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

How did the COVID-19 pandemic affect antibiotic consumption within humanitarian emergencies? Results from five humanitarian contexts

Introduction

Both high- and low-income countries reported increased antibiotic consumption among COVID-19 patients during the first months of the pandemic. To date, however, no studies have examined changes in antibiotic consumption during the COVID-19 pandemic within humanitarian emergency contexts.

Method

Data was collected by Médecins Sans Frontières (MSF) for the years 2018-2021 across the following humanitarian settings: Afghanistan (Lashkar Gah), Bangladesh (Kutupalong), the Democratic Republic of Congo (Mweso and Baraka), and South Sudan (Bentiu). Inpatient and outpatient antibiotic consumption was calculated as Daily Defined Dose (DDD) per 1000 inhabitants per day, as per the World Health Organisation's (WHO) Collaborating Centre for Drug Statistics Methodology. Interrupted time series (ITS) analysis, using an autoregressive integrated moving average (ARIMA) model was used to analyse retrospective monthly antibiotic consumption. The impact of COVID-19 pandemic was evaluated as total antibiotic consumption and according to WHO Access, Watch, Reserve (AWaRe) group classifications within each humanitarian setting.

Results

The COVID-19 pandemic had no statistically significant impact on total antibiotic consumption in South Sudan (Bentiu) and Bangladesh (Kutupalong). Similarly, the pandemic had no impact on total antibiotic consumption in DR Congo (Baraka), despite an initial 0.27% (estimate=.274, p-value=0.006) increase in March 2020 driven by Access group antibiotics. Meanwhile, total antibiotic consumption in DR Congo (Mweso) and Afghanistan (Lashkar Gah) declined by 0.74% (estimate = -.744, p = 0.003) and 0.26% (estimate = -.26, p < 0.001), respectively with the COVID-19 pandemic.

Conclusion

Further studies are required to investigate what may have contributed to these results.

Knowledge, Attitudes, and Practices toward Antimicrobial Resistance among Young Italian Nurses and Students: A Multicenter, Cross-Sectional Study

Background: Nurses play a pivotal role in combating antimicrobial resistance (AMR). However, the success of local and national AMR containment efforts hinges on the knowledge, attitude, and practice (KAP) of nursing staff and undergraduate students. Objectives: This study aims to explore the determinants of nurses' KAP regarding AMR, offering insights to control the emergence and spread of drug-resistant pathogens. Methods: This cross-sectional, multicenter survey involving Italian nurses, nursing students, and healthcare professionals was conducted administering an anonymous online questionnaire focusing on AMR. The median score of 12 was taken as the cutoff for "good KAP." The association between study variables and good KAP was assessed using chi-square or t-tests, followed by multivariable logistic regression analysis for statistically significant (p < 0.05) variables. Findings: Among 848 participants, 61.9% (n = 525) were students, and 39.6% (n = 336) scored as having "low KAP." High KAP was associated with being female and studying AMR independently. Conversely, living in southern Italy and receiving AMR training from pharmaceutical companies were associated with low KAP. Conclusions: Among Italian nurses, AMR awareness relies on those who have studied AMR as self-taught and is affected by gender and region. Italian universities lack in lectures on AMR management, and much needs to be done to improve awareness of antimicrobial stewardship among nonmedical health workers.

Multiple impacts of the COVID-19 pandemic and antimicrobial stewardship on antimicrobial resistance in nosocomial infections: an interrupted time series analysis

Objectives

The emergency response to the COVID-19 pandemic may disrupt hospital management activities of antimicrobial resistance (AMR). This study aimed to determine the changing AMR trend over the period in China when stringent COVID-19 response measures were implemented.

Methods

This retrospective study was conducted in a designated hospital for COVID-19 patients in Guangzhou, China from April 2018 to September 2021. The prevalence of 13 antimicrobial-resistant bacteria was compared before and after the COVID-19 responses through Chi-square tests. Interrupted time series (ITS) models on the weekly prevalence of AMR were established to determine the changing trend. Controlled ITS models were performed to compare the differences between subgroups.

Results

A total of 10,134 isolates over 1,265 days were collected. And antimicrobial-resistant strains presented in 38.6% of the testing isolates. The weekly AMR prevalence decreased by 0.29 percentage point (95% CI [0.05-0.80]) after antimicrobial stewardship (AMS) policy, despite an increase in the prevalence of penicillin-resistant Streptococcus pneumoniae (from 0/43 to 15/43, p < 0.001), carbapenem-resistant Escherichia coli (from 20/1254 to 41/1184, p = 0.005), and carbapenem-resistant Klebsiella pneumoniae (from 93/889 to 114/828, p = 0.042). And the changing trend did not vary by gender (male vs. female), age (<65 vs. ≥65 years), service setting (outpatient vs. inpatient), care unit (ICU vs. non-ICU), the primary site of infection (Lung vs. others), and Gram type of bacteria (positive vs. negative).

Conclusion

The response to COVID-19 did not lead to an increase in overall AMR; however, it appears that management strategy on the prudent use of antimicrobials likely contributed to a sizable long-term drop. The frequency of several multidrug-resistant bacteria continues to increase after the COVID-19 epidemic. It is crucial to continue to monitor AMR when COVID-19 cases have surged in China after the relaxation of restriction measures.

Global antimicrobial resistance and antibiotic use in COVID-19 patients within health facilities: A systematic review and meta-analysis of aggregated participant data

OBJECTIVES

The COVID-19 pandemic has posed a significant threat to the global healthcare system, presenting a major challenge to antimicrobial stewardship worldwide. This study aimed to provide a comprehensive and up-to-date picture of global antimicrobial resistance (AMR) and antibiotic use in COVID-19 patients.

METHODS

We conducted a systematic review to determine the prevalence of AMR and antibiotic usage among COVID-19 patients receiving treatment in healthcare facilities. Our search encompassed the PubMed, Web of Science, Embase, and Scopus databases, spanning studies published from December 2019 to May 2023. We utilized random-effects meta-analysis to assess the prevalence of multidrug-resistant organisms (MDROs) and antibiotic use in COVID-19 patients, aligning with both the WHO's priority list of MDROs and the AWaRe list of antibiotic products. Estimates were stratified by region, country, and country income. Meta-regression models were established to identify predictors of MDRO prevalence and antibiotic use in COVID-19 patients. The study protocol was registered with PROSPERO (CRD 42023449396).

RESULTS

Among the 11,050 studies screened, 173 were included in the review, encompassing a total of 892,312 COVID-19 patients. MDROs were observed in 42.9% (95% CI 31.1-54.5%, I2 = 99.90%) of COVID-19 patients: 41.0% (95% CI 35.5-46.6%) for carbapenem-resistant organisms (CRO), 19.9% (95% CI 13.4-27.2%) for methicillin-resistant Staphylococcus aureus (MRSA), 24.9% (95% CI 16.7-34.1%) for extended-spectrum beta-lactamase-producing organisms (ESBL), and 22.9% (95% CI 13.0-34.5%) for vancomycin-resistant Enterococcus species (VRE), respectively. Overall, 76.2% (95% CI 69.5-82.9%, I2 = 99.99%) of COVID-19 patients were treated with antibiotics: 29.6% (95% CI 26.0-33.4%) with "Watch" antibiotics, 22.4% (95% CI 18.0-26.7%) with "Reserve" antibiotics, and 16.5% (95% CI 13.3-19.7%) with "Access" antibiotics. The MDRO prevalence and antibiotic use were significantly higher in low- and middle-income countries than in high-income countries, with the lowest proportion of antibiotic use (60.1% (95% CI 52.1-68.0%)) and MDRO prevalence (29.1% (95% CI 21.8-36.4%)) in North America, the highest MDRO prevalence in the Middle East and North Africa (63.9% (95% CI 46.6-81.2%)), and the highest proportion of antibiotic use in South Asia (92.7% (95% CI 90.4-95.0%)). The meta-regression identified antibiotic use and ICU admission as a significant predictor of higher prevalence of MDROs in COVID-19 patients.

CONCLUSIONS

This systematic review offers a comprehensive and current assessment of MDRO prevalence and antibiotic use among COVID-19 patients in healthcare facilities. It underscores the formidable challenge facing global efforts to prevent and control AMR amidst the backdrop of the COVID-19 pandemic. These findings serve as a crucial warning to policymakers, highlighting the urgent need to enhance antimicrobial stewardship strategies to mitigate the risks associated with future pandemics.

The "COVID effect" in culture-based clinical microbiology: Changes induced by COVID-19 pandemic in a Hungarian tertiary care center

BACKGROUND

The presence of bacterial and fungal coinfections plays an important role in the mortality of patients with coronavirus 2019 (COVID-19). We compared data from the 3 years before and 3 years after the COVID-19 pandemic outbreak to evaluate its effect on the traits of bacterial and fungal diseases.

METHODS

We retrospectively collected and analyzed data on positive respiratory tract samples (n = 13,133 samples from 7717 patients) and blood cultures (n = 23,652 from 9653 patients) between 2017 and 2022 from the Clinical Center of the University of Szeged, Hungary. We also evaluated antimicrobial susceptibility test results derived from 169,020 respiratory samples and 549,729 blood cultures to gain insight into changes in antimicrobial resistance.

RESULTS

The most common respiratory pathogen in the pre-COVID era was Pseudomonas aeruginosa, whereas Candida albicans was the most frequent during the pandemic. The number of respiratory isolates of Acinetobacter baumannii was also markedly increased. In blood cultures, Staphylococcus epidermidis, Escherichia coli, and S. aureus were dominant during the study period, and A. baumannii was widespread in blood cultures during the pandemic years. Resistance to ofloxacin, penicillin, piperacillin-tazobactam, ceftazidime, cefepime, imipenem, ceftolozane-tazobactam, and itraconazole increased significantly in the COVID era.

CONCLUSIONS

During the COVID-19 pandemic, there were changes in the prevalence of respiratory and blood culture pathogens at the Clinical Center of the University of Szeged. C. albicans became the predominant respiratory pathogen, and the number of A. baumannii isolates increased dramatically. Additionally, antimicrobial resistance notably increased during this period.

Impact of the COVID-19 pandemic on the utilisation and quality of antibiotic use in the Scottish primary care setting: a population-based segmented interrupted time-series analysis

BACKGROUND

Inappropriate use of antibiotics is expected to increase during the COVID-19 pandemic, but there are limited data on COVID-19's long-term impact. We assessed the impact of COVID-19 on the quantity and quality of antibiotic use in Scotland.

RESEARCH DESIGN AND METHODS

A segmented interrupted time series was applied to monthly dispensed antibiotics using prescription cost analysis data from March/2019 to March/2023. Antibiotic use was quantified using the number of items dispensed/1000 inhabitants (TIDs) and defined daily dose/1000 inhabitants/day (DIDs). The quality of antibiotic use was assessed using key quality indicators including the WHO AWaRe classification, proportion of broad-spectrum and "4C"-antibiotics.

RESULTS

Overall, for all antibiotics, there was a non-significant increase in TIDs and DIDs before the first lockdown (March/2020) (β1), but a decline in the level immediately after the first (β2) and second lockdowns (β4) (November/2020), albeit non-significant. However, a significant increase in the time trend after the second lockdown (β5) for all antibiotic classes was observed. COVID-19 had no negative impact on AWaRe utilisation, with the proportion of all antibiotics from the Access group increasing from 76% in March/2019 to 90% in March/2023. The proportion of "4C" antibiotic reduced significantly after the second lockdown.

CONCLUSIONS

Neither the utilisation nor the quality of total antibiotic use appeared to have been significantly affected by COVID-19.

<I>Helicobacter pylori</I> infection and dermatological diseases

Helicobacter pylori (H. Pylori), microaerophilic spiral-shaped Gram-negative bacteria which colonize the gastric mucosa of human population, is the leading causal factor in the development of a whole range of diseases of the gastroduodenal region (chronic gastritis, gastric and duodenal ulcer disease, MALT lymphoma and gastric adenocarcinoma). Since the discovery of H. pylori infection and the identification of its leading role in the development of a range of gastroenterological diseases, researchers have begun to actively study the potential trigger significance of this pathogen in the development of extragastric pathology. At the epidemiological level, H. pylori infection has been shown to be frequently associated with skin diseases such as rosacea, acne, chronic urticaria and psoriasis, although the clinical significance of these associations remains clouded. In fact, recent meta-analytic studies (2019–2024) demonstrate an increased risk of developing the above diseases in H. pylori-infected individuals with odds ratios ranging from 1.19 to 3.00. On the other hand, not all studies have showed that eradication therapy of this microorganism helps reduce the clinical severity of symptoms of skin diseases, which is hypothetically explained only by the trigger role of infection within the complex pathogenesis. In a modern light, such associations can be viewed in terms of pathogenetic findings through the implementation of the syndrome of increased epithelial permeability (SIEP). The chronic gastritis caused by H. pylori infection is believed to lead to increased permeability of the epithelial lining of the stomach, as well as the walls of the mucosal vessels and a higher exposure of bacterial and nutritional antigens in the systemic circulation, which can induce both local release of inflammatory mediators in tissues and systemic immunological reactions (autoimmune and inflammatory processes, formation of molecular mimicry-induced immune complexes and cross-reactive antibodies).

The Trend of Antibiotic Consumption After the COVID-19 Pandemic: Approach to Future Outbreaks

Background

Earlier reports suggested high rates of antibiotic utilization among COVID-19 patients despite the lack of direct evidence of their activity against viral pathogens. Different trends in antibiotic consumption during 2020 compared to 2019 have been reported.

Purpose

The objective of this study is to assess the impact of COVID-19 pandemic on antibiotic consumption in the presence of active Antibiotic Stewardship Program.

Methods

This study represented a five years assessment of the consumption of the commonly prescribed antibiotics measured as DDDs/100-Bed Days. We analyzed the data by using nonparametric Friedman and Friedman tests to compare the antibiotic consumption before and during the three subsequent waves of COVID-19.

Results

Antibiotic consumption through the DDDs/100-BD has shown reduction in the median of antibiotics consumption of most antibiotics during the period of COVID-19 as compared to the pre-COVID-19 period, which was significant for meropenem and ciprofloxacin, except colomycin that slightly increased. Significant reduction in the consumption of imipenem and meropenem during the second and third waves as compared to the pre-COVID period. Throughout the years, significant reductions were observed between 2018 and 2019 (p=<.001), 2018 and 2020 (p=0.008), and 2018 and 2022 (p=0.002).

Conclusion

The reduction in antibiotic consumption is attributed to the strong influence if the ASP and the reluctance of people to visit hospitals during the COVID-19 pandemic. Other related COVID-19 precautions such as physical distance, good hand hygiene, facemasks, that resulted in the prevention of secondary bacterial infections have contributed to the reduction in antibiotic utilization during the pandemic.

Novel silver nanoparticle-antibiotic combinations as promising antibacterial and anti-biofilm candidates against multiple-antibiotic resistant ESKAPE microorganisms

HYPOTHESIS

The emergence of Multiple Antibiotic Resistance (MAR) in ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) pathogens is a global challenge to public health. The inherent antimicrobial nature of silver nanoparticles (AgNPs) makes them promising antimicrobial candidates against antibiotic-resistant pathogens. This study explores the combination of AgNPs with antibiotics (SACs) to create new antimicrobial agents effective against MAR ESKAPE microorganisms.

METHODS

AgNPs were synthesized using Streptococcus pneumoniae ATCC 49619 and characterized for structure and surface properties. The SACs were tested against ESKAPE microorganisms using growth kinetics and time-kill curve methods. The effect of SACs on bacterial biofilms and the disruption of cell membranes was determined. The in-vitro cytotoxicity effect of the AgNPs was also studied.

FINDINGS

The synthesized AgNPs (spherical, 7.37±4.55 nm diameter) were antimicrobial against MAR ESKAPE microorganisms. The SACs showed synergy with multiple conventional antibiotics, reducing their antibacterial concentrations up to 32-fold. Growth kinetics and time-kill studies confirmed the growth retardation effect and bactericidal activity of SACs. Mechanistic studies suggested that these biofilm-eradicating SACs probably resulted in the loss of bacterial cell membrane integrity, leading to leakage of the cytoplasmic content. The AgNPs were highly cytotoxic against skin melanoma cells but non-cytotoxic to normal Vero cells.

Increase of healthcare-onset Clostridioides difficile infection in adult population since SARS-CoV-2 pandemic: A retrospective cohort study in a tertiary care hospital from 2019 to 2022

OBJECTIVES

The aim was to assess the impact of the SARS-CoV-2 pandemic on the prevalence, relative incidence (RI), incidence density (ID), ratio of rate incidence (RRI), rate of incidence density (RID), and relative risks (RR) of healthcare-onset Clostridioides difficile infection (HO-CDI) as well as its correlation with the antibiotic consumption.

METHODS

Demographic and analytical data of adult patients exhibiting diarrhoea and testing positive for C. difficile were systematically collected from a tertiary care hospital in Madrid (Spain). The periods analysed included: prepandemic (P0), first pandemic-year (P1), and second pandemic-year (P2). We compared global prevalence, RI of HO-CDI per 1,000-admissions, ID of HO-CDI per 10,000-patients-days, RRI, RID, and RR. Antibiotic consumption was obtained by number of defined daily dose per 100 patient-days.

RESULTS

In P0, the prevalence of HO-CDI was 7.4% (IC95%: 6.2-8.7); in P1, it increased to 8.7% (IC95%: 7.4-10.1) (p = 0.2), and in P2, it continued to increase to 9.2% (IC95%: 8-10.6) (p < 0.05). During P1, the RRI was 1.5 and RID was 1.4. However, during P2 there was an increase in RRI to 1.6 and RID to 1.6. The RR also reflected the increase in HO-CDI: at P1, the probability of developing HO-CDI was 1.5 times (IC95%: 1.2-1.9) higher than P0, while at P2, this probability increased to 1.6 times (IC95%: 1.3-2.1). There was an increase in prevalence, RI, ID, RR, RRI, and RID during the two postpandemic periods respect to the prepandemic period. During P2, this increase was greater than the P1. Meropenem showed a statistically significant difference increased consumption (p < 0.05) during the pandemic period. Oral vancomycin HO-CDI treatment showed an increase during the period of study (p > 0.05).

CONCLUSIONS

Implementation of infection control measures during the SARS-CoV-2 pandemic did not appear to alleviate the burden of HO-CDI. The escalation in HO-CDI cases did not exhibit a correlation with overall antibiotic consumption, except for meropenem.

Asphaltene-derived nanocomposites for the removal of emerging pollutants and its antimicrobial effects: batch and continuous column studies

Emerging contaminants are diverse ecotoxic materials requiring unique treatment for removal. Asphaltenes are environmentally hazardous carbon-rich solid waste product of the petroleum industry. In the current work, asphaltene-derived activated carbon (AC) was loaded with silver (Ag/AC) and used to remove amoxicillin (AMX) and tetracycline (TC) from aqueous phase. The prepared Ag/AC was characterised using FESEM, FTIR, XRD and surface area analysis. The FESEM micrographs confirmed the spherical silver nanoparticle-laden porous AC, and the BET surface area was found to be 213 m2/g. Batch adsorption studies were performed, and the equilibrium data were fit into adsorption isotherm and kinetic models. The Ag/AC exhibited superior monolayer adsorption capacity of 1012 mg/g and 770 mg/g for AMX and TC, respectively. The continuous column studies were also performed to evaluate the breakthrough parameters. Furthermore, the antimicrobial activity of the adsorbent was evaluated using zone of inhibition studies. Ag/AC was found to have an 8-mm-diameter zone of microbial inhibition. The obtained results showed that Ag/AC was a promising material for the removal of antibiotics and inhibition of resistance-developed mutated microbes in effluent water.

Predictors of antibiogram performance and antibiotic resistance patterns in the northern Syrian region: A cross-sectional investigation

Introduction

Antibiogram use is crucial in the fight against antibiotic resistance in Syria, helping to guide treatment decisions, monitor resistance trends, and implement measures to mitigate this global health threat. This study explores the predictors of antibiogram performance and antibiotic resistance patterns in hospital settings in the Northern Syrian region.

Methods

An observational cross-sectional study was performed over six months, from the beginning of September 2022 to February 2023, targeting patients admitted to two hospitals in Syria with susceptibility to infection. The study excluded patients who did not consent or were unwilling to participate, while all individuals admitted due to infectious diseases, regardless of age, sex, or race, were included in the research. Data were collected prospectively, and antimicrobial susceptibility evaluations were performed using the disc diffusion method (the Kirby-Bauer test). Statistical analyses, including the analysis of the results, were conducted utilizing the Statistical Package for Social Sciences (SPSS Inc., Chicago, Illinois) Version 29.

Results

Of 300 hospitalized patients taking antibiotics, an antibiogram was performed for 200 individuals (cases), while 100 patients (controls) received direct treatment. One-hundred eighty-five cases had a positive culture (69.7% Gram-negative and 30.3% Gram-positive) and subsequently underwent assessment for antibiotic resistance. Cases comprised more females (56.0%) than controls (48.0%), with no statistically significant differences (p > 0.05). Significantly more patients between 25 and 63 were cases (63.8%) than controls (51.0%), while older ages were notably higher among controls (31.7%; p = 0.044), history of cardiovascular diseases was higher among controls (59.0%) than cases (47.0%; p = 0.050). Escherichia coli (N = 60; 30%), Klebsiella (N = 37; 18.5%), and Streptococcus (N = 32; 16%) were the most common bacteria. The study explored antibiotic resistance patterns among identified germs, emphasizing the high sensitivity of all identified germs for broad-spectrum antibiotics, including meropenem, amikacin, gentamicin, and fluoroquinolones (levofloxacin, ciprofloxacin). High resistance (%Sensitivity below 60%) was noted for Sulfamethoxazole, nalidixic acid, amoxiclav, lincomycin cefotaxime, ceftriaxone, and cefixime. Specifically, Escherichia coli exhibited robust sensitivity to meropenem (100%), amikacin (93.2%), and ciprofloxacin (92.7%). However, notable resistance was observed against sulfamethoxazole (68.8%), amoxicillin-clavulanate (78.3%), and cefotaxime (88.3%). For Klebsiella, resistance rates were prominent, particularly against sulfamethoxazole (69.4%), amoxicillin (83.8%), and nalidixic acid (100%). Among Gram-positive bacteria, Staphylococcus demonstrated significant resistance to sulfamethoxazole (95.2%) and ceftriaxone (78.3%) while maintaining high sensitivity to meropenem (100%) and vancomycin (100%). Streptococcus exhibited notable resistance against sulfamethoxazole (87.5%) and cefotaxime (90.6%).

Conclusion

The increase in resistance to penicillins, sulfonamides, and cephalosporins, along with continued sensitivity to broad-spectrum antibiotics, including aminoglycosides, carbapenems, and fluoroquinolones, emphasizes the importance of promoting antibiogram use and antibiotic stewardship programs. The limited availability of new antibiotics reinforces the need for urgent efforts to optimize antibiotic use and improve clinical outcomes in Northern Syria.

Emergence of carbapenem resistant gram-negative pathogens with high rate of colistin resistance in Egypt: A cross sectional study to assess resistance trends during the COVID-19 pandemic

The current study investigated the temporal phenotypic and genotypic antimicrobial resistance (AMR) trends among multi-drug resistant and carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa recovered from Egyptian clinical settings between 2020 and 2021. Bacterial identification and antimicrobial sensitivity of 111 clinical isolates against a panel of antibiotics were performed. Molecular screening for antibiotic resistance determinants along with integrons and associated gene cassettes was implemented. An alarming rate (98.2%) of these isolates were found to be phenotypically resistant to carbapenem. Although 23.9 % K. pneumoniae isolates were phenotypically resistant to colistin, no mobile colistin resistance (mcr) genes were detected. Among carbapenem-resistant isolates, blaNDM and blaOXA-48-like were the most prevalent genetic determinants and were significantly overrepresented among K. pneumoniae. Furthermore, 84.78% of K. pneumoniae isolates co-produced these two carbapenemase genes. The plasmid-mediated quinolone resistance genes (qnrS and qnrB) were detected among the bacterial species and were significantly more prevalent among K. pneumoniae. Moreover, Class 1 integron was detected in 82% of the bacterial isolates. This study alarmingly reveals elevated resistance to last-resort antibiotics such as carbapenems as well as colistin which impose a considerable burden in the health care settings in Egypt. Our future work will implement high throughput sequencing-based antimicrobial resistance surveillance analysis for characterization of novel AMR determinants. This information could be applied as a step forward to establish a robust antibiotic stewardship program in Egyptian clinical settings, thereby addressing the rising challenges of AMR.

Computational modelling of the antimicrobial peptides Cruzioseptin-4 extracted from the frog Cruziohyla calcarifer and Pictuseptin-1 extracted from the frog Boana picturata

A computational study of the peptides Cruzioseptin-4 and Pictuseptin-1, identified in Cruziohyla calcarifer and Boana picturata respectively, has been carried out. The studies on Cruzioseptin-4 show that it is a cationic peptide with a chain of 23 amino acids that possess 52.17% of hydrophobic amino acids and a charge of + 1.2 at pH 7. Similarly, Pictuseptin-1 is a 22 amino acids peptide with a charge of + 3 at pH 7 and 45.45% of hydrophobic amino acids. Furthermore, the predominant secondary structure for both peptides is alpha-helical. The physicochemical properties were predicted using PepCalc and Bio-Synthesis; secondary structures using Jpred4 and PredictProtein; while molecular docking was performed using Autodock Vina. Geometry optimization of the peptides was done using the ONIOM hybrid method with the HF/6-31G basis set implemented in the Gaussian 09 program. Finally, the molecular docking study indicates that the viable mechanism of action for both peptides is through a targeted attack on the cell membrane of pathogens via electrostatic interactions with different membrane components, leading to cell lysis.

Antibiotic resistances of Pseudomonas aeruginosa and Acinetobacter baumannii in urine cultures: experience in a hospital of Southeast Spain

The objectives of this study were to perform a systematic review of publications between 2010 and 2021 on the antibiotic resistance of Pseudomonas aeruginosa and Acinetobacter baumannii from urinary tract infections and to analyze changes over time in hospital urine cultures from 2016 through 2021. The literature was searched, and a retrospective cross-sectional descriptive study was performed in the hospital. Out of 21 838 positive urine cultures, 3.86% were due to P. aeruginosa and 0.44% were due to A. baumannii. For P. aeruginosa, lower resistance rates were observed to virtually all tested antibiotics than were obtained in the systematic review, and the present series of hospital samples showed an in vitro resistance rate <10% to ceftazidime, cefepime, meropenem, piperacillin-tazobactam, amikacin, tobramycin, and colistin. For A. baumannii, the resistance rates to almost all antibiotics were higher in the present series than in the systematic review, being lowest to colistin (10%). Both microorganisms show reduced in vitro susceptibility to some antibiotics during the years of the COVID-19 pandemic in comparison to previous years. In our setting, both piperacillin-tazobactam and meropenem can be recommended for the empirical treatment of UTIs by P. aeruginosa, whereas only colistin can be recommended for UTIs by A. baumannii.

A rationally engineered small antimicrobial peptide with potent antibacterial activity

Antimicrobial resistance (AMR) is a silent pandemic declared by the WHO that requires urgent attention in the post-COVID world. AMR is a critical public health concern worldwide, potentially affecting people at different stages of life, including the veterinary and agriculture industries. Notably, very few new-age antimicrobial agents are in the current developmental pipeline. Thus, the design, discovery, and development of new antimicrobial agents are required to address the menace of AMR. Antimicrobial peptides (AMPs) are an important class of antimicrobial agents for combating AMR due to their broad-spectrum activity and ability to evade AMR through a multimodal mechanism of action. However, molecular size, aggregability, proteolytic degradation, cytotoxicity, and hemolysis activity significantly limit the clinical application of natural AMPs. The de novo design and engineering of a short synthetic amphipathic AMP (≤16 aa, Mol. Wt. ≤ 2 kDa) with an unusual architecture comprised of coded and noncoded amino acids (NCAAs) is presented here, which demonstrates potent antibacterial activity against a few selected bacterial strains mentioned in the WHO priority list. The designer AMP is conformationally ordered in solution and effectively permeabilizes the outer and inner membranes, leading to bacterial growth inhibition and death. Additionally, the peptide is resistant to proteolysis and has negligible cytotoxicity and hemolysis activity up to 150 μM toward cultured human cell lines and erythrocytes. The designer AMP is unique and appears to be a potent therapeutic candidate, which can be subsequently subjected to preclinical studies to explicitly understand and address the menace of AMR.

Insights on the Synthesis of Al-MCM-41 with Optimized Si/Al Ratio for High-Performance Antibiotic Adsorption

Studies indicate that approximately two-thirds of the rivers of the world are contaminated by pharmaceutical compounds, especially antibiotics and hormones. Data reported by the World Health Organization (WHO, 2015) revealed an increase of 65% in antibiotic consumption between 2000 and 2015, with a worldwide increase of 200% expected up to 2030. Environmental contamination by antibiotics and their metabolites can cause the alteration of bacterial genes, leading to the generation of superbacteria. In this work, adsorption was explored as a strategy to mitigate antibiotic contamination, proposing the use of the Al-MCM-41 mesoporous material as an efficient and high-capacity adsorbent. Evaluation of the influence of the synthesis parameters enabled understanding of the main variables affecting the adsorption capacity of Al-MCM-41 for the removal of a typical antibiotic, amoxicillin (AMX). It was found that the adsorbent composition and specific surface area were the main factors that should be optimized in order to obtain the highest AMX removal capacity. Using statistical tools, the best Si/Al ratio in Al-MCM-41 was found to be 10.5, providing an excellent AMX uptake of 132.2 mg per gram of adsorbent. The Si/Al ratio was the most significant factor affecting the adsorption. The cation-π interactions increased with an increase of the Al content, while the interactions involving silanols (Yoshida H-bonding and dipole-dipole hydrogen bridges) decreased.

Prevalence of pharmaceuticals and personal care products, microplastics and co-infecting microbes in the post-COVID-19 era and its implications on antimicrobial resistance and potential endocrine disruptive effects

The COVID-19 (coronavirus disease 2019) pandemic's steady condition coupled with predominance of emerging contaminants in the environment and its synergistic implications in recent times has stoked interest in combating medical emergencies in this dynamic environment. In this context, high concentrations of pharmaceutical and personal care products (PPCPs), microplastics (MPs), antimicrobial resistance (AMR), and soaring coinfecting microbes, tied with potential endocrine disruptive (ED) are critical environmental concerns that requires a detailed documentation and analysis. During the pandemic, the identification, enumeration, and assessment of potential hazards of PPCPs and MPs and (used as anti-COVID-19 agents/applications) in aquatic habitats have been attempted globally. Albeit receding threats in the magnitude of COVID-19 infections, both these pollutants have still posed serious consequences to aquatic ecosystems and the very health and hygiene of the population in the vicinity. The surge in the contaminants post-COVID also renders them to be potent vectors to harbor and amplify AMR. Pertinently, the present work attempts to critically review such instances to understand the underlying mechanism, interactions swaying the current health of our environment during this post-COVID-19 era. During this juncture, although prevention of diseases, patient care, and self-hygiene have taken precedence, nevertheless antimicrobial stewardship (AMS) efforts have been overlooked. Unnecessary usage of PPCPs and plastics during the pandemic has resulted in increased emerging contaminants (i.e., active pharmaceutical ingredients and MPs) in various environmental matrices. It was also noticed that among COVID-19 patients, while the bacterial co-infection prevalence was 0.2-51%, the fungi, viral, protozoan and helminth were 0.3-49, 1-22, 2-15, 0.4-15% respectively, rendering them resistant to residual PPCPs. There are inevitable chances of ED effects from PPCPs and MPs applied previously, that could pose far-reaching health concerns. Furthermore, clinical and other experimental evidence for many newer compounds is very scarce and demands further research. Pro-active measures targeting effective waste management, evolved environmental policies aiding strict regulatory measures, and scientific research would be crucial in minimizing the impact and creating better preparedness towards such events among the masses fostering sustainability.

Association of COVID-19 coinfection with increased mortality among patients with Pseudomonas aeruginosa bloodstream infection in the Veterans Health Administration system

Objective

Pseudomonas aeruginosa bloodstream infection (PA-BSI) and COVID-19 are independently associated with high mortality. We sought to demonstrate the impact of COVID-19 coinfection on patients with PA-BSI.

Design

Retrospective cohort study.

Setting

Veterans Health Administration.

Patients

Hospitalized patients with PA-BSI in pre-COVID-19 (January 2009 to December 2019) and COVID-19 (January 2020 to June 2022) periods. Patients in the COVID-19 period were further stratified by the presence or absence of concomitant COVID-19 infection.

Methods

We characterized trends in resistance, treatment, and mortality over the study period. Multivariable logistic regression and modified Poisson analyses were used to determine the association between COVID-19 and mortality among patients with PA-BSI. Additional predictors included demographics, comorbidities, disease severity, antimicrobial susceptibility, and treatment.

Results

A total of 6,714 patients with PA-BSI were identified. Throughout the study period, PA resistance rates decreased. Mortality decreased during the pre-COVID-19 period and increased during the COVID-19 period. Mortality was not significantly different between pre-COVID-19 (24.5%, 95% confidence interval [CI] 23.3-28.6) and COVID-19 period/COVID-negative (26.0%, 95% CI 23.5-28.6) patients, but it was significantly higher in COVID-19 period/COVID-positive patients (47.2%, 35.3-59.3). In the modified Poisson analysis, COVID-19 coinfection was associated with higher mortality (relative risk 1.44, 95% CI 1.01-2.06). Higher Charlson Comorbidity Index, higher modified Acute Physiology and Chronic Health Evaluation score, and no targeted PA-BSI treatment within 48 h were also predictors of higher mortality.

Conclusions

Higher mortality was observed in patients with COVID-19 coinfection among patients with PA-BSI. Future studies should explore this relationship in other settings and investigate potential SARS-CoV-2 and PA synergy.

Lessons from the field: Supporting infection prevention and control and antimicrobial stewardship in Amman, Jordan

BACKGROUND

To reduce antimicrobial resistance (AMR), appropriate antimicrobial prescribing is critical. In conjunction with Infection Prevention & Control (IPC) programs, Antimicrobial Stewardship Programs (ASP) have been shown to improve prescribing practices and patient outcomes. Low- and middle-income countries (LMIC) face challenges related to inadequate ASP policies and guidelines at both the national and healthcare facility (HCF) levels.

METHODS

To address this challenge, the World Health Organization (WHO) created a policy guidance and practical toolkit for implementation of ASPs in LMIC. We utilized this document to support a situational analysis and two-day ASP-focused workshop. In follow-up, we invited these attendees, additional HCF and hospital directors to attend a workshop focused on the benefits of supporting these programs.

RESULTS

Over the course of a total three days, we recruited hospital directors, ASP team members, and IPC officers from fifteen different healthcare facilities in Jordan. We describe the courses and coordination, feedback from participants, and lessons learned for future implementation.

CONCLUSIONS

Future efforts will include more time for panel-type discussion. which will assist in further delineating enablers and barriers. Also planned is a total three-day workshop; with the first two days being with ASP/IPC teams, and the final third day being with hospital directors and leadership. The WHO policy guidance and toolkit are useful tools to address overuse of antimicrobial agents. Strong leadership support is needed for successful implementation of ASP and IPC. Discussions on quality/safety, as well as cost analyses, are important to generate interest of stakeholders.

Antimicrobial prescribing in a secondary care setting during the COVID-19 pandemic

Background

Increased antimicrobial resistance patterns lead to limited options for antimicrobial agents, affecting patient health and increasing hospital costs.

Objectives

To investigate the antimicrobial prescribing patterns at two district hospitals in Northern Ireland before and during the COVID-19 pandemic.

Methods

A mixed prospective-retrospective study was designed to compare pre- and during pandemic antimicrobial prescribing data in both hospitals using a Global Point Prevalence Survey.

Results

Of the 591 patients surveyed in both hospitals, 43.8% were treated with 402 antimicrobials. A total of 82.8% of antimicrobial prescriptions were for empirical treatment. No significant difference existed in numbers of patients treated or antimicrobials used before and during the pandemic. There was a slight decrease of 3.3% in the compliance rate with hospital antimicrobial guidelines during the pandemic when compared with the pre-pandemic year of 2019, when it was 69.5%. Treatment based on patients' biomarker data also slightly decreased from 83.5% pre-pandemic (2019) to 81.5% during the pandemic (2021).

Conclusions

There was no overall significant impact of the pandemic on the antimicrobial prescribing patterns in either hospital when compared with the pre-pandemic findings. The antimicrobial stewardship programmes would appear to have played an important role in controlling antimicrobial consumption during the pandemic.

Molecular Typing and Resistance Profile of Acinetobacter baumannii Isolates during the COVID-19 Pandemic: Findings from the "EPIRADIOCLINF" Project

Due to the COVID-19 pandemic, there has been a shift in focus towards controlling the spread of SARS-CoV-2, which has resulted in the neglect of traditional programs aimed at preventing healthcare-associated infections and combating antimicrobial resistance. The present work aims to characterize the colonization or infection with Acinetobacter baumannii of COVID-19 patients and to identify any clonality between different isolates. Specifically, data and resistance profiles of A. baumannii isolates were prospectively collected from patients recruited by the EPIRADIOCLINF project. Pulsed-field gel electrophoresis (PFGE) and multi-locus sequence typing (MLST) were used for molecular typing. Overall, we analyzed 64 isolates of A. baumannii from 48 COVID-19 patients. According to our analysis, we have identified the spread of a clonally related isolate, referred to as B. The PFGE pattern B includes four subtypes: B1 (consisting of 37 strains), B2 (11), B3 (5), and B4 (2). Furthermore, in the isolates that were examined using MLST, the most observed sequence type was ST/281. In terms of resistance profiles, 59 out of the total isolates (92.2%) were found to be resistant to gentamicin, carbapenems, ciprofloxacin, and tobramycin. The isolation and identification of A. baumannii from COVID-19 patients, along with the high levels of transmission observed within the hospital setting, highlight the urgent need for the implementation of effective prevention and containment strategies.

The Impact of COVID-19 on Knowledge, Beliefs, and Practices of Ni-Vanuatu Health Workers Regarding Antibiotic Prescribing and Antibiotic Resistance, 2018 and 2022: A Mixed Methods Study

Antimicrobial resistance (AMR) is included in the ten most urgent global public health threats. Global evidence suggests that antibiotics were over prescribed during the early waves of the COVID-19 pandemic, particularly in low- and middle-income countries. Inappropriate use of antibiotics drives the emergence and spread of antibiotic resistance. This study aimed to examine the impact of COVID-19 on Ni-Vanuatu health worker knowledge, beliefs, and practices (KBP) regarding antibiotic prescribing and awareness of antibacterial AMR. A mixed methods study was conducted using questionnaires and in-depth interviews in 2018 and 2022. A total of 49 respondents completed both baseline (2018) and follow-up (2022) questionnaires. Knowledge scores about prescribing improved between surveys, although health workers were less confident about some prescribing activities. Respondents identified barriers to optimal hand hygiene performance. More than three-quarters of respondents reported that COVID-19 influenced their prescribing practice and heightened their awareness of ABR: "more careful", "more aware", "stricter", and "need more community awareness". Recommendations include providing ongoing continuing professional development to improve knowledge, enhance skills, and maintain prescribing competency; formalising antibiotic stewardship and infection, prevention, and control (IPC) programmes to optimise prescribing and IPC practices; and raising community awareness about ABR to support more effective use of medications.

Leading reasons for antibiotic prescriptions in pediatric respiratory infections: influence of fever in a primary care setting

BACKGROUND

Antibiotic overuse in children is a significant public health concern, as it can lead to the emergence and spread of antibiotic-resistant bacteria. Although respiratory infections account for most antibiotic prescriptions in children, many of these infections are viral and do not require antibiotics. In this study, we aimed to investigate the use of antibiotics in children with respiratory infections in a primary care setting and to explore the possible role of fever on antibiotic prescription.

METHODS

We conducted a prospective observational study that evaluated preschool children aged 0-5 years who were assessed by their primary care pediatricians for respiratory infectious diseases between October 2019 and March 2021. The study involved 69 public primary care pediatricians and a total of 678 pediatric episodes for respiratory infections.

RESULTS

Amoxicillin/clavulanate was the most frequently prescribed drug. Bronchitis accounted for most of inappropriate antibiotic prescriptions (73%). Furthermore, the presence of fever was associated with a ~ 300% increase in the likelihood of prescribing antibiotics for respiratory infections that do not typically require antibiotics.

CONCLUSION

Our findings emphasize the need for adherence to international guidelines and recommendations in the primary care of children to reduce unnecessary antibiotic use and prevent the development of antibiotic resistance. This study also underscores the potential relevance of new studies to evaluate antibiotic prescription attitudes in other clinical settings and geographical areas.

Antimicrobial stewardship in primary health care programs in humanitarian settings: the time to act is now

Fragile and conflict-affected settings bear a disproportionate burden of antimicrobial resistance, due to the compounding effects of weak health policies, disrupted medical supply chains, and lack of knowledge and awareness about antibiotic stewardship both among health care providers and health service users. Until now, humanitarian organizations intervening in these contexts have confronted the threat of complex multidrug resistant infections mainly in their surgical projects at the secondary and tertiary levels of care, but there has been limited focus on ensuring the implementation of adequate antimicrobial stewardship in primary health care, which is known to be setting where the highest proportion of antibiotics are prescribed. In this paper, we present the experience of two humanitarian organizations, Médecins sans Frontières and the International Committee of the Red Cross, in responding to antimicrobial resistance in their medical interventions, and we draw from their experience to formulate practical recommendations to include antimicrobial stewardship among the standards of primary health care service delivery in conflict settings. We believe that expanding the focus of humanitarian interventions in unstable and fragile contexts to include antimicrobial stewardship in primary care will strengthen the global response to antimicrobial resistance and will decrease its burden where it is posing the highest toll in terms of mortality.

Antibiotic resistance and the COVID-19 pandemic: A dual crisis with complex challenges in LMICs

Background and Aims

Antimicrobial resistance (AMR), a global health crisis of mounting urgency, has been further complicated by the ongoing COVID-19 pandemic. The intricate relationship between these two phenomena is especially pronounced in low- and middle-income countries (LMICs) due to the distinct obstacles encountered by their healthcare systems and policy structures. This study aims to explore the complex challenges arising from the coexistence of these two crises in LMICs and proffer specific recommendations for holistic management.

Methods

An exhaustive bibliographic survey was executed, employing search queries in specialized databases such as PubMed, SCOPUS, and Web of Science's SCI-EXPANDED index. The timeframe for the literature search extended from January 2020 to January 2023. The search strategy employed key terms including antibiotic resistance, AMR, COVID-19 pandemic, low- and middle-income countries, SARS-CoV-2, and LMICs.

Results

The pandemic has aggravated various drivers of AMR in LMICs, including limited capabilities, weak frameworks, and socioeconomic factors. New challenges have emerged, such as disruptions in the antibiotic supply chain and an increased risk of healthcare-associated infections. The interaction between these drivers presents a complex problem that demands a coordinated response. Specific recommendations include strengthening health systems, funding research and innovation, and enhancing infection prevention control measures.

Conclusion

The coexistence of AMR and the COVID-19 pandemic in LMICs demands an integrated approach involving multiple stakeholders. Emphasis must be placed on constructing aligned regulatory frameworks, nurturing regional collaborations, and focusing on accessible therapeutic options. The study underscores the necessity for actionable strategies to achieve sustainable access to clean water and sanitation and also highlights the importance of long-term planning, funding, and specialized expertise in emerging modalities like phage therapy.

Addressing antimicrobial resistance in low and middle-income countries: overcoming challenges and implementing effective strategies

Antimicrobial resistance (AMR) has become a critical worldwide health crisis. It poses major challenges for healthcare systems across the globe, demanding immediate attention and action. Low and middle-income countries (LMICs), in particular, encounter unique obstacles in addressing AMR due to various factors. This article aims to examine specific challenges and propose effective strategies to combat this issue. Through a comprehensive review of existing literature, this article identifies common barriers and successful interventions in tackling AMR. The research highlights several challenges faced by LMICs in addressing AMR, including limited access to quality healthcare services, socioeconomic disparities, limited awareness, inadequate surveillance systems and data collection, limited regulatory frameworks and quality control, as well as weak healthcare infrastructure and infection prevention practices. The research suggests strategies like improving healthcare access, promoting responsible antimicrobial use, enhancing surveillance, ensuring quality antimicrobial drugs, and fostering global collaboration to address these challenges. By understanding the challenges encountered by LMICs, it is possible to mitigate the impact of AMR and contribute to global efforts in combating this growing threat.

Phage-antibiotic synergy: Cell filamentation is a key driver of successful phage predation

Phages are promising tools to fight antibiotic-resistant bacteria, and as for now, phage therapy is essentially performed in combination with antibiotics. Interestingly, combined treatments including phages and a wide range of antibiotics lead to an increased bacterial killing, a phenomenon called phage-antibiotic synergy (PAS), suggesting that antibiotic-induced changes in bacterial physiology alter the dynamics of phage propagation. Using single-phage and single-cell techniques, each step of the lytic cycle of phage HK620 was studied in E. coli cultures treated with either ceftazidime, cephalexin or ciprofloxacin, three filamentation-inducing antibiotics. In the presence of sublethal doses of antibiotics, multiple stress tolerance and DNA repair pathways are triggered following activation of the SOS response. One of the most notable effects is the inhibition of bacterial division. As a result, a significant fraction of cells forms filaments that stop dividing but have higher rates of mutagenesis. Antibiotic-induced filaments become easy targets for phages due to their enlarged surface areas, as demonstrated by fluorescence microscopy and flow cytometry techniques. Adsorption, infection and lysis occur more often in filamentous cells compared to regular-sized bacteria. In addition, the reduction in bacterial numbers caused by impaired cell division may account for the faster elimination of bacteria during PAS. We developed a mathematical model to capture the interaction between sublethal doses of antibiotics and exposition to phages. This model shows that the induction of filamentation by sublethal doses of antibiotics can amplify the replication of phages and therefore yield PAS. We also use this model to study the consequences of PAS on the emergence of antibiotic resistance. A significant percentage of hyper-mutagenic filamentous bacteria are effectively killed by phages due to their increased susceptibility to infection. As a result, the addition of even a very low number of bacteriophages produced a strong reduction of the mutagenesis rate of the entire bacterial population. We confirm this prediction experimentally using reporters for bacterial DNA repair. Our work highlights the multiple benefits associated with the combination of sublethal doses of antibiotics with bacteriophages.

Trends in Inpatient Antibiotic Use Among Adults Hospitalized During the Coronavirus Disease 2019 Pandemic in Argentina, Brazil, and Chile, 2018-2021

BACKGROUND

High rates of antibiotic use (AU) among inpatients with coronavirus disease 2019 (COVID-19) despite low rates of bacterial coinfection and secondary infection have been reported. We evaluated the impact of the COVID-19 pandemic on AU in healthcare facilities (HCFs) in South America.

METHODS

We conducted an ecologic evaluation of AU in inpatient adult acute care wards in 2 HCFs each in Argentina, Brazil, and Chile. The AU rates for intravenous antibiotics were calculated as the defined daily dose per 1000 patient-days, using pharmacy dispensing records and hospitalization data from March 2018-February 2020 (prepandemic) and March 2020-February 2021 (pandemic). Differences in median AU were compared between the prepandemic and pandemic periods, using the Wilcoxon rank sum test to determine significance. Interrupted time series analysis was used to analyze changes in AU during the COVID-19 pandemic.

RESULTS

Compared with the prepandemic period, the median difference in AU rates for all antibiotics combined increased in 4 of 6 HCFs (percentage change, 6.7%-35.1%; P < .05). In the interrupted time series models, 5 of 6 HCFs had significant increases in use of all antibiotics combined immediately at the onset of the pandemic (immediate effect estimate range, 15.4-268), but only 1 of these 5 HCFs experienced a sustained increase over time (change in slope, +8.13; P < .01). The effect of the pandemic onset varied by antibiotic group and HCF.

CONCLUSIONS

Substantial increases in AU were observed at the beginning of the COVID-19 pandemic, suggesting the need to maintain or strengthen antibiotic stewardship activities as part of pandemic or emergency HCF responses.

Antibiotic dispensing during first year of COVID-19 pandemic in Brazilian public hospitals

Aim: To evaluate the impact of the first year of the COVID-19 pandemic on antibiotic dispensation in three Brazilian hospitals. Methods: Stock movement was accessed from pharmacy databases and microbiological reports from 2018 to 2021. Results: Reduced antibiotic dispensation occurred during 2020 in all hospitals. The most significant reduction was in April at Hospital Doutor Jayme dos Santos Neves (∼58%), and in May at Hospital Doutor Roberto Arnizaut Silvares (∼66%) and Hospital Doutor Dório Silva (∼29%). However, azithromycin dispensation increased in all hospitals in 2020. Macrolide-resistant bacterial isolates rose from 66.6% in 2019 to 77.1% in 2020 and 88.3% in 2021. Conclusion: Despite reduced antibiotic dispensation, the increase in azithromycin consumption in 2020 highlights the urgency to monitor macrolide resistance after the pandemic and improve stewardship activities.

Screening of Chemical Composition, Antimicrobial and Antioxidant Activities in Pomegranate, Quince, and Persimmon Leaf, Peel, and Seed: Valorization of Autumn Fruits By-Products for a One Health Perspective

Antimicrobial resistance is increasing globally and is now one of the major public health problems. Therefore, there is a need to search for new antimicrobial agents. The food industry generates large amounts of by-products that are rich in bioactive compounds, such as phenolic compounds, which are known to have several health benefits, including antioxidant and antimicrobial properties. Thus, we aimed to characterize the phenolic compounds present in pomegranate, quince, and persimmon by-products, as well as their antioxidant and antimicrobial activities. Phenolic compounds were extracted from pomegranate, quince, and persimmon leaves, seeds, and peels using a mixture of ethanol/water (80/20). The polyphenol profile of the extracts was determined by high-performance liquid chromatography. The antioxidant activity of the extracts was determined by the 2,2-diphenyl-1-picrylhydrazyl (DPPH), ferric reducing antioxidant power (FRAP), and cupric reducing antioxidant capacity (CUPRAC) methods. Antimicrobial susceptibility was evaluated using the Kirby-Bauer disk diffusion method. In general, leaves showed higher concentrations of phenolics than the peel and seeds of fruits. In total, 23 phenolic compounds were identified and quantified, with sanguiin and apigenin-3-O-galactoside being present in the highest concentrations. Leaf extracts of pomegranate showed higher antioxidant activities than the other components in all methods used. In general, all extracts had a greater antimicrobial activity against Gram-positive bacteria. Persimmon leaf and seed extracts inhibited a greater number of bacteria, both Gram-positive and -negative. The lowest minimum inhibitory concentration (MIC) detected among Gram-positive and -negative bacteria was 10 mg/mL for pomegranate peel and leaf extracts against Staphylococcus aureus and S. pseudintermedius and for pomegranate leaf extract against Escherichia coli. Our results reinforce the need to value food industry by-products that could be used as food preservatives and antibiotic adjuvants against multiresistant bacteria.

Antibacterial Activity of the Essential Oil of Piper tuberculatum Jacq. Fruits against Multidrug-Resistant Strains: Inhibition of Efflux Pumps and β-Lactamase

Antimicrobial resistance has become a growing public health concern in recent decades, demanding a search for new effective treatments. Therefore, this study aimed to elucidate the phytochemical composition and evaluate the antibacterial activity of the essential oil obtained from the fruits of Piper tuberculatum Jacq. (EOPT) against strains carrying different mechanisms of antibiotic resistance. Phytochemical analysis was performed using gas chromatography-mass spectrometry (GC/MS). The antibacterial activity of EOPT and its ability to inhibit antibiotic resistance was evaluated through the broth microdilution method. The GC-MS analysis identified 99.59% of the constituents, with β-pinene (31.51%), α-pinene (28.38%), and β-cis-ocimene (20.22%) being identified as major constituents. The minimum inhibitory concentration (MIC) of EOPT was determined to assess its antibacterial activity against multidrug-resistant strains of Staphylococcus aureus (IS-58, 1199B, K2068, and K4100). The compound showed a MIC of ≥ 1024 μg/mL, suggesting a lack of intrinsic antibacterial activity. However, when the EOPT was associated with antibiotics and EtBr, a significant decrease in antibiotic resistance was observed, indicating the modulation of efflux pump activity. This evidence was corroborated with the observation of increased fluorescent light emission by the bacterial strains, indicating the involvement of the NorA and MepA efflux pumps. Additionally, the significant potentiation of ampicillin activity against the S. aureus strain K4414 suggests the β-lactamase inhibitory activity of EOPT. These results suggest that the essential oil from P. tuberculatum fruits has antibiotic-enhancing properties, with a mechanism involving the inhibition of efflux pumps and β-lactamase in MDR S. aureus strains. These findings provide new perspectives on the potential use of EOPT against antibiotic resistance and highlight the importance of Piper species as sources of bioactive compounds with promising therapeutic activities against MDR bacteria. Nevertheless, further preclinical (in vivo) studies remain necessary to confirm these in vitro-observed results.

Isolation of Carbapenem and Colistin Resistant Gram-Negative Bacteria Colonizing Immunocompromised SARS-CoV-2 Patients Admitted to Some Libyan Hospitals

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has had a devastating effect, globally. We describe, for the first time, the occurrence of carbapenem-resistant bacteria colonizing SARS-CoV-2 patients who developed hospital-associated infections with carbapenemase-producing, Gram-negative bacteria at some isolation centers of SARS-CoV-2 in the eastern part of Libya. In total, at first, 109 samples were collected from 43 patients, with the samples being recovered from oral (n = 35), nasal (n = 45), and rectal (n = 29) cavities. Strain identification was performed via matrix assisted laser desorption ionization-time of flight (MALDI-TOF). Antibiotic susceptibility testing was carried out on Mueller-Hinton agar, using the standard disk diffusion method. MIC determination was confirmed via E-TEST and microdilution standard methods. A molecular study was carried out to characterize the carbapenem and colistin resistance in Gram-negative bacterial strains. All of the positive results were confirmed via sequencing. Klebsiella pneumoniae (n = 32), Citrobacter freundii (n = 21), Escherichia coli (n = 7), and Acinetobacter baumannii (n = 21) were the predominant isolated bacteria. Gram-negative isolates were multidrug-resistant and carried different carbapenem resistance-associated genes, including NDM-1 (56/119; 47.05%), OXA-48 (15/119; 12.60%), OXA-23 (19/119; 15.96%), VIM (10/119; 8.40%), and the colistin resistance mobile gene mcr-1 (4/119; 3.36%). The overuse of antimicrobials, particularly carbapenem antibiotics, during the SARS-CoV-2 pandemic has led to the emergence of multidrug-resistant bacteria, mainly K. pneumoniae, A. baumannii, and colistin-resistant E. coli strains. Increased surveillance as well as the rational use of carbapenem antibiotics and, recently, colistin are required to reduce the propagation of multidrug-resistant strains and to optimally maintain the efficacy of these antibiotics. IMPORTANCE In this work, we describe, for the first time, the occurrence of carbapenem-resistant bacteria colonizing COVID-19 patients who developed hospital-associated infections with carbapenemase-producing, Gram-negative bacteria at some isolation centers of COVID-19 in the eastern part of Libya. Our results confirmed that the overuse of antimicrobials, such as carbapenem antibiotics, during the COVID-19 pandemic has led to the emergence of multidrug-resistant bacteria, mainly K. pneumoniae and A. baumannii, as well as colistin resistance.

A Comparative Study of Bacterial Infections Between COVID-19 and Non-COVID-19 Patients With Respect to Different Isolates and Their Antibiotic Sensitivity Pattern

Background Following the pandemic caused by SARS-CoV-2, the emergence of and following the pandemic has required major modifications to healthcare systems and frameworks. Antimicrobials have more than a few potential roles in managing COVID-19. Experimental cures for the treatment of SARS-CoV-2 are being explored. The availability of limited data suggests that nosocomial infections are associated with a higher risk of death and severity of COVID-19. To fill this knowledge gap, we conducted a study to assess the spectrum of bacteriological isolates in different samples from COVID-19 patients. Our study aimed to evaluate the antibiotic resistance pattern of these bacterial isolates and compare the spectrum of bacteriological isolates in different samples and their antibiotic sensitivity pattern between COVID-19 and non-COVID-19 patients. Methodology An observational cross-sectional, partly retrospective, and partly prospective study was carried out in the bacteriology section of the Department of Microbiology, Indira Gandhi Institute of Medical Sciences (IGIMS), Patna, Bihar, for a total duration of six months from February 2021 to July 2021. The profile of pathogens isolated from 105 clinical samples from COVID-19 patients was studied. To detect COVID-19, RT-PCR was performed. All clinical specimens (urine, blood, pus, respiratory sample, etc.) were processed and cultured on different media to support the growth of the bacteria as per our standard operating procedures (SOP) for bacteriology samples. Antimicrobial susceptibility testing was carried out based on the Clinical and Laboratory Standards Institute. Results A total of 105 clinical samples were received in the bacteriology section of the Department of Microbiology, IGIMS, Patna, Bihar, from admitted COVID-19 patients. The mean age of study participants was 51.57 ± 14.76 years, and males (66.7%, 70/105) were more than females (33.3%, 35/105). The majority of the patients were 91 out of 105 (86.67%) from the ward and 14 from the ICU (13.33%). Of the total samples tested, 62 (59%) were urine samples, 26 (24.8%) were respiratory specimens, 13 (12.4%) were pus samples, 3 (2.9%) were body fluids, and 1 (1%) were tissue samples. Among the total pathogen isolates (n=57) obtained from patients with SARS-CoV-2 admitted to the ward and ICU, 56.14% (32) were gram-negative, 26.31% (15) were Candida, and 17.54% (10) were gram-positive pathogens. The most isolated pathogen was Escherichia coli (39.02%, 16/41) followed by Klebsiella pneumoniae (29.26%, 12/41), Acinetobacter baumannii (7.31%, 3/41), and Enterobacter cloacae (2.43%, 1/41). Enterococcus spp. as gram-positive bacteria were isolated in 21.95% (9/41) of patients. Among the gram-negative bacteria (Enterobacterales), the highest resistance was seen in ampicillin (100%,29/29). For non-Enterobacterales, the highest resistance was seen in ceftriaxone (66.66%,2/3). Enterococcus spp. showed maximum ciprofloxacin, and gentamicin (high level) resistance was 100% (9/9). Conclusion Secondary infections with resistant pathogens in COVID-19 patients highlight the importance of antimicrobial management programs focused on the optimal selection of empirical treatments based on culture reports.

Reporting of Azithromycin Activity against Clinical Isolates of Extensively Drug-Resistant Salmonella enterica Serovar Typhi

This study aimed to evaluate the minimum inhibitory concentration (MIC) of azithromycin (AZM) in clinical isolates of extensively drug-resistant (XDR) Salmonella Typhi (i.e., resistant to chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin) using the E-test versus the broth microdilution method (BMD). From January to June 2021, a retrospective cross-sectional study was carried out in Lahore, Pakistan. Antimicrobial susceptibility was performed initially by the Kirby-Bauer disk diffusion method for 150 XDR Salmonella enterica serovar Typhi isolates, and MICs of all the recommended antibiotics were determined by the VITEK 2 (BioMérieux) fully automated system using Clinical Laboratory Standard Institute (CLSI) 2021 guidelines. The E-test method was used to determine AZM MICs. These MICs were compared with the BMD, which is the method recommended by the CLSI but not adopted in routine laboratory reporting. Of 150 isolates, 10 (6.6%) were resistant by disk diffusion. Eight (5.3%) of these had high MICs against AZM by the E-test. Only three isolates (2%) were resistant by E-test, having an MIC of 32 μg/mL. All eight isolates had a high MIC by BMD with different MIC distributions, but only one was resistant, having an MIC of 32 μg/mL by BMD. The sensitivity, specificity, negative predictive value, positive predictive value, and diagnostic accuracy of the E-test method versus BMD were 98.65%,100%, 99.3%, 33.3%, and 98.6%, respectively. Similarly, the concordance rate was 98.6%, negative percent agreement was 100%, and positive percent agreement was 33%. The BMD is the most reliable approach for reporting AZM sensitivity in XDR S. Typhi compared with the E-test and disk diffusion methods. Potentially, AZM resistance in XDR S. Typhi is around the corner. Sensitivity patterns should be reported with MIC values, and if possible, higher values should be screened for the presence of any potential resistance genes. Antibiotic stewardship should be strictly implemented.

The menace of colistin resistance across globe: Obstacles and opportunities in curbing its spread

Colistin-resistance in bacteria is a big concern for public health, since it is a last resort antibiotic to treat infectious diseases of multidrug resistant and carbapenem resistant Gram-negative pathogens in clinical settings. The emergence of colistin resistance in aquaculture and poultry settings has escalated the risks associated with colistin resistance in environment as well. The staggering number of reports pertaining to the rise of colistin resistance in bacteria from clinical and non-clinical settings is disconcerting. The co-existence of colistin resistant genes with other antibiotic resistant genes introduces new challenges in combatting antimicrobial resistance. Some countries have banned the manufacture, sale and distribution of colistin and its formulations for food producing animals. However, to tackle the issue of antimicrobial resistance, a one health approach initiative, inclusive of human, animal, and environmental health needs to be developed. Herein, we review the recent reports in colistin resistance in bacteria of clinical and non-clinical settings, deliberating on the new findings obtained regarding the development of colistin resistance. This review also discusses the initiatives implemented globally in mitigating colistin resistance, their strength and weakness.

Disinformation about COVID-19 Preventions and Treatments: Analysis of USFDA Warning Letters

COVID-19 poses a challenge beyond the virus itself, in that lockdown has been associated increased use of the internet and social media. Disinformation about prevention and treatment strategies for COVID-19 can have lethal consequences. The United States Food and Drug Administration (USFDA) is currently monitoring the compliance of manufacturing firms as well as medicinal product advertisers to the Federal Food, Drug, and Cosmetic Act, 21 USC § 321(h) regulations. In the event of noncompliance in the form of advertising products without prior USFDA approval for specific indications, doses, or route of administration, warning letters (WLs) are issued. WLs are intended to address the concerns identified by USFDA and encourage the recipient to take corrective steps to avoid similar instances in the future. We analyzed 182 WLs that were issued for noncompliance with drugs/devices related to either treatment, prevention, or testing of COVID-19 infections. The medicinal product website was identified as the major source of disinformation, followed by disseminated information on Facebook, Twitter, and Instagram. Nearly four-fifths were related to drugs, followed by devices and biologicals. Several biologicals, as well as allopathic, herbal, and non-herbal drugs were identified in the WLs. We observed that noncompliance with the USFDA regulations in terms of advertising a variety of products for prevention and treatment of COVID-19 infection was widely prevalent. More efforts are required by the respective national drug regulatory authorities to initiate or continue their monitoring of disinformation that may have lethal consequences.

Graphene in nanomedicine: A review on nano-bio factors and antibacterial activity

Graphene-based nanomaterials possess potent antibacterial activity and have engrossed immense interest among researchers as an active armour against pathogenic microbes. A comprehensive perception of the antibacterial activity of these nanomaterials is critical to the fabrication of highly effective antimicrobial nanomaterials, which results in highly efficient and enhanced activity. These materials owing to their antimicrobial activity are utilized as nanomedicine against various pathogenic microbes. The present article reviews the antimicrobial activity of graphene and its analogs such as graphene oxide, reduced graphene oxide as well as metal, metal oxide and polymeric composites. The review draws emphasis on the effect of various nano-bio factors on the antibacterial capability. It also provides an insight into the antibacterial properties of these materials along with a brief discussion on the discrepancies in their activities as evidenced by the scientific communities. In this way, the review is expected to shed light on future research and development in graphene-based nanomedicine.

Special Issue "Microbial Biodegradation and Biotransformation"

The current state of the environment is a major concern [...].

Occurrence and Treatment of Antibiotic-Resistant Bacteria Present in Surface Water

According to the World Health Organization, antibiotic resistance is one of the main threats to global health. The excessive use of several antibiotics has led to the widespread distribution of antibiotic-resistant bacteria and antibiotic resistance genes in various environment matrices, including surface water. In this study, total coliforms, Escherichia coli and enterococci, as well as total coliforms and Escherichia coli resistant to ciprofloxacin, levofloxacin, ampicillin, streptomycin, and imipenem, were monitored in several surface water sampling events. A hybrid reactor was used to test the efficiency of membrane filtration, direct photolysis (using UV-C light emitting diodes that emit light at 265 nm and UV-C low pressure mercury lamps that emit light at 254 nm), and the combination of both processes to ensure the retention and inactivation of total coliforms and Escherichia coli as well as antibiotic-resistant bacteria (total coliforms and Escherichia coli) present in river water at occurrence levels. The membranes used (unmodified silicon carbide membranes and the same membrane modified with a photocatalytic layer) effectively retained the target bacteria. Direct photolysis using low-pressure mercury lamps and light-emitting diode panels (emitting at 265 nm) achieved extremely high levels of inactivation of the target bacteria. The combined treatment (unmodified and modified photocatalytic surfaces in combination with UV-C and UV-A light sources) successfully retained the bacteria and treated the feed after 1 h of treatment. The hybrid treatment proposed is a promising approach to use as point-of-use treatment by isolated populations or when conventional systems and electricity fail due to natural disasters or war. Furthermore, the effective treatment obtained when the combined system was used with UV-A light sources indicates that the process may be a promising approach to guarantee water disinfection using natural sunlight.

Plasma-Etched Vertically Aligned CNTs with Enhanced Antibacterial Power

The emergence of multidrug-resistant bacteria represents a growing threat to public health, and it calls for the development of alternative antibacterial approaches not based on antibiotics. Here, we propose vertically aligned carbon nanotubes (VA-CNTs), with a properly designed nanomorphology, as effective platforms to kill bacteria. We show, via a combination of microscopic and spectroscopic techniques, the ability to tailor the topography of VA-CNTs, in a controlled and time-efficient manner, by means of plasma etching processes. Three different varieties of VA-CNTs were investigated, in terms of antibacterial and antibiofilm activity, against Pseudomonas aeruginosa and Staphylococcus aureus: one as-grown variety and two varieties receiving different etching treatments. The highest reduction in cell viability (100% and 97% for P. aeruginosa and S. aureus, respectively) was observed for the VA-CNTs modified using Ar and O₂ as an etching gas, thus identifying the best configuration for a VA-CNT-based surface to inactivate both planktonic and biofilm infections. Additionally, we demonstrate that the powerful antibacterial activity of VA-CNTs is determined by a synergistic effect of both mechanical injuries and ROS production. The possibility of achieving a bacterial inactivation close to 100%, by modulating the physico-chemical features of VA-CNTs, opens up new opportunities for the design of self-cleaning surfaces, preventing the formation of microbial colonies.

Antibiotic consumption and antimicrobial resistance in the SARS-CoV-2 pandemic: A single-center experience

Introduction: Antimicrobial resistance and the rapid spread of multiresistant bacteria represent one of the main public health problem in limited resources countries. This issue is significantly worsening since the COVID-19 pandemic due to the unreasonably increased antibiotics prescription to patients with confirmed SARS-CoV-2 infection. The aim of this study was to examine whether COVID-19 pandemic (2020, 2021) was associated with increased antibiotic consumption in inpatient and outpatient settings in the middle size urban region (Republic of Srpska/Bosnia and Herzegovina) in comparison to period before the pandemic (2019). Additionally, we aimed to determine antimicrobial resistance and the presence of multiresistant bacteria in the regional hospital (“Saint Apostol Luka” Hospital Doboj) in 2021.

Methodology: The consumption of antibiotics in inpatient was calculated as Defined Daily Dose per one hundred of patient-days. The consumption of antibiotics in outpatient was calculated as Defined Daily Dose per thousand inhabitants per day. Resistance of bacteria to antibiotics is expressed as a rates and density for each observed antibiotic. The rate of resistance was calculated as a percentage in relation to the total number of isolates of individual bacteria. The density of resistance of isolated bacteria against a specific antibiotic was expressed as the number of resistant pathogens/1000 patient days.

Results: Antibiotic consumption in hospital setting registered during 2019, 2020 and 2021 was as follows: carbapenems (meropenem: 0.28; 1.91; 2.33 DDD/100 patient-days, respectively), glycopeptides (vancomycin: 0.14; 1.09, 1.54 DDD/100 patient-days, respectively), cephalosporins (ceftriaxone: 6.69; 14.7; 14.0 DDD/100 patient-days, respectively) and polymyxins (colistin: 0.04; 0.25; 0.35 DDD/100 bed-days, respectively). Consumption of azithromycin increased drastically in 2020, and dropped significantly in 2021 (0.48; 5.61; 0.93 DDD/100 patient-days). In outpatient setting, an increase in the consumption of oral forms of azithromycin, levofloxacin and cefixime, as well as parenteral forms of amoxicillin-clavulanic acid, ciprofloxacin and ceftriaxone, was recorded. In 2021, antimicrobial resistance to reserve antibiotics in hospital setting was as follows: Acinetobacter baumanii to meropenem 66.0%, Klebsiella spp to cefotaxime 67.14%, Pseudomonas to meropenem 25.7%.

Conclusion: Recent COVID-19 pandemic was associated with increased antibiotic consumption in inpatient and outpatient settings, with characteristic change of pattern of azithromycin consumption. Also, high levels of antimicrobial resistance to reserve antibiotics were registered in hospital setting with low prevalence of identified pathogen-directed antimicrobial prescription. Strategies toward combat antimicrobial resistance in the Doboj region are urgently needed.

Bacterial infections and antibiotic utilization varies by coronavirus disease 19 (COVID-19) severity in hospitalized cancer patients: Analysis from the first phase of the pandemic

OBJECTIVE

To characterize bacterial infections and antibiotic utilization in hospitalized cancer patients with coronavirus disease 2019 (COVID-19).

DESIGN

Retrospective cohort study.

SETTING

Tertiary cancer center in New York City.

PATIENTS

Hospitalized cancer patients ≥18 years with COVID-19 between March 1, 2020, and May 31, 2020.

METHODS

Patients were classified with mild COVID-19 (ie, with room air), moderate COVID-19 (ie, using nasal cannula oxygen), or severe COVID-19 (ie, using high-flow oxygen or mechanical ventilation). The primary outcome was bacterial infection rate within 30 days of COVID-19 onset. Secondary outcomes included the proportion of patients receiving antibiotics and antibiotic length of therapy (LOT).

RESULTS

Of 358 study patients, 133 had mild COVID-19, 97 had moderate COVID-19, and 128 had severe COVID-19. Of 358 patients, 234 (65%) had a solid tumor. Also, 200 patients (56%) had 245 bacterial infections, of which 67 (27%) were microbiologically confirmed. The proportion of patients with bacterial infection increased with COVID-19 severity: mild (n = 47, 35%) versus moderate (n = 49, 51%) versus severe (n = 104, 81%) (P < .0001). Also, 274 (77%) received antibiotics for a median of 4 days. The median antibiotic LOTs were 7 days with 1 infection and 20 days with multiple infections (P < .0001). Antibiotic durations were 1 day for patients with mild COVID-19, 4 days for patients with moderate COVID-19, and 8 days for patients with severe COVID-19 (P < .0001).

CONCLUSIONS

Hospitalized cancer patients with COVID-19 had a high rate of bacterial infection. As COVID-19 severity increased, the proportion of patients diagnosed with bacterial infection and given antibiotics increased. In mild COVID-19 cases, antibiotic LOT was short, suggesting that empiric antibiotics can be safely avoided or discontinued in this group.

A comparative study of COVID-19 transcriptional signatures between clinical samples and preclinical cell models in the search for disease master regulators and drug repositioning candidates

Coronavirus disease 2019 (COVID-19) is an acute viral disease with millions of cases worldwide. Although the number of daily new cases and deaths has been dropping, there is still a need for therapeutic alternatives to deal with severe cases. A promising strategy to prospect new therapeutic candidates is to investigate the regulatory mechanisms involved in COVID-19 progression using integrated transcriptomics approaches. In this work, we aimed to identify COVID-19 Master Regulators (MRs) using a series of publicly available gene expression datasets of lung tissue from patients which developed the severe form of the disease. We were able to identify a set of six potential COVID-19 MRs related to its severe form, namely TAL1, TEAD4, EPAS1, ATOH8, ERG, and ARNTL2. In addition, using the Connectivity Map drug repositioning approach, we identified 52 different drugs which could be used to revert the disease signature, thus being candidates for the design of novel clinical treatments. Furthermore, we compared the identified signature and drugs with the ones obtained from the analysis of nasopharyngeal swab samples from infected patients and preclinical cell models. This comparison showed significant similarities between them, although also revealing some limitations on the overlap between clinical and preclinical data in COVID-19, highlighting the need for careful selection of the best model for each disease stage.

Epidemiological Characteristics and Antimicrobial Resistance Changes of Carbapenem-Resistant Klebsiella pneumoniae and Acinetobacter baumannii under the COVID-19 Outbreak: An Interrupted Time Series Analysis in a Large Teaching Hospital

Background: To investigate the epidemiological characteristics and resistance changes of carbapenem-resistant organisms (CROs) under the COVID-19 outbreak to provide evidence for precise prevention and control measures against hospital-acquired infections during the pandemic. Methods: The distribution characteristics of CROs (i.e., carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii) were analyzed by collecting the results of the antibiotic susceptibility tests of diagnostic isolates from all patients. Using interrupted time series analysis, we applied Poisson and linear segmented regression models to evaluate the effects of COVID-19 on the numbers and drug resistance of CROs. We also conducted a stratified analysis using the Cochran–Mantel–Haenszel test. Results: The resistance rate of carbapenem-resistant Acinetobacter baumannii (CRAB) was 38.73% higher after the COVID-19 outbreak compared with before (p < 0.05). In addition, the long-term effect indicated that the prevalence of CRAB had a decreasing trend (p < 0.05). However, the overall resistance rate of Klebsiella pneumoniae did not significantly change after the COVID-19 outbreak. Stratified analysis revealed that the carbapenem-resistant Klebsiella pneumoniae (CRKP) rate increased in females (OR = 1.98, p < 0.05), those over 65 years old (OR = 1.49, p < 0.05), those with sputum samples (OR = 1.40, p < 0.05), and those in the neurology group (OR = 2.14, p < 0.05). Conclusion: The COVID-19 pandemic has affected the change in nosocomial infections and resistance rates in CROs, highlighting the need for hospitals to closely monitor CROs, especially in high-risk populations and clinical departments. It is possible that lower adherence to infection control in crowded wards and staffing shortages may have contributed to this trend during the COVID-19 pandemic, which warrants further research.

Antimicrobial prescription patterns in East Africa: a systematic review

BACKGROUND

Antimicrobial resistance is currently a recognized global health problem stemming from poor antibiotic stewardship by health workers and inappropriate antimicrobial use by patients. Data showing the extent of poor antimicrobial stewardship in low- and middle-income countries are scanty though high incidences of antimicrobial resistance are increasingly reported in many settings across the globe. The objective of the present study was, therefore, to evaluate prescriptions for antimicrobials in East Africa.

METHODS

A comprehensive literature search strategy that includes text words and medical subject headings was developed and applied to predefined electronic databases. Two authors independently screened the titles and abstracts of the outputs of the literature search. Full texts were then independently reviewed by the first and the second authors. Eligible studies were formally assessed for quality and risk of bias using a scoring tool. Extracted data from included studies were combined in a meta-analysis where appropriate and presented using forest plots and tables or in a narrative text. Where data were available, subgroup analyses were performed.

RESULTS

A total of 4284 articles were retrieved, but only 26 articles were included in the review. The majority of the included studies (30.8%) were retrieved from Ethiopia, followed by Sudan, Kenya, and Tanzania each contributing 19.2% of the included studies. The overall proportion of encounters with antimicrobials reported by the included studies was 57% CI [42-73%]. Ethiopia had an overall patient encounter with antimicrobials of 63% [50-76%] followed by Sudan with an overall encounter with antimicrobials of 62% CI [34-85%]. Included studies from Kenya reported an overall encounter with antimicrobials of 54% CI [15-90%], whereas included studies from Tanzania reported an overall patient encounter with antimicrobials of 40% CI [21-60%].

CONCLUSION

Prescription patterns demonstrated in this review significantly deviate from WHO recommendations suggesting inappropriate antimicrobial use in the East African countries. Further studies have to be pursued to generate more information on antimicrobial use in this region.

Antimicrobial stewardship implementation before and during the COVID-19 pandemic in the acute care settings: a systematic review

INTRODUCTION

Antibiotics are widely administered for various indications, leading to increased antimicrobial resistance (AMR) in acute care hospitals. Since the onset of the COVID-19 pandemic, Antimicrobial Stewardship (AMS) effective strategies should be used to maintain the rational use of antibiotics and decrease the threat of Antimicrobial Resistance (AMR).

AIM

This systematic literature review aims to investigate the AMS intervention Before-the-pandemic (BP) and During-the-pandemic (DP) from the literature.

DESIGN AND SETTING

Systematic literature review of primary studies on AMS implementation in acute care settings.

METHODS

Relevant studies published between 2000 and March 2021 were obtained from Medline (via PubMed), OVID, CINAHL, International Pharmaceutical Abstracts, Psych Info, Scopus, Web of Science, Cochrane Library, OpenGrey, and Google Scholar, using a comprehensive list of search terms. Public Health England (PHE) toolkit was agreed upon as a gold standard for the AMS implementation.

RESULTS

There were 8763 articles retrieved from the databases. Out of these, 13 full-text articles met the inclusion criteria for the review. The AMS implementation was identified in the included studies into AMS strategies (Core strategies & Supplemental strategies), and AMS measures BP and DP.

CONCLUSION

This Systematic literature review summarises AMS implementation strategies and measures all over the previous 20 years of research. There are many lessons learnt from COVID-19 pandemic. The proper selection of the AMS implementation strategies and measures appeared to be effective in maintaining the appropriate use of antibiotics and decreasing the AMR threat, especially during the COVID-19 pandemic. Further studies are required to provide empirical data to evaluate the AMS implementation and identify which of these strategies and measures were effective BP and DP. In order to be prepared for any emergency/crisis or future pandemics.

The Clash of the Titans: COVID-19, Carbapenem-Resistant Enterobacterales, and First mcr-1-Mediated Colistin Resistance in Humans in Romania

(1) Background: Antibiotic resistance and coronavirus disease-19 (COVID-19) represent a dual challenge in daily clinical practice, inducing a high burden on public health systems. Hence, we aimed to dynamically evaluate the impact of COVID-19 on patients with carbapenem-resistant Enterobacterales (CRE) urinary tract infections (UTIs), as well as the antibiotic resistance trends after the onset of the pandemic. (2) Methods: We conducted a prospective study including patients with CRE UTIs who were enrolled both pre- and during the pandemic from 2019 to 2022. We further performed a standardized and comparative clinical, paraclinical, and microbiological assessment between patients with and without COVID-19. (3) Results: A total of 87 patients with CRE UTIs were included in this study (46 pre-pandemic and 41 during the pandemic, of which 21 had associated Severe Acute Respiratory Syndrome Coronavirus-2 infection). Klebsiella pneumoniae was the main etiological agent of the UTIs, with the majority of strains (82.7%) being carbapenemase producers (mainly OXA-48 producers), while five of the 34 colistin-resistant isolates were harboring the mobile colistin resistance-1 (mcr-1) gene. COVID-19 patients presented a significantly worse outcome with higher rates of intensive care unit (ICU) admissions (66.7% for COVID patients vs. 18.2% for non-COVID patients, p < 0.001), while the fatality rates were also considerably higher among patients with concomitant viral infection (33.3% vs. 12.1%, p < 0.001). Besides COVID-19, additional risk factors associated with increased mortality were urinary catheterization, sepsis with K. pneumoniae, impaired liver and kidney function, and an inappropriate initial empiric antibiotic therapy. (4) Conclusions: COVID-19 showed a pronounced negative impact on patients with CRE UTIs, with significantly longer hospitalizations and higher ICU admissions and mortality rates.

Assessing the Clinical Characteristics and Management of COVID-19 among Pediatric Patients in Ghana: Findings and Implications

There is an increasing focus across countries on researching the management of children admitted to hospital with COVID-19. This stems from an increasing prevalence due to new variants, combined with concerns with the overuse of antimicrobials driving up resistance rates. Standard treatment guidelines (STGs) have been produced in Ghana to improve their care. Consequently, there is a need to document the clinical characteristics of children diagnosed and admitted with COVID-19 to our hospital in Ghana, factors influencing compliance to the STG and treatment outcomes. In all, 201 patients were surveyed between March 2020 and December 2021, with males accounting for 51.7% of surveyed children. Those aged between 6 and 10 years were the largest group (44.8%). Nasal congestion and fever were some of the commonest presenting complaints, while pneumonia was the commonest (80.6%) COVID-19 complication. In all, 80.0% of all admissions were discharged with no untreated complications, with a 10.9% mortality rate. A combination of azithromycin and hydroxychloroquine (41.29%) was the most prescribed antimicrobial regimen. Compliance to the STG was variable (68.2% compliance). Increased compliance was associated with a sore throat as a presenting symptom. Mortality increased following transfer to the ICU. However, current recommendations to prescribe antimicrobials without demonstrable bacterial or fungal infections needs changing to reduce future resistance. These are areas to address in the future.