Accounting for variation in and overuse of antibiotics among humans

A randomized, double-blind, placebo-controlled study on immune improvement effects of ethanolic extract of Echinacea purpurea (L.) Moench in Korean adults

Echinacea purpurea (L.) Moench (EP), a medicinal plant native to North America, is now cultivated in various regions including Europe. With increasing popularity of Echinacea in Korea recently, a human clinical trial was conducted to evaluate immune-enhancing efficacy and safety of EP 60% ethanolic extract (EPE) in Koreans. Eighty volunteers were recruited for this randomized, double-blind, placebo-controlled clinical trial. They were randomly divided into two groups and given either a daily dose of 200 mg of EPE or a placebo. All participants underwent testing for Natural Killer (NK) cell cytotoxic activity, serum cytokine levels (IL-2, IL-6, IL-10, IL-12, IFN-γ, TNF-α), Wisconsin Upper Respiratory Symptom Survey-21 (WURSS-21), and Multidimensional Fatigue Scale (MFS) during this study to assess changes in outcomes. After 8 weeks of EPE consumption, a significant increase in NK cell cytotoxic activity compared to the placebo was observed. Additionally, serum cytokine levels of IL-2, IFN-γ, and TNF-α also significantly increased following EPE consumption. However, no significant changes were observed in WURSS-21 and MFS before and after EPE consumption. Throughout the 8-week study period, no adverse reactions were reported in relation to EPE consumption, and there were no clinically significant changes in diagnostic laboratory tests or vital signs in the EPE group. These results indicate that consumption of EPE could lead to immune improvement without any adverse effects. This clinical trial was the first to demonstrate beneficial effects of EPE consumption on immunity in Korean adults.

Improving Antibiotic Overuse in Primary Care: A Multimodal Quality Improvement Project

PURPOSE

Antibiotic overuse has increased over time related to provider knowledge gaps about best practices, provider perception of patient expectations on receiving an antibiotic, possible pressure to see patients in a timely fashion, and concerns about decreased patient satisfaction when an antibiotic is not prescribed. The Centers for Disease Control and Prevention estimates that up to 30% of antibiotics are inappropriately prescribed in the outpatient setting.

APPROACH

This quality improvement project consisted of a multimodal approach to decrease inappropriate antibiotic prescribing for viral upper respiratory infections (URIs) by using provider education, passive patient education, and clinical decision support tools based on Centers for Disease Control and Prevention recommendations and the Be Antibiotic Aware tool.

OUTCOMES

Following implementation, there was an 11% decrease in viral URI antibiotic prescribing, from a rate of 29.33% to 18.33% following the multimodal implementation.

CONCLUSION

The use of evidence-based education and treatment guidelines was found to decrease inappropriate antibiotic prescribing for patients diagnosed with viral URIs.

Effects of antibiotics ceftriaxone and levofloxacin on the growth of Protophormia terraenovae (Diptera: Calliphoridae)

Protophormia terraenovae is a colonizer of decomposing bodies and is known to cause pre-mortem myiasis as the female flies lay eggs in uncleaned wounds. In this study the effects of different concentrations of antibiotics levofloxacin and ceftriaxone on maggot development, weight, length, and mortality were examined. The maggot length and weight were significantly increased by therapeutical doses of levofloxacin and ceftriaxone. The maggot development time was significantly decreased in every levofloxacin treatment compared to the control. The time to start pupation was significantly increased in the control compared to the antibiotic treatments. Levofloxacin significantly increased the survivability of the maggots. Every levofloxacin treatment significantly improved the rearing conditions for the maggots. Reaching the third instar was delayed by 24 h in the control compared to the Levo 3.57 treatment. The Pupation in the control was delayed by an average of 48 h compared to the Levo 3.57 treatment. The significantly reduced development time of the maggots in the antibiotic treatments might lead to an overestimation of the post-mortem interval and therefore an incorrect time of death determination. The improved rearing conditions may be an indication of the potential of a combined application of antibiotics and maggot therapy.

Tetracycline and sulfadiazine toxicity in human liver cells Huh-7

As typical antibiotics, tetracycline (TC) and sulfadiazine (SDZ) enter the human body through the food chain. Therefore, it is necessary to understand their individual and combined toxicity. In this study, the effects of TC, SDZ, and their mixture on cell viability, cell membrane damage, liver cell damage, and oxidative damage were evaluated in in vitro assays with human liver cells Huh-7. The results showed cytotoxicity of TC, SDZ, and their mixture, which induced oxidative stress and caused membrane and cell damage. The effect of antibiotics on Huh-7 cells increased with increasing concentration, except for lactate dehydrogenase (LDH) activity that commonly showed a threshold concentration response and cell viability, which commonly showed a biphasic trend, suggesting the possibility of hormetic responses where proper doses are included. The toxicity of TC was commonly higher than that of SDZ when applied at the same concentration. These findings shed light on the individual and joint effects of these major antibiotics on liver cells, providing a scientific basis for the evaluation of antibiotic toxicity and associated risks.

Effects of antibiotics ceftriaxone and levofloxacin on the growth of Lucilia sericata (Diptera: Calliphoridae)

Lucilia sericata is one of the most studied species in forensic entomology due to its widespread distribution, forensic importance as well as medical use. The growth and development stage of maggots is often used to determine the post-mortem interval in forensic cases. L. sericata can cause myiasis in humans who are not able to maintain personal hygiene due to age or medical condition and can therefore be used to determine the time period of neglect. The influence of the temperature on the maggot development has been examined in various studies. Different examinations on the effects of toxic substances on the maggot development and survival have been conducted in order to test the influence and resulting deviations. In this study, the effects of different therapeutical doses of the antibiotics ceftriaxone and levofloxacin were examined on L. sericata in order to determine and compare deviations in maggot development and survival. The used antibiotics did not significantly influence the maggot weight and length. A significant delay in the time of pupation has been determined in the treatments with high concentrations of levofloxacin. The mortality was significantly increased in all treatments with antibiotics compared to the control, whereby the survivability of all treatments remained over 80%. Because of the high doses needed to produce an effect, we concluded that an overestimation of the post-mortem interval is unlikely but higher antibiotic concentrations or possible interactions with other medications could increase the maggot development time.

Biologic Mechanisms of Macrophage Phenotypes Responding to Infection and the Novel Therapies to Moderate Inflammation

Pro-inflammatory and anti-inflammatory types are the main phenotypes of the macrophage, which are commonly notified as M1 and M2, respectively. The alteration of macrophage phenotypes and the progression of inflammation are intimately associated; both phenotypes usually coexist throughout the whole inflammation stage, involving the transduction of intracellular signals and the secretion of extracellular cytokines. This paper aims to address the interaction of macrophages and surrounding cells and tissues with inflammation-related diseases and clarify the crosstalk of signal pathways relevant to the phenotypic metamorphosis of macrophages. On these bases, some novel therapeutic methods are proposed for regulating inflammation through monitoring the transition of macrophage phenotypes so as to prevent the negative effects of antibiotic drugs utilized in the long term in the clinic. This information will be quite beneficial for the diagnosis and treatment of inflammation-related diseases like pneumonia and other disorders involving macrophages.

A Supplement with Ribes Nigrum, Boswellia Serrata, Bromelain and Vitamin D to Stop Local Inflammation in Chronic Sinusitis: A Case-Control Study

Although chronic sinusitis widely affects the adult population, the treatments currently used did not always satisfactorily solve the symptoms. Traditional therapy with steroids and antibiotics presents risks and benefits and the new drugs, i.e., monoclonal antibody, are valid solutions despite being quite expensive. Natural molecules could be a valid treatment that combines good efficacy and low price. We conducted a case -control study to evaluate the benefit of an oral supplement with Ribes nigrum, Boswellia serrata, Bromelain and Vitamin D on chronic sinusitis symptoms. 60 patients were randomly assigned to one of the three groups: control using nasal steroids only, treatment 1 using nasal steroid and 1 dose of the oral supplement for 30 days and treatment 2 in which patients used nasal steroid and two oral supplement doses daily for 15 days. Conditions of the nasal mucosa and a blood sample (WBC, IgE and CRP) were analyzed at T0, T1 (15 days after treatment) and T2 (30 days after treatment. Patients treated with the supplement improved their nasal findings (hyperemia of mucosa and rhinorrhea) with statistically significant differences from the control. Our preliminary data suggest that the addition of supplement containing Ribes nigrum, Boswellia serrata, Vitamin D and Bromelain to the traditional local therapy (nasal spray with cortisone) can be a supporting therapy to modulate the local inflammation in the nose in patients affected by chronic sinusitis.

Digestate from Agricultural Biogas Plants as a Reservoir of Antimicrobials and Antibiotic Resistance Genes-Implications for the Environment

Antimicrobials and antibiotic resistance genes (ARGs) in substrates processed during anaerobic digestion in agricultural biogas plants (BPs) can reach the digestate (_D), which is used as fertilizer. Antimicrobials and ARGs can be transferred to agricultural land, which increases their concentrations in the environment. The concentrations of 13 antibiotics in digestate samples from biogas plants (BPs) were investigated in this study. The abundance of ARGs encoding resistance to beta-lactams, tetracyclines, sulfonamides, fluoroquinolones, macrolide-lincosamide-streptogramin antibiotics, and the integrase genes were determined in the analyzed samples. The presence of cadmium, lead, nickel, chromium, zinc, and mercury was also examined. Antimicrobials were not eliminated during anaerobic digestion. Their concentrations differed in digestates obtained from different substrates and in liquid and solid fractions (ranging from 62.8 ng/g clarithromycin in the solid fraction of sewage sludge digestate to 1555.9 ng/L doxycycline in the liquid fraction of cattle manure digestate). Digestates obtained from plant-based substrates were characterized by high concentrations of ARGs (ranging from 5.73 × 10² copies/g_DcfxA to 2.98 × 10⁹ copies/g_Dsul1). The samples also contained mercury (0.5 mg/kg dry mass (dm)) and zinc (830 mg/kg dm). The results confirmed that digestate is a reservoir of ARGs (5.73 × 10² to 8.89 × 10¹⁰ copies/g_D) and heavy metals (HMs). In addition, high concentrations of integrase genes (10⁵ to 10⁷ copies/g_D) in the samples indicate that mobile genetic elements may be involved in the spread of antibiotic resistance. The study suggested that the risk of soil contamination with antibiotics, HMs, and ARGs is high in farms where digestate is used as fertilizer.

Antibiotics in the pathogenesis of diabetes and inflammatory diseases of the gastrointestinal tract

Antibiotic use is increasing worldwide. However, the use of antibiotics is clearly associated with changes in gut microbiome composition and function, and perturbations have been identified as potential environmental risk factors for chronic inflammatory disorders of the gastrointestinal tract. In this Review, we examine the association between the use of antibiotics and the onset and development of both type 1 and type 2 diabetes, inflammatory bowel disease, including ulcerative colitis and Crohn's disease, as well as coeliac disease and eosinophilic oesophagitis. We discuss the key findings of epidemiological studies, provide mechanistic insights into the pathways by which the gut microbiota might contribute to these diseases, and assess clinical trials investigating the effects of antibiotics. Such studies indicate that antibiotic exposures, varying in type, timing and dosage, could explain differences in disease risk. There seems to be a critical window in early life in which perturbation of the microbiome has a substantial effect on disease development. Identifying the antibiotic-perturbed gut microbiota as a factor that contributes to the pathophysiology of these inflammatory disorders might stimulate new approaches to prevention, diagnosis and treatment.

Das gute Leben heute und morgen: Antibiotikaresistente Keime als Nachhaltigkeitsproblem in der Medizin

In einem ersten Kapitel wird am Beispiel der Entstehung von Antibiotikaresistenzen gezeigt, dass es in der Medizin spezifische Nachhaltigkeitsprobleme gibt, die letztlich zu einer Beeinträchtigung der Fähigkeit zukünftiger Patient:innen führen können, ihre Gesundheitsbedürfnisse zu befriedigen und ein gutes Leben zu leben. Nachdem in einem zweiten Kapitel auf den Nachhaltigkeitsbegriff genauer eingegangen wurde, wird im dritten Teil erläutert, dass und warum die Möglichkeit zur Befriedigung elementarer Gesundheitsbedürfnisse z. B. im Rahmen eines Capability-Ansatzes zu Recht als eine Bedingung für ein gutes Leben gilt. Das Konzept der Nachhaltigkeit der Vereinten Nationen fordert, die Ansprüche auf ein gutes Leben zukünftiger Patient:innen angemessen zu berücksichtigen. Im vierten Teil wird dargestellt, wie Nachhaltigkeitsforderungen im klinischen Kontext zu einem Nachhaltigkeits-Dilemma führen können, und geklärt, auf welche Weise mit diesem Dilemma umgegangen werden kann.

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China

Objectives

This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs).

Methods

A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute.

Results

In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001).

Conclusion

Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

Antibiotic-resistant Campylobacter coli and Campylobacter jejuni in commercial and smallholder farm animals in the Asante Akim North Municipality of Ghana

Worldwide, farm animals, in particular poultry, are an important reservoir for Campylobacter spp. However, information on Campylobacter colonization in farm animals in Africa is scarce. Hence, this cross-sectional study determined antibiotic-resistant Campylobacter from both commercial and smallholder farm animals in the Asante Akim North Municipality of Ghana. Fecal samples from poultry and livestock kept by commercial and smallholder farms were collected and analyzed using standard microbiological methods. The overall Campylobacter frequency was 20.3% (n/N = 322/1,585), and frequencies detected were similarly high in isolates from commercial (21.0%, n/N = 169/805) and smallholder (19.6%, n/N = 153/780) farms. Species isolated were C. coli (67.7%, n/N = 218/322) and C. jejuni (32.3%, n/N = 104/322). However, the frequency of C. coli was 2.1 (95% CI: 1.8-2.5) times higher than what was found for C. jejuni. Campylobacter frequencies in the rainy season was 22.2% (n/N = 258/1,160) and 15.1% (n/N = 64/425) in the dry season (prevalence ratio = 1.48, 95% CI: 1.2-1.9). About 1.7% (n/N = 6/322) of the Campylobacter isolates, all from smallholder farms, were susceptible to all antibiotics tested. Multidrug resistance was observed for 4.7% (n/N = 15/322) of the Campylobacter isolates, of which 93.3% (n/N = 14/15) occurred in isolates from commercial farms. This study highlights the need for the implementation of control programs, in commercial farming but also at the smallholder farm level, to formulate clear guidelines aimed at decreasing Campylobacter contamination of meat products and reducing the use of antibiotics in the farming sector.

Association of area-level education with the regional growth trajectories of rates of antibacterial dispensing to patients under 3 years in Norway: a longitudinal retrospective study

OBJECTIVE

To examine the association between area-level education and the local growth trajectories in antibacterial dispensing rates in Norwegian municipalities among children under 3 years old.

DESIGN

Retrospective, longitudinal study using individual primary care prescription data from the Norwegian Prescription Database for the period 2006-2016. Data were collected on the date of dispensing, the type and amount of antibiotic, the patient's age, sex and municipality of residence and linked to municipality-level statistics on education available from Statistics Norway. We used multilevel growth curve modelling, with a linear trend variable modelled as a random effect and a cross-level interaction between linear trends and the proportion of the population in the municipality having received a university or college education.

SETTING

The local government level in Norway. The sample includes all municipalities over the study period.

OUTCOME MEASURE

Number of dispensed antibacterial prescriptions per 100 children in individual primary care by municipality and year.

RESULTS

We identified a significant negative linear trend in the square root of the dispensing rate for children under 3 years old during the period. This trend varied between municipalities. A negative cross-level interaction term between population education levels and random trends showed that municipalities with an average level of population education saw a reduction in their square root dispensing rates of -0.053 (95% CI -0.066 to -0.039) prescriptions per 100 children. Each additional percentage point in population education contributed a further -0.0034 (95% CI -0.006 to -0.001) reduction to the square root dispensing rate.

CONCLUSIONS

Municipalities in which a larger proportion of the local population have high educational achievements have been more successful in reducing antibacterial dispensing rates in children under 3 years old. Adopting area-level strategies and addressing local community disadvantages may help to optimise practices and prescribing patterns across local communities.

Pathogen-Specific Bactericidal Method Mediated by Conjugative Delivery of CRISPR-Cas13a Targeting Bacterial Endogenous Transcripts

The emergence of antibiotic-resistant bacteria threatens public health, and the use of broad-spectrum antibiotics often leads to unintended consequences, including disturbing the beneficial gut microbiota and resulting in secondary diseases. Therefore, developing a novel strategy that specifically kills pathogens without affecting the residential microbiota is desirable and urgently needed. Here, we report the development of a precise bactericidal system by taking advantage of CRISPR-Cas13a targeting endogenous transcripts of Salmonella enterica serovar Typhimurium delivered through a conjugative vehicle. In vitro, the CRISPR-Cas13a system exhibited specific killing, growth inhibition, and clearance of S. Typhimurium in mixed microbial flora. In a mouse infection model, the CRISPR-Cas13a system, when delivered by a donor Escherichia coli strain, significantly reduced S. Typhimurium colonization in the intestinal tract. Overall, the results demonstrate the feasibility and efficacy of the designed CRISPR-Cas13a system in selective killing of pathogens and broaden the utility of conjugation-based delivery of bactericidal approaches.

IMPORTANCE Antibiotics with broad-spectrum activities are known to disturb both pathogens and beneficial gut microbiota and cause many undesired side effects, prompting increased interest in developing therapies that specifically eliminate pathogenic bacteria without damaging gut resident flora. To achieve this goal, we developed a strategy utilizing bacterial conjugation to deliver CRISPR-Cas13a programmed to specifically kill S. Typhimurium. This system produced pathogen-specific killing based on CRISPR RNA (crRNAs) targeting endogenous transcripts in pathogens and was shown to be effective in both in vitro and in vivo experiments. Additionally, the system can be readily delivered by conjugation and is adaptable for targeting different pathogens. With further optimization and improvement, the system has the potential to be used for biotherapy and microbial community modification.

From idioms of distress, concern, and care to moral distress leading to moral injury in the time of Covid

In this invited commentary on the thematic issue of Transcultural Psychiatry on idioms of distress, concern, and care, I provide a brief overview of how my research agenda evolved over the years while conducting community and clinic-based research in South and Southeast Asia as well as North America. I then suggest areas where future research on idioms of distress, concern, care, and resilience will be needed among different demographics given social change and shifts in how we communicate face to face and in virtual reality, the impact of medicalization, pharmaceuticalization and bracket creep, changes in indigenous healing systems, and hybridization. I further call attention to the importance of conducting idioms guided research in occupational settings. Toward this end I highlight the moral distress health care workers in the U.S. have experienced during the Covid-19 pandemic and point out the importance of differentiating individual burnout from moral injury related to structural distress. I conclude by discussing the general utility of an idioms of distress perspective in the practice of cultural psychiatry and suggest that this perspective needs to be included in the training of all practitioners regardless of the system of medicine they practice. Doing so may enable the formation of mental health communities of practice in contexts where there are pluralistic health care arenas.

Sustainable adsorptive removal of antibiotics from aqueous streams using Fe3O4-functionalized MIL101(Fe) chitosan composite beads

In this study, we synthesized recyclable Fe₃O₄-functionalized MIL101(Fe) chitosan composite beads for the removal of tetracycline (TC), doxycycline (DC) and ciprofloxacin (CFX) antibiotics from aqueous streams. More than 99% removal efficiency for each antibiotic was achieved at optimum pH, dosage, concentration and contact time. Langmuir adsorption isotherms and pseudo-second-ord er kinetic model were suitable with correlation coefficient values close to 1 for all the antibiotics. Adsorption capacities of 45.33, 33.20 and 31.30 mg g^-1 for TC, DC and CFX, respectively, were reported by the synthesized Fe₃O₄-functionalized MIL101(Fe) chitosan composite beads. The Fe₃O₄-functionalized MIL101(Fe) chitosan composite beads were also tested for their regeneration ability, and a remarkable regeneration ability over up to 5 cycles was observed. The adsorption of TC, DC and CFX on the surface of Fe₃O₄-functionalized MIL101(Fe) chitosan composite beads was governed by the π-π interaction, H-bonding and electrostatic interaction between the antibiotics and adsorbent due to protonation, deprotonation and cation exchange in the aqueous solution. These results showed a good prospect for applying the reported beads towards removing antibiotics from pharmaceutical industry wastewater.

Oral antibiotic use and early-onset colorectal cancer: findings from a case-control study using a national clinical database

BACKGROUND

Antibiotic-induced gut dysbiosis has been associated with colorectal cancer (CRC) in older adults. This study will investigate whether an association exists between antibiotic usage and early-onset colorectal cancer (CRC), and also evaluate this in later-onset CRC for comparison.

METHODS

A case-control study was conducted using primary care data from 1999-2011. Analysis were conducted separately in early-onset CRC cases (diagnosed < 50 years) and later-onset cases (diagnosed ≥ 50 years). Conditional logistic regression was used to calculate odds ratios and 95% confidence intervals (CI) for the associations between antibiotic exposure and CRC by tumour location, adjusting for comorbidities.

RESULTS

Seven thousands nine hundred and three CRC cases (445 aged <50 years) and 30,418 controls were identified. Antibiotic consumption was associated with colon cancer in both age-groups, particularly in the early-onset CRC cohort (<50 years: adjusted Odds Ratio (ORadj) 1.49 (95% CI 1.07, 2.07), p = 0·018; ≥50 years (ORadj (95% CI) 1.09 (1.01, 1.18), p = 0·029). Antibiotics were not associated with rectal cancer (<50 years: ORadj (95% CI) 1.17 (0.75, 1.84), p = 0.493; ≥50 years: ORadj (95% CI) 1.07 (0.96, 1.19), p = 0.238).

CONCLUSION

Our findings suggest antibiotics may have a role in colon tumour formation across all age-groups.

Effects of antibiotics ceftriaxone and levofloxacin on the growth of Calliphora vomitoria L. (Diptera: Calliphoridae) and effects on the determination of the post-mortem interval

The determination of the post-mortem interval (PMI) is one of the main tasks of forensic entomology, where growth and stages of development of arthropods are used for PMI determination. It is well acknowledged that maggot development is significantly influenced by temperature. Attention has also been paid to the microbial populations of the cadaver, because toxic substances contained in the substrate can influence the microorganisms and affect arthropods growth and development. However, little is known about the influence of antibiotics taken during lifetime of a person on insect development after that persons death. The aim of this study was to test the hypothesis that the antibiotics ceftriaxone and levofloxacin cause inhibition of growth and delay of pupation of the blow fly Calliphora vomitoria, which would then lead to an incorrect determination of the post-mortem interval in forensic cases. It was found that maggot development was delayed by levofloxacin mixed in minced pork, where a mixture of both antibiotics increased this effect. The maggot growth in the samples with ceftriaxone was not delayed. Pupation was delayed in treatments with a mixture of both antibiotics. The mortality was reduced by separate or combined application of ceftriaxone and levofloxacin, which we attribute to a bactericidal effect of the antibiotics on maggot pathogens. Depending on the concentration of the antibiotics, an underestimation of the post-mortem interval between 24 and 48 h could be suspected. We conclude that antibiotics need to be considered if instar stages are to be used to determine the PMI and that some antibiotics may improve the breeding conditions of maggots.