Antibiotic usage and risk of colonization and infection with antibiotic-resistant bacteria: a hospital population-based study.

Accurate assessment of risk factors for nosocomial acquisition of colonization by antibiotic-resistant bacteria (ARB) is often confounded by scarce data on antibiotic use. A 12-month, nested, multicenter cohort study was conducted. Target ARB were methicillin (meticillin)-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and ciprofloxacin-resistant Pseudomonas aeruginosa (CR-PA). Nares and rectal swabs were obtained before and after starting antibiotics. Pulsed-field gel electrophoresis was done to define genetic relatedness of the strains. Primary outcomes were (i) the mean time, in days, for acquisition of target ARB colonization in patients previously not colonized; (ii) the rate of acquisition per 1,000 antibiotic-days according to different classes of antibiotics; (iii) the rate of infection caused by the same bacteria as those previously isolated in screening samples; and (iv) the risk factors for ARB acquisition. In total, 6,245 swabs from 864 inpatients were processed. The rate of acquisition was 3%, 2%, and 1% for MRSA, VRE, and CR-PA, respectively. The rate of acquisition of ARB per 1,000 antibiotic-days was 14 for carbapenems, 9 for glycopeptides, and 6 for broad-spectrum cephalosporins and quinolones. The highest rates of acquisition were observed for carbapenems in dialyzed and diabetic patients. Four risk factors were independently associated with acquisition of target ARB: use of carbapenems, age of >70 years, hospitalization for >16 days, and human immunodeficiency virus infection. During the 30-day follow-up, 4 among 42 patients newly colonized by ARB (9%) suffered from an infection due to the same bacteria as those isolated in a previous screening sample. Colonizing and infecting strains from single patients were genotypically identical. Identifying ARB colonization early during antibiotic therapy could target a high-risk hospitalized population that may benefit from intervention to decrease the risk of subsequent nosocomial infections.

Post-traumatic infection of the lower limb caused by rare Enterobacteriaceae and Mucorales in a young healthy male.

Enterobacter amnigenus and Leclercia adecarboxylata are gram-negative aerobic bacilli of the family Enterobacteriaceae that have been isolated from water and, rarely, from various clinical specimens. Absidia is a filamentous fungus of the class Zygomycetes that is ubiquitous in nature and can cause infection, primarily in immunocompromised hosts. Here, we describe an infection of the left lower limb caused by E. amnigenus and L. adecarboxylata with subsequent isolation of Absidia spp. in a patient with multiple traumatic injuries after a major motor vehicle accident. The severity of the clinical picture made amputation necessary, despite aggressive anti-infective therapy with both antibacterial and antifungal agents. Prompt diagnosis and management are mandatory in order to minimize morbidity and even mortality, and reduce the social and economic cost.

Antibiotic resistance in a very remote Amazonas community.

In a very remote human community of the Peruvian Amazonas with minimal antibiotic exposure, high levels of acquired resistance to the oldest antibiotics (ampicillin, tetracycline, trimethoprim/sulfamethoxazole, streptomycin and chloramphenicol) were detected in commensal Escherichia coli, with remarkable diversity of resistant clones and of resistance genes and plasmids. This pattern was similar overall to that previously observed in a very remote community of Bolivia. It was also similar to that observed in the nearest urban area, except for a lower dominance of resistant isolates and the absolute lack of quinolone resistance in the remote community. Present findings suggest that antibiotic resistance observed in remote communities with minimal antibiotic exposure is a general phenomenon contributed by complex mechanisms and provide new insights into the mechanisms involved in this phenomenon.

Antibiotic resistance in the absence of antimicrobial use: mechanisms and implications.

The selective pressure generated by the use of antibiotics in clinical, veterinary, husbandry and agricultural practices is considered the major factor responsible for the emergence and spread of antibiotic-resistant bacteria since the beginning of the antibiotic era. However, recent studies have consistently demonstrated that acquired resistance traits can also be found in bacteria isolated from humans and wild animals not subjected to significant antibiotic exposure and living in remote areas of the planet. The scope of this article is to review and discuss the current knowledge on this intriguing phenomenon, which underscores the complexity of the mechanisms involved in the emergence and spread of antibiotic resistance and bears some relevant implications to the design and success of resistance-control strategies.

Rapid dissemination and diversity of CTX-M extended-spectrum beta-lactamase genes in commensal Escherichia coli isolates from healthy children from low-resource settings in Latin America.

A survey carried out in 2005 among members of a healthy population of children living in Bolivia and Peru revealed that fecal carriage of Escherichia coli strains resistant to expanded-spectrum cephalosporins was remarkably increased compared to that observed in the same settings in 2002 (1.7% in 2005 versus 0.1% in 2002). In this work, we demonstrated that this phenomenon was mainly related to the dissemination of CTX-M-type extended-spectrum beta-lactamase (ESBL) determinants among commensal E. coli strains. Of 50 ESBL-producing isolates collected in the 2005 survey, 44 harbored a CTX-M-type and 6 an SHV-type (SHV-2 or SHV-12) ESBL. Compared to 2002 results, an increased diversity of CTX-M-type ESBLs was also observed: members of the CTX-M-1 group (CTX-M-15) emerged in Bolivia (where only CTX-M-2 was observed in 2002), while members of the CTX-M-9 group (CTX-M-14 and CTX-M-24) emerged in Peru (where only CTX-M-15 and CTX-M-2 were observed in 2002). A new CTX-M-2 variant named CTX-M-56 was also detected. Molecular characterization of the CTX-M-producing isolates and gene transfer experiments suggested that different mechanisms could be involved in the spreading of different CTX-M group determinants and revealed that additional resistance determinants for non-beta-lactam antibiotics were preferentially carried by plasmids encoding certain CTX-M variants (CTX-M-15 and variants of the CTX-M-2 group). Three CTX-M-15-encoding conjugative plasmids from Peruvian isolates carried the new fluoroquinolone resistance gene aac(6')-Ib-cr. To our best knowledge, this is the first report of the detection of aac(6')-Ib-cr in Latin America.

Population structure and resistance genes in antibiotic-resistant bacteria from a remote community with minimal antibiotic exposure.

In a previous study, we detected unexpectedly high levels of acquired antibiotic resistance in commensal Escherichia coli isolates from a remote Guaraní Indian (Bolivia) community with very low levels of antibiotic exposure and limited exchanges with the exterior. Here we analyzed the structure of the resistant E. coli population from that community and the resistance mechanisms. The E. coli population (113 isolates from 72 inhabitants) showed a high degree of genetic heterogeneity, as evidenced by phylogenetic grouping (77% group A, 10% group B1, 8% group D, 5% group B2) and genotyping by randomly amplified polymorphic DNA (RAPD) analysis (44 different RAPD types). The acquired resistance genes were always of the same types as those found in antibiotic-exposed settings [blaTEM, blaPSE-1, catI, cmlA6, tet(A), tet(B), dfrA1, dfrA7, dfrA8, dfrA17, sul1, sul2, aphA1, aadA1, aadA2, aadA5, aadB, and sat-1]. Class 1 and class 2 integrons were found in 12% and 4% of the isolates, respectively, and harbored arrays of gene cassettes similar to those already described. The cotransferability of multiple-resistance traits was observed from selected isolates and was found to be associated with resistance conjugative plasmids of the F, P, and N types. Overall, these data suggest that the resistance observed in this remote community is likely the consequence of the dissemination of resistant bacteria and resistance genes from antibiotic-exposed settings (rather than of an independent in situ selection) which involved both the clonal expansion of resistant strains and the horizontal transfer/recombination of mobile genetic elements harboring resistance genes.

Multidrug-resistant commensal Escherichia coli in children, Peru and Bolivia.

Using a rapid screening method, we investigated the prevalence of fecal carriage of antimicrobial drug-resistant Escherichia coli in 3,174 healthy children from 4 urban settings in Peru and Bolivia. High resistance rates were observed for ampicillin (95%), trimethoprim-sulfamethoxazole (94%), tetracycline (93%), streptomycin (82%), and chloramphenicol (70%). Lower resistance rates were observed for nalidixic acid (35%), kanamycin (28%), gentamicin (21%), and ciprofloxacin (18%); resistance to ceftriaxone and amikacin was uncommon (<0.5%). In a random sample of 1,080 resistant E. coli isolates, 90% exhibited a multidrug-resistance (MDR) phenotype. The 2 most common MDR phenotypes (ampicillin/tetracycline/trimethoprim-sulfamethoxazole and ampicillin/tetracycline/trimethoprim-sulfamethoxazole/chloramphenicol) could be transferred en bloc in conjugation experiments. The most common acquired resistance genes were blaTEM, tet(A), tet(B), drfA8, sul1, sul2, and catI. These findings underscore the magnitude of the problem of antimicrobial drug resistance in low-resource settings and the urgent need for surveillance and control of this phenomenon.

Evaluation of a rapid screening method for detection of antimicrobial resistance in the commensal microbiota of the gut.

The assessment of antimicrobial resistance among commensal bacteria is an indicator of the spread of antimicrobial resistance. Rapid screening methods for detection of antimicrobial-resistant faecal Escherichia coli directly on MacConkey plates have been successfully adopted but suffer from lack of standardisation. The purpose of this study was to evaluate a direct plating method (DPM) for detection of antimicrobial-resistant faecal E. coli and to compare it with a conventional method. Faecal samples were collected from 71 healthy children from Peru and Bolivia. In the DPM, a faecal swab was directly plated onto a MacConkey agar plate and antimicrobial disks were applied onto the seeded plate. Raw data were obtained by direct reading of the plate and were subjected to confirmatory analysis. Good concordance between the DPM and a conventional method was observed in detecting carriage of resistant E. coli, with a higher sensitivity for the DPM. Analysis of the results allowed interpretive criteria to be defined for DPM raw data. The DPM showed good sensitivity and specificity at very low cost (ten times cheaper than the conventional method) to investigate the faecal carriage of drug-resistant E. coli. It may represent a useful tool to conduct large-scale resistance surveillance studies and to monitor resistance control programmes cost effectively, particularly in low-resource countries.

Epilepsy and neurocysticercosis in rural Bolivia: a population-based survey.

PURPOSE: To evaluate the frequency of neurocysticercosis (NCC) in a well-defined prevalent cohort of epilepsy patients in the rural area of the Cordillera province. METHODS: We carried out a two-phase door-to-door neuroepidemiologic survey in a sample of 10,124 subjects in a rural area of the Cordillera Province, Bolivia, to detect the prevalence of the most common neurologic disorders including epilepsy. A team of health workers administered a standard screening instrument for neurologic diseases; subjects found positive at the screening phase underwent a complete neurologic examination. Epilepsy patients were diagnosed according to the definition proposed by the International League Against Epilepsy (ILAE, 1993). Epilepsy patients identified this way underwent electroencephalographic recording, computed tomography (CT) scan, and serologic evaluation to detect antibodies against Taenia solium by enzyme-linked immunoelectrotransfer blot. RESULTS: At the end of the survey, we detected 124 defined prevalent epilepsy patients. On the basis of the classification proposed by the ILAE in 1981, partial seizures were the most common type diagnosed (66 patients, 53.3%). Of the 124 patients, 105 underwent CT scan, and a serum sample was taken to detect antibodies against T. solium in 112 patients; for 97 patients, both neuroradiologic and serologic data were available. Considering radiologic, serologic, and clinical features, of these 124 patients, 34 (27.4%) fulfilled the diagnostic criteria for definitive or probable NCC proposed in 2001. Of these 34 patients 24 (70.6%) had partial seizures. CONCLUSIONS: Our data confirm a high frequency of NCC among a well-defined prevalent cohort of epilepsy patients.

Detection of CTX-M-type beta-lactamase genes in fecal Escherichia coli isolates from healthy children in Bolivia and Peru.

A survey was carried out from August to November 2002 to evaluate the antimicrobial susceptibilities of fecal Escherichia coli isolates from 3,208 healthy children from four different urban areas of Latin America, two in Bolivia (Camiri and Villa Montes) and two in Peru (Yurimaguas and Moyobamba). Ceftriaxone-resistant E. coli isolates were detected in four children, one from each of the areas sampled. The isolates exhibited a multidrug-resistant phenotype, including resistance to oxyimino-cephalosporins and aztreonam, and the MICs of ceftazidime for the isolates were lower than those of cefotaxime. By PCR and sequencing, the bla(CTX-M-2) determinant was detected in three isolates and the bla(CTX-M-15) determinant was detected in one isolate (from Peru). The CTX-M-2-producing isolates belonged to three different phylogenetic groups (groups A, B2, and D), while the CTX-M-15-producing isolate belonged to phylogenetic group D. The bla(CTX-M-2) determinants were transferable to E. coli by conjugation, while conjugative transfer of the bla(CTX-M-15) determinant was not detectable. Plasmids harboring the bla(CTX-M-2) determinant exhibited similar restriction profiles, and in all of them the gene was located on a 2.2-kb PstI fragment, suggesting a genetic environment similar to that present in In35 and InS21. The findings of the present study confirm the widespread distribution of CTX-M-type beta-lactamases and underscore the role that commensal E. coli isolates could play as a potential reservoir of these clinically relevant resistance determinants. This is the first report of CTX-M-type enzymes in Bolivia and Peru and also the first report of the detection of CTX-M-15 in Latin America.

High prevalence of acquired antimicrobial resistance unrelated to heavy antimicrobial consumption.

In a very remote rural Bolivian community where the use of antimicrobials has been minimal and where exchanges with the exterior are very limited, 67% of subjects were found to be carriers of fecal Escherichia coli with acquired resistance to >/=1 antimicrobial agent(s); the highest rates were observed for tetracycline (64%), ampicillin (58%), trimethoprim-sulfamethoxazole (50%), and chloramphenicol (41%). The most relevant implication of these findings is that, in certain settings, the spread and maintenance of antimicrobial resistance can occur, regardless of whether selective pressure generated by the use of antimicrobials is present.

Molecular alterations of VanA element in vancomycin-resistant enterococci isolated during a survey of colonized patients in an Italian intensive care unit.

To screen for vancomycin-resistant enterococci (VRE) colonization in hospitalized patients and to study molecular evolution and alterations of Tn1546-like elements in VRE among potentially at-risk patients, a 3-year surveillance protocol in an Intensive Care Unit was performed. A total of 397 patients were screened in the period June, 1997-June, 2000, and VRE were isolated from rectal swabs taken at admission, weekly, and when clinically indicated. The susceptibility of the enterococci was determined by the disk diffusion and broth dilution methods. The presence of vancomycin-resistance genes (vanA, vanB, and vanC) was assessed by polymerase chain reaction (PCR); genetic clonality of isolates was assessed by pulsed-field gel electrophoresis (PFGE); Tn1546 types were obtained by restriction fragment length polymorphism (RFLP) analysis of Tn1546 PCR fragments. Thirty-four strains, 31 identified as Enterococcus faecium and 3 strains as E. faecalis, were isolated from 12 of the 397 patients (3.0%); all strains were VanA as assessed by PCR and were resistant to the other antibiotics tested and showed high-level resistance to aminoglycosides. Enterococci isolated during the study period showed that different genetic backgrounds of strains, determined by PFGE combined with RFLP of Tn1546, are present in all the strains isolated in the study. PFGE type B was predominant in 1998 and 1999, and insertion sequence movements were found to have a role in the evolution of VanA resistance elements found in all strains. This study demonstrates that single patients may be colonized by closely related VRE with several PFGE types containing a wide variety of VanA elements. Moreover, isolates with identical PFGE types may contain different VanA elements reflecting rearrangements mediated by insertion sequences in VRE strains during their stay in the gastrointestinal tract.

Effect of antibiotic pretreatment on resistance.

The emergence of bacterial resistance to antibiotics limits the efficacy of technical developments in the field of infectious diseases. This is particularly true for respiratory tract infections, which are by far the main reason for antibiotic use in developed countries. Antimicrobial resistance among respiratory pathogens involves both gram-positive (primarily Streptococcus pneumoniae) and gram-negative (Haemophilus influenzae, Moraxella catarrhalis, and the more rare enterobacteriaceae) microorganisms. A number of epidemiologic studies show a relationship between antibiotic use and antibiotic resistance, and how antibiotic pretreatment can reduce the range of effective drugs for optimal therapy of infections in general and of respiratory tract infections in particular. An appropriate use of antimicrobials is of crucial importance to limit the emergence and spread of bacterial resistance to antibiotics. This can be achieved by avoiding usage in nonspecific, probably viral, infections that are unlikely to be influenced by antibiotic therapy, and by using narrow-spectrum drugs to minimize selective pressure.

Seroprevalence of varicella zoster and rubella antibodies among rural populations of the Chaco region, south-eastern Bolivia.

OBJECTIVE: To determine the seroprevalence of antibodies against varicella zoster virus (VZV) and rubella virus among the population of two rural areas, Camiri and Villa Montes, Chaco region, south-eastern Bolivia. METHODS: In a cross-sectional study, serum samples from randomly selected subjects were screened for VZV- and rubella antibodies using enzyme-linked immunosorbent assay (ELISA). RESULTS: The prevalence of VZV antibodies was 80% (391 of 489). No significant differences were observed between genders and study areas. The prevalence increased with age with a seropositivity rate of 21.2% in the 1-4-year-old children, 56.9% in the 5-9 age group and 83.7% in the 10-14 age group, and reached 98.2% in over 45-year olds. The prevalence of rubella virus antibodies was 76.9% (377 of 490), without significant differences between genders and study areas. Similar to the trend observed for VZV antibodies, the seroprevalence increased with age with a seropositivity rate of 18.1% in the 1-4-year-old children, 53.9% in the 5-9 age group and 78.4% in the 10-14 age group, and reached 94.7% in over 45-year-old subjects. Among the 95 women of childbearing age (15-44 years) the susceptibility rate was 11.6%. CONCLUSIONS: A common seroimmunological profile was evidenced for the two infections. The age-specific profile of VZV seropositivity differs from that reported for other tropical countries where higher median age of seroconversion and lower seroprevalence among adults are observed. Data concerning the prevalence of immunity to rubella may be useful to evaluate the impact of the recently introduced rubella immunization programme.

Anticuerpos contra Trichinella spiralis en la población rural de la provincia Cordillera, Bolivia / Seroprevalence of antibodies to Trichinella spiralis among rural residents of Cordillera province, Bolivia

Se realizó un estudio seroepidemiológico para determinar la prevalencia de anticuerpos contra Trichinella spiralis en el área rural de la provincia Cordillera del Departamento de Santa Cruz en Bolivia. Se examinaron 234 muestras de suero mediante el ensayo de inmunoabsorción enzimática (ELISA) y se detectaron los anticuerpos en siete muestras (3 por cien). Los resultados documentan por primera vez la presencia de infestación humana por Trichinella en Bolivia y sugieren la necesidad de fortalecer la vigilancia sanitaria de la triquinosis en los mataderos municipales, impedir la faena clandestina de animales y, sobre todo, lograr que los productores y pobladores tomen conciencia de los peligros de esta zoonosis

Anticuerpos contra Trichinella spiralis en la población rural de la provincia Cordillera, Bolivia / Seroprevalence of antibodies to Trichinella spiralis among rural residents of Cordillera province, Bolivia

Se realizó un estudio seroepidemiológico para determinar la prevalencia de anticuerpos contra Trichinella spiralis en el área rural de la provincia Cordillera del Departamento de Santa Cruz en Bolivia. Se examinaron 234 muestras de suero mediante el ensayo de inmunoabsorción enzimática (ELISA) y se detectaron los anticuerpos en siete muestras (3 por cien). Los resultados documentan por primera vez la presencia de infestación humana por Trichinella en Bolivia y sugieren la necesidad de fortalecer la vigilancia sanitaria de la triquinosis en los mataderos municipales, impedir la faena clandestina de animales y, sobre todo, lograr que los productores y pobladores tomen conciencia de los peligros de esta zoonosis

A seroepidemiological study was conducted to determine the prevalence of antibodies to Trichinella spiralis among rural residents of Cordillera province, Santa Cruz Department, Bolivia. Using the enzyme-linked immunosorbent assay (ELISA), 234 serum samples were examined, and antibodies were detected in seven of the samples (3%). The results document for the first time the presence of human infestation with Trichinella in Bolivia and suggest the need to strengthen trichinelosis surveillance in the municipal slaughterhouses, to prevent the clandestine slaughter of animals, and particularly to ensure that residents and meat producers in the area become aware of the dangers of this zoonosis