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1.
Artigo em Inglês | MEDLINE | ID: mdl-33813126

RESUMO

BACKGROUND: People living with HIV (PLWH) are at increased risk of infections with resistant organisms due to more frequent healthcare utilisation. OBJECTIVES: investigate the association between HIV and antimicrobial resistance (AMR). DATA SOURCES: we searched MEDLINE, EMBASE, Web of Science, LILACS and African Journals Online. STUDY ELIGIBILITY CRITERIA: Studies reporting on AMR for colonisation or infection with bacterial pathogens excluding mycobacteria and bacteria causing sexual transmitted infections stratified by HIV status, species and antimicrobials tested. PARTICIPANTS: any. INTERVENTIONS: none. METHODS: Pooled odds ratios were used to evaluate the association between HIV and resistance. RESULTS: A total of 92 studies published between 1995 and 2020 were identified. The studies included the following organisms: Staphylococcus (n=47), Streptococcus pneumoniae (n=28), Escherichia coli (n=6) and other Gram-negative bacteria. PLWH had a 2.12 (95% CI 1.36-3.30) higher odds for colonization and 1.90 (95%CI 1.45-2.48) higher odds for infection with methicillin-resistant S. aureus; a 2.28 (95%CI 1.75-2.97) higher odds of infections with S. pneumoniae with decreased penicillin susceptibility and a 1.59 (95%CI 0.83-3.05) higher odds of resistance to third-generation cephalosporins in E. coli and Klebsiella pneumoniae. CONCLUSION: . This review shows an increased risk of AMR in PLWH across a range of bacterial pathogens and multiple drug classes. The lack of laboratory capacity for identifying AMR and limited access to alternative treatment options in countries with the highest burden of HIV highlights the need for more research on AMR in PLWH. Overall, the quality of studies was moderate or low which may impact the findings of this review.

2.
Artigo em Inglês | MEDLINE | ID: mdl-33564871

RESUMO

BACKGROUND: Discriminating viral from bacterial lower respiratory tract infections (LRTIs) in children is challenging thus commonly resulting in antibiotic overuse. The Feverkidstool, a validated clinical decision rule including clinical symptoms and C-reactive protein, safely reduced antibiotic use in children at low/intermediate risk for bacterial LRTIs in a multicentre trial at emergency departments (EDs) in the Netherlands. OBJECTIVES: Using routine data from an observational study, we simulated the impact of the Feverkidstool on antibiotic prescriptions compared with observed antibiotic prescriptions in children with suspected LRTIs at 12 EDs in eight European countries. METHODS: We selected febrile children aged 1 month to 5 years with respiratory symptoms and excluded upper respiratory tract infections. Using the Feverkidstool, we calculated individual risks for bacterial LRTI retrospectively. We simulated antibiotic prescription rates under different scenarios: (1) applying effect estimates on antibiotic prescription from the trial; and (2) varying both usage (50%-100%) and compliance (70%-100%) with the Feverkidstool's advice to withhold antibiotics in children at low/intermediate risk for bacterial LRTI (≤10%). RESULTS: Of 4938 children, 4209 (85.2%) were at low/intermediate risk for bacterial LRTI. Applying effect estimates from the trial, the Feverkidstool reduced antibiotic prescription from 33.5% to 24.1% [pooled risk difference: 9.4% (95% CI: 5.7%-13.1%)]. Simulating 50%-100% usage with 90% compliance resulted in risk differences ranging from 8.3% to 15.8%. Our simulations suggest that antibiotic prescriptions would be reduced in EDs with high baseline antibiotic prescription rates or predominantly (>85%) low/intermediate-risk children. CONCLUSIONS: Implementation of the Feverkidstool could reduce antibiotic prescriptions in children with suspected LRTIs in European EDs.

3.
PLoS One ; 16(1): e0244810, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33411810

RESUMO

OBJECTIVES: Hospitalisation is frequently used as a marker of disease severity in observational Emergency Department (ED) studies. The comparison of ED admission rates is complex in potentially being influenced by the characteristics of the region, ED, physician and patient. We aimed to study variation in ED admission rates of febrile children, to assess whether variation could be explained by disease severity and to identify patient groups with large variation, in order to use this to reduce unnecessary health care utilization that is often due to practice variation. DESIGN: MOFICHE (Management and Outcome of Fever in children in Europe, part of the PERFORM study, www.perform2020.org), is a prospective cohort study using routinely collected data on febrile children regarding patient characteristics (age, referral, vital signs and clinical alarming signs), diagnostic tests, therapy, diagnosis and hospital admission. SETTING AND PARTICIPANTS: Data were collected on febrile children aged 0-18 years presenting to 12 European EDs (2017-2018). MAIN OUTCOME MEASURES: We compared admission rates between EDs by using standardised admission rates after adjusting for patient characteristics and initiated tests at the ED, where standardised rates >1 demonstrate higher admission rates than expected and rates <1 indicate lower rates than expected based on the ED patient population. RESULTS: We included 38,120 children. Of those, 9.695 (25.4%) were admitted to a general ward (range EDs 5.1-54.5%). Adjusted standardised admission rates ranged between 0.6 and 1.5. The largest variation was seen in short admission rates (0.1-5.0), PICU admission rates (0.2-2.2), upper respiratory tract infections (0.4-1.7) and fever without focus (0.5-2.7). Variation was small in sepsis/meningitis (0.9-1.1). CONCLUSIONS: Large variation exists in admission rates of febrile children evaluated at European EDs, however, this variation is largely reduced after correcting for patient characteristics and therefore overall admission rates seem to adequately reflect disease severity or a potential for a severe disease course. However, for certain patient groups variation remains high even after adjusting for patient characteristics.

4.
Antimicrob Resist Infect Control ; 10(1): 3, 2021 01 06.
Artigo em Inglês | MEDLINE | ID: mdl-33407887

RESUMO

BACKGROUND: Antimicrobial resistance (AMR), recognised as a serious and growing threat to global health, is promoted by multiple drivers, including antibiotic use in the livestock sector. Thus, understanding factors influencing antibiotic use in livestock production is essential to the design and implementation of effective interventions to reduce AMR. This qualitative study aimed to explore the experiences and views of the key actors associated with the use of antibiotics for pig farming in Thailand, from local farmers to officers in central government institutions. METHODS: A total of 31 in-depth interviews were conducted with different categories of actors: pig farmers (n = 13), drug retailers (n = 5), veterinarians (n = 7), government officers (n = 3) and representatives of animal and human health associations (n = 2). Themes emerging from the interviews were identified and explored using thematic analysis. In addition, direct observations were conducted in the pig farms. RESULTS: The findings highlight the multi-faceted nature of the views and practices that may contribute to misuse or overuse of antibiotics in the study locations, including misconceptions about the nature of antibiotics and AMR (particularly among smallholders), lack of facilities and financial means to establish an antibiotic-free farm, lack of sufficient training on AMR and antibiotic prescribing for veterinarians, the profit motive of pharmaceutical companies and their ties to farm consultants, and lack of sufficient regulatory oversight. CONCLUSIONS: Our study indicates a clear need to improve antibiotic use for pig production in Thailand. Farmers need better access to veterinary services and reliable information about animal health needs and antibiotics. Innovative investments in biosecurity could improve farm management and decrease reliance on antibiotics, although the cost of these interventions should be low to ensure wide uptake in the livestock sector. Lastly, further development of professional training and clinical guidelines, and the establishment of a code of conduct, would help improve antibiotic dispensing practices.

5.
Wellcome Open Res ; 5: 140, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33088923

RESUMO

Antimicrobial resistance (AMR) is compromising our ability to successfully treat infections. There are few data on gram-negative AMR prevalence in sub-Saharan Africa especially from the outpatient setting. This study aims to investigate the prevalence of and underlying molecular mechanisms for AMR in gram-negative bacilli causing urinary tract infections (UTIs) in Zimbabwe. Risk factors for AMR and how AMR impacts on clinical outcomes will also be investigated. Adults presenting with UTI symptoms at primary health clinics in Harare will be included. A questionnaire will be administered, and urine samples will be collected for culture. Participants with positive urine cultures will be followed up at 7-14 days post-enrolment. All participants will also be followed by telephone at 28 days to determine clinical outcomes. Bacterial identification and antibiotic susceptibility testing will be performed on positive cultures. The results from this study will be used to inform policy and development of treatment recommendations. Whole genome sequencing results will provide a better understanding of the prevalent resistance genes in Zimbabwe, of the spread of successful clones, and potentially will contribute to developing strategies to tackle AMR.

6.
Front Pediatr ; 8: 355, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32775314

RESUMO

Background: Kawasaki disease (KD) is a vasculitis of early childhood mimicking several infectious diseases. Differentiation between KD and infectious diseases is essential as KD's most important complication-the development of coronary artery aneurysms (CAA)-can be largely avoided by timely treatment with intravenous immunoglobulins (IVIG). Currently, KD diagnosis is only based on clinical criteria. The aim of this study was to evaluate whether routine C-reactive protein (CRP) and additional inflammatory parameters myeloid-related protein 8/14 (MRP8/14 or S100A8/9) and human neutrophil-derived elastase (HNE) could distinguish KD from infectious diseases. Methods and Results: The cross-sectional study included KD patients and children with proven infections as well as febrile controls. Patients were recruited between July 2006 and December 2018 in Europe and USA. MRP8/14, CRP, and HNE were assessed for their discriminatory ability by multiple logistic regression analysis with backward selection and receiver operator characteristic (ROC) curves. In the discovery cohort, the combination of MRP8/14+CRP discriminated KD patients (n = 48) from patients with infection (n = 105), with area under the ROC curve (AUC) of 0.88. The HNE values did not improve discrimination. The first validation cohort confirmed the predictive value of MRP8/14+CRP to discriminate acute KD patients (n = 26) from those with infections (n = 150), with an AUC of 0.78. The second validation cohort of acute KD patients (n = 25) and febrile controls (n = 50) showed an AUC of 0.72, which improved to 0.84 when HNE was included. Conclusion: When used in combination, the plasma markers MRP8/14, CRP, and HNE may assist in the discrimination of KD from both proven and suspected infection.

8.
PLoS Med ; 17(8): e1003208, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32813708

RESUMO

BACKGROUND: The prescription rate of antibiotics is high for febrile children visiting the emergency department (ED), contributing to antimicrobial resistance. Large studies at European EDs covering diversity in antibiotic and broad-spectrum prescriptions in all febrile children are lacking. A better understanding of variability in antibiotic prescriptions in EDs and its relation with viral or bacterial disease is essential for the development and implementation of interventions to optimise antibiotic use. As part of the PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union) project, the MOFICHE (Management and Outcome of Fever in Children in Europe) study aims to investigate variation and appropriateness of antibiotic prescription in febrile children visiting EDs in Europe. METHODS AND FINDINGS: Between January 2017 and April 2018, data were prospectively collected on febrile children aged 0-18 years presenting to 12 EDs in 8 European countries (Austria, Germany, Greece, Latvia, the Netherlands [n = 3], Spain, Slovenia, United Kingdom [n = 3]). These EDs were based in university hospitals (n = 9) or large teaching hospitals (n = 3). Main outcomes were (1) antibiotic prescription rate; (2) the proportion of antibiotics that were broad-spectrum antibiotics; (3) the proportion of antibiotics of appropriate indication (presumed bacterial), inappropriate indication (presumed viral), or inconclusive indication (unknown bacterial/viral or other); (4) the proportion of oral antibiotics of inappropriate duration; and (5) the proportion of antibiotics that were guideline-concordant in uncomplicated urinary and upper and lower respiratory tract infections (RTIs). We determined variation of antibiotic prescription and broad-spectrum prescription by calculating standardised prescription rates using multilevel logistic regression and adjusted for general characteristics (e.g., age, sex, comorbidity, referral), disease severity (e.g., triage level, fever duration, presence of alarming signs), use and result of diagnostics, and focus and cause of infection. In this analysis of 35,650 children (median age 2.8 years, 55% male), overall antibiotic prescription rate was 31.9% (range across EDs: 22.4%-41.6%), and among those prescriptions, the broad-spectrum antibiotic prescription rate was 52.1% (range across EDs: 33.0%-90.3%). After standardisation, differences in antibiotic prescriptions ranged from 0.8 to 1.4, and the ratio between broad-spectrum and narrow-spectrum prescriptions ranged from 0.7 to 1.8 across EDs. Standardised antibiotic prescription rates varied for presumed bacterial infections (0.9 to 1.1), presumed viral infections (0.1 to 3.3), and infections of unknown cause (0.1 to 1.8). In all febrile children, antibiotic prescriptions were appropriate in 65.0% of prescriptions, inappropriate in 12.5% (range across EDs: 0.6%-29.3%), and inconclusive in 22.5% (range across EDs: 0.4%-60.8%). Prescriptions were of inappropriate duration in 20% of oral prescriptions (range across EDs: 4.4%-59.0%). Oral prescriptions were not concordant with the local guideline in 22.3% (range across EDs: 11.8%-47.3%) of prescriptions in uncomplicated RTIs and in 45.1% (range across EDs: 11.1%-100%) of prescriptions in uncomplicated urinary tract infections. A limitation of our study is that the included EDs are not representative of all febrile children attending EDs in that country. CONCLUSIONS: In this study, we observed wide variation between European EDs in prescriptions of antibiotics and broad-spectrum antibiotics in febrile children. Overall, one-third of prescriptions were inappropriate or inconclusive, with marked variation between EDs. Until better diagnostics are available to accurately differentiate between bacterial and viral aetiologies, implementation of antimicrobial stewardship guidelines across Europe is necessary to limit antimicrobial resistance.


Assuntos
Antibacterianos/administração & dosagem , Prescrições de Medicamentos , Farmacorresistência Bacteriana/efeitos dos fármacos , Serviço Hospitalar de Emergência/tendências , Febre/tratamento farmacológico , Febre/epidemiologia , Adolescente , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/epidemiologia , Criança , Pré-Escolar , Prescrições de Medicamentos/normas , Farmacorresistência Bacteriana/fisiologia , Serviço Hospitalar de Emergência/normas , Europa (Continente)/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos
9.
BMJ Glob Health ; 5(5)2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32439690

RESUMO

BACKGROUND: Over the last 10 years, there has been a huge shift in malaria diagnosis in public health facilities, due to widespread deployment of rapid diagnostic tests (RDTs), which are accurate, quick and easy to use and inexpensive. There are calls for RDTs to be made available at-scale in the private retail sector where many people with suspected malaria seek care. Retail sector RDT use in sub-Saharan Africa (SSA) is limited to small-scale studies, and robust evidence on value-for-money is not yet available. We modelled the cost-effectiveness of introducing subsidised RDTs and supporting interventions in the SSA retail sector, in a context of a subsidy programme for first-line antimalarials. METHODS: We developed a decision tree following febrile patients through presentation, diagnosis, treatment, disease progression and further care, to final health outcomes. We modelled results for three 'treatment scenarios', based on parameters from three small-scale studies in Nigeria (TS-N), Tanzania (TS-T) and Uganda (TS-U), under low and medium/high transmission (5% and 50% Plasmodium falciparum (parasite) positivity rates (PfPR), respectively). RESULTS: Cost-effectiveness varied considerably between treatment scenarios. Cost per disability-adjusted life year averted at 5% PfPR was US$482 (TS-N) and US$115 (TS-T) and at 50% PfPR US$44 (TS-N) and US$45 (TS-T), from a health service perspective. TS-U was dominated in both transmission settings. CONCLUSION: The cost-effectiveness of subsidised RDTs is strongly influenced by treatment practices, for which further evidence is required from larger-scale operational settings. However, subsidised RDTs could promote increased use of first-line antimalarials in patients with malaria. RDTs may, therefore, be more cost-effective in higher transmission settings, where a greater proportion of patients have malaria and benefit from increased antimalarial use. This is contrary to previous public sector models, where RDTs were most cost-effective in lower transmission settings as they reduced unnecessary antimalarial use in patients without malaria.

10.
BMJ Open ; 10(5): e035343, 2020 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-32371515

RESUMO

OBJECTIVES: To appraise European guidelines for acute otitis media (AOM) in children, including methodological quality, level of evidence (LoE), astrength of recommendations (SoR), and consideration of antibiotic stewardship. DESIGN: Systematic review of the literature. DATA SOURCES: Three-pronged search of (1) databases: Medline, Embase, Cochrane library, Guidelines International Network and Trip Medical Database; (2) websites of European national paediatric associations and (3) contact of European experts. Data were collected between January 2017 and February 2018. ELIGIBILITY CRITERIA: National guidelines of European countries for the clinical management of AOM in children aged <16 years. DATA EXTRACTION AND SYNTHESIS: Data were extracted using tables constructed by the research team. Guidelines were graded using AGREE II criteria. LoE and SoR were compared. Guidelines were assessed for principles of antibiotic stewardship. RESULTS: AOM guidelines were obtained from 17 or the 32 countries in the European Union or European Free Trade Area. The mean AGREE II score was ≤41% across most domains. Diagnosis of AOM was based on similar signs and symptoms. The most common indication for antibiotics was tympanic membrane perforation/otorrhoea (14/15; 93%). The majority (15/17; 88%) recommended a watchful waiting approach to antibiotics. Amoxicillin was the most common first-line antibiotic (14/17; 82%). Recommended treatment duration varied from 5 to 10 days. Seven countries advocated high-dose (75-90 mg/kg/day) and five low-dose (30-60 mg/kg/day) amoxicillin. Less than 60% of guidelines used a national or international scale system to rate level of evidence to support recommendations. Under half of the guidelines (7/17; 41%) referred to country-specific microbiological and antibiotic resistance data. CONCLUSIONS: Guidelines for managing AOM were similar across European countries. Guideline quality was mostly weak, and it often did not refer to country-specific antibiotic resistance patterns. Coordinating efforts to produce a core guideline which can then be adapted by each country may help improve overall quality and contribute to tackling antibiotic resistance.

11.
Neuroimage ; 219: 116846, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32304884

RESUMO

Magnetic resonance imaging (MRI) is an indispensable tool for investigating brain development in young children and the neurobiological mechanisms underlying developmental risk and resilience. Sub-Saharan Africa has the highest proportion of children at risk of developmental delay worldwide, yet in this region there is very limited neuroimaging research focusing on the neurobiology of such impairment. Furthermore, paediatric MRI imaging is challenging in any setting due to motion sensitivity. Although sedation and anesthesia are routinely used in clinical practice to minimise movement in young children, this may not be ethical in the context of research. Our study aimed to investigate the feasibility of paediatric multimodal MRI at age 2-3 years without sedation, and to explore the relationship between cortical structure and neurocognitive development at this understudied age in a sub-Saharan African setting. A total of 239 children from the Drakenstein Child Health Study, a large observational South African birth cohort, were recruited for neuroimaging at 2-3 years of age. Scans were conducted during natural sleep utilising locally developed techniques. T1-MEMPRAGE and T2-weighted structural imaging, resting state functional MRI, diffusion tensor imaging and magnetic resonance spectroscopy sequences were included. Child neurodevelopment was assessed using the Bayley-III Scales of Infant and Toddler Development. Following 23 pilot scans, 216 children underwent scanning and T1-weighted images were obtained from 167/216 (77%) of children (median age 34.8 months). Furthermore, we found cortical surface area and thickness within frontal regions were associated with cognitive development, and in temporal and frontal regions with language development (beta coefficient ≥0.20). Overall, we demonstrate the feasibility of carrying out a neuroimaging study of young children during natural sleep in sub-Saharan Africa. Our findings indicate that dynamic morphological changes in heteromodal association regions are associated with cognitive and language development at this young age. These proof-of-concept analyses suggest similar links between the brain and cognition as prior literature from high income countries, enhancing understanding of the interplay between cortical structure and function during brain maturation.

12.
Lancet Infect Dis ; 20(8): 953-963, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32277908

RESUMO

BACKGROUND: Passively collected malaria case data are the foundation for public health decision making. However, because of population-level immunity, infections might not always be sufficiently symptomatic to prompt individuals to seek care. Understanding the proportion of all Plasmodium spp infections expected to be detected by the health system becomes particularly paramount in elimination settings. The aim of this study was to determine the association between the proportion of infections detected and transmission intensity for Plasmodium falciparum and Plasmodium vivax in several global endemic settings. METHODS: The proportion of infections detected in routine malaria data, P(Detect), was derived from paired household cross-sectional survey and routinely collected malaria data within health facilities. P(Detect) was estimated using a Bayesian model in 431 clusters spanning the Americas, Africa, and Asia. The association between P(Detect) and malaria prevalence was assessed using log-linear regression models. Changes in P(Detect) over time were evaluated using data from 13 timepoints over 2 years from The Gambia. FINDINGS: The median estimated P(Detect) across all clusters was 12·5% (IQR 5·3-25·0) for P falciparum and 10·1% (5·0-18·3) for P vivax and decreased as the estimated log-PCR community prevalence increased (adjusted odds ratio [OR] for P falciparum 0·63, 95% CI 0·57-0·69; adjusted OR for P vivax 0·52, 0·47-0·57). Factors associated with increasing P(Detect) included smaller catchment population size, high transmission season, improved care-seeking behaviour by infected individuals, and recent increases (within the previous year) in transmission intensity. INTERPRETATION: The proportion of all infections detected within health systems increases once transmission intensity is sufficiently low. The likely explanation for P falciparum is that reduced exposure to infection leads to lower levels of protective immunity in the population, increasing the likelihood that infected individuals will become symptomatic and seek care. These factors might also be true for P vivax but a better understanding of the transmission biology is needed to attribute likely reasons for the observed trend. In low transmission and pre-elimination settings, enhancing access to care and improvements in care-seeking behaviour of infected individuals will lead to an increased proportion of infections detected in the community and might contribute to accelerating the interruption of transmission. FUNDING: Wellcome Trust.


Assuntos
Infecções Assintomáticas/epidemiologia , Reservatórios de Doenças/estatística & dados numéricos , Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Adolescente , Adulto , África/epidemiologia , Idoso , Idoso de 80 Anos ou mais , América/epidemiologia , Ásia/epidemiologia , Teorema de Bayes , Criança , Pré-Escolar , Análise por Conglomerados , Estudos Transversais , Reservatórios de Doenças/parasitologia , Feminino , Instalações de Saúde/estatística & dados numéricos , Humanos , Lactente , Estudos Longitudinais , Malária Falciparum/transmissão , Malária Vivax/transmissão , Masculino , Pessoa de Meia-Idade , Prevalência , Vigilância em Saúde Pública/métodos , Estações do Ano , Adulto Jovem
13.
BMJ Glob Health ; 5(2): e001918, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32180998

RESUMO

Background: Rising global concern about antimicrobial resistance has drawn attention to the use of antibiotics in livestock. Understanding the current usage of antibiotics in these animals is essential for effective interventions on the optimisation of antibiotic use. However, to date few studies have been conducted in low- and middle-income countries. This study aimed to explore the use of antibiotics and estimate the total amount of antibiotics used in pig production in Thailand. Methods: This was a mixed-methods study including a cross-sectional questionnaire-based survey of 84 pig farmers, secondary analysis of data from a survey of 31 feed mills to estimate the amount of antibiotics mixed in pig feed and interviews with five veterinarians involved in the feed mill industry to gain an understanding of medicated feed production. Findings: Half of the farmers reported using antibiotics for disease prevention. Use was significantly associated with farmers' experience in raising pigs, farm income, having received advice on animal health and belonging to a farm cooperative. The estimated total amount of active ingredients mixed into medicated feed for pigs for the whole country was 843 tonnes in 2017. Amoxicillin was the most commonly used antibiotic reported by both pig farms and feed mills. The use of Critically Important Antimicrobials including colistin was common, with one-third of farmers reporting their use as oral or as injectable medication, and accounting for nearly two-thirds of antibiotics contained in medicated feed. Conclusion: A majority of antibiotics used in Thai pig farms belonged to the category of Critically Important Antimicrobials. Progressive restriction in the use of antibiotics in pigs is recommended through using prescriptions to control the distribution of certain antibiotics. The government should strengthen veterinary services to improve access of farmers to animal health advice and explore alternative interventions.

14.
Arch Dis Child ; 105(8): 765-771, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32107251

RESUMO

BACKGROUND: Fever among children is a leading cause of emergency department (ED) attendance and a diagnostic conundrum; yet robust quantitative evidence regarding the preferences of parents and healthcare providers (HCPs) for managing fever is scarce. OBJECTIVE: To determine parental and HCP preferences for the management of paediatric febrile illness in the ED. SETTING: Ten children's centres and a children's ED in England from June 2018 to January 2019. PARTICIPANTS: 98 parents of children aged 0-11 years, and 99 HCPs took part. METHODS: Nine focus-groups and coin-ranking exercises were conducted with parents, and a discrete-choice experiment (DCE) was conducted with both parents and HCPs, which asked respondents to choose their preferred option of several hypothetical management scenarios for paediatric febrile illness, with differing levels of visit time, out-of-pocket costs, antibiotic prescribing, HCP grade and pain/discomfort from investigations. RESULTS: The mean focus-group size was 4.4 participants (range 3-7), with a mean duration of 27.4 min (range 18-46 min). Response rates to the DCE among parents and HCPs were 94.2% and 98.2%, respectively. Avoiding pain from diagnostics, receiving a faster diagnosis and minimising wait times were major concerns for both parents and HCPs, with parents willing-to-pay £16.89 for every 1 hour reduction in waiting times. Both groups preferred treatment by consultants and nurse practitioners to treatment by doctors in postgraduate training. Parents were willing to trade-off considerable increases in waiting times (24.1 min) to be seen by consultants and to avoid additional pain from diagnostics (45.6 min). Reducing antibiotic prescribing was important to HCPs but not parents. CONCLUSIONS: Both parents and HCPs care strongly about reducing visit time, avoiding pain from invasive investigations and receiving diagnostic insights faster when managing paediatric febrile illness. As such, overdue advances in diagnostic capabilities should improve child and carer experience and HCP satisfaction considerably in managing paediatric febrile illness.


Assuntos
Atitude do Pessoal de Saúde , Comportamento de Escolha , Serviço Hospitalar de Emergência , Febre/terapia , Pessoal de Saúde/psicologia , Pais/psicologia , Adulto , Criança , Pré-Escolar , Feminino , Grupos Focais , Pesquisas sobre Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Tempo para o Tratamento , Reino Unido
15.
Am J Trop Med Hyg ; 102(2): 307-309, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31820711

RESUMO

Proposed interventions for eliminating drug-resistant Plasmodium falciparum malaria include the targeting of asymptomatic carriers through screening and treatment. We report on the diagnostic performance of the recently developed ultrasensitive rapid diagnostic test (uRDT) compared with screening with conventional RDTs (cRDT) and polymerase chain reaction (PCR) under field conditions in Cambodia in a total of 2,729 individuals. The P. falciparum positivity by quantitative PCR (qPCR) was 3.8% (26/678) in those screened during active case detection and 0.5% (10/2,051) in the cross-sectional survey. Compared with qPCR, the sensitivity of the uRDTs was 53.8% (95% CI: 33.4-73.4%) when used in active case detection and 60.0% (95% CI: 26.2-87.8%) in the cross-sectional survey. The uRDTs did not show a significant improvement in diagnostic performance over cRDTs when used for active case detection and for a malaria prevalence survey in the context of this low-transmission setting.


Assuntos
Testes Diagnósticos de Rotina/métodos , Testes Diagnósticos de Rotina/normas , Malária Falciparum/diagnóstico , Plasmodium falciparum , Camboja/epidemiologia , Humanos , Malária Falciparum/epidemiologia , Reação em Cadeia da Polimerase/métodos , Sensibilidade e Especificidade , Tailândia/epidemiologia , Fatores de Tempo
16.
Malar J ; 18(1): 379, 2019 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-31775755

RESUMO

BACKGROUND: The ongoing spread of artemisinin resistant Plasmodium falciparum malaria is a major threat to global health. In response, countries in the Greater Mekong Sub-region, including Cambodia, have declared ambitious goals to eliminate malaria. Major challenges include the lack of information on the at-risk population-individuals who live or work in or near the forest where the malaria vectors are found, including plantation workers. This study aimed to address this knowledge gap through a cross-sectional survey conducted in rubber plantations in Cambodia in 2014. METHODS: The survey was conducted in two rounds in four provinces and included a malaria prevalence survey, analysis for the K13 genetic mutation, and a comprehensive behavioural questionnaire. Forty plantations were included in each round, and 4201 interviews were conducted. An additional 701 blood samples were collected from family members of plantation workers. RESULTS: Overall malaria prevalence was relatively low with adjusted PCR prevalence rate of 0.6% for P. falciparum and 0.3% for Plasmodium vivax, and was very heterogenous between plantations. There was little difference in risk between permanent residents and temporary workers, and between the two rounds. The main risk factors for P. falciparum infection were smaller plantations, age under 30 years, lack of self-reported use of a treated net and recent travel, especially to the Northeastern provinces. Proximity of plantations to the forest was also a risk factor for malaria in round one, while male gender was also a risk factor for malaria by either species. CONCLUSIONS: With Cambodia's P. falciparum elimination target on the horizon, identifying every single malaria case will become increasingly important. Plantations workers are relatively accessible compared to some other at-risk groups and will likely remain a high priority. Ongoing surveillance and adaptive strategies will be critical if malaria elimination is to be achieved in this setting.


Assuntos
Antimaláricos/farmacologia , Artemisininas/farmacologia , Resistência a Medicamentos , Agricultura Florestal , Malária Falciparum/epidemiologia , Malária Vivax/epidemiologia , Adolescente , Adulto , Camboja/epidemiologia , Estudos Transversais , Feminino , Hevea , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Profissionais/epidemiologia , Doenças Profissionais/parasitologia , Plasmodium falciparum/efeitos dos fármacos , Plasmodium vivax/efeitos dos fármacos , Prevalência , Fatores de Risco , Adulto Jovem
17.
Curr HIV/AIDS Rep ; 16(6): 501-513, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31732866

RESUMO

PURPOSE OF REVIEW: The population of HIV-exposed uninfected (HEU) children is expanding rapidly, and over one million HEU infants are born each year globally. Several recent studies have reported that HEU children, particularly in low- and middle-income countries, are at risk of poor outcomes, including impaired growth and neurodevelopment. However, the reasons for poor clinical outcomes amongst HEU children remain unclear. RECENT FINDINGS: We summarise the findings from recent large studies that have characterised growth and neurodevelopment in HEU children, identified risk factors and explored underlying mechanistic pathways. We propose a conceptual framework to explain how exposure to HIV and antiretroviral therapy (ART) may lead to adverse growth and neurodevelopment in uninfected children, and review the available evidence and research gaps. We propose that HEU children are affected both indirectly, through the augmentation of universal risk factors underlying poor growth and neurodevelopment, and directly through HIV/ART-specific pathways, which ultimately may converge through a series of common pathogenic mechanisms. In the era of universal ART, a better understanding of these pathways is crucial to inform future prevention and intervention strategies.


Assuntos
Antirreumáticos/efeitos adversos , Infecções por HIV/tratamento farmacológico , Exposição Materna/estatística & dados numéricos , Complicações Infecciosas na Gravidez/tratamento farmacológico , Complicações Infecciosas na Gravidez/virologia , Antirreumáticos/uso terapêutico , Criança , Desenvolvimento Infantil/fisiologia , Feminino , Infecções por HIV/transmissão , Humanos , Lactente , Masculino , Gravidez
19.
Lancet Child Adolesc Health ; 3(11): 803-813, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31515160

RESUMO

BACKGROUND: HIV infection is known to cause developmental delay, but the effects of HIV exposure without infection during pregnancy on child development are unclear. We compared the neurodevelopmental outcomes of HIV-exposed uninfected and HIV-unexposed children during their first 2 years of life. METHODS: Pregnant women (>18 years of age) at 20-28 weeks' gestation were enrolled into the Drakenstein Child Health cohort study while attending routine antenatal appointments at one of two peri-urban community-based clinics in Paarl, South Africa. Livebirths born to enrolled women during follow-up were included in the birth cohort. Mothers and infants received antenatal and postnatal HIV testing and antiretroviral therapy per local guidelines. Developmental assessments on the Bayley Scales of Infant and Toddler Development, third edition (BSID-III), were done in a subgroup of infants at 6 months of age, and in the full cohort at 24 months of age, with assessors masked to HIV exposure status. Mean raw scores and the proportions of children categorised as having a delay (scores <-2 SDs from the reference mean) on BSID-III were compared between HIV-exposed uninfected and HIV-unexposed children. FINDINGS: 1225 women were enrolled between March 5, 2012, and March 31, 2015. Of 1143 livebirths, 1065 (93%) children were in follow-up at 6 months and 1000 (87%) at 24 months. Two children were diagnosed with HIV infection between birth and 24-month follow-up and were excluded from the analysis. BSID-III assessments were done in 260 (24%) randomly selected children (61 HIV-exposed uninfected, 199 HIV-unexposed) at 6 months and in 732 (73%) children (168 HIV-exposed uninfected, 564 HIV-unexposed) at 24 months. All HIV-exposed uninfected children were exposed to antiretrovirals (88% to maternal triple antiretroviral therapy). BSID-III outcomes did not significantly differ between HIV-exposed uninfected and HIV-unexposed children at 6 months. At 24 months, HIV-exposed uninfected children scored lower than HIV-unexposed for receptive language (adjusted mean difference -1·03 [95% CI -1·69 to -0·37]) and expressive language (-1·17 [-2·09 to -0·24]), whereas adjusted differences in cognitive (-0·45 [-1·32 to 0·43]), fine motor (0·09 [-0·49 to 0·66]), and gross motor (-0·41 [-1·09 to 0·27]) domain scores between groups were not significant. Correspondingly, the proportions of HIV-exposed uninfected children with developmental delay were higher than those of HIV-unexposed children for receptive language (adjusted odds ratio 1·96 [95% CI 1·09 to 3·52]) and expressive language (2·14 [1·11 to 4·15]). INTERPRETATION: Uninfected children exposed to maternal HIV infection and antiretroviral therapy have increased odds of receptive and expressive language delays at 2 years of age. Further long-term work is needed to understand developmental outcomes of HIV-exposed uninfected children, especially in regions such as sub-Saharan Africa that have a high prevalence of HIV exposure among children. FUNDING: Bill & Melinda Gates Foundation, SA Medical Research Council, Wellcome Trust.


Assuntos
Desenvolvimento Infantil , Infecções por HIV/complicações , HIV , Transtornos do Neurodesenvolvimento/epidemiologia , Complicações Infecciosas na Gravidez , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Adulto , Pré-Escolar , Comorbidade , Feminino , Seguimentos , Infecções por HIV/epidemiologia , Humanos , Incidência , Lactente , Masculino , Transtornos do Neurodesenvolvimento/etiologia , Gravidez , Estudos Retrospectivos , África do Sul/epidemiologia , Fatores de Tempo
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