Antibiotics and antimicrobial resistance in the COVID-19 era: Perspective from resource-limited settings

Some issues of safety of antimicrobial therapy in COVID-19 patients

Currently, there is a lack of evidence for empiric use of antimicrobial agents in most patients with COVID-19 in outpatient and hospital settings as the overall proportion of secondary bacterial infections in COVID-19 is quite low. This literature review summarizes data on changes in antimicrobial resistance over the course of COVID-19 pandemic, especially in nosocomial ESKAPE pathogens. The other significant consequences of excessive and unnecessary administration of antibiotics to COVID-19 patients including risk of Clostridioides difficile infection and adverse effects of antimicrobial agents are also discussed.

Impact of the COVID-19 pandemic on the incidence of multidrug-resistant bacterial infections in an acute care hospital in Brazil

BACKGROUND

The impact of COVID-19 on healthcare- associated infections (HCAI) caused by multidrug-resistant (MDR) bacteria that contribute to higher mortality is a growing area of study METHODS: This retrospective observational study compares the incidence density (ID) of HCAI caused by MDR bacteria (CRE, CRAB, CRP, MRSA and VRE) pre-COVID (2017-2019) and during the COVID-19 pandemic (2020) in overall hospitalized patients and in intensive care (ICU) units.

RESULTS

We identified 8,869 HCAI, of which 2,641 (29.7%) were caused by bacterial MDR, and 1,257 (14.1%) were from ICUs. The overall ID of MDR infections increased 23% (P < .005) during COVID-19. The overall per-pathogen analysis shows significant increases in infections by CRAB and MRSA (+108.1%, p<0.005; +94.7%, p<0.005, respectively), but not in CRE, CRP, or VRE. In the ICU, the overall ID of MDR infections decreased during COVID, but that decline was not significant (-6.5%, P = .26). The ICU per-pathogen analysis of ID of infection showed significant increases in CRAB and MRSA (+42.0%, P = .001; +46.2%, P = .04), significant decreases in CRE and CRP (-26.4%, P = .002; -44.2%, P = 0.003, respectively) and no change in VRE.

CONCLUSIONS

The COVID-19 pandemic correlates to an increase in ID of CRAB and MRSA both in ICU and non-ICU setting, and a decrease in ID of CRE and CRP in the ICU setting. Infection control teams should be aware of possible outbreaks of CRAB and MRSA and promote rigorous adherence to infection control measures as practices change to accommodate changes in healthcare needs during and after the pandemic.

Antimicrobial consumption in patients with COVID-19: a systematic review and meta-analysis

INTRODUCTION

Since the onset of the pandemic, prescribing antimicrobials has become a common practice to treat patients infected with COVID-19.

AREAS COVERED

A systematic literature search was performed in the electronic databases MEDLINE, CINAHL, WHO COVID-19 database, including EMBASE, Scopus, WHO-COVID, LILACS, and Google Scholar to identify original articles published up to 31 July 2021. A random-effects model was used to estimate the pooled prevalence or proportion of antimicrobial consumption among COVID-19 patients.

EXPERT OPINION

We identified 43 original articles, 33 studies from high-income countries, six from upper-middle-income countries, and four from lower-middle-income countries. Most of the studies presented data from hospital or secondary health-care settings (n = 34). Included studies measured antimicrobial consumption as Daily Defined Doses (DDD) or day of therapy (DOT) or percentage. A total of 19 studies measured antimicrobial consumption as DDDs or DOT. Meta-analysis revealed an overall high antimicrobial consumption of 68% (95% CI: 60% to 75%). The subgroup analysis found a lower consumption in high-income countries (58%, 95% CI: 48% to 67%), compared with lower and middle-income countries (89%, 95% CI: 82% to 94%). High antimicrobial consumption found in COVID-19 patients demands implementation of appropriate antimicrobial stewardship interventions.

Prospects of Exploring the Metal-Organic Framework for Combating Antimicrobial Resistance

Infectious diseases are a major public health concern globally. Infections caused by pathogens with resistance against commonly used antimicrobial drugs or antibiotics (known as antimicrobial resistance, AMR) are becoming extremely difficult to control. AMR has thus been declared as one of the top 10 global public health threats, as it has very limited solutions. The drying pipeline of effective antibiotics has further worsened the situation. There is no absolute treatment, and the limitations of existing methods warrant further development in antimicrobials. Recent developments in the nanomaterial field present them as promising therapeutics and effective alternative to conventional antibiotics and synthetic drugs. The metal-organic framework (MOF) is a recent addition to the antimicrobial category with superior properties. The MOF exerts antimicrobial action on a wide range of species and is highly biocompatible. Additionally, their porous structures allow the incorporation of biomolecules and drugs for synergistic antimicrobial action. This review provides an inclusive summary of the molecular events responsible for resistance development and current trends in antimicrobials to combat antibiotic resistance and explores the potential role of the MOF in tackling the drug-resistant microbial species.

An overview on the current available treatment for COVID-19 and the impact of antibiotic administration during the pandemic

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has caused several problems in healthcare systems around the world, as to date, there is no effective and specific treatment against all forms of COVID-19. Currently, drugs with therapeutic potential are being tested, including antiviral, anti-inflammatory, anti-malarial, immunotherapy, and antibiotics. Although antibiotics have no direct effect on viral infections, they are often used against secondary bacterial infections, or even as empiric treatment to reduce viral load, infection, and replication of coronaviruses. However, there are many concerns about this therapeutic approach as it may accelerate and/or increase the long-term rates of antimicrobial resistance (AMR). We focused this overview on exploring candidate drugs for COVID-19 therapy, including antibiotics, considering the lack of specific treatment and that it is unclear whether the widespread use of antibiotics in the treatment of COVID-19 has implications for the emergence and transmission of multidrug-resistant bacteria.

The De-marketing Strategies as a Vital Resolve of Antibiotics Misuse Dilemma

Developing resistance to the currently available antimicrobial agents, particularly anti-Bacterial, is a worrying issue that rises highly worldwide. Communities, health workers, and government officials around the world are joining in, calling for overuse and misuse of antibiotics to stop. The phrase “de-marketing” indicates a strategy that drives to organize the form and the level of the current and future demand; not only that, but rationalizes it by organizations (profit, non-profit organizations as well as governments) specified to discourage and minimize activities of organizations about selling, distribution, using, and advertising… etc. It is to conduct an investigation of the potential impact of de-marketing in both controlling and minimizing the antibiotic misusage in Jordan. The essential purpose of the current analysis research is to manifest the contribution of the general demarketing strategy in influencing the attitude of consumers towards rationalization of taking antibiotics through regular medications, which is under the supervision and recommendations of professional doctors. In this article, we focused on those secondary resources derived from the published literature. Besides, we relied on the output of 450 consumers’ interactions and responses to our 19 questions distributed as a survey with consideration to the general ethics. The model of our study was designed based on the preliminary information collected from exploration study. The insight statistical analysis confirmed a attitude towards rationalization of taking antibiotics without doctor supervision (off prescription) that properly will raise the issue of antibiotics misuse along with its severe and dangerous side effects which will have a possible reduction of the undesirable and toxic effects after misusing the drugs. Moreover, this strategy would have a positive impact in lowering eco-toxicity of antibiotics misuse to words non-target aquatic organisms; plants or sediment and soil-inhabiting organisms. In conclusion, The problem of antibiotic resistance can be minimized only by concerted efforts of all members of society for ensuring the continued efficiency of antibiotics, the demarketing strategy shows a promising approach which could be used by any interested parties working to develop policies, strategies, interventions or campaigns to reduce antibiotic resistance.

Biochar-Supported TiO2-Based Nanocomposites for the Photocatalytic Degradation of Sulfamethoxazole in Water-A Review

Sulfamethoxazole (SMX) is a frequently used antibiotic for the treatment of urinary tract, respiratory, and intestinal infections and as a supplement in livestock or fishery farming to boost production. The release of SMX into the environment can lead to the development of antibiotic resistance among the microbial community, which can lead to frequent clinical infections. SMX removal from water is usually done through advanced treatment processes, such as adsorption, photocatalytic oxidation, and biodegradation. Among them, the advanced oxidation process using TiO2 and its composites is being widely used. TiO2 is a widely used photocatalyst; however, it has certain limitations, such as low visible light response and quick recombination of e-/h+ pairs. Integrating the biochar with TiO2 nanoparticles can overcome such limitations. The biochar-supported TiO2 composites showed a significant increase in the photocatalytic activities in the UV-visible range, which resulted in a substantial increase in the degradation of SMX in water. The present review has critically reviewed the methods of biochar TiO2 composite synthesis, the effect of biochar integration with the TiO2 on its physicochemical properties, and the chemical pathways through which the biochar/TiO2 composite degrades the SMX in water or aqueous solution. The degradation of SMX using photocatalysis can be considered a useful model, and the research studies presented in this review will allow extending this area of research on other types of similar pharmaceuticals or pollutants in general in the future.

Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control

Vancomycin-resistant enterococcus (VRE) is a pathogen of growing concern due to increasing development of antibiotic resistance, increasing length of hospitalizations and excess mortality. The utility of some infection control practices are debatable, as newer developments in infection prevention strategies continued to be discovered. This article summarizes the significance of VRE and VRE transmission, along with highlighting key changes in infection control practices within the past 5 years.

Green and ecofriendly biosynthesis of selenium nanoparticles using Urtica dioica (stinging nettle) leaf extract: Antimicrobial and anticancer activity

BACKGROUND/GOAL/AIM

Plant extract is affordable and does not require any particular conditions; rapid production of nanoparticles using plants offers more advantages than other approaches. Selenium nanoparticles (SeNPs) have received much attention in the last decade due to SeNPs diverse and different applications. Herein, this study aimed to biosynthesize SeNPs using aqueous extract of Urtica dioica leaf through green and ecofriendly method. Moreover to fully characterize SeNPs using different techniques, and to evaluate it for antimicrobial activity as well as anticancer activity.

MAIN METHODS AND MAJOR RESULTS

SeNPs were biosynthesis using aqueous leaf extract of U. dioica (stinging nettle). The biosynthesized SeNPs were characterized using UV-visible spectroscopy (UV-Vis), X-ray diffraction (XRD), Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), energy dispersive electron spectroscopy (EDX), transmission electron microscopy (TEM), and thermal-gravimetric analysis (TGA). Antimicrobial and anticancer activities of biosynthesized SeNPs were assessed. Results illustrated that SeNPs exhibited promising antibacterial activity against Gram-positive and Gram-negative bacteria, as well as unicellular and multi-cellular fungi. Moreover, minimal-inhibitory concentration (MIC) of SeNPs against Escherichia coli, Pseudomonas aeruginosa, Bacillus subtilis, and Staphylococcus aureus were 250, 31.25, and 500 μg mL^-1 , respectively, while were 62.5, 15.62, 31.25, and 7.81 μg mL^-1 against Candida albicans, Aspergillus fumigatus, Aspergillus niger, and Aspergillus flavus, respectively. The cytotoxicity of SeNPs was performed on Vero normal-cell line CCL-81, where IC₅₀ was 173.2 μg mL^-1 .

CONCLUSIONS AND IMPLICATIONS

For the first time, aqueous stinging nettle leaf extract was utilized to biosynthesize SeNPs in a green method. SeNPs have outstanding antimicrobial-activity against pathogenic bacterial and fungal strains. Moreover, SeNPs have promising anticancer activity against HepG2 cancerous cell line without cytotoxicity on Vero normal cell line. Finally, the biosynthesized SeNPs via aqueous extract of stinging nettle leaf exhibited potential antibacterial, antifungal, and anticancer action, making them useful in the medical field.

Survey among Italian experts on existing vaccines' role in limiting antibiotic resistance

Antimicrobial resistance (AMR) is a major public health problem threatening to reverse the progress made against infectious diseases. The rapid increase of AMR exposes Italian hospitals at increased risk of untreatable infections. Vaccinations can potentially limit AMR by reducing the number of infected cases in need of antibiotics. We conducted a survey among Italian vaccine experts to record their opinion regarding the role of vaccinations against antibiotic resistance (ABR). Among 80 invited experts, 51 answered all questions. Most respondents were experts in hygiene and preventive medicine (56.9%) and aged >50 years (72.6%). ABR was a priority concern in the daily professional activity of 82.4% of respondents. Overall, 47.1% of respondents believed that all vaccinations included in the vaccination calendar played a role against ABR: 92.2% for pertussis vaccination followed by 88.2%, 74.5%, and 70.6% for meningococcus, measles, and varicella vaccinations, respectively. Almost all respondents agreed that the role of vaccinations against ABR should be clearly expressed in the national vaccination guidelines (96.1%) and Scientific Societies should take an explicit position on the issue (92.2%). These results show that Italian experts have recognized the vaccinations' potential role in limiting ABR and guidelines from the appropriate scientific and governmental authorities are needed.

Impact of the COVID-19 pandemic on the surveillance, prevention and control of antimicrobial resistance: a global survey

OBJECTIVES

The COVID-19 pandemic has had a substantial impact on health systems. The WHO Antimicrobial Resistance (AMR) Surveillance and Quality Assessment Collaborating Centres Network conducted a survey to assess the effects of COVID-19 on AMR surveillance, prevention and control.

METHODS

From October to December 2020, WHO Global Antimicrobial Resistance and Use Surveillance System (GLASS) national focal points completed a questionnaire, including Likert scales and open-ended questions. Data were descriptively analysed, income/regional differences were assessed and free-text questions were thematically analysed.

RESULTS

Seventy-three countries across income levels participated. During the COVID-19 pandemic, 67% reported limited ability to work with AMR partnerships; decreases in funding were frequently reported by low- and middle-income countries (LMICs; P < 0.01). Reduced availability of nursing, medical and public health staff for AMR was reported by 71%, 69% and 64%, respectively, whereas 67% reported stable cleaning staff availability. The majority (58%) reported reduced reagents/consumables, particularly LMICs (P < 0.01). Decreased numbers of cultures, elective procedures, chronically ill admissions and outpatients and increased ICU admissions reported could bias AMR data. Reported overall infection prevention and control (IPC) improvement could decrease AMR rates, whereas increases in selected inappropriate IPC practices and antimicrobial prescribing could increase rates. Most did not yet have complete data on changing AMR rates due to COVID-19.

CONCLUSIONS

This was the first survey to explore the global impact of COVID-19 on AMR among GLASS countries. Responses highlight important actions to help ensure that AMR remains a global health priority, including engaging with GLASS to facilitate reliable AMR surveillance data, seizing the opportunity to develop more sustainable IPC programmes, promoting integrated antibiotic stewardship guidance, leveraging increased laboratory capabilities and other system-strengthening efforts.

Anti-SARS-CoV-2 and anti-cytokine storm neutralizing antibody therapies against COVID-19: Update, challenges, and perspectives

Coronavirus disease 2019 (COVID-19) has been declared by the World Health Organization (WHO) as a pandemic since March 2020. This disease is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The only available tools to avoid contamination and transmission of this virus are physical distancing, the use of N95 and surgical masks, and hand hygiene. Vaccines are another essential tool to reduce the impact of the pandemic, though these present challenges in terms of production and logistics, particularly in underdeveloped and developing countries. One of the critical early research findings is the interaction of the spike virus protein with the angiotensin-converting enzyme 2 (ACE2) human receptor. Developing strategies to block this interaction has therefore been identified as a way to treat this infection. Neutralizing antibodies (nAbs) have emerged as a therapeutic approach since the pandemic started. Infected patients may be asymptomatic or present with mild symptoms, and others may evolve to moderate or severe disease, leading to death. An immunological phenomenon known as cytokine storm has been observed in patients with severe disease characterized by a proinflammatory cytokine cascade response that leads to lung injury. Thus, some treatment strategies focus on anti-cytokine storm nAbs. This review summarizes the latest advances in research and clinical trials, challenges, and perspectives on antibody-based treatments (ABT) as therapies against COVID-19.

Key considerations on the potential impacts of the COVID-19 pandemic on antimicrobial resistance research and surveillance

Antibiotic use in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients during the COVID-19 pandemic has exceeded the incidence of bacterial coinfections and secondary infections, suggesting inappropriate and excessive prescribing. Even in settings with established antimicrobial stewardship (AMS) programmes, there were weaknesses exposed regarding appropriate antibiotic use in the context of the pandemic. Moreover, antimicrobial resistance (AMR) surveillance and AMS have been deprioritised with diversion of health system resources to the pandemic response. This experience highlights deficiencies in AMR containment and mitigation strategies that require urgent attention from clinical and scientific communities. These include the need to implement diagnostic stewardship to assess the global incidence of coinfections and secondary infections in COVID-19 patients, including those by multidrug-resistant pathogens, to identify patients most likely to benefit from antibiotic treatment and identify when antibiotics can be safely withheld, de-escalated or discontinued. Long-term global surveillance of clinical and societal antibiotic use and resistance trends is required to prepare for subsequent changes in AMR epidemiology, while ensuring uninterrupted supply chains and preventing drug shortages and stock outs. These interventions present implementation challenges in resource-constrained settings, making a case for implementation research on AMR. Knowledge and support for these practices will come from internationally coordinated, targeted research on AMR, supporting the preparation for future challenges from emerging AMR in the context of the current COVID-19 pandemic or future pandemics.

Bacterial and fungal growth in sputum cultures from 165 COVID-19 pneumonia patients requiring intubation: evidence for antimicrobial resistance development and analysis of risk factors

BACKGROUND

Coronavirus SARS-CoV-2 causes COVID-19 illness which can progress to severe pneumonia. Empiric antibacterials are often employed though frequency of bacterial coinfection superinfection is debated and concerns raised about selection of bacterial antimicrobial resistance. We evaluated sputum bacterial and fungal growth from 165 intubated COVID-19 pneumonia patients. Objectives were to determine frequency of culture positivity, risk factors for and outcomes of positive cultures, and timing of antimicrobial resistance development.

METHODS

Retrospective reviews were conducted of COVID-19 pneumonia patients requiring intubation admitted to a 1058-bed four community hospital system on the east coast United States, March 1 to May 1, 2020. Length of stay (LOS) was expressed as mean (standard deviation); 95% confidence interval (95% CI) was computed for overall mortality rate using the exact binomial method, and overall mortality was compared across each level of a potential risk factor using a Chi-Square Test of Independence. All tests were two-sided, and significance level was set to 0.05.

RESULTS

Average patient age was 68.7 years and LOS 19.9 days. Eighty-three patients (50.3% of total) originated from home, 10 from group homes (6.1% of total), and 72 from nursing facilities (43.6% of total). Mortality was 62.4%, highest for nursing home residents (80.6%). Findings from 253 sputum cultures overall did not suggest acute bacterial or fungal infection in 73 (45%) of 165 individuals sampled within 24 h of intubation. Cultures ≥ 1 week following intubation did grow potential pathogens in 72 (64.9%) of 111 cases with 70.8% consistent with late pneumonia and 29.2% suggesting colonization. Twelve (10.8% of total) of these late post-intubation cultures revealed worsened antimicrobial resistance predominantly in Pseudomonas, Enterobacter, or Staphylococcus aureus.

CONCLUSIONS

In severe COVID-19 pneumonia, a radiographic ground glass interstitial pattern and lack of purulent sputum prior to/around the time of intubation correlated with no culture growth or recovery of normal oral flora ± yeast. Discontinuation of empiric antibacterials should be considered in these patients aided by other clinical findings, history of prior antimicrobials, laboratory testing, and overall clinical course. Continuing longterm hospitalisation and antibiotics are associated with sputum cultures reflective of hospital-acquired microbes and increasing antimicrobial resistance.

TRIAL REGISTRATION

Not applicable as this was a retrospective chart review study without interventional arm.

Disc Diffusion Testing of Azithromycin Against Clinical Isolates of Typhoidal Salmonellae: A Diagnostic Conundrum

Introduction: Typhoid remains a major healthcare problem in low and middle-income countries. The emergence of extremely drug-resistant (XDR) typhoid strains from the Indian subcontinent has led to very limited therapeutic options. Azithromycin being the only oral option for XDR typhoid faces a threat of rapid resistance due to its overuse after the COVID-19 pandemic.

Objective: To evaluate the reliability of azithromycin disc diffusion testing against clinical isolates of typhoidal salmonellae in comparison with E-test minimum inhibitory concentrations (MICs).

Study design: This is a cross-sectional validation study.

Place and duration of the study: The Department of Microbiology, Pakistan Navy Ship Shifa hospital, Karachi from June 1 to December 31, 2020.

Methodology: Antimicrobial susceptibility was performed by Kirby Bauer disc diffusion method for 60 isolates including Salmonella enterica ser. Typhi and Paratyphi A using Clinical Laboratory Standard Institute (CLSI) guidelines. MICs by the E-test method were determined for Azithromycin only.

Results: A significant proportion of the isolates (55%) had high azithromycin MIC in the wild-type distribution range (8-16 µg/ml). Ten (16.6%) isolates showed false resistance, i.e., zone diameter <13 mm by disc diffusion method when compared to E-test MIC results. Isolates with MICs close to breakpoint, i.e., 16 µg/ml were more likely to show discordant results. The sensitivity, specificity, negative predictive value, positive predictive value, and diagnostic accuracy of the disc diffusion method versus E-test were 100%, 83%, 100%, 9%, and 83%, respectively.

Conclusions: Disc diffusion method as recommended by CLSI is not reliable for azithromycin susceptibility testing particularly for isolates with high MICs in the susceptible range. The E-test method may be a better alternative to disc diffusion provided appropriate training is done prior to its application.

Overview on the Prevalence of Fungal Infections, Immune Response, and Microbiome Role in COVID-19 Patients

Patients with severe COVID-19, such as individuals in intensive care units (ICU), are exceptionally susceptible to bacterial and fungal infections. The most prevalent fungal infections are aspergillosis and candidemia. Nonetheless, other fungal species (for instance, Histoplasma spp., Rhizopus spp., Mucor spp., Cryptococcus spp.) have recently been increasingly linked to opportunistic fungal diseases in COVID-19 patients. These fungal co-infections are described with rising incidence, severe illness, and death that is associated with host immune response. Awareness of the high risks of the occurrence of fungal co-infections is crucial to downgrade any arrear in diagnosis and treatment to support the prevention of severe illness and death directly related to these infections. This review analyses the fungal infections, treatments, outcome, and immune response, considering the possible role of the microbiome in these patients. The search was performed in Medline (PubMed), using the words "fungal infections COVID-19", between 2020-2021.

Contamination of Hospital Surfaces with Bacterial Pathogens under the Current COVID-19 Outbreak

The SARS-CoV-2 pandemic remains a global health issue for several reasons, such as the low vaccination rates and a lack of developed herd immunity to the evolution of SARS-CoV-2, as well as its potential inclination to elude neutralizing antibodies. It should be noted that the severity of the COVID-19 disease is significantly affected by the presence of co-infections. Comorbid conditions are caused not only by pathogenic and opportunistic microorganisms but also by some representatives of the environmental microbiome. The presence of patients with moderate and severe forms of the disease in hospitals indicates the need for epidemiological monitoring of (1) bacterial pathogens circulating in hospitals, especially the ESKAPE group pathogens, and (2) the microbiome of various surfaces in hospitals. In our study, we used combined methods based on PCR and NGS sequencing, which are widely used for epidemiological monitoring. Through this approach, we identified the DNA of pathogenic bacteria (Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, CoNS, and Achromobacter spp.) on various surfaces. We also estimated the microbiome diversity of surfaces and identified the potential reservoirs of infections using 16S rRNA profiling. Although we did not assess the viability of identified microorganisms, our results indicate the possible risks of insufficient regular disinfection of surfaces, regardless of department, at the Infectious Diseases Hospital. Controlling the transmission of nosocomial diseases is critical to the successful treatment of COVID-19 patients, the rational use of antimicrobial drugs, and timely decontamination measures.

Planning for disposal of COVID-19 pandemic wastes in developing countries: a review of current challenges

The health sector is critical to the well-being of any country, but developing countries have several obstacles that prevent them from providing adequate health care. This became an even larger concern after the COVID-19 outbreak left millions of people dead worldwide and generated huge amounts of infected or potentially infected wastes. The management and disposal of medical wastes during and post-COVID-19 represent a major challenge in all countries, but this challenge is particularly great for developing countries that do not have robust waste disposal infrastructure. The main problems in developing countries include inefficient treatment procedures, limited capacity of healthcare facilities, and improper waste disposal procedures. The management of medical wastes in most developing countries was primitive prior to the pandemic. The improper treatment and disposal of these wastes in our current situation may further speed COVID-19 spread, creating a serious risk for workers in the medical and sanitation fields, patients, and all of society. Therefore, there is a critical need to discuss emerging challenges in handling, treating, and disposing of medical wastes in developing countries during and after the COVID-19 outbreak. There is a need to determine best disposal techniques given the conditions and limitations under which developing countries operate. Several open questions need to be investigated concerning this global issue, such as to what extent developing countries can control the expected environmental impacts of COVID-19, particularly those related to medical wastes? What are the projected management scenarios for medical wastes under the COVID-19 outbreak? And what are the major environmental risks posed by contaminated wastes related to COVID-19 treatment? Studies directed at the questions above, careful planning, the use of large capacity mobile recycling facilities, and following established guidelines for disposal of medical wastes should reduce risk of COVID-19 spread in developing countries.

Antidrug resistance in the Indian ambient waters of Ahmedabad during the COVID-19 pandemic

The ongoing COVID-19 pandemic increases the consumption of antimicrobial substances (ABS) due to the unavailability of approved vaccine(s). To assess the effect of imprudent consumption of ABS during the COVID-19 pandemic, we compare the 2020 prevalence of antidrug resistance (ADR) of Escherichia coli (E. coli) with a similar survey carried out in 2018 in Ahmedabad, India using SARS-CoV-2 gene detection as a marker of ABS usage. We found a significant ADR increase in 2020 compared to 2018 in ambient water bodies, harbouring a higher incidence of ADR E.coli towards non-fluoroquinolone drugs. Effective SARS-CoV-2 genome copies were found to be associated with the ADR prevalence. The prevalence of ADR depends on the efficiency of WWTPs (Wastewater Treatment Plants) and the catchment area in its vicinity. In the year 2018 study, prevalence of ADR was discretely distributed, and the maximum ADR prevalence recorded was ~60%; against the current homogenous ADR increase, and up to 85% of maximum ADR among the incubated E.coli isolated from the river (Sabarmati) and lake (Chandola and Kankaria) samples. Furthermore, wastewater treatment plants showed less increase in comparison to the ambient waters, which eventually imply that although SARS-CoV-2 genes and faecal pollution may be diluted in the ambient waters, as indicated by low Ct-value and E.coli count, the danger of related aftermath like ADR increase cannot be nullified. Also, Non-fluoroquinolone drugs exhibited overall more resistance than quinolone drugs. Overall, this is probably the first-ever study that traces the COVID-19 pandemic imprints on the prevalence of antidrug resistance (ADR) through wastewater surveillance and hints at monitoring escalation of other environmental health parameters. This study will make the public and policyholders concerned about the optimum use of antibiotics during any kind of treatment.

Predisposition of COVID-19 patients to secondary infections: set in stone or subject to change?

PURPOSE OF REVIEW

There likely are several predisposing factors to secondary infections in patients with Coronavirus disease 2019 (COVID-19), some of which may be preventable. The aim of this review is to explore the literature, summarize potential predisposing factors to secondary infections and their incidence. It also summarizes a variety of healthcare scenarios in which different kinds of secondary infections occur.

RECENT FINDINGS

Apart from immune dysregulation, severe resource limitations in healthcare settings have made COVID-19 units conducive to a variety of secondary infections. Long-term effect of excess antibiotic use in COVID-19 patients is yet to be studied. Very few studies have assessed secondary infections as the primary outcome measure making it difficult to know the true incidence. Mortality attributable to secondary infections in COVID-19 patients is also unclear.

SUMMARY

Incidence of secondary infections in COVID-19 patients is likely higher than what is reported in the literature. Well designed studies are needed to understand the incidence and impact of secondary infections in this patient population. Many of these may be preventable especially now, as personal protective equipment and other healthcare resources are recovering. Infection prevention and control (IPC) and antimicrobial stewardship programmes (ASP) must reassess current situation to correct any breaches that could potentially cause more harm in these already vulnerable patients as we brace for a future surge with another pandemic wave.

Isoflavonoid-Antibiotic Thin Films Fabricated by MAPLE with Improved Resistance to Microbial Colonization

Staphylococcus aureus (Gram-positive) and Pseudomonas aeruginosa (Gram-negative) bacteria represent major infectious threats in the hospital environment due to their wide distribution, opportunistic behavior, and increasing antibiotic resistance. This study reports on the deposition of polyvinylpyrrolidone/antibiotic/isoflavonoid thin films by the matrix-assisted pulsed laser evaporation (MAPLE) method as anti-adhesion barrier coatings, on biomedical surfaces for improved resistance to microbial colonization. The thin films were characterized by Fourier transform infrared spectroscopy, infrared microscopy, and scanning electron microscopy. In vitro biological assay tests were performed to evaluate the influence of the thin films on the development of biofilms formed by Gram-positive and Gram-negative bacterial strains. In vitro biocompatibility tests were assessed on human endothelial cells examined for up to five days of incubation, via qualitative and quantitative methods. The results of this study revealed that the laser-fabricated coatings are biocompatible and resistant to microbial colonization and biofilm formation, making them successful candidates for biomedical devices and contact surfaces that would otherwise be amenable to contact transmission.

An Assessment of the Impact of Coronavirus Disease (COVID-19) Pandemic on National Antimicrobial Consumption in Jordan

Coronavirus disease 2019 (COVID-19) has overlapping clinical characteristics with bacterial respiratory tract infection, leading to the prescription of potentially unnecessary antibiotics. This study aimed at measuring changes and patterns of national antimicrobial use for one year preceding and one year during the COVID-19 pandemic. Annual national antimicrobial consumption for 2019 and 2020 was obtained from the Jordan Food and Drug Administration (JFDA) following the WHO surveillance methods. The WHO Access, Watch, and Reserve (AWaRe) classification was used. Total antibiotic consumption in 2020 (26.8 DDD per 1000 inhabitants per day) decreased by 5.5% compared to 2019 (28.4 DDD per 1000 inhabitants per day). There was an increase in the use of several antibiotics during 2020 compared with 2019 (third generation cephalosporins (19%), carbapenems (52%), macrolides (57%), and lincosamides (106%)). In 2020, there was a marked reduction in amoxicillin use (-53%), while the use of azithromycin increased by 74%. National antimicrobial consumption of the Access group decreased by 18% from 2019 to 2020 (59.1% vs. 48.1% of total consumption). The use of the Watch group increased in 2020 by 26%. The study highlighted an increase in the use of certain antibiotics during the pandemic period that are known to be associated with increasing resistance. Efforts to enhance national antimicrobial stewardship are needed to ensure rational use of antimicrobials.

Use of glucocorticoids and azithromycin in the therapy of COVID-19

In December 2019, a new variant coronavirus, SARS-CoV-2, emerged in China, which was initially described as a pneumonia of an unknown agent. The new coronavirus spreads mainly by person-to-person transmission through close contact. The pathophysiology of COVID-19 is related to a complex immune system response that varies between people and, in severe cases of the disease, is characterized by excessive responses called "cytokine storms," which are associated with complications that can lead to a state of hypercoagulation and death. Glucocorticoids and azithromycin are drugs that may be effective in the treatment. This review aims to highlight the clinical findings that demonstrate the effectiveness of glucocorticoid and azithromycin therapy in the treatment of COVID-19. To date, many drugs have been studied for use in combination therapy, and the rapid expansion of knowledge about the virology of SARS-CoV-2 generates a more accurate direction in therapy.

The Beta-Lactam Resistome Expressed by Aerobic and Anaerobic Bacteria Isolated from Human Feces of Healthy Donors

Antibiotic resistance is a major health problem worldwide, causing more deaths than diabetes and cancer. The dissemination of vertical and horizontal antibiotic resistance genes has been conducted for a selection of pan-resistant bacteria. Here, we test if the aerobic and anaerobic bacteria from human feces samples in health conditions are carriers of beta-lactamases genes. The samples were cultured in a brain–heart infusion medium and subcultured in blood agar in aerobic and anaerobic conditions for 24 h at 37 °C. The grown colonies were identified by their biochemical profiles. The DNA was extracted and purified by bacterial lysis using thermal shock and were used in the endpoint PCR and next generation sequencing to identify beta-lactamase genes expression (OXA, VIM, SHV, TEM, IMP, ROB, KPC, CMY, DHA, P, CFX, LAP, and BIL). The aerobic bacterias Aeromonas hydrophila, Citrobacter freundii, Proteus mirabilis, Providencia rettgeri, Serratia fonticola, Serratia liquefaciens, Enterobacter aerogenes, Escherichia coli, Klebsiella pneumoniae, Pantoea agglomerans, Enterococcus faecalis, and Enterobacter cloacae, the anaerobic bacteria: Capnocytophaga species, Bacteroides distasonis, Bifidobacterium adolescentis, Bacteroides ovatus, Bacteroides fragilis, Eubacterium species, Eubacterium aerofaciens, Peptostreptococcus anaerobius, Fusobacterium species, Bacteroides species, and Bacteroides vulgatus were isolated and identified. The results showed 49 strains resistant to beta-lactam with the expression of blaSHV (10.2%), blaTEM (100%), blaKPC (10.2%), blaCYM (14.3%), blaP (2%), blaCFX (8.2%), and blaBIL (6.1%). These data support the idea that the human enteric microbiota constitutes an important reservoir of genes for resistance to beta-lactamases and that such genes could be transferred to pathogenic bacteria.

Cellular Immune Response to COVID-19 and Potential Immune Modulators

Coronavirus disease 2019 (COVID-19) is a respiratory infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Droplets and contacts serve as the main route of transmission of SARS-CoV-2. The characteristic of the disease is rather heterogeneous, ranging from no symptoms to critical illness. The factors associated with the outcome of COVID-19 have not been completely characterized to date. Inspired by previous studies on the relevance of infectious diseases, viral and host factors related to clinical outcomes have been identified. The severity of COVID-19 is mainly related to host factors, especially cellular immune responses in patients. Patients with mild COVID-19 and improved patients with severe COVID-19 exhibit a normal immune response to effectively eliminate the virus. The immune response in patients with fatal severe COVID-19 includes three stages: normal or hypofunction, hyperactivation, and anergy. Eventually, the patients were unable to resist viral infection and died. Based on our understanding of the kinetics of immune responses during COVID-19, we suggest that type I interferon (IFN) could be administered to patients with severe COVID-19 in the hypofunctional stage, intravenous immunoglobulin (IVIG) and glucocorticoid therapy could be administered in the immune hyperactivation stage. In addition, low molecular weight heparin (LMWH) anticoagulation therapy and anti-infective therapy with antibiotics are recommended in the hyperactivation stage.

Implications of COVID-19 Pandemic on the Emergence of Antimicrobial Resistance: Adjusting the Response to Future Outbreaks

The net effect of the coronavirus disease 2019 (COVID-19) pandemic and the response to it on the emergence of antimicrobial resistance is yet unknown. Positive impacts on the spread of multiresistant pathogens and infections in general may be observed with the implementation of general preventative measures for the spread of infectious disease such as social distancing, reduced travel and increased personal hygiene. This pandemic has accelerated the development of novel technologies, such as mRNA vaccines, that may be used to fight other diseases. These should be capitalized upon to manage the ongoing antimicrobial resistance pandemic in the background. However, it is likely that the COVID-19 pandemic is fueling the emergence of antimicrobial resistance due to high rates of inappropriate antimicrobial prescribing, the high use of biocides and the interruption of treatment for other conditions. Clinical uncertainty driven by the lack of effective diagnostics and practice of telemedicine may have driven the inappropriate use of antimicrobials. As pathogens know no borders, increased focus is needed for infectious diseases still threatening low- and middle-income countries such as tuberculosis. Stewardship measures for future outbreaks should stress the importance of social distancing and hand washing but discourage the overuse of disinfectants and antimicrobials that are not proven effective.