PUBH6005 Epidemiology

Question:

Antimicrobial resistance is an emerging global public health problem that has been linked to the use of antibiotics by the livestock industry, doctors over prescribing antibiotics and people not taking a full course of antibiotics.

Construct a research question that seeks to address a specific aspect of the issue of antimicrobial resistant bacteria.

Select 5 studies relevant to your research question about antimicrobial resistant bacteria (a mixture of observational and RCTs, supporting and not supporting the hypothesis).

Rank the studies according to the FORM (Hillier et al., 2011) or GRADE levels of evidence (The GRADE Working Group, 2008).

Review the frameworks in the Learning Resources (Bonita et al., 2006, Rychetnick et al.,2006, Young & Solomon, 2009 and the critical appraisal skills program (CASP) checklist).

Answer:

Introduction

Antibiotics are the group of drugs which are used by physicians to treat several bacterial infection (Young & Solomon, 2009). However, due to several genetic, and environmental factors as well as physiological changes within the host, the bacteria evolves itself in such a way that leads to change the response of the drug on it, leading to the emergence of antibiotic resistance (Skelly, Dettori & Brodt, 2012). As this phenomenon is spreading in increasing pace throughout the world, the world is facing tremendous problems associated with antibiotic resistance, increasing emergence of superbug is the primary concern among these. There are several issues such as proving the antibiotics without prescription for the animal as well as human use, not completing the prescribed course and the increasing level of mutation within bacterial cells are supreme among them. As per the report of World health organization (2015), in most part of the world, overdose of antibiotics are provided without any proper supervision or and is consumed by a large section of public for human and animal use (Bonita, Beaglehole & Kjellström, 2006). Hence, the WHO indicated that the human civilization is again approaching the time when a common disease can kill a person due to increased antibiotic resistance. In this assignment, discussion about antibiotic resistance and its association with livestock and emergence of superbugs will be discussed in the modern context. The GRADE Working Group (2004) mentioned that in the United States of America, more than 80% of antibiotic produced are utilized for the consumption of animals to make them disease free which increases the risk of superbug emergence. Therefore, this assignment will try to comply the emergence of superbug with utilization of antibiotics for livestock and for this purpose, will conduct a critical review using five research articles (Rychetnick et al., 2002). The research question of this assessment will be: Is antibiotic usage for livestock is the reason for the increased number of superbug emergence throughout the world?

Method

While discussing the methodology, the search strategy utilized for identification of five research articles used in the critical review for this assignment should be discussed (NHMRC, 2009). To find the research articles, different databases such as Google scholar, PubMed, CINAHL, and Medscape was searched for livestock associated superbug mergence related articles. The keywords, which were used for this purpose was ‘antibiotic resistance or resistance to antibiotic medication and ‘livestock or animals’ and ‘emergence of superbug or increasing amount of superbug’ and ‘antibiotic resistance and associated superbug emergence’. These key terms were searched with different permutation and combinations throughout the four databases. The exclusion criteria included articles where livestock was used as secondary subject and others were the research was not completely based on animal use of antibiotics. This leads to refine the search and from 31 different literatures, the five articles were chosen for this assessment. Further the CASP tool was used for the review of all the five articles.

Results

The level of evidence for all the five articles are as follows:

Article no.	Type of study	Level of evidence	Citation
1	Systematic Review article	Level 1	(Fitzgerald, 2012)
2	Prospective study	Level 1	(Nadimpalli et al., 2015)
3	Sensitivity analysis study	Level 1	(Zhu et al., 2013)
4	Cross sectional study	Level 2	(Rinsky et al., 2013)
5	Prospective study	Level 1	(Liu et al., 2013)

The critical appraisal of the articles using CASP tool is as follows:

Article 1
Parameters	Response
Mention of a clearly focused question	Yes, the systematic review included a clearly focused question sit included a population for the study, an intervention for the focused question and the outcome was also included in the review.
The authors included correct paper for the review	The paper was able to include different bacterial species found in the animals or poultry which are being used for human purposes and then used their finding sot determine the research question.
All the relevant and important papers were included in the study	The papers that were included in the study were relevant to the research study and the research question
The original papers included enough research to determine the assessment question	This cannot be determined as the researches that were included in the study were completely focused on the staphylococcus aureus and associated resistance in livestock animals whereas, there are several other bacterial strains are present that can become resistant to the used antibiotic.
If the result of the review was combined, is it appropriate?	No the result of the review was not combined, there were 8 sections of the systematic review and separate results were attached with all the sections. Therefore, the result was not appropriate as a combine result would have able to prove the research question in a proper way.
What is the result of the complete review?	The result of the review was holistic as from bovine animals to poultry, their host specificity and their association with human and livestock related infection was determine din the review article.
Results are precise or not	The results of the systematic review was precise as all the papers which was included in the study, determine the linkage between antibiotic resistance and the effect of livestock animals on the emergence of superbugs.
Is it possible to apply the result on local population?	This cannot be determined as in the lack of a common result, the future application of the study results cannot be assessed.
Each important outcome was given importance	Yes, as associated with use of antibiotics for animal purpose, this review was able to discuss each animals associated with human use and consumption so that emergence of resistance and superbugs can be complied.
The harms and costs of the study was less than the benefit of the review	As this was a review article, there were no subject or experiment related harm that occurred during the study and hence, the portion of benefit was higher than harm or cost.

Article 2
Parameters	Response
Did the research address a clear and focused issue?	Yes, it was clearly in the research aim and objectives that the research wants to determine the level of nasal carriage of livestock-associated S. aureus among the workers working in such facilities
The assignment of subject to treatment was randomized or not	For this purpose, the research occurred with industrial hog operation workers however, the assignment of subjects for research groups such as trail group and control group was randomized.
All the subject that were included in the study, accounted for its conclusion	As the study included all the working in such environment and assessed them for specific time limit, all the subject was responsible for accounting to the conclusion.
Were all the subjects included in the assessment were blind to the treatment?	Yes, the subjects were not informed about the research study and after observational study, they were assessed for detection of nasal carriage of antibiotic resistant staphylococcus aureus.
The groups were similar at the start of trial or not	As the workers of the factory was included all the study, no changes in the group was noticed by the researchers while conducting the study.
The groups were treated equally or not?	Yes, all the groups included in the study were treated equally other than research aspect but on ethical ground so that the dignity of the workers can be maintained.
The effect of the treatment lasted for how long?	This cannot be determined form the study as the primary aim of the research was to determine the presence of antibiotic resistance staphylococcus aureus in the body of the workers working in the industrial hog operation.
How correct the estimated effect was?	The researchers already expected that due to methicillin resistant staphylococcus aureus, al the workers will have increased MRSA levels and this estimation was correct.
Is the result found from the research is applicable to local population	Yes, this is applicable to local population as well as due to presence of the hog factory in the environment, other people, who are away from the factory also has the chances to possess MRSA that could affect their healthcare status.
The paper included all the clinically important outcomes of the study	Yes, the paper included all the important aspect of MRSA in the workers working in factories where the animals are provided with antibiotics to protect them for bacterial infections.
The benefits worth the costs of the research or not	The cost of the assessment was not associated with the workers as they used to work in such environment from a long time. Therefore, the benefit of the research was much higher than that of the cost or harm.

Article 3
Parameter	Responses
Aim of the assignment was mentioned clearly	Yes, the aim of the study was clearly mentioned as the primary aim to to identify any antibiotic resistant gene present on the animal farms of China.
As the method of research is qualitative	Yes, the research was qualitative as the high capacity quantitative PCR was used to detect the unique antibiotic resistant genes or ARGs in the subjects.
Research design was proper and determined the aim of the research	The researchers used the same method to determine the presence of ARGs in the swine farms throughout china and in this purpose they assessed more than 10,000 animals. Therefore the research process was appropriate.
Was the requirement was appropriate to the aim of research	As the research was able to meet the objective of the study, the requirement was appropriate to the aim of the research
The way of data collection helped to address the research issue	As the data was collected after determination of ARGs within the swine of farms, the data collection was appropriate. and helped to address the research issue
The relationship between subject and researchers were mentioned properly	This cannot be determined as the subject of the research was animals
Ethical issues were considered properly	This also cannot be determined as there is no mention of ethical consideration while working with animals in the research paper.
The data analysis process was sufficient and rigorous	Yes, the data analysis was rigorous as there is a possibility of error while conducting the research, therefore, the data analysis were inclusive of bias and errors which should be excluded.
The findings were clearly stated	Yes, the findings were clearly stated that Resistance gene diversity and abundance patterns were identified after the completion of the study.
the value of the research	The value of the research is important as it determined that monitored use of antibiotics and metal for the disease prevention of animals can be harmful for the human society.

Article 4

Parameters

Response

Mention of a clearly focused question within the study

Yes, the research article completely focused the study on identification of industrial zones, which are affected with methicillin resistant staphylococcus aureus (MRSA).

Is the method used for research is able to answer the research question?

The research method, cross sectional study was able to determine the increasing risk of MRSA in workers associated with industrial livestock operations.

Selection of the subject is clearly described

Yes, the subject selection was properly described in the article.

The sampling process included bias or not

The selection of the subjects had several inclusion and exclusion criteria such as age, ethnicity, lingual preferences that increased the chances of bias as the workers having the knowledge of English and Spanish were chosen for the study.

Was the sample of the subjects were able to refer to the population?

Yes, the sample size was able to refer to the population as a huge amount of workers were enrolled for the study.

The sample size was based on the pre study statistical power

This cannot be determined as the research article did not mentioned any pre study statistical analysis of the topic.

Response rate was satisfactory

The response rate of the workers was satisfactory as they followed the instructions.

Measurements were reliable and valid

Yes, it was valid and reliable. The researchers depended on collection of swab for the identification of MRSA within industrial livestock operations and antibiotic-free livestock operation workers.

Statistical significance was assessed

Yes, the research calculated the statistical significance of the results. the prevalence of nasal carriages of staphylococcus aureus was calculated for both the groups and also calculated the link between demographic and environmental factors to adjust the prevalence ratio or PR.

The main results included confidence intervals

Yes, the main result of the research study included the 95% confidence interval.

Confounding factors were accounted or not

No confounding factors were accounted in this assessment more than the independent variable

Results are applicable in future studies or not

Yes, the findings of this research are applicable for future studies as it indicated towards the need of systematic national surveillance for prevention of such incidences.

Article 5
Parameters	Responses
Did the research address a clear and focused issue?	Yes, the research was able to focus on a clear research question for the assessment.
The involvement of subject to treatment was randomized or not	It is not clear from the research study that the involvement of the subject in the process was randomized as there were only two groups, research group and the control group.
All the subject that were included in the study, accounted for its conclusion	Yes, all the subject that were included in the study, were responsible for it.
Were all the subjects included in the assessment were blind to the treatment?	It is also not clear as the subject of the study are animals.
The groups were similar at the start of trial or not	Yes, all the animals that were included in the study, observed for the entire trial.
The groups were treated equally or not?	Yes, all the research and control groups included in the study was treated equally.
The effect of the treatment lasted for how long?	This cannot be determine as the aim of the study was to identify the veterinary antibiotics and antibiotic resistance gene residues in swine wastewater.
How correct the estimated effect was?	The estimated effect was completely correct as the researchers were able to find the antibiotic resistance gene in the host body
Is the result found from the research is applicable to local population	Yes, the research results are applicable to the local population of animals as the excessive use of antibiotic resistance is effective.
The paper included all the clinically important outcomes of the study	It cannot be determined from the assessment as the research was able to find its primary aim from the study

Discussion

All these articles were inclusive of the research question mentioned in this assignment, however, several factors that included more in the study and should be termed as the highest quality study. The study by Rinsky et al. (2013) was one of the high quality study as it was able to directly mention the effect if proving livestock animals with antibiotic sin the emergence of antibiotic resistance. It showed the emergence of antibiotic resistant bacteria in the nasal cavity of ILO and AFLO exposed individuals. Besides these study by Nadimpalli et al. (2016) was also high quality as it was able to establish the link between emergence of antibiotic resistant bacteria and the workers working with such animals, who are provided with antibiotics. However, the other papers were not being able to contribute completely to the section as their research was focused on metals and genetic factors in creating antibiotic resistance in bacterial strains, such as Zhu et al. (2013) discussed about ARG gene and metals in their study, limiting the research question of this study. Whereas, the research gap for other literature was presence of different factors such as pH and respective media that initiated the antibiotic resistance among the bacterial strain. Therefore, these studies were not involved in the study.

Conclusion

While concluding, it should be mentioned that antibiotic resistance is the global concern and the extensive uses of it without any proper prescription and knowledge is increasing its deteriorating effects. In this assignment five articles associated with antibiotic resistance and its association with livestock animals has been discussed. The five articles were from different studies of research and hence a holistic approach to find the connection between these two independent research variables were used in the study.

References

Bonita, R., Beaglehole, R., & Kjellström, T. (2006). Basic epidemiology. World Health Organization.

Fitzgerald, J. R. (2012). Livestock-associated Staphylococcus aureus: origin, evolution and public health threat. Trends in microbiology, 20(4), 192-198.

Liu, L., Liu, C., Zheng, J., Huang, X., Wang, Z., Liu, Y., & Zhu, G. (2013). Elimination of veterinary antibiotics and antibiotic resistance genes from swine wastewater in the vertical flow constructed wetlands. Chemosphere, 91(8), 1088-1093.

Nadimpalli, M., Rinsky, J. L., Wing, S., Hall, D., Stewart, J., Larsen, J., … & Strelitz, J. (2015). Persistence of livestock-associated antibiotic-resistant Staphylococcus aureus among industrial hog operation workers in North Carolina over 14 days. Occup Environ Med, 72(2), 90-99.

NHMRC (2009). NHMRC additional levels of evidence and grades for recommendations for developers of guidelines. Retrieved from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evid ence_120423.pdf

Rinsky, J. L., Nadimpalli, M., Wing, S., Hall, D., Baron, D., Price, L. B., … & Heaney, C. D. (2013). Livestock-associated methicillin and multidrug resistant Staphylococcus aureus is present among industrial, not antibiotic-free livestock operation workers in North Carolina. PLoS One, 8(7), e67641.

Rychetnick, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence on public health. Journal of Epidemiology and Community Health, 56, 119-127.

Skelly, A. C., Dettori J. R., & Brodt, E. K. (2012). Assessing bias: the importance of considering confounding. Evidence Based Spine Care Journal, 3(1), 9-12

The GRADE Working Group (2004) Grading quality of evidence and strength of recommendations. British Medical Journal. 328 1490-1494.

World Health Organization. (2015). Antibiotic resistance: Multi-country public awareness survey.

Young, J.M., & Solomon, M.J. (2009). How to critically appraise an article. Nature Clinical Practice Gastroenterology and Hepatology. 6, 82-91.

Zhu, Y. G., Johnson, T. A., Su, J. Q., Qiao, M., Guo, G. X., Stedtfeld, R. D., … & Tiedje, J. M. (2013). Diverse and abundant antibiotic resistance genes in Chinese swine farms. Proceedings of the National Academy of Sciences, 201222743.

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