Conference Material > Poster
Kumar V, Murali S, Goldberg J, Alonso B, Moretó-Planas L, et al.
MSF Scientific Days Asia. 2024 November 8
Conference Material > Poster
Gonzalez Arias M, Alsairy H, Yang SL, Alonso B, Buero MM
MSF Paediatric Days 2024. 2024 May 3; DOI:10.57740/NHGPuP40k
Journal Article > ResearchFull Text
JAC Antimicrob Resist. 2024 January 2; Volume 6 (Issue 1); dlad151.; DOI:10.1093/jacamr/dlad151
Kumar V, Murali S, Goldberg J, Alonso B, Moretó-Planas L, et al.
JAC Antimicrob Resist. 2024 January 2; Volume 6 (Issue 1); dlad151.; DOI:10.1093/jacamr/dlad151
OBJECTIVES
To describe the prevalence of common bacterial pathogens and antibiotic susceptibility patterns amongst advanced HIV disease (AHD) patients admitted between May 2019 and March 2021 to a Médecins Sans Frontières (MSF)-supported AHD inpatient unit in Bihar, India.
METHODS
A retrospective analysis of routinely collected demographic, clinical and microbiological data. Antibacterial susceptibility testing was done by an accredited referral laboratory using the modified Kirby–Bauer disc diffusion method.
RESULTS
A total of 238 isolates from 577 patients were identified through culture testing. Patient median (IQR) age was 38 (31–45) years, and 75% were male. Predominant sample types included blood (600; 38%), urine (266; 17%) and sputum (178; 11%). Of the isolated bacteria, Escherichia coli (80; 13.9%) was the most prevalent, followed by Klebsiella pneumonia (54; 9.4%), Pseudomonas aeruginosa (22; 3.8%), Klebsiella oxytoca (10; 1.7%), Proteus mirabilis (9; 1.6%), and Acinetobacter baumannii (7; 1.2%). The resistance pattern showed that most bacterial isolates were highly resistant to commonly prescribed antibiotics such as third-generation cephalosporins, fluoroquinolones and co-trimoxazole. Most pathogens were moderately resistant to antibiotics from the WHO Watch group, such as meropenem and piperacillin/tazobactam. In contrast, isolates were more susceptible to aminoglycosides, such as amikacin, gentamicin and nitrofurantoin.
CONCLUSIONS
In Bihar, inpatients with AHD displayed a concerning array of antibiotic-resistant infections. This study provides a starting point from which further work on antimicrobial resistance in this vulnerable cohort of patients can be conducted.
To describe the prevalence of common bacterial pathogens and antibiotic susceptibility patterns amongst advanced HIV disease (AHD) patients admitted between May 2019 and March 2021 to a Médecins Sans Frontières (MSF)-supported AHD inpatient unit in Bihar, India.
METHODS
A retrospective analysis of routinely collected demographic, clinical and microbiological data. Antibacterial susceptibility testing was done by an accredited referral laboratory using the modified Kirby–Bauer disc diffusion method.
RESULTS
A total of 238 isolates from 577 patients were identified through culture testing. Patient median (IQR) age was 38 (31–45) years, and 75% were male. Predominant sample types included blood (600; 38%), urine (266; 17%) and sputum (178; 11%). Of the isolated bacteria, Escherichia coli (80; 13.9%) was the most prevalent, followed by Klebsiella pneumonia (54; 9.4%), Pseudomonas aeruginosa (22; 3.8%), Klebsiella oxytoca (10; 1.7%), Proteus mirabilis (9; 1.6%), and Acinetobacter baumannii (7; 1.2%). The resistance pattern showed that most bacterial isolates were highly resistant to commonly prescribed antibiotics such as third-generation cephalosporins, fluoroquinolones and co-trimoxazole. Most pathogens were moderately resistant to antibiotics from the WHO Watch group, such as meropenem and piperacillin/tazobactam. In contrast, isolates were more susceptible to aminoglycosides, such as amikacin, gentamicin and nitrofurantoin.
CONCLUSIONS
In Bihar, inpatients with AHD displayed a concerning array of antibiotic-resistant infections. This study provides a starting point from which further work on antimicrobial resistance in this vulnerable cohort of patients can be conducted.
Journal Article > CommentaryFull Text
Antimicrob Resist Infect Control. 2023 September 4; Volume 12 (Issue 1); 89.; DOI:10.1186/s13756-023-01301-4
Truppa C, Alonso B, Clezy K, Deglise C, Dromer C, et al.
Antimicrob Resist Infect Control. 2023 September 4; Volume 12 (Issue 1); 89.; DOI:10.1186/s13756-023-01301-4
Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.
Journal Article > ResearchFull Text
BMJ Open. 2023 May 19; Volume 13 (Issue 5); e066937.; DOI:10.1136/bmjopen-2022-066937
Moretó-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
BMJ Open. 2023 May 19; Volume 13 (Issue 5); e066937.; DOI:10.1136/bmjopen-2022-066937
OBJECTIVE
Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
DESIGN
Cross-sectional study (July 2019 to April 2020).
SETTING
Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens.
PARTICIPANTS
Patients aged between 6 months and 15 years with presumptive TB.
INTERVENTIONS
Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age.
RESULTS
A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9.
CONCLUSIONS
We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
Description of tuberculosis (TB)-focused point-of-care ultrasound (POCUS) findings for children with presumptive TB.
DESIGN
Cross-sectional study (July 2019 to April 2020).
SETTING
Simão Mendes hospital in Bissau, a setting with high TB, HIV, and malnutrition burdens.
PARTICIPANTS
Patients aged between 6 months and 15 years with presumptive TB.
INTERVENTIONS
Participants underwent clinical, laboratory and unblinded clinician-performed POCUS assessments, to assess subpleural nodules (SUNs), lung consolidation, pleural and pericardial effusion, abdominal lymphadenopathy, focal splenic and hepatic lesions and ascites. Presence of any sign prompted a POCUS positive result. Ultrasound images and clips were evaluated by expert reviewers and, in case of discordance, by a second reviewer. Children were categorised as confirmed TB (microbiological diagnosis), unconfirmed TB (clinical diagnosis) or unlikely TB. Ultrasound findings were analysed per TB category and risk factor: HIV co-infection, malnutrition and age.
RESULTS
A total of 139 children were enrolled, with 62 (45%) women and 55 (40%) aged <5 years; 83 (60%) and 59 (42%) were severely malnourished (SAM) and HIV-infected, respectively. TB confirmation occurred in 27 (19%); 62 (45%) had unconfirmed TB and 50 (36%) had unlikely TB. Children with TB were more likely to have POCUS-positive results (93%) compared with children with unlikely TB (34%). Common POCUS signs in patients with TB were: lung consolidation (57%), SUNs (55%) and pleural effusion (30%), and focal splenic lesions (28%). In children with confirmed TB, POCUS sensitivity was 85% (95% CI) (67.5% to 94.1%). In those with unlikely TB, specificity was 66% (95% CI 52.2% to 77.6%). Unlike HIV infection and age, SAM was associated with a higher POCUS-positivity. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9.
CONCLUSIONS
We found a high prevalence of POCUS signs in children with TB compared with children with unlikely TB. POCUS-positivity was dependent on nutritional status but not on HIV status or age. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
Conference Material > Video
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 2022 June 7; DOI:10.57740/50a1-ba02
Conference Material > Slide Presentation
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 2022 May 11; DOI:10.57740/mpdr-x060
Conference Material > Abstract
Moreto-Planas L, Sagrado MJ, Mahajan R, Gallo J, Biague E, et al.
MSF Scientific Days International 2022. 2022 May 11; DOI:10.57740/b8m1-p572
INTRODUCTION
Tuberculosis (TB) is an important cause of morbidity and mortality in children and over 50% of childhood TB remains undiagnosed every year. As microbiological confirmation is low (<30%), the majority of cases in low and middle-income countries are diagnosed on clinical grounds. Point-of-care ultrasound (POCUS) is a non-invasive bedside tool, and TB-focused POCUS has been validated for diagnosis of TB in adults with HIV. We aimed to describe the performance and findings of TB-focused POCUS for children with presumptive TB at a tertiary care hospital in Guinea- Bissau, a setting with a high burden of HIV, malnutrition and TB.
METHODS
This observational study took place at Simão Mendes hospital in Bissau, from July 2019 to April 2020. Patients aged between 6 months and 15 years with presumptive TB underwent clinical and laboratory assessment, with at least one sample analysed with GeneXpert Ultra, and unblinded clinician-performed POCUS evaluation. POCUS was used to assess for subpleural nodules (SUN’s), lung consolidation, pleural effusion, pericardial effusion, ascites, liver and splenic focal lesions, and abdominal lymph nodes. Presence of any of these signs prompted a POCUS- positive result. Images and clips were evaluated by an expert reviewer and, if discordant, by a second expert reviewer.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the Guinea-Bissau Ministry of Health ERB.
RESULTS
A total of 139 children were enrolled, with 62 (45%) female and 55 (40%) aged under 5 years. HIV infection and severe acute malnutrition (SAM) were found in 59 (42%) and 83 (60%) of patients, respectively. Confirmation of TB was achieved in 27 (19%); 62 (45%) had unconfirmed TB, and 50 (36%) had unlikely TB. Children with TB were more likely to have a POCUS positive result (83/89; 93%) as compared to children with unlikely TB (17/50; 34%). The most common POCUS signs in TB patients were: lung consolidation (51; 57%), SUN’s (49; 55%), pleural effusion (27; 30%), and focal splenic lesions (25; 28%). In children with confirmed TB (n=27), POCUS sensitivity was 85.2% (95% confidence interval (CI) 67.5-94.1). In those with unlikely TB (n=50), specificity was 66% (95%CI 2.2-77.6). Unlike HIV infection, SAM was associated with higher risk of positive POCUS. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9 depending on the POCUS sign, while overall POCUS concordance was 0.8.
CONCLUSION
We found high prevalence of any POCUS sign in children with TB, as compared to children with unlikely TB. POCUS positivity was independent of HIV status, but not of nutritional status. POCUS concordance between field and expert reviewers was moderate to high. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
CONFLICTS OF INTEREST
None declared.
Tuberculosis (TB) is an important cause of morbidity and mortality in children and over 50% of childhood TB remains undiagnosed every year. As microbiological confirmation is low (<30%), the majority of cases in low and middle-income countries are diagnosed on clinical grounds. Point-of-care ultrasound (POCUS) is a non-invasive bedside tool, and TB-focused POCUS has been validated for diagnosis of TB in adults with HIV. We aimed to describe the performance and findings of TB-focused POCUS for children with presumptive TB at a tertiary care hospital in Guinea- Bissau, a setting with a high burden of HIV, malnutrition and TB.
METHODS
This observational study took place at Simão Mendes hospital in Bissau, from July 2019 to April 2020. Patients aged between 6 months and 15 years with presumptive TB underwent clinical and laboratory assessment, with at least one sample analysed with GeneXpert Ultra, and unblinded clinician-performed POCUS evaluation. POCUS was used to assess for subpleural nodules (SUN’s), lung consolidation, pleural effusion, pericardial effusion, ascites, liver and splenic focal lesions, and abdominal lymph nodes. Presence of any of these signs prompted a POCUS- positive result. Images and clips were evaluated by an expert reviewer and, if discordant, by a second expert reviewer.
ETHICS
This study was approved by the MSF Ethics Review Board (ERB) and by the Guinea-Bissau Ministry of Health ERB.
RESULTS
A total of 139 children were enrolled, with 62 (45%) female and 55 (40%) aged under 5 years. HIV infection and severe acute malnutrition (SAM) were found in 59 (42%) and 83 (60%) of patients, respectively. Confirmation of TB was achieved in 27 (19%); 62 (45%) had unconfirmed TB, and 50 (36%) had unlikely TB. Children with TB were more likely to have a POCUS positive result (83/89; 93%) as compared to children with unlikely TB (17/50; 34%). The most common POCUS signs in TB patients were: lung consolidation (51; 57%), SUN’s (49; 55%), pleural effusion (27; 30%), and focal splenic lesions (25; 28%). In children with confirmed TB (n=27), POCUS sensitivity was 85.2% (95% confidence interval (CI) 67.5-94.1). In those with unlikely TB (n=50), specificity was 66% (95%CI 2.2-77.6). Unlike HIV infection, SAM was associated with higher risk of positive POCUS. Cohen’s kappa coefficient for concordance between field and expert reviewers ranged from 0.6 to 0.9 depending on the POCUS sign, while overall POCUS concordance was 0.8.
CONCLUSION
We found high prevalence of any POCUS sign in children with TB, as compared to children with unlikely TB. POCUS positivity was independent of HIV status, but not of nutritional status. POCUS concordance between field and expert reviewers was moderate to high. TB-focused POCUS could potentially play a supportive role in the diagnosis of TB in children.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
Confl Health. 2018 July 2; Volume 12 (Issue 1); 30.; DOI:10.1186/s13031-018-0161-1
Ferreyra C, O'Brien DP, Alonso B, Al-Zomour A
Confl Health. 2018 July 2; Volume 12 (Issue 1); 30.; DOI:10.1186/s13031-018-0161-1
BACKGROUND
Unstable settings present challenges for the effective provision of antiretroviral treatment (ART). In this paper, we summarize the experience and results of providing ART and implementing contingency plans during acute instability in the Central African Republic (CAR) and Yemen.
CASE PRESENTATION
In CAR, MSF has provided HIV care in three conflict-affected rural regions; these were put on hold throughout the acute phase of violence. "Run-away bags" containing 3 or 4 months of ART were distributed to patients at MSF facilities. Among 1820 HIV patients enrolled into care, 1440 (79%) initiated ART. By December 2016, 782 (54%) patients were still under ART, 354 (25%) have been lost to follow up and 182 (13%) had died. In 2013, when violence disrupted services, 683 patients were receiving ART. Between September-December 2013, 594 (87%) patients received runaway bags and by February 2014, 313 (53%) of these patients returned to the clinic.In Yemen, when violence erupted, patients received a health card that included a helpline to call in case of drug shortages in admission to emergency stocks; this was not possible in CAR due to lack of a functioning telephone network. One thousand six hundred fifty-five PLWHA have been enrolled in care and 1470 (89%) initiated ART; 1056 (72%) are still followed on ART, 126 (9%) were lost to follow up, and 288 (20%) died. In January 2011 clashes began and by April 2011 MSF medical activities were interrupted. Of the 363 patients receiving ART, 363 (100%) received emergency bags to cover 9 months and by February 2012, 354 (98%) patients returned to care. In March 2015 a new wave of conflict affected Yemen, forcing HIV activities to revert to contingency planning.
CONCLUSIONS
This experience provides further evidence that provision of HIV treatment and emergency drug stocks can be successfully provided to most patients in both conflict-affected settings.
Unstable settings present challenges for the effective provision of antiretroviral treatment (ART). In this paper, we summarize the experience and results of providing ART and implementing contingency plans during acute instability in the Central African Republic (CAR) and Yemen.
CASE PRESENTATION
In CAR, MSF has provided HIV care in three conflict-affected rural regions; these were put on hold throughout the acute phase of violence. "Run-away bags" containing 3 or 4 months of ART were distributed to patients at MSF facilities. Among 1820 HIV patients enrolled into care, 1440 (79%) initiated ART. By December 2016, 782 (54%) patients were still under ART, 354 (25%) have been lost to follow up and 182 (13%) had died. In 2013, when violence disrupted services, 683 patients were receiving ART. Between September-December 2013, 594 (87%) patients received runaway bags and by February 2014, 313 (53%) of these patients returned to the clinic.In Yemen, when violence erupted, patients received a health card that included a helpline to call in case of drug shortages in admission to emergency stocks; this was not possible in CAR due to lack of a functioning telephone network. One thousand six hundred fifty-five PLWHA have been enrolled in care and 1470 (89%) initiated ART; 1056 (72%) are still followed on ART, 126 (9%) were lost to follow up, and 288 (20%) died. In January 2011 clashes began and by April 2011 MSF medical activities were interrupted. Of the 363 patients receiving ART, 363 (100%) received emergency bags to cover 9 months and by February 2012, 354 (98%) patients returned to care. In March 2015 a new wave of conflict affected Yemen, forcing HIV activities to revert to contingency planning.
CONCLUSIONS
This experience provides further evidence that provision of HIV treatment and emergency drug stocks can be successfully provided to most patients in both conflict-affected settings.