Endemicity of Pseudomonas aeruginosa producing IMP-18 and/or VIM-2 MBLs from the high-risk clone ST111 in Central America.

Background: Pseudomonas aeruginosa is an important cause of serious nosocomial infections. Despite the overall genetic diversity of this species, highly conserved clonal complexes (CCs) have been observed among MDR isolates. Many of these CCs are associated with MBL-producing isolates. Objectives: To evaluate five P. aeruginosa isolates from Central America that carried IMP-18- and/or VIM-2-encoding genes from the SENTRY Antimicrobial Surveillance Program (2017-2018). Methods: Susceptibility testing was performed by broth microdilution (CLSI). WGS was performed using MiSeq (Illumina) and MinION (Oxford Nanopore). Assembled contigs from short and long reads were combined for in silico screening of resistance genes, MLST, core genome (cg)MLST and SNP analysis. Results: The P. aeruginosa isolates were collected in Panama and Mexico from patients with urinary tract infections or pneumonia. Isolates were categorized as XDR (CLSI/EUCAST). All isolates belonged to ST111 but carried different combinations of resistance-encoding genes. Transposon-associated MBL genes, blaIMP-18 and/or blaVIM-2, were chromosomally located. blaIMP-18 was detected in an In1666 integron whereas blaVIM-2 was embedded in an In59-like integron. Isolates were closely related based on cgMLST (average allele distance 2-34) and SNP analysis (5-423 different SNPs). Conclusions: MBL-producing ST111 P. aeruginosa have become endemic in Panama and may have spread to Mexico via clonal dissemination. Recombination events are apparent in the evolution of this CC. Surveillance is warranted to track the expansion and movement of this clone.

Antimicrobial stewardship programs in adult intensive care units in Latin America: Implementation, assessments, and impact on outcomes.

OBJECTIVE: To assess the impact of antimicrobial stewardship programs (ASPs) in adult medical-surgical intensive care units (MS-ICUs) in Latin America. DESIGN: Quasi-experimental prospective with continuous time series. SETTING: The study included 77 MS-ICUs in 9 Latin American countries. PATIENTS: Adult patients admitted to an MS-ICU for at least 24 hours were included in the study. METHODS: This multicenter study was conducted over 12 months. To evaluate the ASPs, representatives from all MS-ICUs performed a self-assessment survey (0-100 scale) at the beginning and end of the study. The impact of each ASP was evaluated monthly using the following measures: antimicrobial consumption, appropriateness of antimicrobial treatments, crude mortality, and multidrug-resistant microorganisms in healthcare-associated infections (MDRO-HAIs). Using final stewardship program quality self-assessment scores, MS-ICUs were stratified and compared among 3 groups: ≤25th percentile, >25th to <75th percentile, and ≥75th percentile. RESULTS: In total, 77 MS-ICU from 9 Latin American countries completed the study. Twenty MS-ICUs reached at least the 75th percentile at the end of the study in comparison with the same number who remain within the 25th percentile (score, 76.1 ± 7.5 vs 28.0 ± 7.3; P < .0001). Several indicators performed better in the MS-ICUs in the 75th versus 25th percentiles: antimicrobial consumption (143.4 vs 159.4 DDD per 100 patient days; P < .0001), adherence to clinical guidelines (92.5% vs 59.3%; P < .0001), validation of prescription by pharmacist (72.0% vs 58.0%; P < .0001), crude mortality (15.9% vs 17.7%; P < .0001), and MDRO-HAIs (9.45 vs 10.96 cases per 1,000 patient days; P = .004). CONCLUSION: MS-ICUs with more comprehensive ASPs showed significant improvement in antimicrobial utilization.

Phenotypic and genotypic characteristics of carbapenemase- and extended spectrum ß-lactamase-producing Klebsiella pneumoniae ozaenae clinical isolates within a hospital in Panama City.

Klebsiella pneumoniae spp ozaenae is a versatile bacterial species able to acquire antimicrobial resistance; the species presents a higher antimicrobial resistance profile compared to Klebsiella pneumoniae spp pneumoniae. Carbapenemase and extended spectrum ß-lactamase (ESBL)-producing bacteria commonly arise in clinical settings where antimicrobial stewardship is limited. Our study aims to report the phenotypical and genetic characteristics of nosocomial Klebsiella pneumoniae spp ozaenae isolates associated with mortality collected from a tertiary-level hospital in Panama City. In October 2020, 11 consecutive multidrug-resistant Gram-negative isolates were recovered from secretions and blood cultures from hospitalized patients. Nearly 90% (10/11) of these patients died, and bacteria was obtained from six patients for investigation. Biochemical evaluation of the six isolates revealed the presence of multidrug-resistant Klebsiella pneumoniae spp ozaenae. Phenotypic evaluation indicated resistance to carbapenemase and EBSL. In contrast, genetic evaluation by PCR showed that only 30% (2/6) were resistant to CTX-M-1 (CTX-M group 1), whereas 60.7% (4/6) presented carbapenemase resistance genes, and 33.3% (2/6) presented New Delhi metallo-ß-lactamase (NDM) resistance genes. Klebsiella pneumoniae ST258 was identified in 83.3% (5/6) of the isolates. Phylogenetic analysis using 16S revealed low homology among the six isolates. These results suggest that antibiotic resistance genes may have been incorporated into these Klebsiella pneumoniae spp ozaenae isolates within the hospital environment. We recommend strengthening the antimicrobial stewardship program and antibiotic control policy, as well as heightened infection control and prevention measures, such as ward sanitation and increased hand washing frequency.

Intervenciones en infecciones del tracto urinario, neumonías, COVID-19 y bacteriemias por programas de uso optimizado de antimicrobianos (PROA): enfoque síndrome específico

Introducción: El uso de los antibióticos ha logrado curar infecciones anteriormente letales. Como profilaxis ha mejorado el pronóstico de pacientes en múltiples escenarios; sin embargo, estos fármacos tienen efectos adversos los cuales pueden ocurrir en 1 de cada 5 pacientes hospitalizados que los reciben, algunos de estos eventos son potencialmente mortales. Los programas de Antimicrobial Stewardship (ASP), conocidos en español como Programas de Uso Optimizado de Antibióticos (PROA), son intervenciones coordinadas, diseñadas para mejorar y medir el uso apropiado de antibióticos, promoviendo la selección del régimen óptimo, incluyendo dosis, duración de la terapia y su ruta de administración. Objetivo: describir el beneficio de las intervenciones síndrome específico en infecciones del tracto urinario, neumonías, bacteriemias y COVID-19, realizadas por programas de uso optimizado de antimicrobianos (PROA). Metodología: se realizó una búsqueda en PubMed y se seleccionó aquellos artículos donde se realizaron intervenciones que mostraron beneficios clínicos en infecciones del tracto urinario, neumonías, bacteriemias y COVID-19 por parte de programas de uso optimizado de antimicrobianos. Síntesis de los datos: se seleccionaron 18 estudios, de los cuales 3 mostraron intervenciones con beneficios en el tratamiento de Infecciones del tracto urinario, 9 en neumonías, 1 en COVID-19 y 5 en bacteriemias. Conclusión: Las intervenciones síndrome específicas, en Infecciones del tracto urinario (ITU), neumonías COVID-19 y bacteriemias, de los programas de uso optimizado de antibióticos (PROA) se han asociado con disminución de los costos de atención y mejores resultados clínicos. (provisto por Infomedic International)

Update on the epidemiology of carbapenemases in Latin America and the Caribbean.

INTRODUCTION: Carbapenemases are ß-lactamases able to hydrolyze a wide range of ß-lactam antibiotics, including carbapenems. Carbapenemase production in Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp., with and without the co-expression of other ß-lactamases is a serious public health threat. Carbapenemases belong to three main classes according to the Ambler classification: class A, class B, and class D. AREAS COVERED: Carbapenemase-bearing pathogens are endemic in Latin America. In this review, we update the status of carbapenemases in Latin America and the Caribbean. EXPERT OPINION: Understanding the current epidemiology of carbapenemases in Latin America and the Caribbean is of critical importance to improve infection control policies limiting the dissemination of multi-drug-resistant pathogens and in implementing appropriate antimicrobial therapy.

Antimicrobial susceptibility among Gram-positive and Gram-negative organisms collected from the Latin American region between 2004 and 2015 as part of the Tigecycline Evaluation and Surveillance Trial.

BACKGROUND: The in vitro activity of tigecycline and comparator agents was evaluated against Gram-positive and Gram-negative isolates collected in Latin American centers between 2004 and 2015 as part of the Tigecycline Evaluation and Surveillance Trial (T.E.S.T.) global surveillance study. METHODS: Minimum inhibitory concentrations (MICs) were determined using the broth microdilution methodology according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Antimicrobial susceptibility was determined using CLSI breakpoints, except for tigecycline for which the US Food and Drugs Administration breakpoints were used. RESULTS: A total of 48.3% (2202/4563) of Staphylococcus aureus isolates were methicillin-resistant S. aureus (MRSA). All MRSA isolates were susceptible to linezolid and vancomycin, and 99.9% (2199/2202) were susceptible to tigecycline. Among Streptococcus pneumoniae isolates, 13.8% (198/1436) were penicillin-resistant; all were susceptible to linezolid and vancomycin, and 98.0% (194/198) were susceptible to tigecycline. Susceptibility was >99.0% for linezolid and tigecycline against Enterococcus faecium and Enterococcus faecalis isolates. A total of 40.8% (235/576) E. faecium and 1.6% (33/2004) E. faecalis isolates were vancomycin-resistant. Among the Enterobacteriaceae, 36.3% (1465/4032) of Klebsiella pneumoniae isolates, 16.4% (67/409) of Klebsiella oxytoca isolates and 25.4% (1246/4912) of Escherichia coli isolates were extended-spectrum ß-lactamase (ESBL) producers. Of the ESBL-producing K. pneumoniae and E. coli isolates, susceptibility was highest to tigecycline [93.4% (1369/1465) and 99.8% (1244/1246), respectively] and meropenem [86.9% (1103/1270) and 97.0% (1070/1103), respectively]. A total of 26.7% (966/3613) of Pseudomonas aeruginosa isolates were multidrug-resistant (MDR). Among all P. aeruginosa isolates, susceptibility was highest to amikacin [72.8% (2632/3613)]. A total of 70.3% (1654/2354) of Acinetobacter baumannii isolates were MDR, and susceptibility was highest to minocycline [88.3% (2079/2354) for all isolates, 86.2% (1426/1654) for MDR isolates]. Tigecycline had the lowest MIC90 (2 mg/L) among A. baumannii isolates, including MDR isolates. CONCLUSIONS: This study of isolates from Latin America shows that linezolid, vancomycin and tigecycline continue to be active in vitro against important Gram-positive organisms such as MRSA, and that susceptibility rates to meropenem and tigecycline against members of the Enterobacteriaceae, including ESBL-producers, were high. However, we report that Latin America has high rates of MRSA, MDR A. baumannii and ESBL-producing Enterobacteriaceae which require continued monitoring.

Mycobacterium tuberculosis isolates from single outpatient clinic in Panama City exhibit wide genetic diversity.

Understanding Mycobacterium tuberculosis biodiversity and transmission is significant for tuberculosis control. This short report aimed to determine the genetic diversity of M. tuberculosis isolates from an outpatient clinic in Panama City. A total of 62 M. tuberculosis isolates were genotyped by 12 loci mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU-VNTR) and Spoligotyping. Forty-five (72.6%) of the isolates showed unique MIRU-VNTR genotypes, and 13 (21%) of the isolates were grouped into four clusters. Four isolates showed polyclonal MIRU-VNTR genotypes. The MIRU-VNTR Hunter-Gaston discriminatory index reached 0.988. The Spoligotyping analysis revealed 16 M. tuberculosis families, including Latin American-Mediterranean, Harlem, and Beijing. These findings suggest a wide genetic diversity of M. tuberculosis isolates at one outpatient clinic. A detailed molecular epidemiology survey is now warranted, especially following second massive immigration for local Panama Canal expansion activities.

Participatory Processes Applied to Developing Culturally Appropriate Educational Material Among the Ngäbe-Buglé Women of Panama for Domestic Violence Prevention.

The Ngäbe-Buglé is the largest underserved indigenous population in Panama facing extreme health disparities compounded by structural, social, and cultural factors. Contributing factors to the poor health outcomes in this region include extreme poverty, low education, high maternal and infant mortality, alcohol use, and an increasing trend of domestic violence. The present intervention used community participatory processes to develop tailored material within the Ngäbe-Buglé community and training health promoters to deliver health education to the most rural areas. There were 78 health promoters who were trained using the training-of-trainers approach. Promoters distributed the health messages to their communities using the tailored material, the main topic discussed being domestic violence. Almost 7,000 community members received health education, demonstrating increased knowledge and intent to act on information received. Future directions include further funding, research, and education of indigenous groups in Panama on domestic violence.

Susceptibility rates in Latin American nations: report from a regional resistance surveillance program (2011)

OBJECTIVE: To establish a resistance (R) surveillance program monitoring antimicrobial susceptibility patterns in Latin America (LATAM; Argentina [ARG], Brazil [BRA], Chile, Colombia [CBA], Costa Rica, Ecuador [ECU], Guatemala [GUA], Mexico [MEX], Panama [PAN], Peru, and Venezuela [VEN]). METHODS: In 2011, 4979 organisms were collected from 11 nations (20 laboratories) for susceptibility testing in a central laboratory design. Antimicrobials were tested by CLSI methods and results interpreted by CLSI and EUCAST breakpoints. Most common Gram-positive (Staphylococcus aureus [SA, 921], other staphylococci [CoNS; 299], enterococci [218], Streptococcus pneumoniae [SPN; 182], β-haemolytic streptococci [115]) and Gram-negative (E. coli [EC; 644], Klebsiella spp. [KSP; 517], Enterobacters [272], Pseudomonas aeruginosa [PSA; 586], Acinetobacters [ACB; 494]) pathogens were analyzed against linezolid (LZD), vancomycin (VAN), tigecycline (TIG), colistin (COL), cefoperazone/sulbactam (C/S), and amikacin (AMK). RESULTS: MRSA rates varied from 29% (CBA, BRA) to 79% (Peru); but LZD (MIC90, 2 mg/L), TIG (MIC90, 0.12mg/L) and VAN (MIC90, 1mg/L) covered all strains. Enterococci showed a 14% VRE rate, highest in BRA and MEX; all inhibited by TIG and daptomycin, but not LZD (three non-susceptible with G2576T mutations or cfr). Penicillin-R among SPN and viridans streptococci was 51.6 and 41.1%, respectively. LZD overall R against Gram-positives was 0.3%. High ESBL rates were observed in EC (54-71%) and KSP (>50%) from GUA, MEX and Peru, and six nations, respectively. Carbapenem-R in KSP was 9%, highest rates associated with KPC in BRA, CBA, ECU, PAN and VEN; also a NDM-1 in KSP from CBA. AMK, TIG, C/S and carbapenems were the broadest-spectrum agents tested against Enterobacteriaceae. Only COL inhibited >90% of PSA; COL and TIG (<2 mg/L) covered >85% of ACB. CONCLUSIONS: LATAM nations demonstrated variable levels of antimicrobial R especially among Enterobacteriaceae (β-lactamase-mediated), PSA and ACB. MRSA (48%), VRE (14%) and multidrug-R SPN were also regional therapeutic challenges.

Susceptibility rates in Latin American nations: report from a regional resistance surveillance program (2011).

OBJECTIVE: To establish a resistance (R) surveillance program monitoring antimicrobial susceptibility patterns in Latin America (LATAM; Argentina [ARG], Brazil [BRA], Chile, Colombia [CBA], Costa Rica, Ecuador [ECU], Guatemala [GUA], Mexico [MEX], Panama [PAN], Peru, and Venezuela [VEN]). METHODS: In 2011, 4979 organisms were collected from 11 nations (20 laboratories) for susceptibility testing in a central laboratory design. Antimicrobials were tested by CLSI methods and results interpreted by CLSI and EUCAST breakpoints. Most common Gram-positive (Staphylococcus aureus [SA, 921], other staphylococci [CoNS; 299], enterococci [218], Streptococcus pneumoniae [SPN; 182], ß-haemolytic streptococci [115]) and Gram-negative (E. coli [EC; 644], Klebsiella spp. [KSP; 517], Enterobacters [272], Pseudomonas aeruginosa [PSA; 586], Acinetobacters [ACB; 494]) pathogens were analyzed against linezolid (LZD), vancomycin (VAN), tigecycline (TIG), colistin (COL), cefoperazone/sulbactam (C/S), and amikacin (AMK). RESULTS: MRSA rates varied from 29% (CBA, BRA) to 79% (Peru); but LZD (MIC90, 2mg/L), TIG (MIC90, 0.12mg/L) and VAN (MIC90, 1mg/L) covered all strains. Enterococci showed a 14% VRE rate, highest in BRA and MEX; all inhibited by TIG and daptomycin, but not LZD (three non-susceptible with G2576T mutations or cfr). Penicillin-R among SPN and viridans streptococci was 51.6 and 41.1%, respectively. LZD overall R against Gram-positives was 0.3%. High ESBL rates were observed in EC (54-71%) and KSP (≥50%) from GUA, MEX and Peru, and six nations, respectively. Carbapenem-R in KSP was 9%, highest rates associated with KPC in BRA, CBA, ECU, PAN and VEN; also a NDM-1 in KSP from CBA. AMK, TIG, C/S and carbapenems were the broadest-spectrum agents tested against Enterobacteriaceae. Only COL inhibited >90% of PSA; COL and TIG (≤2mg/L) covered ≥85% of ACB. CONCLUSIONS: LATAM nations demonstrated variable levels of antimicrobial R especially among Enterobacteriaceae (ß-lactamase-mediated), PSA and ACB. MRSA (48%), VRE (14%) and multidrug-R SPN were also regional therapeutic challenges.

Testing a top-down strategy for establishing a sustainable telemedicine program in a developing country: the Arizona telemedicine program-US Army-Republic of Panama Initiative.

OBJECTIVE: Many developing countries have shown interest in embracing telemedicine and incorporating it into their healthcare systems. In 2000, the U.S. Army Yuma Proving Ground (YPG) initiated a program to assist the Republic of Panama in establishing a demonstration Panamanian rural telemedicine program. YPG engaged the Arizona Telemedicine Program (ATP) to participate in the development and implementation of the program. MATERIALS AND METHODS: The ATP recommended adoption of a "top-down" strategy for creating the program. Early buy-in of the Panamanian Ministry of Health and academic leaders was regarded as critical to the achievement of long-term success. RESULTS: High-level meetings with the Minister of Health and the Rectors (i.e., Presidents) of the national universities gained early program support. A telemedicine demonstration project was established on a mountainous Indian reservation 230 miles west of Panama City. Today, three rural telemedicine clinics are linked to a regional Ministry of Health hospital for teleconsultations. Real-time bidirectional videoconferencing utilizes videophones connected over Internet protocol networks at a data rate of 768 kilobits per second to the San Felix Hospital. Telepediatrics, tele-obstetrics, telepulmonology, teledermatology, and tele-emergency medicine services became available. Telemedicine services were provided to the three sites for a total of 1,013 cases, with numbers of cases increasing each year. These three demonstration sites remained in operation after discontinuation of the U.S. involvement in September 2009 and serve as a model program for other telemedicine initiatives in Panama. CONCLUSIONS: Access to the assets of a partner-nation was invaluable in the establishment of the first model telemedicine demonstration program in Panama. After 3 years, the Panamanian Telemedicine and Telehealth Program (PTTP) became self-sufficient. The successful achievement of sustainability of the PTTP after disengagement by the United States fits the Latifi-Weinstein model for establishing telemedicine programs in developing countries.

Aislamiento de estafilococos meticilina-resistentes en pacientes hospitalizados en el Complejo Hospitalario Metropolitano de la Caja de Seguro Social / Isolation of resistent methicillin staphylococcus in hospitalized patients in the Complejo Hospitalario Metropolitano de la Caja de Seguro Social

Los estafilococos son gérmenes de gran capacidad para adquirir resistencia a los antibióticos. La aparición de cepas resistentes a la meticilina se ha convertido en un importante problema de salud en todos los centros hospitalarios; lo que hace necesaria su cuantificación. Revisamos en 1993, en forma retrospectiva, 1,095 cepas de estafilococos aisladas en las salas del Complejo Hospitalario Metropolitano de la Caja de Seguro Social, de los cuales 598 fueron S. aureus y 497 estafilococos coagulasa negativa. El (35 por ciento) de éstas fueron resistentes a la meticilina y entre los S. aureus también encontramos un (6.2 por ciento) de cepas con resistencia a meticilina. Al aplicar los criterios del National Committee for Clinical Laboratory Standars encontramos que los resultados obtenidos en la sensibilidad por el método convencional no se modificaron significativamente al utilizar el disco de oxacilina de 1 ug (INV.)

Resistencia antimicrobiana de patógenos pediátricos comunitarios / Antibiotic resistance in community acquired pediatric infections

La prevalencia de patógenos pediátricos resistentes adquiridos en la comunidad está aumentando progresivamente. Debido a significativas diferencias regionales en los patrones de susceptibilidad antimicrobiana, resulta imperativo la realización de investigaciones bacteriológicas destinadas a conocer la resistencia antibiótica en nuestro medio. Ejemplos importantes de resistencia de patógenos pediátricos incluyen cepas de Sthaphylococcus aureus resistentes a metilicina y oxicilina, cepas de Streptococcus pneumoniae resistentes a penicilina, cepas de Streptococcus pyogenes resistentes a eritromicina, y cepas de Haemophilus influenzae resistentes a ampicilinas y cloranfenicol. En esta revisión discutimos la prevalencia de cepas resistentes en tres hospitales metropolitanos (Hospital Gorgas, Hospital Arnulfo Arias Madrid, C.S.S. y Hospital del Niño) y ofrecemos recomendaciones generales sobre la utilización de antibióticos para el tratamiento de infecciones adquiridas en la comunidad. Podemos anticipar que en Panamá habrá un aumento significativo de resistencia de estos patógenos pediátricos comunes y que solamente el uso juicioso de antibióticos podrá atenuar esta tendencia