Plasmid-encoded insertion sequences promote rapid adaptation in clinical enterobacteria

Plasmids are extrachromosomal genetic elements commonly found in bacteria. They are known to fuel bacterial evolution through horizontal gene transfer, and recent analyses indicate that they can also promote intragenomic adaptations. However, the role of plasmids as catalysts of bacterial evolution beyond horizontal gene transfer is poorly explored. In this study, we investigated the impact of a widespread conjugative plasmid, pOXA-48, on the evolution of several multidrug-resistant clinical enterobacteria. Combining experimental and within-patient evolution analyses, we unveiled that plasmid pOXA-48 promotes bacterial evolution through the transposition of plasmid-encoded insertion sequence 1 (IS1) elements. Specifically, IS1-mediated gene inactivation expedites the adaptation rate of clinical strains in vitro and fosters within-patient adaptation in the gut microbiota. We deciphered the mechanism underlying the plasmid-mediated surge in IS1 transposition, revealing a negative feedback loop regulated by the genomic copy number of IS1. Given the overrepresentation of IS elements in bacterial plasmids, our findings suggest that plasmid-mediated IS1 transposition represents a crucial mechanism for swift bacterial adaptation.

Pre-analytical stability and physiological fluctuations affect plasma steroid hormone outcomes: A real-world study

Since steroids are crucial for diagnosing endocrine disorders, the lack of research on factors that affect hormone levels makes interpreting the results difficult. Our study aims to assess the stability of the pre-analytical procedure and the impact of hormonal physiological fluctuations using real-world data. The datasets were created using 12,418 records from individuals whose steroid hormone measurements were taken in our laboratory between September 2019 and March 2024. 22 steroid hormones in plasma by a well-validated liquid chromatography tandem mass spectrometry method were measured. After normalization transformation, outlier removal, and z-score normalization, generalized additive models were constructed to evaluate preanalytic stability and age, sex, and sample time-dependent hormonal fluctuations. Most hormones exhibit significant variability with age, particularly steroid hormone precursors, sex hormones, and certain corticosteroids such as aldosterone. 18-hydroxycortisol, 18-oxocortisol. Sex hormones varied between males and females. Levels of certain hormones, including cortisol, cortisone, 11-deoxycortisol, 18-hydroxycortisol, 18-oxocortisol, corticosterone, aldosterone, estrone, testosterone, dihydrotestosterone, dehydroepiandrosterone sulfate, 11-ketotestosterone, and 11-hydroxytestosterone, fluctuated with sampling time. Moreover, levels of pregnenolone and progesterone decreased within 1 hour of sampling, with pregnenolone becoming unstable with storage time at 4 degrees after centrifugation, while other hormone levels remained relatively stable for a short period of time without or after centrifugation of the sample. This is the first instance real-world data has been used to assess the pre-analytic stability of plasma hormones and to evaluate the impact of physiological factors on steroid hormones.

'Effectiveness of various sulbactam-based combination antibiotic therapy in the management of ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii in a tertiary care Health centre'

OBJECTIVE

Carbapenem-resistant Acinetobacter baumannii (CRAB) is a common cause of ventilator-associated pneumonia (VAP). Some in vitro data favour various combination antibiotic therapy. However, there is a need for more in vivo studies for the management of VAP caused by CRAB. This retrospective study was done to evaluate the effectiveness of various combination antibiotic therapy including sulbactam on outcomes of VAP caused by CRAB.

METHODS

Adult patients (age ≥18 years) diagnosed with VAP caused by CRAB were included. Patients with polymicrobial infections were excluded from the study. Patients with CRAB associated VAP who were given sulbactam based antibiotic combinations were observed for outcomes. The primary outcome was 28-day mortality after diagnosis of VAP caused by CRAB. Reduction in serum HsCRP (High sensitivity C-reactive protein) during treatment and requirement of inotropes were the secondary outcomes. Outcomes were compared between various sulbactam based antibiotic combination therapies.

RESULTS

A total of 103 patients were included. A total of 44 (42.7 %) patients received sulbactam and minocycline or sulbactam and polymyxin B dual antibiotic combination, and 59 (57.3 %) patients received sulbactam, polymyxin B and minocycline triple antibiotic combination. The percentage difference in 28 days mortality was 27.51 % (95 % CI 8.03 %-44.06 %; p = 0.005) in dual vs triple sulbactam based antibiotic combination therapy. The percentage difference in requirement of inotropes during therapy and HsCRP reduction after 7 days of therapy was 23.65 % (95 % CI 6.43 %-38.3 %; p = 0.007) and 25.1 % (95%CI 10.1 %-38.2 %; p < 0.001) respectively when compared between dual vs triple sulbactam based antibiotic combination therapy.

CONCLUSION

Treatment with sulbactam, polymyxin B and minocycline combination antibiotic therapy was associated with significantly lower 28-day mortality. Moreover, the lower requirement of inotropes during treatment and a significant reduction in HsCRP level favours this combination antibiotic therapy in VAP caused by CRAB.

Preparedness for infection prevention and control practice among undergraduate health sciences students: A systematic review protocol

Introduction

The World Health Organization (WHO) advocates for the strengthening of education and training in infection prevention and control (IPC) in higher educational institutions (HEIs). This is fundamental to ensure health science students are confident and competent in clinical practice.

Aim

Explore the preparedness of undergraduate health science students for IPC practice.

Search strategy

The PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, ProQuest, Scopus, Web of Science, ClinicalKey, and Google Scholar databases and grey literature will be searched for relevant articles.

Inclusion criteria

Quantitative, and mixed methods studies on teaching and learning, technological methods, strengths and limitations, and challenges of IPC practice in HEI undergraduate curricula.

Participant characteristics

Undergraduate health science students including medical, nursing, pharmacy, dental, physiotherapy, radiology, medical imaging, and paramedicine.

Setting and time frame

Studies published anywhere in the world, in English, and from 2010 to 2023.

Search terms

Preparedness, health science students, infection prevention and control, technology, higher education institutions.

Data extraction

The data extracted will be recorded on a data extraction form.

Assessment of risk of bias

This will be conducted according to the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.

Ethics and dissemination

No ethical approval was required for this protocol. Interim findings will be presented at relevant local and international conferences and a manuscript will be published in a peer reviewed journal.

Discussion

This systematic review will provide a baseline for recommendations for developing innovative ways to improve IPC teaching and learning in HEI.

Intersecting social and environmental determinants of multidrug-resistant urinary tract infections in East Africa beyond antibiotic use

The global health crisis of antibacterial resistance (ABR) poses a particular threat in low-resource settings like East Africa. Interventions for ABR typically target antibiotic use, overlooking the wider set of factors which drive vulnerability and behaviours. In this cross-sectional study, we investigated the joint contribution of behavioural, environmental, socioeconomic, and demographic factors associated with higher risk of multi-drug resistant urinary tract infections (MDR UTIs) in Kenya, Tanzania, and Uganda. We sampled outpatients with UTI symptoms in healthcare facilities and linked their microbiology data with patient, household and community level data. Using bivariate statistics and Bayesian profile regression on a sample of 1610 individuals, we show that individuals with higher risk of MDR UTIs were more likely to have compound and interrelated social and environmental disadvantages: they were on average older, with lower education, had more chronic illness, lived in resource-deprived households, more likely to have contact with animals, and human or animal waste. This suggests that interventions to tackle ABR need to take account of intersectional socio-environmental disadvantage as a priority.

Antibiotic Prescribing Behavior of Physicians in Outpatient Departments in Hospitals in Northwest Ethiopia: Structural Equation Modeling Approach

BACKGROUND

Antibiotic resistance, fueled by irrational prescribing, is a global threat associated with health, social, and economic consequences. Understanding antibiotic prescribing behavior and associated factors is important to promote good prescribing practice.

OBJECTIVE

This study aimed to determine the factors affecting antibiotic prescribing behaviors of physicians based on the theory of planned behavior in hospitals in northwest Ethiopia in 2022.

METHODS

A cross-sectional study was conducted from September 2022 to October 2022. A total of 185 health professionals were included, and a self-administered questionnaire was used to collect data. A structural equation model based on the modified theory of planned behavior was used to determine factors affecting antibiotic prescribing behavior. The percentages of physicians' estimated prescriptions for patients with upper respiratory tract infections (URTIs) and during weekly outpatient visits were used to predict antibiotic prescribing behavior and finally linked with behavioral constructs. A P value <.05 was considered significant.

RESULTS

Physicians estimated that they prescribed antibiotics for 54.8% (9896/18,049) of weekly outpatient encounters, and 178 (96.2%) of the 185 physicians estimated they prescribed antibiotics for patients who presented with symptoms of a URTI. Physicians aged ≤30 years were less likely to prescribe antibiotics (48/100, 48%) for patients who presented with a URTI than physicians older than 30 years (51/100, 51%; P=.004), and general practitioners were less likely to prescribe antibiotics (47/100, 47%) for patients who presented with a URTI than residents (51/100, 51%; P=.03). Similarly, during outpatient visits, physicians ≤30 years old were less likely to prescribe antibiotics (54/100, 54%) than physicians older than 30 years (57/100, 57%; P<.001), male physicians were less likely to prescribe antibiotics (53/100, 53%) than female physicians (64/100, 64%; P=.03), and general practitioners were less likely to prescribe antibiotics (53/100, 53%) than residents (57/100, 57%; P=.02). Physicians with good knowledge were less affected by perceived social pressure (mean 4.4, SD 0.6) than those with poor knowledge (mean 4.0, SD 0.9; P<.001) and felt it was easy to make rational decisions (mean 4.1, SD 1.1) compared with those with poor knowledge (mean 3.8, SD 1; P<.001). However, intentions to reduce and prescribe antibiotics were not affected by attitudes, subjective norms, or perceived behavioral control, and perceived antibiotic prescribing behavior was not related to intentions to reduce or prescribe antibiotics.

CONCLUSIONS

Antibiotic prescribing behavior was not under the volitional control of physicians. This calls for a systematic approach to change antibiotic prescribing practices in hospital.

Advances in the research of intestinal fungi in Crohn's disease

This article reviews of the original research published by Wu et al in the World Journal of Gastroenterology, delving into the pivotal role of the gut microbiota in the pathogenesis of Crohn's disease (CD). Insights were gained from fecal microbiota transplantation (FMT) in mouse models, revealing the intricate interplay between the gut microbiota, mesenteric adipose tissue (MAT), and creeping fat. The study uncovered the characteristics of inflammation and fibrosis in the MAT and intestinal tissues of patients with CD; moreover, through the FMT mouse model, it observed the impact of samples from healthy patients and those with CD on symptoms. The pathogenesis of CD is complex, and its etiology remains unclear; however, it is widely believed that gut microbiota dysbiosis plays a significant role. Recently, with the development and application of next-generation sequencing technology, research on the role of fungi in the pathogenesis and chronicity of CD has deepened. This editorial serves as a supplement to the research by Wu et al who discussed advances related to the study of fungi in CD.

Metacognition-Associated Factors in Physical and Occupational Therapy Students: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

Supporting the mental well-being of students through their educational journey is of vital importance. The objective of this study was to investigate the relationship between metacognition, personality traits, and various factors affecting mental health in a cohort of physical therapy (PT) and occupational therapy (OT) students.

METHODS

This cross-sectional observational study involved a self-administered questionnaire (distributed in October to November 2020) that gathered demographic information and included six scales measuring personality characteristics, health literacy, self-management skills, exercise habits (benefits and barriers), cognitive thinking, and cognitive deliberateness and impulsivity.

RESULTS

A cohort of 195 PT and OT students participated in the study. The findings revealed significant associations between metacognition and personality, particularly the association between low cognitive self-confidence and high emotional instability. This link suggests that students who struggle with cognitive self-confidence may also experience greater emotional instability, highlighting a need for targeted mental health support. Additionally, health literacy was negatively correlated with anxiety, while metacognition was positively correlated with perceived exercise benefits.

CONCLUSIONS

This study highlights the importance of individualized metacognitive approaches to support students' mental well-being. Interventions should focus on strengthening cognitive self-confidence through methods such as resilience training, cognitive restructuring, and mindfulness practices to help manage emotional instability. Furthermore, promoting physical activity, particularly among female students, and incorporating gender-specific strategies could enhance mental health outcomes.

Challenges associated with the implementation of institutional quarantine and isolation strategies during major multicountry viral outbreaks in Africa (2000-2023): a scoping review

BACKGROUND

Quarantine and isolation (Q&I) are interrelated but not mutually exclusive public health practices for disease control, which may face public resistance in the context of health emergencies due to associated challenges. Hence, it is often tough for most countries to implement Q&I even in the context of health emergencies. Therefore, this scoping review examines the challenges associated with the implementation of institutional Q&I strategies during major multicountry viral outbreaks (Ebola, Lassa and COVID-19) in Africa between 2000 and 2023.

METHODS

This scoping review was designed based on Arksey and O'Malley's guidelines. A systematic literature search, using nine online research databases, was conducted with the aid of relevant search terms, Boolean operators and truncations. All articles obtained from the literature search were electronically imported into Rayyan web application for deduplication based on specific inclusion and exclusion criteria. From the included literature, relevant data were charted, summarized, collated, and presented.

RESULTS

This review included 24 of the 787 retrieved articles. Sixteen of the 24 selected articles investigated issues related to COVID-19 prevention and control in Africa. Two assessed precautionary practices for Lassa fever, while five were on Ebola virus disease. However, one article explored knowledge, preventive practices, and general isolation precautions. The review identified various challenges that hindered the implementation of successful Q&I practices during viral infection outbreaks in Africa. Essential healthcare infrastructure, equipment (medical supplies including personal protective equipment and testing kits) and facilities that are essential for Q&I were deficient. Q&I implementation was often threatened by low human resource capacity and inefficiencies in the healthcare system which portray Africa as unprepared to handle complex public health crises.

CONCLUSIONS

This review shows that Q&I implementation in Africa is often threatened by low human resource capacity and inefficiencies in the healthcare system and also portrays Africa as unprepared to handle complex public health crises. Hence, Q&I for major multicountry outbreaks in Africa is very challenging. Therefore, continuous efforts to address these identified challenges are crucial to enhancing health emergency preparedness in Africa.

Molecular Epidemiology of Pseudomonas aeruginosa in Brazil: A Systematic Review and Meta-Analysis

BACKGROUND

Globally, Pseudomonas aeruginosa is a high-priority opportunistic pathogen which displays several intrinsic and acquired antimicrobial resistance (AMR) mechanisms, leading to challenging treatments and mortality of patients. Moreover, its wide virulence arsenal, particularly the type III secretion system (T3SS) exoU+ virulotype, plays a crucial role in pathogenicity and poor outcome of infections. In depth insights into the molecular epidemiology of P. aeruginosa, especially the prevalence of high-risk clones (HRCs), are crucial for the comprehension of virulence and AMR features and their dissemination among distinct strains. This study aims to evaluate the prevalence and distribution of HRCs and non-HRCs among Brazilian isolates of P. aeruginosa.

METHODS

A systematic review and meta-analysis were conducted on studies published between 2011 and 2023, focusing on the prevalence of P. aeruginosa clones determined by multilocus sequence typing (MLST) in Brazil. Data were extracted from retrospective cross-sectional and case-control studies, encompassing clinical and non-clinical samples. The analysis included calculating the prevalence rates of various sequence types (STs) and assessing the regional variability in the distribution of HRCs and non-HRCs.

RESULTS

A total of 872 samples were analyzed within all studies, of which 298 (34.17%) were MLST typed, identifying 78 unique STs. HRCs accounted for 48.90% of the MLST-typed isolates, with ST277 being the most prevalent (100/298-33.55%), followed by ST244 (29/298-9.73%), ST235 (13/298-4.36%), ST111 (2/298-0.67%), and ST357 (2/298-0.67%). Significant regional variability was observed, with the Southeast region showing a high prevalence of ST277, while the North region shows a high prevalence of MLST-typed samples and HRCs.

CONCLUSIONS

Finally, this systematic review and meta-analysis highlight the role of P. aeruginosa clones in critical issue of AMR in P. aeruginosa in Brazil and the need of integration of comprehensive data from individual studies.

Rapid quantification of polymyxin B in human pulmonary epithelial lining fluid by LC-MS/MS and its clinical application

Pulmonary epithelial lining fluid (ELF) was commonly used for the pharmacokinetic study in lower respiratory tract infections. To characterize the intrapulmonary pharmacokinetic properties of polymyxin B following aerosol delivery, we developed and fully validated a liquid chromatography/tandem mass spectrometry (LC/MS/MS) method for quantifying polymyxin B in human bronchoalveolar lavage fluid (BALF). The ELF concentrations were calculated by the BALF values of polymyxin B using urea as a volume normalizer. Chromatographic separation was achieved on a Phonomenex Kinetex XB-C18 column(100 mm × 2.1 mm I.D., 2.6 μm)in acetonitrile and water both containing 0.2 % formic acid. The flow rate was set as 0.4 mL/min for a 3.5 min running time. Protein precipitation was used in preparing BALF samples with polymyxin E1 as an internal standard. Polymyxin B was detected under multiple reaction monitoring conditions using the electrospray ionization interface running in the positive ionization mode. The assay showed a good linear relationship over the tested concentration ranges of 0.0300/0.00306---10.0/1.02 mg/L for polymyxin B1/B2 in bronchoalveolar lavage fluid (R2 > 0.99). The inter- and inter-day precisions (RSD, %) were < 12.2 %(15.2 % for LLOQ samples)and the accuracies (%) were within the range of 94.3 ∼ 110.4 %. This reliable LC-MS/MS method for detection of polymyxin B was successfully applied to conduct a pulmonary penetration study in patients following aerosol administration.

Acute Sarcopenia: Mechanisms and Management

BACKGROUND

Acute sarcopenia refers to the swift decline in muscle function and mass following acute events such as illness, surgery, trauma, or burns that presents significant challenges in hospitalized older adults.

METHODS

narrative review to describe the mechanisms and management of acute sarcopenia.

RESULTS

The prevalence of acute sarcopenia ranges from 28% to 69%, likely underdiagnosed due to the absence of muscle mass and function assessments in most clinical settings. Systemic inflammation, immune-endocrine dysregulation, and anabolic resistance are identified as key pathophysiological factors. Interventions include early mobilization, resistance exercise, neuromuscular electrical stimulation, and nutritional strategies such as protein supplementation, leucine, β-hydroxy-β-methyl-butyrate, omega-3 fatty acids, and creatine monohydrate. Pharmaceuticals show variable efficacy.

CONCLUSIONS

Future research should prioritize serial monitoring of muscle parameters, identification of predictive biomarkers, and the involvement of multidisciplinary teams from hospital admission to address sarcopenia. Early and targeted interventions are crucial to improve outcomes and prevent long-term disability associated with acute sarcopenia.

First report of carbapenems encoding multidrug-resistant gram-negative bacteria from a pediatric hospital in Gaza Strip, Palestine

BACKGROUND

The worldwide prevalence of multi-drug resistance (MDR) in Gram-negative bacteria (GNB), particularly related to extended-spectrum beta-lactamases (ESBLs) and carbapenemases, poses significant global public health and clinical challenges.

OBJECTIVES

To characterize ESBL-producing Gram-negative bacilli, within a pediatric hospital in Gaza using whole genome sequencing (WGS).

METHODS

A total of 158 clinical isolates of Gram-negative bacilli were collected from Al-Nasser Pediatric Hospital. These isolates were tested for ESBL production using the double disk synergy test. The antibiotic susceptibility profile was determined using the Kirby Bauer method following the Clinical and Laboratory Standard Institute guidelines. Selected 15 phenotypically MDR isolates were whole-genome sequenced and characterized for their genome-based species identity and antibiotic resistance gene profile.

RESULTS

Of the 158 isolates, 93 (58.9%) were positive for ESBL production. The frequency of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Proteus mirabilis, and Serratia marcescens was 50%, 22.7%, 22.7%, 1.8%, 1.2%, and 1.2% respectively. The prevalence of ESBL among urine, pus, blood, and sputum was 64%, 44%, 23%, and 63.6%, respectively. Chloramphenicol, Imipenem, and Meropenem were the most effective antibiotics against ESBL producers. In sequenced isolates,  an average of six anti-microbial resistance (AMR) genes were noted per isolate, where one of them carried up to 13 antibiotic resistance genes. Carbapenem resistance genes such as blaKPC-2(6.6%), blaPDC-36/12 (6.6%), and blaPOM-1 (6.6%) were detected. All the sequenced E. coli isolates (n = 8) showed multiple resistance genes, mainly against β-lactamase (25.0%), aminoglycosides (37.5%), sulfonamides (37.5%), and genes conferring resistance to tetracyclines (25.0).

CONCLUSION

Our results showed a high prevalence of ESBL-producing GNB isolated from a pediatric hospital in the Gaza Strip. Various antibiotic resistance genes were identified, including those encoding ESBL and carbapenems. The results highlight the significant challenge posed by MDR in GNB and emphasize the need for effective antibiotic strategies. Given the high endemicity observed in various studies from Palestine, it is important to conduct clinical and molecular epidemiology research to identify risk factors, transmission patterns, and clinical outcomes associated with GNB strains that carry ESBL and carbapenem resistance genes.

Molecular epidemiological analysis of blaNDM-5-producing Klebsiella pneumoniae ST2407-K25 causing infection outbreaks in pediatric patients based on whole genome sequencing

BACKGROUND

Pediatric patients are vulnerable to the threat of carbapenem-resistant Klebsiella pneumoniae (CRKP) due to their limited immunity and few available antibiotics. Especially when these pathogens exhibit hypervirulent phenotypes, they are often associated with poor clinical outcomes.

METHODS

In this study, we investigated a CRKP outbreak in pediatric patients from 2019 to 2021 in a teaching hospital in China based on whole genome sequencing. We sequenced twenty-nine CRKP isolates isolated from unduplicated pediatric patients to understand their genetic relationships, virulence factors, resistance mechanisms, and transmission trajectories. Conjugation experiments were performed to evaluate the horizontal transfer ability of carbapenem resistance determinants in twenty-nine CRKP isolates. We then characterized these isolates for biofilm formation ability and serum resistance. Genetic relatedness, comparison of plasmids, and chromosomal locus variation of CRKP isolates were analyzed by bioinformatics.

RESULTS

All the isolates were carbapenemase-producers harbouring blaNDM-5. Among them, twenty-eight isolates belonged to the ST2407 group, with the consistent capsular serotype K25. The virulence-related factors: ureA, fim, ybtA, irp1/irp2, and mrkA were prevalent in these isolates. Additionally, most CRKP isolates showed moderately adherent biofilm formation. Although the ST2407 clonal group did not exhibit serum resistance, the heterogeneous level of serum resistance was related to the disruption of oqxR. Conjugation and WGS revealed that the blaNDM-5 carried by the twenty-eight CRKP ST2407 isolates was located on nonconjugative IncX3 plasmids associated with deleting the T4SS-encoding genes. Clonal transmission of CRKP ST2407 in pediatric patients was suggested by the phylogenetic tree.

CONCLUSIONS

Our study provides evidence of the clonal spread of blaNDM-5-producing K. pneumoniae in pediatric patients and the necessity for the T4SS system for horizontal transfer of the IncX3 plasmid carrying blaNDM-5. Additionally, the disruption of oqxR may have affected the serum resistance of CRKP. The results of this study emphasize the importance of continuously monitoring for CRKP infection in pediatric patients to prevent recurrent infections.

Emerging Fungal Infections of the Central Nervous System in the Past Decade: A Literature Review

INTRODUCTION

Invasive fungal infections affecting the central nervous system (CNS) are a major health concern worldwide associated with high mortality rates. Their increased incidence is largely due to an increase in the vulnerable immunocompromised population, changing environmental factors, and development of more accurate diagnostic methods. The aim of this article is to identify fungal causes of CNS infections that are recently emerging or have the potential to become emerging pathogens in the near future, as well as their clinical characteristics, including: Candida auris, Trichosporon spp., Blastomyces spp., Sporothrix spp., Talaromyces marneffei, Lomentospora prolificans, and Scedosporium spp.

METHODS

A review of the literature in PubMed in the last ten years was conducted to identify central nervous system infections caused by each of these fungi.

RESULTS

The review identified 10 cases caused by C. auris, 5 cases by Trichosporon spp., 82 cases by Blastomyces spp., 36 cases by Sporothrix spp., 21 cases by T. marneffei, 22 cases by Lomentospora prolificans, and 42 cases by Scedosporium spp.

DISCUSSION

The exact burden of these diseases remains difficult to ascertain, but their apparent rise underscores the urgent need for improved diagnostic, treatment, and management strategies against CNS fungal pathogens to improve outcomes against these life-threatening infections.

Evaluation of ventilator-associated pneumonia care practice in the intensive care units of a comprehensive specialized hospital in Northwest Ethiopia: a 1.5-year prospective observational study

BACKGROUND

Nosocomial infections pose a global health threat, with Ventilator-Associated Pneumonia (VAP) emerging as a prominent hospital-acquired infection, particularly in intensive care units (ICU).VAP is the commonest form of pneumonia in ICUs, contributing significantly to morbidity and mortality rates, which can reach around 30%. Despite the substantial impact of VAP on healthcare, there is a lack of data on adherence to VAP prevention protocols in our hospital. Consequently, this study aims to assess the adherence to ventilator-associated pneumonia care bundles in critical care units at a comprehensive specialized hospital in northwest Ethiopia.

METHODS

A hospital-based prospective observational study was conducted from July 3, 2022, to January 7, 2024. All adult patients who were on mechanical ventilators for more than 48 h during the study period were included. Data were collected using the Institute of Healthcare Improvement VAP prevention standards as checklists via direct observation and chart review. The data were entered and analyzed using SPSS version 20.

RESULTS

A total of 300 surgical and medical ICU patients were observed. Among the patients, 66.3% were from the medical ICU. In terms of admission reasons, 22.3%, 15.7% and, 12% were attributed to infections excluding respiratory origin, respiratory disorders, and other causes, respectively. The rate of compliance with all components of the bundle was 70%. A 100% adherence rate was observed for the prophylaxis for peptic ulcer and deep vein thrombosis (DVT). The lowest adherence rate was observed in the practice of oral hygiene with 0.5% chlorhexidine solution (0%) followed by humidification with heat and moisture exchangers (23.3%). Endotracheal tube cuff pressure measurement and use of endotracheal tubes with subglottic suction were not applicable.

CONCLUSION

The study revealed suboptimal compliance with the VAP care bundle, indicating unsatisfactory overall practice. Specific attention is warranted for subglottic suction, cuff pressure measurement, humidification, oral care with chlorhexidine, and sedation vacation.

International Nosocomial Infection Control Consortium (INICC) report of health care-associated infections, data summary of 25 countries for 2014 to 2023, Surgical Site Infections Module

BACKGROUND

Surgical site infection (SSI) rates are higher in low-resource countries (LRC) than in high-income counterparts.

METHODS

Prospective cohort study using the INICC Surveillance Online System, from 116 hospitals in 75 cities across 25 Latin-American, Asian, Eastern-European, and Middle-Eastern countries: Argentina, Bahrain, Brazil, Colombia, Costa Rica, Dominican Republic, Ecuador, Egypt, Honduras, India, Kosovo, Kuwait, Lebanon, Mexico, Mongolia, Pakistan, Papua New Guinea, Philippines, Poland, Romania, Saudi Arabia, Thailand, Turkey, Venezuela, Vietnam. CDC/NHSN definitions were applied. Surgical procedures (SPs) were categorized according to the International Classification of Diseases criteria.

RESULTS

From 2014 to 2023, we collected data on 1,251 SSIs associated with 56,617 SPs. SSI rates were significantly higher in SPs of INICC compared to CDC/NHSN data: hip prosthesis (3.68% vs 0.67%, relative risk [RR]=5.46, 95% confidence interval [CI]=3.71-8.03, P<.001), knee prosthesis (2.02% vs 0.58%, RR=3.49, 95% CI=1.87-6.49, P<.001), coronary artery bypass (4.16% vs 1.37%, RR=3.03, 95% CI=2.35-3.91, P<.001), peripheral vascular bypass (15.69% vs 2.93%, RR=5.35, 95% CI=2.30-12.48, P<.001), abdominal aortic aneurysm repair (8.51% vs 2.12%, RR=4.02, 95% CI=2.11-7.65, P<.001), spinal fusion (6.47% vs 0.70%, RR=9.27, 95% CI=6.21-13.84, P<.001), laminectomy (2.68% vs 0.72%, RR=3.75, 95% CI=2.36-5.95, P<.001), among others.

CONCLUSIONS

Elevated SSI rates in LRCs emphasize the need for effective interventions.

Community pharmacists' knowledge and practices towards antimicrobial stewardship: findings and implications

BACKGROUND

Antimicrobial stewardship (AMS) programmes have been implemented around the world to optimally manage antimicrobial use to attenuate antimicrobial resistance (AMR). This study assessed the knowledge and practices of community pharmacists towards AMS strategies in the Lusaka District, Zambia.

METHODS

This cross-sectional study was conducted among 194 community pharmacists in the Lusaka district using a structured questionnaire from August 2022 to September 2022. Data analysis was done using Statistical Package for Social Science (SPSS) version 22.0.

RESULTS

Of the 194 participants, 86% of the community pharmacists had good knowledge of AMS. The present study found that 83.5% were aware of AMS strategies used in community pharmacy practice. Further, 83.5% of the CPs were familiar with the goals of AMS and 89.2% believed that AMS was necessary for their pharmacy practice. Furthermore, 66.7% of the participants exhibited good practice towards the AMS strategies. Finally, 61.3% frequently avoided the use of broad-spectrum antimicrobials that were not necessary.

CONCLUSIONS

According to the findings of this study, the majority of community pharmacists had good knowledge of the AMS strategies that were employed to combat AMR; nonetheless, some of them had poor practices. Therefore, there is a need for community pharmacists to have access to sufficient ongoing professional development programmes and educational activities through AMS programmes to address AMR.

A Risk Prediction Model to Identify People Living with HIV Who are High-risk for Disengagement from Care after HIV Diagnosis in South Africa

The provision of ART in South Africa has transformed the HIV epidemic, resulting in an increase in life expectancy by over 10 years. Despite this, nearly 2 million people living with HIV are not on treatment. The objective of this study was to develop and externally validate a practical risk assessment tool to identify people with HIV (PWH) at highest risk for attrition from care after testing. A machine learning model incorporating clinical and psychosocial factors was developed in a primary cohort of 498 PWH. LASSO regression analysis was used to optimize variable selection. Multivariable logistic regression analysis was applied to build a model using 80% of the primary cohort as a training dataset and validated using the remaining 20% of the primary cohort and data from an independent cohort of 96 participants. The risk score was developed using the Sullivan and D'Agostino point based method. Of 498 participants with mean age 35.7 years, 192 (38%) did not initiate ART after diagnosis. Controlling for site, factors associated with non-engagement in care included being < 35 years, feeling abandoned by God, maladaptive coping strategies using alcohol or other drugs, no difficulty concentrating, and having high levels of confidence in one's ability to handle personal challenges. An effective risk score can enable clinicians and implementers to focus on tailoring care for those most in need of ongoing support. Further research should focus on potential strategies to enhance the generalizability and evaluate the implementation of the proposed risk prediction model in HIV treatment programs.

The emerging role of the gut microbiota and its application in inflammatory bowel disease

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is a complex disorder with an unknown cause. However, the dysbiosis of the gut microbiome has been found to play a role in IBD etiology, including exacerbated immune responses and defective intestinal barrier integrity. The gut microbiome can also be a potential biomarker for several diseases, including IBD. Currently, conventional treatments targeting pro-inflammatory cytokines and pathways in IBD-associated dysbiosis do not yield effective results. Other therapies that directly target the dysbiotic microbiome for effective outcomes are emerging. We review the role of the gut microbiome in health and IBD and its potential as a diagnostic, prognostic, and therapeutic target for IBD. This review also explores emerging therapeutic advancements that target gut microbiome-associated alterations in IBD, such as nanoparticle or encapsulation delivery, fecal microbiota transplantation, nutritional therapies, microbiome/probiotic engineering, phage therapy, mesenchymal stem cells (MSCs), gut proteins, and herbal formulas.

Regional variation in the interpretation of contact precautions for multi-drug-resistant Gram-negative bacteria: a cross-sectional survey

BACKGROUND

Contact precautions are recommended when caring for patients with carbapenemase-producing Enterobacterales (CPE), carbapenemase-producing Pseudomonas aeruginosa (CPPA), and extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E).

AIM

Our aim was to determine the interpretation of contact precautions and associated infection prevention and control (IPC) measures in the non-ICU hospital setting for patients with CPE, CPPA or ESBL-E in 11 hospitals in the Southwest of the Netherlands.

METHODS

A cross-sectional survey was developed to collect information on all implemented IPC measures, including use of personal protective equipment, IPC measures for visitors, cleaning and disinfection, precautions during outpatient care and follow-up strategies. All 11 hospitals were invited to participate between November 2020 and April 2021.

FINDINGS

The survey was filled together with each hospital. All hospitals installed isolation precautions for patients with CPE and CPPA during inpatient care and day admissions, whereas 10 hospitals (90.9%) applied isolation precautions for patients with ESBL-E. Gloves and gowns were always used during physical contact with the patient in isolation. Large variations were identified in IPC measures for visitors, cleaning and disinfection products used, and precautions during outpatient care. Four hospitals (36.4%) actively followed up on CPE or CPPA patients with the aim of declaring them CPE- or CPPA-negative as timely as possible, and two hospitals (20.0%) actively followed up on ESBL-E patients.

CONCLUSION

Contact precautions are interpreted differently between hospitals, leading to regional differences in IPC measures applied in clinical settings. Harmonizing infection-control policies between the hospitals could facilitate patient transfers and benefit collective efforts of preventing transmission of multi-drug-resistant Gram-negative bacteria.

A Global Evaluation of Generic Antimicrobial Prescribing Competencies for Use in Veterinary Curricula

The European Society for Clinical Microbiology and Infectious Diseases (ESCMID) developed consensus-based generic competencies in antimicrobial prescribing and stewardship. These may be useful in structuring and evaluating antimicrobial prescribing education to veterinary students, but their applicability has not been evaluated. We aimed to evaluate whether the ESCMID competencies are currently taught and how relevant they are to veterinary prescribing in veterinary schools globally. A multi-center, cross-sectional survey was performed by administering an online questionnaire to academics teaching antimicrobial prescribing to veterinary students. Targeted recruitment was undertaken to ensure the representation of diverse geographical locations. Responses (48) were received from veterinary schools in Europe (26), North America (7), Asia (6), Australia (3), Central and South America (3), and Africa (3). Of the 37 ESCMID prescribing competencies, only 6 were considered only "slightly" or "not at all" relevant by more than 10% of respondents. Of the 37 competencies, 25 of the competencies were taught in more than 90% of schools and another 6 were taught in 80%-89% of schools. Time spent teaching was "too little" or "far too little" for five competencies according to more than 50% of the respondents. Additional competencies to address extra-label drug use; the use of compounded antimicrobials; the use of antimicrobials for metaphylaxis, prophylaxis, and growth promotion; and the importance rating of antimicrobials were suggested. The ESCMID antimicrobial prescribing competencies had broad relevance and were widely covered in the veterinary curriculum globally.

Healthcare as a driver, reservoir and amplifier of antimicrobial resistance: opportunities for interventions

Antimicrobial resistance (AMR) is a global health challenge that threatens humans, animals and the environment. Evidence is emerging for a role of healthcare infrastructure, environments and patient pathways in promoting and maintaining AMR via direct and indirect mechanisms. Advances in vaccination and monoclonal antibody therapies together with integrated surveillance, rapid diagnostics, targeted antimicrobial therapy and infection control measures offer opportunities to address healthcare-associated AMR risks more effectively. Additionally, innovations in artificial intelligence, data linkage and intelligent systems can be used to better predict and reduce AMR and improve healthcare resilience. In this Review, we examine the mechanisms by which healthcare functions as a driver, reservoir and amplifier of AMR, contextualized within a One Health framework. We also explore the opportunities and innovative solutions that can be used to combat AMR throughout the patient journey. We provide a perspective on the current evidence for the effectiveness of interventions designed to mitigate healthcare-associated AMR and promote healthcare resilience within high-income and resource-limited settings, as well as the challenges associated with their implementation.

Antimicrobial stewardship situation analysis in selected hospitals in Zambia: findings and implications from a national survey

Background

Antimicrobial stewardship (AMS) programs are critical in combating antimicrobial resistance (AMR). In Zambia, there is little information regarding the capacity of hospitals to establish and implement AMS programs. The objective of this study was to conduct a baseline assessment of WHO core elements for an AMS program implementation in eight hospitals in Zambia.

Materials and methods

We conducted an exploratory cross-sectional study from September 2023 to December 2023 using a self-scoring Periodic National and Healthcare Facility Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Eight public hospitals were surveyed across the five provinces of Zambia. Data was analyzed using the WHO self-scoring tool and thematic analysis.

Results

Overall, 62.5% (6/8) of the facilities scored low (below 60%) in implementing AMS programs. Most facilities had challenges with reporting AMS feedback within the hospital (average score = 46%), Drugs and Therapeutics Committee (DTC) functionality (average score = 49%), AMS actions (average score = 50%), education and training (average score = 54%), and leadership commitment to AMS activities (average score = 56%). The overall score for all AMS core elements was average (56%). All the hospitals (100%) did not have an allocated budget for AMS programs. Finally, there were neither antibiograms to guide antimicrobial utilization nor AMS-trained staff in more than 50% of the hospitals surveyed.

Conclusion

This study found low AMS implementation in these public hospitals, especially where DTCs were non-functional. The identified challenges and gaps require urgent attention for sustainable multidisciplinary AMS programs.

Medical residents' knowledge, attitudes and practices regarding antibiotics, antimicrobial stewardship and multidrug-resistant bacteria: a cross-sectional study in a major university in Iran

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health systems. This study aimed to assess the knowledge, attitudes and practice about AMR, antimicrobial stewardship programs (ASPs) and multidrug-resistant (MDR) bacteria.

Methods

A web-based questionnaire survey was conducted among the residents of Isfahan University of Medical Sciences from May to November 2023. Data analysis was done using SPSS version 24.0 software.

Results

Overall, 400 out of 450 medical residents responded to the questionnaire, giving a response rate of 88.9%. The participants' ages ranged from 26 to 54 years, and the majority were female (227/400 56.8%). Average scores for knowledge, attitudes, and practices were 53.70 ± 15.88, 36.97 ± 5.89 and 24.69 ± 4.24, respectively. In terms of knowledge, only 26.8% had heard the term "ASPs" and knew what it was. Most incorrect answers appeared to the treatment of infection caused by MDR bacteria including ESBL-producing Escherichia coli (27.8%) and carbapenem-resistant Klebsiella pneumoniae (30.8%), as well as the atypical bacteria (45.5%). Approximately, 50 and 71.7% said they had received no specific training in the fields of microbiological sampling methods and the appropriate time to prescribe antibiotics, respectively. Surprisingly, regarding practice, 81.8% of the respondents stated that antibiotics are used to treat flu or the common cold.

Conclusion

Residents considered their training on important issues including ASPs, MDR bacteria and the spectrum of antibiotics insufficient. This result highlights the need for targeted training interventions about antibiotic prescription in the curriculum at the university with more emphasis on ASPs to limit the development of resistance.

An Overview of the Recent Advances in Antimicrobial Resistance

Antimicrobial resistance (AMR), frequently considered a major global public health threat, requires a comprehensive understanding of its emergence, mechanisms, advances, and implications. AMR's epidemiological landscape is characterized by its widespread prevalence and constantly evolving patterns, with multidrug-resistant organisms (MDROs) creating new challenges every day. The most common mechanisms underlying AMR (i.e., genetic mutations, horizontal gene transfer, and selective pressure) contribute to the emergence and dissemination of new resistant strains. Therefore, mitigation strategies (e.g., antibiotic stewardship programs-ASPs-and infection prevention and control strategies-IPCs) emphasize the importance of responsible antimicrobial use and surveillance. A One Health approach (i.e., the interconnectedness of human, animal, and environmental health) highlights the necessity for interdisciplinary collaboration and holistic strategies in combating AMR. Advancements in novel therapeutics (e.g., alternative antimicrobial agents and vaccines) offer promising avenues in addressing AMR challenges. Policy interventions at the international and national levels also promote ASPs aiming to regulate antimicrobial use. Despite all of the observed progress, AMR remains a pressing concern, demanding sustained efforts to address emerging threats and promote antimicrobial sustainability. Future research must prioritize innovative approaches and address the complex socioecological dynamics underlying AMR. This manuscript is a comprehensive resource for researchers, policymakers, and healthcare professionals seeking to navigate the complex AMR landscape and develop effective strategies for its mitigation.

Long-Term Glucocorticoid Exposure and Incident Cardiovascular Diseases-The Lifelines Cohort

CONTEXT

Long-term glucocorticoid levels in scalp hair (HairGCs), including cortisol and the inactive form cortisone, represent the cumulative systemic exposure to glucocorticoids over months. HairGCs have repeatedly shown associations with cardiometabolic and immune parameters, but longitudinal data are lacking.

DESIGN

We investigated 6341 hair samples of participants from the Lifelines cohort study for cortisol and cortisone levels and associated these to incident cardiovascular diseases (CVD) during 5 to 7 years of follow-up. We computed the odds ratio (OR) of HairGC levels for incident CVD via logistic regression, adjusting for classical cardiovascular risk factors, and performed a sensitivity analysis in subcohorts of participants < 60 years and ≥ 60 years of age. We also associated HairGC levels to immune parameters (total leukocytes and subtypes).

RESULTS

Hair cortisone levels (available in n = 4701) were independently associated with incident CVD (P < .001), particularly in younger individuals (multivariate-adjusted OR 4.21, 95% CI 1.91-9.07 per point increase in 10-log cortisone concentration [pg/mg], P < .001). All immune parameters except eosinophils were associated with hair cortisone (all multivariate-adjusted P < .05).

CONCLUSION

In this large, prospective cohort study, we found that long-term cortisone levels, measured in scalp hair, represent a relevant and significant predictor for future CVD in younger individuals. These results highlight glucocorticoid action as possible treatment target for CVD prevention, where hair glucocorticoid measurements could help identify individuals that may benefit from such treatments.

Association of Wild-Type TP53 with Downregulation of Lovastatin Sensitivity in Human Non-Small Cell Lung Cancer Cells

Statins inhibit 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR), the rate-limiting enzyme of the mevalonate pathway, and reduce cholesterol synthesis. They also have been demonstrated to improve prognosis in patients with various cancers, suggesting a potential anti-cancer effect of statins. However, there is no consensus on the molecular targets of statins for their anti-cancer effects. Docetaxel (DOC) is a microtubule-stabilizing agent currently used as a chemotherapeutic drug in several cancers, including lung cancer. Interestingly, the anti-cancer effects of either drug that are related to abnormal or wild-type TP53 gene have been implied. Therefore, the drug sensitivity of DOC and lovastatin in human lung cancer cells was evaluated. We found that H1355 (mutant TP53-E285K), CL1 (mutant TP53-R248W), and H1299 (TP53-null) human non-small cell lung cancer cells were more sensitive to lovastatin than A549 and H460 cells expressing wild-type TP53. Conversely, A549 and H460 cells showed higher sensitivity to DOC than H1299 and CL1 cells, as demonstrated by the MTT assay. When endogenous TP53 activity was inhibited by pifithrin-α in A549 and H460 cells, lovastatin sensitivities significantly increased, and cancer cell viabilities markedly reduced. These results indicate that TP53 status is associated with the anti-cancer effect of statins in human lung cancer cells. Mutated or null TP53 status is correlated with higher statin sensitivity. Furthermore, DOC-resistant H1299 (H1299/D8) cells showed significant sensitivity to lovastatin treatment compared to DOC-resistant A549 (A549/D16) cells, indicating a potential application of statins/chemotherapy combination therapy to control wild-type and abnormal TP53-containing human lung tumors.

Prescription patterns of antibiotics and associated factors among outpatients diagnosed with respiratory tract infections in Jinja city, Uganda, June 2022-May 2023

BACKGROUND

Most respiratory tract infections (RTIs) are viral and do not require antibiotics, yet their inappropriate prescription is common in low-income settings due to factors like inadequate diagnostic facilities. This misuse contributes to antibiotic resistance. We determined antibiotic prescription patterns and associated factors among outpatients with RTIs in Jinja City, Uganda.

METHODS

We conducted a retrospective observational study that involved data abstraction of all patient records with a diagnosis of RTIs from the outpatient registers for the period of June 1, 2022, to May 31, 2023. An interviewer-administered questionnaire capturing data on prescribing practices and factors influencing antibiotic prescription was administered to drug prescribers in the health facilities where data were abstracted and who had prescribed from June 1, 2022, to May 31, 2023. We used modified Poisson regression analysis to identify factors associated with antibiotic prescription.

RESULTS

Out of 1,669 patient records reviewed, the overall antibiotic prescription rate for respiratory tract infections (RTIs) was 79.8%. For specific RTIs, rates were 71.4% for acute bronchitis, 93.3% for acute otitis media, and 74.4% for acute upper respiratory tract infections (URTIs). Factors significantly associated with antibiotic prescription included access to Uganda Clinical Guidelines (Adjusted prevalence ratio [aPR] = 0.61, 95% CI = 0.01-0.91) and Integrated Management of Childhood Illness guidelines (aPR = 0.14, 95% CI = 0.12-0.87, P = 0.002), which reduced the likelihood of prescription. Prescribers without training on antibiotic use were more likely to prescribe antibiotics (aPR = 3.55, 95% CI = 1.92-3.98). Patients with common cold (aPR = 0.06, 95% CI = 0.04-0.20) and cough (aPR = 0.11, 95% CI = 0.09-0.91) were less likely to receive antibiotics compared to those with pneumonia.

CONCLUSION

The study reveals a high rate of inappropriate antibiotic prescription for RTIs, highlighting challenges in adherence to treatment guidelines. This practice not only wastes national resources but also could contribute to the growing threat of antibiotic resistance. Targeted interventions, such as enforcing adherence to prescription guidelines, could improve prescription practices and reduce antibiotic misuse in this low-income setting.

The Collaborative Outcome Study on Health and Functioning during Infection Times (COH-FIT): Results from Cyprus

Many studies have shown that COVID-19 caused many problems in mental health. This paper presents the results of the Cyprus sample, part of the global initiative named "The Collaborative Outcomes Study on Health and Functioning during Infection Times" (COH-FIT). Methods: The study took place from April 2019 to January 2022, using the Greek version of the online standard COH-FIT questionnaire on 917 Cypriot adults. Weighted t-tests were applied to test the differences between pre-pandemic and intra-pandemic scores using the anesrake package. Results: Participant responses indicated a significant negative impact of the pandemic on measures of mental health (-7.55; 95% CI: -9.01 to -6.07), with worsening in the scores for anxiety (12.05; 95% CI: 9.33 to 14.77), well-being (-11.06; 95% CI: -12.69 to -9.45) and depression (4.60; 95% CI: 2.06 to 7.14). Similar negative effects were observed for feelings of anger (12.92; 95% CI: 10.54 to 15.29), helplessness (9.66; 95% CI: 7.25 to 12.07), fear (22.25; 95% CI: 19.25 to 25.26), and loneliness (12.52; 95% CI: 9.94 to15.11). Increased use of social media (0.89; 95% CI: 0.71 to 1.09), internet (0.86; 95% CI: 0.67 to 1.04), and substance consumption (0.06; 95% CI: 0.00 to 0.11) were reported, along with a significant decrease in physical health (-3.45; 95% CI: -4.59 to -2.32), self-care (-7.10; 95% CI: -9.00 to -5.20), and social function (-11.27; 95% CI: -13.19 to -9.35), including support (-0.72; 95% CI: -1.09 to -0.34) and family function (-7.97; 95% CI: -9.90 to -6.05). Conclusions: The COVID-19 pandemic significantly affected the daily life and emotional well-being of Cypriots. Identifying factors that influence vulnerability and resilience is essential to prioritize mental health support and address the long-term effects of the pandemic.

Exploring the synergistic effects of vitamin D and synbiotics on cytokines profile, and treatment response in breast cancer: a pilot randomized clinical trial

This study was designed to investigate the effect of vitamin D and/or synbiotics on the response to treatment, cytokines profile and hormonal biomarkers in breast cancer patients undergoing neoadjuvant therapy. A total of 76 patients were recruited and completed the course of the intervention between 2019 and 2021 in Kerman, Iran. breast cancer patients were randomly enrolled in this study. Patients divided into four groups to receive one of the following regimens: placebo, vitamin D, synbiotics and a combination of vitamin D and synbiotics. clinicopathologic parameters, inflammatory and anti-inflammatory biomarkers and hormonal levels were measured at the baseline and four months after intervention. The study results found no clear link between the interventions and achieving pathological complete response (pCR), and a similar trend was observed in Ki-67 index examination. After neoadjuvant therapy, TNF-α concentrations decreased, with vitamin D supplementation moderating this decline. Vitamin D supplemented groups showed a significant increase in serum IL-6 levels. While IL-10 levels decreased in the placebo group, all intervention groups were protected from this decline. Moreover, there was a notable increase in the anti-inflammatory index, particularly in the group receiving both vitamin D and synbiotic supplementation, suggesting potential synergistic anti-inflammatory effects from their combined administration. The outcomes suggest a potential anti-inflammatory function of this combination. Consequently, more extensive studies with prolonged follow-up periods and substantial sample sizes are warranted to thoroughly evaluate their potential benefits for breast cancer patients.

Complex Infection-Control Measures with Disinfectant Switch Help the Successful Early Control of Carbapenem-Resistant Acinetobacter baumannii Outbreak in Intensive Care Unit

A carbapenem-resistant Acinetobacter baumannii (CRAB) outbreak in an intensive care unit (ICU) was contained by an improved infection-control measure that included a disinfectant policy. In our retrospective cohort study, we describe the epidemiological investigations and infection-control measures during this outbreak. Descriptive analysis was used to summarize patient demographics, neurological diseases, surgical treatment, underlying diseases, infection, and outcomes. In December 2023, two CARB-positive patients were observed in the ICU, and four more patients became CRAB-positive in January. During this outbreak, there was an overlap of hospitalization periods among the CRAB-positive patients, and CRAB was isolated from the environment; the isolated CRAB strain was identical. Infection-control measures, including hand hygiene, contact precautions and isolation, surveillance, decolonization, environmental cleaning, and disinfection, were reviewed and modified. The aim of this study was to examine the molecular background of the effectiveness of the disinfectant shift used during successful outbreak control. Experiments were carried out to study the phenotypic sensitivity and genetic background of different disinfectant agents. A thorough analysis of the detected CRAB strain included whole-genome sequencing (WGS), investigation of the qacE and qacEΔ1 genes' relative expression by qPCR after exposure to different disinfectant solutions, as well as an analysis of biofilm formation. WGS analysis of the CRAB strain identified that an ST2 high-risk clone was responsible for the outbreak, which produced OXA-83 and ADC-30 beta-lactamases; in addition, qacE and qacEΔ1 genes were also detected, which confer resistance to disinfectants containing quaternary ammonium compounds (QACs). A qPCR analysis demonstrated that after exposure to different disinfectants, the gene expression levels of qacE and qacEΔ1 increased and correlated with concentrations of QACs of disinfectants. During the outbreak, the standard-of-care QAC-based disinfectant was changed to a mainly alcohol-based agent in the ICU, which contributed to the successful control of this outbreak, and no additional patients were identified with CRAB. We conclude that continuous surveillance and hand hygiene training combined with fast identification and reaction to new cases, as well as an in-depth analysis of multidrug-resistant outbreak strains and investigation of their disinfectant tolerance/resistance during an outbreak, are essential to effectively control the spread of nosocomial pathogens. The smart policy of disinfectant agent selection played a crucial role in controlling the outbreak and ensuring patient safety in the ICU.

Inducible clindamycin-resistant and biofilm formation in the Staphylococcus aureus isolated from healthcare worker's anterior nasal carriage

OBJECTIVE

The purpose of this study is a new update on the resistance profile, Macrolide-Lincosamide-Streptogramin B resistance mechanisms and biofilm formation in the Staphylococcus aureus isolated from health care workers (HCWs) nasal carriage at a children's teaching hospital in Babol (Northern Iran).

RESULTS

A total of 143 non-repetitive nasal swab samples were collected from volunteers, where 53.8% (n; 77/143) were HCWs, 33.6% (n; 48/143) medical students, and 12.6% (n; 18/143) resident students. The prevalence of nasal carriers of S. aureus was 22.4% (n; 32/143), among them, 40.6% (n; 13/32) were identified as methicillin-resistant Staphylococcus aureus (MRSA( carriers. Antimicrobial susceptibility testing showed that erythromycin (68.8%, n; 22/32) and ciprofloxacin (15.6%, n; 5/32) had the highest and lowest resistance rate, respectively. The frequency of resistance genes in the strains was as follows; ermC (n; 17/32, 53.1%), ermA (n; 11/32, 34.4%), ermB (n; 6/32, 18.7%), ereA (n; 3/32, 9.4%). Moreover, 50.0% (n; 16/32), 28.1% (n; 9/32) and 21.8% (n; 7/32) of isolates were strongly, weakly and moderately biofilm producer, respectively. Macrolides-lincosamides-streptogramins B (MLSB) antibiotic resistance among S. aureus isolates from HCWs nasal carriage have found significant prevalence rates throughout the globe. It is crucial to remember that the development of biofilms and MLS B antibiotic resistance are both dynamic processes.

Severe acute pancreatitis complicated with intra-abdominal infection secondary to trauma: A case report

BACKGROUND

Pancreatic trauma (PT) is rare among traumatic injuries and has a low incidence, but it can still lead to severe infectious complications, resulting in a high mortality rate. Acute pancreatitis (AP) is a common complication after PT, and when combined with organ dysfunction and sepsis, it will result in a poorer prognosis.

CASE SUMMARY

We report a 25-year-old patient with multiple organ injuries, including the pancreas, due to abdominal trauma, who developed necrotising pancreatitis secondary to emergency caesarean section, combined with intra-abdominal infection (IAI). The patient underwent performed percutaneous drainage, pancreatic necrotic tissue debridement, and abdominal infection foci debridement on the patient.

CONCLUSION

We report a case of severe AP and IAI secondary to trauma. This patient was managed by a combination of conservative treatment such as antibiotic therapy and fluid support with surgery, and a better outcome was obtained.

Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area

BACKGROUND

Hand hygiene is known to reduce healthcare-associated infections. However, it remains suboptimal among healthcare providers. In this study, we used the Behaviour-centered Design approach to explore the facilitators and deterrents to hand hygiene among healthcare providers in the Kampala Metropolitan area, Uganda.

METHODS

We conducted a formative qualitative study as part of a cluster randomised trial in 19 healthcare facilities (HCFs). The study used 19 semi-structured and 18 key informant interviews to collect data on hand hygiene status and facilitators and deterrents of hand hygiene. Research assistants transcribed verbatim and used a thematic framework aided by Nvivo 14.0. to undertake analysis. We used thick descriptions and illustrative quotes to enhance the credibility and trustworthiness of our findings.

RESULTS

About 47.4% of the HCFs had sufficient hand hygiene infrastructure, and 57.9% did not report total compliance with hand hygiene during patient care. The physical facilitator for hand hygiene was the presence of constant reminders such as nudges, while the biological included the frequency of patient contact and the nature of clinical work. The only biological deterrent was the heavy workload in HCFs. The executive brain facilitators included knowledge of workplace health risks, infection prevention and control (IPC) guidelines, and a positive attitude. A negative attitude was the executive brain deterrent to hand hygiene. Recognition, rewards, and fear of infections were the only motivated brain facilitators. Behavioural setting facilitators included proximity to functional hand hygiene infrastructure, the existence of active IPC committees, good leadership, and the availability of a budget for hand hygiene supplies. Behavioural setting deterrents included the non-functionality and non-proximity to hand hygiene infrastructure and inadequate supplies.

CONCLUSIONS

The study revealed low compliance with hand hygiene during the critical moments of patient care and inadequacy of hand hygiene infrastructure. The deterrents to hand hygiene included a heavy workload, negative attitude, inadequate supplies, non-functionality, and long distance to hand washing stations. Facilitators included constant reminders, fear of infections, frequency of patient contact and nature of clinical work, positive attitude, knowledge of IPC guidelines, recognition and reward, good leadership, availability of budgets for hand hygiene supplies, availability and proximity to hand hygiene supplies and infrastructure and active IPC committees.

TRIAL REGISTRATION

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Oral Staphylococcus Species and MRSA Strains in Patients with Orofacial Clefts Undergoing Surgical Rehabilitation Diagnosed by MALDI-TOF MS

This study investigated the occurrence and dynamics of oral Staphylococcus species in patients with orofacial clefts undergoing surgical rehabilitation treatment. Patients (n = 59) were statistically stratified and analyzed (age, gender, types of orofacial clefts, surgical history, and types of previous surgical rehabilitation). Salivary samples were obtained between hospitalization and the return to the specialized medical center. Microbiological diagnosis was performed by classical methods, and MALDI-TOF MS. MRSA strains (SCCmec type II, III, and IV) were characterized by the Decision Tree method. A total of 33 (55.9%) patients showed oral staphylococcal colonization in one, two, or three sampling steps. A high prevalence has been reported for S. aureus (including HA-, MRSA and CA-MRSA), followed by S. saprophyticus, S. epidermidis, S. sciuri, S. haemolyticus, S. lentus, S. arlettae, and S. warneri. The dynamics of oral colonization throughout surgical treatment and medical follow-up may be influenced by (i) imbalances in staphylococcal maintenance, (ii) efficiency of surgical asepsis or break of the aseptic chain, (iii) staphylococcal neocolonization in newly rehabilitated anatomical oral sites, and (iv) total or partial maintenance of staphylococcal species. The highly frequent clinical periodicity in specialized medical and dental centers may contribute to the acquisition of MRSA in these patients.

Effectiveness of nirmatrelvir/ritonavir and molnupiravir in non-hospitalized adults with COVID-19: systematic review and meta-analysis of observational studies

OBJECTIVE

To determine the effectiveness of nirmatrelvir/ritonavir and molnupiravir among vaccinated and unvaccinated non-hospitalized adults with COVID-19.

METHODS

Observational studies of nirmatrelvir/ritonavir or molnupiravir compared to no antiviral drug treatment for COVID-19 in non-hospitalized adults with data on vaccination status were included. We searched MEDLINE, EMBASE, Scopus, Web of Science, WHO COVID-19 Research Database and medRxiv for reports published between 1 January 2022 and 8 November 2023. The primary outcome was a composite of hospitalization or mortality up to 35 days after COVID-19 diagnosis. Risk of bias was assessed with ROBINS-I. Risk ratios (RR), hazard ratios (HR) and risk differences (RD) were separately estimated using random-effects models.

RESULTS

We included 30 cohort studies on adults treated with nirmatrelvir/ritonavir (n = 462 279) and molnupiravir (n = 48 008). Nirmatrelvir/ritonavir probably reduced the composite outcome (RR 0.62, 95%CI 0.55-0.70; I2 = 0%; moderate certainty) with no evidence of effect modification by vaccination status (RR Psubgroup = 0.47). In five studies, RD estimates against the composite outcome for nirmatrelvir/ritonavir were 1.21% (95%CI 0.57% to 1.84%) in vaccinated and 1.72% (95%CI 0.59% to 2.85%) in unvaccinated subgroups.Molnupiravir may slightly reduce the composite outcome (RR 0.75, 95%CI 0.67-0.85; I2 = 32%; low certainty). Evidence of effect modification by vaccination status was inconsistent among studies reporting different effect measures (RR Psubgroup = 0.78; HR Psubgroup = 0.08). In two studies, RD against the composite outcome for molnupiravir were -0.01% (95%CI -1.13% to 1.10%) in vaccinated and 1.73% (95%CI -2.08% to 5.53%) in unvaccinated subgroups.

CONCLUSIONS

Among cohort studies of non-hospitalized adults with COVID-19, nirmatrelvir/ritonavir is effective against the composite outcome of severe COVID-19 independent of vaccination status. Further research and a reassessment of molnupiravir use among vaccinated adults are warranted.

REGISTRATION

PROSPERO CRD42023429232.

Real-World Clinical Characteristics and Outcomes with Daptomycin Use in Pediatric Patients: A Retrospective Case Series

INTRODUCTION

Daptomycin (DAP) is a cyclic lipopeptide that exhibits potent in vitro activity against many drug-resistant gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). Despite substantial reports evaluating the clinical outcomes of DAP within the adult population, real-world data are lacking in children. The primary goal of this evaluation was to describe the clinical characteristics and outcomes of DAP use in pediatric patients across a wide range of infections.

METHODS

This retrospective evaluation included patients < 18 years of age who were treated with DAP from January 2014 to May 2023. The primary objective was to evaluate the composite clinical success, which was defined as a 30-day survival, the lack of a 30-day microbiological recurrence, and the resolution of signs and symptoms of an acute infection without therapy modifications based on clinical failures. Secondary objectives included adverse effects potentially attributable to DAP and reasons for DAP utilization.

RESULTS

Forty patients were included, which were predominately male (62.5%) and white (52.5%), with a median age of 8.7 [IQR, 4.4-16.0] years. DAP was used for a wide range of infections, including central line-associated bloodstream infections (CLABSIs; 32.5%), infective endocarditis (15.0%), surgical-site infections (12.5%), and osteomyelitis (12.5%). The most common pathogen isolated was MRSA (37.5%), and most patients were bacteremic (60.0%). The median DAP dose was 8 [IQR, 6-10] mg/kg, and the median duration of the DAP therapy was 11.5 [IQR, 4.8-18.8] days. Most patients achieved composite clinical success (75.0%). An adverse effect occurred in 5.0% of the patients. DAP was prescribed the most for its ease of use/ability to facilitate discharge (40.0%) and/or for issues with alternative therapies (37.5%).

CONCLUSION

Most pediatric patients that received DAP demonstrated clinical success with a low incidence of adverse effects. Larger, real-world studies of DAP use are necessary to further assess clinical outcomes.

Accumulation of senescent cells in the adrenal gland induces hypersecretion of corticosterone via IL1β secretion

Aging progresses through the interaction of metabolic processes, including changes in the immune and endocrine systems. Glucocorticoids (GCs), which are regulated by the hypothalamic-pituitary-adrenal (HPA) axis, play an important role in regulating metabolism and immune responses. However, the age-related changes in the secretion mechanisms of GCs remain elusive. Here, we found that corticosterone (CORT) secretion follows a circadian rhythm in young mice, whereas it oversecreted throughout the day in aged mice >18 months old, resulting in the disappearance of diurnal variation. Furthermore, senescent cells progressively accumulated in the zF of the adrenal gland as mice aged beyond 18 months. This accumulation was accompanied by an increase in the number of Ad4BP/SF1 (SF1), a key transcription factor, strongly expressing cells (SF1-high positive: HP). Removal of senescent cells with senolytics, dasatinib, and quercetin resulted in the reduction of the number of SF1-HP cells and recovery of CORT diurnal oscillation in 24-month-old mice. Similarly, administration of a neutralizing antibody against IL1β, which was found to be strongly expressed in the adrenocortical cells of the zF, resulted in a marked decrease in SF1-HP cells and restoration of the CORT circadian rhythm. Our findings suggest that the disappearance of CORT diurnal oscillation is a characteristic of aging individuals and is caused by the secretion of IL1β, one of the SASPs, from senescent cells that accumulate in the zF of the adrenal cortex. These findings provide a novel insight into aging. Age-related hypersecretory GCs could be a potential therapeutic target for aging-related diseases.

Prevalence of hyponatremia among medically hospitalized patients and associated outcomes: a retrospective cohort study

BACKGROUND

Hyponatremia is a common electrolyte disturbance among hospitalized patients and is linked to increased mortality as well as poor outcomes.

OBJECTIVES

Study the prevalence of hyponatremia among medically admitted patients and the outcomes associated with hyponatremia.

DESIGN

Retrospective cohort.

SETTING

Medical ward at tertiary hospital setting.

PATIENTS AND METHODS

The study included adult (≥18 years) hospitalized patients in general medical wards. Three readings of serum sodium level were taken (initial sodium level, nadir during admission, and before discharge).

SAMPLE SIZE AND BASIS

The sample size of 350 was determined based on a presumed 35% incidence of hyponatremia among hospitalized patients, with a 5% error margin.

MAIN OUTCOME MEASURES

The prevalence of hyponatremia among medically hospitalized patients and association with health outcomes including length of hospital stay, inpatient mortality, 90-days readmission and 1-year mortality.

RESULTS

In this study, 736 patients met the inclusion criteria. Of these, 377 (51.2%) had hyponatremia on admission, increasing to 562 (76.35%) during hospitalization. Mild hyponatremia was observed in 49.6% (n=365), moderate in 13.6% (n=100), and severe in 13.2% (n=97). Severe hyponatremia patients were significantly older (P<.01), predominantly female (P=.014), and had lower serum magnesium and albumin levels (P<.01). Hypertension, ischemic heart disease, heart failure, and diabetes were more prevalent in severe hyponatremia cases (P<.01, P<.01, P=.045, P<.01, respectively). Hospital stays were significantly shorter for patients with normal sodium levels (P<.01). Patients with severe hyponatremia had a shorter time for first hospital readmission (HR=0.80, P<.01 [95% CI; 0.69-0.94]).

CONCLUSION

Hyponatremia was prevalent among medically hospitalized patients and more common among old patients, women, and patients with comorbidities. Hyponatremia was associated with increased length of stay in hospital and increased risk of 90-day re-admission.

LIMITATIONS

Single-centre design and retrospective nature.

International Nosocomial Infection Control Consortium (INICC) report of health care associated infections, data summary of 45 countries for 2015 to 2020, adult and pediatric units, device-associated module

BACKGROUND

Reporting on the International Nosocomial Infection Control Consortium study results from 2015 to 2020, conducted in 630 intensive care units across 123 cities in 45 countries spanning Africa, Asia, Eastern Europe, Latin America, and the Middle East.

METHODS

Prospective intensive care unit patient data collected via International Nosocomial Infection Control Consortium Surveillance Online System. Centers for Disease Control and Prevention/National Health Care Safety Network definitions applied for device-associated health care-associated infections (DA-HAI).

RESULTS

We gathered data from 204,770 patients, 1,480,620 patient days, 936,976 central line (CL)-days, 637,850 mechanical ventilators (MV)-days, and 1,005,589 urinary catheter (UC)-days. Our results showed 4,270 CL-associated bloodstream infections, 7,635 ventilator-associated pneumonia, and 3,005 UC-associated urinary tract infections. The combined rates of DA-HAIs were 7.28%, and 10.07 DA-HAIs per 1,000 patient days. CL-associated bloodstream infections occurred at 4.55 per 1,000 CL-days, ventilator-associated pneumonias at 11.96 per 1,000 MV-days, and UC-associated urinary tract infections at 2.91 per 1,000 UC days. In terms of resistance, Pseudomonas aeruginosa showed 50.73% resistance to imipenem, 44.99% to ceftazidime, 37.95% to ciprofloxacin, and 34.05% to amikacin. Meanwhile, Klebsiella spp had resistance rates of 48.29% to imipenem, 72.03% to ceftazidime, 61.78% to ciprofloxacin, and 40.32% to amikacin. Coagulase-negative Staphylococci and Staphylococcus aureus displayed oxacillin resistance in 81.33% and 53.83% of cases, respectively.

CONCLUSIONS

The high rates of DA-HAI and bacterial resistance emphasize the ongoing need for continued efforts to control them.

Surveillance of ventilator associated pneumonia in a network of indian hospitals using modified definitions: a pilot study

Background

Ventilator-associated pneumonia (VAP) is a major cause of morbidity and mortality in patients receiving mechanical ventilation in India. Surveillance of VAP is essential to implement data-based preventive measures. Implementation of ventilator-associated events (VAE) criteria for surveillance has major constraints for low resource settings, which can lead to significant underreporting. Surveillance of VAP using common protocols in a large network of hospitals would give meaningful estimates of the burden of VAP in low resource settings. This study leverages a previously established healthcare-associated infections (HAI) surveillance network to develop and test a modified VAP definition adjusted for Indian settings.

Methods

In this observational pilot study, thirteen hospitals from the existing HAI surveillance network were selected for developing and testing a modified VAP definition between February 2021 and April 2023. The criteria used for diagnosing VAP were adapted from the CDC's Pediatric VAP definition and modified to cater to the needs of Indian hospitals. Designated nurses recorded each VAP event in a case report form (CRF) and also collected denominator data. The data was entered into an indigenously developed database for validation and analysis. At the time of data analysis, a questionnaire was sent to sites to get feedback on the performance of the modified VAP definitions.

Findings

Out of 133,445 patient days and 40,533 ventilator days, 261 VAP events were recorded, with an overall VAP rate of 6.4 per 1000 ventilator days and a device utilization ratio (DUR) of 0.3. A total of 344 organisms were reported from the VAP events. Of these, Acinetobacter spp (29.6%, 102) was the most frequent, followed by Klebsiella spp (26.7%, 92). Isolates of Acinetobacter spp (98%) and Enterobacterales (85.5%) showed very high resistance against Carbapenem. Colistin resistance was observed in 6% of Enterobacterales and 3.2% of Acinetobacter spp.

Interpretation

Data from this pilot study needs to validated in the larger Indian HAI surveillance network so that it can help in wider implementation of this protocol in order to assess its applicability p VAP across India.

Funding

This work was supported by a grant received from the Indian Council of Medical Research (code I-1203).

Exploring the potential of the TCR repertoire as a tumor biomarker (Review)

T cells play an important role in adaptive immunity. Mature T cells specifically recognize antigens on major histocompatibility complex molecules through T-cell receptors (TCRs). As the TCR repertoire is highly diverse, its analysis is vital in the assessment of T cells. Advances in sequencing technology have provided convenient methods for further investigation of the TCR repertoire. In the present review, the TCR structure and the mechanisms by which TCRs function in tumor recognition are described. In addition, the potential value of the TCR repertoire in tumor diagnosis is reviewed. Furthermore, the role of the TCR repertoire in tumor immunotherapy is introduced, and the relationships between the TCR repertoire and the effects of different tumor immunotherapies are discussed. Based on the reviewed literature, it may be concluded that the TCR repertoire has the potential to serve as a biomarker for tumor prognosis. However, a wider range of cancer types and more diverse subjects require evaluation in future research to establish the TCR repertoire as a biomarker of tumor immunity.

Community awareness initiative about antimicrobial resistance: An educational intervention by medical undergraduates

BACKGROUND

Antimicrobial resistance (AMR) is a global problem and an important consequence of inappropriate use of antimicrobial agents (AMAs). Studies have observed that a lack of awareness of AMR among healthcare professionals as well as consumers results in the irrational use of AMAs, a significant driver of AMR.

MATERIALS AND METHODS

This educational intervention study was undertaken to assess community awareness regarding AMAs and AMR and to educate them. Ten volunteer students from II MBBS were made aware of AMR, its impact and measures to reduce resistance through a lecture by Pharmacology faculty. Students interacted with 220 family representatives in the community to assess their knowledge about AMAs and AMR using a 15-item pre-validated questionnaire. Charts, videos, and role-play were used to impart knowledge about the rational use of AMAs, AMR, and its consequences. Participants' understanding was ensured with feedback taken on Lickert scale.

RESULTS

Students interacted with the study participants and found that most were aware of the term 'antibiotic' (90.8%), but 67% were clueless regarding antibiotic resistance. The purpose of AMA use was not adequately known to 43% as they mentioned using these for diarrhea, viral fever, cough, cold, and sore throat. AMAs were purchased by 40% of participants as OTC medicine, whereas Azithromycin and Amoxicillin were the AMAs they could remember by name. The reasons for buying OTC antibiotics were the inconvenience of doctors' clinic timings, unaffordable consultation charges, and easy antibiotic availability. Students also learned about communication etiquette during this community interaction. This educational intervention proved helpful as the participants agreed that the unnecessary use of AMAs makes them ineffective and AMR is preventable by simple measures.

CONCLUSION

A multifactorial approach involving prescribers, regulatory Government authorities and general public is needed to control irrational use of antimicrobials. Timely interventions are necessary to increase the awareness of AMR in the community.

Drug-Drug Interactions in Nosocomial Infections: An Updated Review for Clinicians

Prevention, assessment, and identification of drug-drug interactions (DDIs) represent a challenge for healthcare professionals, especially in nosocomial settings. This narrative review aims to provide a thorough assessment of the most clinically significant DDIs for antibiotics used in healthcare-associated infections. Complex poly-pharmaceutical regimens, targeting multiple pathogens or targeting one pathogen in the presence of another comorbidity, have an increased predisposition to result in life-threatening DDIs. Recognising, assessing, and limiting DDIs in nosocomial infections offers promising opportunities for improving health outcomes. The objective of this review is to provide clinicians with practical advice to prevent or mitigate DDIs, with the aim of increasing the safety and effectiveness of therapy. DDI management is of significant importance for individualising therapy according to the patient, disease status, and associated comorbidities.