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Small-scale production poultry operations are increasingly common worldwide. To investigate how these operations influence antimicrobial resistance and mobile genetic elements (MGEs), Escherichia coli isolates were sampled from small-scale production birds (raised in confined spaces with antibiotics in feed), household birds (no movement constraints; fed on scraps), and humans associated with these birds in rural Ecuador (2010-2012). Isolates were screened for genes associated with MGEs as well as phenotypic resistance to 12 antibiotics. Isolates from small-scale production birds had significantly elevated odds of resistance to 7 antibiotics and presence of MGE genes compared with household birds (adjusted odds ratio (OR) range = 2.2-87.9). Isolates from humans associated with small-scale production birds had elevated odds of carrying an integron (adjusted OR = 2.0; 95% confidence interval (CI): 1.06, 3.83) compared with humans associated with household birds, as well as resistance to sulfisoxazole (adjusted OR = 1.9; 95% CI: 1.01, 3.60) and trimethoprim/sulfamethoxazole (adjusted OR = 2.1; 95% CI: 1.13, 3.95). Stratifying by the presence of MGEs revealed antibiotic groups that are explained by biological links to MGEs; in particular, resistance to sulfisoxazole, trimethoprim/sulfamethoxazole, or tetracycline was highest among birds and humans when MGE exposures were present. Small-scale production poultry operations might select for isolates carrying MGEs, contributing to elevated levels of resistance in this setting.
Assuntos
Resistência Microbiana a Medicamentos/genética , Infecções por Escherichia coli/transmissão , Escherichia coli/genética , Sequências Repetitivas Dispersas/imunologia , Doenças Profissionais/epidemiologia , Aves Domésticas/microbiologia , Animais , Galinhas , Resistência Microbiana a Medicamentos/imunologia , Equador/epidemiologia , Escherichia coli/imunologia , Infecções por Escherichia coli/epidemiologia , Infecções por Escherichia coli/microbiologia , Feminino , Indústria Alimentícia , Humanos , Masculino , Doenças Profissionais/imunologia , Doenças Profissionais/microbiologia , Aves Domésticas/imunologia , População RuralRESUMO
OBJECTIVES: Despite a strong link between antibiotic use and resistance, and highly variable antibiotic consumption rates across the USA, drivers of differences in consumption rates are not fully understood. The objective of this study was to examine how provider density affects antibiotic prescribing rates across socioeconomic groups in the USA. METHODS: We aggregated data on all outpatient antibiotic prescriptions filled in retail pharmacies in the USA in 2000 and 2010 from IMS Health into 3436 geographically distinct hospital service areas and combined this with socioeconomic and structural factors that affect antibiotic prescribing from the US Census. We then used fixed-effect models to estimate the interaction between poverty and the number of physician offices per capita (i.e. physician density) and the presence of urgent care and retail clinics on antibiotic prescribing rates. RESULTS: We found large geographical variation in prescribing, driven in part by the number of physician offices per capita. For an increase of one standard deviation in the number of physician offices per capita there was a 25.9% increase in prescriptions per capita. However, the determinants of the prescription rate were dependent on socioeconomic conditions. In poorer areas, clinics substitute for traditional physician offices, reducing the impact of physician density. In wealthier areas, clinics increase the effect of physician density on the prescribing rate. CONCLUSIONS: In areas with higher poverty rates, access to providers drives the prescribing rate. However, in wealthier areas, where access is less of a problem, a higher density of providers and clinics increases the prescribing rate, potentially due to competition.
Assuntos
Assistência Ambulatorial/métodos , Antibacterianos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Uso de Medicamentos , Humanos , Fatores Socioeconômicos , Estados UnidosRESUMO
STUDY OBJECTIVE: To assess familiarity with long-acting reversible contraceptives (LARC) among current obstetrics and gynecology (OB/GYN), family medicine (FM), and pediatrics senior residents in the United States. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We selected 156 OB/GYN, FM, and pediatrics residency programs using the American Medical Association Freida database. Senior residents completed a survey addressing any training they had received on LARC, and rated their comfort level counseling about and inserting LARC. Residents rated their likelihood of recommending LARC to an adolescent, nulliparous patient, and indicated whether they would like additional training on LARC. Descriptive and analytic statistics were generated using R statistical software (The R Project for Statistical Computing; https://www.r-project.org). RESULTS: The survey was completed by 326 of 1,583 residents (20.6% response rate); at least 1 resident completed the survey at 105 (67.3%) of the residency programs contacted. Most programs (84.8%) provided some training on LARC. Residents in OB/GYN programs were comfortable counseling about and inserting contraceptive implants (97%, 83%), copper intrauterine devices (IUDs; 100%, 86%), and levonorgestrel (LNG) IUDs (100%, 86%). In FM programs, fewer residents were comfortable counseling about and inserting contraceptive implants (71%, 47%), copper IUDs (68%, 21%), and LNG IUDs (79%, 18%). Residents in pediatrics programs had low comfort levels counseling about contraceptive implants (14%), copper IUDs (14%), and LNG IUDs (25%); no pediatrics residents were comfortable inserting LARC. OB/GYN residents were significantly more likely to recommend a LARC to an adolescent, nulliparous patient (P = .019). Most pediatric and FM residents desired additional training on LARC (82.7% and 60.7%, respectively). CONCLUSION: This study shows that knowledge gaps exist regarding LARC among FM and pediatrics residents.
Assuntos
Anticoncepcionais Femininos/administração & dosagem , Conhecimentos, Atitudes e Prática em Saúde , Dispositivos Intrauterinos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Criança , Medicina de Família e Comunidade/educação , Feminino , Ginecologia/educação , Humanos , Internato e Residência , Obstetrícia/educação , Médicos , Gravidez , Inquéritos e Questionários , Estados UnidosRESUMO
BACKGROUND: Despite the availability of objective tests, gastroesophageal reflux disease (GERD) diagnosis and management in infants remains controversial and highly variable. Our purpose was to characterize national variation in diagnostic testing and surgical utilization for infants with GERD. METHODS: Using the Pediatric Health Information System, we identified infants <1 year old diagnosed with GERD between January 2011 and March 2015. Outcomes included progression to antireflux surgery (ARS) and use of relevant diagnostic testing. By using adjusted generalized linear mixed models, we compared facility-level ARS utilization. RESULTS: Of 5 299 943 infants, 149 190 had GERD (2.9%), and 4518 (3.0%) of those patients underwent ARS. Although annual rates of GERD and ARS decreased, there was a wide range of GERD diagnoses (1.8%-6.2%) and utilization of ARS (0.2%-11.2%). Facilities varied in the use of laparoscopic versus open ARS (mean: 66%, range: 23%-97%). Variation in facility-level ARS rates persisted after adjustment. Overall 3.8% of patients underwent diagnostic testing, whereas 22.8% of ARS patients underwent diagnostic testing. The proportion of surgeries done laparoscopically was independently associated with ARS utilization (odds ratio: 1.57; 95% confidence interval: 1.21-2.02). Facility-level utilization of diagnostics (P > .1) and prevalence of GERD (P > .1) were not associated with utilization of ARS. CONCLUSIONS: There is notable variation in the overall utilization of ARS and in the surgical and diagnostic approach in infants with GERD. Fewer than 4% of infants with GERD undergo diagnostic testing. This variation in care merits development of consensus guidelines and further research.
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Fundoplicatura/métodos , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/cirurgia , Cuidados Pré-Operatórios , Consenso , Estudos Transversais , Fundoplicatura/estatística & dados numéricos , Refluxo Gastroesofágico/epidemiologia , Guias como Assunto , Humanos , Lactente , Laparoscopia/estatística & dados numéricos , Modelos Lineares , Avaliação de Resultados em Cuidados de Saúde , Revisão da Utilização de Recursos de SaúdeRESUMO
The effects of animal agriculture on the spread of antibiotic resistance (AR) are cross-cutting and thus require a multidisciplinary perspective. Here we use ecological, epidemiological, and ethnographic methods to examine populations of Escherichia coli circulating in the production poultry farming environment versus the domestic environment in rural Ecuador, where small-scale poultry production employing nontherapeutic antibiotics is increasingly common. We sampled 262 "production birds" (commercially raised broiler chickens and laying hens) and 455 "household birds" (raised for domestic use) and household and coop environmental samples from 17 villages between 2010 and 2013. We analyzed data on zones of inhibition from Kirby-Bauer tests, rather than established clinical breakpoints for AR, to distinguish between populations of organisms. We saw significantly higher levels of AR in bacteria from production versus household birds; resistance to either amoxicillin-clavulanate, cephalothin, cefotaxime, and gentamicin was found in 52.8% of production bird isolates and 16% of household ones. A strain jointly resistant to the 4 drugs was exclusive to a subset of isolates from production birds (7.6%) and coop surfaces (6.5%) and was associated with a particular purchase site. The prevalence of AR in production birds declined with bird age (P < 0.01 for all antibiotics tested except tetracycline, sulfisoxazole, and trimethoprim-sulfamethoxazole). Farming status did not impact AR in domestic environments at the household or village level. Our results suggest that AR associated with small-scale poultry farming is present in the immediate production environment and likely originates from sources outside the study area. These outside sources might be a better place to target control efforts than local management practices. IMPORTANCE In developing countries, small-scale poultry farming employing antibiotics as growth promoters is being advanced as an inexpensive source of protein and income. Here, we present the results of a large ecoepidemiological study examining patterns of antibiotic resistance (AR) in E. coli isolates from small-scale poultry production environments versus domestic environments in rural Ecuador, where such backyard poultry operations have become established over the past decade. Our previous research in the region suggests that introduction of AR bacteria through travel and commerce may be an important source of AR in villages of this region. This report extends the prior analysis by examining small-scale production chicken farming as a potential source of resistant strains. Our results suggest that AR strains associated with poultry production likely originate from sources outside the study area and that these outside sources might be a better place to target control efforts than local management practices.
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BACKGROUND: Enterobacteriaceae infections resistant to extended-spectrum ß-lactams are an emerging problem in children. We used a large database of clinical isolates to describe the national epidemiology of extended-spectrum ß-lactamase (ESBL)-producing and third-generation cephalosporin-resistant (G3CR) Enterobacteriaceae. METHODS: Antimicrobial susceptibilities of Klebsiella pneumoniae, Escherichia coli, and Proteus mirabilis reported to â¼300 laboratories participating in The Surveillance Network (TSN) between January 1999 and December 2011 were used to phenotypically identify G3CR and ESBL isolates cultured from patients <18 years. Bi-annual trends in the prevalence of each phenotype were stratified by species, patient location, culture site, age, and region. Children of age 0-1 years were excluded from analysis as data were only available from 2010 onwards. RESULTS: Out of 368,398 pediatric isolates, 1.97% (7255) were identified as G3CR, and 0.47% (1734) as ESBL producers. The prevalence of both phenotypes increased, respectively, from 1.39% and 0.28% in 1999-2001 to 3% and 0.92% in 2010-2011. Trends were significant across all demographic and age groups, including outpatients, with the highest proportion of isolates in the 1-5-year-old age group. The majority of G3CR and ESBL isolates were E. coli (67.8% and 65.2%, respectively). Among ESBLs, resistance to ≥3 antibiotic classes was 74%. The lower regional prevalence of ESBL-producing bacteria in the upper Midwest relative to the rest of the country is consistent with recent local data. CONCLUSIONS: Rates of G3CR and ESBL infections in children are increasing in both inpatient and ambulatory settings nationally. The identification of host factors and exposures leading to infection in children is essential.
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BACKGROUND: Extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae infections are an emerging problem in children. We sought to identify risk factors and describe outcomes associated with pediatric ESBL-producing bacterial infections at 2 hospitals in Chicago, IL from 2008 to 2011. METHODS: A case-case-control study of children aged 0-17 years was conducted. Cases of Escherichia coli, Klebsiella, and Proteus spp. ESBL-producing bacterial infections (n = 30) were compared to uninfected controls and in parallel, cases of non-ESBL-producing bacterial infections (n = 30) were compared to uninfected controls (n = 60). We then qualitatively compared these results. RESULTS: Median age of cases was 1.06 years; 62% of isolates were from urine, and 60% were E. coli. By multivariable analysis, ESBL cases were 5.7 and 3.3 times more likely to have gastrointestinal (P = .001; 95% confidence interval [CI] 1.9-17.0) and neurologic (P = .001; 95% CI 1.1-3.7) comorbidities, respectively, than controls; non-ESBL cases were also more likely to have gastrointestinal comorbidities than controls (P = .014; odds ratio 3.6; 95% CI 1.2-10.1). Study period prevalence remained stable (1.7%). Most (60%) infections occurred in the intensive care unit; however, 30% of children presented in the outpatient setting. Seventy-seven percent of isolates were multidrug resistant (ie, resistant to ≥3 antibiotic classes). Recurrence of infection occurred in 17% of ESBL cases. Crude mortality rates (7%) did not differ between cases and controls. CONCLUSIONS: The incidence of pediatric infection due to ESBL-positive Enterobacteriaceae was stable at 2 large tertiary-care medical centers over a 4-year period. Multidrug resistance in pediatric ESBL isolates is common. Risk factors for infection due to ESBL-producing bacteria include neurologic medical conditions.
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BACKGROUND: Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. METHODS: We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0·1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. FINDINGS: Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05-2·70) and no infection was noted on an initial radiological study (1·76, 1·11-2·79). Escalation was associated with multiple infection sites (2·54, 1·34-4·83) and a positive culture (1·99, 1·20-3·29). INTERPRETATION: Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. FUNDING: US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
OBJECTIVE: Multidrug-resistant Enterobacteriaceae pose a serious infection control challenge and have emerged as a public health threat. We examined national trends in the proportion of Klebsiella pneumoniae isolates resistant to carbapenems (CRKP) and third-generation cephalosporins (G3CRKP). DESIGN AND SETTING: Retrospective analysis of approximately 500,000 K. pneumoniae isolates cultured between January 1999 and July 2010 at 287 clinical laboratories throughout the United States. METHODS: Isolates were defined as CRKP if they were nonsusceptible to 1 or more carbapenems and were defined as G3CRKP if they were nonsusceptible to ceftazidime, ceftriaxone, or related antibiotics. A multivariable analysis examined trends in the proportion of resistant isolates, adjusting for age, sex, isolate source, patient location, and geographic region. RESULTS: The crude proportion of CRKP increased from less than 0.1% to 4.5% between 2002 and 2010; the frequency of G3CRKP increased from 5.3% to 11.5% between 1999 and 2010. G3CRKP and CRKP were more common among elderly patients (those greater than 65 years of age); the adjusted odds ratio (aOR) relative to pediatric patients (those less than 18 years of age) was 1.2 for G3CRKP (95% confidence interval [CI], 1.2-1.3) and 3.3 for CRKP (95% CI, 2.6-4.2). G3CRKP and CRKP were also more common among patients from the northeastern United States (aOR, 2.9 [95% CI, 2.8-3.0] and 9.0 [95% CI, 7.9-10.4]) than among those from the western United States. The prevalence of outpatient CRKP isolates increased after 2006, reaching 1.9% of isolates in our sample in 2010 (95% CI, 1.6%-2.1%). CONCLUSIONS: The frequency of G3CRKP and CRKP is increasing in all regions of the United States, and resistance is emerging among isolates recovered in the outpatient setting. This underscores the need for enhanced laboratory capacity and coordinated surveillance strategies to contain the further spread of these emerging pathogens.