The Diversity, Resistance Profiles and Plasmid Content of Klebsiella spp. Recovered from Dairy Farms Located around Three Cities in Pakistan.

The rise of antimicrobial resistance (AMR) in bacterial pathogens such as Klebsiella pneumoniae (Kp) is a pressing public health and economic concern. The 'One-Health' framework recognizes that effective management of AMR requires surveillance in agricultural as well as clinical settings, particularly in low-resource regions such as Pakistan. Here, we use whole-genome sequencing to characterise 49 isolates of Klebisella spp. (including 43 Kp) and 2 presumptive Providencia rettgeri isolates recovered from dairy farms located near 3 cities in Pakistan-Quetta (n = 29), Faisalabad (n = 19), and Sargodha (n = 3). The 43 Kp isolates corresponded to 38 sequence types (STs), and 35 of these STs were only observed once. This high diversity indicates frequent admixture and limited clonal spread on local scales. Of the 49 Klebsiella spp. isolates, 41 (84%) did not contain any clinically relevant antimicrobial resistance genes (ARGs), and we did not detect any ARGs predicted to encode resistance to carbapenems or colistin. However, four Kp lineages contained multiple ARGs: ST11 (n = 2), ST1391-1LV (n = 1), ST995 (n = 1) and ST985 (n = 1). STs 11, 1391-1LV and 995 shared a core set of five ARGs, including blaCTX-M-15, harboured on different AMR plasmids. ST985 carried a different set of 16 resistance genes, including blaCTX-M-55. The two presumptive P. rettgeri isolates also contained multiple ARGs. Finally, the four most common plasmids which did not harbour ARGs in our dataset were non-randomly distributed between regions, suggesting that local expansion of the plasmids occurs independently of the host bacterial lineage. Evidence regarding how dairy farms contribute to the emergence and spread of AMR in Pakistan is valuable for public authorities and organizations responsible for health, agriculture and the environment, as well as for industrial development.

A Preliminary Test of an mHealth Facilitated Health Coaching Intervention to Improve Medication Adherence among Persons Living with HIV.

This study examined feasibility, acceptability, and preliminary efficacy of an mHealth facilitated health coaching antiretroviral therapy (ART) adherence intervention. Persons living with HIV (n = 53) were randomized to an in-person adherence session and 12 months of app access and health coaching via the app (Fitbit Plus) versus single adherence session (SOC). At baseline and 1, 3, 6, and 12 months, we measured ART adherence, substance use, and depressive symptoms. We also conducted individual qualitative interviews. The intervention was found to be largely feasible and highly acceptable, with the health coach spending an average of 2.4 min per month with a participant and 76.5% of Fitbit Plus participants using the app regularly at 12 months. While most comparisons were not significant, the pattern of results was consistent with better adherence in the Fitbit Plus compared to SOC condition. Substance use was significantly associated with poorer ART adherence while depressive symptoms were not.ClinicalTrials.gov Identifier: NCT02676128; Registered: 2/8/2016.

RESUMEN: En este estudio se examinó la viabilidad, aceptabilidad y la eficacia preliminar de una intervención de cumplimiento de la terapia antirretroviral (ART, por sus siglas en inglés) proporcionada por mHealth. Los pacientes con VIH (n = 53) fueron seleccionados al azar para participar en una sesión de cumplimiento presencial y para tener acceso a la aplicación y recibir asesoría médica a través de la aplicación (Fitbit Plus) durante 12 meses contra una sola sesión de cumplimiento (SOC, por sus siglas en inglés). Al comenzar y al mes 1, 3, 6 y 12, evaluamos el cumplimiento con la ART, el uso de sustancias y los síntomas de depresión; también realizamos entrevistas cualitativas individuales. Se encontró que la intervención es bastante viable y muy aceptable, con un promedio de 2.4 minutos de interacción entre el asesor médico y el participante y un 76.5% de uso de la aplicación por parte de los participantes de Fitbit Plus a los 12 meses. Si bien la mayoría de las comparaciones no fueron significativas, el patrón en los resultados fue consistente con un mayor cumplimiento en Fitbit Plus comparado con la condición SOC. El uso de sustancias se asoció significativamente con un cumplimiento de la ART más deficiente mientras que los síntomas depresivos no.

Linking Women Experiencing Incarceration to Community-Based HIV Pre-Exposure Prophylaxis Care: A Qualitative Study.

Women experiencing incarceration (WEI) in the United States are disproportionately impacted by HIV, yet HIV pre-exposure prophylaxis (PrEP) is underutilized by women in the United States. In order to inform an intervention to promote PrEP initiation during incarceration and facilitate linkage to PrEP care following release from incarceration, we conducted individual, semistructured qualitative interviews with WEI (N = 21) and key stakeholders (N = 14). While WEI had little or no previous knowledge about PrEP, they viewed it as something that would benefit women involved in the criminal justice system. Participants stated that HIV-related stigma and underestimation of HIV risk might serve as barriers to PrEP initiation during incarceration. Participants reported that competing priorities, difficulty scheduling an appointment, and lack of motivation could interfere with linkage to PrEP care in the community. Further, cost, substance use, and difficulty remembering to take the medication were cited most commonly as likely barriers to adherence.

A high prevalence of blaOXA-48 in Klebsiella (Raoultella) ornithinolytica and related species in hospital wastewater in South West England.

Klebsiella species occupy a wide range of environmental and animal niches, and occasionally cause opportunistic infections that are resistant to multiple antibiotics. In particular, Klebsiella pneumoniae (Kpne) has gained notoriety as a major nosocomial pathogen, due principally to the rise in non-susceptibility to carbapenems and other beta-lactam antibiotics. Whilst it has been proposed that the urban water cycle facilitates transmission of pathogens between clinical settings and the environment, the level of risk posed by resistant Klebsiella strains in hospital wastewater remains unclear. We used whole genome sequencing (WGS) to compare Klebsiella species in contemporaneous samples of wastewater from an English hospital and influent to the associated wastewater treatment plant (WWTP). As we aimed to characterize representative samples of Klebsiella communities, we did not actively select for antibiotic resistance (other than for ampicillin), nor for specific Klebsiella species. Two species, Kpne and K. (Raoultella) ornithinolytica (Korn), were of equal dominance in the hospital wastewater, and four other Klebsiella species were present in low abundance in this sample. In contrast, despite being the species most closely associated with healthcare settings, Kpne was the dominant species within the WWTP influent. In total, 29 % of all isolates harboured the blaOXA-48 gene on a pOXA-48-like plasmid, and these isolates were almost exclusively recovered from the hospital wastewater. This gene was far more common in Korn (68 % of isolates) than in Kpne (3.4 % of isolates). In general plasmid-borne, but not chromosomal, resistance genes were significantly enriched in the hospital wastewater sample. These data implicate hospital wastewater as an important reservoir for antibiotic-resistant Klebsiella, and point to an unsuspected role of species within the Raoultella group in the maintenance and dissemination of plasmid-borne blaOXA-48. This article contains data hosted by Microreact.

A Mobile Health App to Improve HIV Medication Adherence: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Adherence to antiretroviral therapy (ART) is essential for allowing persons living with HIV to live longer, healthier lives. However, a large portion of this population has suboptimal adherence and are not virally suppressed. Conventional interventions aimed at improving ART adherence lack portability and scalability, and improvements in adherence are not often sustained. Mobile health (mHealth) ART interventions offer a low-cost and accessible method of improving adherence, but many have limited functionality and do not offer comprehensive support. The combination of an mHealth intervention with a face-to-face adherence intervention and interactive health coaching feature may offer sufficient support in a manner that is sensitive to resource limitations that are often found in HIV treatment settings. This paper details the protocol of a study designed to evaluate the potential of an enhanced mHealth intervention for improving ART adherence. OBJECTIVE: The primary objective of this study is to assess the feasibility and acceptability of the Fitbit Plus app enhanced with a face-to-face LifeSteps session (Fitbit Plus condition) for improving ART adherence. In addition, we will determine the preliminary efficacy of the intervention by calculating treatment effect sizes. METHODS: This study will be conducted in 2 phases. The intervention will be developed and piloted with a small group of participants during phase 1. Pilot participants will provide feedback that will be used to refine the intervention for phase 2. In phase 2, a preliminary randomized controlled trial (RCT) comparing Fitbit Plus with a condition that approximates the standard of care (SOC) will be conducted with 60 persons living with HIV. Interviews will be conducted with RCT participants at baseline, and follow-up interviews will be conducted at 1, 3, 6, and 12 months. ART adherence is the primary outcome and will be monitored throughout the study via electronic pill boxes. Effect sizes will be generated using a fractional logit model estimated by generalized estimating equations. RESULTS: Phase 1 of this trial is complete; data collection for phase 2 is ongoing. Follow-ups with enrolled participants will conclude in January 2020. CONCLUSIONS: This study will contribute to the literature on ART adherence and may produce an efficacious intervention. Owing to a small sample size, there may be insufficient power to detect statistically significant differences between Fitbit Plus and SOC. However, if Fitbit Plus is found to be acceptable and feasible and yields promising effect size estimates, this pilot study could serve as the foundation for a larger, fully powered trial of Fitbit Plus. TRIAL REGISTRATION: ClinicalTrials.gov NCT02676128; https://clinicaltrials.gov/ct2/show/NCT02676128. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/15356.

Same-Day Associations Between Substance Use and Medication Nonadherence Among Persons Living with HIV.

OBJECTIVES: To examine the same-day associations between substance use and objectively measured antiretroviral therapy (ART) nonadherence among persons living with HIV (PLWH). METHODS: PLWH (N = 53) were given an electronic pill box (EPB), and their ART adherence was monitored for 14 days. During a follow-up interview, participants were asked about any alcohol or drug use that occurred during those same 14 days. RESULTS: Daily heavy drinking (⩾5 drinks for males and ⩾4 drinks for females) was associated with a nearly five times greater likelihood of same-day ART nonadherence (OR = 4.90, 95% CI = 1.79-13.36, P = .002). Further, drug use was associated with a nearly two times greater likelihood of ART nonadherence on the same day (OR = 1.80, 95% CI = 1.14-2.85, P = .012). CONCLUSIONS: These results highlight the importance of continuing to pursue interventions to effectively address heavy drinking and drug use among PLWH in order to improve ART adherence.

Workplace Violence Against Nurses in Psychiatric Hospital Settings: Perspectives from Saudi Arabia.

OBJECTIVES: Workplace violence (WPV) has become a world-wide concern. This study aimed to measure the prevalence of WPV among nurses working in psychiatric hospitals in Saudi Arabia. METHODS: This cross-sectional study was conducted at three psychiatric hospitals in Saudi Arabia between March and May 2017. Participants completed a self-reported questionnaire which was used to measure the prevalence and explore the associated factors of WPV. A multivariate logistic regression analysis was also performed. RESULTS: A total of 310 nurses (response rate: 62%) were included in this study. The prevalence of WPV against nurses was 90.3%, of which 57.7% had been exposed to both physical and verbal abuse. More nurses were exposed to WPV during the morning shift than the evening shift (58.4% versus 42.3%). Violent behaviour was exhibited mostly by the patients themselves (81.3%). Over half of the nurses (57.4%) required medical intervention in such cases. The majority of nurses felt either stressed (64.2%) or anxious (53.5%) and 34.2% felt depressed after the incident. Multivariate logistic regression analysis revealed that time of violence, source of violence, patient dissatisfaction with medical care and lack of organisational support for nurses were significantly associated with the occurrence of WPV in psychiatric units. CONCLUSION: WPV has reached an alarming rate among nurses in psychiatric hospitals in Saudi Arabia. It is crucial to invest in the prevention of WPV by constant training of workers and a mutual policy with the police and the civic prosecutor in Saudi Arabia on how to respond to violent psychiatric patients.

Herbal medicines: Saudi population knowledge, attitude, and practice at a glance.

Herbal medicines are widely used in many countries in preventing and treating health disorders. In this study, a multiregional cross-sectional survey, a random sample of 809 adults from Saudi Arabia and territories were used to explore the participants' knowledge, attitude, and practice regarding the use of tradition medicines in Saudi society. Data were collected through direct simple observation, interviews, and structured questionnaires. Observations were made and interviews conducted in public places such as markets and popular schools. The questionnaire included data on sociodemographic such as age and gender and was drafted with optional questions and predefined answer. Data were collected from May 1st to the end of July 2014. Most of the respondents were female (85%). Approximately 70% of participants were found to be highly knowledgeable about the use of herbal medicine. The study found that 88.4% of the respondents stated to have used herbal medicines and 84.3% were interested in traditional recipes. Most of the participants used it for therapeutic reason (88.7%), with a successful effectiveness of 61.2%. In addition, the study found that 48.2% of the participants were taking information from friends and 76% stated that they do not trust the published information in commercial channels. Statistical analysis showed an association between the perception and the demographic data, with an increase in the use of herbal medicines. Because of the increased use of herbal medicine in Saudi Arabia facilitated by perceptions and attitudes of the population, it is important to ensure standardization, stability, and quality control of the use of medicine in Saudi Arabia.

The Impact of Nurse-Led Clinics on the Mortality and Morbidity of Patients with Cardiovascular Diseases: A Systematic Review and Meta-analysis.

BACKGROUND: Nurse-led clinics (NLCs) have been developed in several health specialties in recent years. The aim of this analysis is to summarize and appraise the available evidence about the effectiveness of NLCs on the morbidity and mortality outcomes in patients with cardiovascular diseases (CVDs). METHODS: We searched Cochrane databases, MEDLINE, Web of Science, PubMed, EMBASE, Google Scholar, BIOSIS, and bibliography of secondary sources from inception through February 20, 2013. Studies were selected and data were extracted independently by 2 investigators. Eligible studies were randomized trials of NLCs of patients with CVD. Of 56 potentially relevant articles screened initially, 12 trials met the inclusion criteria. The outcomes of interest were all-cause mortality, cardiovascular mortality, nonfatal myocardial infarction, major adverse cardiac events, revascularization, lipids control, and adherence to antiplatelet medications. We performed random-effects meta-analysis to estimate summary risk ratios and quantified between-studies heterogeneity with the I2 statistic. RESULTS: The 12 trials allocated 4886 patients to NLCs and 4954 patients to usual care. The NLC patients had decreased all-cause mortality (odds ratio, 0.78; 95% confidence interval [CI], 0.65-0.95; P < .01) and myocardial infarction (odds ratio, 0.63; 95% CI, 0.39-1.00; P = .05) and had higher adherence to lipid-lowering medication (odds ratio, 1.57; 95% CI, 1.14-2.17; P = .006) compared with controls. They also had increased adherence to antiplatelet therapy compared with controls (odds ratio, 1.42; 95% CI, 1.01-1.98; P = .04). There was no statistically significant difference in the risk of cardiovascular death (odds ratio, 0.68; 95% CI, 0.40-1.15; P = .68), major adverse cardiac events (odds ratio, 0.79; 95% CI, 0.55-1.14; P = .21),or revascularization (odds ratio, 0.87; 95% CI, 0.66-1.16; P = .36) between NLC patients and controls. CONCLUSIONS: The available evidence suggests a favorable effect of NLCs on all-cause mortality, rate of major adverse cardiac events, and adherence to medications in patients with CVD.