Protocol: a 'One health' two year follow-up, mixed methods study on antibiotic resistance, focusing children under 5 and their environment in rural India.

BACKGROUND: Antibiotic resistance has been referred to as 'the greatest malice of the 21st century' and a global action plan was adopted by the World Health Assembly in 2015. There is a wealth of independent studies regarding antibiotics and resistant bacteria in humans, animals and their environment, however, integrated studies are lacking, particularly ones that simultaneously also take into consideration the health related behaviour of participants and healthcare providers. Such, 'One health' studies are difficult to implement, because of the complex teamwork that they entail. This paper describes the protocol of a study that investigates 'One health' issues regarding antibiotic use and antibiotic resistance in children and their environment in Indian villages. METHODS/DESIGN: Both quantitative and qualitative studies are planned for a cohort of children, from 6 villages, and their surrounding environment. Repeated or continues data collection is planned over 2 years for quantitative studies. Qualitative studies will be conducted once. Studies include parents' health seeking behavior for their children (1-3 years of age at the onset), prescribing pattern of formal and informal healthcare providers, analysis of phenotypic antibiotic resistance of Escherichia coli from samples of stool from children and village animals, household drinking water, village source water and waste water, and investigation on molecular mechanisms governing resistance. Analysis of interrelationship of these with each other will also be done as basis for future interventions. Ethics approval has been obtained from the Institutional Ethics Committee R.D. Gardi Medical College, Ujjain, India (No: 2013/07/17-311). DISCUSSION: The findings of the study presented in this protocol will add to our knowledge about the multi-factorial nature of causes governing antibiotic use and antibiotic resistance from a 'One health' perspective. Our study will be the first of its kind addressing antibiotic use and resistance issues related to children in a One-health approach, particularly for rural India.

A step-wise approach towards introduction of an alcohol based hand rub, and implementation of front line ownership- using a, rural, tertiary care hospital in central India as a model.

BACKGROUND: Appropriate hand hygiene is a gold standard to combat healthcare associated infections (HAIs). The World Health Organization (WHO) has recommended alcohol based hand rub (ABHR) as the most effective tool to maintain hand hygiene. In resource poor settings commercially available ABHR is not "economically accessible". The objectives of this study were to assess the acceptability of, and to build confidence for an in-house prepared (based on WHO guidelines) alcohol based hand rub among healthcare workers (HCWs) using a rural, tertiary care hospital in central India as an example. METHODS: A series of activities were developed and conducted based on the Precede-Proceed model, the Trans Theoretical model of behaviour change, Front line ownership and Social marketing. A modified WHO-ABHR formulation, the 'test product' and 'WHO product evaluation form' were used for self assessment of acceptability of the 'test product'. Confidence building activities, as finger tip culture, visual portrayal method and handmade posters, were used in high-risk wards for HAIs, to build confidence for the 'test product' in removing transient flora from the hands. A locally developed feedback from was used to evaluate the impact of the activities conducted. RESULTS: Overall 183 HCWs were enrolled for the assessment of the 'test product' (130- doctors and 53 nurses). Out of these 83% (108/130) doctors and 94% (50/53) nurses were satisfied with the 'test product'. The confidence building activity was conducted with 116 participants (49 doctors). After single use of the 'test product', overall a significant reduction was observed for the CFUs on the blood agar plates (0.77 Log(10), p < 0.001). A complete reduction (100%) in colony forming units on incubated blood agar plates was seen for 13% (15/116) participants. Eighty two percent (95/116) participants expressed their confidence in the 'test product'. CONCLUSION: The self reported acceptance level for the 'test product' was high. The use of finger tip culture coupled with the visual portrayal was perceived as a convincing and highly effective way to develop confidence in HCWs. Thus, is the foremost step towards successful introduction of ABHR and can be seen as a model for similar settings.

Antibiotic resistance among Escherichia coli isolates from stool samples of children aged 3 to 14 years from Ujjain, India.

BACKGROUND: Antibiotic resistance is a major global public health concern, particularly in settings where few treatment options are available. Limited research has been done on antibiotic resistance in Escherichia coli of Indian children at community level. Therefore we studied antibiotic resistance patterns in E. coli isolates from stool samples of children aged 3-14 years from Ujjain, Central India, to investigate associations of resistance with demographic variables. METHODS: Children, 3-14 years of age, were included from 30 randomly selected villages of Palwa demographic surveillance site, Ujjain, India. Parents were interviewed using a questionnaire, and stool samples were collected from participating children. E. coli were isolated from stool samples (n = 529), and susceptibility testing to 18 different antibiotics was done using standard methods. RESULTS: The proportions of isolates resistant to various antibiotics were, nalidixic acid, (45%), tetracycline (37%), ampicillin (37%), sulfamethoxazole/trimethoprim (29%) and amoxicillin/clavulanic acid (29%). No isolates were resistant to imipenem. Overall, 72% of isolates were resistant to at least one antibiotic and 33% were multi-drug resistant. High rates of cross-resistance were seen for 15 (83%) of the antibiotics studied. E. coli isolates from children with literate mothers were more resistant to penicillins and fluoroquinolones. ESBL-producers comprised 9% of the isolates. CONCLUSION: Antibiotic resistance and cross-resistance were common in E. coli from stools of children. Resistance rates were associated with maternal literacy.

A case report of relapsing fever.

Relapsing fever is an acute febrile illness caused by spirochetes of the genus Borrelia. The high fevers of presenting patients spontaneously abate and then recur. Here we report a 50-year-old woman having relapsing fever associated with thrombocytopenia. Giemsa staining of peripheral blood smear revealed spiral organisms morphologically resembling Borrelia. A rare case of relapsing fever which was successfully treated with doxycycline is discussed.

"How Can the Patients Remain Safe, If We Are Not Safe and Protected from the Infections"? A Qualitative Exploration among Health-Care Workers about Challenges of Maintaining Hospital Cleanliness in a Resource Limited Tertiary Setting in Rural India.

Background: Health care-associated infections (HAIs) result in treatment delays as well as failures and financial losses not only to patients but also to the treating hospital and overall health-care delivery system. Due to hospital-acquired infections, there are problems of increase in morbidity and mortality, additional diagnostic and therapeutic interventions and ultimately antimicrobial resistance. Proper understanding among health-care workers about the ill effects of HAIs is very important to address this issue. The present study is a qualitative exploration aimed at understanding various aspects of hospital environmental hygiene and Infection prevention control program, by exploring the staff perception regarding the challenges, facilitators and barriers as well as feasible measures towards improvement in a rural tertiary teaching hospital in central India. Method: A qualitative study was conducted using 10 focus group discussions (FGDs) among five different professional groups, which included hospital administrators, doctors, nurses, environmental cleaning staff, and undergraduate medical students. The FGD guide included the following topics: (1) opinion about the status of cleanliness, (2) concepts and actual practices prevailing of hospital environmental hygiene, (3) Barriers, constraints, and problems in maintaining hospital environmental hygiene, (4) Suggestions for improvements. The data were analyzed manually using the content (thematic) analysis method. Results: Two themes were identified: Theme 1: "Prevailing practices and problems related to hospital surface/object contamination and hospital infection control". Theme 2: "Measures suggested for improving hospital cleanliness within the existing constraints". The participants emphasized the influence of resource constraints and needed inputs. They brought up the consequent prevailing practices and problems related, on one hand, to various stakeholders (service consumers, hospital personnel including the management), on the other, to specific infection prevention and control processes. They also suggested various measures for improvement. Conclusions: The study has revealed prevailing practices, problems, and suggested measures related to hospital environmental hygiene, particularly hospital cleanliness and HAI prevention and control processes. These insights and assertions are important for developing future behavioral and structural interventions in resource-limited settings. This study recommends a nationwide reliable HAI surveillance system and a robust infection prevention and control program in each health-care institution.

Antibiotic Resistance in an Indian Rural Community: A 'One-Health' Observational Study on Commensal Coliform from Humans, Animals, and Water.

Antibiotic-resistant bacteria are an escalating grim menace to global public health. Our aim is to phenotype and genotype antibiotic-resistant commensal Escherichia coli (E. coli) from humans, animals, and water from the same community with a 'one-health' approach. The samples were collected from a village belonging to demographic surveillance site of Ruxmaniben Deepchand (R.D.) Gardi Medical College Ujjain, Central India. Commensal coliforms from stool samples from children aged 1-3 years and their environment (animals, drinking water from children's households, common source- and waste-water) were studied for antibiotic susceptibility and plasmid-encoded resistance genes. E. coli isolates from human (n = 127), animal (n = 21), waste- (n = 12), source- (n = 10), and household drinking water (n = 122) carried 70%, 29%, 41%, 30%, and 30% multi-drug resistance, respectively. Extended spectrum beta-lactamase (ESBL) producers were 57% in human and 23% in environmental isolates. Co-resistance was frequent in penicillin, cephalosporin, and quinolone. Antibiotic-resistance genes blaCTX-M-9 and qnrS were most frequent. Group D-type isolates with resistance genes were mainly from humans and wastewater. Colistin resistance, or the mcr-1 gene, was not detected. The frequency of resistance, co-resistance, and resistant genes are high and similar in coliforms from humans and their environment. This emphasizes the need to mitigate antibiotic resistance with a 'one-health' approach.

A Three-Year Follow-Up Study of Antibiotic and Metal Residues, Antibiotic Resistance and Resistance Genes, Focusing on Kshipra-A River Associated with Holy Religious Mass-Bathing in India: Protocol Paper.

BACKGROUND: Antibiotic resistance (ABR) is one of the major health emergencies for global society. Little is known about the ABR of environmental bacteria and therefore it is important to understand ABR reservoirs in the environment and their potential impact on health. METHOD/DESIGN: Quantitative and qualitative data will be collected during a 3-year follow-up study of a river associated with religious mass-bathing in Central India. Surface-water and sediment samples will be collected from seven locations at regular intervals for 3 years during religious mass-bathing and in absence of it to monitor water-quality, antibiotic residues, resistant bacteria, antibiotic resistance genes and metals. Approval has been obtained from the Ethics Committee of R.D. Gardi Medical College, Ujjain, India (No. 2013/07/17-311). RESULTS: The results will address the issue of antibiotic residues and antibiotic resistance with a focus on a river environment in India within a typical socio-behavioural context of religious mass-bathing. It will enhance our understanding about the relationship between antibiotic residue levels, water-quality, heavy metals and antibiotic resistance patterns in Escherichia coli isolated from river-water and sediment, and seasonal differences that are associated with religious mass-bathing. We will also document, identify and clarify the genetic differences/similarities relating to phenotypic antibiotic resistance in bacteria in rivers during religious mass-bathing or during periods when there is no mass-bathing.

Detection of virulence genes in ESBL producing, quinolone resistant commensal Escherichia coli from rural Indian children.

INTRODUCTION: Extended-spectrum ß-lactamase producing commensal Escherichia coli are considered as a reservoir of antibiotic resistance genes that may be transmitted in the community. This study aimed to determine the genes coding for ESBLs, plasmid mediated quinolone resistance and virulence markers in commensal E. coli isolated from healthy school children. METHODOLOGY: ESBL producing E. coli isolates (n = 47) were obtained from 529 fecal samples of healthy school children from a rural area in central India. Multiplex PCR was used to detect the genes coding for cephalosporin and quinolone resistance, for virulence fluA, fluB, stx1, stx2, eae, bfp, lt, stII, virF, ipaH, daaE, aafII and phylogenetic groups. RESULTS: Of the 47 ESBL producing E. coli, 41 were positive for CTXM-15, 23 for TEM-1, 8 for OXA-1and a single for SHV-12. For plasmid-mediated quinolone resistance, all the 47 isolates carried the aac(6')-ib-cr gene, and amongst them18 were qnrS positive. Virulence gene, fluA was detected in 32,whereas eae in 14, daaE in 7 and fluB in 1. In 10 isolates, fluA and eae and in 7, fluA and daaE co-existed. Of the 47 E. coli isolates, 18 were grouped into the phylogenetic group B2, 17 in D and 12 in A. The proportion of isolates positive for fluA gene in the phylogenetic group B2 (18/18), was significantly higher than in group A (7/12) and D (6/17). CONCLUSION: Commensal E. coli in healthy children in rural India may serve as reservoirs of resistance towards cephalosporins and fluoroquinolones and virulence coding genes for urinary tract and diarrheal infections.

Understanding Healthcare Workers Self-Reported Practices, Knowledge and Attitude about Hand Hygiene in a Medical Setting in Rural India.

AIM: To describe self-reported practices and assess knowledge and attitudes regarding hand hygiene among healthcare workers in a rural Indian teaching hospital. SETTING: A rural teaching hospital and its associated medical and nursing colleges in the district of Ujjain, India. METHOD: The study population consisted of physicians, nurses, teaching staff, clinical instructors and nursing students. Self-administered questionnaires based on the World Health Organization Guidelines on Hand Hygiene in Healthcare were used. RESULTS: Out of 489 healthcare workers, 259 participated in the study (response rate = 53%). The proportion of healthcare workers that reported to 'always' practice hand hygiene in the selected situations varied from 40-96% amongst categories. Reported barriers to maintaining good hand hygiene were mainly related to high workload, scarcity of resources, lack of scientific information and the perception that priority is not given to hand hygiene, either on an individual or institutional level. Previous training on the topic had a statistically significant association with self-reported practice (p = 0.001). Ninety three per cent of the respondents were willing to attend training on hand hygiene in the near future. CONCLUSION: Self-reported knowledge and adherence varied between situations, but hand hygiene practices have the potential to improve if the identified constraints could be reduced. Future training should focus on enhancing healthcare workers' knowledge and understanding regarding the importance of persistent practice in all situations.

Staff perception on biomedical or health care waste management: a qualitative study in a rural tertiary care hospital in India.

BACKGROUND: Health care or biomedical waste, if not managed properly, can be of high risk to the hospital staff, the patients, the community, public health and the environment, especially in low and middle income settings where proper disposal norms are often not followed. Our aim was to explore perceptions of staff of an Indian rural tertiary care teaching hospital on hospital waste management. METHOD: A qualitative study was conducted using 10 focus group discussions (FGDs), with different professional groups, cleaning staff, nurses, medical students, doctors and administrators. The FGD guide included the following topics: (i) role of Health Care Waste Management (HCWM) in prevention of health care associated infections, (ii) awareness of and views about HCWM-related guidelines/legislation, (iii) current HCWM practices, (iv) perception and preparedness related to improvements of the current practices, and (v) proper implementation of the available guidelines/legislation. The FGDs were recorded, transcribed verbatim, translated to English (when conducted in Hindi) and analysed using content analysis. RESULTS: Two themes were identified: Theme (A), 'Challenges in integration of HCWM in organizational practice,' with the categories (I) Awareness and views about HCWM, (II) Organizational practices regarding HCWM, and (III) Challenges in Implementation of HCWM; and Theme (B), 'Interventions to improve HCWM,' with three categories, (I) Educational and motivational interventions, (II) Organizational culture change, and (III) Policy-related interventions. CONCLUSION: A gap between knowledge and actual practice regarding HCWM was highlighted in the perception of the hospital staff. The participants suggested organizational changes, training and monitoring to address this. The information generated is relevant not merely to the microsystem studied but to other institutions in similar settings.

Incidence and factors associated with surgical site infections in a teaching hospital in Ujjain, India.

BACKGROUND: Surgical site infections (SSI) are among the most commonly reported health care-associated infections; however, there is a paucity of data on SSI from India. This study aimed to determine the incidence of SSI and explore its associated factors at a teaching hospital in India. METHODS: Direct and indirect surveillance methods, based on Centers for Disease Control and Prevention guidelines, were used to define SSI. Patients were followed up for 30 days postsurgery. Prescribing and resistance data were collected. RESULTS: The SSI rate among the 720 patients investigated was 5%. Risk factors for SSI identified were as follows: severity of disease (P = .001), presence of drains (P = .020), history of previous hospitalization (P = .003), preoperative stay (P = .005), wound classification (P < .001), and surgical duration (P < .001). Independent risk factors identified included wound classification (odds ratio = 4.525; P < .001) and surgical duration (odds ratio = 2.554; P = .015). Most patients (99%) were prescribed antibiotics. Metronidazole (24.5%), ciprofloxacin (11%), and amikacin (9%) were the most commonly prescribed antibiotics. Most commonly isolated bacteria were Staphylococcus aureus (n = 14), of which 34% were methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa (n = 6), which showed resistance to ceftazidime (70%), ciprofloxacin (63%), and gentamicin (57%). CONCLUSION: Incidence of SSI at the hospital was lower than reported in many low- and middle-income countries, although higher than reported in most high-income countries. Targeted implementation strategies to decrease incidence of preventable SSI are needed to further improve quality and safety of health care in this hospital and similar hospitals elsewhere.