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Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL), a family of bacteria that includes Escherichia coli, have emerged as a global health threat. This study examined risks associated with carriage of third-generation cephalosporin-resistant (3GC-R) E. coli, including ESBL-producing, multidrug-resistant, and extensively drug-resistant (XDR) strains in children living in semirural parishes of Quito, Ecuador. We conducted a longitudinal study with two cycles of sampling (N = 374, N = 366) that included an analysis of child fecal samples and survey questions relating to water, sanitation, and hygiene, socioeconomic status, household crowding, and animal ownership. We used multivariate regression models to assess risk factors associated with a child being colonized. Across the two cycles, 18.4% (n = 516) of the 3GC-R isolates were ESBL-producing E. coli, and 40.3% (n = 516) were XDR E. coli. Children living in households that owned between 11 and 20 backyard animals had an increased odds of being colonized with XDR E. coli (odds ratio [OR] = 1.94, 95% confidence interval [CI]: 1.05–3.60) compared with those with no animals. Households that reported smelling odors from commercial poultry had increased odds of having a child positive for XDR E. coli (OR = 1.72, 95% CI: 1.11–2.66). Our results suggest that colonization of children with antimicrobial-resistant E. coli is influenced by exposure to backyard and commercial livestock and poultry. Future studies should consider community-level risk factors because child exposures to drug-resistant bacteria are likely influenced by neighborhood and regional risk factors.

BackgroundThe spread of antibiotic-resistant bacteria may be driven by human-animal-environment interactions, especially in regions with limited restrictions on antibiotic use, widespread food animal production, and free-roaming domestic animals. In this study, we aimed to identify risk factors related to domestic animals, backyard food animals, and commercial food animal production in Ecuadorian communities.Methods & FindingsWe conducted a repeated-measures study from 2018-2021 in 7 semi-rural parishes of Quito, Ecuador to identify determinants of third-generation cephalosporin-resistantE. coli(3GCR-EC) and extended-spectrum beta-lactamaseE. coli(ESBL-EC) in children and domestic animals. We used multivariable log-binomial regression models to estimate relative risks (RR) of 3GCR-EC and ESBL-EC carriage. We collected 1,699 child fecal samples from 600 households and 1,871 animal fecal samples from 376 of the same households. Risk factors for 3GCR-EC included living within 5 km of more than 5 commercial food animal operations (RR: 1.36; 95% Confidence Interval: 1.16, 1.59), household pig ownership (1.23; 1.02, 1.48), child pet contact (1.23; 1.09, 1.39), and rarely/never washing hands after contact with animals (1.15; 0.98, 1.34). Risk factors for ESBL-EC were dog ownership (1.43; 1.00, 2.04), child pet contact (1.54; 1.10, 2.16), placing animal feces on household land/crops (1.63; 1.09, 2.46), and combined exposures to both household food animals and commercial food animal operation drainage paths (1.80; 0.94, 3.45).ConclusionsPolicies and interventions that improve the safety of animal waste management in communities and in commercial food animal production operations may be necessary to curb the spread of resistant bacteria.

The presence of intestinal pathogenic Escherichia coli in drinking water is well recognized as a risk for diarrhea. The role of drinking water in extraintestinal infections caused by E. coli—such as urinary tract infections (UTIs)—remains poorly understood. Urinary tract infections are a leading cause of outpatient infections globally, with a lifetime incidence of 50–60% in adult women. We reviewed the scientific literature on the occurrence of uropathogenic E. coli (UPEC) in water supplies to determine whether the waterborne route may be an important, overlooked, source of UPEC. A limited number of studies have assessed whether UPEC isolates are present in drinking water supplies, but no studies have measured whether their presence in water may increase UPEC colonization or the risk of UTIs in humans. Given the prevalence of drinking water supplies contaminated with E. coli across the globe, efforts should be made to characterize UTI-related risks associated with drinking water, as well as other pathways of exposure.

We investigated the prevalence and clinical outcomes of COVID-19 in recipients of kidney transplants in the Bronx, New York, one of the epicenters of the pandemic. Between March 16 and June 2, 2020, 132 kidney transplant recipients tested positive by SARS-CoV-2 RT-PCR. From May 3 to July 29, 2020, 912 kidney transplant recipients were screened for SARS-CoV-2 IgG antibodies during routine clinic visits, of which 16.6% tested positive. Fifty-five of the 152 patients had previously tested positive by RT-PCR, while the remaining 97 did not have significant symptoms and had not been previously tested by RT-PCR. The prevalence of SARS-CoV-2 infection was 23.4% in the 975 patients tested by either RT-PCR or SARS-CoV-2 IgG. Older patients and patients with higher serum creatinine levels were more likely diagnosed by RT-PCR compared to SARS-CoV-2 IgG. Sixty-nine RT-PCR positive patients were screened for SARS-CoV-2 IgG antibodies at a median of 44 days post-diagnosis (Inter Quartile Range 31-58) and 80% were positive. Overall mortality was 20.5% but significantly higher (37.8% ) in the patients who required hospitalization. Twenty-three percent of the hospitalized patients required kidney replacement therapy and 6.3% lost their allografts. In multivariable analysis, older age, receipt of deceased-donor transplantation, lack of influenza vaccination in the previous year and higher serum interleukine-6 levels were associated with mortality. Thus, 42% of patients with a kidney transplant and with COVID-19 were diagnosed on antibody testing without significant clinical symptoms, 80% of patients with positive RT-PCR developed SARS-CoV-2 IgG and mortality was high among patients requiring hospitalization., Graphical abstract

Author(s): Kim, S; Laughlin, M; Morris, J; Otieno, R; Odhiambo, A; Oremo, J; Graham, J; Hirai, M; Wells, E; Basler, C; Okello, A; Matanock, A; Eleveld, A; Quick, R | Abstract: The Safe Water and AIDS Project (SWAP), a non-governmental organization in western Kenya, opened kiosks run as businesses by community health promoters (CHPs) to increase access to health products among poor rural families. We conducted a baseline survey in 2014 before kiosks opened, and a post-intervention follow-up in 2016, enrolling 1,517 households with children l18 months old. From baseline to follow-up, we observed increases in reported exposure to the SWAP program (3–11%, p = 0.01) and reported purchases of any SWAP product (3–10%, p l 0.01). The percent of households with confirmed water treatment (detectable free chlorine residual (FCR) g0.2 mg/ml) was similar from baseline to follow-up (7% vs. 8%, p = 0.57). The odds of reported diarrhea in children decreased from baseline to follow-up (odds ratios or OR: 0.77, 95% CI: 0.64–0.93) and households with detectable FCR had lower odds of diarrhea (OR: 0.53, 95% CI: 0.34–0.83). Focus group discussions with CHPs suggested that high product prices, lack of affordability, and expectations that products should be free contributed to low sales. In conclusion, modest reported increases in SWAP exposure and product sales in the target population were insufficient to impact health, but children in households confirmed to chlorinate their water had decreased diarrhea.

Domestic animals in the household environment have the potential to affect a child's carriage of zoonotic enteric pathogens and risk of diarrhea. This study examines the risk factors associated with pediatric diarrhea and carriage of zoonotic enteric pathogens among children living in communities where smallholder livestock production is prevalent. We conducted an observational study of children younger than 5 years that included the analysis of child (n = 306) and animal (n = 480) fecal samples for Campylobacter spp., atypical enteropathogenic Escherichia coli, Shiga toxin-producing E. coli, Salmonella spp., Yersinia spp., Cryptosporidium parvum, and Giardia lamblia. Among these seven pathogens, Giardia was the most commonly identified pathogen among children and animals in the same household, most of which was found in child-dog pairs. Campylobacter spp. was also relatively common within households, particularly among child-chicken and child-guinea pig pairs. We used multivariable Poisson regression models to assess risk factors associated with a child being positive for at least one zoonotic enteric pathogen or having diarrhea during the last week. Children who interacted with domestic animals-a behavior reported by nearly three-quarters of households owning animals-were at an increased risk of colonization with at least one zoonotic enteric pathogen (prevalence ratio [PR] = 1.56, 95% CI: 1.00-2.42). The risk of diarrhea in the last seven days was elevated but not statistically significant (PR = 2.27, CI: 0.91, 5.67). Interventions that aim to reduce pediatric exposures to enteric pathogens will likely need to be incorporated with approaches that remove animal fecal contamination from the domestic environment and encourage behavior change aimed at reducing children's contact with animal feces through diverse exposure pathways.

Background: Transplant recipients are susceptible to cardiovascular complications, obesity, and increased insulin resistance after transplant. Here we assess weight gain in diabetic recipients after pancreas transplantation. Methods: This is a single-center study of 32 simultaneous pancreas and kidney and 5 pancreas after kidney transplant recipients from 2014 to 2018. Starting C-peptide levels ≤ 0.1 ng/mL were used to denote insulin nondetectability (n = 25) and C-peptide levels > 0.1 ng/mL as insulin detectability (n = 12). Hemoglobin A1c, body mass index (BMI), and weight following transplantation were assessed. Results: Hemoglobin A1c at 1 year was 5.9% in the insulin nondetectable recipients and 5.6% in the insulin detectable group ( P = .56). Average BMI after transplant was higher in the insulin detectable group 28.6 versus 24.4 kg/m2 ( P = .03) despite no difference in starting BMIs (24.9 versus 24.0 kg/m2, P = .42). The insulin detectable group also had a larger percentage weight change from their starting weight 13.1% versus 0.9 % at 1 year ( P = .02). Linear regression demonstrated that starting C-peptide was a significant predictor of weight gain posttransplant. Conclusions: Patients with elevated C-peptides at time of transplant are susceptible to rapid weight gain postoperatively. These patients may benefit from aggressive nutritional management.

Background Extended release LCP-tacrolimus (LCPT) allows once-daily dosing in transplant recipients. The improved bioavailability may be beneficial for simultaneous pancreas-kidney recipients (SPK). Methods This is a study of 39 SPK recipients on standard immediate-release tacrolimus (IR-TAC, n = 21) or LCPT (n = 18). Coefficient of variability (CV = 100∗standard deviation/mean) was calculated to assess drug levels. Hemoglobin A1c (HbA1c), tacrolimus and creatinine levels were measured postoperatively. Results There was no difference in tacrolimus CV in the IR-TAC and LCPT groups at 1 month or 3 months postoperatively; however, a greater difference was observed at 1 year (41.0 vs. 33.1%; p = 0.19). There were six episodes of acute rejection in the IR-TAC group compared to zero episodes in the LCPT group (p = 0.01). HbA1c was significantly higher in the IR-TAC group compared to LCPT at 3 (5.5 vs. 4.9%, p = 0.01), 6 (5.6 vs. 4.9%, p = 0.01) and 12 months (5.8 vs. 5.1%, p = 0.07). Conclusions Significantly lower rates of rejection were observed in patients receiving LCPT. The once daily dosing may facilitate medication adherence and result in improved long-term outcomes.

Background Antibiotics are increasingly used throughout the world in food animal production for controlling and preventing disease and for promoting growth. But this trend also has the potential for promoting antibiotic resistance, which represents a threat to human, animal, and environmental health. The use of antibiotics and the potential effects of antibiotic dependence has often been associated with large-scale food animal production. But rural households also engage in small-scale production, often operating literally in backyards. While some small-scale producers use veterinary antibiotics, many do not. This paper examines knowledge, attitudes, beliefs, and agricultural practices (KAP) that represent an alternative to dependence on antibiotics. Methods Qualitative field research was based on four focus group discussions (FGDs) with non-indigenous backyard food animal producers in four communities near Quito, Ecuador and two FGDs with veterinarians. FGDs were supplemented by structured observations and key informant interviews. They were recorded with digital audio devices and transcriptions were analyzed independently by two researchers using a three-stage coding procedure. Open coding identifies underlying concepts, while axial coding develops categories and properties, and selective coding integrates the information in order to identify the key dimensions of the collective qualitative data. Results Backyard food animal producers in the Ecuadorian highlands generally do not use antibiotics while rearing small batches of animals and poultry for predominantly non-commercial household consumption. Instead, they rely on low cost traditional veterinary remedies. These practices are informed by their Andean history of agriculture and a belief system whereby physical activity is a holistic lifestyle through which people maintain their health by participating in the physical and spiritual environment. Conclusions Backyard food animal producers in the Ecuadorian highlands implement complex strategies based on both economic calculations and sociocultural underpinnings that shape perceptions, attitudes, and practices. They use traditional veterinary remedies in lieu of antibiotics in most cases because limited production of food animals in small spaces contributes to a predictable household food supply, while at the same time conforming to traditional concepts of human and environmental health.

Background: Hundreds of thousands of biodigesters have been constructed in Nepal. These household-level systems use human and animal waste to produce clean-burning biogas used for cooking, which can reduce household air pollution from woodburning cookstoves and prevent respiratory illnesses. The biodigesters, typically operated by female caregivers, require the handling of animal waste, which may increase domestic fecal contamination, exposure to diarrheal pathogens, and the risk of enteric infections, especially among young children. Objective: We estimated the effect of daily reported biogas cookstove use on incident diarrhea among children

As a result of the COVID-19 pandemic, as well as other outbreaks, such as SARS and Ebola, bats are recognized as a critical species for mediating zoonotic infectious disease spillover events. While there is a growing concern of increased antimicrobial resistance (AMR) globally during this pandemic, knowledge of AMR circulating between bats and humans is limited. In this paper, we have reviewed the evidence of AMR in bats and discussed the planetary health aspect of AMR to elucidate how this is associated with the emergence, spread, and persistence of AMR at the human–animal interface. The presence of clinically significant resistant bacteria in bats and wildlife has important implications for zoonotic pandemic surveillance, disease transmission, and treatment modalities. We searched MEDLINE through PubMed and Google Scholar to retrieve relevant studies (n = 38) that provided data on resistant bacteria in bats prior to 30 September 2022. There is substantial variability in the results from studies measuring the prevalence of AMR based on geographic location, bat types, and time. We found all major groups of Gram-positive and Gram-negative bacteria in bats, which are resistant to commonly used antibiotics. The most alarming issue is that recent studies have increasingly identified clinically significant multi-drug resistant bacteria such as Methicillin Resistant Staphylococcus aureus (MRSA), ESBL producing, and Colistin resistant Enterobacterales in samples from bats. This evidence of superbugs abundant in both humans and wild mammals, such as bats, could facilitate a greater understanding of which specific pathways of exposure should be targeted. We believe that these data will also facilitate future pandemic preparedness as well as global AMR containment during pandemic events and beyond.

Antimicrobial resistance (AMR) threatens to undermine nearly a century of progress since the first use of antimicrobial compounds. There is an increasing recognition of the links between antimicrobial use and AMR in humans, animals, and the environment (i.e., One Health) and the spread of AMR between these domains and around the globe. This systematic review applies a One Health approach—including humans, animals, and the environment—to characterize AMR in Escherichia coli in India. E. coli is an ideal species because it is readily shared between humans and animals, its transmission can be tracked more easily than anaerobes, it can survive and grow outside of the host environment, and it can mobilize AMR genes more easily than other intestinal bacteria. This review synthesized evidence from 38 studies examining antimicrobial-resistant E. coli (AR-E) across India. Studies of AR-E came from 18 states, isolated from different sample sources: Humans (n = 7), animals (n = 7), the environment (n = 20), and combinations of these categories, defined as interdisciplinary (n = 4). Several studies measured the prevalence of AMR in relation to last-line antimicrobials, including carbapenems (n = 11), third-generation cephalosporins (n = 18), and colistin (n = 4). Most studies included only one dimension of the One Health framework, highlighting the need for more studies that aim to characterize the relationship of AMR across different reservoirs of E. coli.

Antimicrobial resistance (AMR) threatens to undermine nearly a century of progress since the first use of antimicrobial compounds. There is an increasing recognition of the links between antimicrobial use and AMR in humans, animals, and the environment (i.e., One Health) and the spread of AMR between these domains and around the globe. This systematic review applies a One Health approach—including humans, animals, and the environment—to characterize AMR in Escherichia coli in India. E. coli is an ideal species because it is readily shared between humans and animals, its transmission can be tracked more easily than anaerobes, it can survive and grow outside of the host environment, and it can mobilize AMR genes more easily than other intestinal bacteria. This review synthesized evidence from 38 studies examining antimicrobial-resistant E. coli (AR-E) across India. Studies of AR-E came from 18 states, isolated from different sample sources: Humans (n = 7), animals (n = 7), the environment (n = 20), and combinations of these categories, defined as interdisciplinary (n = 4). Several studies measured the prevalence of AMR in relation to last-line antimicrobials, including carbapenems (n = 11), third-generation cephalosporins (n = 18), and colistin (n = 4). Most studies included only one dimension of the One Health framework, highlighting the need for more studies that aim to characterize the relationship of AMR across different reservoirs of E. coli.

(1) Background: Water and solid fuel collection and transport are domestic duties for millions of households across the globe. People in areas with limited or no access to safely managed sources of water and household energy must fetch these resources on a frequent basis. The health, gender, and economic impacts associated with water and solid fuel collection labor have not been systematically reviewed. (2) Methods: Studies were identified through database searches and included using a list of inclusion and exclusion criteria. Studies were summarized and grouped into one of eight thematic categories. (4) Conclusions: The findings suggest that a diverse and heavy health burden is associated with water and solid fuel collection and transport. The literature also suggests that the provision of safely managed and accessible water and improved fuel options can mitigate these negative outcomes. Filling research gaps and utilizing results to guide policy and funding would likely be an effective way to ensure low- and middle-income countries are not left behind as the world strives to meet the sustainable development goals.

BackgroundOpen defecation due to a lack of access to sanitation facilities remains a public health issue in the United States. People experiencing homelessness face barriers to accessing sanitation facilities, and are often forced to practice open defecation on streets and sidewalks. Exposed feces may contain harmful pathogens posing a significant threat to public health, especially among unhoused persons living near open defecation sites. The City of San Francisco’s Department of Public Works implemented the Pit Stop Program to provide the unhoused and the general public with improved access to sanitation with the goal of reducing fecal contamination on streets and sidewalks. The objective of this study was to assess the impact of these public restroom interventions on reports of exposed feces in San Francisco, California.MethodsWe evaluated the impact of various public restroom interventions implemented from January 1, 2014 to January 1, 2020 on reports of exposed feces, captured through a 311 municipal service. Publicly available 311 reports of exposed feces were spatially and temporally matched to 31 Pit Stop restroom interventions at 27 locations across 10 San Francisco neighborhoods. We conducted an interrupted time-series analysis to compare pre- versus post-intervention rates of feces reports near the restrooms.ResultsFeces reports declined by 12.47 reports per week after the installation of 13 Pit Stop restrooms (p-value = 0.0002). In the same restrooms, the rate of reports per week declined from the six-month pre-intervention period to the post-intervention period (slope change = -0.024 [95% CI = -0.033, -0.014]). In a subset of restrooms, where new installations were made (Mission and Golden Gate Park), and in another subset of restrooms where restroom attendants were provided (Mission, Castro/Upper Market, and Financial District/South Beach), feces reports also declined.ConclusionsIncreased access to public toilets reduced feces reports in San Francisco, especially in neighborhoods with people experiencing homelessness. The addition of restroom attendants also appeared to have reduced feces reports in some neighborhoods with PEH. These interventions should be audited for implementation quality, observed utilization data, and user experience at the neighborhood level in order to tailor sanitation interventions to neighborhood-specific needs.

Kidney-Transplant Recipients with Covid-19 A cohort of 36 consecutive kidney-transplant recipients had less fever, lower CD3, CD4, and CD8 cell counts, more rapid clinical deterioration, and a high...

OBJECTIVE The pharmacokinetic implications of direct-acting antiviral (DAA) use on tacrolimus posttransplant are unknown. This study sought to investigate the effects of glecaprevir/pibrentasvir (G/P), a CYP3A4 substrate and inhibitor, on weight-adjusted tacrolimus (FK) trough/dose ratio (T/D) following heart or kidney transplantation. MATERIAL AND METHODS This was a single-center, retrospective analysis of hepatitis C virus (HCV) viremic donors to HCV negative heart or kidney transplant recipients who received 12 weeks of G/P therapy. Weight-adjusted T/D was assessed while patients were at steady-state before, during, and after G/P treatment. Forty-one HCV negative recipients (three heart, 38 kidney) were evaluated. RESULTS The weight-adjusted T/D significantly increased during G/P treatment (119.31, IQR 88-173.8) compared to before G/P treatment (67.4, IQR 53.4-115.9) (p

COVID-19 disease has significantly affected the transplant community by leading to decreased transplant activity and increased waiting list time. As expected, COVID-19 causes substantial mortality in both end-stage renal disease and kidney transplant populations. This is due to underlying chronic kidney disease and a high prevalence of comorbid conditions such as diabetes mellitus, hypertension, and cardiovascular disease in this group. Transplant programs have faced the difficult decision of weighing the risks and benefits of transplantation during the pandemic. On one hand there is a risk of COVID-19 exposure leading to infection while patients are on maximum immunosuppression. Alternatively, there are risks of delaying transplantation, which will increase waitlist-time and may lead to waitlist-associated morbidity and mortality. Cautious and thoughtful selection of both the recipient9s and donor9s post-transplant management is required during the pandemic to mitigate the risk of morbidity and mortality associated with COVID-19. In this review article we aimed to discuss previous publications related to clinical outcomes of COVID-19 disease in kidney transplant recipients, end-stage renal disease patients on dialysis or on the transplant waiting-list and precautions transplant centers should take in decision making for recipient and donor selection and immunosuppressive management during the pandemic. Nevertheless, transplantation in this milieu does seem to be the correct decision with a careful patient and donor selection with safeguard protocols for infection prevention. Each center should do risk assessment based on their patient9s age and medical comorbidities, waitlist time, degree of sensitization, cold ischemia time, status of vaccination, and severity of pandemic in their region.

Background: Antimicrobials are widely used throughout the world in food animal production for controlling and preventing disease and for promoting growth. But this trend also has the potential for promoting antimicrobial resistance, which represents a threat to human, animal, and environmental health. The use of antimicrobials and the potential effects of antimicrobial dependence has often been associated with large-scale food animal production. But rural households also engage in small-scale agricultural production, often operating literally in backyards. While some small-scale producers use veterinary antimicrobials, most do not. This paper examines knowledge and attitudes to understand alternative practices. Methods: Qualitative field research was based on four focus group discussions (FGDs) with backyard food animal producers in six communities near Quito, Ecuador and two FGDs with veterinarians. FGDs were supplemented by structured observations and key informant interviews. They were recorded with digital audio devices and transcriptions were analyzed independently by two researchers using a three-stage coding procedure. Open coding identifies underlying concepts, while axial coding develops categories and properties, and selective coding integrates the information in order to identify the key dimensions of the collective qualitative data.Results: The qualitative data analysis shows that first, backyard food animal producers use few purchased inputs, including antimicrobials for keeping small numbers of animals and poultry for predominantly non-commercial household consumption and they use traditional veterinary remedies at little or no cost. Second, indigenous households and other small-scale producers in the Ecuadorian highlands and other parts of the Andean region retain traditional views of human productive activity as a component of the physical and spiritual environment. Conclusions: Backyard food animal producers in the Ecuadorian highlands implement complex household survival strategies based on both economic calculations and sociocultural underpinnings that shape perceptions, attitudes, and practices. They use traditional veterinary remedies in lieu of antimicrobials in most cases because limited production of food animals in small spaces allows them to contribute to a predictable household food supply, while at the same time conforming to traditional concepts of human and environmental health.

Introduction: We compared clinicopathologic characteristics and outcomes of radical nephrectomy (RN) for small renal masses (SRM) in patients with end-stage renal disease (ESRD) before or after transplant at a high-volume urologic and transplant center. Methods: We performed a retrospective review of patients with ESRD (glomerular filtration rate [GFR]

Background: There is a significant gap in our understanding of the sources of multidrug-resistant bacteria and resistance genes in community settings where human–animal interfaces exist. Objectives: This study characterized the relationship of third-generation cephalosporin-resistant Escherichia coli (3GCR-EC) isolated from animal feces in the environment and child feces based on phenotypic antimicrobial resistance (AMR) and whole genome sequencing (WGS). Methods: We examined 3GCR-EC isolated from environmental fecal samples of domestic animals and child fecal samples in Ecuador. We analyzed phenotypic and genotypic AMR, as well as clonal relationships (CRs) based on pairwise single-nucleotide polymorphisms (SNPs) analysis of 3GCR-EC core genomes. CRs were defined as isolates with fewer than 100 different SNPs. Results: A total of 264 3GCR-EC isolates from children (n=21), dogs (n=20), and chickens (n=18) living in the same region of Quito, Ecuador, were identified. We detected 16 CRs total, which were found between 7 children and 5 domestic animals (5 CRs) and between 19 domestic animals (11 CRs). We observed that several clonally related 3GCR-EC isolates had acquired different plasmids and AMR genes. Most CRs were observed in different homes (n=14) at relatively large distances. Isolates from children and domestic animals shared the same blaCTX-M allelic variants, and the most prevalent were blaCTX-M-55 and blaCTX-M-65, which were found in isolates from children, dogs, and chickens. Discussion: This study provides evidence of highly dynamic horizontal transfer of AMR genes and mobile genetic elements (MGEs) in the E. coli community and shows that some 3GCR-EC and (extended-spectrum β-lactamase) ESBL genes may have moved relatively large distances among domestic animals and children in semirural communities near Quito, Ecuador. Child–animal contact and the presence of domestic animal feces in the environment potentially serve as important sources of drug-resistant bacteria and ESBL genes. https://doi.org/10.1289/EHP7729

BackgroundThe rapid spread of extended-spectrum beta-lactamase-producingE. coli(ESBL-EC) is an urgent global health threat. We examined child caretaker knowledge, attitudes, and practices (KAP) towards proper antimicrobial agent use and whether certain KAP were associated with ESBL-EC colonization of their children.MethodsChild caretakers living in semi-rural neighborhoods in peri-urban Quito, Ecuador were visited and surveyed about their KAP towards antibiotics. Fecal samples from one child (less than 5 years of age) per household were collected at two time points between July 2018 and May 2019 and screened for ESBL-EC. A repeated measures analysis with logistic regression was used to assess the relationship between KAP levels and child colonization with ESBL-EC.ResultsWe analyzed 740 stool samples from 444 children living in households representing a range of environmental conditions. Of 374 children who provided fecal samples at the first household visit, 44 children were colonized with ESBL-EC (11.8%) and 161 were colonized with multidrug-resistantE. coli(43%). The prevalences of ESBL-EC and multidrug-resistantE. coliwere similar at the second visit (11.2% and 41.3%, respectively; N = 366). Only 8% of caretakers knew that antibiotics killed bacteria but not viruses, and over a third reported that they “always” give their children antibiotics when the child’s throat hurts (35%). Few associations were observed between KAP variables and ESBL-EC carriage among children. The odds of ESBL-EC carriage were 2.17 times greater (95% CI: 1.18–3.99) among children whose caregivers incorrectly stated that antibiotics do not kill bacteria compared to children whose caregivers correctly stated that antibiotics kill bacteria. Children from households where the caretaker answered the question “When your child’s throat hurts, do you give them antibiotics?” with “sometimes” had lower odds of ESBL-EC carriage than those with a caretaker response of “never” (OR 0.48, 95% CI 0.27–0.87).ConclusionCaregivers in our study population generally demonstrated low knowledge regarding appropriate use of antibiotics. Our findings suggest that misinformation about the types of infections (i.e. bacterial or viral) antibiotics should be used for may be associated with elevated odds of carriage of ESBL-EC. Understanding that using antibiotics is appropriate to treat infections some of the time may reduce the odds of ESBL-EC carriage. Overall, however, KAP measures of appropriate use of antibiotics were not strongly associated with ESBL-EC carriage. Other individual- and community-level environmental factors may overshadow the effect of KAP on ESBL-EC colonization. Intervention studies are needed to assess the true effect of improving KAP on laboratory-confirmed carriage of antimicrobial resistant bacteria, and should consider community-level studies for more effective management.

Background A One Health approach requires integrative research to elucidate antimicrobial resistance (AMR) in the environment and the risks it poses to human health. Research on this topic involves experts from diverse backgrounds and professions. Shortcomings exist in terms of consistent, complete, and transparent reporting in many environmental studies. Standardized reporting will improve the quality of scientific papers, enable meta-analyses and enhance the communication among different experts. In this study, we aimed to generate a consensus of reporting standards for AMR research in wastewater and related aquatic environments. Methods Based on a risk of bias assessment of the literature in a systematic review, we proposed a set of study quality indicators. We then used a multistep modified Delphi consensus to develop the EMBRACE-WATERS statement (rEporting antiMicroBial ResistAnCE in WATERS), a checklist of recommendations for reporting in studies of AMR in wastewater and related aquatic environments. Findings Consensus was achieved among a multidisciplinary panel of twenty-one experts in three steps. The developed EMBRACE-WATERS statement incorporates 21 items. Each item contains essential elements of high-quality reporting and is followed by an explanation of their rationale and a reporting-example. The EMBRACE-WATERS statement is primarily intended to be used by investigators to ensure transparent and comprehensive reporting of their studies. It can also guide peer-reviewers and editors in evaluation of manuscripts on AMR in the aquatic environment. This statement is not intended to be used to guide investigators on the methodology of their research. Interpretation We are hopeful that this statement will improve the reporting quality of future studies of AMR in wastewater and related aquatic environments. Its uptake would generate a common language to be used among researchers from different disciplines, thus advancing the One Health approach towards understanding AMR spread across aquatic environments. Similar initiatives are needed in other areas of One Health research., Highlights • One Health research links experts from different disciplines assessing antimicrobial resistance. • Non transparent reporting in environmental studies hinders data communication. • Transparent reporting ensures research reproducibility and generalizability. • EMBRACE-WATERS lists recommendations for reporting of studies on AMR in aquatic environment. • EMBRACE-WATERS can assist authors in improving reporting quality of studies.

Introduction: The aim of this study was to explore the barriers to implementing an infection prevention and control (IPC) programme in three public district hospitals in Tamil Nadu by interviewing key stakeholders involved in the roll-out of the programme. Materials and methods: Investigators conducted interviews (n = 17) with chief medical officers (CMOs), physicians, and IPC nurses at three secondary public district hospitals and their affiliated primary health centres (PHCs). Results: Six major themes emerged from the interviews: (1) prevalent IPC practices before the programme began; (2) barriers to implementation; (3) perceptions of the effectiveness of the IPC programme; (4) suggestions for future expansion of the programme; (5) the role of healthcare sanitation workers, and (6) water, sanitation and hygiene (WaSH) infrastructure. Stakeholders noted improvements in IPC knowledge, infection control related behaviour, and overall healthcare quality in the three hospitals. In regards to the future of this programme, stakeholders noted the need for more institutional support, a staff nurse solely dedicated to IPC, and the continued training of all staff members. Discussion: The results of this study highlight the importance of having high-functioning WaSH infrastructure and training for hospital sanitary workers in order to have an effective IPC programme. While the scale-up of this IPC programme is warranted, the barriers to implementation outlined in this study should be considered. To achieve a more effective IPC programme, we suggest that the following steps be carried out: (1) dedicate at least one full-time nurse to implementing IPC activities at each district hospital; (2) ensure that state and national policies for IPC are synchronised, and (3) provide sufficient and consistent funding for IPC activities.

Small-scale food animal production has been celebrated as a means of economic mobility and improved food security but the use of veterinary antibiotics among these producers may be contributing to the spread of antibiotic resistance in animals and humans. In order to improve antibiotic stewardship in this sector, it is critical to identify the drivers of producers&rsquo, antibiotic use. This study assessed the determinants of antibiotic use in small-scale food animal production through simulated client visits to veterinary supply stores and surveys with households that owned food animals (n = 117) in Ecuador. Eighty percent of households with food animals owned chickens and 78% of those with chickens owned fewer than 10 birds. Among the households with small-scale food animals, 21% reported giving antibiotics to their food animals within the last six months. Simulated client visits indicated that veterinary sales agents frequently recommended inappropriate antibiotic use, as 66% of sales agents recommended growth promoting antibiotics, and 48% of sales agents recommended an antibiotic that was an inappropriate class for disease treatment. In contrast, few sales agents (3%) were willing to sell colistin, an antibiotic banned for veterinary use in Ecuador as of January 2020, which supports the effectiveness of government regulation in antibiotic stewardship. The cumulative evidence provided by this study indicates that veterinary sales agents play an active role in promoting indiscriminate and inappropriate use of antibiotics in small-scale food animal production.

The gastrointestinal tract (GIT) constitutes a complex and diverse ecosystem. Escherichia coli is one of the most frequently studied and characterized species in the gut ecosystem. Nevertheless, there has been little research to determine their diversity and population dynamics in the intestines of children over time. Many intestinal E. coli lineages carry antimicrobial resistance and virulence genes, which have implications in disease and public health. In this one-year prospective study, a fresh fecal sample was obtained from 30 children longitudinally for one year (n = 82 fecal samples). From each stool sample, five Escherichia coli colonies were randomly selected to characterize their genotype and phenotypic antimicrobial resistance pattern (n = 405 E. coli isolates). We found that the most numerically dominant E. coli lineages in children’s intestines were transient colonizers, and phenotypic antimicrobial resistance varied significantly over time, however, ST131 a multi-drug resistant pathogen, and 3 additional STs persisted in a child’s intestine for 3 months or more.IMPORTANCEThe length of residency and numeric dominance of antimicrobial-resistant E. coli may affect the extent to which an isolate contributes to the dissemination of antimicrobial resistance. We studied the persistence of numerically dominant and antimicrobial-resistant lineages of E. coli in the human intestine and found that E. coli lineages in the gut of children change rapidly over time.

Community-acquired antimicrobial resistant Enterobacteriaceae (CA-ARE) are an increasingly important issue around the world. Characterizing the distribution of regionally specific patterns of resistance is important to contextualize and develop locally relevant interventions. This systematic review adopts a One Health framework considering the health of humans, animals, and the environment to describe CA-ARE in Central America. Twenty studies were identified that focused on antimicrobial resistance (AMR) in Enterobacteriaceae. Studies on CA-ARE in Central America characterized resistance from diverse sources, including humans (n = 12), animals (n = 4), the environment (n = 2), and combinations of these categories (n = 2). A limited number of studies assessed prevalence of clinically important AMR, including carbapenem resistance (n = 3), third generation cephalosporin resistance (n = 7), colistin resistance (n = 2), extended spectrum beta-lactamase (ESBL) production (n = 4), or multidrug resistance (n = 4). This review highlights significant gaps in our current understanding of CA-ARE in Central America, most notably a general dearth of research, which requires increased investment and research on CA-ARE as well as AMR more broadly.

Introduction The advent of direct-acting antivirals (DAAs) has created an avenue for transplantation of hepatitis C virus (HCV)-infected donors into uninfected recipients (D+/R-). The donor transmission of HCV is then countered by DAA administration during the post-operative period. However, initiation of DAA treatment is ultimately dictated by insurance companies. Methods A retrospective chart review of 52 D+/R- kidney recipients who underwent DAA treatment post-transplant was performed. Patients were grouped according to their prescription coverage plans, managed by either commercial or government pharmacy benefit managers (PBMs). Results Thirty-nine patients had government PBMs and 13 had commercial PBMs. Demographics were similar between the two groups. All patients developed HCV viremia, but cleared the virus after treatment with DAA. Patients with government PBMs were treated earlier compared to those with commercial PBMs (11 days vs 26 days, P = .01). Longer time to DAA initiation resulted in higher peak viral loads (β = 0.39, R2 = .15, P = .01) and longer time to HCV viral load clearance (β = 0.41, R2 = .17, P = .01). Conclusions D+/R- transplantation offers patients an alternative strategy to increase access. However, treatment can be profoundly delayed by a third-party payer authorization process that may be subjecting patients to unnecessary risks and worsened outcomes.

Manure from poultry operations is typically applied to nearby cropland and may affect nutrient loading and the spread of antibiotic resistance (ABR). We analyzed the concentrations of nitrogen and phosphorus and the occurrence of ABR in Escherichia coli (E. coli) and extra-intestinal pathogenic E. coli isolates from streams draining 15 small (

Background Simultaneous pancreas and kidney transplantation (SPK) in the setting of end-stage renal disease offers unmatched outcomes in insulin dependent diabetic patients. Donor pool expansion through the transplantation of kidneys with acute kidney injury (AKI) is controversial. Methods 59 SPK transplants were classified by presence of donor AKI, defined as donor terminal creatinine ≥ 1.5x the initial creatinine or donor terminal creatinine > 4.0 mg/dL. Endpoints included graft and patient survival, delayed graft function (DGF), serum creatinine, glomerular filtration rate (GFR), Hemoglobin A1c (HbA1c) and acute rejection. Results The donor AKI group (n = 35) had significantly higher rates of DGF (38 v. 9%, p = 0.01). There was no difference in creatinine or GFR at 1, 3, 6 and 12 months. HbA1c was comparable at 3, 6 and 12 months. There was no significant difference in the percentage of patients that required anti-diabetic agents after transplant (14 v. 4%, p = 0.56). Conclusions We observed increased rates of DGF in SPK recipients with donor AKI. However, equivalent outcomes of pancreas and kidney function in both groups were observed.

At Montefiore Medical Center in The Bronx, NY, the first case of coronavirus disease 2019 (COVID-19) was admitted on March 11, 2020. At the height of the pandemic, there were 855 patients with COVID-19 admitted on April 13, 2020. Due to high demand for dialysis and shortages of staff and supplies, we started an urgent peritoneal dialysis (PD) program. From April 1 to April 22, a total of 30 patients were started on PD. Of those 30 patients, 14 died during their hospitalization, 8 were discharged, and 8 were still hospitalized as of May 14, 2020. Although the PD program was successful in its ability to provide much-needed kidney replacement therapy when hemodialysis was not available, challenges to delivering adequate PD dosage included difficulties providing nurse training and availability of supplies. Providing adequate clearance and ultrafiltration for patients in intensive care units was especially difficult due to the high prevalence of a hypercatabolic state, volume overload, and prone positioning. PD was more easily performed in non-critically ill patients outside the intensive care unit. Despite these challenges, we demonstrate that urgent PD is a feasible alternative to hemodialysis in situations with critical resource shortages.

Recent studies have found limited associations between antimicrobial resistance (AMR) in domestic animals (and animal products), and AMR in human clinical settings. These studies have primarily used Escherichia coli, a critically important bacterial species associated with significant human morbidity and mortality. E. coli is found in domestic animals and the environment, and it can be easily transmitted between these compartments. Additionally, the World Health Organization has highlighted E. coli as a “highly relevant and representative indicator of the magnitude and the leading edge of the global antimicrobial resistance (AMR) problem”. In this paper, we discuss the weaknesses of current research that aims to link E. coli from domestic animals to the current AMR crisis in humans. Fundamental gaps remain in our understanding the complexities of E. coli population genetics and the magnitude of phenomena such as horizontal gene transfer (HGT) or DNA rearrangements (transposition and recombination). The dynamic and intricate interplay between bacterial clones, plasmids, transposons, and genes likely blur the evidence of AMR transmission from E. coli in domestic animals to human microbiota and vice versa. We describe key factors that are frequently neglected when carrying out studies of AMR sources and transmission dynamics.

The advent of direct-acting antivirals (DAAs) has provided the impetus to transplant kidneys from hepatitis C virus-positive donors into uninfected recipients (D+/R-). Thirty D+/R- patients received DAA treatment. Sustained virologic response (SVR12) was defined as an undetectable viral load in 12 weeks after treatment. An age-matched cohort of uninfected donor and recipient pairs (D-/R-) transplanted during same time period was used for comparison. The median day of viral detection was postoperative day (POD) 2. The detection of viremia in D+/R- patients was 100%. The initial median viral load was 531 copies/μL (range: 10-1 × 108 copies/μL) with a median peak viral load of 3.4 × 105 copies/μL (range: 804-1.0 × 108 copies/μL). DAAs were initiated on median POD 9 (range: 5-41 days). All 30 patients had confirmed SVR12. During a median follow-up of 10 months, patient and graft survival was 100%, and acute rejection was 6.6% with no major adverse events related to DAA treatment. Delayed graft function was significantly decreased in D+/R- patients as compared to the age-matched cohort (27% vs 60%; P = .01). D+/R- transplantation offers patients an alternative strategy to increase access.

Morbid obesity is a relative contraindication for abdominal organ transplantation. Obese patients present technical challenges intra-operatively and are at increased risk of post-operative complications. Bariatric surgery has been shown to be more effective than conventional weight loss strategies in morbidly obese patients, however, current literature is limited to the kidney transplant population. Here were present a case report of a patient with morbid obesity who underwent a laparoscopic Roux-en-Y gastric bypass prior to simultaneous pancreas kidney transplantation.

Handwashing (HW) with soap is considered the most cost-effective intervention for reducing the risk of child diarrhea, but reliable measurement of HW behaviors is difficult. This study examined the association between proxy HW measures and child diarrhea by analyzing nationally representative household survey data from 25 countries in sub-Saharan Africa (n = 212,492). The main explanatory variable was the HW ladder, representing a varying level of availability of HW materials in the household, and the outcome variable was a 2-week prevalence of child diarrhea. We estimated the prevalence ratio of child diarrhea between children with a basic HW station and without a HW place. Our analysis revealed that availability of water and soap at a HW place was associated with both increased and decreased prevalence ratios: 0.89 (95% CI 0.79–0.99) in Chad, 0.82 (0.69–0.97) in Mauritania, 1.30 (1.02–1.66) in Burkina Faso, and 1.67 (1.20–2.33) in Ghana. After controlling for country-fixed effects, the prevalence ratio was 0.95 (0.92–0.99), suggesting a protective effect of having a HW station with water and soap. Availability of HW resources is an important indicator to prevent child diarrhea, and HW promotion programs should be tailored to the unique context of each country.

We aimed to investigate the impact of the new kidney allocation system (KAS) on the rate of transplantation of sensitized patients at our center. Pre-KAS and post-KAS intervals were Jan 1st to Dec 3rd 2014 and Jan 1st 2015 to Dec 3rd 2015, respectively. The number of deceased-donor crossmatches performed by flow cytometry increased from 715 pre-KAS to 1188 post-KAS. The percent of crossmatches performed for sensitized patients with calculated panel reactive antibody (cPRA)0% increased from 19% pre-KAS to 26% post-KAS (p0.0001). The number of deceased-donor kidney transplants performed at our center increased from 115 pre-KAS to 125 post-KAS (9% increase). There was a significant increase in the percentage of deceased-donor kidney transplants received by sensitized candidates (from 14% to 26% pre- and post-KAS, respectively; p0.0001). The highest increase was seen in the patients with cPRA98%, from 0% to 9%, followed by the group with cPRA 50-79%, from 5% to 8%. This increase was balanced by a decrease of 12% in the percentage of non-sensitized recipients, and a modest decrease of 1% in the group with cPRA 1-49%. In conclusion, transplant rate has increased in sensitized patients after KAS. The highest increase was observed among highly sensitized patients (cPRA98%).