Membrane Organization Strategies in Vesicular Antibiotic Delivery

Small molecule antibiotics are often derived from microorganisms that thrive in competitive environments. Their importance as therapeutics for infectious disease in humans has been established over many years. It has now become clear that antibiotic-producing organisms use packaging and delivery in the form of vesicles in many cases. A similar strategy has evolved in recent decades in the pharmaceutical industry for formulation of antibiotic therapies. The top-down approach that has evolved over millions of years in various micro-organisms has generated complex, efficient delivery systems that we are just now beginning to understand. The bottom-up formulation approach involves simple, safe compositions, which are being continually enhanced by trying to add features of which the natural systems inform us. A comparison is made here of these paradigms. Despite the differences, there are a number of common features in the basic physical and biological requirements that must be satisfied. In this review, illustration and comparison of some of these requirements is given, demonstrating the ongoing challenges in this area of research.

Rapid increase in occurrence of carbapenem-resistant Enterobacteriaceae in healthy rural residents in Shandong province, China, from 2015 to 2017

OBJECTIVES

The global increase of carbapenem-resistant Enterobacteriaceae (CRE) is a growing concern. Infections caused by CRE are associated with increased mortality and length of hospital stay, emphasizing the health and economic burden posed by these pathogens. Although CRE can inhabit the human gut asymptomatically, colonization with CRE is associated with increased risk of CRE infection and mortality. In this study, we investigated the occurrence and characteristics of CRE in fecal samples from healthy persons in 12 villages in Shandong, China.

METHODS

Screening for CRE in fecal samples was performed by selective cultivation. MICs of meropenem were determined with the agar dilution method. Multilocus sequence type (MLST) and carbapenemase gene carriage of the isolates were determined with whole-genome sequencing. Genetic relatedness of E. coli isolates was determined by core genome MLST.

RESULTS

CRE carriage increased from 2.4% to 13% from 2015 to 2017. Most CRE isolates (93%) were E. coli and all carried NDM-type carbapenemases. The STs among the E. coli were diverse. The single most common was the highly epidemic strain ST167, which was only observed among isolates from 2017.

CONCLUSION

We report a rapid increase in occurrence of CRE from 2.4% to 13% among fecal samples collected from healthy rural residents of Shandong province, China, from 2015 to 2017. Colonization with CRE is known to increase the risk of CRE infection and the worrying deterioration of the epidemiological situation in the region reported here indicate a need for further monitoring and possible interventions.

C-reactive protein velocity discriminates between acute viral and bacterial infections in patients who present with relatively low CRP concentrations

Background

To assess the utility of C-reactive protein (CRP) velocity to discriminate between patients with acute viral and bacterial infections who presented with relatively low CRP concentrations and were suspected of having a bacterial infection.

Methods

We analyzed a retrospective cohort of patients with acute infections who presented to the emergency department (ED) with a relatively low first CRP measurement (CRP1) ≤ 31.9 mg/L and received antibiotics shortly after. We then calculated C-reactive protein velocity (CRPv), milligram per liter per hour, for each patient based on CRP1 and the second CRP value (CRP2) measured within the first 24 h since admission. Finally, we compared CRPv between patients with bacterial and viral infections.

Results

We have presently analyzed 74 patients with acute bacterial infections and 62 patients with acute viral infections at the mean age of 80 and 66 years respectively, 68 male and 68 female. CRP1 did not differ between both groups of patients (16.2 ± 8.6 and 14.8 ± 8.5 for patients with viral and bacterial infections respectively, p value = 0.336). However, the CRP2 was significantly different between the groups (30.2 ± 21.9 and 75.6 ± 51.3 for patients with viral and bacterial infections respectively, p-value < 0.001) and especially the CRPv was much higher in patients with acute bacterial infections compared to patients with acute viral infections (0.9 ± 1.2 and 4.4 ± 2.7 respectively, p-value < 0.001).

Conclusion

CRPv and CRP2 are useful biomarkers that can discriminate significantly between patients who present with acute bacterial and viral infections, and relatively low CRP concentration upon admission who were suspected of having a bacterial infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06878-y.

What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies

AIMS

This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

METHODS

We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study.

RESULTS

Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%).

CONCLUSION

Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article: Bone Joint J 2021;103-B(12):1745-1753.

Factors Conditioning the Potential Effects TiO2 NPs Exposure on Human Microbiota: a Mini-Review

The recent years have seen a significant interest in the applications of nanotechnology in various facets of our lives. Due to their increasingly widespread use, human exposure to nanoparticles (NPs) is fast becoming unavoidable. Among the wide group of nanoparticles currently employed in industry, titanium dioxide nanoparticles, TiO₂ NPs, are particularly popular. Due to its white colour, TiO₂ is widely used as a whitening food additive (E 171). Yet, there have been few studies aimed at determining its direct impact on bacteria, while the available data suggest that TiO₂ NPs may influence microbiota causing problems such as inflammatory bowel disease, obesity, or immunological disorders. Indeed, there are increasing concerns that its presence may lead to intestinal barrier impairment, including dysbiosis of intestinal microbiota. This article aims to present an overview of studies conducted to date with regard to the impact of TiO₂ NPs on human microbiota as well as factors that can affect the same. Such information is necessary if we are to conclusively determine the potential toxicity of inorganic nanoparticles.

Bacteria bioaerosol in the indoor air of educational microenvironments: Measuring exposures and assessing health effects

Exposure to bioaerosols has been identified to be linked the incidence of various health effects, i.e., infectious diseases, acute toxic effects, allergies, and cancer. The aim of this study was to determine the bacterial bioaerosols in the indoor air of the educational environments of Ardabil universities and to evaluate the exposure and to determine its health risk. In this cross-sectional study, different sections of the educational environments of Ardabil universities were studied. For differential diagnosis of bacteria, methods such as gram staining and biochemical detection methods including DNAse, catalase, oxidase, coagulase, bile esculin hydrolysis test, urease, citrate test, antibiotic resistance to novobiocin and Bacitracin, optochin, glucose uptake, and other differential tests were used. For sampling, a single-stage Anderson sampler was used at a flow rate of 28.3 l at a duration of 10 min per minute. The results showed that, in medical school of Ardabil University of Medical Sciences, the average concentration of bacteria in the outdoor air of school, halls, classes and rooms of professors and staff were 18, 88.4, 76.6, and 77.4 CFU/m³, respectively, and, in Ardabil Islamic Azad University, the average bacterial concentration was 103, 97, 124, and 132 CFU/m³ in the outdoor air of the schools, halls, classrooms, and rooms of professors and staff, respectively. The predominant bacterial species in indoor air are S. aureus, S. epidermidis, Actinomycetes, and Bacillus, respectively. As results indicated, the concentration of bacterial bioaerosols in indoor air is within the standard levels, but due to frequency of bacterial species, occurrence of different in lung and intestinal diseases can be expected among faculty, staff and students in the long-term.

Bacterial Brain Abscess: An Outline for Diagnosis and Management

Despite advances in the diagnosis and management of brain abscess, significant associated morbidity and mortality remain high. We retrospectively reviewed adults who presented with pyogenic brain abscess from January 1, 2009, through June 30, 2020. Overall, 247 patients were identified. The median age was 59 years, and 33.6% had a history of head and neck surgery or traumatic brain injury. Diagnostic brain magnetic resonance imaging (MRI) was performed in the bulk (93.1%) of patients. A total of 205 patients (83%) were managed with medical and surgical treatment. The most common definitive antibiotic regimen was monotherapy (48.2%). The median duration of antimicrobial therapy was 42 days. Compared with those who received combined therapy, patients with medical therapy alone had a higher mortality rate (21.4% vs 6%; P =. 003) with more neurologic sequelae (31% vs 27.1%; P = .5). Most patients with brain abscesses are older with multiple underlying comorbidities, and one-third had antecedent head and neck surgery. A prompt combined surgical and medical approach with prolonged antimicrobial therapy may cure the infection with avoidance of permanent residual neurologic deficits.

Novel multi-virus rapid respiratory microbiological point-of-care testing in primary care: a mixed-methods feasibility evaluation

BACKGROUND AND OBJECTIVES

Rapid multi-viral respiratory microbiological point-of-care tests (POCTs) have not been evaluated in UK primary care. The aim of this study was to evaluate the use of a multi-viral microbiological POCT for suspected respiratory tract infections (RTIs).

METHODS

In this observational, mixed-methods feasibility study practices were provided with a POCT machine for any patient aged ≥3 months with suspected RTI. Dual throat/nose swabs tested for 17 respiratory viruses and three atypical bacteria, 65 minutes per sample.

RESULTS

Twenty clinicians recruited 93 patients (estimated 1:3 of all RTI cases). Patient's median age was 29, 57% female, and 44% with co-morbidities. Pre-test diagnoses: upper RTI (48%); lower RTI (30%); viral/influenza-like illness (18%); other (4%). Median set-up time was 2.72 minutes, with 72% swabs processed <4 hours, 90% <24 hours. Tests detected ≥1 virus in 58%, no pathogen 37% and atypical bacteria 2% (3% inconclusive). Antibiotics were prescribed pre-test to 35% of patients with no pathogen detected and 25% with a virus. Post-test diagnoses changed in 20%, and diagnostic certainty increased (P = 0.02), more so when the test was positive rather than negative (P < 0.001). Clinicians predicted decreased antibiotic benefit post-test (P = 0.02). Interviews revealed the POCT has clear potential, was easy to use and well-liked, but limited by time-to-result and the absence of testing for typical respiratory bacteria.

CONCLUSIONS

This POCT was acceptable and appeared to influence clinical reasoning. Clinicians wanted faster time-to-results and more information about bacteria. Randomized trials are needed to understand the safety, efficacy and patient perceptions of these POCTs.

National surveillance of bacterial and fungal coinfection and secondary infection in COVID-19 patients in England: lessons from the first wave

Objectives

The impact of bacterial/fungal infections on the morbidity and mortality of persons with coronavirus disease 2019 (COVID-19) remains unclear. We have investigated the incidence and impact of key bacterial/fungal infections in persons with COVID-19 in England.

Methods

We extracted laboratory-confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (1st January 2020 to 2nd June 2020) and blood and lower-respiratory specimens positive for 24 genera/species of clinical relevance (1st January 2020 to 30th June 2020) from Public Health England's national laboratory surveillance system. We defined coinfection and secondary infection as a culture-positive key organism isolated within 1 day or 2–27 days, respectively, of the SARS-CoV-2-positive date. We described the incidence and timing of bacterial/fungal infections and compared characteristics of COVID-19 patients with and without bacterial/fungal infection.

Results

1% of persons with COVID-19 (2279/223413) in England had coinfection/secondary infection, of which >65% were bloodstream infections. The most common causative organisms were Escherichia coli, Staphylococcus aureus and Klebsiella pneumoniae. Cases with coinfection/secondary infections were older than those without (median 70 years (IQR 58–81) versus 55 years (IQR 38–77)), and a higher percentage of cases with secondary infection were of Black or Asian ethnicity than cases without (6.7% versus 4.1%, and 9.9% versus 8.2%, respectively, p < 0.001). Age-sex-adjusted case fatality rates were higher in COVID-19 cases with a coinfection (23.0% (95%CI 18.8–27.6%)) or secondary infection (26.5% (95%CI 14.5–39.4%)) than in those without (7.6% (95%CI 7.5–7.7%)) (p < 0.005).

Conclusions

Coinfection/secondary bacterial/fungal infections were rare in non-hospitalized and hospitalized persons with COVID-19, varied by ethnicity and age, and were associated with higher mortality. However, the inclusion of non-hospitalized persons with asymptomatic/mild COVID-19 likely underestimated the rate of secondary bacterial/fungal infections. This should inform diagnostic testing and antibiotic prescribing strategy.

Recurrent acute otitis media: a survey of current management in England

OBJECTIVE

Recurrent acute otitis media is common in children. The preferred treatment measures for recurrent acute otitis media have a mixed evidence base. This study sought to assess baseline practice across ENT departments in England.

METHODS

A national telephone survey of healthcare staff was conducted. Every ENT centre in England was contacted. A telephone script was used to ask about antibiotic and grommet use and duration in recurrent acute otitis media cases.

RESULTS

Ninety-six centres (74 per cent) provided complete information. Recurrent acute otitis media treatment across England by ENT departments varied. The antibiotic first- and second-line prophylaxis offered varies, with trimethoprim used in 33 centres and 29 centres not offering any antibiotics. The timing or choice about when to use grommets also varies, but 87 centres (91 per cent) offer grommet surgery at one stage.

CONCLUSION

The treatments received by children in England for recurrent acute otitis media vary by centre; collaborative research in this area is advised.

Bacterial and fungal ventilator associated pneumonia in critically ill COVID-19 patients during the second wave

BACKGROUND

The pandemic of coronavirus disease (COVID-19) has caused huge number of patients admitted to intensive care units (ICUs) in a critical need to mechanical ventilation. Ventilator associated pneumonia (VAP) has been noticed as a common complication in these patients with unfavorable outcomes. The current study aimed to assess bacterial and fungal VAP in COVID-19 patients admitted to ICUs during the second wave and to identify the possible risk factors.

METHODS

Respiratory samples were collected from 197 critically ill COVID-19 patients under mechanical ventilation. Bacterial and fungal superinfections were diagnosed by microbiological cultures with subsequent antimicrobial susceptibility testing of the isolates using available kits.

RESULTS

All specimens 197/197 (100%) were positive for bacterial infections, while fungal elements were detected in 134/197 (68%) of specimens. The most frequently isolated bacteria were pan drug resistant (PDR) Klebsiella pneumoniae (41.1%), followed by multi drug resistant (MDR) Acinetobacter baumannii (27.4%). On the other hand, Candida species represented the most frequently isolated fungi (75.4%) followed by molds including Aspergillus (16.4%) and Mucor (8.2%) species. Possible risk factors for fungal VAP included underlying diabetes mellitus (95% confidence interval [CI] 1.09-3.31; p = 0.02), chest disease (95% CI 1.01-3.32; p = 0.05), hypothyroidism (95% CI 1.01-4.78; p = 0.05), and longer duration of mechanical ventilation (p < 0.001). Furthermore, all patients 134/134 (100%) who developed fungal VAP, were already under treatment with corticosteroids and Tocilizumab.

CONCLUSION

Bacterial and fungal VAP in critically ill COVID-19 patients is a serious problem in the current pandemic. Urgent and strategic steps to keep it under control are compulsory.

Pediatric endophthalmitis: clinical profile, outcomes, and a proposed protocol

PURPOSE

To investigate the clinical profile and visual outcomes of infectious endophthalmitis in children at a single tertiary hospital in France, and propose an evidence-based protocol for management.

METHODS

This is a retrospective monocentric study that involved children with a history of endophthalmitis between January 2008 and January 2020. The clinical characteristics, etiology, microbiological spectrum from aqueous/vitreous tab, anatomical and visual outcomes, and management were analyzed. The Fischer and chi-square tests were used in the statistical evaluation.

RESULTS

Twenty-six children were eligible for inclusion. The mean patients age at presentation was 4.2 years (range, 8 days-14.3 years). With regard to etiology, patients were divided into posttraumatic group (n = 7 (26.9%)), postoperative group (n = 15 (57.7%)), endogenous group (n = 3 (11.5%)), and infectious corneal ulcer group (n = 1 (3.9%)). Time-to-onset of symptoms was highest in children ≤ 3 years old and in the postoperative subgroup who had at least one glaucoma procedure. Microbiology results showed growth in 12/26 (46.2%). The most common microorganism identified was Streptococcus pneumoniae (5/12 (41.7%)). The antibiotic regimen varied depending on age, organism, and sensitivities. The final visual outcomes were 20/200 or better in 11/26 (42.3%) eyes, and 13/26 (50.0%) eyes had no light perception. Twelve of twenty-six (46.2%) eyes ended up with phthisis bulbi.

CONCLUSION

Pediatric endophthalmitis is a rare but devastating condition with poor visual prognosis, requiring prompt recognition and treatment. Despite aggressive management with antibiotics and vitrectomy, the visual prognosis is generally poor. A protocol for management with an adapted systemic antibiotic therapy is proposed in order to improve outcomes.

Antimicrobial stewardship in rural and remote primary health care: a narrative review

BACKGROUND

Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies.

METHODS

The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools.

RESULTS

Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing.

CONCLUSIONS

Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

Identification of bacterial co-detections in COVID-19 critically Ill patients by BioFire® FilmArray® pneumonia panel: a systematic review and meta-analysis

Among critically ill COVID-19 patients, bacterial coinfections may occur, and timely appropriate therapy may be limited with culture-based microbiology due to turnaround time and diagnostic yield challenges (e.g. antibiotic pre-exposure). We performed a systematic review and meta-analysis of the impact of BioFire® FilmArray® Pneumonia Panel in detecting bacteria and clinical management among critically ill COVID-19 patients admitted to the ICU. Seven studies with 558 patients were included. Antibiotic use before respiratory sampling occurred in 28-79% of cases. The panel incidence of detections was 33% (95% CI 0.25 to 0.41, I²=32%) while culture yielded 18% (95% CI 0.02 to 0.45; I²=93%). The panel was associated with approximately a 1 and 2 day decrease in turnaround for identification and common resistance targets, respectively. The panel may be an important tool for clinicians to improve antimicrobial use in critically ill COVID-19 patients.

Tanzanian primary healthcare workers' experiences of antibiotic prescription and understanding of antibiotic resistance in common childhood infections: a qualitative phenomenographic study

Background

Antibiotic resistance is a threat to global child health. Primary healthcare workers play a key role in antibiotic stewardship in the community, but few studies in low-income countries have described their experiences of initiating antibiotic treatment in children. Thus, the present study aimed to describe primary healthcare workers’ experiences of antibiotic prescription for children under 5 years of age and their conceptions of antibiotic resistance in Northern Tanzania.

Methods

A qualitative study involving individual in-depth interviews with 20 prescribing primary healthcare workers in Moshi urban and rural districts, Northern Tanzania, was performed in 2019. Interviews were transcribed verbatim, translated from Kiswahili into English and analysed according to the phenomenographic approach.

Findings

Four conceptual themes emerged during the analysis; conceptions in relation to the prescriber, the mother and child, other healthcare actors and in relation to outcome. The healthcare workers relied mainly on clinical examination and medical history provided by the mother to determine the need for antibiotics. Confidence in giving advice concerning non-antibiotic treatment varied among the participants and expectations of antibiotic treatment were perceived to be common among the mothers. Antibiotic resistance was mainly perceived as a problem for the individual patient who was misusing the antibiotics.

Conclusions

To increase rational antibiotic prescription, an awareness needs to be raised among Tanzanian primary healthcare workers of the threat of antibiotic resistance, not only to a few individuals, but to public health. Guidelines on childhood illnesses should be updated with advice concerning symptomatic treatment when antibiotics are not necessary, to support rational prescribing practices and promote trust in the clinician and mother relationship.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-00952-5.

Secondary Bacterial Infection of a Solitary Cysticercus Granuloma

The most common presenting form of neurocysticercosis in the Indian subcontinent is a solitary cysticercus granuloma (SCG). Patients with typical SCGs almost never require any form of surgical intervention. Herein, we report an extremely rare case of bacterial superinfection of a left frontal SCG in a 23-year-old female, resulting in severe perilesional edema and mass effect. The patient had to undergo an emergency left decompressive hemicraniectomy and excision of the infected granuloma. Serum enzyme-linked immunoelectrotransfer blot (EITB) for cysticercal antibodies was positive and histopathological examination of the lesion revealed a cysticercus. The culture of the pus from within the lesion grew vancomycin-resistant Enterococcus spp. for which she was treated with linezolid for 6 weeks. At 6 months follow-up, she had residual motor dysphasia, right homonymous hemianopia, and right hemiparesis but was steadily improving. Secondary bacterial infection of an SCG is very uncommon and can be devastating. A high index of suspicion is therefore required when there is disproportionate perilesional edema and mass effect.

Intraventricular treatment of paediatric meningitis due to extensively drug-resistant Gram-negative bacteria: two case reports and review of the literature

Nosocomial meningitis caused by Gram-negative bacteria is associated with increasingly common neurosurgical procedures in children, with an increase in incidence recently reported. These infections are associated with an increased risk of mortality, prolonged hospitalisation, and increased costs. In this report, we describe two paediatric cases with central nervous system infections caused by extensively drug-resistant Gram-negative bacteria that were successfully treated with intraventricular colistin. To the best of our knowledge, this is the first comprehensive review and discussion of intraventricular antimicrobial therapy in a paediatric population. Based on our comprehensive review of the relevant literature, it appears that intraventricular administration of colistin may be a promising and effective option in the treatment of central nervous system infections in children who do not respond to other treatment options.

Response of Escherichia coli minimal ter operon to UVC and auto-aggregation: pilot study

Aim

The study of minimal ter operon as a determinant of tellurium resistance (Te^R) is important for the purpose of confirming the relationship of these genes to the pathogenicity of microorganisms. The ter operon is widespread among bacterial species and pathogens, implicated also in phage inhibition, oxidative stress and colicin resistance. So far, there is no experimental evidence for the role of the Escherichia coli (E. coli) minimal ter operon in ultraviolet C (UVC) resistance, biofilm formation and auto-aggregation. To identify connection with UVC resistance of the minimal ter operon, matched pairs of Ter-positive and -negative E. coli cells were stressed and differences in survival and whole genome sequence analysis were performed. This study was aimed also to identify differences in phenotype of cells induced by environmental stress.

Methods

In the current study, a minimal ter operon(terBCDEΔF) originating from the uropathogenic strain E. coli KL53 was used. Clonogenic assay was the method of choice to determine cell reproductive death after treatment with UVC irradiation at certain time intervals. Bacterial suspensions were irradiated with 254 nm UVC-light (germicidal lamp in biological safety cabinet) in vitro. UVC irradiance output was 2.5 mW/cm² (calculated at the UVC device aperture) and plate-lamp distance of 60 cm. DNA damage analysis was performed using shotgun sequencing on Illumina MiSeq platform. Biofilm formation was measured by a crystal violet retention assay. Auto-aggregation assay was performed according to the Ghane, Babaeekhou & Ketabi (2020).

Results

A large fraction of Ter-positive E. coli cells survived treatment with 120-s UVC light (300 mJ/cm²) compared to matched Ter-negative cells; ∼5-fold higher resistance of Ter-positive cells to UVC dose (p = 0.0007). Moreover, UVC surviving Ter-positive cells showed smaller mutation rate as Ter-negative cells. The study demonstrated that a 1200-s exposure to UVC (3,000 mJ/cm²) was sufficient for 100% inhibition of growth for all the Ter-positive and -negative E. coli cells. The Ter-positive strain exhibited of 26% higher auto-aggregation activities and was able to inhibit biofilm formation over than Ter- negative strain (**** P < 0.0001).

Conclusion

Our study shows that Ter-positive cells display lower sensitivity to UVC radiation, corresponding to a presence in minimal ter operon. In addition, our study suggests that also auto-aggregation ability is related to minimal ter operon. The role of the minimal ter operon (terBCDEΔF) in resistance behavior of E. coli under environmental stress is evident.

A Clinicopathological Diagnostic and Therapeutic Approach to Cytolytic Vaginosis: An Extremely Rare Entity that may Mimic Vulvovaginal Candidiasis

Objectives:

Cytolytic vaginosis is a very rare entity that may be clinically misdiagnosed as vulvovaginal candidiasis. The aim of this study was to determine the incidence of cytolytic vaginosis in patients displaying symptoms similar to vulvovaginal candidiasis and to develop a clinicopathological diagnostic and therapeutic approach.

Materials and Methods:

In total, 3000 cervical smear samples were evaluated at our center between 2015 and 2018. Patients whose PAP smears demonstrated significant epithelial cytolysis, naked nuclei, excessive increase in lactobacilli population, absent or minimal neutrophils and no microorganisms were subjected to a symptom assessment questionnaire and had their vaginal pHs measured. They were classified into two groups according to their complaints, symptoms and vaginal pHs: Cytolytic vaginosis and Asymptomatic intravaginal lactobacillus overgrowth. A standardized NaHCO3 Sitz bath therapy was applied to the cytolytic vaginosis group.

Results:

Fifty-three of the patients (1.7%) were diagnosed as cytolytic vaginosis. After Sitz bath therapy, there was a statistically significant decrease in the cytolysis and lactobacillus scores of the patients. Vaginal discharge of 43 (81%) patients ceased completely while that of the remaining 10 (19%) patients decreased after the therapy. The improvement was statistically significant (P < 0.001). There was a complete resolution in 28 (96%) patients with severe; and in 21 (94%) patients with intermediate vaginal discomfort, after the therapy. Dyspareunia was resolved in 35 (97%) patients (P < 0.001).

Conclusion:

Cytolytic vaginosis is a rare entity that can be diagnosed with the help of cytopathology and has a therapy based on the modulation microbiota by decreasing the vaginal pH.

Antimicrobial activity of essential plant oils and their major components

Development of bactericides and fungicides in terms of isolation and identification of substances is an important area of research. Presently, under the concept of integrated pest management, all possible plant pest and disease control methods are integrated to minimize the excessive use of synthetic chemicals and also the incidence of disease.

The potential of various essential oils against Gram-positive and Gram-negative bacteria and fungi is being actively investigated in various laboratories across the world. Rice the most important crop, suffers from huge yield losses due to blast and blight diseases. Most of the labs have focussed to use transgenic approaches, the use of environmentally friendly natural products, as disease control strategies. In this context, we propose to evaluate the antimicrobial properties of essential oils and their ability to control diseases of rice. Seven Essential oils from seven different plants were selected for the study. The antimicrobial activity was assessed in terms of their antibacterial activity towards non-pathogenic bacteria and pathogenic drug resistant bacteria by means of their ability to sensitize the drug resistant bacteria in plasmid curing and, ß-lactamase inhibition and as antifungal agents. In conclusion, out of the seven essential oils used, lemongrass, palm rosa and eucalyptus were found to be good antimicrobial agents.

Fungal and bacterial coinfections increase mortality of severely ill COVID-19 patients

Background

SARS-CoV-2 predisposes patients to secondary infections; however, a better understanding of the impact of coinfections on the outcome of hospitalized COVID-19 patients is still necessary.

Aim

To analyse death risk due to coinfections in COVID-19 patients.

Methods

The odds of death of 212 severely ill COVID-19 patients were evaluated, with detailed focus on the risks for each pathogen, site of infection, comorbidities and length of hospitalization.

Findings

The mortality rate was 50.47%. Fungal and/or bacterial isolation occurred in 89 patients, of whom 83.14% died. Coinfected patients stayed hospitalized longer and had an increased odds of dying (odds ratio (OR): 13.45; R² = 0.31). The risk of death was increased by bacterial (OR: 11.28) and fungal (OR: 5.97) coinfections, with increased levels of creatinine, leucocytes, urea and C-reactive protein. Coinfections increased the risk of death if patients suffered from cardiovascular disease (OR: 11.53), diabetes (OR: 6.00) or obesity (OR: 5.60) in comparison with patients with these comorbidities but without pathogen isolation. The increased risk of death was detected for coagulase-negative Staphylococcus (OR: 25.39), Candida non-albicans (OR: 11.12), S. aureus (OR: 10.72), Acinetobacter spp. (OR: 6.88), Pseudomonas spp. (OR: 4.77), and C. albicans (OR: 3.97). The high-risk sites of infection were blood, tracheal aspirate, and urine. Patients with coinfection undergoing invasive mechanical ventilation were 3.8 times more likely to die than those without positive cultures.

Conclusion

Severe COVID-19 patients with secondary coinfections required longer hospitalization and had higher risk of death. The early diagnosis of coinfections is essential to identify high-risk patients and to determine the right interventions to reduce mortality.

Current antibiotic resistance patterns of rare uropathogens: survey from Central European Urology Department 2011-2019

BACKGROUND

While the resistance rates of commonly detected uropathogens are well described, those of less frequent Gram-negative uropathogenic bacteria have seldom been reported. The aim of this study was to examine the resistance rates of less frequent uropathogenic Gram-negatives in a population of patients treated in a Department of Urology of a tertiary referral centre in Central Europe over a period of 9 years.

METHODS

Data on all positive urine samples from urological in- and out-patients were extracted form the Department of Clinical Microbiology database from 2011 to 2019. Numbers of susceptible and resistant isolates per year were calculated for these uropathogens: Acinetobacter spp. (n = 74), Citrobacter spp. (n = 60), Enterobacter spp. (n = 250), Morganella morganii (n = 194), Providencia spp. (n = 53), Serratia spp. (n = 82) and Stenotrophomonas maltophilia (n = 27). Antimicrobial agents selected for the survey included: ampicillin, amoxicillin/clavulanic acid, piperacillin/tazobactam; cefuroxime, cefotaxime, ceftazidime and cefepime; ciprofloxacin and ofloxacin; gentamicin and amikacin; ertapenem, meropenem and imipenem; trimethoprim-sulfamethoxazole (co-trimoxazole), nitrofurantoin and colistin.

RESULTS

Penicillin derivatives have generally poor effect except piperacillin/tazobactam. Cefuroxime is not efficient unlike cefotaxime (except against Acinetobacter spp. and S. maltophilia). Susceptibility to fluoroquinolones is limited. Amikacin is somewhat more efficient than gentamicine but susceptibilities for both safely exceed 80%. Nitrofurantoin shows virtually no efficiency. Cotrimoxazole acts well against Citrobacter spp., Serratia spp. and it is the treatment of choice for S. maltophilia UTIs. Among carbapenems, ertapenem was less efficient than meropenem and imipenem except for S. maltophilia whose isolates were mostly not suceptible to any carbapenems.

CONCLUSIONS

Uropathogenic microorganisms covered in this report are noteworthy for their frequently multi-drug resistant phenotypes. Knowledge of resistance patterns helps clinicians choose the right empirical antibiotic treatment when the taxonomical assignment of the isolate is known but sensitivity results are pending.

Effects of infections on the pathogenesis of cancer

Several studies have shown an inverse relationship between acute infections and cancer development. On the other hand, there is a growing evidence that chronic infections may contribute significantly to the carcinogenesis. Factors responsible for increased susceptibility to infections may include modifications of normal defence mechanisms or impairment of host immunity due to altered immune function, genetic polymorphisms, ageing and malnourishment. Studies have demonstrated that children exposed to febrile infectious diseases show a subsequent reduced risk for ovarian cancer, melanoma and many other cancers, while common acute infections in adults are associated with reduced risks for melanoma, glioma, meningioma and multiple cancers. Chronic inflammation associated with certain infectious diseases has been suggested as a cause for the development of tumours. Mechanisms of carcinogenesis due to infections include cell proliferation and DNA replication by mitogen-activated protein kinase pathway, production of toxins that affect the cell cycle and lead to abnormal cell growth and inhibition of apoptosis. This review was aimed to summarize the available evidence on acute infections as a means of cancer prevention and on the role of chronic infections in the development and progression of cancer.

Knowledge and behavior of consumers towards the non-prescription purchase of antibiotics: An insight from a qualitative study from New Delhi, India

Background:

In Low-and Middle-Income Countries, including India, consumers often purchase antibiotics over-the-counter (OTC) from retail pharmacies. This practice leads to the inappropriate use of antibiotics in the community which is an important driver for the development of antimicrobial resistance. A better understanding of consumers’ views towards this grave public health concern is critical to developing evidence-based intervention programs for awareness among the general population.

Objective:

To explore knowledge, practice and, behavior of consumers towards antibiotics, antibiotic use, antimicrobial resistance, purchasing behavior of consumers for antibiotics, and to gain insight which will help in developing evidence-based policy interventions.

Methods:

72 in-depth consumer interviews were conducted in all 11 districts of the National Capital Territory of Delhi. The qualitative data were analyzed using thematic analysis.

Results:

Our study found that retail pharmacies were the first point of consultation for common ailments for patients/consumers once home remedies failed; they were largely unaware of the threat of antimicrobial resistance. Consumers’ knowledge of antibiotic use and about antimicrobial resistance was low, they used old prescriptions, and bought antibiotics OTC to save time and money. Despite the presence of regulations constituted to regulate the sale of antibiotics by the Government and the implementation of national campaigns, the practice of self-medication and behaviors such as OTC purchase, non-adherence to prescribed antibiotics was prevalent. Consumers perceive that antibiotics provide quick relief and accelerate the curing process and retail pharmacy shops try to protect their retail business interests by honoring old prescriptions and self-medication for antibiotics.

Conclusions:

The lack of awareness and insufficient knowledge about what antibiotics are and issues such as antimicrobial resistance or antibiotic resistance resulted in misuse of antibiotics by consumers. Limited access to public healthcare and affordability of private healthcare are factors that contribute towards the self-medication/OTC purchase of antibiotics. The regular misuse of antibiotics through irrational use reinforces the need for strong enactment of strategies like continuous community awareness campaigns. Mitigation efforts should focus upon educating consumers continuously and sustainably for the understanding of antibiotic misuse, antimicrobial resistance, and promote better compliance with regulations.

Physicians' attitudes on the implementation of an antimicrobial stewardship program in Lebanese hospitals

Background

Misuse of antibiotics and antimicrobial resistance are global concerns. Antibiotic stewardship programs (ASP) are advocated to reduce pathogens resistance by ensuring appropriate antimicrobial use. Several factors affect the implementation of ASPs in hospitals. The size and types of care provided, as well as the complexity of antibiotic prescription, are all issues that are considered in designing an effective hospital-based program.

Objectives

To examine physicians' attitude on implementation of an antimicrobial stewardship program in Lebanese hospitals.

Methods

A descriptive cross-sectional survey was carried out using an online questionnaire. Survey items assessed ASP implementations, physicians' attitudes, usefulness of the tools, and barriers of implementation. The questionnaire was based on the Center for Disease Control core-elements.

Results

158 physicians completed the survey with a response rate of 4%. Our results showed that the majority (66%) of physicians were familiar with the ASP concept. Most respondents reported a lack of regular educational programs (41%), as well as a lack of support from the medical staff (76%). This study demonstrated positive attitudes and support for ASP implementation. However, ASPs were reported as affecting physicians' autonomy by 34 % of the participants. Antibiotic rounds and prospective audit and feedback were rated as most useful interaction methods with the ASPs. A minimal support of the Ministry Of Public Health, as well as the absence of regulation and of national guidelines, were reported as barriers to ASPs. The shortage of Infectious Disease physicians was seen as a barrier by half of the respondents.

Conclusions

Physicians are supportive of ASP, with preference for interventions that provide information and education rather than restrictive ones. Additional research is needed on a larger sample of physicians.

Effects of a national policy advocating rational drug use on decreases in outpatient antibiotic prescribing rates in Thailand

Objective:

This study examined the effects of a national policy advocating rational drug use (RDU), namely, the ‘RDU Service Plan’, starting in fiscal year 2017 and implemented by the Thai Ministry of Public Health (MOPH), on trends in antibiotic prescribing rates for outpatients. The policy was implemented subsequent to a voluntary campaign involving 136 hospitals, namely, the ‘RDU Hospital Project’, which was implemented during fiscal years 2014-2016.

Methods:

Hospital-level antibiotic prescribing rates in fiscal years 2014-2019 for respiratory infections, acute diarrhea, and fresh wounds were aggregated for two hospital groups using equally weighted averages: early adopters of RDU activities through the RDU Hospital Project and late adopters under the RDU Service Plan. Pre-/post-policy annual changes in the prescribing levels and trends were compared between the two groups using an interrupted time-series analysis.

Results:

In fiscal years 2014-2016, decreases in antibiotic prescribing rates for respiratory infections and acute diarrhea in both groups reflected a trend that existed before the RDU Service Plan was implemented. The immediate effect of the RDU Service Plan policy occurred in fiscal year 2017, when the prescribing level among the late adopters dropped abruptly for all three conditions with a greater magnitude than in the decrease among the early adopters, despite nonsignificant differences. The medium-term effect of the RDU Service Plan was identified through a further decreasing trend during fiscal years 2017-2019 for all conditions in both groups, except for acute diarrhea among the early adopters.

Conclusions:

The national policy on rational drug use effectively reduced antibiotic prescribing for common but questionable outpatient conditions.

Utilization of environmentally friendly essential oils on enhancing the postharvest characteristics of Chrysanthemum morifolium Ramat cut flowers

Chrysanthemum is one of the most consumed and most valuable cut flowers worldwide. In this study, the effectiveness of three concentrations of either thyme oil (300,400 and 500 mg/l) or clove oil (150,250 and 500 mg/l) as additives in holding the postharvest solutions of chrysanthemum ‘‘Arctic Queen White’’ cut flowers were investigated. The experiments were carried out as a completely randomized design in three replicates. Many postharvest characteristics have been evaluated, such as the vase life of cut flowers, diameters of head flowers and stem, dry matter of flowers, total vase water uptake, total loss of water, relative fresh weight. Additionally, the chlorophyll contents, total sugar, and bacterial counts were determined. The results showed that the longest vase life of cut chrysanthemum was 36.50, 33.40 days, and 35.88, 31.33 days by addition of either the thyme oil (500 mg/l) or clove oil (250 mg/l) in holding solution as compared with distilled water (18.09 and 17.22 days) in both seasons. The highest total vase water uptake and relative fresh weight were (225.00, 211.05 g/flower/day) and (79.89, 70.37 %) of cut chrysanthemum treated with 500 mg/l thyme oil in both seasons. Whereas the lowest total water loss in the two seasons was 155.11 and 156.60 g/flower/day was found with 400 mg/l thyme oil. The greatest chlorophyll a, b, carotenoids, and total sugar contents obtained from treated cut chrysanthemum with 500 mg/l thyme oil (6.89, 2.37, 5.99 mg/g, and 0.88 mg/gm D.W, respectively). Furthermore, the treatment of cut flowers with selected oils has significantly decreased the bacterial growth compared to the control. Whereas the minimum bacterial activities were <1 C.F.U/ml with cut chrysanthemum fortified with 500 mg/l thyme and clove oils. Moreover, the superlative treatments with thyme (500 mg/l) and clove (250 mg/l) showed a prime state of xylem vessels comparable with the control.thus, the usage (addition) of thyme and clove oils as a natural preservative in holding solutions instead of chemicals would be of great economic and environmental impact (Values).

A systematic review and meta-analysis of studies on the diagnostic accuracy and screening of tests to detect antimicrobial resistance in leprosy

Although multidrug therapy is considered an effective treatment for leprosy, antimicrobial resistance is a serious concern. We performed a systematic review of studies on the diagnostic accuracy and screening of tests for antimicrobial resistance in leprosy. This review was registered in PROSPERO (CRD42020177958). In April 2020, we searched for studies in the PubMed, EMBASE, Web of Science, Scopus, Scielo, and LILACS databases. A random effects regression model was used for the meta-analysis. We included 129 studies. Molecular tests for dapsone resistance had a sensitivity of 78.8% (95% confidence interval [CI] = 65.6-87.9) and a specificity of 97.0% (95% CI = 94.0-98.6). Molecular tests for rifampicin resistance had a sensitivity and specificity of 88.7% (95% CI = 80.0-93.9) and 97.3% (95% CI = 94.3-98.8), respectively. Molecular tests for ofloxacin resistance had a sensitivity and specificity of 80.9% (95% CI = 60.1-92.3) and 96.1% (95% CI = 90.2-98.5), respectively. In recent decades, no increase in the resistance proportion was detected. However, the growing number of resistant cases is still a clinical concern.

[Clinical analysis of 14 infective endocarditis in patients with obstructive hypertrophic cardiomyopathy]

Objective: This observational study was aimed to analyze the clinical characteristics of infective endocarditis (IE) in patients with hypertrophic cardiomyopathy (HCM). Methods: A total of 668 patients with IE, and 7 427 patients with HCM were treated in Fuwai Hospital from August 2006 to December 2018. Among them, 14 patients were diagnosed with HCM and IE. The clinical characteristics of these patients including clinical manifestations, pathogen distribution, echocardiography features, in-hospital treatment and outcomes were analyzed retrospectively. Results: The proportion of HCM patients with IE was 0.19%,with the estimated incidence of 0.15/1 000 person-years in HCM patients. Of the 14 patients, 11 patients were male. The most common clinical manifestations were fever and heart murmur, and the main complications were heart failure (12/14) and bacterial embolism (8/14). There were 8 cases (8/14) with positive blood culture, and all causative bacteria were gram positive coccus, in which 5/8 were Streptococcus. The median interventricular septum thickness was (21.2±2.7) mm, and left ventricular outflow obstruction was severe based on echocardiography (Echo) examination. The Echo showed that vegetation was found in all 14 patients and most of the vegetation attached at the anterior leaflet of mitral valve (12/14). The proportions of patients with circulatory embolism (8/14) and valve lesions (12/14) were relatively high. Most cases (10/14) were cured, especially those underwent cardiac surgery (8 cases). The rest 4 cases died with 2 in hospital and 2 after auto-discharge. Conclusions: HCM patients complicated with IE are rare. Septic embolization and valve lesions are common in these patients. IE patients with HCM might have a poor prognosis compared to those without HCM and should receive cardiac surgery as early as possible.

Oral microbiota and vitamin D impact on oropharyngeal squamous cell carcinogenesis: a narrative literature review

An emerging body of research is revealing the microbiota pivotal involvement in determining the health or disease state of several human niches, and that of vitamin D also in extra-skeletal regions. Nevertheless, much of the oral microbiota and vitamin D reciprocal impact in oropharyngeal squamous cell carcinogenesis (OPSCC) is still mostly unknown. On this premise, starting from an in-depth scientific bibliographic analysis, this narrative literature review aims to show a detailed view of the state of the art on their contribution in the pathogenesis of this cancer type. Significant differences in the oral microbiota species quantity and quality have been detected in OPSCC-affected patients; in particular, mainly high-risk human papillomaviruses (HR-HPVs), Fusobacterium nucleatum, Porphyromonas gingivalis, Pseudomonas aeruginosa, and Candida spp. seem to be highly represented. Vitamin D prevents and fights infections promoted by the above identified pathogens, thus confirming its homeostatic function on the microbiota balance. However, its antimicrobial and antitumoral actions, well-described for the gut, have not been fully documented for the oropharynx yet. Deeper investigations of the mechanisms that link vitamin D levels, oral microbial diversity and inflammatory processes will lead to a better definition of OPSCC risk factors for the optimization of specific prevention and treatment strategies.

Considerations on antimicrobial prophylaxis in patients with lymphoproliferative diseases: A SEIFEM group position paper

The therapeutic armamentarium for the treatment of patients with lymphoproliferative diseases has grown considerably over the most recent years, including a large use of new immunotherapeutic agents. As a consequence, the epidemiology of infectious complications in this group of patients is poorly documented, and even more importantly, the potential benefit of antimicrobial prophylaxis remains a matter of debate when considering the harmful effect from the emergence of multidrug resistant pathogens. The present position paper is addressed to all hematologists treating patients affected by lymphoproliferative malignancies with the aim to provide clinicians with a useful tool for the prevention of bacterial, fungal and viral infections.

Travel to Mexico and uropathogen-antibiotic susceptibility mismatch in the emergency department

INTRODUCTION

International travel results in an increased risk of colonization and infection with multidrug-resistant organisms. This study aimed to determine if recent travel to Mexico affects the rate of uropathogen-antibiotic susceptibility mismatch (UASM) in outpatients treated for urinary tract infection (UTI) in a South Texas emergency department (ED).

METHODS

A retrospective cohort of adult patients presenting to the ED and treated outpatient for UTI from October 1, 2014, to February 25, 2020, was conducted at a community hospital located within approximately 15 miles of the United States-Mexico border. Rates of UASM were compared between patients with a history of recent travel to Mexico and those who have not recently traveled.

RESULTS

A total of 192 patients were included, with 64 in the travel to Mexico group and 128 in the no travel group. UASM was significantly higher in the recent travel to Mexico group when compared to the no travel group (RR 1.49, 95% CI 1.03-2.13). Antibiotics most commonly associated with UASM included fluoroquinolones, cephalexin, and sulfamethoxazole-trimethoprim. There was no significant difference between the rates of resistance to first-line agents for the treatment of UTI among the two groups.

CONCLUSION

In addition to known antibiotic resistance risk factors, recent travel to Mexico may increase the risk of UASM for ED patients with UTI. Considering the potential consequences of UTI treatment failure, antimicrobial stewardship services in the ED should include screening for antibiotic resistance risk factors and urine culture follow-up to ensure appropriate outpatient antibiotic therapy, especially among patients with recent international travel.

Typhoid fever infection - Antibiotic resistance and vaccination strategies: A narrative review

Typhoid fever is a bacterial infection caused by the Gram-negative bacterium Salmonella enterica subspecies enterica serovar Typhi (S. Typhi), prevalent in many low- and middle-income countries. In high-income territories, typhoid fever is predominantly travel-related, consequent to travel in typhoid-endemic regions; however, data show that the level of typhoid vaccination in travellers is low. Successful management of typhoid fever using antibiotics is becoming increasingly difficult due to drug resistance; emerging resistance has spread geographically due to factors such as increasing travel connectivity, affecting those in endemic regions and travellers alike. This review provides an overview of: the epidemiology and diagnosis of typhoid fever; the emergence of drug-resistant typhoid strains in the endemic setting; drug resistance observed in travellers; vaccines currently available to prevent typhoid fever; vaccine recommendations for people living in typhoid-endemic regions; strategies for the introduction of typhoid vaccines and stakeholders in vaccination programmes; and travel recommendations for a selection of destinations with a medium or high incidence of typhoid fever.

Epidemiology of carbapenem-resistant Enterobacteriaceae in hospitals of a large healthcare system in Miami, Florida from 2012 to 2016: Five years of experience with an internal registry

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) is an urgent public health threat globally. Limited data are available regarding the epidemiology of CRE in South Florida. We describe the epidemiology of CRE within a large public healthcare system in Miami, FL, the experience with an internal registry, active surveillance testing, and the impact of infection prevention practices.

METHODS

Retrospective cohort study in 4 hospitals from a large healthcare system in Miami-Dade County, FL from 2012 to 2016. The internal registry included all CRE cases from active surveillance testing from rectal and/or tracheal screening occurring in the intensive care units of 2 of the hospitals and clinical cultures across the healthcare system. All CRE cases were tagged in the electronic medical record and automatically entered into a platform for automatic infection control surveillance. The system alerted about new cases, readmissions, and transfers.

RESULTS

A total of 371 CRE cases were identified. The overall prevalence was 0.077 cases per 100 patient-admissions; the admission prevalence was 0.019 per 100 patient-admissions, and the incidence density was 1.46 cases per 10,000 patient-days. Rates increased during the first 3 years of the study and declined later to a lower level than at the beginning of study period.

CONCLUSIONS

Active surveillance testing and the use of an internal registry facilitated prompt identification of cases contributing to control increasing rates of CRE by rapid implementation of infection prevention strategies.

BIOCOM-PIPE: a new user-friendly metabarcoding pipeline for the characterization of microbial diversity from 16S, 18S and 23S rRNA gene amplicons

Background

The ability to compare samples or studies easily using metabarcoding so as to better interpret microbial ecology results is an upcoming challenge. A growing number of metabarcoding pipelines are available, each with its own benefits and limitations. However, very few have been developed to offer the opportunity to characterize various microbial communities (e.g., archaea, bacteria, fungi, photosynthetic microeukaryotes) with the same tool.

Results

BIOCOM-PIPE is a flexible and independent suite of tools for processing data from high-throughput sequencing technologies, Roche 454 and Illumina platforms, and focused on the diversity of archaeal, bacterial, fungal, and photosynthetic microeukaryote amplicons. Various original methods were implemented in BIOCOM-PIPE to (1) remove chimeras based on read abundance, (2) align sequences with structure-based alignments of RNA homologs using covariance models, and (3) a post-clustering tool (ReClustOR) to improve OTUs consistency based on a reference OTU database. The comparison with two other pipelines (FROGS and mothur) and Amplicon Sequence Variant definition highlighted that BIOCOM-PIPE was better at discriminating land use groups.

Conclusions

The BIOCOM-PIPE pipeline makes it possible to analyze 16S, 18S and 23S rRNA genes in the same packaged tool. The new post-clustering approach defines a biological database from previously analyzed samples and performs post-clustering of reads with this reference database by using open-reference clustering. This makes it easier to compare projects from various sequencing runs, and increased the congruence among results. For all users, the pipeline was developed to allow for adding or modifying the components, the databases and the bioinformatics tools easily, giving high modularity for each analysis.

Exploration of the effects of altitude change on bacteria and fungi in the rumen of yak (Bos grunniens)

The yak (Bos grunniens) is a ruminant animal with strong regional adaptability. However, little is known about the adaptation of the rumen microbial community of yaks at different altitudes and the adaptation mechanism of the host and intestinal microorganisms to the habitat. We investigated the adaptability of the rumen microorganisms of yaks at high and low altitudes. We also compared and analyzed the abundance and diversity of core microorganisms and those that varied between different animals. The aim was to compare the rumen bacterial and fungal communities of grazing yak living at two elevations. Bacteroidetes, Firmicutes, Ascomycota, and Chytridiomycota were the dominant bacteria in the plateau and low-altitude regions. Significant differences between the dominant microorganisms in the rumen of yaks were evident in the two regions. The proportion of fiber-degrading bacteria was significantly different between yaks dwelling at high-altitude and low-altitude regions. The abundance of starch-degrading bacteria was not significantly different with altitude. Species clustering similarity analysis showed that the rumen microorganisms in the two areas were obviously isolated and clustered into branches. Functional prediction showed significant differences in rumen microbial methane metabolism, starch and sucrose metabolism, ion-coupled transporter and bacterial secretion system at different altitudes. Overall, the results of this study improved our understanding of the abundance and composition of microorganisms in the rumen of yak at different altitudes.

Exploring the microbial mechanisms of organic matter transformation during pig manure composting amended with bean dregs and biochar

This study researched the impacts of biochar (B) and bean dregs (BD) on organic matter degradation and humification, as well as the bacterial community and functional characteristics during pig manure (PM) composting. The temperature, pH, and dissolved organic carbon (DOC) were reached the maturity of compost. Results indicated that BD + B treatment promoted organic matter degradation and increased humic acid content by 19.5-25.1% from the control (CK). Additionally, the bacterial communities were determined by high-throughput sequencing, and their metabolic functions were evaluated through the phylogenetic investigation of communities by reconstructing unobserved states (PICRUSt). BD + B influenced the microbial community structure of compost, and the PICRUSt results indicated that BD + B strengthened the metabolism of carbohydrates and amino acids. Redundancy analysis (RDA) was conducted, and a positive correlation was observed between organic matter transformation and temperature, pH, DOC, and community structure. Therefore, regulating these compost properties can effectively promote organic matter transformation during composting.

pruni on plumcot in South Korea

Plumcot is an interspecific hybrid product between Japanese plums (Prunus salicina) and apricots (Prunus armeniaca) obtained by the NIHHS, Korea in 1999 [1]. At the early of 2017, black spots-like symptoms were observed on plumcot fruits and leaves at cultivation areas in Naju (34.965595, 126.665853) province. Further investigation shows that approximately 60% of the plumcot leaves in the affected orchard were infected, which caused 40% total production loss. At the early stage of infection, disease symptoms appear as small, angular and water-soaked spots and develop into circular brown spots at the later stages of infection. As the disease progresses, the leaf tissues around the spots became yellow and the lesions enlarged. When the adjacent lesions merged and the necrotic tissues fall off, shot-hole symptoms appear on the leaves. To identify the causal agent of this disease, infected leaf tissues were excised and surface-sterilized with 1% NaOCl for 30 secs prior to rinsing with sterile water, thrice . Tissue samples were then placed in sterile water (0.5 mL) for 5 min before its aliquots were streaked onto Luria-Bertani (LB) agar. Plates then were incubated at 28°C. To obtain pure colonies, bacteria were re-streak into a new LB agar and colonies showing typical Xanthomonas spp. morphology (i.e. convex, smooth, yellow, and mucoid) were subjected to Gram staining assay. For molecular identification, 16S ribosomal DNA (16S-rDNA) and gyrase B (gyrB) genes were amplified using a 9F/1512r and UP-1/UP-2Sr primers [2,3] respectively from 5 gram-negative isolates. PCR products were sequenced and analysed using BLASTN. Result shows that 16S-rDNA and gyrB genes are 99-100% identical to a similar genomic region of Xanthomonas arboricola pv. pruni (Xap) isolated in almond (MK156163), peach (MG049922) and apricot (KX950802) respectively [4,5,6]. 16S-rDNA and gyrB gene sequences were deposited in the GenBank (LC485472 and LC576824), whereas pathogen isolate was deposited into Korean Agricultural Culture Collection (KACC19949). Pathogenicity test was performed using Xap bacterial suspension (108 cfu/mL) inoculated on the abaxial and adaxial surface of plumcot detached leaves. For inoculation, 10 healthy young leaves were used whereas, 5 young leaves mock-inoculated with sterile LB broth were used as a control. Both leaf samples were kept in a closed container to maintain 100% humidity before being incubated at 25°C. The water-soaked symptoms were observed visually on the inoculated leaves 2 to 3 days post-inoculation. No water-soaked symptoms were observed on the control leaves. Morphology and sequences of molecular markers used showed that the 3 bacterial colonies re-isolated from the inoculated leaves were identical to the original isolate, fulfilling Koch's postulate. Pathogenicity tests were repeated twice and the results obtained were consistent with the first experiment. As a new variety of stone fruit cultivated in Korea, information about pathogens and registered agrochemicals to control disease outbreak in plumcot are still limited. Therefore, the identification of Xap as a causal agent to the black spot disease is critical for the development of disease management strategies and to identify appropriate agrochemicals to control the occurrence of this disease in the field. To our knowledge, this is the first report of Xap as a causal agent to the shot-hole disease on the plumcot in Korea.

Selected Emerging Infectious Diseases of Squamata: An Update

This article details emerging infectious diseases that have devastating impacts on captive and wild squamates. Treatment advances have been attempted for Cryptosporidium infections in squamates. Gram-positive bacteria, Devriesea agamarum and Austwickia chelonae, are contributing to severe disease in captive and now in wild reptiles, some critically endangered. Nannizziposis, Paranannizziopsis, and Ophidiomyces continue to cause fatal disease as primary pathogens in wild and captive populations of squamates and sphenodontids. Nidovirus, bornavirus, paramyxovirus, sunshine virus, and arenavirus have emerged to be significant causes of neurorespiratory disease in snakes. Controlled studies evaluating environmental stability, disinfection, transmission control, and treatment are lacking.

Pharmacists' practices for non-prescribed antibiotic dispensing in Mozambique

Background

Antibiotics are the most frequently used medicines worldwide with most of the countries defining these as prescription-only medicines. Though, dispensing non-prescribed antibiotics represent one of the chief causal factors to the irrational use of antibiotics that paves the way to the development of antimicrobial resistance.

Objective

We aimed at describing the practices and the enablers for non-prescribed antibiotic dispensing in Maputo city, Mozambique.

Methods

A qualitative study was conducted, between October 2018 and March 2019, in nine private pharmacies randomly selected across Maputo city. Eighteen pharmacists were contacted and seventeen enrolled through snowball sampling. In-depth interviews were conducted, audiotaped, and transcribed verbatim. Transcripts were coded and analysed though thematic analysis with guidelines from Braun and Clark. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist by (Tong, 2007) was performed.

Results

Out of seventeen, fifteen pharmacists admitted non-prescribed dispensing of antibiotics. Common antibiotic dispensing practices included; dispensing without prescription, without asking for a brief clinical history of patients, without clear explanation of the appropriate way of administering, without advising on the side effects. Reasons for non-prescribed antibiotic dispensing are linked to patients' behaviour of demanding for non-prescribed antibiotics, to the patients expectations and beliefs on the healing power of antibiotics, to the physicians' prescribing practices. Other reasons included the pressure for profits from the pharmacy owners, the fragile law enforcement, and absence of accountability mechanisms.

Conclusions

The practices of non-prescribed antibiotic dispensing characterize the 'daily life' of the pharmacists. On the one hand, the patient's demand for antibiotics without valid prescriptions, and pharmacist's wish to assist based on their role in the pharmacy, the pressure for profits and on the understanding of the larger forces driving the practices of self-medication with antibiotics - rock. On the other hand, pharmacists are aware of the legal status of antibiotics and the public health consequences of their inappropriate dispensing practices and their professional and ethical responsibility for upholding the law - hard place. Highlighting the role of pharmacists and their skills as health promotion professionals is needed to optimizing antibiotic dispensing and better conservancy in Mozambique.

Conjunctivitis: A Systematic Review

Conjunctivitis is a commonly encountered condition in ophthalmology clinics throughout the world. In the management of suspected cases of conjunctivitis, alarming signs for more serious intraocular conditions, such as severe pain, decreased vision, and painful pupillary reaction, must be considered. Additionally, a thorough medical and ophthalmic history should be obtained and a thorough physical examination should be done in patients with atypical findings and chronic course. Concurrent physical exam findings with relevant history may reveal the presence of a systemic condition with involvement of the conjunctiva. Viral conjunctivitis remains to be the most common overall cause of conjunctivitis. Bacterial conjunctivitis is encountered less frequently and it is the second most common cause of infectious conjunctivitis. Allergic conjunctivitis is encountered in nearly half of the population and the findings include itching, mucoid discharge, chemosis, and eyelid edema. Long-term usage of eye drops with preservatives in a patient with conjunctival irritation and discharge points to the toxic conjunctivitis as the underlying etiology. Effective management of conjunctivitis includes timely diagnosis, appropriate differentiation of the various etiologies, and appropriate treatment.

What you need to know about brain abscesses

A brain abscess is a focal accumulation of pus in the brain parenchyma arising from direct inoculation, contiguous spread from local anatomical structures or haematogenous seeding from a remote source of infection. It can result in significant morbidity and mortality, making early diagnosis and treatment vital. Only one fifth of patients present with the classic triad of headache, fever and focal neurological symptoms. More commonly patients show signs and symptoms of raised intracranial pressure alone, such as confusion or reduced conscious level, headache, nausea and vomiting, which can be a presentation of many intracranial pathologies. Distinguishing an abscess from other pathologies such as meningitis and tumours is crucial, as clinically these can present in similar ways, but their management and outcomes are very different. Diffusion-weighted magnetic resonance imaging brain scans can help localise the lesion and differentiate ring-enhancing lesions caused by a brain abscess from malignant tumours. Cerebral abscesses are considered a neurosurgical emergency; early stabilisation, diagnosis and management in a neurosurgical centre is important in reducing morbidity and mortality.

Factors associated with early complications in inpatients who were treated in our clinic between 1992 and 2011 with a diagnosis of acute bacterial meningitis

Aim:

To evaluate factors associated with the development of early complications in acute bacterial meningitis.

Material and Methods:

In our study, 389 patients diagnosed with acute bacterial meningitis between January 1992 and January 2011 at Cerrahpaşa Medical Faculty were retrospectively analyzed to determine the risk factors for the development of early complications.

Results:

The causative agent was N. meningitidis in 17% of cases, S. pneumoniae in 13.6%, and H. influenzae type b in 6.4%. In 55.5% of cases, the causative agent could not be identified. The mortality rate was found as 1% and the early complication rate was 27.8%. The complications observed included septic shock and disseminated intravascular coagulation (33.3%), hydrocephalus (23.1%), subdural effusion (19.4%), and epilepsy (12%). Risk factors for early complications included being aged below two years (p<0.010), restlessness (p<0.010), rash (p<0.010), leukocytosis in complete blood count (p<0.010), and a cerebrospinal fluid glucose level of <45 mg/dL (p<0.010). Three of the four patients who died were male. The incidence of hydrocephalus was higher in patients who used ampicillin-cefotaxime and who did not receive steroid therapy before treatment (p<0.050).

Conclusion:

When acute bacterial meningitis is treated properly and adequately, recovery without sequela is possible. Knowing the risk factors for early complications will guide in the monitoring of patients and decrease morbidity and mortality rates.

Infective vegetative endocarditis of the mitral, aortic, and pulmonary valves due to Enterococcus hirae in a cat with a ventricular septal defect

A 2.5-year-old female intact British Shorthair was presented for progressive complaints of abdominal distention, increased respiratory effort, lethargy and hyporexia. Based on the clinical presentation and a loud heart murmur, a cardiac cause was suspected. An echocardiogram was performed and the presumptive diagnosis of infective endocarditis of the aortic, mitral and pulmonic valves was made. Antemortem blood culture and postmortem valve biopsy confirmed bacterial endocarditis with Enterococcus hirae as etiological agent. To the authors' best knowledge, this case report is the first to describe an infective endocarditis with vegetative lesions on three cardiac valves associated with a ventricular septal defect in a cat, and Enterococcus hirae as causative agent for endocarditis in small animals.

A global perspective of pediatric non-viral keratitis: literature review

PURPOSE

This focused review aims to explore pediatric non-viral keratitis and to compare associated risk factors, etiologies, antibiotic susceptibilities, empiric treatments and outcomes.

METHODS

The authors performed a literature research for articles, published on PubMed, Google Scholar, Scopus and Embase online library, relevant to pediatric keratitis etiology, risk factors, antibiotic susceptibilities, treatment and outcomes. From the bibliography of selected articles, additional relevant articles were also considered. Of 34 articles identified, 21 were suitable for the purpose of this review.

RESULTS

Several risk factors are noted in the field of pediatric keratitis. Trauma is the most common in developing countries, while contact lenses wear is seen in developed economies. Previous ocular conditions and systemic diseases also contribute. Associated malnourishment and vitamin A deficit are fraught with a catastrophic prognosis. Among causative organisms, bacteria are more common than fungi and protozoa. Gram-positive organisms are predominant where contact lenses use is infrequent. Pseudomonas aeruginosa is often the leading pathogen in developed countries and is strongly associated with contact lens wear or malnourishment. Fungi are common in the tropics and associated with trauma. Levofloxacin seems the more effective empirical treatment when bacteria are suspected, but there is no agreement on a standard of care.

CONCLUSION

There are differences in etiologic patterns between developing and developed countries and different regions globally. Risk factors follow the same trend; however, there is no standard regimen being followed for empirical treatment of pediatric infectious keratitis. Associated malnourishment and vitamin A deficiency result in poorer outcomes.

Immediate Outcomes of Aortic Valve Neocuspidization with Glutaraldehyde-treated Autologous Pericardium: a Multicenter Study

Objective

To determine the feasibility of aortic valve neocuspidization (AVNeo) with glutaraldehyde-treated autologous pericardium.

Methods

One hundred and seventy (170) AVNeo (84 males/86 females) were performed from January 2017 through March 2019 in three centers. All the records were prospectively collected and retrospectively reviewed.

Results

Most of the patients were older than 60 years and over 95% were operated for aortic stenosis. Preoperatively, pressure gradients were 69.9±21.3 mmHg for patients with aortic stenosis, and the surgical annular diameter was 21.0±2.0 mm for all patients. Effective orifice area (EOA) and indexed EOA (iEOA) averaged 0.7±0.3 cm² and 0.4±0.2 cm²/m² for patients with aortic stenosis before surgery, respectively. There was no conversion to prosthetic aortic valve replacement. Eight patients needed reoperation for bleeding, but no patient needed reoperation due to early infective endocarditis. There were five in-hospital deaths due to noncardiac cause. Compared to preoperative echocardiographic measurements, postoperative peak pressure gradient decreased significantly (-58.7±1.7 mmHg; P<0.001) and reached 11.2±5.6 mmHg, and mean pressure gradient also decreased significantly (-36.8±1.1 mmHg; P<0.001) and reached 6.0±3.5 mmHg. Accordingly, EOA and iEOA increased significantly 2.0 cm² and 1.0 cm²/m² (both P<0.001) to reach 2.7±0.6 cm² and 1.4±0.3 cm²/m² after surgery, respectively, with minimal significant aortic regurgitation (0.6% > mild).

Conclusion

AVNeo is feasible and reproducible with good clinical results. Hemodynamically, AVNeo produces immediate postoperative low-pressure gradients, large EOA, and minimal regurgitation of the aortic valve. Further studies are necessary to evaluate mid- and long-term evolution.

Uncommon clinical presentation of a common bug: Group A Streptococcus meningitis

Group A Streptococcus (GAS) is a common pathogen in paediatric infections. However, it is a rare etiologic agent of bacterial meningitis. We describe a case of Streptococcus pyogenes meningitis complicated by sensorineural hearing loss in an immunocompetent 7-year-old boy. Clinicians should be aware of GAS as a potential cause of paediatric meningitis, especially with prominent symptoms suggestive of frontal sinusitis. Meningitis caused by GAS has been shown to be associated with significant mortality and morbidity, including neurological complications. Early screening for sensorineural hearing loss in patients with GAS meningitis can facilitate timely cochlear implant.

Extremely high canine C-reactive protein concentrations > 100 mg/l - prevalence, etiology and prognostic significance

BACKGROUND

In human medicine, extremely high CRP (C-reactive protein) concentrations > 100 mg/l are indicators of bacterial infection and the need of antibiotic treatment. Similar decision limits for septic pneumonia are recommended for dogs but have not yet been evaluated for other organ systems. The aim of the retrospective study was to investigate the prevalence and evaluate dogs with CRP concentrations > 100 mg/l regarding the underlying etiology, the affected organ system and the prognostic significance.

RESULTS

Prevalence of CRP > 100 mg/l was investigated in dogs presented between 2014 and 2015 and was 12%. For evaluation of etiology and organ systems, dogs with CRP > 100 mg/l presented between 2014 and 2016 were enrolled. Dogs were classified into 4 main disease categories, i.e. inflammatory, neoplastic, tissue damage or "diverse". Diseases were assigned to the affected organ system. If an organ classification was not possible, dogs were classified as "multiple". 147 dogs with CRP 101-368 mg/l were included and classified into disease categories: 86/147 (59%) with inflammatory etiology (among these, 23/86 non-infectious, 44/86 infectious (33/44 bacterial), 19/86 inflammation non-classifiable), 31/147 (21%) tissue damage, 17/147 (12%) neoplastic (all malignant) and 13/147 (9%) diverse diseases. The affected organ systems included 57/147 (39%) multiple, 30/147 (20%) trauma, 21/147 (14%) gastrointestinal tract, 10/147 (7%) musculoskeletal system, 8/147 (5%) respiratory tract, 7/147 (5%) urinary/reproductive tract, 6/147 (4%) skin/subcutis/ear, 6/147 (4%) central/peripheral nervous system and 2/147 (1%) heart. The disease group (p = 0.081) or organ system (p = 0.17) did not have an impact on CRP. Based on CRP, a detection of bacterial infection was not possible. The prognostic significance was investigated by determining the 3-months survival and hospitalization rate in a subgroup with known outcome. The 3-months survival rate was 46/73 (63%) while the majority 66/73 (90%) of patients was hospitalized.

CONCLUSIONS

CRP concentrations > 100 mg/l are occasionally seen in a clinic population. They indicate a severe systemic disease of various etiologies with guarded prognosis. Extremely high CRP concentrations do not allow a conclusion of the underlying etiology or an identification of bacterial inflammation.