Knowledge, attitudes and perceptions of Latin American healthcare workers relating to antibiotic stewardship and antibiotic use: a cross-sectional multi-country study.

BACKGROUND: The burden of antimicrobial resistance (AMR) in Latin America is high. Little is known about healthcare workers' (HCWs) knowledge, attitudes, and perceptions of antimicrobial stewardship (AS), AMR, and antibiotic use (AU) in the region. METHODS: HCWs from 42 hospitals from 5 Latin American countries were invited to take an electronic, voluntary, anonymous survey regarding knowledge, attitudes, and perceptions of AS, AMR, and AU between March-April 2023. FINDINGS: Overall, 996 HCWs completed the survey (52% physicians, 32% nurses, 11% pharmacists, 3% microbiologists, and 2% "other"). More than 90% of respondents indicated optimizing AU was a priority at their healthcare facility (HCF), 69% stated the importance of AS was communicated at their HCF, and 23% were unfamiliar with the term "antibiotic stewardship". Most (> 95%) respondents acknowledged that appropriate AU can reduce AMR; however, few thought AU (< 30%) or AMR (< 50%) were a problem in their HCF. Lack of access to antibiogram and to locally endorsed guidelines was reported by 51% and 34% of HCWs, respectively. Among prescribers, 53% did not consider non-physicians' opinions to make antibiotic-related decisions, 22% reported not receiving education on how to select antibiotics based on culture results and 60% stated patients and families influence their antibiotic decisions. CONCLUSIONS: Although HCWs perceived improving AU as a priority, they did not perceive AU or AMR as a problem in their HCF. AS opportunities include improved access to guidelines, access to AMR/AU data, teamwork, and education on AS for HCWs and patients and families.

Deep Dive Into Gaps and Barriers to Implementation of Antimicrobial Stewardship Programs in Hospitals in Latin America.

BACKGROUND: Antimicrobial resistance has worsened in Latin America. There is an urgent need to understand the development of antimicrobial stewardship programs (ASPs) and the barriers to implementing effective ASPs in light of limited national action plans or policies to promote ASPs in the region. METHODS: We performed a descriptive mixed-methods study of ASPs in 5 Latin American countries in March-July 2022. An electronic questionnaire with an associated scoring system (hospital ASP self-assessment) was used, and ASP development was classified based on the scores (inadequate, 0-25; basic, 26-50; intermediate, 51-75; or advanced, 76-100). Interviews among healthcare workers (HCWs) involved in antimicrobial stewardship (AS) inquired about behavioral and organizational factors that influence AS activities. Interview data were coded into themes. Results from the ASP self-assessment and interviews were integrated to create an explanatory framework. RESULTS: Twenty hospitals completed the self-assessment, and 46 AS stakeholders from these hospitals were interviewed. ASP development was inadequate/basic in 35% of hospitals, intermediate in 50%, and advanced in 15%. For-profit hospitals had higher scores than not-for-profit hospitals. Interview data validated the self-assessment findings and provided further insight into ASP implementation challenges, which included limited formal hospital leadership support, inadequate staffing and tools to perform AS work more efficiently, limited awareness of AS principles by HCWs, and limited training opportunities. CONCLUSIONS: We identified several barriers to ASP development in Latin America, suggesting the need to create accurate business cases for ASPs to obtain the necessary funding for their effective implementation and sustainability.

Chloroplast and ITS phylogenies to understand the evolutionary history of southern South American Azorella, Laretia and Mulinum (Azorelloideae, Apiaceae).

Azorella, Laretia and Mulinum are taxonomically complex, and good candidates to study evolutionary radiations in the Andes and the importance of hybridizations. Previous phylogenetic studies of subfamily Azorelloideae agree that Azorella and Mulinum as currently conceived are not monophyletic, and hence a revision of their circumscription is necessary. However, these phylogenies were based only on chloroplast DNA sequence data. Here, phylogenetic relationships within Azorelloideae were inferred using sequence data from five chloroplast DNA (rps16 intron, trnQ-rps16, rps16-trnKUUU 5' -exon, trnGGCC-trnSGCU and rpL32-trnLUAG), and from nuclear rDNA ITS regions to assess the monophyly of Azorella and Mulinum and discuss generic re-circumscriptions, determine hybridization and radiation events, identify and characterize important lineages, and propose hypotheses on evolution of key morphological characters. In total, 121 accessions of Azorelloideae were analyzed. Phylogenetic analyses of the different genomes were conducted separately and combined, with and without indels, using maximum parsimony, maximum likelihood, and Bayesian methods. To analyze the incongruence between plastid and nuclear-derived trees a consensus network from strongly supported nodes from cpDNA and ITS trees was constructed. Internode certainty values were calculated to evaluate the reliability of the relationships estimated from the individual cpDNA and ITS data sets and to examine the degree of conflict within the total evidence data set. Azorella and Mulinum were confirmed as not monophyletic. Except three Azorella species, the remaining azorellas, all species of Mulinum, and Laretia form a monophyletic group, designated here as Andean-Patagonian. The three species of Azorella that are not part of the Andean-Patagonian lineage are grouped together with Huanaca and Schizeilema in another lineage, designated here as Austral. Within the Andean-Patagonian clade, three major lineages can be recognized: Diversifolia, Trifurcata, and Spinosum. Each of these lineages have different leaf morpho-anatomies, Diversifolia species being more mesomorphic compared to species of Trifurcata, and species of Spinosum being the most xeromorphic. Hybridizations have been important in the evolution of the group, especially within Diversifolia, with at least six reticulation events resulting in putative homoploid and allopolyploid hybrid species. Evidence from branch lengths and low sequence divergences suggest a rapid radiation in the Spinosum group, probably associated with the acquisition of wings in the fruits.

On the Prepuna biogeographic province: A nomenclatural clarification.

The nomenclatural status of the Prepuna province sensu Cabrera (1951) and sensu Morrone (1999) is clarified. The Prepuna province sensu Cabrera (1951) is demoted to a district of the Monte province, stat. nov. The valid name of the Prepuna province sensu Morrone (1999) is Cuyan High Andean province Cabrera, 1971, stat. nov. Diagnoses of these areas are provided and their endemic taxa are listed.

[Plasmodium falciparum malaria acquired in Sub-Saharan Africa]. / Paludismo por Plasmodium falciparum adquirido en Africa subsahariana.

The purpose of this paper is to present the cases of malaria caused by Plasmodium falciparum in travelers coming from tropical Africa, who were treated at the Hospital Alemán (Buenos Aires). African malaria was defined as an infection acquired in any country within Africa, diagnosed and treated in Argentina. Diagnostic tools included clinical features and optic microscopy with Giemsa stained peripheral blood films. We reviewed the medical records of 11 adult patients -five tourists and six sailors- with no history of malaria, immunosuppressive condition or associated morbidity, admitted from 1993 to 2007. The age ranged from 21 to 48 years old, nine of them were males and two females. The patients were retrospectively classified into severe malaria -six of them- or mild malaria -five of them- according to severity criteria established by the World Health Organization, within the first three days of the beginnings of the symptoms. All patients presented fever; severe complications included encephalitis, renal failure, bleeding, haemoglobinuria, hypoglycemia, and pulmonary edema. Three patients required admission at the intensive care unit; no patient died. Only three off them had received properly chemoprophylaxis before traveling; all received treatment with at least one of the following drugs: mefloquine, quinidine, clyndamicine and cotrimoxazol.

Paludismo por Plasmodium falciparum adquirido en África subsahariana / Plasmodium falciparum malaria acquired in Subsaharian Africa

El objetivo de este trabajo es presentar los casos de paludismo por Plasmodium falciparum ocurridos en viajeros provenientes del África tropical, atendidos en el Hospital Alemán. Se definió paludismo de origen africano como la infección adquirida en un país del África subsahariana, diagnosticado y tratado en la Argentina. El diagnóstico se realizó por la clínica y la microscopía óptica en frotis de sangre periférica coloreados con Giemsa. Se revieron las historias clínicas de 11 pacientes adultos -cinco turistas y seis marineros mercantes- no oriundos de área endémica, sin condición inmunosupresora, ni morbilidad asociada, internados entre 1993 y 2007. El rango de edad fue de 21 a 48 años; nueve hombres y dos mujeres. Los pacientes fueron clasificados retrospectivamente en malaria grave (seis) o no grave (cinco) según cumplieran con uno o más de los criterios de gravedad de la Organización Mundial de la Salud. Todos presentaron fiebre como signo más significativo. Como complicaciones graves se observaron casos de insuficiencia renal, epistaxis, hemoglobinuria, hipoglucemia, edema pulmonar, acidosis y coma. Tres pacientes requirieron internación en la unidad de terapia intensiva. Todos sobrevivieron y solamente tres habían recibido la quimioprofilaxis correcta antes de viajar. El tratamiento se realizó con una o más de las siguientes drogas: mefloquina, quinidina, clindamicina y cotrimoxazol.

The purpose of this paper is to present the cases of malaria caused by Plasmodium falciparum in travelers coming from tropical Africa, who were treated at the Hospital Alemán (Buenos Aires). African malaria was defined as an infection acquired in any country within Africa, diagnosed and treated in Argentina. Diagnostic tools included clinical features and optic microscopy with Giemsa stained peripheral blood films. We reviewed the medical records of 11 adult patients -five tourists and six sailors- with no history of malaria, immunosuppressive condition or associated morbidity, admitted from 1993 to 2007. The age ranged from 21 to 48 years old, nine of them were males and two females. The patients were retrospectively classified into severe malaria -six of them- or mild malaria -five of them- according to severity criteria established by the World Health Organization, within the first three days of the beginnings of the symptoms. All patients presented fever; severe complications included encephalitis, renal failure, bleeding, haemoglobinuria, hypoglycemia, and pulmonary edema. Three patients required admission at the intensive care unit; no patient died. Only three off them had received properly chemoprophylaxis before traveling; all received treatment with at least one of the following drugs: mefloquine, quinidine, clyndamicine and cotrimoxazol.

Uncoupled geographical variation between leaves and flowers in a South-Andean Proteaceae.

BACKGROUND AND AIMS: Geographical variation in foliar and floral traits and their degree of coupling can provide relevant information on the relative importance of abiotic, biotic and even neutral factors acting at geographical scales as generators of evolutionary novelty. Geographical variation was studied in leaves and flowers of Embothrium coccineum, a species that grows along abrupt environmental gradients and exhibits contrasting pollinator assemblages in the southern Andes. METHODS: Five foliar and eight floral morphological characters were considered from 32 populations, and their patterns of variation and covariation were analysed within and among populations, together with their relationship with environmental variables, using both univariate and multivariate methods. The relationships between foliar and floral morphological variation and geographical distance between populations were compared with Mantel permutation tests. KEY RESULTS: Leaf and flower traits were clearly uncoupled within populations and weakly associated among populations. Whereas geographical variation in foliar traits was mostly related to differences in precipitation associated with geographical longitude, variation in floral traits was not. CONCLUSIONS: These patterns suggest that leaves and flowers responded to different evolutionary forces, environmental (i.e. rainfall) in the case of leaves, and biotic (i.e. pollinators) or genetic drift in the case of flowers. This study supports the view that character divergence at a geographical scale can be moulded by different factors acting in an independent fashion.

Floristic relationships among vegetation types of new zealand and the southern andes: similarities and biogeographic implications.

BACKGROUND AND AIMS: Similarities between the floras of geographically comparable regions of New Zealand (NZ) and the southern Andes (SA) have interested biologists for over 150 years. The present work selects vegetation types that are physiognomically similar between the two regions, compares their floristic composition, assesses the environmental factors that characterize these matching vegetation types, and determines whether phylogenetic groups of ancestral versus modern origin are represented in different proportions in their floras, in the context of their biogeographic history. METHODS: Floristic relationships based on 369 genera of ten vegetation types present in both regions were investigated with correspondence analysis (CA) and ascending hierarchical clustering (AHC). The resulting ordination and classification were related to the environmental characteristics of the different vegetation types. The proportions of different phylogenetic groups between the regions (NZ, SA) were also compared, and between forest and non-forest communities. KEY RESULTS: Floristic similarities between NZ and SA tend to increase from forest to non-forest vegetation, and are highest in coastal vegetation and bog. The floras of NZ and SA also differ in their phylogenetic origin, NZ being characterized by an 'excess' of genera of basal origin, especially in forests. CONCLUSIONS: The relatively low similarities between forests of SA and NZ are related to the former being largely of in situ South American and Gondwanan origin, whereas the latter have been mostly reconstituted though transoceanic dispersal of propagules since the Oligocene. The greater similarities among non-forest plant communities of the two regions result from varied dispersal routes, including relatively recent transoceanic dispersal for coastal vegetation, possible dispersal via a still-vegetated Antarctica especially for bog plants, and independent immigration from Northern Hemisphere sources for many genera of alpine vegetation and grassland.

[Acute cholecystitis and biliary tract infections due to Candida]. / Colecistitis aguda e infección de la vía biliar por Candida.

Candida biliary tract infection is a rare disease. Most of the reported cases have been diagnosed in patients with surgery or invasive procedures of the biliary tract, critical illness, immunosuppression or antibiotic treatment. This report deals with an 85 years old female patient with Candida albicans cholecystitis without previous risk factors and with a literature review on the subject. Only four patients without risk factors have been so far reported.

Colecistitis aguda e infección de la vía biliar por Candida / Acute cholecystitis and biliary tract infections due to Candida

La infección de la vía biliar por Candida es una enfermedad de baja frecuenciaque se asocia a procedimientos quirúrgicos o invasores de la vía biliar,a situaciones críticas, a inmunodepresión o a la utilización de antibióticos.Se presenta un caso de colecistitis aguda por Candida albicans en unapaciente de 85 años sin factores de riesgo previos, además de una revisiónbibliográfica del tema. Sólo en cuatro casos de los publicados, los pacientesno habían presentado factores de riesgo asociados(AU)

Candida biliary tract infection is a rare disease. Most of the reported caseshave been diagnosed in patients with surgery or invasive procedures ofthe biliary tract, critical illness, immunosuppression or antibiotic treatment.This report deals with an 85 years old female patient with Candida albicanscholecystitis without previous risk factors and with a literature review on thesubject. Only four patients without risk factors have been so far reported(AU)

Importancia de los conocimientos ecológicos para la interpretación de eventos médicos / Importance of the environmental knowledge for the interpretation of medical events

Es posible entender al hospital como un ecosistema. Ecología es el estudio científico de la interacción que determina la distribución y abundancia de los organismos en su locus. Medicamentos, particularmente los antibióticos, tienen una fuerte influencia en él. La flora normal, de los pacientes hospitalizados, sufre transformaciones. La principal fuente de micoorganismos emergente en el paciente internado es la micorbiota humana. La razón es una necesidad imperiosa de cambio y adaptación a las condiciones cambiantes del medio ambiente. Las caractrísticas de virulencia y epidemicidad de los diferentes microorganismos que componen los nichos harán que dominene el escenario hospitalario. Son aquellas que frente a la debilidad del paciente toman un comportamiento oportunista

Importancia de los conocimientos ecológicos para la interpretación de eventos médicos / Importance of the environmental knowledge for the interpretation of medical events

Es posible entender al hospital como un ecosistema. Ecología es el estudio científico de la interacción que determina la distribución y abundancia de los organismos en su locus. Medicamentos, particularmente los antibióticos, tienen una fuerte influencia en él. La flora normal, de los pacientes hospitalizados, sufre transformaciones. La principal fuente de micoorganismos emergente en el paciente internado es la micorbiota humana. La razón es una necesidad imperiosa de cambio y adaptación a las condiciones cambiantes del medio ambiente. Las caractrísticas de virulencia y epidemicidad de los diferentes microorganismos que componen los nichos harán que dominene el escenario hospitalario. Son aquellas que frente a la debilidad del paciente toman un comportamiento oportunista