Global challenges and opportunities for tackling antimicrobial resistance

This post was written by Sophie Allcock andoriginally posted on the Global Health, Epidemiology and Genomics blog – view more at: http://gheg-journal.co.uk/blog/

Antimicrobial resistance (AMR) is a global public health concern. In 2014, an estimated 700,000 deaths were attributed to AMR globally and it is predicted that by 2050 this number could reach 10 million.[1] Antibiotics have been the cornerstone of many medical interventions, for example surgical interventions, transplants and the treatment of common bacterial infections, for decades. Without effective antibiotics, many medical practices that we now consider to be routine will be jeopardised.

Although there is much global attention to AMR, there is a need to better understand the burden, distribution and determinants of AMR at the population level. Antimicrobial use, appropriate or inappropriate, is a driver of AMR yet there is a lack of specific advice as to which interventions are likely to have the greatest impact on reducing the emergence and spread of AMR in both hospital and community settings.

In our paper “Antimicrobial resistance in human populations: challenges and opportunities”, we argue for the integration of a range of epidemiological approaches, which could help to improve our understanding of the population level factors that may influence the development and spread of AMR. This is important for informing interventions to reducing excess use of antimicrobials, whilst also ensuring that those in need of these treatments have access to them.

One such approach is to use routine clinical data and electronic health records (EHRs) in combination with pathogen surveillance, using techniques such as whole-genome sequencing. This could help to improve our understanding of drug resistance, how it emerges and how it spreads. EHRs could also provide an insight into prescribing practices in general practices and hospitals, and how this could be related to the emergence of drug-resistant infections. Using prospective (or longitudinal) study designs, researchers could explore the real-time development of resistant strains in a given population as well as the factors that may drive resistance.

Other preventative strategies to reduce the burden of AMR include basic hygiene and sanitation practices, waste management and safe food preparation. However, in some low- and middle-income countries (LMICs), conducting these basic practices can be challenging due to human resource constrains and weaker civil and health infrastructures. Furthermore, it is often the case in these countries that more people suffer due to a lack of access to drugs than drug resistance itself.

The suggested research initiatives may help to better understand the burden, distribution and determinants of AMR. These approaches should be combined with improved preventative measures, including vaccinations and good hygiene and sanitation practices to reduce the need for therapy in the first instance, and strategies to reduce excess use of antimicrobials to slow the development of resistance. Furthermore, although AMR is a global problem, we need to consider that the issue differs by county and setting, therefore so must the approach taken to tackle AMR.

Reference:
1. O’Niell J., Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, in The review on antimicrobial resistance. 2016, HM Government and the Wellcome Trust: London.

The paper “Antimicrobial resistance in human populations: challenges and opportunities” by S. Allcock, E. H. Young, M. Holmes, D. Gurdasani, G. Dougan, M. S. Sandhu, L. Solomon and M. E. Török has been published Open Access in Global Health, Epidemiology and Genomics and is available here.

Are men with moustaches more likely to carry nasal bacteria?

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This paper discusses the results of an investigation concentrating on men with and without a moustache, to explore whether having facial hair may lead to an increase in nasal Staphylococcus aureus (S aureus) colonisation.

S. aureus can be considered as a serious public health issue. It can cause a range of illnesses, from minor skin infections to life-threatening diseases such as pneumonia, meningitis, and food poisoning, although the presence of S. aureus does not always indicate infection.

The anterior nares (nostrils) are where S. aureus resides in human beings, and it has been shown that nasal carriers of S aureus have an increased risk of acquiring an infection with this pathogen. Despite antibiotic therapy, nasal infections occur frequently in hospitalised patients, often with severe consequences.  In order to fully address this public health problem, it is important to understand whether the presence of a moustache effects the colonisation of nasal infections.

To test this hypothesis the researchers took men who had been wearing a moustache for at least one year and compared them to the participants in the control group who had shaved the hair in this region daily over the previous year. None of the participants had been hospitalised or treated with antibiotics in the previous three months nor were they smokers or had any previous respiratory infections in the past.

The study group consisted of 118 adult men with a moustache and 123 men without a moustache, all of whom gave samples from their right nasal cavity for the study of cytology and the left nasal for microbiology testing.

The results of the swab testing indicated that nasal Staphylococcus aureus carriage is similar in men with (19.5%) and without (20.3%) a moustache.

As a moustache is situated at the entrance to the nostrils, some bacterial contamination might be possible, especially in nasal S aureus carriers. Nevertheless, this study indicated that nasal S aureus carriage is similar in men with and without a moustache. The carrier rate of S aureus observed here is comparable to those rates reported in the literature. Therefore, having a moustache does not increase the risk of S aureus colonisation in the nose.

The full paper, published in The Journal of Laryngology & Otology, “Effect of a moustache on nasal Staphylococcus aureus colonisation and nasal cytology results in men” by E. Soylu, I. Orhan, A. Cakir, A. Istanbullu, G. Altin, R. Yilmazer and O. F. Calim can be viewed free of charge here for a limited period.

A provisional consensus clinical and research definition for Agitation in cognitive disorders

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The January International Psychogeriatrics Article of the Month is entitled ‘Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition’ by Jeffrey Cummings, Jacobo Mintzer, Henry Brodaty, Mary Sano et al.

Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome.

Agitation is a common clinical manifestation of many neuropsychiatric disorders. It is a frequent manifestation of Alzheimer’s disease (AD), frontotemporal dementia (FTD), dementia with Lewy bodies (DLB), and other dementia but also occurs in schizophrenia, bipolar illness, and depression. While agitation may include aggressive behaviors, it is not identical to aggression, and agitation can occur without aggression (e.g. pacing, rocking, repetitious mannerisms).

The International Psychogeriatric Association (IPA) formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.

The ADWG implemented a transparent process that included nearly 1,000 survey respondents and engaged the memberships of the IPA, IPA affiliates, and other organizations involved in the care and research of neuropsychiatric disorders in patients with cognitive impairment. The group used a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.

An initial survey provided valuable insights from those involved in the care of agitated patients, and key elements of the definition were identified. Of the items listed as possible behaviors to be included in a definition of agitation, the following were endorsed by at least 50% of the respondents: pacing, aimless wandering, verbal aggression, constant unwarranted requests for attention or help, hitting others, hitting self, pushing people, throwing things, general restlessness, screaming, resistiveness, hurting self, hurting others, tearing things or destroying property, shouting, and kicking furniture. This information guided the elements included in the definition by the ADWG.

Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as “strongly agree” or “somewhat agree” (68–88% across elements). A majority of the respondents also agreed that the definition is appropriate for clinical and research applications.

The development of a provisional definition of agitation is the first step in advancing a research agenda for the definition. Not all elements were unanimously endorsed; a consensus was achieved on all aspects of the definition. Validity studies using other agitation assessments, reliability of the application of the definition, usefulness in clinical trials, usefulness in non-pharmacologic research, and real-world application in clinical and healthcare settings will lead to refinements and adjustments that will enhance the definition and advance the study of neuropsychiatric syndromes in cognitive impairment disorders.

 

The full paper “Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition” has been published Open Access and is available here.

The commentary on the paper, “Defining agitation in the cognitively impaired–a work in progress” is also available free of charge here.

DMPHP Special Issue on Ebola

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Accurate knowledge regarding Ebola is critical and pertinent for practicing physicians and clinicians given the current risk of hazardous global outbreak and epidemic. Disaster Medicine and Public Health Preparedness has launched a special issue, Ebola Virus and Public Health, to surround the public, medical professionals and media with necessary knowledge in this critical societal moment.

As part of this special issue, the journal has published A Primer on Ebola for Clinicians. The primer was prepared by Dr. Eric Toner, internist and emergency physician, as well as Amesh A. Adalja and Thomas V. Inglesby (all of the University of Pittsburgh Medical Center). The primer discusses the history, epidemiology, microbiology, clinical manifestations, biosafety, prevention, treatment and experimental vaccines to offer an informative and inclusive background on the Ebola virus for clinicians.

The scale of the uncontrolled outbreak in Western Africa makes further exportation to other parts of the world an unfortunate possibility (as citizens across the globe have already witnessed, with cases appearing in Europe and the United States). Those who serve at the frontlines of emergency medicine, critical care, infectious diseases and infection control are in high need and demand, and in some cases, high risk. The primer provided by the UPMC professionals offers clear and concise information on the fundamentals of the virus, including its diagnosis, treatment and control. The public and media are especially apt to benefit from the clear and accurate information provided by the primer, as the popularity of social media makes misinformation about Ebola easily (and rapidly) sharable, believed and misattributed.

The DMPHP Special Edition on Ebola has been designed from the outset to be a conduit for operational and policy level information that will improve outcomes and decision making, and to ensure that this information is available to all practitioners.

As such, published contributions will go online immediately after appropriate review and placed chronologically to ensure a ready historical track for future review and debate. The Special Edition will be made available to everyone in the field as well as at the policy level decision makers worldwide.

View the special issue contents here free of charge. More articles will be added as soon as they become available online.

 
The SDMPH have released press releases on some of these papers- you can view these by using the links below:

Volunteer guidelines for clinicians in the ebola epidemic
A Primer on Ebola for Clinicians
Special issue on Ebola

 

 

What emergency medicine can teach emergency managers

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When a tsunami hit Japan in 2011 and crippled the Fukushima Daiichi nuclear power plant, the American Ambassador called in a team of radiation, health, communications, and nuclear power plant experts to join him in Tokyo to provide Americans visiting or living in Japan with information they needed. The team used a real-time, medical decision model and now recommends that model to emergency managers as they make key decisions during an incident.

Used daily in emergency medicine, medical decision-making provides timely decisions and relies on on-site subject matter experts. Decisions are made based on the best information available at the time, and these decisions are modified the course as new information emerges.

Consider the process for treating cancer. When recommending a treatment plan, doctors look at the likelihood of the treatment’s effectiveness and risk of toxicity on the patient’s overall medical condition. They consider the properties of the tumor (not all of which will be immediately known), and current scientific data. They may consult with other experts as they identify a course of action to avoid tumor growth and dissemination. Then working closely with patients and their families, doctors develop a treatment plan, initiate it in a timely manner, monitor its effectiveness, and modify its course as appropriate.

This approach contrasts to the deliberative, multistep, and more time-consuming decision-making process that waits for a great degree of certainty when more of the outcome is known before making a decision. This deliberative approach can go on in the background and provide advice and guidance.

Like traditional approaches to disaster response, the medical decision model uses experts and committees for consultation and advice, but the medical decision model differs in that those experts are on-site, not “back at headquarters,” and decision makers are empowered to make time-critical decisions based on information, experience, and data from the on-site experts. Those decisions are made refined as new data becomes available.

Using the medical decision model, emergency response officials can act without undue delay using readily available and high-level scientific, medical, communication, and policy expertise. The decisions they make are appropriately modified as the information changes. Ongoing assessment, consultation, and adaption to the changing conditions and additional information play prominently in this model.

In Japan, the decisions about the health-related consequences of the disaster encompassed more than just the potential risk from the radiation, which dominated the media and public conversation. The team also had to consider risks associated with evacuation and public relocation, the impact on physical and mental health from disruptions to normal life, economic losses, and the ongoing anxiety of living through a widespread physical and economic disaster.

Using the medical decision model requires decision makers to be open and transparent with the public about what is known and unknown and that recommended courses of action may change as they learn more data becomes available. The American ambassador embraced this concept and fostered public trust and credibility as a result.

In emergency response, the medical decision model would use the same lines of command and local control abdicated in the National Response Framework. Given the central role of health and medical issues in all disasters, the model should be considered in effective management of complex, large-scale, and large-consequence incidents.

Learn more about applying the medical decision model to emergency response (paper freely available for a limited time).

 

Turn down the Volume? An examination of the effects of nightclubs on hearing

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There is a growing body of evidence that suggests excessive noise levels in nightclubs have an adverse effect on hearing, and may ultimately be responsible for noise-induced hearing loss.

A study by researchers at the University of Birmingham found that although students didn’t want to alter their attendance, the majority would rather see noise limits reduced to safe limits, contrary to the widely held preconception that high volume levels in nightclubs are demanded by young people.

The hearing of all employees in the music and entertainment sector is now protected by The Control of Noise at Work Regulations (2005), which require employers to prevent or reduce risks to employees’ hearing in the workplace when exposed to noise levels above 85 dB. However, this law does not apply to members of the public attending nightclubs, as it is presumed they are making an informed decision to attend such venues.

This study investigated the prevalence of symptoms related to noise-induced hearing loss that were experienced by students after attending nightclubs. It also aimed to explore students’ awareness of the association between noise-induced hearing loss and nightclub attendance, and examine their attitudes towards this.

A questionnaire was distributed to students entering or leaving the University of Birmingham Medical School over a 5-day period during March 2012, with a total of 357 individuals completing the questionnaire, with almost half the students attending a nightclub at least once per week.

Of those students surveyed in the present study (excluding those who never attended nightclubs and those with pre-existing hearing problems), 88% had experienced transient tinnitus after attending a nightclub. This finding is important because transient tinnitus can also be a precursor to other noise-induced hearing loss symptoms, including permanent tinnitus, hyperacusis or irreversible hearing loss.

The majority of students in the sample population (90%) were aware that current nightclub noise levels are potentially damaging to hearing. However, most students who attended nightclubs (73%) reported that they would not alter their attendance, despite being told that the noise levels could lead to permanent hearing loss. Nonetheless, 70% of nightclub attendees agreed that noise levels should be limited to volumes that are not damaging to hearing.

Mr Oliver Johnson, one of the paper’s authors, commented. “This is encouraging for policy makers, as noise levels could potentially be lowered below the threshold for hearing damage without nightclub attendance being significantly compromised. The implementation of relevant legislation could therefore potentially reduce the long-term risks of irreversible hearing loss in this young age group without damaging the nightclub industry.”

The study also demonstrated that 87% of students with normal hearing had never received information about noise-induced hearing loss or had earplugs recommended in the nightclub setting. The findings and those of other research groups indicate that young people attending nightclubs are at high risk of noise-induced hearing loss, and it is therefore of the utmost importance that they should be provided with adequate information regarding the potential damage that excessive music levels in nightclubs may cause.

Mr Johnson added, “We believe the current assumption implied by legislation, namely that nightclub attendees are consenting to the risks of hearing damage, is spurious, as the majority of young people in nightclubs are likely to be unaware of these risks.”

The full paper “British university students’ attitudes towards noise-induced hearing loss caused by nightclub attendance” is published in The Journal of Laryngology & Otology and can be read free of charge for a limited time here.

Implications of inconsistent anaemia policies for children and adolescents in Africa

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The January Nutrition Society Paper of the Month is from Public Health Nutrition and is entitled ‘Implications of inconsistent anaemia policies for children and adolescents in Africa’

Almost 50 % of children and adolescents in sub-Saharan Africa are anaemic, which has profound effects on their intellectual and physical development and their chance of survival. Evidence-based policies are essential in order to reduce anaemia, but as it results from interdependent factors there are difficulties in the development of cohesive policies for diagnosis, prevention and treatment. Nutritional requirements are also derived from food intake studies in healthy Western children and may not always be appropriate in a developing country situation.

This study evaluated the quality of these policies and the extent to which they were based on evidence relevant to the African context. Recommendations are made for improving the policy-making process.

What have we done?

A comprehensive and unrestricted database and website search for guidelines (as defined by WHO). We identified policies which targeted anaemia diagnosis, treatment and prevention in children and non-pregnant adolescents (18 years old) in Africa. Policy quality was assessed using   ‘The Appraisal of Guidelines for Research and Evaluation instrument (AGREE II)’ without any adaptation. A search for high-quality evidence in the Cochrane Library was performed to assess the evidence base for policies.

What did we find?

A total of 1247 documents were identified and screened and 46 were selected for analysis. There was policy consensus on usefulness of iron supplements, the need to treat co-morbidities and the use of blood transfusions for severe anaemia. Information about diagnosis was scarce, and messages regarding the control of anaemia were mixed. Few of the policies were tailored for the African context, and they were located on several websites hosted by different health programmes.

There were examples of ambiguities within individual policies and inconsistencies between policies on key issues. For example, the definitions for categories of anaemia severity were inconsistent, specific age groups were often not identified, and when target age groups were specified these varied between policies.

Does evidence support the anaemia policies?

Few policy documents described their evidence base, and it was not possible to draw conclusions on how policy changes were related to evidence, or the recommendations made. Anomalies within and between policies, and lack of generalisability, limited the option to pool data.

Is there any way forward?

Context-specific research is required to fill evidence gaps, to identify need for local adaptations, and for advice on clinical interventions. Global policy may need to be modified by WHO at the regional level to allow for these factors. Appropriate guideline development and peer review groups should be constituted and rigorous methods for policy updates and development should be established. A comprehensive review of existing research evidence concerning anaemia in African children is urgently needed so that knowledge gaps can be identified and prioritised and research commissioned to fill the gaps. Context-specific issues concerning, safety and benefits of iron supplementation in infection endemic areas, or in HIV infection, sickle cell disease, or young infants are important.

There are many issues and wider discussion is required on this important contributor to child survival.

This paper is freely available for one month via the following link: journals.cambridge.org/ns/jan14

Nutrition Society Paper of the Month

Each month a paper is selected by one of the Editors of the five Nutrition Society Publications (British Journal of NutritionPublic Health NutritionNutrition Research ReviewsProceedings of the Nutrition Society and Journal of Nutritional Science). This paper is freely available for one month.

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