Among 777,512 Indian adults with extrapulmonary tuberculosis, in-treatment mortality varied over tenfold by site, highest for tuberculous meningitis (adjusted odds ratio 12.48 vs. lymph node TB), miliary (5.17), and pericardial TB (3.86). Associations of HIV, diabetes, alcohol, and tobacco use with mortality varied across sites. Risk-stratified, comorbidity-aware care is warranted.
Abstract Background The Dalbavancin as an Option for the Treatment of S. aureus bacteremia (DOTS) trial demonstrated similar clinical outcomes among 200 adults with complicated Staphylococcus aureus bacteremia (SAB) randomized to 2 doses of dalbavancin or standard-therapy antibiotics after initial clearance. We aimed to determine whether the higher cost of dalbavancin is offset through reductions in medical resource use. Methods We used dates for hospitalizations and antibiotics from the trial starting from randomization. Antibiotic costs were based on generic pricing for dalbavancin and most other antibiotics. Medicare payment rates were used to estimate costs for scenarios representing home-based or clinic-based outpatient parenteral antibiotic therapy (OPAT). Results On average, patients randomized to dalbavancin spent 2.2 fewer SAB-related days in the hospital (95% confidence interval [CI], −5.3 to 1.3) and received antibiotics on 24.4 fewer days (95% CI, −29.0 to −19.9). Mean inpatient costs for SAB-related admissions were lower by $5805 (95% CI, −$14 311 to $3390) in the dalbavancin group. Antibiotic drug costs were $2343 higher (95% CI, $1728–$3027), but OPAT costs were lower with dalbavancin by $2469 (95% CI, −$2913 to −$1970) in the home-based scenario and $1112 (95% CI, −$1289 to −$914) in the clinic-based scenario. Net costs for SAB-related care were $5931 lower (95% CI, −$14 660 to $3004) and $4574 lower (95% CI, −$13 312 to $4335) with dalbavancin versus standard therapy with home-based and clinic-based OPAT, respectively. Among patients with injection drug use (IDU), savings with dalbavancin were approximately $22 000. Conclusions On average, savings from reduced inpatient care and less OPAT fully offset the higher cost of dalbavancin in patients with SAB. Savings were greater in patients with IDU. Clinical Trials Registration. NCT04775953.
Abstract Antimicrobial resistance (AMR) is a major global health threat, with the greatest burden falling on low- and middle-income countries (LMICs) also challenged with limited surveillance capacity. The UK Government's Fleming Fund was established in 2015 to strengthen AMR surveillance across Africa and Asia through a One Health approach. This paper draws on program experience, country implementation evidence, and published literature to describe how the Fleming Fund operationalized AMR surveillance, assess its contribution to the quantity and quality of surveillance data, identify key implementation challenges, and consider implications for future global surveillance strategies. The Fleming Fund combined investments in laboratory infrastructure, workforce development, quality assurance, data systems, governance, and data use. Across supported countries, these investments enabled substantial growth in routine bacteriology and antimicrobial susceptibility testing, strengthened reference and surveillance laboratory capacity, increased participation in external quality assessment, and expanded reporting to the World Health Organization's Global Antimicrobial Resistance and Use Surveillance System. The program also supported complementary surveillance approaches, including antimicrobial use and consumption data and, in some settings, burden-of-disease and genomic surveillance. Progress, however, has been uneven and remains vulnerable to fragile infrastructure, procurement and supply chain bottlenecks, workforce turnover, fragmented data systems, weak clinical–laboratory interfaces, limited representativeness, and uncertain long-term financing. The Fleming Fund experience shows that strengthening AMR surveillance in LMICs is feasible, but requires sustained, system-wide investment. Future strategies should prioritize integration with clinical care, stronger digital and analytical capacity, broader diagnostic access, and domestic financing to ensure that high-quality AMR data are generated, shared, and translated into action.
