Determinants of carriage of resistant Staphylococcus aureus among S. aureus carriers in the Indonesian population inside and outside hospitals

Objectives To identify determinants of carriage of resistant Staphylococcus aureus in both hospitalized patients and individuals from the community in two urban centres in Indonesia. Methods Staphylococcus aureus cultures and data on recent antibiotic use, demographic, socioeconomic, disease‐related and healthcare‐related variables were collected from 3995 community dwellers and hospitalized persons. Nasal S. aureus carriage was found in 362 persons (9.1%). Logistic regression analysis was performed to identify which variables were independently associated with carriage of resistant S. aureus. Results The penicillins were the most frequently used antibiotics both in the community and in hospitalized patients. In the community, admission to a hospital was associated with carriage of S. aureus resistant to any of the tested antibiotics [odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.3–4.9] and any tetracycline resistance (OR 2.4, 95% CI 1.1–5.1). Having no symptoms was associated with less carriage of S. aureus with resistance to any of the tested antibiotics (OR 0.5, 95% CI 0.3–0.9) and any tetracycline resistance (OR 0.5, 95% CI 0.3–0.9). Crowding (OR 4.5, 95% CI 1.2–4.9) and low income (OR 8.9, 95% CI 1.8–43.9) were associated with multidrug resistance. In hospitalized patients, the use of penicillins was associated with resistance to any of the tested antibiotics (OR 3.9, 95% CI 1.4–11.6) and any tetracycline resistance (OR 3.7, 95% CI 1.1–12.0). Conclusions Antibiotic policies including proper diagnosis, treatment and drug delivery process should be made by healthcare providers in Indonesia to help limit the emergence of antibiotic resistance.     

Mycobacterium tuberculosis in a HIV-1-infected population from Southeastern Brazil in the HAART era

Objective To evaluate retrospectively the microbiological profile of Mycobacterium species isolated from HIV‐infected patients attending the HIV/TB reference health care units in São José do Rio Preto, Brazil. Method Retrospective evaluation of all HIV‐1 positive patients whose IAL‐SJRP laboratorial analysis was positive for Mycobacterium sp. after diagnosis of HIV Infection, from January 2000 to December 2006. Results Of 198 patients, acid‐fast staining detected mycobacteria early in 41%. Culture revealed 52.5% to be infected with Mycobacterium tuberculosis (MT). 42.4% had non‐tuberculous mycobacteria (NTM) and 5.1% had MT/NTM positive cultures. Eleven per cent of MT strains were resistant to at least one of the antimycobacterial drugs and 3.1% were multidrug resistant. 39.4% of isolated mycobacteria were NTM species. Conclusion Our data may serve as a starting point for further comparisons with other Brazilian regions and other developing countries. The data may provide important clues to the future understanding, prevention and control of such co‐infections around the world.     

Performance of the new WHO diagnostic algorithm for smear‐negative pulmonary tuberculosis in HIV prevalent settings: a multisite study in Uganda

Objective To compare the performance of the new WHO (2007) diagnostic algorithm for pulmonary tuberculosis (PTB) in high HIV prevalent settings (WHO07) to the WHO 2003 guidelines used by the Ugandan National Tuberculosis Program (UgWHO03). Methods A prospective observational cohort design was used at Reach Out Mbuya Parish HIV/AIDS Initiative, an urban slum community‐based AIDS Service Organisation (ASO) and Kayunga Rural District Government Hospital. Newly diagnosed and enrolled HIV‐infected patients were assessed for PTB. Research staff interviewed patients and staff and observed operational constraints. Results WHO07 reduced the time to diagnosis of smear‐negative PTB with increased sensitivity compared with the UgWHO03 at both sites. Time to diagnosis of smear‐negative PTB was significantly shorter at the urban ASO than at the rural ASO (12.4 vs. 28.5 days, P = 0.003). Diagnostic specificity and sensitivity [95% confidence intervals (CIs)] for smear‐negative PTB were higher at the rural hospital compared with the urban ASO: [98% (93–100%) vs. 86% (77–92%), P = 0.001] and [95% (72–100%) vs. 90% (54–99%), P > 0.05], respectively. Common barriers to implementation of algorithms included failure by patients to attend follow‐up appointments and poor adherence by healthcare workers to algorithms. Conclusion At both sites, WHO07 expedited diagnosis of smear‐negative PTB with increased diagnostic accuracy compared with the UgWHO03. The WHO07 expedited diagnosis more at the urban ASO but with more diagnostic accuracy at the rural hospital. Barriers to implementation should be taken into account when operationalising these guidelines for TB diagnosis in resource‐limited settings.     

dhfr and dhps genotype and sulfadoxine‐pyrimethamine treatment failure in children with falciparum malaria in the Democratic Republic of Congo

Objective To determine the relationship between mutations in dhfr and dhps and SP treatment failure in Plasmodium falciparum malaria in the Democratic Republic of the Congo (DRC). Methods Therapeutic efficacy trial was conducted in Rutshuru, Eastern DRC, between June and September 2002, comparing sulfadoxine‐pyrimethamine (SP), SP plus amodiaquine (AQSP) and artesunate plus SP (ASSP) regimens for treating malaria in children under 5 years old. We genotyped 212 samples for mutations associated with SP resistance and investigated their association with treatment failure. Results In the SP arm, 61% of the subjects experienced treatment failure after 14 days. The failure rate was lower in the combination arms (AQSP: 32%, ASSP: 21%). The dhfr‐108 and dhfr‐51 mutations were nearly universal while 89% of the samples had at least one additional mutation at dhfr‐59, dhps‐437 or dhps‐540. Dhps mutations had a bigger impact on treatment failure in children with high parasite density: for children with a parasite density <45 000 parasites/μl, the risk of treatment failure was 37% for mutations at dhps‐437 and dhps‐540 mutation and 21% for neither mutation [risk difference (RD) = 17%, 95% CI: ?3%, 36%]. In children with a parasite density >45 000 parasites/μl, the treatment failure risk was 58% and 8% for children with both mutations or neither mutation, respectively (RD = 51%, 95% CI: 34%, 67%). Conclusions Dhps‐437 and dhps‐540 are strongly associated with SP treatment failure and should be evaluated further as a method for surveillance of SP‐based therapy in DRC.     

Defining the research agenda to reduce the joint burden of disease from Diabetes mellitus and Tuberculosis

The steadily growing epidemic of diabetes mellitus poses a threat for global tuberculosis (TB) control. Previous studies have identified an important association between diabetes mellitus and TB. However, these studies have limitations: very few were carried out in low‐income countries, with none in Africa, raising uncertainty about the strength of the diabetes mellitus–TB association in these settings, and many critical questions remain unanswered. An expert meeting was held in November 2009 to discuss where there was sufficient evidence to make firm recommendations about joint management of both diseases, to address research gaps and to develop a research agenda. Ten key research questions were identified, of which 4 were selected as high priority: (i) whether, when and how to screen for TB in patients with diabetes mellitus and vice versa; (ii) the impact of diabetes mellitus and non‐diabetes mellitus hyperglycaemia on TB treatment outcomes and deaths, and the development of strategies to improve outcomes; (iii) implementation and evaluation of the tuberculosis ‘DOTS’ model for diabetes mellitus management; and (iv) the development and evaluation of better point‐of‐care diagnostic and monitoring tests, including measurements of blood glucose and glycated haemoglobin A_1c (HbA_1c) for patients with diabetes mellitus. Implementation of this research agenda will benefit the control of both diseases.