Introduction:India possibly carries the highest burden of antimicrobial resistant typhoidal salmonellae in the world. We report on the health-care ecosystem that produces data on antimicrobial resistance (AMR) testing and the resistance patterns of typhoidal Salmonella isolates in the city of Ahmedabad.Materials and Methods:Through municipality records and internet searches, we identified 1696 private and 83 public laboratories in the city; 4 medical colleges, 4 health-care institution attached laboratories, and 4 corporate laboratories (CLs) were performing culture and antibiotic sensitivity testing (AST), but only 2 medical colleges and 1 CL shared their data with us. There was considerable variation in culturing and sensitivity testing methodology across laboratories.Results:Out of 51,260 blood cultures, Salmonella isolates were detected in only 146 (0.28%). AST was conducted on 124 isolates, of which 67 (54%) were found resistant. Multidrug resistance was absent. Concurrent resistance to more than one antibiotic was very high, 88%, among the 67 resistant isolates. Ciprofloxacin resistance varied widely between the private and public sector laboratories. Notably, isolates from the private sector laboratory showed complete resistance to azithromycin.Conclusions:High resistance to ciprofloxacin and azithromycin observed in Ahmedabad may be due to the increased use of these two antibiotics in the public and private sectors, respectively. The need of the hour is to identify a representative sample of laboratories from both the public and the private sectors and encourage them to participate in the national AMR surveillance network.
Background The UN Sustainable Development Goal aims at a 50% reduction of anemia in women of reproductive age (WRA) by 2030. Several nutrition-specific and sensitive interventions are targeted across LMICs to reduce anemia. Objectives The meta-review comprehensively assessed the effectiveness of nutrition-specific and sensitive interventions on hemoglobin (Hb) and serum ferritin (SF) concentrations, the prevalence of iron deficiency and anemia among WRA, pregnant women and lactating women from LMICs. Method The preparation of the present meta-review followed a double-blinded synthesis process with three stages- screening, quality appraisal and data extraction in Eppi Reviewer. Earlier, a well-designed peer-reviewed protocol was published (1). A comprehensive search was performed for systematic reviews (SRs) published between January 2000 and May 2022 using 21 international, national, and regional databases. The methodological quality appraisal of included studies was conducted using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) checklist. Results A total of 23 SRs evaluated the effects of various nutrition-specific interventions included in the final synthesis. The included SRs on nutrition-specific interventions such as supplementation of nutrients iron (n = 7), iron and folic acid (n = 4), vitamin A (n = 3), calcium (n = 2), multiple micronutrients (n = 7) and intravenous iron sucrose (n = 2). Also, SRs on fortification of nutrients included multiple micronutrients (n = 6), iron and folic acid (n = 4) and iron (n = 4). Of the 23 SRs, 22 were of high quality. Iron with or without folic acid supplementation and fortification and vitamin A supplementation consistently showed positive effects on either reduction in the prevalence of anemia or iron deficiency and in improving the Hb concentrations or SF concentrations in WRA and pregnant women from LMICs. Conclusion The comprehensive meta-review reported the beneficial effects of iron with or without folic acid, multiple micronutrient supplementation/fortification, and vitamin A supplementation in reducing the prevalence of anemia or iron deficiency and increase in Hb or SF concentrations in WRA from LMICs.
Objective To report on (i) the health care eco-system that produces data on AMR, and (ii) pattern of resistance in typhoidal Salmonellae isolates in the city of Ahmedabad in western India. Introduction India carries the highest burden of Enteric Fever in the world. This is further aggravated by the high prevalence of antimicrobial resistance (AMR) in typhoidal Salmonellae. The strategy to combat resistance has been to combine and cycle anti-microbials based on the regional AMR pattern of the organism. But this requires that resistance patterns and genetic mechanisms are mapped at a regional level and regularly recorded and disseminated by a national surveillance system. Methods Through municipality records and internet searches we identified 1696 private and 83 public labs. Our screening of these yielded 4 public medical colleges, 4 private healthcare-institution-attached labs, and 4 corporate labs which were probably performing culture and antibiotic sensitivity testing (AST). Only 2 public medical colleges and 1 corporate lab shared their data with us (Fig 1). There was considerable variation in culturing and sensitivity testing methodology across labs. Results Out of 51,260 blood cultures, Salmonellae isolates were detected in only 146 (0.28%); 67 (54%) of these were resistant. Multi-drug resistance was absent. The extremely low isolation rates in our three facilities may be indicative of lower referral rates of suspected patients for blood culture or, possibly, lower incidence of Salmonella infection in Ahmedabad. Anti-microbial susceptibility testing (AST) was conducted on 124 isolates, of which 67 (54%) were found resistant. Multi-drug resistance was absent, but ciprofloxacin resistance varied widely between the private and public sector labs. The minimal resistance to 3rd generation cephalosporins probably indicates initiation of resistance to this important group of antibiotics in the city's typhoidal salmonella. Notably, isolates from the private sector lab showed complete resistance to azithromycin. Concurrent resistance to more than 1 antibiotic was very high, 88%, amongst the 67 resistant isolates. Although we were unable to estimate the true size of salmonella positivity against total blood cultures in our city, the difference in proportion of AMR isolates reported in our public and private samples, 30% vs 100%, is important because it may be indicative of high levels of AMR in the private. Notably, isolates from the public sector showed higher resistance to Ciprofloxacin and from private sector showed complete resistance to Azithromycin. The higher Ciprofloxacin resistance in the public sector may be indicative of more usage of the relatively cheaper ciprofloxacin among public hospital clientele. The 100% resistance to azithromycin seen in our private sample is a significant finding, and has also been reported in another recent study from Ahmedabad [1]. Out of approximately 1779 big and small facilities in Ahmedabad, we identified 12 (4 public and 8 private) laboratories which had the ability to report AMR in typhoidal salmonella. 2 public and 4 private refused to share data with us. Based on data shared by 3 medium-sized private facilities, we believe that salmonella isolation and testing in private health-institution-attached laboratories is negligible. Our data collection efforts over one year led to reasonable volume of data from only 2 publicly funded teaching hospitals and 1 private standalone lab. Although all facilities claimed to follow CLSI guidelines, the total number of antibiotics tested at each facility varied. Minimum inhibitory concentration to assess extent of resistance was not reported by any of the labs. The publicly-funded teaching hospitals in the city have the largest concentration of microbiologists and the motivation to test for AMR in indoor patients. But they did not consistently test all isolates against all antibiotics in their list. The proportion of private hospitals and laboratories that conduct ASTs in Ahmedabad is relatively small. For individual labs, both private and public, there is no inherent incentive to detect city-level AMR patterns or subsequent molecular level mechanisms of transmission of resistance. This lack of enthusiasm among microbiologists to further process their samples through more specialized lab testing and analysis is an issue in other parts of the world too [2]. Thus patchy performance of AST and incomparability of sensitivity across labs results in poor surveillance [3]. The antibiotic regimen currently recommended by ICMR for treatment of Enteric Fever in the entire country is based on 209 Salmonella isolates from only four public institutes [4]. Across India’s cities and towns, there are several hundreds of public and private hospitals and laboratories undertaking ASTs, just like the ones in Ahmedabad presented in this study [5]. Unless practitioners are guided by regional data on resistance in endemic organisms, uninformed prescription practices will worsen existing microbial resistance. Drawing these varied facilities, or at least a representative sample of them into a cohesive network is essential for surveillance of antimicrobial resistance in all major bacterial pathogens; particularly so for typhoidal Salmonella which are endemic in our part of the world and are primarily exposed to antibiotics consumed by humans since they are obligate human parasites. Only a representative network of labs will provide the contextualized and stratified data necessary for development of the most accurate strategy to formulate regional prescription guidelines. However, this is an enormous challenge in our setting. Conclusions High resistance to Ciprofloxacin and Azithromycin in Ahmedabad may be due to increased use of these two antibiotics in the public and private sectors respectively. But they are in need of further molecular characterization. Clinical microbiological methods lack uniformity and laboratory referral networks are not developed even in large cities of India. Although some useful data is produced by a few individual labs, the crucial exercise of meaningful networking for effective surveillance remains. As we enter an era of internationally linked anti-microbial resistance surveillance systems, the biggest challenge lies in selecting performing laboratories and inducing them to integrate with it. References 1) Jeeyani HN, Mod HK, Tolani JN. Current perspectives of enteric fever : a hospital based study of 185 culture positive cases from Ahmedabad , India. 2017;4: 4–9. 2) Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory Medicine in Africa : A Barrier to Effective Health Care. Clin Infect Dis. 2006;42: 377–382. 3) Masterton RG. Surveillance studies: how can they help the management of infection? J Antimicrob Chemother. 2000;46: 53–58. doi:10.1093/jac/46.suppl_2.53 4) ICMR. Treatment Guidelines for Antimicrobial Use in Common Syndromes Indian Council of Medical Research Department of Health Research New Delhi , India. 2017; 5) Gandra S, Merchant AT, Laxminarayan R. A role for private sector laboratories in public health surveillance of antimicrobial resistance. Future Microbiol. 2016;11: 709–712. doi:10.2217/fmb.16.17
Background: Undernutrition remains an unfinished agenda for a majority of low- and middle-income countries (LMICs). Numerous nutrition interventions have been implemented in LMICs and various indicators have been used to measure the impact of these interventions. The aim of this meta-review was to summarise the findings on the effectiveness of various nutrition interventions that have been implemented in LMICs on the WHO global nutrition targets-related outcomes. The six outcomes are- reducing stunting, wasting, anemia among women of reproductive age, low birthweight, childhood overweight, and improving exclusive breastfeeding. This study presents the results for one of the outcomes (stunting). Methods: We conducted a comprehensive search on 21 electronic databases, including six regional and four systematic reviews (SRs) specific databases. Two researchers independently screened identified records against the inclusion criteria. Quality of included SRs were assessed using the AMSTAR tool. Extracted data were narratively synthesised examining the direction of impact. The review protocol was registered with the EPPI-Centre. Results: Of 6,597 SRs initially identified, 28 SRs that assessed outcomes of WHO global nutrition targets-related outcomes were eligible for inclusion. We found 12 SRs that assessed stunting outcomes, these SRs synthesised 68 quantitative primary studies, from 29 LMICs. All included SRs were of high quality. Eight nutrition interventions were reported in the included SRs- five nutrition-specific (n=9) and three nutrition-sensitive (n=3). Among all interventions, two nutrition-specific (complementary feeding: n=1; dietary supplementation: n=2) interventions showed a positive effect. Conclusion: This meta-review identified, two interventions, complementary feeding and dietary supplementation, with most frequently reported evidence of positive impact on stunting. In LMICs, public health policymakers should consider these two interventions for scaling-up.
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