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1.  Antimicrobial co-resistance patterns of gram-negative bacilli isolated from bloodstream infections: a longitudinal epidemiological study from 2002–2011 
BMC Infectious Diseases  2014;14(1):393.
Background
Increasing multidrug resistance in gram-negative bacilli (GNB) infections poses a serious threat to public health. Few studies have analyzed co-resistance rates, defined as an antimicrobial susceptibility profile in a subset already resistant to one specific antibiotic. The epidemiologic and clinical utility of determining co-resistance rates are analyzed and discussed.
Methods
A 10-year retrospective study from 2002–2011 of bloodstream infections with GNB were analyzed from three hospitals in Greater Vancouver, BC, Canada. Descriptive statistics were calculated for antimicrobial resistance and co-resistance. Statistical analysis further described temporal trends of antimicrobial resistance, correlations of resistance between combinations of antimicrobials, and temporal trends in co-resistance patterns.
Results
The total number of unique blood stream isolates of GNB was 3280. Increasing resistance to individual antimicrobials was observed for E. coli, K. pneumoniae, K. oxytoca, E. cloacae, and P. aeruginosa. Ciprofloxacin resistance in E. coli peaked in 2006 at 40% and subsequently stabilized at 29% in 2011, corresponding to decreasing ciprofloxacin usage after 2007, as assessed by defined daily dose utilization data. High co-resistance rates were observed for ceftriaxone-resistant E. coli with ciprofloxacin (73%), ceftriaxone-resistant K. pneumoniae with trimethoprim-sulfamethoxazole (83%), ciprofloxacin-resistant E. cloacae with ticarcillin-clavulanate (91%), and piperacillin-tazobactam-resistant P. aeruginosa with ceftazidime (83%).
Conclusions
Increasing antimicrobial resistance was demonstrated over the study period, which may partially be associated with antimicrobial consumption. The study of co-resistance rates in multidrug resistant GNB provides insight into the epidemiology of resistance acquisition, and may be used as a clinical tool to aid prescribing empiric antimicrobial therapy.
doi:10.1186/1471-2334-14-393
PMCID: PMC4287581  PMID: 25308184
Co-resistance; Multi-drug resistance; Gram-negative bacilli; Bloodstream infections; Antibiograms
2.  Population-Based Study of the Increased Incidence of Skin and Soft Tissue Infections and Associated Antimicrobial Use 
Antimicrobial Agents and Chemotherapy  2012;56(12):6243-6249.
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has spread rapidly throughout the world in the last decade. We sought to demonstrate the impact of the emergence of CA-MRSA in Western Canada on physician visits, incision-and-drainage procedures, and antibiotic prescribing for skin and soft tissue infections (SSTI). We used the provincial physician billing system to determine the rate of physician visits (per 1,000 population per year) of SSTI and incision-and-drainage procedures. A database capturing all outpatient prescriptions in the province was anonymously linked to associated physician billing codes to quantify prescriptions associated with SSTI. Antibiotic prescriptions (overall and class specific) were expressed as their defined daily dose (DDD) per 1,000 inhabitants per day. Between 1996 and 2008, the rate of visits for all SSTI increased by 15%, and the majority of visits did not include an incision-and-drainage procedure. The rate of antibiotic prescribing for SSTI increased by 49%. The majority of this increase was attributable to the higher rates of use of clindamycin (627%), trimethoprim-sulfamethoxazole (380%), cephalosporins (160%), and amoxicillin-clavulanate (627%). Health care utilization and antibiotic prescribing rates for SSTI, but not incision-and-drainage procedures, have increased in association with the CA-MRSA epidemic. While much of the increase in antibiotic use reflects an appropriate change to trimethoprim-sulfamethoxazole, there is room for education regarding the limitations of cephalosporins and clindamycin, given current susceptibility profiles.
doi:10.1128/AAC.00649-12
PMCID: PMC3497163  PMID: 23006762
3.  Establishing a community of practice of researchers, practitioners, policy-makers and communities to sustainably manage environmental health risks in Ecuador 
Background
The Sustainably Managing Environmental Health Risk in Ecuador project was launched in 2004 as a partnership linking a large Canadian university with leading Cuban and Mexican institutes to strengthen the capacities of four Ecuadorian universities for leading community-based learning and research in areas as diverse as pesticide poisoning, dengue control, water and sanitation, and disaster preparedness.
Methods
In implementing curriculum and complementary innovations through application of an ecosystem approach to health, our interdisciplinary international team focused on the question: “Can strengthening of institutional capacities to support a community of practice of researchers, practitioners, policy-makers and communities produce positive health outcomes and improved capacities to sustainably translate knowledge?” To assess progress in achieving desired outcomes, we review results associated with the logic framework analysis used to guide the project, focusing on how a community of practice network has strengthened implementation, including follow-up tracking of program trainees and presentation of two specific case studies.
Results
By 2009, train-the-trainer project initiation involved 27 participatory action research Master’s theses in 15 communities where 1200 community learners participated in the implementation of associated interventions. This led to establishment of innovative Ecuadorian-led master’s and doctoral programs, and a Population Health Observatory on Collective Health, Environment and Society for the Andean region based at the Universidad Andina Simon Bolivar. Building on this network, numerous initiatives were begun, such as an internationally funded research project to strengthen dengue control in the coastal community of Machala, and establishment of a local community eco-health centre focusing on determinants of health near Cuenca.
Discussion
Strengthening capabilities for producing and applying knowledge through direct engagement with affected populations and decision-makers provides a fertile basis for consolidating capacities to act on a larger scale. This can facilitate the capturing of benefits from the “top down” (in consolidating institutional commitments) and the “bottom up” (to achieve local results).
Conclusions
Alliances of academic and non-academic partners from the South and North provide a promising orientation for learning together about ways of addressing negative trends of development. Assessing the impacts and sustainability of such processes, however, requires longer term monitoring of results and related challenges.
doi:10.1186/1472-698X-11-S2-S5
PMCID: PMC3247836  PMID: 22165915
4.  Etiology of cervicitis and treatment with minocycline 
Objective:
To evaluate the etiology of cervicitis using the recommended Canadian definition, and to evaluate the efficacy and tolerability of seven days of minocycline treatment, 100 versus 200 mg at bedtime.
Design:
Randomized double-blind study with initial microbiological evaluation, and intended follow-up through 12 weeks.
Setting:
Women attending the major sexually transmitted disease clinic in Vancouver and the major teaching hospital in Winnipeg.
Population Studied:
Women with cervicitis (inclusion criteria were an off-white or yellow colour of cervical mucus when viewed on a white-tipped swab, and a mean of 10 or more polymorphonuclear leukocytes per oil immersion [× 1000] field on Gram stain of cervical mucus). Fourty-four women were enrolled but two were excluded because of contaminated cultures.
Interventions:
Treatment with two identical appearing capsules of 50 mg (100 mg dose) or 100 mg (200 mg dose) of minocycline taken at bedtime with water for seven days.
Main Results:
Of the 42 evaluable women, Chlamydia trachomatis was initially isolated from 19 (45%) and Neisseria gonorrhoeae from four (10%). The study was prematurely terminated because of an unacceptable and significantly higher frequency of adverse reactions on the higher dose regimen of minocycline – severe reactions in one (4%) on 100 mg compared with six (30%) on 200 mg (P=0.05). Major reactions were dizziness, mood alterations and nausea. Clinical parameters, but not numbers of polymorphonuclear leukocytes, improved significantly irrespective of initial microbiology or the regimen received. Cultures became and stayed negative for C trachomatis in seven of eight on minocycline 100 mg and five of six on minocycline 200 mg. Both ‘failures’ had an intervening negative culture and were re-exposed to untreated sexual partners.
Conclusions:
Although not a definitive study in terms of proving efficacy of lower dose regimens, the results are consistent with efficacy and demonstrate the significant advantage of the lower dose regimen in terms of adverse reactions.
PMCID: PMC3250768  PMID: 22346429
Cervicitis; Chlamydia trachomatis; Neisseria gonorrhoeae; Minocycline
5.  Urethral Discharge in the Male 
Canadian Family Physician  1987;33:1863-1868.
Urethritis in the male is frequent, and is almost always sexually transmitted. It is classically divided into gonorrhea, and nongonococcal urethritis. By definition, men with gonorrhea have Neisseria gonorrhoeae present, but approximately 20% also have Chlamydia trachomatis. C. trachomatis is present in 30%-50% of men with acute nongonococcal urethritis. The specific etiologic diagnosis requires laboratory evaluation. Recommended treatment for urethritis includes a one-week regimen of a tetracycline for all men, plus a single-dose regimen active against N. gonorrhoeae in men in whom gonorrhea is proven or has not been excluded. Partners should be investigated and should receive similar treatment. Recurrence of nongonococcal urethritis is frequent after treatment, but the condition is only rarely the result of persistent C. trachomatis infection. Men with recurrent urethritis require re-evaluation. If no cause is found or if Ureaplasma urealyticum is isolated, the men are treated with a two-week course of erythromycin. If there are subsequent recurrences, they are usually left untreated.
PMCID: PMC2218242  PMID: 21263808
urethritis; males; sexually transmitted diseases
6.  Coordinated Response to SARS, Vancouver, Canada 
Emerging Infectious Diseases  2006;12(1):155-158.
Two Canadian urban areas received travelers with severe acute respiratory syndrome (SARS) before the World Health Organization issued its alert. By July 2003, Vancouver had identified 5 cases (4 imported); Toronto reported 247 cases (3 imported) and 43 deaths. Baseline preparedness for pandemic threats may account for the absence of sustained transmission and fewer cases of SARS in Vancouver.
doi:10.3201/eid1201.050327
PMCID: PMC3291383  PMID: 16494736
SARS; emerging pathogens; outbreak; nosocomial infections; coronavirus; dispatch
7.  Perspectives on emerging zoonotic disease research and capacity building in Canada 
Zoonoses are fundamental determinants of community health. Preventing, identifying and managing these infections must be a central public health focus. Most current zoonoses research focuses on the interface of the pathogen and the clinically ill person, emphasizing microbial detection, mechanisms of pathogenicity and clinical intervention strategies, rather than examining the causes of emergence, persistence and spread of new zoonoses. There are gaps in the understanding of the animal determinants of emergence and the capacity to train highly qualified individuals; these are major obstacles to preventing new disease threats. The ability to predict the emergence of zoonoses and their resulting public health and societal impacts are hindered when insufficient effort is devoted to understanding zoonotic disease epidemiology, and when zoonoses are not examined in a manner that yields fundamental insight into their origin and spread.
Emerging infectious disease research should rest on four pillars: enhanced communications across disciplinary and agency boundaries; the assessment and development of surveillance and disease detection tools; the examination of linkages between animal health determinants of human health outcomes; and finally, cross-disciplinary training and research. A national strategy to predict, prevent and manage emerging diseases must have a prominent and explicit role for veterinary and biological researchers. An integrated health approach would provide decision makers with a firmer foundation from which to build evidence-based disease prevention and control plans that involve complex human/animal/environmental systems, and would serve as the foundation to train and support the new cadre of individuals ultimately needed to maintain and apply research capacity in this area.
PMCID: PMC2094993  PMID: 18159512
Emerging disease; Epidemiology; Zoonoses
8.  Perspectives on emerging zoonotic disease research and capacity building in Canada. 
Zoonoses are fundamental determinants of community health. Preventing, identifying and managing these infections must be a central public health focus. Most current zoonoses research focuses on the interface of the pathogen and the clinically ill person, emphasizing microbial detection, mechanisms of pathogenicity and clinical intervention strategies, rather than examining the causes of emergence, persistence and spread of new zoonoses. There are gaps in the understanding of the animal determinants of emergence and the capacity to train highly qualified individuals; these are major obstacles to preventing new disease threats. The ability to predict the emergence of zoonoses and their resulting public health and societal impacts are hindered when insufficient effort is devoted to understanding zoonotic disease epidemiology, and when zoonoses are not examined in a manner that yields fundamental insight into their origin and spread. Emerging infectious disease research should rest on four pillars: enhanced communications across disciplinary and agency boundaries; the assessment and development of surveillance and disease detection tools; the examination of linkages between animal health determinants of human health outcomes; and finally, cross-disciplinary training and research. A national strategy to predict, prevent and manage emerging diseases must have a prominent and explicit role for veterinary and biological researchers. An integrated health approach would provide decision makers with a firmer foundation from which to build evidence-based disease prevention and control plans that involve complex human/animal/environmental systems, and would serve as the foundation to train and support the new cadre of individuals ultimately needed to maintain and apply research capacity in this area.
PMCID: PMC2831550  PMID: 15759832
9.  Measurement of antibiotic consumption: A practical guide to the use of the Anatomical Thgerapeutic Chemical classification and Definied Daily Dose system methodology in Canada 
Despite the global public health importance of resistance of microorganisms to the effects of antibiotics, and the direct relationship of consumption to resistance, little information is available concerning levels of consumption in Canadian hospitals and out-patient settings. The present paper provides practical advice on the use of administrative pharmacy data to address this need. Focus is made on the use of the Anatomical Therapeutic Chemical classification and Defined Daily Dose system. Examples of consumption data from Canadian community and hospital settings, with comparisons to international data, are used to incite interest and to propose uses of this information. It is hoped that all persons responsible for policy decisions regarding licensing, reimbursement, prescribing guidelines, formulary controls or any other structure pertaining to antimicrobial use become conversant with the concepts of population antibiotic consumption and that this paper provides them with the impetus and direction to begin accurately measuring and comparing antibiotic use in their jurisdictions.
PMCID: PMC2094921  PMID: 18159441
Antibacterial agents; Drug utilization; Pharmacoepidemiology
10.  Availability and estimates of veterinary antimicrobial use in British Columbia 
The Canadian Veterinary Journal  2004;45(4):309-311.
Abstract
The amount of antimicrobial use is a significant selection pressure that alters the frequency of antimicrobial resistance. This paper summarizes attempts to estimate the weight of antimicrobial purchases in British Columbia for use in animals. The data reported here do not capture all sources of veterinary antimicrobial use in British Columbia. This paper highlights how information deficits on veterinary drug use complicate the development of an evidence-based policy framework for combating antimicrobial resistance.
PMCID: PMC548615  PMID: 15144102
11.  Novel Cryptosporidium Genotypes in Sporadic Cryptosporidiosis Cases: First Report of Human Infections with a Cervine Genotype 
Emerging Infectious Diseases  2002;8(3):263-268.
In this study, we genotyped parasites from the fecal specimens of sporadic cryptosporidiosis cases in British Columbia from 1995 to 1999. Genotyping was conducted by polymerase chain amplification of the internal transcribed spacer region, a hypervariable region in the 18S rRNA gene and the Cryptosporidium oocyst wall protein gene. Subsequent analysis was by restriction fragment length polymorphism and DNA sequencing. We identified two new Cryptosporidium genotypes in humans. One of these genotypes has been found recently in deer in New York state. The other genotype has not been identified in humans or animals. These results have important implications for drinking water quality strategies, especially for communities that obtain drinking water supplies from surface sources located in forested regions with deer populations.
doi:10.3201/eid0803.010194
PMCID: PMC2732472  PMID: 11927023
Cryptosporidium; cryptosporidiosis; molecular; genotype; polymerase chain reaction; restriction fragment length polymorphism; 18S rRNA; sequencing
12.  Detection of Toxoplasma gondii Oocysts in Drinking Water 
The world’s largest outbreak of waterborne toxoplasmosis occurred in a municipality in the western Canadian province of British Columbia. When drinking water emerged as a possible source of infection during the outbreak investigation, a laboratory method was needed to attempt detection of the parasite, Toxoplasma gondii. The method developed was based on the current U.S. Environmental Protection Agency method for detection of Cryptosporidium oocysts. Collection of large-volume drinking water samples and cartridge filter processing were unchanged, although identification of Toxoplasma oocysts in the filter retentate was carried out by using a previously described rodent model. Validation of the method developed was tested by using oocysts from a well-characterized Toxoplasma strain.
PMCID: PMC106314  PMID: 9603850
13.  Need for treatment of gonorrhea to be effective against Chlamydia trachomatis 
Men and women with gonorrhea or contact to gonorrhea are frequently co-infected with Chlamydia trachomatis. To assess the importance of using treatment regimens active against both Neisseria gonorrhoeae and C trachomatis, tetracycline 500 mg orally four times daily for five days, with activity against both organisms, was compared with ceftriaxone, 250 mg once intramuscularly, with activity against only N gonorrhoeae. N gonorrhoeae microbiological failure occurred in six of 148 patients (4%) on tetracycline and zero of 85 on ceftriaxone. Microbiological failure for C trachomatis occurred in zero of 27 on tetracycline and 10 of 12 (83%) on ceftriaxone (P<0.001). In addition, 14 others on ceftriaxone had C trachomatis first isolated after treatment. When all types of microbiologialc and clinical failures are included, outcome was significantly better on tetracycline (P<0.001). Optimal treatment of patients with gonorrhea must include regimens with activity against both C trachomatis and N gonorrhoeae.
PMCID: PMC3250770  PMID: 22346471
Ceftriaxone; Chlamydia trachomatis; Gonorrhea; Neisseria gonorrhoeae; Tetracycline
14.  Rapid Presumptive Identification of Gardnerella vaginalis (Haemophilus vaginalis) from Human Blood Agar Media 
Journal of Clinical Microbiology  1981;14(1):108-110.
Presumptive identification of Gardnerella vaginalis from 48-h human blood agar cultures by using a Gram stain, hemolysis, and colonial morphology was highly accurate.
PMCID: PMC271910  PMID: 6973571

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