Publications by authors named "Ben Cooper"

128 Publications

Populations of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae are different in human-polluted environment and food items: A multicentre European study.

Clin Microbiol Infect 2021 Jul 26. Epub 2021 Jul 26.

Infection Control Unit, University Hospital of Besancon, Besancon, France; UMR 6249, Laboratoire Chrono-environnement, CNRS-Université de Bourgogne Franche-Comté, Besançon, France; Centre de Ressources Biologiques - Filière Microbiologique de Besançon, Centre Hospitalier Régional Universitaire, Besançon, France.

Objectives: To assess the extent to which food items are a source of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (ESBL-Ec) and ESBL-producing Klebsiella pneumoniae (ESBL-Kp) for humans in five European cities.

Methods: We sampled 122 human polluted (hp)-environments (sewers and polluted rivers, as a proxy of human contamination) and 714 food items in Besançon (France), Geneva (Switzerland), Sevilla (Spain), Tübingen (Germany), and Utrecht (The Netherlands). 254 ESBL-Ec and 39 ESBL-Kp isolates were cultured. All genomes were fully sequenced to compare their sequence types (ST) and core genomes, along the distribution of bla genes and their genetic supports (i.e. chromosome or plasmid).

Results: Sequence data revealed that ESBL-Ec and ESBL-Kp isolates from hp-environment were genetically different from those contaminating food items. ESBL-Ec ST131 was widespread in the hp-environment (21.5% of the isolates) but absent from the food items tested. ESBL-Ec ST10 was in similar proportions in hp-environment and food items (15 and 10 isolates, respectively) but mostly carried reservoir-specific bla. bla and bla predominated in food-related E. coli isolates (32% and 34% of the isolates, respectively), while bla and bla predominated in isolates from hp-environment (52% and 15% of the isolates, respectively).

Conclusions: We found a very limited connection between ESBL-Ec and ESBL-Kp populations and bla, retrieved in food items and from hp-environment. This suggests that human-to-human contamination, rather than the food chain, is possibly the most frequent route of ESBL-Ec and ESBL-Kp transmission in high-income countries.
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http://dx.doi.org/10.1016/j.cmi.2021.07.022DOI Listing
July 2021

Population-level faecal metagenomic profiling as a tool to predict antimicrobial resistance in isolates causing invasive infections: An exploratory study across Cambodia, Kenya, and the UK.

EClinicalMedicine 2021 Jun 30;36:100910. Epub 2021 May 30.

Nuffield Department of Medicine, University of Oxford, Oxford, UK.

Background: Antimicrobial resistance (AMR) in is a global health threat. Capacity for individual-level surveillance remains limited in many countries, whilst population-level surveillance approaches could inform empiric antibiotic treatment guidelines.

Methods: In this exploratory study, a novel approach to population-level prediction of AMR in clinical isolates using metagenomic (Illumina) profiling of pooled DNA extracts from human faecal samples was developed and tested. Taxonomic and AMR gene profiles were used to derive taxonomy-adjusted population-level AMR metrics. Bayesian modelling, and model comparison based on cross-validation, were used to evaluate the capacity of each metric to predict the number of resistant invasive infections at a population-level, using available bloodstream/cerebrospinal fluid infection data.

Findings: Population metagenomes comprised samples from 177, 157, and 156 individuals in Kenya, the UK, and Cambodia, respectively, collected between September 2014 and April 2016. Clinical data from independent populations included 910, 3356 and 197 bacterial isolates from blood/cerebrospinal fluid infections in Kenya, the UK and Cambodia, respectively (samples collected between January 2010 and May 2017). were common colonisers and pathogens, and faecal taxonomic/AMR gene distributions and proportions of antimicrobial-resistant infections differed by setting. A model including terms reflecting the metagenomic abundance of the commonest clinical species, and of AMR genes known to either increase the minimum inhibitory concentration (MIC) or confer clinically-relevant resistance, had a higher predictive performance in determining population-level resistance in clinical isolates compared to models considering only AMR gene information, only taxonomic information, or an intercept-only baseline model (difference in expected log predictive density compared to best model, estimated using leave-one-out cross-validation: intercept-only model = -223 [95% credible interval (CI): -330,-116]; model considering only AMR gene information = -186 [95% CI: -281,-91]; model considering only taxonomic information = -151 [95% CI: -232,-69]).

Interpretation: Whilst our findings are exploratory and require validation, intermittent metagenomics of pooled samples could represent an effective approach for AMR surveillance and to predict population-level AMR in clinical isolates, complementary to ongoing development of laboratory infrastructures processing individual samples.
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http://dx.doi.org/10.1016/j.eclinm.2021.100910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8173267PMC
June 2021

Effect of Delays in Concordant Antibiotic Treatment on Mortality in Patients with Hospital-Acquired Acinetobacter spp. Bacteremia: Emulating a Target Randomised Trial with a 13-year Retrospective Cohort.

Am J Epidemiol 2021 May 27. Epub 2021 May 27.

Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Thailand.

Delays in treating bacteremias with antibiotics to which the causative organism is susceptible are expected to adversely affect patient outcomes. Quantifying the impact of such delays to concordant treatment is important for decision-making about interventions to reduce the delays and for quantifying the burden of disease due to antimicrobial resistance. There are, however, potentially important biases to be addressed including immortal time bias. Here, we aim to estimate the impact of delays in appropriate antibiotic treatment of patients with Acinetobacter spp. hospital-acquired bacteremia in Thailand on 30-day mortality by emulating a target trial using retrospective cohort data from Sunpasitthiprasong Hospital in 2003 to 2015. For each day, we defined treatment as concordant if the isolated organism was susceptible to at least one antibiotic given. Amongst 1,203 patients with Acinetobacter spp. hospital-acquired bacteremia, 682 had one or more days of delays to concordant treatment. Surprisingly, crude 30-day mortality was lower in patients with delays of ≥3 days compared to those with 1-2 days of delays. Accounting for confounders and immortal time bias resolved this paradox. Emulating a target trial, we found that these delays were associated with an absolute increase in expected 30-day mortality of 6.6% (95% CI: 0.2%, 13.0%), from 33.8% to 40.4%.
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http://dx.doi.org/10.1093/aje/kwab158DOI Listing
May 2021

Reducing antibiotic treatment duration for ventilator-associated pneumonia (REGARD-VAP): a trial protocol for a randomised clinical trial.

BMJ Open 2021 05 13;11(5):e050105. Epub 2021 May 13.

Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.

Introduction: Ventilator-associated pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICUs). Using short-course antibiotics to treat VAP caused by Gram-negative non-fermenting bacteria has been reported to be associated with excess pneumonia recurrences. The "REducinG Antibiotic tReatment Duration for Ventilator-Associated Pneumonia" (REGARD-VAP) trial aims to provide evidence for using a set of reproducible clinical criteria to shorten antibiotic duration for individualised treatment duration of VAP.

Methods And Analysis: This is a randomised controlled hierarchical non-inferiority-superiority trial being conducted in ICUs across Nepal, Thailand and Singapore. The primary outcome is a composite endpoint of death and pneumonia recurrence at day 60. Secondary outcomes include ventilator-associated events, multidrug-resistant organism infection or colonisation, total duration of antibiotic exposure, mechanical ventilation and hospitalisation. Adult patients who satisfy the US Centers for Disease Control and Prevention National Healthcare Safety Network VAP diagnostic criteria are enrolled. Participants are assessed daily until fever subsides for >48 hours and have stable blood pressure, then randomised to a short duration treatment strategy or a standard-of-care duration arm. Antibiotics may be stopped as early as day 3 if respiratory cultures are negative, and day 5 if respiratory cultures are positive in the short-course arm. Participants receiving standard-of-care will receive antibiotics for at least 8 days. Study participants are followed for 60 days after enrolment. An estimated 460 patients will be required to achieve 80% power to determine non-inferiority with a margin of 12%. All outcomes are compared by absolute risk differences. The conclusion of non-inferiority, and subsequently superiority, will be based on unadjusted and adjusted analyses in both the intention-to-treat and per-protocol populations.

Ethics And Dissemination: The study has received approvals from the Oxford Tropical Research Ethics Committee and the respective study sites. Results will be disseminated to patients, their caregivers, physicians, the funders, the critical care societies and other researchers.

Trial Registration Number: NCT03382548.
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http://dx.doi.org/10.1136/bmjopen-2021-050105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8126270PMC
May 2021

Pervasive transmission of a carbapenem resistance plasmid in the gut microbiota of hospitalized patients.

Nat Microbiol 2021 May 29;6(5):606-616. Epub 2021 Mar 29.

Servicio de Microbiología, Hospital Universitario Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain.

Infections caused by carbapenemase-producing enterobacteria (CPE) are a major concern in clinical settings worldwide. Two fundamentally different processes shape the epidemiology of CPE in hospitals: the dissemination of CPE clones from patient to patient (between-patient transfer), and the transfer of carbapenemase-encoding plasmids between enterobacteria in the gut microbiota of individual patients (within-patient transfer). The relative contribution of each process to the overall dissemination of carbapenem resistance in hospitals remains poorly understood. Here, we used mechanistic models combining epidemiological data from more than 9,000 patients with whole genome sequence information from 250 enterobacteria clones to characterize the dissemination routes of a pOXA-48-like carbapenemase-encoding plasmid in a hospital setting over a 2-yr period. Our results revealed frequent between-patient transmission of high-risk pOXA-48-carrying clones, mostly of Klebsiella pneumoniae and sporadically Escherichia coli. The results also identified pOXA-48 dissemination hotspots within the hospital, such as specific wards and individual rooms within wards. Using high-resolution plasmid sequence analysis, we uncovered the pervasive within-patient transfer of pOXA-48, suggesting that horizontal plasmid transfer occurs in the gut of virtually every colonized patient. The complex and multifaceted epidemiological scenario exposed by this study provides insights for the development of intervention strategies to control the in-hospital spread of CPE.
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http://dx.doi.org/10.1038/s41564-021-00879-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610705PMC
May 2021

Remote-Controlled and Pulse Pressure-Guided Fluid Treatment for Adult Patients with Viral Hemorrhagic Fevers.

Am J Trop Med Hyg 2021 Feb 16. Epub 2021 Feb 16.

1Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Circulatory shock, caused by severe intravascular volume depletion resulting from gastrointestinal losses and profound capillary leak, is a common clinical feature of viral hemorrhagic fevers, including Ebola virus disease, Marburg hemorrhagic fever, and Lassa fever. These conditions are associated with high case fatality rates, and they carry a significant risk of infection for treating personnel. Optimized fluid therapy is the cornerstone of management of these diseases, but there are few data on the extent of fluid losses and the severity of the capillary leak in patients with VHFs, and no specific guidelines for fluid resuscitation and hemodynamic monitoring exist. We propose an innovative approach for monitoring VHF patients, in particular suited for low-resource settings, facilitating optimizing fluid therapy through remote-controlled and pulse pressure-guided fluid resuscitation. This strategy would increase the capacity for adequate supportive care, while decreasing the risk for virus transmission to health personnel.
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http://dx.doi.org/10.4269/ajtmh.20-1515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045617PMC
February 2021

Don't Ditch the Laptop Just Yet: A Direct Replication of Mueller and Oppenheimer's (2014) Study 1 Plus Mini Meta-Analyses Across Similar Studies.

Psychol Sci 2021 03 4;32(3):326-339. Epub 2021 Feb 4.

Department of Psychology, Tufts University.

In this direct replication of Mueller and Oppenheimer's (2014) Study 1, participants watched a lecture while taking notes with a laptop ( = 74) or longhand ( = 68). After a brief distraction and without the opportunity to study, they took a quiz. As in the original study, laptop participants took notes containing more words spoken verbatim by the lecturer and more words overall than did longhand participants. However, laptop participants did not perform better than longhand participants on the quiz. Exploratory meta-analyses of eight similar studies echoed this pattern. In addition, in both the original study and our replication, higher word count was associated with better quiz performance, and higher verbatim overlap was associated with worse quiz performance, but the latter finding was not robust in our replication. Overall, results do not support the idea that longhand note taking improves immediate learning via better encoding of information.
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http://dx.doi.org/10.1177/0956797620965541DOI Listing
March 2021

Cost-effectiveness and budget impact analyses for the prioritisation of the four available rotavirus vaccines in the national immunisation programme in Thailand.

Vaccine 2021 03 30;39(9):1402-1414. Epub 2021 Jan 30.

Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine & Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Background: Rotavirus is a major cause of diarrhoea in children less than five years old in Thailand. Vaccination has been shown to be an effective intervention to prevent rotavirus infections but has yet to be enlisted in the national immunisation programme. This study aimed to assess the cost-utility of introducing rotavirus vaccines, taking all WHO-prequalified vaccines into consideration.

Methods: A cost-utility analysis was performed using a transmission dynamic model to estimate, from a societal perspective, the costs and outcomes of four WHO-prequalified rotavirus vaccines: Rotarix®, RotaTeq®, ROTAVAC® and ROTASIIL®. The model was used to simulate the impact of introducing the vaccines among children aged < 1 year and compare this with no rotavirus vaccination. The vaccination programme was considered to be cost-effective if the incremental cost-effectiveness ratio was less than a threshold of USD 5,110 per QALY gained.

Results: Overall, without the vaccine, the model predicted the average annual incidence of rotavirus to be 312,118 cases. With rotavirus vaccination at a coverage of more than 95%, the average number of rotavirus cases averted was estimated to be 144,299 per year. All rotavirus vaccines were cost-saving. ROTASIIL® was the most cost-saving option, followed by ROTAVAC®, Rotarix® and RotaTeq®, providing average cost-savings of USD 32, 31, 23 and 22 million per year, respectively, with 999 QALYs gained. All vaccines remained cost-saving with lower QALYs gained, even when ignoring indirect beneficial effects. The net saving to the healthcare system when implementing any one of these vaccines would be between USD 13 and 33 million per year.

Conclusion: Rotavirus vaccines should be included in the national vaccination programme in Thailand. Implementing any one of these four WHO-prequalified vaccines would reduce government healthcare spending while yielding health benefits to the population.
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http://dx.doi.org/10.1016/j.vaccine.2021.01.051DOI Listing
March 2021

Probabilistic transmission models incorporating sequencing data for healthcare-associated Clostridioides difficile outperform heuristic rules and identify strain-specific differences in transmission.

PLoS Comput Biol 2021 01 14;17(1):e1008417. Epub 2021 Jan 14.

Big Data Institute, Nuffield Department of Population Health, University of Oxford, United Kingdom.

Fitting stochastic transmission models to electronic patient data can offer detailed insights into the transmission of healthcare-associated infections and improve infection control. Pathogen whole-genome sequencing may improve the precision of model inferences, but computational constraints have limited modelling applications predominantly to small datasets and specific outbreaks, whereas large-scale sequencing studies have mostly relied on simple rules for identifying/excluding plausible transmission. We present a novel approach for integrating detailed epidemiological data on patient contact networks in hospitals with large-scale pathogen sequencing data. We apply our approach to study Clostridioides difficile transmission using a dataset of 1223 infections in Oxfordshire, UK, 2007-2011. 262 (21% [95% credibility interval 20-22%]) infections were estimated to have been acquired from another known case. There was heterogeneity by sequence type (ST) in the proportion of cases acquired from another case with the highest rates in ST1 (ribotype-027), ST42 (ribotype-106) and ST3 (ribotype-001). These same STs also had higher rates of transmission mediated via environmental contamination/spores persisting after patient discharge/recovery; for ST1 these persisted longer than for most other STs except ST3 and ST42. We also identified variation in transmission between hospitals, medical specialties and over time; by 2011 nearly all transmission from known cases had ceased in our hospitals. Our findings support previous work suggesting only a minority of C. difficile infections are acquired from known cases but highlight a greater role for environmental contamination than previously thought. Our approach is applicable to other healthcare-associated infections. Our findings have important implications for effective control of C. difficile.
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http://dx.doi.org/10.1371/journal.pcbi.1008417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840057PMC
January 2021

Household acquisition and transmission of extended-spectrum β-lactamase (ESBL) -producing Enterobacteriaceae after hospital discharge of ESBL-positive index patients.

Clin Microbiol Infect 2021 Jan 7. Epub 2021 Jan 7.

Infection Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland. Electronic address:

Objectives: This study aimed to determine rates and risk factors of extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and transmission within households after hospital discharge of an ESBL-PE-positive index patient.

Methods: Two-year prospective cohort study in five European cities. Patients colonized with ESBL-producing Escherichia coli (ESBL-Ec) or Klebsiella pneumoniae (ESBL-Kp), and their household contacts were followed up for 4 months after hospital discharge of the index case. At each follow up, participants provided a faecal sample and personal information. ESBL-PE whole-genome sequences were compared using pairwise single nucleotide polymorphism-based analysis.

Results: We enrolled 71 index patients carrying ESBL-Ec (n = 45), ESBL-Kp (n = 20) or both (n = 6), and 102 household contacts. The incidence of any ESBL-PE acquisition among household members initially free of ESBL-PE was 1.9/100 participant-weeks at risk. Nineteen clonally related household transmissions occurred (case to contact: 13; contact to case: 6), with an overall rate of 1.18 transmissions/100 participant-weeks at risk. Most of the acquisition and transmission events occurred within the first 2 months after discharge. The rate of ESBL-Kp household transmission (1.16/100 participant-weeks) was higher than of ESBL-Ec (0.93/100 participant-weeks), whereas more acquisitions were noted for ESBL-Ec (1.06/100 participant-weeks) compared with ESBL-Kp (0.65/100 participant-weeks). Providing assistance for urinary and faecal excretion to the index case by household members increased the risk of ESBL-PE transmission (adjusted prevalence ratio 4.3; 95% CI 1.3-14.1).

Conclusions: ESBL-PE cases discharged from the hospital are an important source of ESBL-PE transmission within households. Most acquisition and transmission events occurred during the first 2 months after hospital discharge and were causally related to care activities at home, highlighting the importance of hygiene measures in community settings.

Clinical Study Registration: German Clinical Trials Register, DRKS-ID: DRKS00013250.
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http://dx.doi.org/10.1016/j.cmi.2020.12.024DOI Listing
January 2021

Household transmission of carbapenemase-producing Enterobacteriaceae: a prospective cohort study.

J Antimicrob Chemother 2021 04;76(5):1299-1302

Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore.

Objectives: To estimate the transmission rate of carbapenemase-producing Enterobacteriaceae (CPE) in households with recently hospitalized CPE carriers.

Methods: We conducted a prospective case-ascertained cohort study. We identified the presence of CPE in stool samples from index subjects, household contacts and companion animals and environmental samples at regular intervals. Linked transmissions were identified by WGS. A Markov model was constructed to estimate the household transmission potential of CPE.

Results: Ten recently hospitalized index patients and 14 household contacts were included. There were seven households with one contact, two households with two contacts, and one household with three contacts. Index patients were colonized with blaOXA-48-like (n = 4), blaKPC-2 (n = 3), blaIMP (n = 2), and blaNDM-1 (n = 1), distributed among divergent species of Enterobacteriaceae. After a cumulative follow-up time of 9.0 years, three family members (21.4%, 3/14) acquired four different types of CPE in the community (hazard rate of 0.22/year). The probability of CPE transmission from an index patient to a household contact was 10% (95% CI 4%-26%).

Conclusions: We observed limited transmission of CPE from an index patient to household contacts. Larger studies are needed to understand the factors associated with household transmission of CPE and identify preventive strategies.
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http://dx.doi.org/10.1093/jac/dkaa561DOI Listing
April 2021

Factors Associated With Postpartum Diabetes Screening in Women With Gestational Diabetes and Medicaid During Pregnancy.

Am J Prev Med 2021 02 11;60(2):222-231. Epub 2020 Dec 11.

Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.

Introduction: Women with gestational diabetes are 7 times more likely to develop type 2 diabetes and require lifelong diabetes screening. Loss of health coverage after pregnancy, as occurs in states that did not expand Medicaid, limits access to guideline-driven follow-up care and fosters health inequity. This study aims to understand the factors associated with the receipt of postpartum diabetes screening for women with gestational diabetes in a state without Medicaid expansion.

Methods: Electronic health record and Medicaid claims data were linked to generate a retrospective cohort of 1,078 women with gestational diabetes receiving care in Federally Qualified Health Centers in Missouri from 2010 to 2015. In 2019-2020, data were analyzed to determine the factors associated with the receipt of recommended postpartum diabetes screening (fasting plasma glucose, 2-hour oral glucose tolerance test, or HbA1c in specified timeframes) using a Cox proportional hazards model through 18 months of follow-up.

Results: Median age in this predominantly urban population was 28 (IQR=24-33) years. Self-reported racial or ethnic minorities comprised more than half of the population. Only 9.7% of women were screened at 12 weeks, and 20.8% were screened at 18 months. Prenatal certified diabetes education (adjusted hazard ratio=1.74, 95% CI=1.22, 2.49) and access to public transportation (adjusted hazard ratio=1.70, 95% CI=1.13, 2.54) were associated with increased screening in a model adjusted for race/ethnicity, the total number of prenatal visits, the use of diabetes medication during pregnancy, and a pregnancy-specific comorbidity index that incorporated age.

Conclusions: This study underscores the importance of access to public transportation, prenatal diabetes education, and continued healthcare coverage for women on Medicaid to support the receipt of guideline-recommended follow-up care and improve health equity.
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http://dx.doi.org/10.1016/j.amepre.2020.08.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851940PMC
February 2021

Impact of low blood culture usage on rates of antimicrobial resistance.

J Infect 2021 03 2;82(3):355-362. Epub 2020 Dec 2.

Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom; Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand. Electronic address:

Objectives: The magnitude of impact caused by low blood culture utilization on estimates of the proportions and incidence rates of antimicrobial-resistant (AMR) bacterial infections is largely unknown.

Methods: We used routine electronic databases of microbiology, hospital admission and drug prescription at Sunpasitthiprasong Hospital, Ubon Ratchathani, Thailand, from 2011 to 2015, and bootstrap simulations.

Results: The proportions of Escherichia coli and Klebsiella pneumoniae bacteraemias caused by 3rd generation cephalosporin resistant isolates (3GCREC and 3GCRKP) were estimated to increase by 13 and 24 percentage points (from 44% to 57% and from 51% to 75%), respectively, if blood culture utilization rate was reduced from 82 to 26 blood culture specimens per 1,000 patient-days. Among patients with hospital-origin bloodstream infections, the proportion of 3GCREC and 3GCRKP whose first positive blood culture was taken within ±1 calendar day of the start of a parenteral antibiotic at the study hospital was substantially lower than those whose first positive blood culture was taken later into parenteral antibiotic treatment (30% versus 79%, p<0.001; and 37% versus 86%, p<0.001). Similar effects were observed for methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter spp. and carbapenem-resistant Pseudomonas aeruginosa.

Conclusion: Impacts of low blood culture utilization rate on the estimated proportions and incidence rates of AMR infections could be high. We recommend that AMR surveillance reports should additionally include blood culture utilization rate and stratification by exposure to a parenteral antibiotic at the hospital.
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http://dx.doi.org/10.1016/j.jinf.2020.10.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994019PMC
March 2021

Automating the Generation of Antimicrobial Resistance Surveillance Reports: Proof-of-Concept Study Involving Seven Hospitals in Seven Countries.

J Med Internet Res 2020 10 2;22(10):e19762. Epub 2020 Oct 2.

Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Background: Reporting cumulative antimicrobial susceptibility testing data on a regular basis is crucial to inform antimicrobial resistance (AMR) action plans at local, national, and global levels. However, analyzing data and generating a report are time consuming and often require trained personnel.

Objective: This study aimed to develop and test an application that can support a local hospital to analyze routinely collected electronic data independently and generate AMR surveillance reports rapidly.

Methods: An offline application to generate standardized AMR surveillance reports from routinely available microbiology and hospital data files was written in the R programming language (R Project for Statistical Computing). The application can be run by double clicking on the application file without any further user input. The data analysis procedure and report content were developed based on the recommendations of the World Health Organization Global Antimicrobial Resistance Surveillance System (WHO GLASS). The application was tested on Microsoft Windows 10 and 7 using open access example data sets. We then independently tested the application in seven hospitals in Cambodia, Lao People's Democratic Republic, Myanmar, Nepal, Thailand, the United Kingdom, and Vietnam.

Results: We developed the AutoMated tool for Antimicrobial resistance Surveillance System (AMASS), which can support clinical microbiology laboratories to analyze their microbiology and hospital data files (in CSV or Excel format) onsite and promptly generate AMR surveillance reports (in PDF and CSV formats). The data files could be those exported from WHONET or other laboratory information systems. The automatically generated reports contain only summary data without patient identifiers. The AMASS application is downloadable from https://www.amass.website/. The participating hospitals tested the application and deposited their AMR surveillance reports in an open access data repository.

Conclusions: The AMASS is a useful tool to support the generation and sharing of AMR surveillance reports.
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http://dx.doi.org/10.2196/19762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568216PMC
October 2020

Duration of Carbapenemase-Producing Enterobacteriaceae Carriage in Hospital Patients.

Emerg Infect Dis 2020 09;26(9):2182-2185

To determine the duration of carbapenemase-producing Enterobacteriaceae (CPE) carriage, we studied 21 CPE carriers for »1 year. Mean carriage duration was 86 days; probability of decolonization in 1 year was 98.5%, suggesting that CPE-carriers' status can be reviewed yearly. Prolonged carriage was associated with use of antimicrobial drugs.
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http://dx.doi.org/10.3201/eid2609.190592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454053PMC
September 2020

Non-adherence in non-inferiority trials: pitfalls and recommendations.

BMJ 2020 07 1;370:m2215. Epub 2020 Jul 1.

Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

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http://dx.doi.org/10.1136/bmj.m2215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7327542PMC
July 2020

Statistical considerations in the design and analysis of non-inferiority trials with binary endpoints in the presence of non-adherence: a simulation study.

Wellcome Open Res 2019 24;4:207. Epub 2020 Apr 24.

Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.

Protocol non-adherence is common and poses unique challenges in the interpretation of trial outcomes, especially in non-inferiority trials. We performed simulations of a non-inferiority trial with a time-fixed treatment and a binary endpoint in order to: i) explore the impact of various patterns of non-adherence and analysis methods on treatment effect estimates; ii) quantify the probability of claiming non-inferiority when the experimental treatment effect is actually inferior; and iii) evaluate alternative methods such as inverse probability weighting and instrumental variable estimation. We found that the probability of concluding non-inferiority when the experimental treatment is actually inferior depends on whether non-adherence is due to confounding or non-confounding factors, and the actual treatments received by the non-adherent participants. With non-adherence, intention-to-treat analysis has a higher tendency to conclude non-inferiority when the experimental treatment is actually inferior under most patterns of non-adherence. This probability of concluding non-inferiority can be increased to as high as 0.1 from 0.025 when the adherence is relatively high at 90%. The direction of bias for the per-protocol analysis depends on the directions of influence the confounders have on adherence and probability of outcome. The inverse probability weighting approach can reduce bias but will only eliminate it if all confounders can be measured without error and are appropriately adjusted for. Instrumental variable estimation overcomes this limitation and gives unbiased estimates even when confounders are not known, but typically requires large sample sizes to achieve acceptable power. Investigators need to consider patterns of non-adherence and potential confounders in trial designs. Adjusted analysis of the per-protocol population with sensitivity analyses on confounders and other approaches, such as instrumental variable estimation, should be considered when non-compliance is anticipated. We provide an online power calculator allowing for various patterns of non-adherence using the above methods.
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http://dx.doi.org/10.12688/wellcomeopenres.15636.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205408PMC
April 2020

Quantifying antibiotic impact on within-patient dynamics of extended-spectrum beta-lactamase resistance.

Elife 2020 05 7;9. Epub 2020 May 7.

University of Oxford, Oxford, United Kingdom.

Antibiotic-induced perturbation of the human gut flora is expected to play an important role in mediating the relationship between antibiotic use and the population prevalence of antibiotic resistance in bacteria, but little is known about how antibiotics affect within-host resistance dynamics. Here we develop a data-driven model of the within-host dynamics of extended-spectrum beta-lactamase (ESBL) producing . We use bla (the most widespread ESBL gene family) and 16S rRNA (a proxy for bacterial load) abundance data from 833 rectal swabs from 133 ESBL-positive patients followed up in a prospective cohort study in three European hospitals. We find that cefuroxime and ceftriaxone are associated with increased bla abundance during treatment (21% and 10% daily increase, respectively), while treatment with meropenem, piperacillin-tazobactam, and oral ciprofloxacin is associated with decreased bla (8% daily decrease for all). The model predicts that typical antibiotic exposures can have substantial long-term effects on bla carriage duration.
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http://dx.doi.org/10.7554/eLife.49206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205461PMC
May 2020

Contact isolation versus standard precautions to decrease acquisition of extended-spectrum β-lactamase-producing Enterobacterales in non-critical care wards: a cluster-randomised crossover trial.

Lancet Infect Dis 2020 05 19;20(5):575-584. Epub 2020 Feb 19.

Institute of Hygiene and Environmental Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.

Background: The effectiveness of contact isolation for decreasing the spread of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) has been questioned. The aim of this study was to establish the benefits of contact isolation over standard precautions for reducing the incidence density of ESBL-E colonisation and infection in adult medical and surgical wards with an active surveillance culture programme.

Methods: We did a cluster-randomised crossover trial in adult wards in four European university hospitals. Medical, surgical, or combined medical-surgical wards without critical care were randomised to continue standard precautions alone or implement contact isolation alongside standard precautions for 12 months, followed by a 1 month washout period and 12 months of the alternate strategy. Randomisation was done via a computer-generated sequence, with a block size of two consecutive wards. Only laboratory technicians and data analysts were masked to allocation. Patients were screened for ESBL-E carriage within 3 days of admission, once a week thereafter, and on discharge. The primary outcome was the incidence density of ESBL-E, defined as the acquisition rate per 1000 patient-days at risk at the ward level and assessed in the per-protocol population, which included all patients screened at least twice with a length of stay of more than 1 week for each intervention period. No specific safety measures were assessed given the minimal risk of adverse events. The trial is registered, ISRCTN57648070.

Findings: We enrolled 20 wards from four hospitals in Germany (eight wards), the Netherlands (four wards), Spain (four wards), and Switzerland (four wards). Between Jan 6, 2014, and Aug 31, 2016, 38 357 patients were admitted to these wards. Among 15 184 patients with a length of stay of more than 1 week, 11 368 patients (75%) were screened at least twice. The incidence density of ward-acquired ESBL-E was 6·0 events per 1000 patient-days at risk (95% CI 5·4-6·7) during periods of contact isolation and 6·1 (5·5-6·7) during periods of standard precautions (p=0·9710). Multivariable analysis adjusted for length of stay, percentage of patients screened, and prevalence in first screening cultures yielded an incidence rate ratio of 0·99 (95% CI 0·80-1·22; p=0·9177) for care under contact isolation compared with standard precautions.

Interpretation: Contact isolation showed no benefit when added to standard precautions for controlling the spread of ESBL-E on non-critical care wards with extensive surveillance screening.

Funding: European Commission.
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http://dx.doi.org/10.1016/S1473-3099(19)30626-7DOI Listing
May 2020

Transmission dynamics and control of multidrug-resistant in neonates in a developing country.

Elife 2019 12 3;8. Epub 2019 Dec 3.

Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

Multidrug-resistant is an increasing cause of infant mortality in developing countries. We aimed to develop a quantitative understanding of the drivers of this epidemic by estimating the effects of antibiotics on nosocomial transmission risk, comparing competing hypotheses about mechanisms of spread, and quantifying the impact of potential interventions. Using a sequence of dynamic models, we analysed data from a one-year prospective carriage study in a Cambodian neonatal intensive care unit with hyperendemic third-generation cephalosporin-resistant . All widely-used antibiotics except imipenem were associated with an increased daily acquisition risk, with an odds ratio for the most common combination (ampicillin + gentamicin) of 1.96 (95% CrI 1.18, 3.36). Models incorporating genomic data found that colonisation pressure was associated with a higher transmission risk, indicated sequence type heterogeneity in transmissibility, and showed that within-ward transmission was insufficient to maintain endemicity. Simulations indicated that increasing the nurse-patient ratio could be an effective intervention.
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http://dx.doi.org/10.7554/eLife.50468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6977969PMC
December 2019

UK Patients of Bangladeshi Descent with Crohn's Disease Respond Less Well to TNF Antagonists Than Caucasian Patients.

Dig Dis Sci 2020 06 26;65(6):1790-1799. Epub 2019 Oct 26.

Department of Gastroenterology, Royal London Hospital, Barts Health NHS Trust, London, E1 1FR, UK.

Background: Patients with inflammatory bowel disease are currently managed with the assumption that trial data are applicable to all ethnic groups. Previous studies demonstrate differences in disease severity and phenotype of Asian patients with Crohn's disease (CD), including Bangladeshi Asians within the UK. No study has evaluated the impact of ethnicity on response to anti-TNFs.

Aim: Our primary endpoint was a comparison of failure-free survival on first prescribed anti-TNF (anti-tumor necrosis factor) therapy in UK Bangladeshi and Caucasian patients with CD. Our secondary aims were to evaluate disease phenotype, indication for anti-TNF prescription, and duration from diagnosis until first anti-TNF prescribed between groups.

Methods: The records of consecutive outpatient appointments over a 12-month period were used to identify Caucasian and Bangladeshi patients prescribed an anti-TNF for CD. Information on patient demographics, ethnicity, disease phenotype, immunomodulator use, outcome from first biologic, duration of therapy, and reason for cessation was recorded.

Results: In total, 224 Caucasian and Bangladeshi patients were prescribed an anti-TNF for CD. Bangladeshi patients started an anti-TNF 4.3 years earlier after diagnosis than Caucasian patients (3.9 years vs. 8.2 years: p < 0.01). Bangladeshi patients experienced shorter failure-free survival than Caucasian patients (1.8 vs. 4.8 years p < 0.01). By 2 years, significantly more Bangladeshi patients had stopped anti-TNF due to loss of response (OR 6.35, p < 0.01).

Conclusions: This is the first study to suggest that Bangladeshi patients resident in the UK with CD respond less well to treatment with TNF antagonists than Caucasian patients.
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http://dx.doi.org/10.1007/s10620-019-05907-wDOI Listing
June 2020

Optimising trial designs to identify appropriate antibiotic treatment durations.

BMC Med 2019 06 21;17(1):115. Epub 2019 Jun 21.

Modelling and Economics Unit, National Infection Service, Public Health England, London, UK.

Background: For many infectious conditions, the optimal antibiotic course length remains unclear. The estimation of course length must consider the important trade-off between maximising short- and long-term efficacy and minimising antibiotic resistance and toxicity.

Main Body: Evidence on optimal treatment durations should come from randomised controlled trials. However, most antibiotic randomised controlled trials compare two arbitrarily chosen durations. We argue that alternative trial designs, which allow allocation of patients to multiple different treatment durations, are needed to better identify optimal antibiotic durations. There are important considerations when deciding which design is most useful in identifying optimal treatment durations, including the ability to model the duration-response relationship (or duration-response 'curve'), the risk of allocation concealment bias, statistical efficiency, the possibility to rapidly drop arms that are clearly inferior, and the possibility of modelling the trade-off between multiple competing outcomes.

Conclusion: Multi-arm designs modelling duration-response curves with the possibility to drop inferior arms during the trial could provide more information about the optimal duration of antibiotic therapies than traditional head-to-head comparisons of limited numbers of durations, while minimising the probability of assigning trial participants to an ineffective treatment regimen.
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http://dx.doi.org/10.1186/s12916-019-1348-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587258PMC
June 2019

The influence of race and sex on gonorrhea and chlamydia treatment in the emergency department.

Am J Emerg Med 2020 03 30;38(3):566-570. Epub 2019 May 30.

Department of Medicine, Washington University in Saint Louis, Saint Louis, MO, USA. Electronic address:

Background: Emergency Departments (EDs) are a care source for patients with sexually transmitted diseases (STDs). St. Louis, MO reports among the highest rates of gonorrhea and chlamydia infection. We examined STD treatment in a high-volume urban ED, in St. Louis MO, to identify factors that may influence treatment.

Methods: A retrospective chart review and analysis was conducted on visits to a high volume, academic ED in St. Louis, MO where patients received a gonorrhea/chlamydia nucleic acid amplification test (NAAT) with a valid matching test result over two years. Using multiple logistic regression, we examined available predictors for under and overtreatment.

Results: NAATs were performed on 3.3% of all ED patients during the study period. Overall prevalence was 6.9% for gonorrhea (95% CI: 6.2, 7.7) and 11.6% for chlamydia (95% CI: 10.6, 12.5). Race was not a statistically significant predictor for undertreatment but Black patients were significantly more likely to be overtreated compared to White patients. (OR 1.83, 95% CI: 1.5, 2.2). Females were more likely to be undertreated when positive for infection compared to males (OR 7.34, 95% CI: 4.8, 11.2) and less likely to be overtreated when negative for infection (OR 0.27, 95% CI: 0.2, 0.3).

Conclusion: The burden of STDs in a high-volume academic ED was significant and treatment varied across groups. Attention should be paid to particular groups, specifically women and patients reporting Black as their race, to ensure appropriate treatment is administered. Patients would benefit from targeted STD management protocols and training in the ED.
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http://dx.doi.org/10.1016/j.ajem.2019.05.054DOI Listing
March 2020

Impact of 13-Valent Pneumococcal Conjugate Vaccine on Colonization and Invasive Disease in Cambodian Children.

Clin Infect Dis 2020 04;70(8):1580-1588

Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom.

Background: Cambodia introduced the 13-valent pneumococcal conjugate vaccine (PCV13) in January 2015 using a 3 + 0 dosing schedule and no catch-up campaign. We investigated the effects of this introduction on pneumococcal colonization and invasive disease in children aged <5 years.

Methods: There were 6 colonization surveys done between January 2014 and January 2018 in children attending the outpatient department of a nongovernmental pediatric hospital in Siem Reap. Nasopharyngeal swabs were analyzed by phenotypic and genotypic methods to detect pneumococcal serotypes and antimicrobial resistance. Invasive pneumococcal disease (IPD) data for January 2012-December 2018 were retrieved from hospital databases. Pre-PCV IPD data and pre-/post-PCV colonization data were modelled to estimate vaccine effectiveness (VE).

Results: Comparing 2014 with 2016-2018, and using adjusted prevalence ratios, VE estimates for colonization were 16.6% (95% confidence interval [CI] 10.6-21.8) for all pneumococci and 39.2% (95% CI 26.7-46.1) for vaccine serotype (VT) pneumococci. There was a 26.0% (95% CI 17.7-33.0) decrease in multidrug-resistant pneumococcal colonization. The IPD incidence was estimated to have declined by 26.4% (95% CI 14.4-35.8) by 2018, with a decrease of 36.3% (95% CI 23.8-46.9) for VT IPD and an increase of 101.4% (95% CI 62.0-145.4) for non-VT IPD.

Conclusions: Following PCV13 introduction into the Cambodian immunization schedule, there have been declines in VT pneumococcal colonization and disease in children aged <5 years. Modelling of dominant serotype colonization data produced plausible VE estimates.
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http://dx.doi.org/10.1093/cid/ciz481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145996PMC
April 2020

Mountain Rescue Casualty Care and the Undergraduate Medical Elective.

Wilderness Environ Med 2019 Jun 7;30(2):210-216. Epub 2019 Mar 7.

Academic Unit of Medical Education and Department of Oncology and Metabolism, The Medical School, Sheffield, UK. Electronic address:

Many UK medical curricula lack dedicated prehospital education other than first aid courses and basic life support training. In contrast, nonmedical mountain rescue team members receive advanced prehospital training addressing scene management and various clinical interventions. This article reports a condensed mountain rescue casualty care course designed for medical students by a mountain rescue team. The course was offered as part of a student-selected module during phase 3A at the University of Sheffield Medical School. Within the module, students also learned the relevant biomedical sciences and clinical skills to construct their knowledge of mountain rescue casualty care.
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http://dx.doi.org/10.1016/j.wem.2018.12.010DOI Listing
June 2019

Microbiology Investigation Criteria for Reporting Objectively (MICRO): a framework for the reporting and interpretation of clinical microbiology data.

BMC Med 2019 03 29;17(1):70. Epub 2019 Mar 29.

Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.

Background: There is a pressing need to understand better the extent and distribution of antimicrobial resistance on a global scale, to inform development of effective interventions. Collation of datasets for meta-analysis, mathematical modelling and temporo-spatial analysis is hampered by the considerable variability in clinical sampling, variable quality in laboratory practice and inconsistencies in antimicrobial susceptibility testing and reporting.

Methods: The Microbiology Investigation Criteria for Reporting Objectively (MICRO) checklist was developed by an international working group of clinical and laboratory microbiologists, infectious disease physicians, epidemiologists and mathematical modellers.

Results: In keeping with the STROBE checklist, but applicable to all study designs, MICRO defines items to be included in reports of studies involving human clinical microbiology data. It provides a concise and comprehensive reference for clinicians, researchers, reviewers and journals working on, critically appraising, and publishing clinical microbiology datasets.

Conclusions: Implementation of the MICRO checklist will enhance the quality and scientific reporting of clinical microbiology data, increasing data utility and comparability to improve surveillance, grade data quality, facilitate meta-analyses and inform policy and interventions from local to global levels.
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http://dx.doi.org/10.1186/s12916-019-1301-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440102PMC
March 2019

Endothelin neurotransmitter signalling controls zebrafish social behaviour.

Sci Rep 2019 02 28;9(1):3040. Epub 2019 Feb 28.

Department of Neuroscience, Psychology and Behaviour, College of Life Sciences, University of Leicester, Leicester, LE1 7RH, UK.

The formation of social groups is an adaptive behaviour that can provide protection from predators, improve foraging and facilitate social learning. However, the costs of proximity can include competition for resources, aggression and kleptoparasitism meaning that the decision whether to interact represents a trade-off. Here we show that zebrafish harbouring a mutation in endothelin receptor aa (ednraa) form less cohesive shoals than wild-types. ednraa mutants exhibit heightened aggression and decreased whole-body cortisol levels suggesting that they are dominant. These behavioural changes correlate with a reduction of parvocellular arginine vasopressin (AVP)-positive neurons in the preoptic area, an increase in the size of magnocellular AVP neurons and a higher concentration of 5-HT and dopamine in the brain. Manipulation of AVP or 5-HT signalling can rescue the shoaling phenotype of ednraa providing an insight into how the brain controls social interactions.
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http://dx.doi.org/10.1038/s41598-019-39907-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395658PMC
February 2019

Antibiotic resistance, stewardship, and consumption.

Lancet Planet Health 2019 02;3(2):e66

Modelling and Economics Unit, National Infection Service, Public Health England, London NW9 5EQ, UK; National Institute for Health Research, Health Protection Research Unit in Healthcare Associated Infection and Antimicrobial Resistance, Imperial College London, London, UK.

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http://dx.doi.org/10.1016/S2542-5196(18)30283-3DOI Listing
February 2019

Using machine learning to guide targeted and locally-tailored empiric antibiotic prescribing in a children's hospital in Cambodia.

Wellcome Open Res 2018 10;3:131. Epub 2018 Oct 10.

Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.

: Early and appropriate empiric antibiotic treatment of patients suspected of having sepsis is associated with reduced mortality. The increasing prevalence of antimicrobial resistance reduces the efficacy of empiric therapy guidelines derived from population data. This problem is particularly severe for children in developing country settings. We hypothesized that by applying machine learning approaches to readily collect patient data, it would be possible to obtain individualized predictions for targeted empiric antibiotic choices. : We analysed blood culture data collected from a 100-bed children's hospital in North-West Cambodia between February 2013 and January 2016. Clinical, demographic and living condition information was captured with 35 independent variables. Using these variables, we used a suite of machine learning algorithms to predict Gram stains and whether bacterial pathogens could be treated with common empiric antibiotic regimens: i) ampicillin and gentamicin; ii) ceftriaxone; iii) none of the above. 243 patients with bloodstream infections were available for analysis. We found that the random forest method had the best predictive performance overall as assessed by the area under the receiver operating characteristic curve (AUC). The random forest method gave an AUC of 0.80 (95%CI 0.66-0.94) for predicting susceptibility to ceftriaxone, 0.74 (0.59-0.89) for susceptibility to ampicillin and gentamicin, 0.85 (0.70-1.00) for susceptibility to neither, and 0.71 (0.57-0.86) for Gram stain result. Most important variables for predicting susceptibility were time from admission to blood culture, patient age, hospital versus community-acquired infection, and age-adjusted weight score. : Applying machine learning algorithms to patient data that are readily available even in resource-limited hospital settings can provide highly informative predictions on antibiotic susceptibilities to guide appropriate empiric antibiotic therapy. When used as a decision support tool, such approaches have the potential to improve targeting of empiric therapy, patient outcomes and reduce the burden of antimicrobial resistance.
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http://dx.doi.org/10.12688/wellcomeopenres.14847.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352926PMC
October 2018

Postpartum diabetes screening among low income women with gestational diabetes in Missouri 2010-2015.

BMC Public Health 2019 Feb 4;19(1):148. Epub 2019 Feb 4.

Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8100, St. Louis, MO, 63110, USA.

Background: Gestational diabetes increases risk for type 2 diabetes seven-fold, creating a large public health burden in a young population. In the US, there are no large registries for tracking postpartum diabetes screening among women in under-resourced communities who face challenges with access to care after pregnancy. Existing data from Medicaid claims is limited as women often lose this coverage within months of delivery. In this study, we aim to leverage data from electronic health records and administrative claims to better assess postpartum diabetes screening rates among low income women.

Methods: A retrospective population of 1078 women with gestational diabetes who delivered between 1/1/2010 and 10/8/2015 was generated by linking electronic health record data from 21 Missouri Federally Qualified Health Centers (FQHCs) with Medicaid administrative claims. Screening rates for diabetes were calculated within 12 weeks and 1 year of delivery. Initial screening after the first postpartum year was also documented.

Results: Median age in the final population was 28 (IQR 24-33) years with over-representation of black non-Hispanic and urban women. In the final population, 9.7% of women had a recommended diabetes screening test within 12 weeks and 18.9% were screened within 1 year of delivery. An additional 125 women received recommended screening for the first time beyond 1 year postpartum. The percentage of women who had a postpartum visit (83.9%) and any glucose testing (40.6%) in the first year far exceeded the proportion of women with recommended screening tests.

Conclusions: Linking electronic health record and administrative claims data provides a more complete picture of healthcare follow-up among low income women after gestational diabetes. While screening rates are higher than reported with claims data alone, there are opportunities to improve adherence to screening guidelines in this population.
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http://dx.doi.org/10.1186/s12889-019-6475-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360751PMC
February 2019
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