Antibiotic resistance is a global public health issue, particularly in low- and middle-income countries (LMICs), where antibiotics required to treat resistant infections are not affordable. LMICs ...also bear a disproportionately high burden of bacterial diseases, particularly among children, and resistance jeopardizes progress made in these areas. Although outpatient antibiotic use is a major driver of antibiotic resistance, data on inappropriate antibiotic prescribing in LMICs are scarce at the community level, where the majority of prescribing occurs. Here, we aimed to characterize inappropriate antibiotic prescribing among young outpatient children and to identify its determinants in 3 LMICs.
We used data from a prospective, community-based mother-and-child cohort (BIRDY, 2012 to 2018) conducted across urban and rural sites in Madagascar, Senegal, and Cambodia. Children were included at birth and followed-up for 3 to 24 months. Data from all outpatient consultations and antibiotics prescriptions were recorded. We defined inappropriate prescriptions as antibiotics prescribed for a health event determined not to require antibiotic therapy (antibiotic duration, dosage, and formulation were not considered). Antibiotic appropriateness was determined a posteriori using a classification algorithm developed according to international clinical guidelines. We used mixed logistic analyses to investigate risk factors for antibiotic prescription during consultations in which children were determined not to require antibiotics. Among the 2,719 children included in this analysis, there were 11,762 outpatient consultations over the follow-up period, of which 3,448 resulted in antibiotic prescription. Overall, 76.5% of consultations resulting in antibiotic prescription were determined not to require antibiotics, ranging from 71.5% in Madagascar to 83.3% in Cambodia. Among the 10,416 consultations (88.6%) determined not to require antibiotic therapy, 25.3% (n = 2,639) nonetheless resulted in antibiotic prescription. This proportion was much lower in Madagascar (15.6%) than in Cambodia (57.0%) or Senegal (57.2%) (p < 0.001). Among the consultations determined not to require antibiotics, in both Cambodia and Madagascar the diagnoses accounting for the greatest absolute share of inappropriate prescribing were rhinopharyngitis (59.0% of associated consultations in Cambodia, 7.9% in Madagascar) and gastroenteritis without evidence of blood in the stool (61.6% and 24.6%, respectively). In Senegal, uncomplicated bronchiolitis accounted for the greatest number of inappropriate prescriptions (84.4% of associated consultations). Across all inappropriate prescriptions, the most frequently prescribed antibiotic was amoxicillin in Cambodia and Madagascar (42.1% and 29.2%, respectively) and cefixime in Senegal (31.2%). Covariates associated with an increased risk of inappropriate prescription include patient age greater than 3 months (adjusted odds ratios (aOR) with 95% confidence interval (95% CI) ranged across countries from 1.91 1.63, 2.25 to 5.25 3.85, 7.15, p < 0.001) and living in rural as opposed to urban settings (aOR ranged across countries from 1.83 1.57, 2.14 to 4.40 2.34, 8.28, p < 0.001). Diagnosis with a higher severity score was also associated with an increased risk of inappropriate prescription (aOR = 2.00 1.75, 2.30 for moderately severe, 3.10 2.47, 3.91 for most severe, p < 0.001), as was consultation during the rainy season (aOR = 1.32 1.19, 1.47, p < 0.001). The main limitation of our study is the lack of bacteriological documentation, which may have resulted in some diagnosis misclassification and possible overestimation of inappropriate antibiotic prescription.
In this study, we observed extensive inappropriate antibiotic prescribing among pediatric outpatients in Madagascar, Senegal, and Cambodia. Despite great intercountry heterogeneity in prescribing practices, we identified common risk factors for inappropriate prescription. This underscores the importance of implementing local programs to optimize antibiotic prescribing at the community level in LMICs.
Chronic hepatitis C virus (HCV) infection is a risk factor of insulin resistance, and HCV‐infected patients are at a high risk of developing diabetes. In the general population, research has shown ...the potential benefit of cannabis use for the prevention of diabetes and related metabolic disorders. We aimed to test whether cannabis use is associated with a lower risk of diabetes in chronic HCV‐infected patients. Chronic HCV‐infected patients (n = 10 445) were selected from the French national, multicenter, observational ANRS CO22 Hepather cohort. Cross‐sectional data collected at cohort enrollment were used to assess the association between patients’ clinical and behavioural characteristics and the risk of diabetes. Logistic regression model was performed with cannabis use as the main independent variable and a significance level set at 5%. A similar model stratified by the presence of advanced liver fibrosis (FIB‐4 > 3.25) was also run. After multivariable adjustment, current (AOR 95%CI: 0.49 0.38‐0.63) and former (0.81 0.67‐0.98, P < .001) cannabis use were both associated with a reduced odds of diabetes. Conversely, male gender, tobacco use, elevated BMI, poverty, being a migrant and advanced fibrosis were associated with increased odds of diabetes. The association between cannabis use and diabetes was maintained in the stratified analysis. In this large cross‐sectional study of chronic HCV‐infected patients, cannabis use was associated with a lower risk of diabetes independently of clinical and socio‐behavioural factors. Further studies are needed to elucidate a potential causal link and shed light on cannabis compounds and mechanisms involved in this relationship.
To monitor the prevalence of hepatitis B and hepatitis C a cross-sectional survey was conducted in 2004 among French metropolitan residents. A complex sampling design was used to enroll 14,416 adult ...participants aged 18-80 years. Data collected included demographic and social characteristics and risk factors. Sera were tested for anti-HCV, HCV-RNA, anti-HBc and HBsAg. Data were analyzed with SUDAAN® software to provide weighted estimates for the French metropolitan resident population. The overall anti-HCV prevalence was 0.84% (95% CI: 0.65-1.10). Among anti-HCV positive individuals, 57.4% (95% CI: 43.2-70.5) knew their status. Factors associated independently with positive anti-HCV were drug use (intravenous and nasal), blood transfusion before 1992, a history of tattoos, low socioeconomic status, being born in a country where anti-HCV prevalence >2.5%, and age >29 years. The overall anti-HBc prevalence was 7.3% (95%: 6.5-8.2). Independent risk factors for anti-HBc were intravenous drug use, being a man who has sex with men, low socioeconomic status, a stay in a psychiatric facility or facility for the mentally disabled, <12 years of education, being born in a country where HBsAg prevalence >2%, age >29 and male sex. The HCV RNA and HBsAg prevalence were 0.53% (95% CI: 0.40-0.70) and 0.65% (95% CI: 0.45-0.93), respectively. Among HBsAg positive individuals, 44.8% (95% CI: 22.8-69.1) knew their status. Anti-HCV prevalence was close to the 1990s estimates whereas HBsAg prevalence estimate was greater than expected. Screening of hepatitis B and C should be strengthened and should account for social vulnerability. J. Med. Virol. 82:546-555, 2010.
Objective
To identify current risk factors for hepatitis C virus (HCV) acquisition among Egyptians.
Methods
Patients with acute HCV were identified through a surveillance system of acute hepatitis in ...four fever hospitals in Egypt between 2002 and 2012. Case–control analysis was conducted, cases being incident acute symptomatic HCV and controls being acute hepatitis A identified at the same hospitals. The questionnaire covered iatrogenic, community and household exposures to HCV in the 1–6 months prior to onset of symptoms. Multivariate models were built to identify risk factors associated with HCV acquisition among non‐drug users and drug users separately.
Results
Among non‐drug users, hospital admission was independently associated with acute HCV infection (OR = 4.2, 95% CI = 1.7–10.5). Several iatrogenic procedures, for example admission in a surgery unit, sutures, IV injections and IV infusions, highly correlated with hospital admission, were also associated with acute HCV infection and could have been used in the final model instead of hospital admission. Among drug users, identified risk factors were multiple sexual relations (OR = 4.0, 95% CI = 1.1–14.7), intravenous drug use (OR = 3.9, 95% CI = 1.2–13.0) and shaving at the barbershops (OR = 8.7, 95% CI = 2.4–31.4). Illiteracy and marriage were significant risk factors in both groups.
Conclusion
Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt, as is illicit drug use in spreading HCV infection.
Objectif
Identifier les facteurs de risque actuels pour l'acquisition du virus de l'hépatite C (VHC) chez les Egyptiens.
Méthodes
Les patients atteints du VHC aiguë ont été identifiés grâce à un système de surveillance de l'hépatite aiguë dans quatre hôpitaux de la fièvre en Egypte entre 2002 et 2012. Une analyse cas‐témoins a été réalisée, les cas étant des incidents symptomatiques de VHC aiguë et les témoins, des cas d'hépatite A aiguë identifiés dans les mêmes hôpitaux. Le questionnaire portait sur les expositions iatrogènes, familiales et communautaires au VHC entre un à six mois avant l'apparition des symptômes. Des modèles multivariés ont été construits pour identifier les facteurs de risque associés à l'acquisition du VHC chez les non‐toxicomanes et les toxicomanes séparément.
Résultats
Parmi les non‐toxicomanes, l'admission à l'hôpital était indépendamment associée à l'infection aigüe par le VHC (OR = 4,2; IC95% = 01,07 à 10,05). Plusieurs procédures iatrogènes, par exemple, l'admission dans une unité de chirurgie, les sutures, les injections IV, les perfusions IV, corrélaient fortement avec l'admission à l'hôpital, étaient également associées à l'infection par le VHC aigüe et auraient pu être utilisées dans le modèle final plutôt que l'admission à l'hôpital. Parmi les usagers de drogues, les facteurs de risque identifiés étaient des relations sexuelles multiples (OR = 4,0; IC95% = 1,1 à 14,7), l'utilisation de drogues par voie intraveineuse (OR = 3,9; IC95% = 1,2 à 13,0) et le rasage chez le barbier (OR = 8,7; IC95% = 2,4 à 31,4). L'analphabétisme et le mariage étaient des facteurs de risque importants dans les deux groupes.
Conclusion
Les procédures médicales invasives sont toujours un risque majeur pour l'acquisition de nouvelles infections par le VHC en Égypte, ainsi que l'utilisation de drogues illicites dans la propagation de l'infection par le VHC.
Objetivo
Identificar los factores de riesgo actuales para la adquisición del virus de la hepatitis C (VHC) entre Egipcios.
Métodos
Se identificaron pacientes con VHC aguda mediante un sistema de vigilancia de hepatitis aguda en cuatro hospitales en Egipto, entre el 2002 y 2012. Se realizó un análisis de caso‐control, en el que los casos eran pacientes con VHC aguda sintomáticos y los controles pacientes con hepatitis A aguda, identificados en los mismos hospitales. El cuestionario cubría exposiciones iatrogénicas, comunitarias y dentro del hogar al VHC entre uno y seis meses antes del inicio de los síntomas. Se construyeron modelos multinomiales para identificar los factores de riesgo asociados a la adquisición del VHC entre consumidores de drogas y no consumidores de forma separada.
Resultados
Entre los no consumidores, la admisión hospitalaria estaba independiente asociada con una infección aguda por el VHC (OR=4.2, IC 95% =1.7‐10.5). Varios procedimientos iatrogénicos, por ejemplo la admisión en una unidad quirúrgica, las suturas, las inyecciones intravenosas (IV), o las infusiones IV, estaban altamente correlacionadas con la admisión hospitalaria al igual que con la infección aguda por VHC y podrían haberse utilizado en el modelo final en vez de la admisión hospitalaria. Entre los usuarios de drogas, los factores de riesgo identificados eran múltiples relaciones sexuales (OR=4.0, IC 95% =1.1‐14.7), uso de drogas intravenosas (OR=3.9, IC 95% =1.2‐13.0) y afeitarse en el barbero (OR=8.7, IC 95% =2.4‐31.4). El analfabetismo y el matrimonio eran factores de riesgo significativos en ambos grupos.
Conclusión
Los procedimientos médicos invasivos continúan siendo un factor de riesgo importante para la adquisición de nuevas infecciones por VHC en Egipto, al igual que el uso de drogas ilícitas lo es para diseminar la infección.
To ensure the success of COVID-19 vaccination, public authorities need to have the support of the entire population and build vaccine confidence. Identifying and understanding the determinants of ...vaccine acceptance is essential for conducting vaccine strategy. The aim was to estimate vaccine hesitancy among healthcare students in France and to investigate the associated factors.
A web-based cross-sectional study was conducted in a large French University in greater Paris area, among 4927 healthcare students from the different training courses such as medicine studies, midwifery studies, physiotherapy studies, nurse studies and others health studies. The study was conducted between January 21 and February 8, 2021 based on a questionnaire including 25 single or multiple-choice questions, made using the free software Limesurvey. The link of the questionnaire was distributed to the students by the teachers and the student associations. The SAGE group definition of vaccine hesitancy was used. All estimates were weighted using the gender and training courses category of all healthcare students registered for the 2020-2021 year. Crude and adjusted weighted odds ratio (wOR) and 95% confidence interval (95%CI) were estimated using logistic regression.
A total of 1465 healthcare students answered. A proportion of 44.5% (95%CI = 41.7-47.3) of them were considered as hesitant. Women were more hesitant (50.9, 95%CI = 48.0-53.9) than men (21.6, 95%CI = 15.2-28.0). Vaccine hesitancy was significantly associated with gender (wOR = 0.27, 95%CI = 0.18-0.39) and training courses: medical students were less likely to be hesitant than students in the common and first year of several health studies (wOR = 0.48, 95%CI = 0.33-0.70) while nursing students were more than 5 times more likely to be hesitant (wOR = 5.20, 95%CI = 3.71-7.28). Students who did an internship during the epidemic (wOR = 0.53, 95%CI = 0.41-0.69) and who downloaded the mobile contact-tracing mobile app "TousAntiCovid" (wOR = 0.34, 95%CI = 0.26-0.44) were significantly less likely to be hesitant.
Overall vaccine hesitancy among healthcare students was high, substantial differences were found between training courses. To reduce these disparities, interdisciplinary lectures on vaccines for all healthcare students may be implemented and evaluated.
Severe bacterial infections are a leading cause of death among neonates in low-income countries, which harbor several factors leading to emergence and spread of multidrug-resistant bacteria. ...Low-income countries should prioritize interventions to decrease neonatal infections; however, data are scarce, specifically from the community. To assess incidence, etiologies, and antimicrobial drug-resistance patterns of neonatal infections, during 2012-2014, we conducted a community-based prospective investigation of 981 newborns in rural and urban areas of Madagascar. The incidence of culture-confirmed severe neonatal infections was high: 17.7 cases/1,000 live births. Most (75%) occurred during the first week of life. The most common (81%) bacteria isolated were gram-negative. The incidence rate for multidrug-resistant neonatal infection was 7.7 cases/1,000 live births. In Madagascar, interventions to improve prevention, early diagnosis, and management of bacterial infections in neonates should be prioritized.
Bacterial vaginosis (BV) is associated with a higher risk of preterm delivery and spontaneous abortion. Yet little data on BV prevalence exist for sub-Saharan countries. The aim of this study was to ...estimate the prevalence of bacterial vaginosis and associated risk factors among pregnant women in Senegal. From October 2013 to December 2018, pregnant women in their third trimester were recruited in two primary health centers (one suburban, one rural) in Senegal. Healthcare workers interviewed women and collected a lower vaginal swab and a blood sample. Vaginal flora were classified into four categories using vaginal smear microscopic examination and Gram's coloration. In our study, BV was defined as vaginal flora with no Lactobacillus spp. Variables associated with BV were analyzed using STATAR through univariate and multivariate analysis. A total of 457 women provided a vaginal sample for analysis. Overall, BV prevalence was 18.6% (85/457) 95% CI 15.4-22.6) and was similar in suburban and rural areas (18.9% versus 18.1%, p = 0.843). Multivariate analysis showed that primigravidity was the only factor independently associated with a lower risk of BV (aOR 0.35 95% CI 0.17-0.72). Our study showed significant BV prevalence among pregnant women in Senegal. Although the literature has underscored the potential consequences of BV for obstetric outcomes, data are scarce on BV prevalence in sub-Saharan African countries. Before authorities consider systematic BV screening for pregnant women, a larger study would be useful in documenting prevalence, risk factors and the impact of BV on pregnancy outcomes.
In low and middle income countries (LMICs), where the burden of neonatal sepsis is the highest, the spread of extended spectrum beta-lactamase-producing enterobacteriaceae (ESBL-PE) in the community, ...potentially contributing to the neonatal mortality, is a public health concern. Data regarding the acquisition of ESBL-PE during the neonatal period are scarce. The routes of transmission are not well defined and particularly the possible key role played by pregnant women. This study aimed to understand the neonatal acquisition of ESBL-PE in the community in Madagascar. The study was conducted in urban and semi-rural areas. Newborns were included at birth and followed-up during their first month of life. Maternal stool samples at delivery and six stool samples in each infant were collected to screen for ESBL-PE. A Cox proportional hazards model was performed to identify factors associated with the first ESBL-PE acquisition. The incidence rate of ESBL-PE acquisition was 10.4 cases/1000 newborn-days 95% CI: 8.0-13.4 cases per 1000 newborn-days. Of the 83 ESBL-PE isolates identified, Escherichia coli was the most frequent species (n = 28, 34.1%), followed by Klebsiella pneumoniae (n = 20, 24.4%). Cox multivariate analysis showed that independent risk factors for ESBL-PE acquisition were low birth weight (adjusted Hazard-ratio (aHR) = 2.7, 95% CI 1.2; 5.9), cesarean-section, (aHR = 3.4, 95% CI 1.7; 7.1) and maternal use of antibiotics at delivery (aHR = 2.2, 95% CI 1.1; 4.5). Our results confirm that mothers play a significant role in the neonatal acquisition of ESBL-PE. In LMICs, public health interventions during pregnancy should be reinforced to avoid unnecessary caesarean section, unnecessary antibiotic use at delivery and low birth weight newborns.
The proportion of infections among young children that are antimicrobial-resistant is increasing across the globe. Newborns may be colonized with enteric antimicrobial-resistant pathogens early in ...life, which is a risk factor for infection-related morbidity and mortality. Breastfeeding is actively promoted worldwide for its beneficial impacts on newborn health and gut health. However, the role of breastfeeding and human milk components in mitigating young children's carriage of antimicrobial-resistant pathogens and antibiotic resistance genes has not been comprehensively explored.
Here, we review how the act of breastfeeding, early breastfeeding, and/or human milk components, such as the milk microbiota, secretory IgA, human milk oligosaccharides, antimicrobial peptides, and microRNA -bearing extracellular vesicles, could play a role in preventing the establishment of antimicrobial-resistant pathogens in young children's developing gut microbiomes. We describe findings from recent human studies that support this concept.
Given the projected rise in global morbidity and mortality that will stem from antimicrobial-resistant infections, identifying behavioral or nutritional interventions that could decrease children's susceptibility to colonization with antimicrobial-resistant pathogens may be one strategy for protecting their health. We suggest that breastfeeding and human milk supplements deserve greater attention as potential preventive measures in the global effort to combat antimicrobial resistance, particularly in low- and middle-income settings.
Background: Klebsiella pneumoniae (hereafter, Kp) is a major public health threat responsible for high levels of multidrug resistant (MDR) human infections. Besides, Kp also causes severe infections ...in the community, especially in Asia and Africa. Although most Kp infections are caused by endogenous intestinal carriage, little is known about the prevalence and microbiological characteristics of Kp in asymptomatic human carriage, and attached risk factors including environmental sources exposure.
Methods: Here, 911 pregnant women from communities in Madagascar, Cambodia, and Senegal were screened for gut colonization by Kp. Characteristics of Kp strains (antimicrobial susceptibility, genomic diversity, virulence, and resistance genes) were defined, and associated risk factors were investigated.
Results: Kp carriage rate was 55.9%, and Kp populations were highly heterogeneous (6 phylogroups, 325 sequence types, Simpson index 99.6%). One third of Kp isolates had acquired antimicrobial resistance genes. MDR-Kp (11.7% to 39.7%) and extended spectrum beta-lactamase (ESBL)-producing Kp (0.7% to 14.7%) varied among countries. Isolates with virulence genes were detected (14.5%). Environmental exposure factors including food, animal contacts, or hospitalization of household members were associated with carriage of Kp, antimicrobial resistance and hypervirulence. However, risk factors were country-specific and Kp subpopulation-specific.
Conclusion: This large-scale multicenter study uncovers the huge diversity of Kp in human gut carriage, demonstrates that antimicrobial resistance is widespread in communities of three low-income countries, and underlines the challenges posed by Kp colonization to the control of antimicrobial resistance.
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