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Background The increasing prevalence of drug-resistant Neisseria gonorrhoeae(NG) infections has caused great concern. Ciprofloxacin remains the empiric antimicrobial recommended to treat NG infections in Peru disregarding the susceptibility profile of circulating NG strains. We report the prevalence of individuals infected with NG strains presenting mutations in the gyrAgene that confers ciprofloxacin resistance.Methods We conducted a descriptive study assessing extragenital swab samples collected from a cohort of men who have sex with men and transgender women in Lima, Peru. Anal and pharyngeal NG positive swabs for Aptima Combo 2 assay (Hologic Inc., USA) were used for DNA extraction. We performed TaqMan real time PCR assays to detect a point mutation at codon Ser91 of the gyrase A (gyrA) gene.Results From 156 individuals who had at least one positive sample for NG reported by the Aptima assay, 80 individuals had at least one amplified DNA for the gyrAgene. We found that 67 of them (84.0%) were infected with a gyrA-mutated NG strain at the Ser91 codon.Conclusions We report a high prevalence of gyrAmutation conferring ciprofloxacin resistance among individuals with extragenital NG infection. Empirical treatment of NG needs to be urgently updated in Peru in concordance with international guidelines.

Introduction: Rotavirus (RV) infection is the leading cause of severe diarrhea in children worldwide. It is responsible for around 25% of gastroenteritis (GE) cases, 33% of hospitalized GE cases, and an annual mortality rate of 113.4/100,000 in children < 5 years of age in Peru. RV infant vaccination is recommended by the World Health Organization and provides the best public health strategy to manage the disease. Universal RV vaccination was introduced in Peru in 2009. Methods: Trends in GE ambulatory visits, hospitalizations, and deaths in children < 5 years of age are described in the pre-vaccination (2004–2008) versus post-vaccination (2010–2018) periods. Time-trend analysis was performed (using generalized linear regression models) to assess the impact of vaccination nationwide and by region after adjusting for variables. Results: Between 2009 and 2011, vaccination coverage increased to over 80% in Peru. In infants < 1 year of age, GE ambulatory cases, hospitalizations, and deaths decreased in the post-vaccination period by 40.3%, 46.2%, and 55.5%, respectively (and in children < 5 years of age, by 34.4%, 41.9%, and 54.3%, respectively) compared with the pre-vaccination period. Results of the multivariate time-trend analysis also found significant decreases in the post-vaccination period of 10.7% (GE ambulatory cases), 17.2% (GE hospitalizations), and 37.3% (GE mortality) in children < 5 years of age. Data analyzed by region varied, with Costa and Sierra regions generally in line with the national findings; however, some findings were less robust for Selva due to fewer available data. Conclusion: After 9 years of RV vaccination in Peru, there appears to be a statistically significant positive impact of vaccination, in terms of reducing GE-related mortality, hospitalizations, and ambulatory visits in infants and young children. For policymakers to understand regional differences and future vaccination needs, continued improvement in surveillance is needed. Graphical Abstract:

Parasites can cause respiratory symptoms through focal or diffuse lung involvement, depending on the location of the parasite and the host's immune response. Pulmonary involvement can be a major feature of some parasitic infections or a complication during transpulmonary larval migration. Parasites should be included in the differential diagnosis of common lung diseases, especially in the presence of peripheral eosinophilia or extrapulmonary symptoms (abdominal pain, diarrhea, jaundice, skin lesions).

We evaluated the presence of sIgA in saliva, versus Escherichia colisecreted proteins (Esp) related to the type III secretion system (T3SS), and its semi-quantitative concentration in children under 2 years-old (no longer breastfed) who were previously colonized or infected with enteropathogenic E. coli(EPEC).

Antimicrobial resistance (AMR) is an urgent global health challenge and a critical threat to modern health care. Quantifying its burden in the WHO Region of the Americas has been elusive—despite the region’s long history of resistance surveillance. This study provides comprehensive estimates of AMR burden in the Americas to assess this growing health threat.

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•Escherichia colifrom bacteraemia in Peruvian children have high levels of antimicrobial resistance.•Widespread of blaCTX-M-15and first description of blaCTX-M-65in Peru.•Relevant role of efflux pump overexpression in azithromycin resistance.•Low number of transferable mechanisms of quinolone resistance among bacteraemic E. coli.•Mph(A) was the most frequent transferable mechanisms of macrolide resistance.

Lactoferrin (LF) is a broad-spectrum antimicrobial and immunomodulatory milk glycoprotein.

Some enteropathogens use the type III secretion system to secrete proteins that allows them to interact with enterocytes and promote bacterial attachment or intracellular survival. These proteins are Salmonellainvasion proteins (Sip), invasion plasmid antigens (Ipa) of Shigellaand Escherichia colisecreted proteins (Esp) of enteropathogenic E. coli. There are no previous studies defining the presence of colostral sIgA against all these 3 major enteric pathogens.

Enteropathogenic Escherichia coli(EPEC) is an important diarrheal pathogen of young children. As the diagnosis of EPEC is now based mainly on molecular criteria, there has been an important change in its prevalence. The purpose of this study is to review the current epidemiology of EPEC infection and the new insights into its physiopathology.

ABSTRACTThe purpose of this study was to determine the presence and quantity of fecal leukocytes in children infected with diarrheagenic Escherichia coliand to compare these levels between diarrhea and control cases. We analyzed 1,474 stool samples from 935 diarrhea episodes and 539 from healthy controls of a cohort study of children younger than 2 years of age in Lima, Peru. Stools were analyzed for common enteric pathogens, and diarrheagenic E. coliisolates were studied by a multiplex real-time PCR. Stool smears were stained with methylene blue and read by a blinded observer to determine the number of polymorphonuclear leukocytes per high-power field (L/hpf). Fecal leukocytes at >10 L/hpf were present in 11.8% (110/935) of all diarrheal episodes versus 1.1% (6/539) in controls (P< 0.001). Among stool samples with diarrheagenic E. colias the only pathogen isolated (excluding coinfection), fecal leukocytes at >10 L/hpf were present in 8.5% (18/212) of diarrhea versus 1.3% (2/157) of control samples (P< 0.01). Ninety-five percent of 99 diarrheagenic E. colidiarrhea samples were positive for fecal lactoferrin. Adjusting for the presence of blood in stools, age, sex, undernutrition, and breastfeeding, enterotoxigenic E. coli(ETEC) isolation as a single pathogen, excluding coinfections, was highly associated with the presence of fecal leukocytes (>10 L/hpf) with an odds ratio (OR) of 4.1 (95% confidence interval [CI], 1.08 to 15.51; P< 0.05). Although diarrheagenic E. coliwas isolated with similar frequencies in diarrhea and control samples, clearly it was associated with a more inflammatory response during symptomatic infection; however, in general, these pathogens elicited a mild inflammatory response.

Objective. To determine the epidemiology of invasive pneumococcal disease (IPD) and the antibiotic susceptibility and serotype distribution of S. pneumoniae in pediatric patients in Lima, Peru. Methods. A 2-year, multicenter, passive surveillance study conducted from May 2006- April 2008 in 11 public hospitals and five private laboratories in Lima, Peru, in patients less than 16 years of age with sterile site cultures yielding S. pneumoniae. Antibiotic susceptibility was performed by Etest® (AB Biodisk, Solna, Switzerland). Strains were serotyped by the Quellung reaction. Results. In all, 101 IPD episodes were studied, 68.3% of which were among children less than 24 months of age. Diagnoses were: pneumonia (47.5%), meningitis (38.6%), and sepsis (7.9%). The overall case fatality rate was 22.0%; case fatality rate in meningitis was 32.4%. While 80.0% of fatal cases were in those less than 24 months of age, only 50.7% of non-fatal cases (P < 0.05) were in this age group. Resistance rates were high for trimethoprim/sulfamethoxazole (76.2%), erythromycin (24.8%), and penicillin (22.8%). The most common serotypes were 14, 6B, 19F, 23F, and 5, which accounted for 69.7% of all strains and 87.0% of penicillin non-susceptible strains. Conclusion. IPD in hospitalized children in Lima is associated with high antimicrobial resistance levels and elevated case fatality rate, especially in young children. This baseline data will be useful for evaluating the effects of vaccine introduction. [ABSTRACT FROM AUTHOR]

ABSTRACTDiarrheagenic Escherichia colistrains are important causes of diarrhea in children from the developing world and are now being recognized as emerging enteropathogens in the developed world. Current methods of detection are too expensive and labor-intensive for routine detection of these organisms to be practical. We developed a real-time fluorescence-based multiplex PCR for the detection of all six of the currently recognized classes of diarrheagenic E. coli. The primers were designed to specifically amplify eight different virulence genes in the same reaction: aggRfor enteroaggregative E. coli, stIa/stIband ltfor enterotoxigenic E. coli, eaeAfor enteropathogenic E. coliand Shiga toxin-producing E. coli(STEC), stx1and stx2for STEC, ipaHfor enteroinvasive E. coli, and daaDfor diffusely adherent E. coli(DAEC). Eighty-nine of ninety diarrheagenic E. coliand 36/36 nonpathogenic E. colistrains were correctly identified using this approach (specificity, 1.00; sensitivity, 0.99). The single false negative was a DAEC strain. The total time between preparation of DNA from E. colicolonies on agar plates and completion of PCR and melting-curve analysis was less than 90 min. The cost of materials was low. Melting-point analysis of real-time multiplex PCR is a rapid, sensitive, specific, and inexpensive method for detection of diarrheagenic E. coli.

ABSTRACTDiarrhea in children is often caused by enteropathogen infections that might benefit from early empirical antibiotic therapy. However, when the definition of the pathogen requires sophisticated laboratory studies, the etiology of enteritis is not known early in illness. Empirical therapy may be dangerous if the child is infected with a Shiga toxin-producing Escherichia coli(STEC) strain because antimicrobials may increase Shiga toxin (Stx) release, resulting in increased risk of microangiopathic hemolytic anemia with acute renal failure (hemolytic-uremic syndrome [HUS]) and death. There is a need for antimicrobials that would be effective against multiple bacterial enteropathogens yet not induce Stx release or increase the risk of HUS. Rifaximin has been evaluated in adults for treatment of bacterial enteritis and has a good record for safety and efficacy, but it has not been evaluated extensively in children with gastroenteritis. We therefore evaluated rifaximin's potential for phage induction, drug-induced bacteriolysis, and toxin release in 57 STEC strains (26 O157 and 31 non-O157 strains). Growth in ciprofloxacin, a known Stx phage inducer, caused bacteriolysis and release of toxin in 25/26 (96%) O157 strains and 15/31 (48%) non-O157 strains. In contrast, rifaximin did not induce phage replication or lysis in any strain. Toxin release in the presence of rifaximin was not different from release in the absence of antibiotic. Rifaximin, unlike many antibiotics used to treat pediatric gastroenteritis, does not induce phage-mediated bacteriolysis and Stx release.

Enteropathogenic Escherichia coli (EPEC) is an important cause of infant diarrhea in developing countries. EPEC uses a type III secretory system to deliver effector proteins into the host cell. These proteins cause the characteristic attaching and effacing lesion on enterocytes. Lactoferrin, a glycoprotein present in human milk, inhibits EPEC adherence to mammalian cells. To determine the effect of lactoferrin on the initial host cell attachment step that is mediated by the type III secretory system, we focused on EPEC-induced actin polymerization in HEp2 cells, on the hemolytic activity, and on measurement of E. coli secreted proteins A, B, and D (EspABD). Lactoferrin blocked EPEC-mediated actin polymerization in HEp2 cells and blocked EPEC-induced hemolysis. The mechanism of this inhibition was lactoferrin-mediated degradation of secreted proteins necessary for bacterial contact and pore formation, particularly EspB. The proteolytic effect of lactoferrin was prevented by serine protease inhibitors. This disruption of the type III secretory system implies that lactoferrin could provide broad cross protection against the enteropathogens that share this mechanism.

The Shiga toxin-producing Escherichia colistrains, such as E. coliO157:H7, have emerged as major diarrheal pathogens both in the United States and elsewhere. These organisms are important because gastrointestinal infection (afebrile hemorrhagic colitis) can trigger microangiopathic hemolytic anemia and renal failure (hemolytic uremic syndrome). Understanding the pathophysiology of this illness is likely to lead to important new treatment interventions.

Shigella species cause bacillary dysentery in humans by invasion, intracellular multiplication, spread to adjacent cells, and induction of brisk inflammatory responses in the intestinal epithelium. In vitro data suggest that lactoferrin, a glycoprotein present in human mucosal secretions, has a role in protection from bacterial enteric infections. We sought to determine the activity of lactoferrin in vivo, using the concentration present in human colostrum, to investigate its effect on the development of clinical and pathological evidence of inflammation in a rabbit model of enteritis. Lactoferrin protected rabbits infected with Shigella flexneri from developing inflammatory intestinal disease. Typical histological changes in ill animals included villous blunting with sloughing of epithelial cells, submucosal edema, infiltration of leukocytes, venous congestion, and hemorrhage. Lactoferrin at a concentration normally found in human colostrum blocks development of S. flexneri-induced inflammatory enteritis.

ABSTRACTThis study aims to characterize the presence of virulence factors of enterotoxigenic Escherichia coli(ETEC) causing traveler's diarrhea. Among 52 ETEC isolates, the most common toxin type was STh, and the most frequent colonization factors (CFs) were CS21, CS6, and CS3. On the other hand, the nonclassical virulence factors EAST1 and EatA were frequently present.

Shiga toxin-producing Escherichia coli(STEC) is not routinely sought in clinical laboratories in developing counties. Among 131 bloody diarrhea samples in Peruvian children <5 years of age, STEC was found in 9.2 and was associated with absence of fever, an observation that may increase suspicion of these pathogens. Because of the significant prevalence of STEC locally, proper diagnostics methods should be implemented in the region.

Airway obstruction associated with Pott's disease is rare. We present a case of severe airway obstruction caused by an extensive paravertebral mediastinal abscess in a 3-year-old boy with tuberculosis of the thoracic spine.

In an active diarrhea surveillance study of children aged 12–24 months in Lima, Peru, norovirus was the most common pathogen identified. The percentage of mixed (bacterial and noroviral) infections was significantly higher among norovirus-positive samples (53%) than among norovirus-negative samples (12%). The combination of norovirus with the most common bacterial pathogens was associated with increased clinical severity over that of either single-pathogen norovirus or single-pathogen bacterial infections.

Objective. To 1) describe the correlation between the zones of inhibition in 1-µg oxacillin disk diffusion (ODD) tests and penicillin and ceftriaxone minimum inhibitory concentrations (MICs) of meningeal and non-meningeal strains of Streptococcus pneumoniae and 2) evaluate the usefulness of the ODD test as a predictor of susceptibility to penicillin in S. pneumoniae and as a quick and cost-effective method easily implemented in a routine clinical laboratory setting. Methods. S. pneumoniae isolates from healthy nasopharyngeal carriers less than 2 years old, obtained in a multicentric cross-sectional study conducted in various Peruvian hospitals and health centers from 2007 to 2009, were analyzed. Using Clinical and Laboratory Standards Institute (CLSI) breakpoints, the correlation between the zones of inhibition of the ODD test and the MICs of penicillin and ceftriaxone was determined. Results. Of the 571 S. pneumoniae isolates, 314 (55%) showed resistance to penicillin (MIC ≥ 0.12 µg/mL) and 124 (21.7%) showed resistance to ceftriaxone (MIC > 1 µg/mL). Comparison of the ODD test zones of inhibition and the penicillin MICs, using the CLSI meningeal breakpoints, showed good correlation (Cohen's kappa coefficient = 0.8239). Conclusions. There was good correlation between ODD zones of inhibition and penicillin meningeal breakpoints but weak correlation between the ODD results and non-meningeal breakpoints for both penicillin and ceftriaxone. Therefore, the ODD test appears to be a useful tool for predicting penicillin resistance in cases of meningeal strains of S. pneumoniae, particularly in low- and middle- income countries, where MIC determination is not routinely available. [ABSTRACT FROM AUTHOR]

Objective. To describe the use of antibiotics in Peruvian children under 1 year in a setting where they are available without a prescription. Methods. Data were analyzed from a cohort study between September 2006 and December 2007 of 1 023 children < 2 months old in periurban Lima, Peru, followed until they were 1 year old. Results. Seven hundred seventy of 1 023 (75.3%) children took 2 085 courses of antibiotics. There were two courses per child per year (range 0-12). Higher rates of antibiotic use were found in children 3-6 months old (37.2%). Antibiotics were given to children for 8.2% of common colds, 58.6% of all pharyngitis, 66.0% of bronchitis, 40.7% of diarrheas, 22.8% of dermatitis, and 12.0% of bronchial obstructions. A physician's prescription was the most common reason for antibiotic use (90.8%). Medication use without a prescription was found in 6.9% of children, and in 63.9% of them it was preceded by a physician's prescription. Conclusions. Infants are often exposed to antibiotics in this setting. Overuse of antibiotics is common for diagnoses such as pharyngitis, bronchitis, bronchial obstruction, and diarrhea but is typically inappropriate (83.1% of courses) based on the most common etiologies for this age group. Interventions to improve the use of antibiotics should focus on physicians, since a physician's prescription was the most common reason for antibiotic use. [ABSTRACT FROM AUTHOR]