Identifying the know-do gap in evidence-based neonatal care practices among informal health care providers-a cross-sectional study from Ujjain, India.

BACKGROUND: More than a quarter of global neonatal deaths are reported from India, and a large proportion of these deaths are preventable. However, in the absence of robust public health care systems in several states in India, informal health care providers (IHCPs) with no formal medical education are the first contact service providers. The aim of this study was to assess the knowledge of IHCPs in basic evidence-based practices in neonatal care in Ujjain district and investigated factors associated with differences in levels of knowledge. METHODS: A cross-sectional survey was conducted using a questionnaire with multiple-choice questions covering the basic elements of neonatal care. The total score of the IHCPs was calculated. Multivariate quantile regression model was used to look for association of IHCPs knowledge score with: the practitioners' age, years of experience, number of patients treated per day, and whether they attended children in their practice. RESULTS: Of the 945 IHCPs approached, 830 (88%) participated in the study. The mean ± SD score achieved was 22.3 ± 7.7, with a median score of 21 out of maximum score of 48. Although IHCPs could identify key tenets of enhancing survival chances of neonates, they scored low on the specifics of cord care, breastfeeding, vitamin K use to prevent neonatal hemorrhage, and identification and care of low-birth-weight babies. The practitioners particularly lacked knowledge about neonatal resuscitation, and only a small proportion reported following up on immunizations. Results of quantile regression analysis showed that more than 5 years of practice experience and treating more than 20 patients per day had a statistically significant positive association with the knowledge score at higher quantiles (q75th and q90th) only. IHCPs treating children had significantly better scores across quantiles accept at the highest quantile (90th). CONCLUSIONS: The present study highlighted that know-do gap exists in evidence-based practices for all key areas of neonatal care tested among the IHCPs. The study provides the evidence that some IHCPs do possess knowledge in basic evidence-based practices in neonatal care, which could be built upon by future educational interventions. Targeting IHCPs can be an innovative way to reach a large rural population in the study setting and to improve neonatal care services.

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.

Community perceptions of infectious diseases, antibiotic use and antibiotic resistance in context of environmental changes: a study in Odisha, India.

BACKGROUND: The public health impact of environmental changes and the faceless threat of antibiotic resistance are currently among the top global health challenges. Community understanding of health, diseases and medicines in relation to the changing environment is necessary to mitigate the impact of these changes on health and for prudent use of antibiotics. OBJECTIVE: The objective is to explore community perceptions of infectious diseases, antibiotic use and antibiotic resistance in the context of environmental changes. METHODS: A qualitative study was conducted among community members with various backgrounds in education, gender, age and occupation of two districts of Odisha, India. Eight focus groups discussions and ten individual interviews were conducted. Data were analysed using content analysis. RESULTS: Two themes emerged: 'Interpretation of infectious diseases and health hazards in the context of environmental changes', and 'Understanding of antibiotic use and its consequences for resistance development and the environment'. The participants perceived that nowadays there is irregularity in the occurrence of seasons, particularly an increase in average temperature, which is influencing health. Participants' perceptions of infectious diseases, antibiotic use and resistance varied according to their social environment. Furthermore, they perceived that improved sanitation, choice of alternative medicine and awareness and education on prudent use of antibiotics are probably some ways to prevent antibiotic resistance. CONCLUSIONS: The participants perceived that climate variability is increasing and that this has health consequences for the community. They also hypothesized an interrelationship between the environment, infectious diseases and medicine use, particularly antibiotics. This is helpful for further empirical studies.

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.

Improvement in health and empowerment of families as a result of watershed management in a tribal area in India - a qualitative study.

BACKGROUND: Tribal people in India, as in other parts of the world, reside mostly in forests and/or hilly terrains. Water scarcity and health problems related to it are their prime concern. Watershed management can contribute to resolve their health related problems and can put them on a path of socio-economic development. Integrated management of land, water and biomass resources within a watershed, i.e. in an area or a region which contributes rainfall water to a river or lake, is referred to as watershed management. Watershed management includes soil and water conservation to create water resources, management of drinking water, improving hygiene and sanitation, plantation of trees, improving agriculture, formation of self-help groups and proper utilisation and management of available natural resources. For successful implementation of such a solution, understanding of perceptions of the tribal community members with regard to public health and socioeconomic implications of watershed management is essential. METHODS: A qualitative study with six focus group discussions (FGDs), three each separately for men and women, was conducted among tribal community members of the Maharashtra state of India. The data collected from the FGDs were analyzed using manifest and latent content analysis. RESULTS: "Improvement in health and empowerment of families as a result of watershed management" was identified as the main theme. Participants perceived that their health problems and socio-economic development are directly and/or indirectly dependent upon water availability. They further perceived that watershed management could directly or indirectly result in reduction of their public health related challenges like waterborne diseases, seasonal migration, alcoholism, intimate partner violence, as well as drudgery of women and may enhance overall empowerment of families through agricultural development. CONCLUSIONS: Tribal people perceived that water scarcity is the main reason for their physical, mental and social health problems and a major obstacle for their overall development. The perceptions of tribal participants indicate that infectious diseases, migration, alcoholism, intimate partner violence and drudgery of women are end results of water scarcity and efforts to increase water availability through watershed management may help them to achieve their right to health which is embedded in their right to access to water.

Antibiotic concentrations and antibiotic resistance in aquatic environments of the WHO Western Pacific and South-East Asia regions: a systematic review and probabilistic environmental hazard assessment.

BACKGROUND: Antibiotic resistance poses human health risks, and there are concerns about the effect of environmental antibiotic residues in the selection and spread of antibiotic resistance. The aim of this study was to identify antibiotic residue levels that are likely to select for resistance and relative contributions from different aquatic sources, of various aquatic environmental compartments of the WHO Western Pacific region (WPR) and the WHO South-East Asia region (SEAR), including in China and India. METHODS: A systematic review of empirical studies that measured antibiotic concentrations in aquatic environments, published between 2006 and 2019, and a probabilistic environmental hazard assessments approach, were used to identify antibiotic concentrations that are likely to select for resistance in various aquatic environmental compartments of the WPR and SEAR, including in China and India. The assessment involved the use of measured environmental concentrations and predicted no-effect concentrations (PNECs). FINDINGS: The systematic review found 218 relevant studies of 5230 screened from the WPR and 22 relevant studies of 2625 screened from the SEAR; some of these relevant studies were largely from China (n=168) and India (n=15). 92 antibiotics in the WPR and 45 in the SEAR were detected in various aquatic compartments. Antibiotic concentrations that most likely exceeded PNECs (0-100%) were observed in wastewater, and influents and effluents of wastewater treatment plants. Antibiotic concentrations that most likely exceeded PNECs were also observed in aquatic environmental compartments. The highest risk for the development of resistance was in tap or drinking water of the WPR and China for ciprofloxacin (62·5%). The relative contributions of potential sources of antibiotic contamination in waterways, such as hospitals, municipals, livestock, and pharmaceutical manufacturing, was determined for each antibiotic. INTERPRETATION: The concentrations of antibiotic residues found in wastewater and wastewater treatment plants of the WPR and SEAR make them potential hotspots for the development of antibiotic resistance, which creates human health risks from environmental exposure via drinking water. These findings can help decision makers to target risk reduction measures against environmental residues of priority antibiotics in high-risk sites, and help to focus research efforts in these world regions. FUNDING: Swedish Research Council.

The development of an integrated environment-human risk approach for the prioritisation of antibiotics for policy decisions.

Environmental contamination with antibiotic residues has caused significant concern. Antibiotics are continually emitted into the environment which potentially threatens environmental and human health, particularly, the risk in the development of antibiotic resistance. A list of priority antibiotics in the environment is essential for eco-pharmacovigilance and policy decisions. This study developed a prioritisation system of antibiotics based on their integrated environmental (resistance and ecotoxicity) and human health (resistance and toxicity) risks, considering various aquatic environmental compartments. Data obtained by conducting a systematic review of the literature of antibiotic residues in various aquatic environmental compartments in China was used as an example. The list of priority antibiotics was created by ranking the antibiotics in descending order, based on the risk scores of their a) overall risk, (b) antibiotic resistance risk to environment, (c) ecotoxicity risk, (d) overall environmental risk, (e) antibiotic resistance risk to human health, (f) toxicity risk to human health and (g) overall human health risk. Ciprofloxacin posed the greatest risk and chloramphenicol posed the least risk. The output from this research can be used to implement eco-pharmacovigilance and to develop targeted policies which would prevent / minimise the environmental and human health risks from antibiotic residues. The use of this list of priority antibiotics will allow for a country / region / setting to (a) optimise the use of antibiotics and their prescribing practices, (b) create effective monitoring and mitigation strategies, (c) minimise the discharge of antibiotic residues and (d) focus research efforts.

Utility of constructed wetlands for treatment of hospital effluent and antibiotic resistant bacteria in resource limited settings: A case study in Ujjain, India.

Increasing generation of wastewater and its indiscriminate disposal is detrimental to human and animal health. Resource-limited settings often struggle for efficient wastewater treatment systems owing to lack of funds and operational difficulties. Therefore, alternative treatment systems involving low expenditure and simplistic operations are need of the hour. Constructed wetlands are one such alternative that can efficiently remove variety of pollutants from wastewater. In this study, we have assessed the utility of constructed wetlands for treatment of hospital wastewater in Ujjain. An in-house wetland system was designed and constructed using Typha latifolia and Phragmites karka. Results showed that wetland was efficient for removal of various physico-chemical and biological contaminants, namely, biochemical-oxygen-demand (77.1%), chemical-oxygen-demand (64.9%), turbidity (68.3%), suspended-solids (63%), total-phosphorus (58.7%), nitrate-nitrogen (33%), fecal coliforms (96.8%), and total coliforms (95.6%). Paired t test revealed that removal efficiencies for various parameters were significantly different among Phragmites, Typha, and control cells (p ≤ 0.05). Study also depicted that most of the bacterial isolates in inlet wastewater were selectively resistant to antibiotics (ciprofloxacin and sulphamethaxazole) as well and these isolates were also removed. Precisely, Typha was fairly suitable for antibiotic resistant bacteria removal. Thus, constructed wetlands were found to be one of the suitable options for wastewater treatment in resource-limited settings. PRACTITIONER POINTS: Constructed wetlands are one of the suitable options for wastewater treatment in resource limited settings. These systems involve wetland vegetation, soil, and associated microbial assemblages to improve the water quality. Typha and Phragmites were found to be efficient for treating the hospital wastewater. Experiments showed that antibiotic resistant bacteria may also be removed through constructed wetland systems. Easy operation, cost effectiveness, and efficiency are important attributes.

Determinants and pathways of healthcare-seeking behaviours in under-5 children for common childhood illnesses and antibiotic prescribing: a cohort study in rural India.

OBJECTIVES: To explore the healthcare-seeking pathways, antibiotic prescribing and determine the sociodemographic factors associated with healthcare-seeking behaviour (HSB) of caregivers for common illnesses in under-5 (U-5) children in rural Ujjain, India. STUDY DESIGN: Prospective cohort study. STUDY SETTING AND STUDY SAMPLE: The cohort included 270 U-5 children from selected six villages in rural demographic surveillance site, of the R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India. A community-based cohort was visited two times weekly for over 113 weeks (August 2014 to October 2016) to record the HSB of caregivers using HSB diaries. Sociodemographic information was also solicited. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes: first point of care, healthcare-seeking pathway and quantify antibiotic prescribing for the common acute illnesses. SECONDARY OUTCOME: HSB risk factors were determined using mixed-effects multinomial logistic regression. RESULTS: A total of 60 228 HSB follow-up time points for 270 children were recorded with a total of 2161 acute illness episodes. The most common illnesses found were respiratory tract infections (RTI) (69%) and gastrointestinal tract infections (8%). No healthcare was sought in 33% of illness episodes, mostly for RTIs. The most common healthcare-seeking pathway was to informal healthcare providers (IHCPs, 49% of illness episodes). The adjusted relative risk for obtaining no treatment, home treatment and treatment by IHCPs was higher for RTIs (aRR=11.54, 1.82 and 1.29, respectively), illiterate mothers (aRR=2.86, 2.38 and 1.93, respectively), and mothers who were homemakers (aRR=2.90, 4.17 and 2.10, respectively). Socioeconomic status was associated with HSB, with the highest aRR for no treatment in the lowest two socioeconomic quintiles (aRR=6.59 and 6.39, respectively). Antibiotics were prescribed in 46% (n=670/1450) illness episodes and the majority (85%, n=572/670) were broad spectrum. CONCLUSION: In our rural cohort for many acute episodes of illnesses, no treatment or home treatment was done, which resulted in overall reduced antibiotic prescribing. The most common healthcare-seeking pathway was to visit IHCPs, which indicates that they are major healthcare providers in rural areas. Most of the antibiotics were prescribed by IHCPs and were commonly prescribed for illnesses where they were not indicated.

Antibiotics and antibiotic-resistant bacteria in waters associated with a hospital in Ujjain, India.

BACKGROUND: Concerns have been raised about the public health implications of the presence of antibiotic residues in the aquatic environment and their effect on the development of bacterial resistance. While there is information on antibiotic residue levels in hospital effluent from some other countries, information on antibiotic residue levels in effluent from Indian hospitals is not available. Also, concurrent studies on antibiotic prescription quantity in a hospital and antibiotic residue levels and resistant bacteria in the effluent of the same hospital are few. Therefore, we quantified antibiotic residues in waters associated with a hospital in India and assessed their association, if any, with quantities of antibiotic prescribed in the hospital and the susceptibility of Escherichia coli found in the hospital effluent. METHODS: This cross-sectional study was conducted in a teaching hospital outside the city of Ujjain in India. Seven antibiotics--amoxicillin, ceftriaxone, amikacin, ofloxacin, ciprofloxacin, norfloxacin and levofloxacin--were selected. Prescribed quantities were obtained from hospital records. The samples of the hospital associated water were analysed for the above mentioned antibiotics using well developed and validated liquid chromatography/tandem mass spectrometry technique after selectively isolating the analytes from the matrix using solid phase extraction. Escherichia coli isolates from these waters were tested for antibiotic susceptibility, by standard Kirby Bauer disc diffusion method using Clinical and Laboratory Standard Institute breakpoints. RESULTS: Ciprofloxacin was the highest prescribed antibiotic in the hospital and its residue levels in the hospital wastewater were also the highest. In samples of the municipal water supply and the groundwater, no antibiotics were detected. There was a positive correlation between the quantity of antibiotics prescribed in the hospital and antibiotic residue levels in the hospital wastewater. Wastewater samples collected in the afternoon contained both a higher number and higher levels of antibiotics compared to samples collected in the morning hours. No amikacin was found in the wastewater, but E.coli isolates from all wastewater samples were resistant to amikacin. Although ciprofloxacin was the most prevalent antibiotic detected in the wastewater, E.coli was not resistant to it. CONCLUSIONS: Antibiotics are entering the aquatic environment of countries like India through hospital effluent. In-depth studies are needed to establish the correlation, if any, between the quantities of antibiotics prescribed in hospitals and the levels of antibiotic residues found in hospital effluent. Further, the effect of this on the development of bacterial resistance in the environment and its subsequent public health impact need thorough assessment.

Mass bathing events in River Kshipra, Central India- influence on the water quality and the antibiotic susceptibility pattern of commensal E.coli.

BACKGROUND: Antibiotic resistance is one of the major global health emergencies. One potential source of dissemination of resistant bacteria is mass gatherings, e.g. mass bathing events. We evaluated the physicochemical parameters of water quality and the antibiotic resistance pattern in commensal Escherichia coli from river-water and river-sediment in pre-, during- and post-mass bathing events in river Kshipra, Central India. METHOD/DESIGN: Water and sediment samples were collected from three selected points during eight mass bathing events during 2014-2016. Water quality parameters (physical, chemical and microbiological) were analyzed using standard methods. In river water and sediment samples, antibiotic susceptibility patterns of isolated E. coli to 17 antibiotics were tested. RESULTS: pH, turbidity and dissolved oxygen were significantly lower and total dissolved solid, free carbon dioxide were higher during mass bathing, whilst TSS, BOD and COD were lowest in pre-bathing and highest in post-bathing period. E.coli with multi drug resistance (MDR) or extended spectrum beta-lactamase (ESBL) production were between 9-44% and 6-24%, respectively in river-water as well as river-sediment. Total coliform count/ml and E. coli count were higher during-and post-bathing in river water than in pre-bathing period. Thus, the percentage of resistance was significantly higher during and post-bathing period (p<.05) than in pre-bathing. Colony forming unit (CFU)/ml in river-sediment was much higher than in river-water. Percentage of resistance was significantly higher in river-water (p<.05) than in river-sediment. CONCLUSIONS: Antibiotic resistance in E.coli isolated from the Kshipra River showed significant variation during mass bathing events. Guidelines and regulatory standards are needed to control environmental dissemination of resistant bacteria.

Monitoring of Water Quality, Antibiotic Residues, and Antibiotic-Resistant Escherichiacoli in the Kshipra River in India over a 3-Year Period.

The emergence of antibiotic resistance is a major global and environmental health issue, yet the presence of antibiotic residues and resistance in the water and sediment of a river subjected to excessive anthropogenic activities and their relationship with water quality of the river are not well studied. The objectives of the present study were a) to investigate the occurrence of antibiotic residues and antibiotic-resistant Escherichiacoli (E.coli) in the water and sediment of the Kshipra river in India at seven selected sites during different seasons of the years 2014, 2015, and 2016 and b) to investigate the association between antibiotic residues and antibiotic-resistant E.coli in water and sediment and measured water quality parameters of the river. Antibiotic residues and resistant E.coli were present in the water and sediment and were associated with the measured water quality parameters. Sulfamethoxazole was the most frequently detected antibiotic in water at the highest concentration of 4.66 µg/L and was positively correlated with the water quality parameters. Significant (p < 0.05) seasonal and spatial variations of antibiotic-resistant E.coli in water and sediment were found. The resistance of E.coli to antibiotics (e.g., sulfamethiazole, norfloxacin, ciprofloxacine, cefotaxime, co-trimoxazole, ceftazidime, meropenem, ampicillin, amikacin, metronidazole, tetracycline, and tigecycline) had varying associations with the measured water and sediment quality parameters. Based on the results of this study, it is suggested that regular monitoring and surveillance of water quality, including antibiotic residues and antibiotic resistance, of all rivers should be taken up as a key priority, in national and Global Action Plans as these can have implications for the buildup of antibiotic resistance.

Biogenic Ag/CaO nanocomposites kill Staphylococcus aureus with reduced toxicity towards mammalian cells.

Rapid increase in the case of bacterial infections is considered as a major public health concern and hence exploration of alternative treatment procedures including development of nanomaterials based therapeutic strategies is receiving much attention. In this aspect, here we investigated the antibacterial efficacy of a simple and potential metal/metal oxide nanocomposite system. Biogenic synthetic protocol was designed for processing of Ag/CaO nanocomposites (NCs). Structural features and morphology of the synthesized nanomaterials were investigated by X-ray diffraction (XRD) and electron microscopy techniques respectively. Optical properties of the nanomaterials were analyzed by UV-vis spectrophotometer. Presence of water and possible impurity molecules on the materials surface was examined by Fourier-transform infrared spectroscopy (FTIR). Effective antibacterial activity of the NCs was observed (within a range of 25-150 µg/mL of NCs) against Staphylococcus aureus (S. aureus) and Methicillin-resistant Staphylococcus aureus (MRSA). The potential anti-biofilm effect of as synthesized NCs was tested against S. aureus. Experimental results suggest that the antibacterial action of the NCs could be due to the induction of reactive oxygen species (ROS). DNA degradation and change in the bacterial cell membrane has further indicated the complete disinfection of the target bacterial system. The cytotoxicity evaluation has confirmed that the formation of NCs has maintained the antibacterial efficacy of Ag NPs but reduced its toxicity towards mammalian cells.

Antimicrobials and Antimicrobial Resistance in the Environment and Its Remediation: A Global One Health Perspective.

The awareness about pollution of the environment by antimicrobials/antibiotics is increasing globally [...].

Therapeutic Characterization and Efficacy of Bacteriophage Cocktails Infecting Escherichia coli, Klebsiella pneumoniae, and Enterobacter Species.

Infections due to antibiotic resistant bacteria are increasing globally and this needs immediate attention. Bacteriophages are considered an effective alternative for the treatment of bacterial infections. The aim of this study was to isolate and characterize the bacteriophages that infect Escherichia coli, Klebsiella pneumoniae, and Enterobacter species. For this, clinical bacterial isolates of the mentioned species were obtained from diagnostic centers located in Chennai, Tamil Nadu, India. The bacteriophages were isolated from sewage water samples collected from Tamil Nadu, India. Phage isolation was performed using enrichment method and agar overlay method was used to confirm the presence of bacteriophages. All the phages were characterized for their life cycle parameters, genome analysis, and in vitro phage cocktail activity. The three bacteriophages exhibited broad host range activity: Escherichia virus myPSH2311 infecting E. coli belonging to six different pathotypes, Klebsiella virus myPSH1235 infecting K. pneumoniae belonging to four different serotypes and Enterobacter virus myPSH1140 infecting four different species of Enterobacter. Morphological observations suggested that the bacteriophages belonged to, Phieco32virus (Escherichia virus myPSH2311), Podoviridae (Klebsiella virus myPSH1235), and Myoviridae (Enterobacter virus myPSH1140). The life cycles (adsorption, latent period, and cell burst) of Escherichia virus myPSH2311, Klebsiella virus myPSH1235 and Enterobacter virus myPSH1140 were found to be 26, 40, and 11 min, respectively. Genomic analysis revealed that Escherichia virus myPSH2311 is closely related to Escherichia phage vB_EcoP_SU10, Klebsiella virus myPSH1235 is closely related to Klebsiella phage vB_KpnP_KpV48 and Enterobacter virus myPSH1140 is closely related to Enterobacter phage PG7 and Enterobacter phage CC31. When phage cocktail was used against multiple bacterial mixtures, there was a reduction in bacterial load from 106 to 103 CFU/mL within 2 h. All the three characterized phages were found to have a broad host range activity and the prepared phage cocktails were effective against mixed bacterial population that are resistant to meropenem and colistin, two last resort antibiotics. Infections caused by drug resistant bacteria will be a serious threat in the future and the use of virulent bacteriophages in therapy may offer an effective solution.

Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India.

Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

Characteristics of a Nationwide Voluntary Antibiotic Resistance Awareness Campaign in India; Future Paths and Pointers for Resource Limited Settings/Low and Middle Income Countries.

Antibiotic resistance has reached alarming proportions globally, prompting the World Health Organization to advise nations to take up antibiotic awareness campaigns. Several campaigns have been taken up worldwide, mostly by governments. The government of India asked manufacturers to append a 'redline' to packages of antibiotics as identification marks and conducted a campaign to inform the general public about it and appropriate antibiotic use. We investigated whether an antibiotic resistance awareness campaign could be organized voluntarily in India and determined the characteristics of the voluntarily organized campaign by administering a questionnaire to the coordinators, who participated in organizing the voluntary campaign India. The campaign characteristics were: multiple electro-physical pedagogical and participatory techniques were used, 49 physical events were organized in various parts of India that included lectures, posters, booklet/pamphlet distribution, audio and video messages, competitions, and mass contact rallies along with broadcast of messages in 11 local languages using community radio stations (CRS) spread all over India. The median values for campaign events were: expenditure-3000 Indian Rupees/day (US$~47), time for planning-1 day, program spread-4 days, program time-4 h, direct and indirect reach of the message-respectively 250 and 500 persons/event. A 2 min play entitled 'Take antibiotics as prescribed by the doctor' was broadcast 10 times/day for 5 days on CRS with listener reach of ~5 million persons. More than 85%ofcoordinators thought that the campaign created adequate awareness about appropriate antibiotic use and antibiotic resistance. The voluntary campaign has implications for resource limited settings/low and middle income countries.

Determinants of Antibiotic Consumption - Development of a Model using Partial Least Squares Regression based on Data from India.

Antibiotic resistance, a consequence of antibiotic use, is a threat to health, with severe consequences for resource constrained settings. If determinants for human antibiotic use in India, a lower middle income country, with one of the highest antibiotic consumption in the world could be understood, interventions could be developed, having implications for similar settings. Year wise data for India, for potential determinants and antibiotic consumption, was sourced from publicly available databases for the years 2000-2010. Data was analyzed using Partial Least Squares regression and correlation between determinants and antibiotic consumption was evaluated, formulating 'Predictors' and 'Prediction models'. The 'prediction model' with the statistically most significant predictors (root mean square errors of prediction for train set-377.0 and test set-297.0) formulated from a combination of Health infrastructure + Surface transport infrastructure (HISTI), predicted antibiotic consumption within 95% confidence interval and estimated an antibiotic consumption of 11.6 standard units/person (14.37 billion standard units totally; standard units = number of doses sold in the country; a dose being a pill, capsule, or ampoule) for India for 2014. The HISTI model may become useful in predicting antibiotic consumption for countries/regions having circumstances and data similar to India, but without resources to measure actual data of antibiotic consumption.

Isolation, characterization and in vivo efficacy of Escherichia phage myPSH1131.

Phage therapy is the use of lytic bacteriophages to cure infections caused by bacteria. The aim of this study is to isolate and to characterize the bacteriophages against Escherichia coli isolated from clinical samples. For isolation of bacteriophages, water samples were collected from the Ganges River, and phage enrichment method was followed for phage isolation. Microbiological, genomic and lyophilization experiments were carried out to characterize the bacteriophage. Galleria mellonella was used to study the potential of phages against E. coli infection. Escherichia phage myPSH1131 belonging to Podoviridae family and found to have broad host range infectivity (n = 31) to infect Enterohemorrhagic E. coli (n = 9), Enteropathogenic E. coli (n = 6), Enterotoxigenic E. coli (n = 3), Enteroaggregative E. coli (n = 3), Uropathogenic E. coli (n = 9) and one unknown E. coli. The genome size is 76,163 base pairs (97 coding regions) and their genes show high similarity to SU10 phage. Lyophilization studies showed that the use of 1M sucrose, 2% gelatin and the combination of both 0.5M sucrose plus 1% gelatin could restore phage viability up to 20 months at 4°C. For in vivo studies, it was observed that a single phage dose can reduce the E. coli infection but to achieve 100% survival rate the infected larvae should be treated with three phage doses (20 µL, 10(3) PFU/mL) at 6 hours interval. The characterized Escherichia phage myPSH1131 was found to have broad host range activity against E. coli pathogens and in vivo studies showed that multiple doses are required for effective treatment.