the abscesses successfully. We also did a review of the literature on S. epidermidis bacteremia, an entity which has acquired increasing importance in the etiology of hospital infections. (Rev Med Hered 2003; 14:221-223

Síndrome respiratorio agudo severo (SRAS).

En esta revisión actualizada presentamos los principales aspectos históricos, epidemiológicos, clínicos, terapéuticos y medidas de control y prevención de esta nueva enfermedad conocida como SRAS ( Síndrome Respiratorio Agudo Severo), que se ha considerado como la primera enfermedad infecciosa de origen viral epidémica del siglo XXI afectando principalmente áreas de China, incluyendo Taiwán y Hong Kong, así como Vietnam, Singapur y Canadá (Toronto). El agente viral causante de esta enfermedad es un nuevo coronavirus. El tratamiento mas efectivo aun no ha sido definido

Síndrome respiratorio agudo severo (SRAS)

In this review we present the main historical, epidemiological, clinical and control& prevention aspects of this new disease known as Severe Acute Respiratory Syndrome (SARS). This has been considered the first epidemic infectious disease of the XXI century caused by a virus that principally has affected some areas of China (including Taiwan and Hong Kong), Vietnam, Singapur and Canada (Toronto). The discovered agent is a new virus belonged to the coronavirus family. An effective treatment has not been found yet. ( Rev Med Hered 2003; 14: 89-93)