Global increase and geographic convergence in antibiotic consumption between 2000 and 2015

Two cadmium(ii) coordination polymers as luminescent sensors for the detection of nitrofuran/nitroimidazole antibiotics

p-Terphenyl-2,2′′,5′′,5′′-tetracarboxylate acid and bis(imidazol-1-ylmethyl)benzene-based two Cd(ii) coordination polymers act as the luminescent sensors for the detection of nitrofuran/nitroimidazole antibiotics.

Selective effect and elimination of antibiotics in membrane bioreactor of urban wastewater treatment plant

Analyzing the temporal dynamics of antibiotics, antibiotic resistance genes (ARGs) and the functional community could contribute to the regulation and optimization of wastewater treatment plant (WWTP) operation to achieve better antibiotics and ARGs removal performances during different seasons. However, there is little research in this area. Therefore, in this study, samples were collected from the influent, activated sludge (AS), and permeate of the membrane bioreactor (MBR) in a WWTP located in Beijing, China, biweekly over 13 months, and then analyzed systematically. The removal efficiency for all detected antibiotics through biodegradation and adsorption was 59.25 ± 2.79%, with the highest rate of 64.79 ± 4.68% observed in summer, indicating that the higher temperature in summer may promote biodegradation in MBR. In contrast, the elimination of antibiotics through microfiltration was negligible and unfavorable, with negative overall removal rates. However, a positive rejection rate of 9.48 ± 8.92% was only observed in winter, indicating that a colder temperature might lead to better, but still limited, antibiotics rejection. Sulfonamides (SAs) were more likely to impose a selective pressure on their corresponding ARGs. However, due to the degradability of tetracyclines (TCs) and potential selection of ARGs in wastewater before entering WWTP, there were still TC resistances with non-detectable TCs. Significantly negative relationships were observed between the relative abundance of nitrifying bacteria (Nitrosomonas and Nitrospira) and the concentrations of certain antibiotic classes, indicating that nitrifying bacteria could be involved in the co-metabolic biodegradation of certain antibiotics through enzyme catalyzation during nitrification.

Appropriate use of antibiotics: an unmet need

Increasing bacterial resistance combined with a steady decline in the discovery of new antibiotics has resulted in a global healthcare crisis. Overuse of antibiotics, for example, in the poultry and cattle industry, and misuse and improper prescription of antibiotics are leading causes of multidrug resistance (MDR). The increasing use of antibiotics, particularly in developing countries, is a big concern for antibiotic resistance and can cause other health threats such as increased risk of recurrent infections and increased risk of cardiovascular death with chronic use of macrolides. Carbapenems are the last line of defense in many cases of resistant infection, but trends show that resistance against these agents is also increasing. This narrative review is based on relevant literature according to the experience and expertise of the authors and presents an overview of the current knowledge on antibiotic resistance, the key driving factors, and possible strategies to tackle antibiotic resistance. Collectively, studies show that hospital-wide antibiotic stewardship programs are effective in decreasing the spread of antibacterial resistance. As resistance varies according to local patterns of use, it is essential to observe the epidemiology at both a regional and an institutional level. Furthermore, adaptation of clinical guidelines is necessary, particularly for inpatient care. Future guidelines should include a justification step for continued treatment of antibiotic treatments and criteria for selection of antibiotics at the start of treatment. Nonantibiotic prevention strategies can limit infections and should also be considered in treatment plans. Vaccines against MDR organisms have shown some efficacy in phase II trials in critical care patients. Nonimmunogenic and microbiologic treatment options such as fecal transplants may be particularly important for elderly and immune-compromised patients.

The diminished antimicrobial pipeline

Australians love antibiotics, with one of the highest rates of human antibiotic usage in the world. Unfortunately, they are being loved to death, as high rates of inappropriate use, both here and around the globe, are contributing to the rise of drug-resistant bacteria against which our current arsenal of antibiotics is becoming increasingly ineffective. In the past, advancements in developing new antibiotics kept pace with developing resistance, but we are now facing a deadly reality where the pipeline of ‘new and improved' antibiotics is rapidly drying up. There are a number of global initiatives attempting to reprime the pipeline, but the exit of major pharmaceutical companies from antibiotic research and the poor financial performance of antibiotic-focused biotechnology companies continues.

Mitochondria Inspire a Lifestyle

Tucked inside our cells, we animals (and plants, and fungi) carry mitochondria, minuscule descendants of bacteria that invaded our common ancestor 2 billion years ago. This unplanned breakthrough endowed our ancestors with a convenient, portable source of energy, enabling them to progress towards more ambitious forms of life. Mitochondria still manufacture most of our energy; we have evolved to invest it to grow and produce offspring, and to last long enough to make it all happen. Yet because the continuous generation of energy is inevitably linked to that of toxic free radicals, mitochondria give us life and give us death. Stripping away clutter and minutiae, here we present a big-picture perspective of how mitochondria work, how they are passed on virtually only by mothers, and how they shape the lifestyles of species and individuals. We discuss why restricting food prolongs lifespan, why reproducing shortens it, and why moving about protects us from free radicals despite increasing their production. We show that our immune cells use special mitochondria to keep control over our gut microbes. And we lay out how the fabrication of energy and free radicals sets the internal clocks that command our everyday rhythms-waking, eating, sleeping. Mitochondria run the show.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Antibiotic resistance, the 3As and the road ahead

Antibiotic resistance is by far one of the most important health threats of our time. Only a global concerted effort of several disciplines based on the One-Health concept will help in slowing down this process and potentially mitigate the ruin of healthcare we have come to enjoy. In this review, we attempt to summarize the most basic and important topics that serve as good information tools to create Awareness. The Availability of antibiotics or the lack thereof is another significant factor that must be given thought, and finally because antibiotic resistance is a problem that will not go away, it is important to have Alternatives. Together, we have the 3As, essential concepts, in dealing with this growing and complex problem.

Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

Background

Global action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia.

Methods

Tikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ² and fisher exact tests. Qualitative data was analyzed thematically.

Findings

A total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia.

Conclusions

This knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.

Antibacterial isoamphipathic oligomers highlight the importance of multimeric lipid aggregation for antibacterial potency

Cationic charge and hydrophobicity have long been understood to drive the potency and selectivity of antimicrobial peptides (AMPs). However, these properties alone struggle to guide broad success in vivo, where AMPs must differentiate bacterial and mammalian cells, while avoiding complex barriers. New parameters describing the biophysical processes of membrane disruption could provide new opportunities for antimicrobial optimization. In this work, we utilize oligothioetheramides (oligoTEAs) to explore the membrane-targeting mechanism of oligomers, which have the same cationic charge and hydrophobicity, yet show a unique ~ 10-fold difference in antibacterial potency. Solution-phase characterization reveals little difference in structure and dynamics. However, fluorescence microscopy of oligomer-treated Staphylococcus aureus mimetic membranes shows multimeric lipid aggregation that correlates with biological activity and helps establish a framework for the kinetic mechanism of action. Surface plasmon resonance supports the kinetic framework and supports lipid aggregation as a driver of antimicrobial function.

Joseph Brown et al. use oligothioetheramides (oligo TEAs) to show that multimeric lipid aggregation in Staphylococcus aureus mimetic membranes correlates with the biological activity of oligoTEAs. These results may explain why antimicrobial peptides with identical cationic charge and hydrophobicity show different biological activity.

Trends and Drivers of Inpatient Antibiotic Consumption among 89 China Tertiary General Hospitals from 2011Q1 to 2015Q4

Antibacterial surveillance is an essential measure for strengthening the management of clinical antibiotic use. This study aimed to determine the trends and drivers of inpatient antibiotic consumption in China. A sample of 89 hospitals with complete data from 2011Q1 to 2015Q4 was included. Accumulative defined daily doses (DDDs), antibiotic use density (AUD), and drug variety were calculated to evaluate antibiotic consumption. From 2011Q1 to 2015Q4, the median values of DDDs, AUD, and drug variety dropped by 10.49%, 39.19%, and 27.96%, respectively. Panel regression results showed, for each additional quarter, DDDs reduced by 6.714 DDDs, AUD reduced by 0.013 DDDs per 100 inpatients per day, and drug variety reduced by 0.012 types (p < 0.001). National hospitals were more likely to use antibiotics, with the highest number of DDDs (106 709 DDDs) and AUD (60 DDDs per 100 inpatients per day) and a large number of drug variety (71 types of drug) all reported from national hospitals. Overall, a downward trend of inpatient antibiotic consumption was observed in competitive tertiary general hospitals in China. However, antibiotic use in China, especially in national hospitals, continues to exceed the guidelines set forth by the nationwide antibiotic stewardship program. China must continue to improve surveillance of antibiotic consumption by constructing a more comprehensive, continuous, and targeted stewardship program. Policy interventions in China should be made in consideration of unbalanced regional development and the consequences this may have on antibiotic consumption.

How actively should we screen for chlamydia and gonorrhoea in MSM and other high-ST-prevalence populations as we enter the era of increasingly untreatable infections? A viewpoint

A number of national and international organizations are advocating more intensive screening for Chlamydia trachomatis and Neisseria gonorrhoeae in high-prevalence populations as a way to reduce the prevalence of these infections. In this article, we review the available evidence and conclude that there is a paucity of evidence to support this approach. We further hypothesize that increasing screening intensity in high-prevalence populations will result in a considerable risk for the emergence of antimicrobial resistance in Neisseria gonorrhoeae and other pathobionts.

Prevalence of macrolide resistance in Treponema pallidum is associated with macrolide consumption

We hypothesized that the large global variations in the prevalence of macrolide resistance in Treponema pallidum are related to differences in population-level macrolide consumption. The hypothesis was tested by, at a country-level, regressing the peak prevalence of macrolide resistance against the national macrolide consumption in the year prior to this, controlling for the year of the resistance prevalence estimate. A strong association was found between the per capita consumption of macrolides and macrolide resistance (coefficient 0.7, 95 % confidence interval 0.2-0.12, P=0.009).

Expected Practice as a Novel Antibiotic Stewardship Intervention

"Expected practice" is a recently described method to alter clinical behavior. We implemented an expected practice around short-course antibiotic therapy, which was associated with decreased antibiotic utilization for multiple bacterial infections. Thus, we describe this expected practice as a novel, simple, and inexpensive tool to enhance antibiotic stewardship.

Antimicrobial resistance in the Gulf Cooperation Council region: A proposed framework to assess threats, impacts and mitigation measures associated with AMR in the marine and aquatic environment

It is becoming increasingly clear that the genetic diversity and abundance of antimicrobial resistance (AMR) in non-clinical settings has been underestimated and that the environment plays an integral role in enabling the development of AMR. Due to specific demographic and environmental factors the Gulf Cooperation Council (GCC) region may be particularly susceptible to the threat of AMR, with the marine and aquatic environment potentially playing a specific role in its development and propagation. The demographic factors include rapid population growth, significant international population movements, heavy antibiotic use and insufficient antibiotic stewardship. Environmental factors leading to susceptibility include notable inputs of untreated sewage effluent, high ambient water temperatures, elevated concentrations of heavy metals, and poorly regulated use of antimicrobials in veterinary settings. However, to date there is only a limited understanding of the role that this environment plays in enabling the emergence and propagation AMR in this region. This article provides an overview of the risk associated with AMR in the marine and aquatic environment in the GCC region and proposes a framework for understanding how such environments interact with the wider development and propagation of resistance. It identifies priority actions aligned with the World Health Organisation AMR Global Action Plan and associated national action plans to evaluate the role of marine and aquatic systems relative to the wider factors driving AMR emergence and propagation. The proposed framework and actions to evaluate the role of marine and aquatic environments in driving propagation and emergence of AMR are equally applicable at the regional and national level beyond the GCC.

Co-contamination of antibiotics and metals in peri-urban agricultural soils and source identification

To identify the dominant sources of contamination in peri-urban land, this study investigated the concentrations and distributions of antibiotics and metals in agricultural soil of this area. An index of landscape development intensity (LDI) was used to characterize the distribution of human disturbance-related land use. The results showed that total antibiotic concentration in the soil reached 395.55 μg/kg and that chlortetracycline was the predominant antibiotic compound, with a relatively high mean concentration of 30.62 μg/kg. In soils, the mean concentrations of Cu, Zn, and Pb were 38.41, 127.88, and 56.61 mg/kg and those of Al, Fe, and K were 83.73, 24.17, and 23.42 g/kg, respectively. A redundancy analysis showed that the landscape pattern in a 300-m buffer zone can well explain the variation in the concentrations of antibiotics and metals (24%, p < 0.05). The LDI in the 300-m buffer zone significantly correlated with the concentrations of total antibiotics and total amounts of Cu and Zn in the soil, suggesting that the risk of soil contamination increases with the intensity of anthropogenic activities. A structural equation modeling analysis indicated that Al, Cu, and Zn could significantly aggravate accumulation of tetracycline antibiotics in the soil, whereas there were only significantly direct paths from Cu to ciprofloxacin and norfloxacin. Overall, the results showed that aggravated co-contamination of antibiotics and metals occurs in agricultural soil under intensive human disturbance.

Transcriptional and Functional Analysis of Bifidobacterium animalis subsp. lactis Exposure to Tetracycline

Commercial probiotic bacteria must be tested for acquired antibiotic resistance elements to avoid potential transfer to pathogens. The European Food Safety Authority recommends testing resistance using microdilution culture techniques previously used to establish inhibitory thresholds for the Bifidobacterium genus. Many Bifidobacterium animalis subsp. lactis strains exhibit increased resistance to tetracycline, historically attributed to the ribosomal protection gene tet(W). However, some strains that harbor genetically identical tet(W) genes show various inhibition levels, suggesting that other genetic elements also contribute to observed differences. Here, we adapted several molecular assays to confirm the inhibition of B. animalis subsp. lactis strains Bl-04 and HN019 and employed RNA sequencing to assess the transcriptional differences related to genomic polymorphisms. We detected specific stress responses to the antibiotic by correlating ATP concentration to number of viable genome copies from droplet digital PCR and found that the bacteria were still metabolically active in high drug concentrations. Transcriptional analyses revealed that several polymorphic regions, particularly a novel multidrug efflux transporter, were differentially expressed between the strains in each experimental condition, likely having phenotypic effects. We also found that the tet(W) gene was upregulated only during subinhibitory tetracycline concentrations, while two novel tetracycline resistance genes were upregulated at high concentrations. Furthermore, many genes involved in amino acid metabolism and transporter function were upregulated, while genes for complex carbohydrate utilization, protein metabolism, and clustered regularly interspaced short palindromic repeat(s) (CRISPR)-Cas systems were downregulated. These results provide high-throughput means for assessing antibiotic resistances of two highly related probiotic strains and determine the genetic network that contributes to the global tetracycline response.IMPORTANCEBifidobacterium animalis subsp. lactis is widely used in human food and dietary supplements. Although well documented to be safe, B. animalis subsp. lactis strains must not contain transferable antibiotic resistance elements. Many B. animalis subsp. lactis strains have different resistance measurements despite being genetically similar, and the reasons for this are not well understood. In the current study, we sought to examine how genomic differences between two closely related industrial B. animalis subsp. lactis strains contribute to different resistance levels. This will lead to a better understanding of resistance, identify future targets for analysis of transferability, and expand our understanding of tetracycline resistance in bacteria.

Antimicrobial Consumption and Susceptibility of Neisseria gonorrhoeae: A Global Ecological Analysis

Aims: The reasons why antimicrobial resistance in Neisseria gonorrhoeae has emerged explosively in certain populations but not others are poorly understood. We hypothesized that population level consumption of antimicrobials plays a role.

Methods: Using susceptibility data from the World Health Organizations Global Gonococcal Antimicrobial Surveillance Programme and antimicrobial consumption data from the IMS Health MIDAS database we built linear regression models with country-level cephalosporin, macrolide, and fluoroquinolone consumption (standard doses/1,000 population/year) as the explanatory variable and 1-year lagged ceftriaxone, azithromycin, and ciprofloxacin resistance as the outcome variables. These were performed at two time points 2008/2009 and 2013/2014.

Results: The association between antimicrobial resistance and consumption at the level of individual countries was positive in all six assessments. In four instances the positive associations were statistically significant (cephalosporins 2008: coefficient 0.0005 [95% confidence interval (CI) 0.0002–0.0007] and 2013: coefficient 0.0003 [95% CI 0.0002–0.0004]; macrolides 2013: coefficient 0.0005 [95% CI 0.00002–0.001]; fluoroquinolones 2013: coefficient 0.02 [95% CI 0.006–0.031]).

Conclusions: Differences in population level consumption of particular antimicrobials may play a role in explaining the variations in the emergence of antimicrobial resistance in N. gonorrhoeae.

Short- and long-term impacts of azithromycin treatment on the gut microbiota in children: A double-blind, randomized, placebo-controlled trial

Background

Macrolides are commonly prescribed for respiratory infections and asthma-like episodes in children. While their clinical benefits have been proved, concerns regarding the side-effects of their therapeutic use have been raised. Here we assess the short- and long-term impacts of azithromycin on the gut microbiota of young children.

Methods

We performed a randomized, double-blind, placebo-controlled trial in a group of children aged 12–36 months, diagnosed with recurrent asthma-like symptoms from the COPSAC₂₀₁₀ cohort. Each acute asthma-like episode was randomized to a 3-day course of azithromycin oral solution of 10 mg/kg per day or placebo. Azithromycin reduced episode duration by half, which was the primary end-point and reported previously. The assessment of gut microbiota after treatment was the secondary end-point and reported in this study. Fecal samples were collected 14 days after randomization (N = 59, short-term) and again at age 4 years (N = 49, long-term, of whom N = 18 were placebo treated) and investigated by 16S rRNA gene amplicon sequencing.

Findings

Short-term, azithromycin caused a 23% reduction in observed richness and 13% reduction in Shannon diversity. Microbiota composition was shifted primarily in the Actinobacteria phylum, especially a reduction of abundance in the genus Bifidobacterium. Long-term (13–39 months after treatment), we did not observe any differences between the azithromycin and placebo recipients in their gut microbiota composition.

Interpretation

Azithromycin treatment induced a perturbation in the gut microbiota 14 days after randomization but did not have long-lasting effects on the gut microbiota composition. However, it should be noted that our analyses included a limited number of fecal samples for the placebo treated group at age 4 years.

Fund

Lundbeck Foundation, Danish Ministry of Health, Danish Council for Strategic Research, Capital Region Research Foundation, China Scholarship Council.

Synthesis and mechanistic studies of diketo acids and their bioisosteres as potential antibacterial agents

A series of diketo esters and their pertinent bioisosteres were designed and synthesized as potent antibacterial agents by targeting methionine amino peptidases (MetAPs). In the biochemical assay against purified MetAPs from Streptococcus pneumoniae (SpMetAP1a), Mycobacterium tuberculosis (MtMetAP1c), Enterococcus faecalis (EfMetAP1a) and human (HsMetAP1b), compounds 3a, 4a and 5a showed more than 85% inhibition of all the tested MetAPs at 100 μM concentration. Compounds 4a and 5a also exhibited antibacterial potential with MIC values 62.5 μg/mL (S. pneumoniae), 31.25 μg/mL (E. faecalis), 62.5 μg/mL (Escherichia coli) and 62.5 μg/mL (S. pneumoniae), 62.5 μg/mL (E. coli), respectively. Moreover, 5a also significantly inhibited the growth of multidrug resistant E. coli strains at 512 μg/mL conc., while showing no cytotoxic effect towards healthy CHO cells and thus being selected. Growth kinetics study showed significant inhibition of bacterial growth when treated with different conc. of 5a. TEM analysis also displayed vital damage to bacterial cells by 5a at MIC conc. Moreover, significant inhibition of biofilm formation was observed in bacterial cells treated with MIC conc. of 5a as visualized by SEM micrographs. Interestingly, 5a did not cause an alteration in the hemocyte density in Galleria mellonella larvae which is considered in vivo model for antimicrobial studies and was non-toxic up to a conc. of 2.5 mg/mL.

A High-Resolution Spatial Model to Predict Exposure to Pharmaceuticals in European Surface Waters: ePiE

Environmental risk assessment of pharmaceuticals requires the determination of their environmental exposure concentrations. Existing exposure modeling approaches are often computationally demanding, require extensive data collection and processing efforts, have a limited spatial resolution, and have undergone limited evaluation against monitoring data. Here, we present ePiE (exposure to Pharmaceuticals in the Environment), a spatially explicit model calculating concentrations of active pharmaceutical ingredients (APIs) in surface waters across Europe at ∼1 km resolution. ePiE strikes a balance between generating data on exposure at high spatial resolution while having limited computational and data requirements. Comparison of model predictions with measured concentrations of a diverse set of 35 APIs in the river Ouse (UK) and Rhine basins (North West Europe), showed around 95% were within an order of magnitude. Improved predictions were obtained for the river Ouse basin (95% within a factor of 6; 55% within a factor of 2), where reliable consumption data were available and the monitoring study design was coherent with the model outputs. Application of ePiE in a prioritisation exercise for the Ouse basin identified metformin, gabapentin, and acetaminophen as priority when based on predicted exposure concentrations. After incorporation of toxic potency, this changed to desvenlafaxine, loratadine, and hydrocodone.

Exposure to Antibiotics Affects Saponin Immersion-Induced Immune Stimulation and Shift in Microbial Composition in Zebrafish Larvae

In the last decades, pollution of the environment by large scale use of antibiotics in agriculture and human medicine have led to increased antimicrobial resistance in both the environment and the host animal microbiome. Disturbances in the host microbiome can result in impaired immunity and reduced resilience of aquaculture species. Here, we investigated whether environmentally measured levels of the commonly used antibiotics ciprofloxacin and oxytetracycline influences the host microbiome and susceptibility toward saponin-induced immune stimulation in larval zebrafish. Firstly, neutrophil and macrophage reporter zebrafish larvae were exposed to different concentrations of soy saponin by immersion. A dose-dependent increase in neutrophil presence in the intestinal area was observed together with increased expression of immune genes il1b, tnfa, il22 and mmp9. To investigate the effect of antibiotics, larval zebrafish were immersed in ciprofloxacin or oxytetracycline in the presence or absence of a low dose of saponin. In vivo imaging revealed that antibiotic treatment did not reduce the number of neutrophils that were recruited to the intestinal area upon saponin exposure, although it did tend to lower pro-inflammatory cytokine levels. Microbial sequencing of whole larvae revealed that exposure to a low dose of saponin already shifted the microbial composition. The combination of oxytetracycline and saponin significantly increased α-diversity compared to the controls. In conclusion, the current study provides evidence that the combination of low levels of antibiotics with low levels of anti-nutritional factors (saponin) can induce inflammatory phenotypes and can modify the microbiota, which might lead to altered disease susceptibility.

Association between early life antibiotic use and childhood overweight and obesity: a narrative review

Background

Recent research implicates antibiotic use as a potential contributor to child obesity risk. In this narrative review, we examine current observational evidence on the relation between antibiotic use in early childhood and subsequent measures of child body mass.

Methods

We searched PubMed, Web of Science and the Cochrane Library to identify studies that assessed antibiotic exposure before 3 years of age and subsequent measures of body mass or risk of overweight or obesity in childhood.

Results

We identified 13 studies published before October 2017, based on a total of 6 81 332 individuals, which examined the relation between early life antibiotic exposure and measures of child body mass. Most studies did not appropriately account for confounding by indication for antibiotic use. Overall, we found no consistent and conclusive evidence of associations between early life antibiotic use and later child body mass [minimum overall adjusted odds ratio (aOR) reported: 1.01, 95% confidence interval (95% CI) 0.98-1.04, N = 2 60 556; maximum overall aOR reported: 2.56, 95% CI 1.36-4.79, N = 616], with no clinically meaningful increases in weight reported (maximum increase: 1.50 kg at 15 years of age). Notable methodological differences between studies, including variable measures of association and inclusion of confounders, limited more comprehensive interpretations.

Conclusions

Evidence to date is insufficient to indicate that antibiotic use is an important risk factor for child obesity, or leads to clinically important differences in weight. Further comparable studies using routine clinical data may help clarify this association.

Antibiotic-Resistant Escherichia coli and Class 1 Integrons in Humans, Domestic Animals, and Wild Primates in Rural Uganda

Antibiotic resistance is a global concern, although it has been studied most extensively in developed countries. We studied Escherichia coli and class 1 integrons in western Uganda by analyzing 1,685 isolates from people, domestic animals, and wild nonhuman primates near two national parks. Overall, 499 isolates (29.6%) were resistant to at least one of 11 antibiotics tested. The frequency of resistance reached 20.3% of isolates for trimethoprim-sulfamethoxazole but was nearly zero for the less commonly available antibiotics ciprofloxacin (0.4%), gentamicin (0.2%), and ceftiofur (0.1%). The frequency of resistance was 57.4% in isolates from people, 19.5% in isolates from domestic animals, and 16.3% in isolates from wild nonhuman primates. Isolates of livestock and primate origin displayed multidrug resistance patterns identical to those of human-origin isolates. The percentage of resistant isolates in people was higher near Kibale National Park (64.3%) than near Bwindi Impenetrable National Park (34.6%), perhaps reflecting local socioeconomic or ecological conditions. Across antibiotics, resistance correlated negatively with the local price of the antibiotic, with the most expensive antibiotics (nalidixic acid and ciprofloxacin) showing near-zero resistance. Among phenotypically resistant isolates, 33.2% harbored class 1 integrons containing 11 common resistance genes arranged into nine distinct gene cassettes, five of which were present in isolates from multiple host species. Overall, these results show that phenotypic resistance and class 1 integrons are distributed broadly among E. coli isolates from different host species in this region, where local socioeconomic and ecological conditions may facilitate widespread diffusion of bacteria or resistance-conferring genetic elements.IMPORTANCE Antibiotic resistance is a global problem. This study, conducted in rural western Uganda, describes antibiotic resistance patterns in Escherichia coli bacteria near two forested national parks. Resistance was present not only in people, but also in their livestock and in nearby wild nonhuman primates. Multidrug resistance and class 1 integrons containing genes that confer resistance were common and were similar in people and animals. The percentage of resistant isolates decreased with increasing local price of the antibiotic. Antibiotic resistance in this setting likely reflects environmental diffusion of bacteria or their genes, perhaps facilitated by local ecological and socioeconomic conditions.

A systematic review of antimicrobial resistance in Salmonella enterica serovar Typhi, the etiological agent of typhoid

BACKGROUND

The temporal and spatial change in trends of antimicrobial resistance (AMR) in typhoid have not been systematically studied, and such information will be critical for defining intervention, as well as planning sustainable prevention strategies.

METHODOLOGY AND FINDINGS

To identify the phenotypic trends in AMR, 13,833 individual S. Typhi isolates, reported from 1973 to 2018 in 62 publications, were analysed to determine the AMR preponderance over time. Separate analyses of molecular resistance determinants present in over 4,000 isolates reported in 61 publications were also conducted. Multi-drug resistant (MDR) typhoid is in decline in Asia in a setting of high fluoroquinolone resistance while it is on the increase in Africa. Mutations in QRDRs in gyrA (S83F, D87N) and parC (S80I) are the most common mechanisms responsible for fluoroquinolone resistance. Cephalosporin resistant S. Typhi, dubbed extensively drug-resistant (XDR) is a real threat and underscores the urgency in deploying the Vi-conjugate vaccines.

CONCLUSION

From these observations, it appears that AMR in S. Typhi will continue to emerge leading to treatment failure, changes in antimicrobial policy and further resistance developing in S. Typhi isolates and other Gram-negative bacteria in endemic regions. The deployment of typhoid conjugate vaccines to control the disease in endemic regions may be the best defence.

Emerging evolutionary paradigms in antibiotic discovery

Antibiotics revolutionized medicine and remain its cornerstone. Despite their global importance and the continuous threat of resistant pathogens, few antibiotics have been discovered in recent years. Natural products, especially the secondary metabolites of Actinobacteria, have been the traditional discovery source of antibiotics. In nature, the chemistry of antibiotic natural products is shaped by the unique evolution and ecology of their producing organisms, yet these influences remain largely unknown. Here, we highlight the ecology of antibiotics employed by microbes in defensive symbioses and review the evolutionary processes underlying the chemical diversity and activity of microbe-derived antibiotics, including the dynamics of vertical and lateral transmission of biosynthetic pathways and the evolution of efficacy, targeting specificity, and toxicity. We argue that a deeper understanding of the ecology and evolution of microbial interactions and the metabolites that mediate them will allow for an alternative, rational approach to discover new antibiotics.

[Twenty-five myths in infectious diseases in primary care associated with overdiagnosis and overtreatment]

Overdiagnosis and overprescribing is common in current clinical practice of infectious diseases in primary care. On the basis of studies published in the medical literature we identify my means of a non-systematic review a total of 25 myths associated with the diagnosis and treatment and present the literature pertaining to each myth. These myths result in extraneous testing (overdiagnosis) and excessive antimicrobial treatment (overtreatment). Most of these myths are ingrained among general practitioners in our country. Not only should these myths be debunked from our clinical practice, but they should also be reversed, and we encourage our readers to critically appraise their practice when it comes down to the misconceptions treated in this manuscript. We attempt to give guidance to clinicians facing these frequent clinical scenarios.

Assessment of General Public's Knowledge and Opinions towards Antibiotic Use and Bacterial Resistance: A Cross-Sectional Study in an Urban Setting, Rufisque, Senegal

Background: Bacterial resistance is a major public health problem worldwide. One solution to this scourge is to sensitize the general public on rational use of antibiotics. Our goal was to assess people’s knowledge and opinions about antibiotic use and bacterial resistance in an urban setting. Method: We performed a cross-sectional study. A convenience sampling was done. A questionnaire was administered to 400 persons during face-to-face interviews. Results: Most respondents thought that antibiotics are effective against colds/flu (69.8%), cough (72.3%) and sore throat (64.4%). At the same time, 42.8% stated that antibiotic therapy can be stopped as soon as the symptoms disappear. Only 8.8% and 41.8% of people knew that handwashing and vaccination prevented bacterial resistance. Globally, 7% of people had a good knowledge. Socio-demographic variables were not associated with the level of knowledge. The main sources of information were entourage and pharmacy staff. Regarding the opinions, 78.3% of surveyed participants the people thought that that people overuse antibiotics. Additionally, 28% said that they have no role to play against bacterial resistance. Conclusion: People living in an urban setting had a low knowledge about antibiotic use and bacterial resistance. There is a need to implement awareness campaigns. Further studies on population practices toward antibiotic use are necessary.

Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis

BACKGROUND

Understanding of the factors driving global antimicrobial resistance is limited. We analysed antimicrobial resistance and antibiotic consumption worldwide versus many potential contributing factors.

METHODS

Using three sources of data (ResistanceMap, the WHO 2014 report on antimicrobial resistance, and contemporary publications), we created two global indices of antimicrobial resistance for 103 countries using data from 2008 to 2014: Escherichia coli resistance-the global average prevalence of E coli bacteria that were resistant to third-generation cephalosporins and fluoroquinolones, and aggregate resistance-the combined average prevalence of E coli and Klebsiella spp resistant to third-generation cephalosporins, fluoroquinolones, and carbapenems, and meticillin-resistant Staphylococcus aureus. Antibiotic consumption data were obtained from the IQVIA MIDAS database. The World Bank DataBank was used to obtain data for governance, education, gross domestic product (GDP) per capita, health-care spending, and community infrastructure (eg, sanitation). A corruption index was derived using data from Transparency International. We examined associations between antimicrobial resistance and potential contributing factors using simple correlation for a univariate analysis and a logistic regression model for a multivariable analysis.

FINDINGS

In the univariate analysis, GDP per capita, education, infrastructure, public health-care spending, and antibiotic consumption were all inversely correlated with the two antimicrobial resistance indices, whereas higher temperatures, poorer governance, and the ratio of private to public health expenditure were positively correlated. In the multivariable regression analysis (confined to the 73 countries for which antibiotic consumption data were available) considering the effect of changes in indices on E coli resistance (R² 0·54) and aggregate resistance (R² 0·75), better infrastructure (p=0·014 and p=0·0052) and better governance (p=0·025 and p<0·0001) were associated with lower antimicrobial resistance indices. Antibiotic consumption was not significantly associated with either antimicrobial resistance index in the multivariable analysis (p=0·64 and p=0·070).

INTERPRETATION

Reduction of antibiotic consumption will not be sufficient to control antimicrobial resistance because contagion-the spread of resistant strains and resistance genes-seems to be the dominant contributing factor. Improving sanitation, increasing access to clean water, and ensuring good governance, as well as increasing public health-care expenditure and better regulating the private health sector are all necessary to reduce global antimicrobial resistance.

FUNDING

None.

Dysbiosis and early mortality in zebrafish larvae exposed to subclinical concentrations of streptomycin

Exposure to low concentrations of antibiotics found in aquatic environments can increase susceptibility to infection in adult fish due to microbiome disruption. However, little is known regarding the effect of antibiotic pollution on fish larvae. Here, we show that exposure to streptomycin, a common antibiotic used in medicine and aquaculture, disrupts the normal composition of zebrafish larvae microbiomes, significantly reducing the microbial diversity found in the fish. Exposure to streptomycin also significantly increased early mortality among fish larvae, causing full mortality within a few days of exposure at 10 μg/mL. Finally, we found that subclinical concentrations of streptomycin also increased the abundance of class 1 integrons, an integrase-dependent genetic system associated to the horizontal transfer of antibiotic resistance genes, in the larvae microbiomes. These results suggest that even low concentrations of streptomycin associated with environmental pollution could impact fish populations and lead to the creation of antibiotic resistance reservoirs.

Global development of the studies focused on antibiotics in aquatic systems from 1945 to 2017

Antibiotics are used to fight diseases in humans and farm animals. Their residues, however, can enter aquatic environments and affect the resistance of non-target microbial strains, and the prevalence of antibiotic resistance genes (ARGs) potentially poses negative impacts on human health. In order to better understand how the studies of antibiotics have been conducted, we analyzed the publications on antibiotics in aquatic systems for the period of 1945-2017. We applied a bibliometric analysis method by coupling cluster analysis and network analysis. Results indicated that early research on antibiotics in water was mostly performed in America and Europe, while, in recent years, publications for the same subject were dominated by China and the USA. The majority of the articles were published in journal Chemosphere and the most representative subject categories of the seven sections were "Environmental science and ecology," "Chemistry," "Engineering," "Biochemistry and molecular biology," "Water resources," "Agriculture," and "Pharmacology and pharmacy." The most studied class of antibiotics was tetracyclines in wastewater. Antibiotic resistance, ARGs, Escherichia coli, and some mechanistic studies such as adsorption, toxicity, degradation, and kinetics were common topics in this field. ARGs present a major public health concern and much attention should be directed at the problems with antibiotics in the future studies of water.

Retrospective review of the management of acute infections and the indications for antibiotic prescription in primary care in northern Thailand

INTRODUCTION

Antibiotic use in low-income and middle-income countries continues to rise despite the knowledge that antibiotic overuse can lead to antimicrobial resistance. There is a paucity of detailed data on the use of antibiotics in primary care in low-resource settings.

OBJECTIVE

To describe the presentation of acute infections and the indications for antibiotic prescription.

DESIGN

A 2-year retrospective review of routinely collected data.

SETTING

All 32 primary care units in one district in northern Thailand.

PARTICIPANTS

Patients attending primary care with a history of fever, documented temperature, International Statistical Classification of Diseases 10 code for infection or prescribed a systemic antibiotic. Patients attending after the initiation of a study on C-reactive protein testing in four centres were excluded.

OUTCOME MEASURES

The proportion of patients prescribed an antibiotic and the frequency of clinical presentations.

RESULTS

762 868 patients attended the health centres, of whom 103 196 met the inclusion criteria, 5966 were excluded resulting in 97 230 attendances consisting of 83 661 illness episodes.46.9% (39 242) of the patients were prescribed an antibiotic during their illness. Indications for antibiotic prescription in the multivariable logistic regression analysis included male sex (adjusted OR (aOR) 1.21 (95% CI 1.16 to 1.28), p<0.001), adults (aOR 1.77 (95% CI 1.57 to 2), p<0.001) and a temperature >37.5°C (aOR 1.24 (95% CI 1.03 to 1.48), p=0.020). 77.9% of the presentations were for respiratory-related problems, of which 98.6% were upper respiratory tract infections. The leading infection diagnoses were common cold (50%), acute pharyngitis (18.9%) and acute tonsillitis (5%) which were prescribed antibiotics in 10.5%, 88.7% and 87.1% of cases, respectively. Amoxicillin was the most commonly prescribed antibiotic.

CONCLUSIONS

Nearly half of the patients received an antibiotic, the majority of whom had a respiratory infection. The results can be used to plan interventions to improve the rational use of antibiotics. Further studies in private facilities, pharmacies and dental clinics are required.

Trends in outpatient antibiotic use and prescribing practice among US older adults, 2011-15: observational study

OBJECTIVE

To identify temporal trends in outpatient antibiotic use and antibiotic prescribing practice among older adults in a high income country.

DESIGN

Observational study using United States Medicare administrative claims in 2011-15.

SETTING

Medicare, a US national healthcare program for which 98% of older adults are eligible.

PARTICIPANTS

4.5 million fee-for-service Medicare beneficiaries aged 65 years old and older.

MAIN OUTCOME MEASUREMENTS

Overall rates of antibiotic prescription claims, rates of potentially appropriate and inappropriate prescribing, rates for each of the most frequently prescribed antibiotics, and rates of antibiotic claims associated with specific diagnoses. Trends in antibiotic use were estimated by multivariable regression adjusting for beneficiaries' demographic and clinical covariates.

RESULTS

The number of antibiotic claims fell from 1364.7 to 1309.3 claims per 1000 beneficiaries per year in 2011-14 (adjusted reduction of 2.1% (95% confidence interval 2.0% to 2.2%)), but then rose to 1364.3 claims per 1000 beneficiaries per year in 2015 (adjusted reduction of 0.20% over 2011-15 (0.09% to 0.30%)). Potentially inappropriate antibiotic claims fell from 552.7 to 522.1 per 1000 beneficiaries over 2011-14, an adjusted reduction of 3.9% (3.7% to 4.1%). Individual antibiotics had heterogeneous changes in use. For example, azithromycin claims per beneficiary decreased by 18.5% (18.2% to 18.8%) while levofloxacin claims increased by 27.7% (27.2% to 28.3%). Azithromycin use associated with each of the potentially appropriate and inappropriate respiratory diagnoses decreased, while levofloxacin use associated with each of those diagnoses increased.

CONCLUSION

Among US Medicare beneficiaries, overall antibiotic use and potentially inappropriate use in 2011-15 remained steady or fell modestly, but individual drugs had divergent changes in use. Trends in drug use across indications were stronger than trends in use for individual indications, suggesting that guidelines and concerns about antibiotic resistance were not major drivers of change in antibiotic use.

Antimicrobial Porous Surfaces Prepared by Breath Figures Approach

Herein, efficient antimicrobial porous surfaces were prepared by breath figures approach from polymer solutions containing low content of block copolymers with high positive charge density. In brief, those block copolymers, which were used as additives, are composed of a polystyrene segment and a large antimicrobial block bearing flexible side chain with 1,3-thiazolium and 1,2,3-triazolium groups, PS54-b-PTTBM-M44, PS54-b-PTTBM-B44, having different alkyl groups, methyl or butyl, respectively. The antimicrobial block copolymers were blended with commercial polystyrene in very low proportions, from 3 to 9 wt %, and solubilized in THF. From these solutions, ordered porous films functionalized with antimicrobial cationic copolymers were fabricated, and the influence of alkylating agent and the amount of copolymer in the blend was investigated. Narrow pore size distribution was obtained for all the samples with pore diameters between 5 and 11 µm. The size of the pore decreased as the hydrophilicity of the system increased; thus, either as the content of copolymer was augmented in the blend or as the copolymers were quaternized with methyl iodide. The resulting porous polystyrene surfaces functionalized with low content of antimicrobial copolymers exhibited remarkable antibacterial efficiencies against Gram positive bacteria Staphylococcus aureus, and Candida parapsilosis fungi as microbial models.

Extended-spectrum β-lactamase-producing and carbapenemase-producing Enterobacteriaceae

Antimicrobial resistance (AMR) is a global public-health emergency, which threatens the advances made by modern medical care over the past century. The World Health Organization has recently published a global priority list of antibiotic-resistant bacteria, which includes extended-spectrum β-lactamase-producing Enterobacteriaceae and carbapenemase-producing Enterobacteriaceae. In this review, we highlight the mechanisms of resistance and the genomic epidemiology of these organisms, and the impact of AMR.