Methicillin-Resistant Staphylococcus aureus Bloodstream Infections in Hospitalized Patients in Peru.

There is a knowledge gap in the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) causing bloodstream infections (BSIs) in Peru. Through a surveillance study in 13 hospitals of 10 Peruvian regions (2017-2019), we assessed the proportion of MRSA among S. aureus BSIs as well as the molecular typing of the isolates. A total of 166 S. aureus isolates were collected, and 36.1% of them were MRSA. Of note, MRSA isolates with phenotypic and genetic characteristics of the hospital-associated Chilean-Cordobes clone (multidrug-resistant SCCmec I, non-Panton-Valentine leukocidin [PVL] producers) were most commonly found (70%), five isolates with genetic characteristics of community-associated MRSA (CA-MRSA)-SCCmec IV, PVL-producer-(8.3%) were seen in three separate regions. These results demonstrate that hospital-associated MRSA is the most frequent MRSA found in patients with BSIs in Peru. They also show the emergence of S. aureus with genetic characteristics of CA-MRSA. Further studies are needed to evaluate the extension of CA-MRSA dissemination in Peru.

Prevalence of Antimicrobial Resistance in Gram-Negative Bacteria Bloodstream Infections in Peru and Associated Outcomes: VIRAPERU Study.

Surveillance of antimicrobial resistance among gram-negative bacteria (GNB) is of critical importance, but data for Peru are not available. To fill this gap, a non-interventional hospital-based surveillance study was conducted in 15 hospitals across Peru from July 2017 to October 2019. Consecutive unique blood culture isolates of key GNB (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter spp.) recovered from hospitalized patients were collected for centralized antimicrobial susceptibility testing, along with linked epidemiological and clinical data. A total of 449 isolates were included in the analysis. Resistance to third-generation cephalosporins (3GCs) was present in 266 (59.2%) GNB isolates. Among E. coli (n = 199), 68.3% showed 3GC resistance (i.e., above the median ratio for low- and middle-income countries in 2020 for this sustainable development goal indicator). Carbapenem resistance was present in 74 (16.5%) GNB isolates, with wide variation among species (0% in E. coli, 11.0% in K. pneumoniae, 37.0% in P. aeruginosa, and 60.8% in Acinetobacter spp. isolates). Co-resistance to carbapenems and colistin was found in seven (1.6%) GNB isolates. Empiric treatment covered the causative GNB in 63.3% of 215 cases. The in-hospital case fatality ratio was 33.3% (92/276). Pseudomonas aeruginosa species and carbapenem resistance were associated with higher risk of in-hospital death. In conclusion, an important proportion of bloodstream infections in Peru are caused by highly resistant GNB and are associated with high in-hospital mortality.

Underutilization and Quality Gaps in Blood Culture Processing in Public Hospitals of Peru.

Correct processing of blood cultures may impact individual patient management, antibiotic stewardship, and scaling up of antimicrobial resistance surveillance. To assess the quality of blood culture processing, we conducted four assessments at 16 public hospitals across different regions of Peru. We assessed the following standardized quality indicators: 1) positivity and contamination rates, 2) compliance with recommended number of bottles/sets and volume of blood sampled, 3) blood culture utilization, and 4) possible barriers for compliance with recommendations. Suboptimal performance was found, with a median contamination rate of 4.2% (range 0-15.1%), with only one third of the participating hospitals meeting the target value of < 3%; and a median positivity rate of 4.9% (range 1-8.1%), with only 6 out of the 15 surveilled hospitals meeting the target of 6-12%. None of the assessed hospitals met both targets. The median frequency of solitary blood cultures was 71.9% and only 8.9% (N = 59) of the surveyed adult bottles met the target blood volume of 8 - 12 mL, whereas 90.5% (N = 602) were underfilled. A high frequency of missed opportunities for ordering blood cultures was found (69.9%, 221/316) among patients with clinical indications for blood culture sampling. This multicenter study demonstrates important shortcomings in the quality of blood culture processing in public hospitals of Peru. It provides a national benchmark of blood culture utilization and quality indicators that can be used to monitor future quality improvement studies and diagnostic stewardship policies.

Effect of bovine lactoferrin on prevention of late-onset sepsis in infants <1500 g: a pooled analysis of individual patient data from two randomized controlled trials.

We previously conducted two randomized controlled trials with bovine lactoferrin (bLF) for the prevention of late-onset sepsis (LOS) in infants with a birth weight <2500 g (Study 1) and <2000 g (Study 2). The aim of this study was to determine the preventative effects of bLF on culture-proven or probable LOS in infants with a birth weight <1500 g from both studies, and to determine the effect of bLF in relation to intake of human milk. Both trial designs had similar inclusion and exclusion criteria, the same dose of bLF [200 mg·(kg body mass)-1·day-1], and used the same control (maltodextrin). We fitted multivariate Cox regression models to estimate the effect of bLF on the risk of development of the composite outcome, adjusting for covariates. We included 335 neonates with a mean birth weight of 1162 ± 244 g; 27.5% were <1000 g. There were 33 first episodes of LOS in the bLF treatment group and 48 in the control group (19.5% vs. 28.9%). bLF had a protective effect on the risk of development of LOS [hazard ratio (HR) = 0.64; %95 CI = 0.41-0.99; p = 0.048]; particularly among infants weighing <1000 g [HR = 0.46; %95 CI = 0.22-0.96; p = 0.039] and infants with a low intake of human milk [HR = 0.40; %95 CI = 0.19-0.84; p = 0.015]. Therefore, bLF supplementation protects infants <1500 g from LOS, particularly those infants not receiving human milk.

Characterization of ESBL-Producing Salmonella enterica Serovar Infantis Infection in Humans, Lima, Peru.

Salmonella enterica serovar Infantis is causing an increasing number of infections worldwide. Our aim was to describe the characteristics of S. enterica serovar Infantis among patients attended in a hospital of Lima, Peru. Fifty cases of salmonellosis were seen during October 2015-May 2017; Salmonella Infantis was detected in 36% (n = 18) of them, displacing Enteritidis and Typhimurium (n = 13, 26%, each). Seventeen cases caused by Salmonella Infantis were presented as diarrheal illnesses; only one extraintestinal case (bacteremia) was seen in a 1-year-old infant. This serovar is resistant to multiple groups of antimicrobials, showing only fully susceptibility to carbapenems. Compared with Infantis, other serovars analyzed (mainly Enteritidis and Typhimurium) showed a lower frequency of resistance to antimicrobials such as trimethoprim-sulfamethoxazole, ampicillin, and chloramphenicol. The antibiotic with the highest frequency of resistance was ciprofloxacin. Further studies are needed to evaluate the routes of transmission and measures of control of this multidrug-resistant Salmonella.

Chikungunya virus infection in Aruba: Diagnosis, clinical features and predictors of post-chikungunya chronic polyarthralgia.

BACKGROUND: Chikungunya virus (CHIKV) emerged in Aruba for the first time in 2014. We studied the clinical presentation of acute CHIKV infection and the contribution of serologic and molecular assays to its diagnosis. In a cohort of confirmed CHIKV cases, we analysed the frequency, duration and predictors of post-chikungunya chronic polyarthralgia (pCHIK-CPA), defined as joint pains lasting longer than 6 weeks or longer than 1 year. METHODOLOGY: Patient sera obtained within 10 days of symptom onset were tested for CHIKV, using an indirect immunofluorescence test for the detection of CHIKV-specific Immunoglobulin M (IgM) and post-hoc, by reverse-transcription polymerase chain reaction (RT-PCR). CHIKV was isolated from selected samples and genotyped. For confirmed CHIKV cases, clinical data from chart review were complemented by a Telephone survey, conducted 18-24 months after diagnosis. When joint pain was reported, the duration, presence of inflammatory signs, type and number of joints affected, were recorded. Joint involvement was scored according to the 2010 'American College of Rheumatology/ European League Against Rheumatism' criteria for seronegative rheumatoid arthritis (ACR-score). Risk factors for pCHIK-CPA were identified by logistic regression. PRINCIPAL FINDINGS: Acute CHIKV infection was diagnosed in 269 of 498 sera, by detection of IgM (n = 105), by RT-PCR (n = 59), or by both methods (n = 105). Asian genotype was confirmed in 7 samples. Clinical data were complete for 171 of 248 (69.0%) patients, aged 15 years or older (median 49.4 [35.0-59.6]). The female-to-male ratio was 2.2. The main acute symptoms were arthralgia (94%), fever (85%), myalgia (85%), headache (73%) and rash (63%). In patients with arthralgia (n = 160), pCHIK-CPA longer than 6 weeks was reported by 44% and longer than 1 year by 26% of cases. Inflammatory signs, stiffness, edema and redness were frequent (71%, 39% and 21%, respectively). Joints involved were knees (66%), ankles (50%), fingers (52%), feet (46%), shoulders (36%), elbows (34%), wrists (35%), hips (31%), toes (28.1%) and spine (28.1%). Independent predictors of pCHIK-CPA longer than 1 year were female gender (OR 5.9, 95%-CI [2.1-19.6]); high ACR-score (7.4, [2.7-23.3]), and detection of CHIKV-RNA in serum beyond 7 days of symptom onset (6.4, [1.4-34.1]. CONCLUSIONS: We identified 269 CHIKV patients after the first outbreak of Asian genotype CHIKV in Aruba in 2014-2015. RT-PCR yielded 59 (28%) additional CHIKV diagnoses compared to IgM antibody detection alone. Arthralgia, fever and skin rash were the dominant acute phase symptoms. pCHIK-CPA longer than 1 year affected 26% of cases and was predicted by female gender, high ACR-score and CHIKV-RNA detection beyond 7 days of symptom onset.

Characterization of Salmonella enterica isolates causing bacteremia in Lima, Peru, using multiple typing methods.

In this study, different molecular typing tools were applied to characterize 95 Salmonella enterica blood isolates collected between 2008 and 2013 from patients at nine public hospitals in Lima, Peru. Combined results of multiplex PCR serotyping, two- and seven-loci multilocus sequence typing (MLST) schemes, serotyping, IS200 amplification and RAPD fingerprints, showed that these infections were caused by eight different serovars: Enteritidis, Typhimurium, Typhi, Choleraesuis, Dublin, Paratyphi A, Paratyphi B and Infantis. Among these, Enteritidis, Typhimurium and Typhi were the most prevalent, representing 45, 36 and 11% of the isolates, respectively. Most isolates (74%) were not resistant to ten primarily used antimicrobial drugs; however, 37% of the strains showed intermediate susceptibility to ciprofloxacin (ISC). Antimicrobial resistance integrons were carried by one Dublin (dfra1 and aadA1) and two Infantis (aadA1) isolates. The two Infantis isolates were multidrug resistant and harbored a large megaplasmid. Amplification of spvC and spvRA regions showed that all Enteritidis (n = 42), Typhimurium (n = 34), Choleraesuis (n = 3) and Dublin (n = 1) isolates carried the Salmonella virulence plasmid (pSV). We conclude that the classic serotyping method can be substituted by the multiplex PCR and, when necessary, sequencing of only one or two loci of the MLST scheme is a valuable tool to confirm the results. The effectiveness and feasibility of different typing tools is discussed.

Multidrug-Resistant Microorganisms Colonizing Lower Extremity Wounds in Patients in a Tertiary Care Hospital, Lima, Peru.

Multidrug-resistant organism (MDRO) infections cause high morbidity and mortality, and high costs to patients and hospitals. The study aims were to determine the frequency of MDRO colonization and associated factors in patients with lower-extremity wounds with colonization. A cross-sectional study was designed during November 2015 to July 2016 in a tertiary care hospital in Lima, Peru. A wound swab was obtained for culture and susceptibility testing. MDRO colonization was defined if the culture grew with methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and/or extended spectrum beta-lactamase (ESBL) microorganisms. The frequency of MDRO wound colonization was 26.8% among the 97 patients enrolled. The most frequent MDRO obtained was ESBL-producing Escherichia coli, which was significantly more frequent in chronic wounds versus acute wounds (17.2% versus 0%, P < 0.05). Infection control measures should be implemented when patients with chronic lower-extremity wounds are admitted.

Virulence factors profiles and ESBL production in Escherichia coli causing bacteremia in Peruvian children.

The presence of 25 virulence genes (VGs), genetic phylogroups, quinolone-resistance and Extended Spectrum ß-lactamase (ESBL)-production was assessed in 65 Escherichia coli isolates from blood cultures in children <5 years in Peru. The most frequent VGs were fimA (89.2%), iutA (83.1%), agn43 (72.3%), iucA (67.7%), and fyuA (49.2%). The isolates belonged to D (47.7%), A (26.1%), B1 (21.5%), and B2 (4.6%) phylogroups. D + B2 isolates presented a high number of fimA, hly, papC, sat, and fyuA genes. Quinolone-susceptible (22 isolates - 33.8%) and ESBL-negative (31 isolates - 47.7%) isolates carried more VGs that their respective counterparts (5.7 vs. 4.7 and 5.3 vs. 4.4 respectively); the frequency of the fyuA, aat, aap, and hly genes significantly differed between quinolone-resistant and quinolone-susceptible isolates. Neonatal sepsis isolates tended to be more quinolone-resistant (P = 0.0697) and ESBL-producers (P = 0.0776). Early-onset neonatal sepsis isolates possessed a high number of VGs (5.2 VGs), especially in neonates of ≤1 day (5.9 VGs).

Molecular Characterization of Extended-Spectrum ß-Lactamase-Producer Klebsiella pneumoniae Isolates Causing Neonatal Sepsis in Peru.

Klebsiella pneumoniae (KP) is the most common cause of neonatal sepsis in the low- and middle-income countries. Our objective was to describe the phenotypic and molecular characteristics of extended-spectrum ß-lactamase (ESBL)-producer KP in neonatal care centers from Peru. We collected 176 non-duplicate consecutive KP isolates from blood isolates of neonates from eight general public hospitals of Lima, Peru. The overall rate of ESBL production was 73.3% (N = 129). The resistance rates were higher among ESBL-producer isolates when compared with the nonproducers: 85.3% versus 12.8% for gentamicin (P < 0.01), 59.7% versus 8.5% for trimethoprim-sulfamethoxazole (P < 0.01), 45.0% versus 8.5% for ciprofloxacin (P < 0.01), and 36.4% versus 12.8% for amikacin (P < 0.01). A total of 359 ß-lactamase-encoding genes were detected among 129 ESBL-producer isolates; 109 isolates (84.5%) carried two or more genes. Among 37 ESBL-producer isolates randomly selected, CTX-M-15 and CTX-M-2 were the most common ESBLs detected. Most of the isolates (92%) belonged to the group KpI. Pulsed-field gel electrophoresis showed that multiple KP clones were circulating among the eight neonatal units included.

Intermediate susceptibility to ciprofloxacin among Salmonella enterica serovar Typhi isolates in Lima, Peru.

Thirty-three Salmonella enterica serovar Typhi blood isolates from Lima, Peru (2008 to 2012), were fully susceptible to trimethoprim-sulfamethoxazole, chloramphenicol, ceftriaxone, and tetracycline; 8/33 (24.2%) showed intermediate susceptibility to ciprofloxacin carrying mutations in the quinolone resistance-determining region of the gyrA gene (Ser83-Phe and Asp87-Asn) and in the gyrB gene (Ser464-Phe).

Staphylococcus aureus causing tropical pyomyositis, Amazon Basin, Peru.

We studied 12 Staphylococcus aureus isolates causing tropical pyomyositis in the Amazon Basin of Peru. All isolates were methicillin-susceptible; 11 carried Panton-Valentine leukocidin-encoding genes, and 5 belonged to multilocus sequence type 25 and possessed an extensive set of enterotoxins. Our findings suggest sequence type 25 is circulating in tropical areas of South America.

Rapid diagnostic tests for malaria diagnosis in the Peruvian Amazon: impact of pfhrp2 gene deletions and cross-reactions.

BACKGROUND: In the Peruvian Amazon, Plasmodium falciparum and Plasmodium vivax malaria are endemic in rural areas, where microscopy is not available. Malaria rapid diagnostic tests (RDTs) provide quick and accurate diagnosis. However, pfhrp2 gene deletions may limit the use of histidine-rich protein-2 (PfHRP2) detecting RDTs. Further, cross-reactions of P. falciparum with P. vivax-specific test lines and vice versa may impair diagnostic specificity. METHODS: Thirteen RDT products were evaluated on 179 prospectively collected malaria positive samples. Species diagnosis was performed by microscopy and confirmed by PCR. Pfhrp2 gene deletions were assessed by PCR. RESULTS: Sensitivity for P. falciparum diagnosis was lower for PfHRP2 compared to P. falciparum-specific Plasmodium lactate dehydrogenase (Pf-pLDH)-detecting RDTs (71.6% vs. 98.7%, p<0.001). Most (19/21) false negative PfHRP2 results were associated with pfhrp2 gene deletions (25.7% of 74 P. falciparum samples). Diagnostic sensitivity for P. vivax (101 samples) was excellent, except for two products. In 10/12 P. vivax-detecting RDT products, cross-reactions with the PfHRP2 or Pf-pLDH line occurred at a median frequency of 2.5% (range 0%-10.9%) of P. vivax samples assessed. In two RDT products, two and one P. falciparum samples respectively cross-reacted with the Pv-pLDH line. Two Pf-pLDH/pan-pLDH-detecting RDTs showed excellent sensitivity with few (1.0%) cross-reactions but showed faint Pf-pLDH lines in 24.7% and 38.9% of P. falciparum samples. CONCLUSION: PfHRP2-detecting RDTs are not suitable in the Peruvian Amazon due to pfhrp2 gene deletions. Two Pf-pLDH-detecting RDTs performed excellently and are promising RDTs for this region although faint test lines are of concern.

Antimicrobial resistance and molecular typing of Staphylococcus aureus bloodstream isolates from hospitals in Peru.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) infections are of worldwide concern. The present study describes the antimicrobial resistance and molecular typing of methicillin-resistant and methicillin-susceptible S. aureus (MSSA) bloodstream isolates in Peru. METHODS: Consecutive non-duplicate S. aureus bloodstream isolates were collected over a 15-month period (2008-2009) from seven hospitals in Lima and Callao, two contiguous cities in Peru. Detection of mecA gene, spa typing and Staphylococcal Chromosomal Cassette (SCC)mec typing were performed. Antimicrobial resistance was assessed by disk diffusion. RESULTS: Of 338 isolates, MRSA rate was 50.0%. Among MRSA isolates (n = 169), 81.7% were associated to MLST CC5, 68.8% had spa t149/SCCmec I, and more than 85% were co-resistant to ciprofloxacin, clindamycin, erythromycin and gentamicin; 8.9% (n = 15) were associated to MLST CC8, 14 of them had spa t148/SCCmec IV, and more than 70% were co-resistant to ciprofloxacin, clindamycin and erythromycin. Among MSSA isolates (n = 169), there was a higher diversity of spa types (n = 56) compared to MRSA isolates (n = 17), 27.2% were associated to MLST CC8, 23.7% were resistant to erythromycin and clindamycin resistance exceeded 20%. CONCLUSIONS: MRSA rate among bloodstream isolates in Peru was 50%, with MLST CC5/t149/SCCmec I representing the most frequent clone.

Knowledge, attitudes and practice survey about antimicrobial resistance and prescribing among physicians in a hospital setting in Lima, Peru.

BACKGROUND: Misuse of antimicrobials (AMs) and antimicrobial resistance (AMR) are global concerns. The present study evaluated knowledge, attitudes and practices about AMR and AM prescribing among medical doctors in two large public hospitals in Lima, Peru, a middle-income country. METHODS: Cross-sectional study using a self-administered questionnaire RESULTS: A total of 256 participants completed the questionnaire (response rate 82%). Theoretical knowledge was good (mean score of 6 ± 1.3 on 7 questions) in contrast to poor awareness (< 33%) of local AMR rates of key-pathogens. Participants strongly agreed that AMR is a problem worldwide (70%) and in Peru (65%), but less in their own practice (22%). AM overuse was perceived both for the community (96%) and the hospital settings (90%). Patients' pressure to prescribing AMs was considered as contributing to AM overuse in the community (72%) more than in the hospital setting (50%). Confidence among AM prescribing was higher among attending physicians (82%) compared to residents (30%, p < 0.001%). Sources of information considered as very useful/useful included pocket-based AM prescribing guidelines (69%) and internet sources (62%). Fifty seven percent of participants regarded AMs in their hospitals to be of poor quality. Participants requested more AM prescribing educational programs (96%) and local AM guidelines (92%). CONCLUSIONS: This survey revealed topics to address during future AM prescribing interventions such as dissemination of information about local AMR rates, promoting confidence in the quality of locally available AMs, redaction and dissemination of local AM guidelines and addressing the general public, and exploring the possibilities of internet-based training.

Assessment of the knowledge of graphical symbols labelled on malaria rapid diagnostic tests in four international settings.

BACKGROUND: Graphical symbols on in vitro diagnostics (IVD symbols) replace the need for text in different languages and are used on malaria rapid diagnostic tests (RDTs) marketed worldwide. The present study assessed the comprehension of IVD symbols labelled on malaria RDT kits among laboratory staff in four different countries. METHODS: Participants (n = 293) in Belgium (n = 96), the Democratic Republic of the Congo (DRC, n = 87), Cambodia (n = 59) and Cuba (n = 51) were presented with an anonymous questionnaire with IVD symbols extracted from ISO 15223 and EN 980 presented as stand-alone symbols (n = 18) and in context (affixed on RDT packages, n = 16). Responses were open-ended and scored for correctness by local professionals. RESULTS: Presented as stand-alone, three and five IVD symbols were correctly scored for comprehension by 67% and 50% of participants; when contextually presented, five and seven symbols reached the 67% and 50% correct score respectively. 'Batch code' scored best (correctly scored by 71.3% of participants when presented as stand-alone), 'Authorized representative in the European Community' scored worst (1.4% correct). Another six IVD symbols were scored correctly by less than 10% of participants: 'Do not reuse', 'In vitro diagnostic medical device', 'Sufficient for', 'Date of manufacture', 'Authorised representative in EC', and 'Do not use if package is damaged'. Participants in Belgium and Cuba both scored six symbols above the 67% criterion, participants from DRC and Cambodia scored only two and one symbols above this criterion. Low correct scores were observed for safety-related IVD symbols, such as for 'Biological Risk' (42.7%) and 'Do not reuse' (10.9%). CONCLUSION: Comprehension of IVD symbols on RDTs among laboratory staff in four international settings was unsatisfactory. Administrative and outreach procedures should be undertaken to assure their acquaintance by end-users.