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

"Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi

BACKGROUND

The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not.

OBJECTIVE

We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi.

METHODS

Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting.

RESULTS

Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred.

CONCLUSIONS

Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care.

Occurrence and distribution of emerging contaminants in wastewater treatment plants: A globally review over the past two decades

Emerging contaminants are pervasive in aquatic environments globally, encompassing pharmaceuticals, personal care products, steroid hormones, phenols, biocides, disinfectants and various other compounds. Concentrations of these contaminants are detected ranging from ng/L to μg/L. Even at trace levels, these contaminants can pose significant risks to ecosystems and human health. This article systematically summarises and categorizes data on the concentrations of 54 common emerging contaminants found in the influent and effluent of wastewater treatment plants across various geographical regions: North America, Europe, Oceania, Africa, and Asia. It reviews the occurrence and distribution of these contaminants, providing spatial and causal analyses based on data from these regions. Notably, the maximum concentrations of the pollutants observed vary significantly across different regions. The data from Africa, in particular, show more frequent detection of pharmaceutical maxima in wastewater treatment plants.

The longitudinal trend and influential factors exploring of global antimicrobial resistance in Klebsiella pneumoniae

Klebsiella pneumoniae (Kp) is a human symbiotic opportunistic pathogen capable of causing severe hospital-based infections and community-acquired infections. The problem of antimicrobial resistance (AMR) has become increasing serious over time, posing a major threat to socio-economic and human development. In this study, we explored the global trend of AMR in 1786 strains of Kp isolated between 1982 and 2023. The number of antibiotic resistance genes (ARGs) in Kp increased significantly from 24.29 ± 5.44 to 32.42 ± 8.52 over time. Mobile genetic elements (MGEs) were responsible for the ARGs horizontal transfer of Kp strains. The results of structural equation modeling (SEM) indicated a strong association between the human development index and the increase of antibiotic consumption, which indirectly affected the occurrence and development of antibiotic resistance in Kp. The results of Generalized Linear Models (GLM) indicated that the influence of environmental factors such as temperature on the development of Kp resistance could not be ignored. Overall, this study monitored the longitudinal trend of antimicrobial resistance in Kp, explored the factors influencing antibiotic resistance, and provided insights for mitigating the threat of antimicrobial resistance.

Functional characterization of a novel Chlamydomonas reinhardtii hydrolase involved in biotransformation of chloramphenicol

Microalgae-based biotechnology is one of the most promising alternatives to conventional methods for the removal of antibiotic contaminants from diverse water matrices. However, current knowledge regarding the biochemical mechanisms and catabolic enzymes involved in microalgal biodegradation of antibiotics is scant, which limits the development of enhancement strategies to increase their engineering feasibility. In this study, we investigated the removal dynamics of amphenicols (chloramphenicol, thiamphenicol, and florfenicol), which are widely used in aquaculture, by Chlamydomonas reinhardtii under different growth modes (autotrophy, heterotrophy, and mixotrophy). We found C. reinhardtii removed >92 % chloramphenicol (CLP) in mixotrophic conditions. Intriguingly, gamma-glutamyl hydrolase (GGH) in C. reinhardtii was most significantly upregulated according to the comparative proteomics, and we demonstrated that GGH can directly bind to CLP at the Pro77 site to induce acetylation of the hydroxyl group at C3 position, which generated CLP 3-acetate. This identified role of microalgal GGH is mechanistically distinct from that of animal counterparts. Our results provide a valuable enzyme toolbox for biocatalysis and reveal a new enzymatic function of microalgal GGH. As proof of concept, we also analyzed the occurrence of these three amphenicols and their degradation intermediate worldwide, which showed a frequent distribution of the investigated chemicals at a global scale. This study describes a novel catalytic enzyme to improve the engineering feasibility of microalgae-based biotechnologies. It also raises issues regarding the different microalgal enzymatic transformations of emerging contaminants because these enzymes might function differently from their counterparts in animals.

Exposure modes determined the effects of nanomaterials on antibiotic resistance genes: The different roles of oxidative stress and quorum sensing

The effects of co-occurrent pollutants on antibiotic resistance genes (ARGs) in wastewater treatment plants (WWTPs) have raised attentions. However, how the different realistic exposure scenarios determining the effects of nanomaterials (NMs) on ARGs, was still unknown. Herein, the effects of NMs on ARGs under two realistic scenarios was investigated by short-term and long-term exposure modes. The presence of NMs with two different exposure modes could both promote the dissemination of ARGs, and the results were dose-, type- and duration-dependent. Compared to short-term exposure, the long-term exposure increased the abundances of ARGs with a greater extent except nano-ZnO. The long-term exposure increased the overall abundances of target ARGs by 2.9%-20.4%, while shot-term exposure caused the 3.4%-10.5% increment. The mechanisms of ARGs fates driven by NMs exposure were further investigated from the levels of microbial community shift, intracellular oxidative stress, and gene abundance. The variations of several potential bacterial hosts did not contribute to the difference in the ARGs transmission with different exposure modes because NMs types played more vital roles in the shift of microbial community compared to the exposure modes. For the short-term exposure, NMs were capable of triggering the QS by upregulating relevant genes, and further activated the production of surfactin and increased membrane permeability, resulting in the facilitation of ARGs transfer. However, NMs under long-term exposure scenario preferentially stimulated oxidative stress by generating more ROS, which then enhanced ARGs dissemination. Therefore, the exposure mode of NMs was one of the pivotal factors determining the ARGs fates by different triggering mechanisms. This study highlighted the importance of exposure scenario of co-occurrent pollutants on ARGs spread, which will benefit the comprehensive understanding of the actual environmental fates of ARGs.

Cyanobacteria mediate the dissemination of bacterial antibiotic resistance through conjugal transfer

Cyanobacterial blooms are expanding world-wide in freshwater and marine environments, and can cause serious ecological and environmental issues, which also contribute to the spread of antibiotic resistance genes (ARGs). However, the mechanistic understanding of cyanobacteria-mediated resistance dynamics is not fully elucidated yet. We selected Microcystis aeruginosa as a model cyanobacteria to illustrate how cyanobacteria mediate the evolution and transfer processes of bacterial antibiotic resistance. The results show that the presence of cyanobacteria significantly decreased the abundance of antibiotic resistant bacteria (ARB) and antibiotic resistant genes (ARGs) by 3%-99% and 2%-18%, respectively. In addition, it clearly altered bacterial community structure, with the dominant genera evolving from Acinetobacter (27%) and Enterobacter (42%) to Porphyrobacter (59%). The abundance of ARGs positively correlated with Proteobacteria and Firmicutes, rather than Cyanobacteria, and Bacteroidetes. In the presence of cyanobacteria, the transfer events of bacterial resistance genes via conjugation were found to decrease by 10%-89% (p < 0.05). Surprisingly, we found an extradentary high transfer frequency (about 0.1) for the ARGs via plasmid conjugation from the bacteria into M. aeruginosa population. It confirmed the role of cyanobacterial population as the competent hosts to facilitate ARGs spreading. Our findings provide valuable information on the risk evaluation of ARGs caused by cyanobacterial blooms in aquatic environments, key for the protection and assessment of aquatic environmental quality.

Global epidemiology and genetic diversity of mcr-positive Klebsiella pneumoniae: A systematic review and genomic analysis

The rapid increase of mcr-positive Klebsiella pneumoniae (K. pneumoniae) has received considerable attention and poses a major public health concern. Here, we systematically analyzed the global distribution of mcr-positive K. pneumoniae isolates based on published articles as well as publicly available genomes. Combining strain information from 78 articles and 673 K. pneumoniae genomes, a total of 1000 mcr-positive K. pneumoniae isolates were identified. We found that mcr-positive K. pneumoniae has disseminated widely worldwide, especially in Asia, with a higher diversity of sequence types (STs). These isolates were disseminated in 57 countries and were associated with 12 different hosts. Most of the isolates were found in China and were isolated from human sources. Moreover, MLST analysis showed that ST15 and ST11 accounted for the majority of mcr-positive K. pneumoniae, which deserve sustained attention in further surveillance programs. mcr-1 and mcr-9 were the dominant mcr variants in mcr-positive K. pneumoniae. Furthermore, a Genome-wide association study (GWAS) demonstrated that mcr-1- and mcr-9-producing genomes exhibited different antibiotic resistance genes (ARGs) and mobile genetic elements (MGEs), thereby indicating a distinct evolutionary path. Notably, the phylogenetic analysis suggested that certain mcr-positive K. pneumoniae genomes from various geographical areas and hosts harbored a high degree of genetic similarities (<20 SNPs), suggesting frequent cross-region and cross-host clonal transmission. Overall, our results emphasize the significance of monitoring and exploring the transmission and evolution of mcr-positive K. pneumoniae in the context of "One health".

Harnessing biotechnology for penicillin production: Opportunities and environmental considerations

Since the discovery of antibiotics, penicillin has remained the top choice in clinical medicine. With continuous advancements in biotechnology, penicillin production has become cost-effective and efficient. Genetic engineering techniques have been employed to enhance biosynthetic pathways, leading to the production of new penicillin derivatives with improved properties and increased efficacy against antibiotic-resistant pathogens. Advances in bioreactor design, media formulation, and process optimization have contributed to higher yields, reduced production costs, and increased penicillin accessibility. While biotechnological advances have clearly benefited the global production of this life-saving drug, they have also created challenges in terms of waste management. Production fermentation broths from industries contain residual antibiotics, by-products, and other contaminants that pose direct environmental threats, while increased global consumption intensifies the risk of antimicrobial resistance in both the environment and living organisms. The current geographical and spatial distribution of antibiotic and penicillin consumption dramatically reveals a worldwide threat. These challenges are being addressed through the development of novel waste management techniques. Efforts are aimed at both upstream and downstream processing of antibiotic and penicillin production to minimize costs and improve yield efficiency while lowering the overall environmental impact. Yield optimization using artificial intelligence (AI), along with biological and chemical treatment of waste, is also being explored to reduce adverse impacts. The implementation of strict regulatory frameworks and guidelines is also essential to ensure proper management and disposal of penicillin production waste. This review is novel because it explores the key remaining challenges in antibiotic development, the scope of machine learning tools such as Quantitative Structure-Activity Relationship (QSAR) in modern biotechnology-driven production, improved waste management for antibiotics, discovering alternative path to reducing antibiotic use in agriculture through alternative meat production, addressing current practices, and offering effective recommendations.

Antimicrobial resistance and prevalence of extended-spectrum beta-lactamase-producing Klebsiella species in East Tennessee dairy farms

Klebsiella species commonly reside in dairy cattle guts and are consistently exposed to beta-lactam antibiotics, including ceftiofur, which are frequently used on the U.S. dairy farms. This may impose selection pressure and result in the emergence of extended-spectrum beta-lactamase (ESBL)-producing strains. However, information on the status and antimicrobial resistance (AMR) profile of ESBL-Klebsiella spp. in the U.S. dairy farms is largely unknown. This study aimed to determine the prevalence and AMR profile of ESBL-Klebsiella spp. and the factors affecting their occurrence in dairy cattle farms. Rectal fecal samples (n = 508) and manure, feed, and water samples (n = 64) were collected from 14 dairy farms in Tennessee. Samples were directly plated on CHROMagar ESBL, and presumptive Klebsiella spp. were confirmed using matrix-assisted laser desorption/ionization-time of flight mass spectrometry. Antimicrobial susceptibility testing was performed on the isolates against panels of 14 antimicrobial agents from 10 classes using minimum inhibitory concentration. Of 572 samples, 57 (10%) were positive for ESBL-Klebsiella spp. The fecal prevalence of ESBL-Klebsiella spp. was 7.2% (95% CI: 6.5-8.0). The herd-level fecal prevalence of ESBL-Klebsiella spp. was 35.7% (95% CI: 12.7-64.8). The fecal prevalence of ESBL-Klebsiella spp. was significantly higher in calves than in cows and higher in cows with higher parity (≥3) as compared to cows with low parity (P < 0.001). Most (96.5%, n = 57) ESBL-Klebsiella spp. were resistant to ceftriaxone. The highest level of acquired co-resistance to ceftriaxone in ESBL-Klebsiella spp. was to sulfisoxazole (66.7%; 38/57). About 19% of ESBL-Klebsiella spp. were multidrug resistant. The presence of ESBL-producing Klebsiella spp. in dairy cattle, feed, and water obtained from troughs could play a crucial epidemiological role in maintaining and spreading the bacteria on farms and serving as a point source of transmission.

IMPORTANCE

We collected 572 samples from dairy farms, including rectal feces, manure, feed, and water. We isolated and identified extended-spectrum beta-lactamase (ESBL)-Klebsiella spp. and conducted an antimicrobial susceptibility test and analyzed different variables that may be associated with ESBL-Klebsiella spp. in dairy farms. The results of our study shed light on how ESBL-Klebsiella spp. are maintained through fecal-oral routes in dairy farms and possibly exit from the farm into the environment. We determine the prevalence of ESBL-Klebsiella spp. and their antimicrobial susceptibility profiles, underscoring their potential as a vehicle for multiple resistance gene dissemination within dairy farm settings. We also collected data on variables affecting their occurrence and spread in dairy farms. These findings have significant implications in determining sources of community-acquired ESBL-Enterobacteriaceae infections and designing appropriate control measures to prevent their spread from food animal production systems to humans, animals, and environments.

Pharmacokinetic/pharmacodynamic model-based optimization of temocillin dosing strategies for the treatment of systemic infections

BACKGROUND

Temocillin is increasingly considered as an alternative to carbapenems. However, there is no consensus on optimal dosing strategies and limited data on temocillin efficacy in systemic infections.

OBJECTIVES

We compared temocillin dosing strategies using pharmacokinetic/pharmacodynamic (PK/PD) modelling and simulation based on plasma exposure and in vitro time-kill data.

METHODS

Temocillin effects on four Escherichia coli strains were evaluated using static time-kill experiments and the hollow-fibre infection model, in which unbound plasma concentrations following intermittent and continuous infusion regimens of 4 and 6 g daily were replicated over 72 h. A PK/PD model was developed to describe the time-kill data. The PK/PD model was coupled to a population PK model of temocillin in critically ill patients to predict bacterial killing and resistance development following various dosing regimens.

RESULTS

Amplification of resistant subpopulations was observed within 24 h for all strains. The PK/PD model described the observed bacterial kill kinetics and resistance development from both experimental systems well. Simulations indicated dose-dependent bacterial killing within and beyond the currently used daily dose range, and a superiority of continuous compared with intermittent infusions. However, regrowth of resistant subpopulations was frequently observed. For two strains, bacteriostasis over 72 h was predicted only with doses that are higher than those currently licensed.

CONCLUSIONS

Continuous infusions and 6 g daily doses of temocillin kill E. coli more effectively than 4 g daily doses and intermittent infusions, and may increase efficacy in the treatment of systemic infections. However, higher daily doses may be required to suppress resistance development.

An early and stable mouse model of polymyxin-induced acute kidney injury

BACKGROUND

Polymyxins have been revived as a last-line therapeutic option for multi-drug resistant bacteria and continue to account for a significant proportion of global antibiotic usage. However, kidney injury is often a treatment limiting event with kidney failure rates ranging from 5 to 13%. The mechanisms underlying polymyxin-induced nephrotoxicity are currently unclear. Researches of polymyxin-associated acute kidney injury (AKI) models need to be more standardized, which is crucial for obtaining consistent and robust mechanistic results.

METHODS

In this study, male C57BL/6 mice received different doses of polymyxin B (PB) and polymyxin E (PE, also known as colistin) by different routes once daily (QD), twice daily (BID), and thrice daily (TID) for 3 days. We continuously monitored the glomerular filtration rate (GFR) and the AKI biomarkers, including serum creatinine (Scr), blood urea nitrogen (BUN), neutrophil gelatinase-associated lipocalin (NGAL), and kidney injury molecule-1 (KIM-1). We also performed histopathological examinations to assess the extent of kidney injury.

RESULTS

Mice receiving PB (35 mg/kg/day subcutaneously) once daily exhibited a significant decrease in GFR and a notable increase in KIM-1 two hours after the first dose. Changes in GFR and KIM-1 at 24, 48 and 72 h were consistent and demonstrated the occurrence of kidney injury. Histopathological assessments showed a positive correlation between the severity of kidney injury and the changes in GFR and KIM-1 (Spearman's rho = 0.3167, P = 0.0264). The other groups of mice injected with PB and PE did not show significant changes in GFR and AKI biomarkers compared to the control group.

CONCLUSION

The group receiving PB (35 mg/kg/day subcutaneously) once daily consistently developed AKI at 2 h after the first dose. Establishing an early and stable AKI model facilitates researches into the mechanisms of early-stage kidney injury. In addition, our results indicated that PE had less toxicity than PB and mice receiving the same dose of PB in the QD group exhibited more severe kidney injury than the BID and TID groups.

Source apportionment and specific-source-site risk of quinolone antibiotics for effluent-receiving urban rivers and groundwater in a city, China

There is a large surface-groundwater exchange downstream of wastewater treatment plants (WWTPs), and antibiotics upstream may influence sites downstream of rivers. Thus, samples from 9 effluent-receiving urban rivers (ERURs) and 12 groundwater sites were collected in Shijiazhuang City in December 2020 and April 2021. For ERURs, 8 out of 13 target quinolone antibiotics (QNs) were detected, and the total concentration of QNs in December and April were 100.6-4,398 ng/L and 8.02-2,476 ng/L, respectively. For groundwater, all target QNs were detected, and the total QNs concentration was 1.09-23.03 ng/L for December and 4.54-170.3 ng/L for April. The distribution of QNs was dissimilar between ERURs and groundwater. Most QN concentrations were weakly correlated with land use types in the system. The results of a positive matrix factorization model (PMF) indicated four potential sources of QNs in both ERURs and groundwater, and WWTP effluents were the main source of QNs. From December to April, the contribution of WWTP effluents and agricultural emissions increased, while livestock activities decreased. Singular value decomposition (SVD) results showed that the spatial variation of most QNs was mainly contributed by sites downstream (7.09%-88.86%) of ERURs. Then, a new method that combined the results of SVD and PMF was developed for a specific-source-site risk quotient (SRQ), and the SRQ for QNs was at high level, especially for the sites downstream of WWTPs. Regarding temporal variation, the SRQ for WWTP effluents, aquaculture, and agricultural emissions increased. Therefore, in order to control the antibiotic pollution, more attention should be paid to WWTP effluents, aquaculture, and agricultural emission sources for the benefit of sites downstream of WWTPs.

Does exposure timing of macrolide antibiotics affect the development of river periphyton? Insights into the structure and function

Discharged sewage is the dominant source of urban river pollution. Macrolide antibiotics have emerged as prominent contaminants, which are frequently detected in sewage and rivers and pose a threat to aquatic microbial community. As a typical primary producer, periphyton is crucial for maintaining the biodiversity and functions of aquatic ecosystem. However, effects of antibiotic exposure time as well as the recovery process of periphyton remain undetermined. In the present study, five exposure scenarios of two typical macrolides, erythromycin (ERY) and roxithromycin (ROX) were investigated at 50 µg/L, dose to evaluate their potential detrimental effects on the structure and function of periphyton and the subsequent recovery process in 14 days. Results revealed that the composition of periphytic community returned to normal over the recovery period, except for a few sensitive species. The antibiotics-caused significant photodamage to photosystem II, leading to continuous inhibition of the photosynthetic capacity of periphyton. Furthermore, no significant difference in carbon metabolism capacity was observed after direct antibiotic exposure, while the amine carbon utilization capacity of periphyton remarkably increased during the recovery process. These results indicated that periphyton community was capable of coping with the periodic exposure of antibiotic pollutants and recovering on its own. However, the ecological functions of periphyton can be permanently disturbed due to macrolide exposure. Overall, this study sheds light on the influence of macrolide exposure on the development, structure and function of the periphytic microbial community in rivers.

Great truths are always simple: A millimeter-sized macroscopic lanthanum-calcium dual crosslinked carboxymethyl chitosan aerogel bead as a promising adsorbent for scavenging oxytetracycline from wastewater

Given their increasing environmental and health harms, it is crucial to develop green and sustainable techniques for scavenging antibiotics represented by oxytetracycline (OTC) from wastewater. In the present work, a structurally simple lanthanum-calcium dual crosslinked carboxymethyl chitosan (CMCS-La3+-Ca2+) aerogel was innovatively synthesized for adsorptive removal of OTC. It was found that CMCS and La3+ sites collaboratively participated in OTC elimination, and OTC removal peaked over the wide pH range of 4-7. The process of OTC sorption was better described by the pseudo-second-order kinetic model and Redlich-Peterson model, and the saturated uptake amount toward OTC was up to 580.91 mg/g at 303 K, which was comparable to the bulk of previous records. The as-fabricated composite also exerted exceptional capture capacity toward OTC in consecutive adsorption-desorption runs and high-salinity wastewater. Amazingly, its packed column continuously ran for over 60 h with a dynamic uptake amount of 215.21 mg/g until the adsorption was saturated, illustrating its great potential in scale-up applications. Mechanism studies demonstrated that multifarious spatially-isolated reactive sites of CMCS-La3+-Ca2+ cooperatively involved in OTC capture via multi-mechanisms, such as n-π EDA interaction, H-bonding, La3+-complexation, and cation-π bonding. All the above superiorities endow it as a promising adsorbent for OTC-containing wastewater decontamination.

Co-metabolism of microorganisms: A study revealing the mechanism of antibiotic removal, progress of biodegradation transformation pathways

The widespread use of antibiotics has resulted in large quantities of antibiotic residues entering aquatic environments, which can lead to the development of antibiotic-resistant bacteria and antibiotic-resistant genes, posing a potential environmental risk and jeopardizing human health. Constructing a microbial co-metabolism system has become an effective measure to improve the removal efficiency of antibiotics by microorganisms. This paper reviews the four main mechanisms involved in microbial removal of antibiotics: bioaccumulation, biosorption, biodegradation and co-metabolism. The promotion of extracellular polymeric substances for biosorption and extracellular degradation and the regulation mechanism of enzymes in biodegradation by microorganisms processes are detailed therein. Transformation pathways for microbial removal of antibiotics are discussed. Bacteria, microalgae, and microbial consortia's roles in antibiotic removal are outlined. The factors influencing the removal of antibiotics by microbial co-metabolism are also discussed. Overall, this review summarizes the current understanding of microbial co-metabolism for antibiotic removal and outlines future research directions.

Trends and geographical variations in outpatient antimicrobial consumption in Ireland in relation to socio-economic deprivation

Background

Different factors have been associated with changes in antimicrobial consumption rates in Ireland, however the relationship between socio-economic deprivation and antimicrobial consumption has not been explored. The presented ecological analysis explores the temporal and geographical variation in outpatient antimicrobial consumption and socio-economic deprivation in Ireland from January 2015 to March 2022.

Method

Deprivation index (DI) was used as a socio-economic proxy. A multilevel mixed model was applied to explore temporal variation and analyse the longitudinal antimicrobial consumption (DID) in relation to DI. Furthermore, maps were generated based on antimicrobial consumption rates, and spatial autocorrelation analyses were carried out to study geographical variation in antimicrobial consumption rates.

Results

The antimicrobial consumption rates per month varied from 26.2 DID (January 2015) to 22.1 DID (March 2022) showing an overall reduction of 16 %. Overall, total antimicrobial consumption in the multilevel model showed a consistent correlation with higher DI score (6.6 (95%CI 3.9 to 9.3)), and winter season (3.6 (95%CI 3.2 to 3.9)). In contrast, before COVID-19 showed significant lower antimicrobial consumption rates compared to during COVID-19 (-4.0 (95%CI -4.7 to -3.23)). No consistent trends were observed for geographical variation between areas.

Conclusion

Antimicrobial consumption rates decreased from 2015 to 2021 in Ireland. No geographical patterns were observed in antimicrobial consumption rates but associations between deprivation and antimicrobial consumption rates were observed.

Global Antimicrobial Susceptibility Patterns of Staphylococcus aureus in Atopic Dermatitis: A Systematic Review and Meta-Analysis

Importance

Individuals with atopic dermatitis are frequently colonized and infected with Staphylococcus aureus. Empirical antibiotic therapy for individuals with atopic dermatitis is common, but data about the antimicrobial susceptibility profiles of S aureus strains isolated from these individuals are scarce for those living in particular geographic areas.

Objective

To determine the antimicrobial susceptibility of S aureus from individuals with atopic dermatitis and analyze differences according to the income level of the country of origin and the data collection period.

Data Sources

A meta-analysis of the literature was performed from the inception of the included databases (MEDLINE, Embase, Web of Science, Scopus, and Cochrane) to June 20, 2023, using predetermined Medical Subject Headings.

Study Selection

Studies were included if they reported antibiotic susceptibility profiles of 1 or more S aureus cutaneous isolates from individuals with atopic dermatitis. Articles written in English, Spanish, French, or German were included.

Data Extraction and Synthesis

Working in pairs, 6 of the authors conducted the data extraction. The guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

Main Outcomes and Measures

The outcome of interest was antimicrobial susceptibility.

Results

A total of 61 studies reported 4091 S aureus isolates from individuals with atopic dermatitis. For 4 of the 11 commonly used antibiotics (36.4%), antimicrobial susceptibility was 85% or less, including for methicillin (binomial proportion, 0.85 [95% CI, 0.76-0.91]), erythromycin (binomial proportion, 0.73 [95% CI, 0.61-0.83]), fusidic acid (binomial proportion, 0.80 [95% CI, 0.62-0.91]), and clindamycin (binomial proportion, 0.79 [95% CI, 0.65-0.89]). Most studies (46; 75.4%) were conducted in high-income countries. Antimicrobial susceptibility to erythromycin, methicillin, and trimethoprim and sulfamethoxazole was significantly lower in lower middle-income countries and upper middle-income countries. Regarding the temporal trends, 33 studies (54.1%) reported data collected from 1998 to 2010. Antimicrobial susceptibility patterns have not changed over time.

Conclusions and Relevance

In this systematic review and meta-analysis, antimicrobial susceptibility of S aureus to β-lactams, erythromycin, clindamycin, and fusidic acid may be suboptimal for empirical use in individuals with atopic dermatitis. Significant differences in antimicrobial susceptibility patterns were found in high-income countries and in lower middle-income countries and upper middle-income countries for some antibiotics.

Long-term antibiotic prophylaxis for prevention of rheumatic fever recurrence and progression to rheumatic heart disease

BACKGROUND

Rheumatic fever is a non-suppurative, inflammatory sequela of group A Streptococcus pharyngitis that can occur at two to four weeks after infection. Following an episode of rheumatic fever, there is a risk of developing rheumatic heart disease (RHD) later in life that carries significant risk of morbidity and mortality. RHD remains the largest global cause of cardiovascular disease in the young (age < 25 years). The historical literature provides inconclusive evidence that antibiotic prophylaxis is beneficial in reducing the risk of recurrence of rheumatic fever and development of RHD. Antibiotics are thought to work by reducing the carriage of group A Streptococcus and thus reducing the risk of infection. This review was commissioned by the World Health Organization (WHO) for an upcoming guideline.

OBJECTIVES

1. To assess the effects of long-term antibiotics versus no antibiotics (control) for secondary prevention of rheumatic fever recurrence and associated sequelae in people with previous rheumatic fever or RHD. 2. To assess the effects of long-term intramuscular penicillin versus long-term oral antibiotics for secondary prevention of rheumatic fever recurrence and associated sequelae in people with previous rheumatic fever or RHD.

SEARCH METHODS

We systematically searched CENTRAL, MEDLINE, Embase, Conference Proceedings Citation Index-Science, clinical trial registers, ISRCTN.com and reference lists without restrictions on language or date up to 10 March 2024.

SELECTION CRITERIA

We sought randomised controlled trials or quasi-randomised trials, described in any language, including participants with previous rheumatic fever and/or RHD of any age, based in community or hospital settings. Studies were included if they compared firstly antibiotic prophylaxis with no antibiotic prophylaxis, and, secondly, intramuscular penicillin prophylaxis versus oral antibiotic prophylaxis.

DATA COLLECTION AND ANALYSIS

We used standardised methodological, Cochrane-endorsed procedures and performed meta-analyses with risk ratios (RR) and Peto odds ratios (Peto OR). Our primary outcomes were recurrence of rheumatic fever, progression or severity of RHD and cardiac complications. Our secondary outcomes were obstetric complications (maternal and foetal events), mortality, treatment adherence, adverse events and acceptability to participants. We performed comprehensive assessments of risk of bias and certainty of evidence, applying the GRADE methodology.

MAIN RESULTS

We included 11 studies (seven RCTs and four quasi-randomised trials) including 3951 participants. The majority of the included studies were conducted in the USA, UK and Canada during the 1950s to 1960s. Most participants with previous rheumatic fever had been diagnosed using the modified Jones criteria (mJC) (four studies), were an average of 12.3 years of age and 50.6% male. We assessed the majority of the included studies to be at high risk of bias, predominantly relating to blinding and attrition bias. Comparison one: antibiotics versus no antibiotics Pooled meta-analysis of six RCTs provides moderate-certainty evidence that antibiotics overall (oral or intramuscular) probably reduce the risk of recurrence of rheumatic fever substantially (0.7% versus 1.7%, respectively) (risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.69; 1721 participants). People with early or mild RHD likely have the greatest capacity to benefit from intramuscular antibiotic prophylaxis (8.1%) compared to no antibiotics (0.7%) (RR 0.09, 95% CI 0.03 to 0.29; 1 study, 818 participants; moderate-certainty evidence). Antibiotics may not affect mortality in people with late-stage RHD (RR 1.23, 95% CI 0.78 to 1.94; 1 study, 994 participants; low-certainty evidence). Antibiotics may not affect the risk of anaphylaxis (Peto odds ratio (OR) 7.39, 95% CI 0.15 to 372; 1 study, 818 participants; low-certainty evidence) or sciatic nerve injury (Peto OR 7.39, 95% CI 0.15 to 372; 1 study, 818 participants; low-certainty evidence) compared with no antibiotics, but probably have an increased risk of hypersensitivity reactions (RR 137, 8.51 to 2210; 2 studies, 894 participants; moderate-certainty evidence) and local reactions (RR 29, 1.74 to 485; 1 study, 818 participants; moderate-certainty evidence). Comparison two: intramuscular antibiotics versus oral antibiotics Pooled analysis of two RCTs showed that prophylactic intramuscular benzathine benzylpenicillin likely reduces recurrence of rheumatic fever substantially when compared to oral antibiotics (0.1% versus 1%, respectively) (RR 0.07, 95% CI 0.02 to 0.26; 395 participants; moderate-certainty evidence). Furthermore, it is unclear whether intramuscular benzyl penicillin is superior to oral antibiotics in reducing the risk of mortality in the context of RHD (Peto OR 0.22, 95% CI 0.01 to 4.12; 1 study, 431 participants; very low-certainty evidence). There were no data available on progression of latent RHD or adverse events including anaphylaxis, sciatic nerve injury, delayed hypersensitivity/allergic reactions and local reactions to injection.

AUTHORS' CONCLUSIONS

This review provides evidence that antibiotic prophylaxis likely reduces the risk of recurrence of rheumatic fever compared to no antibiotics, and that intramuscular benzathine benzylpenicillin is probably superior to oral antibiotics (approximately 10 times better). Moreover, intramuscular benzathine benzylpenicillin likely reduces the risk of progression of latent RHD. Evidence is scarce, but antibiotics compared with no antibiotics may not affect the risk of anaphylaxis or sciatic nerve injury, but probably carry an increased risk of hypersensitivity reactions and local reactions. Antibiotics may not affect all-cause mortality in late-stage RHD compared to no antibiotics. There is no evidence available to comment on the effect of intramuscular penicillin over oral antibiotics for progression of latent RHD and adverse events, and little evidence for all-cause mortality. It is important to interpret these findings in the context of major limitations, including the following: the vast majority of the included studies were conducted more than 50 years ago, many before contemporary echocardiographic studies; methodology was often at high risk of bias; outdated treatments were used; only one study was in latent RHD; and there are concerns regarding generalisability to low socioeconomic regions. This underlines the need for ongoing research to understand who benefits most from prophylaxis.

'Primary' antibiotics in wastewater treatment plants

There are anywhere from 5 to 8 priority antibiotics in typical wastewater treatment plants (WWTPs) whose concentrations exceed the maximum allowed, out of 12 priority antibiotics designated by the World Health Organization as the species to pose severe health hazard than others. If the priority antibiotics to deal with could be reduced to just one or two, such reduction would greatly simplify the construction and operation of the treatment plants. Introduced here is a concept of 'primary' antibiotic, the abatement of which ensures mitigation of all the other priority antibiotics in the wastewater. A criterion for determining primary antibiotic is developed. For a demonstration of the approach, the wastewater systems treated with solar-based photocatalysts are considered. The criterion reveals that the primary antibiotic in the typical European WWTP as well as in the typical municipal and hospital wastewater is ciprofloxacin, whereas the typical industrial wastewater contains ciprofloxacin and oxytetracycline.

Effect of rotavirus vaccination on the burden of rotavirus disease and associated antibiotic use in India: A dynamic agent-based simulation analysis

BACKGROUND

Rotavirus is a leading cause of diarrhea in infants and young children in many low- and middle-income countries. India launched a childhood immunization program for rotavirus in 2016, starting with four states and expanding it to cover all states by 2019. The objective of this study was to estimate the effects of the rotavirus vaccination program in India on disease burden and antibiotic misuse.

METHODS

We built a dynamic agent-based model of rotavirus progression in children under five within each district in India. Simulations were run for various scenarios of vaccination coverage in the context of India's Universal Immunization Programme. Population data were obtained from the National Family Household Surveys and used to calibrate the models. Disease parameters were obtained from published studies. We estimated past and projected future reduction of disease burden and antibiotic misuse due to full vaccination nationwide, by state, and by wealth quintile.

RESULTS

We estimate that rotavirus vaccination in India has reduced the prevalence of rotavirus cases by 33.7% (prediction interval: 30.7-36.0%), total antibiotic misuse due to rotavirus by 21.8% (18.6-25.1%), and total deaths due to rotavirus by 38.3% (31.3-44.4%) for children under five. We estimate total antibiotic misuse due to rotavirus infection to be 7.6% (7.5-7.9%) of total antibiotic consumption in this demographic versus 9.6% (9.4-9.9%) in the absence of vaccination. We project rotaviral prevalence to drop to below one case for every 100,000 individuals in those below five if vaccination coverage is increased by 50.3% (45.2-58.5%) to 68.1% (63.1-76.4) nationwide.

CONCLUSION

Universal coverage of childhood rotavirus vaccination can substantially reduce inappropriate antibiotic use in India.

Effect of sponge city facilities on the exposure characteristics and ecological risks of antibiotics in urban inland lakes: A case study at Fuzhou, China

Antibiotics are increasingly found in urban lakes, posing significant ecological risks to lake ecosystems. The impact of sponge city facilities on urban flood control is significant; however, their influence on the exposure characteristics and risks associated with antibiotics in urban inland lakes remains unclear. This study investigated the exposure characteristics and evaluated the ecological risks of 15 antibiotics across seven lakes of Fuzhou (as the target of sponge city) in different seasons, in comparison to non-sponge cities. The results revealed that 12 antibiotics were consistently detectable across all lakes, with concentrations ranging from non-detectable (ND) to 20.61 ng/L, with sulfamethoxazole (SMX) emerging as the predominant contaminant. Most antibiotics exhibited higher concentrations in the dry season, attributed to environmental conditions, biological mechanisms, and their physicochemical properties. SMX, tetracycline (TTC), oxytetracycline (OTC), and ciprofloxacin (CIP) posed moderate to high ecological risks, with risk quotient (RQ) values of 0.46, 0.14, 0.17, and 0.61, respectively, while the remaining antibiotics presented lower ecological risks in both seasons. Notably, the RQ values for TTC, OTC, and CIP were elevated during the dry season, whereas SMX displayed a higher RQ value in the wet season, indicating an increased ecological risk during the dry months. In comparison to non-sponge cities, sponge cities exhibited significantly lower concentrations of nearly all antibiotics, particularly during the wet season (p ≤ 0.05). Moreover, over 85% of the antibiotics in non-sponge cities were classified as high risk, contrasted with only 55% in sponge cities, underscoring the heightened ecological risks associated with non-sponge urban designs. This study provides critical insights for controlling antibiotic pollution in the lakes of Fuzhou and serves as a valuable reference for maintaining aquatic ecosystem health through the implementation of sponge city infrastructure.

Integrative multi-omics analysis reveals the underlying toxicological mechanisms of enrofloxacin on the growth of wheat seedling roots

The continuous release of antibiotics into agroecosystems has raised concerns about the potential negative effects of antibiotic residues on crops. In this study, the toxicological effects of enrofloxacin (ENR) on wheat seedlings were analyzed using a combination of morpho-physiological, transcriptomic, proteomic, and metabolomic approaches. ENR inhibited the growth of wheat (Triticum aestivum L.) roots and induced oxidative stress. In particular, ENR downregulated the oxidative phosphorylation pathway, while it enhanced glycolysis and the tricarboxylic acid cycle, thereby regulating the balance of intracellular energy metabolism. In addition, sustained exposure to excessive reactive oxygen species (ROS) resulted in an increase in reduced glutathione (GSH), a slight decrease in ascorbic acid (AsA), and a significant decrease in the ratio of GSH to oxidized glutathione (GSSG), which imbalanced the AsA-GSH cycle. In addition, the resulting increase in abnormal proteins triggered ubiquitin-independent proteasomal degradation pathways. Further, an increase in abscisic acid (ABA) and a decrease in jasmonic acid (JA) and its derivatives alleviated the inhibitory effect of ENR on the growth of wheat roots. In conclusion, direct damage and signaling by ROS, hormonal regulation, a decrease in the GSH to GSSG ratio, and insufficient energy supply were identified as key factors for the significant inhibition of wheat root growth under ENR stress.

Profiles, drivers, and prioritization of antibiotics in China's major rivers

Through a systematic review of literature references from 2007 to 2022, we compiled a comprehensive national dataset comprising over 67,000 records and covering information on 129 antibiotics detected in the surface water and sediments of China's major rivers. Our analysis revealed notably high antibiotic concentrations in the Liaohe and Yellow Rivers. Among the antibiotics examined, sulfonamides, quinolones, and tetracyclines exhibited relatively high median concentrations in river water. Regional distribution analysis highlighted increased antibiotic levels in Shandong and Tianjin compared to other areas. Partial least squares path modeling revealed that animal production and pollution discharge positively influenced antibiotic levels in river water, whereas natural and socioeconomic factors had negative impacts. Based on the ecological risk assessment, we formulated a prioritized national list of antibiotics, with sulfonamides having the largest number of entries, followed by quinolones. Importantly, our analysis revealed a declining trend in antibiotic concentrations and the associated risk levels across China during the study period. This study not only enhances our understanding of antibiotic distribution in China's water systems, but also contributes to the development of a scientifically sound approach for prioritizing antibiotics. Ultimately, these findings will inform targeted antibiotic management and control strategies. ENVIRONMENTAL IMPLICATION: Antibiotics, posing threats to ecosystems and human health, exhibit pseudo-persistence in the environment. we compiled a national dataset of over 67,000 records on antibiotics, our study scrutinized antibiotic distribution in China's major river water and sediment. Through this analysis, we identified key factors influencing distribution patterns and crafted a national priority ranking for antibiotics. These findings deepen our understanding of antibiotic presence and contribute to the development of targeted management strategies aimed at minimizing environmental impact.

Exploring Antibiotic Use in the Community: A Household-Based Survey Using the Drug Bag Method in Rural Burkina Faso

In Burkina Faso, there is lack of awareness of antibiotic use at the community level. This study aims to generate information on the commonly used antibiotics along with the reasons for which they have been used in rural Burkina Faso. The drug bag method was employed to collect information from 423 households in the health district of Nanoro. Descriptive analyses were performed using R software version 4.2.1. Of the 33 antibiotics inventoried, amoxicillin tablets and oxytetracycline were the most recognized and used antibiotics. This study indicated that antibiotics were used for a range of health problems in the community, some of which were administered as painkillers. While primary healthcare facilities constituted the primary source of drugs for households (76.8%), informal drug sellers constituted an additional option (61.5%) for community members. This is a significant concern, given that some antibiotics classified as "Watch"-such as norfloxacin-were readily available in these outlets, despite not being included on the country's Essential Medicines List. This study underscores the necessity of considering the role played by formal providers in the inappropriate use of antibiotics and the importance of understanding the circumstances and logical reasoning underlying communities' access to and use of antibiotics.

Context-Seq: CRISPR-Cas9 Targeted Nanopore Sequencing for Transmission Dynamics of Antimicrobial Resistance

Antimicrobial resistance (AMR) aligns with a One Health framework in that resistant bacteria and antibiotic resistance genes (ARGs) can be transmitted between humans, animals, and the environment. However, there is a critical need to more precisely understand how and to what extent AMR is exchanged between animals and humans. Metagenomic sequencing has low detection for rare targets such as ARGs, while whole genome sequencing of isolates is burdensome and misses exchange between uncultured bacterial species. We developed a novel, targeted sequencing assay using CRISPR-Cas9 to selectively sequence ARGs and their genomic context with long-read sequencing. Using this method, termed Context-Seq, we investigated overlapping AMR elements containing the ARGs bla CTX-M and bla TEM between adults, children, poultry, and dogs in animal-owning households in Nairobi, Kenya. We identified 22 genetically distinct clusters (> 80%ID over ≥ 3000 bp) containing bla TEM and one cluster containing bla CTX-M that were shared within and between households. Half of the clusters were shared between humans and animals, while the other half were shared only between animals (poultry-poultry, dog-dog, and dog-poultry). We identified potentially pathogenic hosts of ARGs including Escherichia coli, Klebsiella pneumonia, and Haemophilus influenzae across sample types. Context-Seq complements conventional methods to obtain an additional view of bacterial and mammalian hosts in the proliferation of AMR.

Arcopilins: A New Family of Staphylococcus aureus Biofilm Disruptors from the Soil Fungus Arcopilus navicularis

Biofilms represent a key challenge in the treatment of microbial infections; for instance, Staphylococcus aureus causes chronic or fatal infections by forming biofilms on medical devices. Herein, the fungus Arcopilus navicularis was found to produce a novel family of PKS-NRPS metabolites that are able to disrupt preformed biofilms of S. aureus. Arcopilins A-F (1-6), tetramic acids, and arcopilin G (7), a 2-pyridone, were elucidated using HR-ESI-MS and one-dimensional (1D) and two-dimensional (2D) nuclear magnetic resonance (NMR) spectroscopy. Their absolute configuration was established by the synthesis of MPTA-esters for 2, analysis of 1H-1H coupling constants, and ROESY correlations, along with comparison with the crystal structure of 7. Arcopilin A (1) not only effectively disrupts preformed biofilms of S. aureus but also potentiates the activity of gentamicin and vancomycin up to 115- and 31-fold times, respectively. Our findings demonstrate the potential application of arcopilins for the conjugated treatment of infections caused by S. aureus with antibiotics unable to disrupt preformed biofilms.

Surveillance of antimicrobial utilization in Africa: a systematic review and meta-analysis of prescription rates, indications, and quality of use from point prevalence surveys

BACKGROUND

Antimicrobial resistance (AMR) is a global public health concern that is fueled by the overuse of antimicrobial agents. Low- and middle-income countries, including those in Africa,. Point prevalence surveys (PPS) have been recognized as valuable tools for assessing antimicrobial utilization and guiding quality improvement initiatives. This systematic review and meta-analysis aimed to evaluate the prescription rates, indications, and quality of antimicrobial use in African health facilities.

METHODS

A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Embase, Hinari (Research4Life) and Google Scholar. Studies reporting the point prevalence of antimicrobial prescription or use in healthcare settings using validated PPS tools were included. The quality of the studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist. A random-effects meta-analysis was conducted to combine the estimates. Heterogeneity was evaluated using Q statistics, I² statistics, meta-regression, and sensitivity analysis. Publication bias was assessed using a funnel plot and Egger's regression test, with a p-value of < 0.05 indicating the presence of bias.

RESULTS

Out of 1790 potential studies identified, 32 articles were included in the meta-analysis. The pooled prescription rate in acute care hospitals was 60%, with significant heterogeneity (I2 = 99%, p < 0.001). Therapeutic prescriptions constituted 62% of all the prescribed antimicrobials. Prescription quality varied: documentation of reasons in notes was 64%, targeted therapy was 10%, and parenteral prescriptions were 65%, with guideline compliance at 48%. Hospital-acquired infections comprised 20% of all prescriptions. Subgroup analyses revealed regional disparities in antimicrobial prescription prevalence, with Western Africa showing a prevalence of 65% and 44% in Southern Africa. Publication bias adjustment estimated the prescription rate at 54.8%, with sensitivity analysis confirming minor variances among studies.

CONCLUSION

This systematic review and meta-analysis provide valuable insights into antimicrobial utilization in African health facilities. The findings highlight the need for improved antimicrobial stewardship and infection control programs to address the high prevalence of irrational antimicrobial prescribing. The study emphasizes the importance of conducting regular surveillance through PPS to gather reliable data on antimicrobial usage, inform policy development, and monitor the effectiveness of interventions aimed at mitigating AMR.

Prevalence of inappropriate antibiotic doses among pediatric patients of inpatient, outpatient, and emergency care units in Bangladesh: A cross-sectional study

The heterogeneous pediatric populations, their physiological differences, along with the necessity of performing additional dose calculation, make the pediatric population more vulnerable to the incidences of inappropriate antibiotic doses. This study was conducted to examine and evaluate the appropriateness of antibiotic doses. A cross-sectional study with a quantitative approach was conducted in three hospitals located in Savar from January 06, 2021 to October 17, 2022. This study had used a convenient sampling method to collect 405 filled prescription orders from heterogeneous pediatric patients prescribed by physicians from emergency, inpatient, and outpatient care units of various clinical settings. The Harriet Lane Handbook was used as reference to investigate inappropriate doses of antibiotics. Subsequently, all analyses were conducted using the RStudio 1.3.959 software. Binary logistic regression was used to assess the risk of inappropriate antibiotic prescription in pediatrics. The overall prevalence of inappropriate antibiotic dosing in pediatrics was 335 out of 545 (61.5%). Overdosing (36.3%) and oral antibiotic prescriptions (64%) were more common than underdosing (20.4%) and parenteral antibiotics (36%). The majority (230 out of 405, 56.8%) of pediatric patients had prescriptions with inappropriate antibiotic doses, with prevalence rates of 33.8% for inpatients, 86.7% for outpatients, and 50% for emergency pediatrics. The results also indicated that pediatric patients in outdoor and emergency care units, infants, toddlers, and early childhood, those prescribed two antibiotics simultaneously, and those receiving parenteral antibiotics, were less likely to have inappropriate antibiotic dosages in their prescriptions. This study demonstrated that about one out of every two prescriptions had inappropriate antibiotic doses; in particular, prescriptions containing only one antibiotic exhibited a substantial proportion of inappropriate antibiotic doses. Inappropriate antibiotic doses may result in therapeutic failure, patient harm, and antibiotic resistance. Good clinical pharmacy practice and careful adherence to pediatric dosing standards may minimize inappropriate antibiotic doses.

Antimicrobial prescription pattern and appropriateness for respiratory tract infection in outpatients: a systematic review and meta-analysis

BACKGROUND

Millions of people die every year as a result of antimicrobial resistance worldwide. An inappropriate prescription of antimicrobials (e.g., overuse, inadequate use, or a choice that diverges from established guidelines) can lead to a heightened risk of antimicrobial resistance. This study aimed to determine the rate and appropriateness of antimicrobial prescriptions for respiratory tract infections.

METHODS

This review was conducted in accordance with the PRISMA guidelines. Web of Science, PubMed, ProQuest Health and Medicine, and Scopus were searched between October 1, 2023, and December 15, 2023, with no time constraints. Studies were independently screened by the first author and the co-authors. We included original studies reporting antimicrobial prescription patterns and appropriateness for respiratory tract infections. The quality of included studies' was assessed via the Joanna Briggs Institute's Critical Appraisal Checklists for Cross-Sectional Studies. The assessment of publication bias was conducted using a funnel plot and Egger's regression test. A random effect model was employed to estimate the pooled antibiotic prescribing and inappropriate rates. Subgroup analysis was conducted by country, study period, data source, and age group.

RESULTS

Of the total 1220 identified studies, 36 studies were included in the review. The antimicrobial prescribing rate ranged from 25% (95% CI 0.24-0.26) to 90% (95% CI 0.89-0.91). The pooled antimicrobial prescription rate was 66% (95% CI 0.57 to 0.73). Subgroup analysis by region revealed that the antimicrobial prescription rate was highest in Africa (79%, 95% CI 0.48-0.94) and lowest in Europe (47%, 95% CI 0.32-0.62). Amoxicillin and amoxicillin-clavulanate antimicrobials from the Access group, along with azithromycin and erythromycin from the Watch group, were the most frequently used antimicrobial agents. This study revealed that the major reasons for antimicrobial prescription were acute bronchitis, pharyngitis, sinusitis, and the common cold. The pooled inappropriate antimicrobial prescription rate was 45% (95% CI 0.38-0.52). Twenty-eight of the included studies reported that prescribing antimicrobials without proper indications was the main cause of inappropriate antimicrobial prescriptions. Additionally, subgroup analysis by region showed a higher inappropriate antimicrobial prescription rate in Asia at 49% (95% CI 0.38-0.60). The result of the funnel plot and Egger's tests revealed no substantial publication bias (Egger's test: p = 0.268).

CONCLUSION

The prescribing rate and inappropriate use of antimicrobials remain high and vary among countries. Further studies should be conducted to generate information about factors contributing to unnecessary antimicrobial prescriptions in outpatients.

SYSTEMATIC REVIEW REGISTRATION

Systematic review registration: CRD42023468353.

Prevalence of systemic antibacterial use during pregnancy worldwide: A systematic review

OBJECTIVES

In this study, we aimed to systematically review the literature of the prevalence of systemic antibacterial use during pregnancy and to perform a descriptive analysis focused on methodological characteristics.

MATERIALS AND METHODS

This study was registered in PROSPERO under protocol number CRD42022376634. Medline, Embase, Scientific Electronic Library Online, Biblioteca Virtual em Saúde, Cumulative Index to Nursing and Allied Health Literature, and Web of Science databases were searched (published studies until November 3rd, 2022). Selected studies were population-based cross-sectional or cohort, carried out with pregnant women, and providing information about the prevalence of systemic antibacterial use at least in one trimester of pregnancy. Reviewers conducted in pairs the title and abstract screening, eligibility criteria check, and data extraction of selected studies. Quality appraisal was performed with an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Data of included studies were pooled into a graphical and tabular summary.

RESULTS

A total of 16,251,280 pregnant women and 5,169,959 pregnancy registers were identified. The prevalence estimates of systemic antibacterial use during pregnancy ranged from 2.0% (95%CI 2.0-2.0) to 64.3% (95%CI not reported) in the 79 included studies. The majority were performed in high-income countries (91.5%). Overall, the studies revealed considerable prevalence heterogeneity in terms of study type and dataset used. The 95% confidence intervals were not reported in 41% of studies.

CONCLUSION

The disparities in the prevalence of systemic antibacterial use during pregnancy can be related to methodological issues and different health policies. Lack of uniform databases and changes in data collection methods over time should be taken into account in public health strategy planning. The scarce evidence in low- and middle-income settings hampers the comprehensiveness of the global prevalence of antibacterial use during pregnancy.

Microbiology testing capacity and antimicrobial drug resistance in surgical-site infections: a post-hoc, prospective, secondary analysis of the FALCON randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical-site infection (SSI) is one of the most common health-care-associated infections, substantially contributing to antibiotic use. Targeted antibiotic prophylaxis to prevent SSIs and effective treatment are crucial to controlling antimicrobial resistance (AMR). This study aimed to describe the testing capacity and multidrug resistance (MDR) of SSI microorganisms in low-income and middle-income countries (LMICs).

METHODS

This analysis included patients undergoing abdominal surgery in seven LMICs (Benin, Ghana, India, Mexico, Nigeria, Rwanda, and South Africa) as part of the FALCON randomised controlled trial. Wound swabs were collected from patients diagnosed with SSI, as per US Centers for Disease Control and Prevention (CDC) definition. Data on microorganism species and MDR, as per CDC and European Centre for Disease Prevention and Control definitions, were analysed alongside hospital-level data on local microbiological practices. An adjusted analysis was performed to identify perioperative factors associated with MDR. Testing capacity was assessed by the completion of swab testing in positively diagnosed SSIs.

FINDINGS

Between Dec 10, 2018, and Sept 7, 2020, 5788 patients were recruited to the FALCON trial. 1163 patients were diagnosed with an SSI, of whom 905 (77·8%) received prophylactic antibiotics before surgery. In patients with SSIs, 935 of 1163 (80·4%) did not have a wound swab; 195 were from hospitals not performing swabs (15 hospitals) and 740 were from hospitals with capacity but no swab performed (35 hospitals). Of 228 patients swabbed, 200 (88·5%) had microorganisms detected. Escherichia coli (89 of 200, 37·9%) was the most common microorganism and 116 of 200 (58·0%) patients were not covered by the perioperative prophylactic antibiotic. MDR was found in 102 of 147 (69·4%) patients for whom data were available to determine MDR status. Adjusted analysis found that appropriate prophylactic antibiotic coverage (adjusted odds ratio 0·43, 95% CI 0·19-0·96) and regular availability of infection control teams (0·32, 0·11-0·93) were associated with a significant reduction in MDR.

INTERPRETATION

Targeted perioperative antibiotic prophylaxis during contaminated abdominal surgery is insufficient in LMICs, with very few SSI organisms undergoing formal diagnosis. Expansion of testing capacity, development of local guidelines, and implementation of infection control teams could support the prevention of SSI through directed antibiotic prophylaxis, subsequently reducing the burden of MDR.

FUNDING

National Institute for Health and Care Research.

TRANSLATIONS

For the French and Spanish translations of the abstract see Supplementary Materials section.

An escape from ESKAPE pathogens: A comprehensive review on current and emerging therapeutics against antibiotic resistance

The rise of antimicrobial resistance has positioned ESKAPE pathogens as a serious global health threat, primarily due to the limitations and frequent failures of current treatment options. This growing risk has spurred the scientific community to seek innovative antibiotic therapies and improved oversight strategies. This review aims to provide a comprehensive overview of the origins and resistance mechanisms of ESKAPE pathogens, while also exploring next-generation treatment strategies for these infections. In addition, it will address both traditional and novel approaches to combating antibiotic resistance, offering insights into potential new therapeutic avenues. Emerging research underscores the urgency of developing new antimicrobial agents and strategies to overcome resistance, highlighting the need for novel drug classes and combination therapies. Advances in genomic technologies and a deeper understanding of microbial pathogenesis are crucial in identifying effective treatments. Integrating precision medicine and personalized approaches could enhance therapeutic efficacy. The review also emphasizes the importance of global collaboration in surveillance and stewardship, as well as policy reforms, enhanced diagnostic tools, and public awareness initiatives, to address resistance on a worldwide scale.

Understanding antibiotic purchasing practices in community pharmacies: A potential driver of emerging antimicrobial resistance

Introduction

Antimicrobial resistance (AMR), a transboundary health issue, critically impacting low- and middle-income countries (LMICs) where 80% of antibiotics are used in the community, with 20-50% being inappropriate. Southeast-Asia, including Bangladesh, faces heightened AMR risk due to suboptimal healthcare standard and unregulated antibiotic sales. This study aimed to audit antibiotic dispensing patterns from community pharmacies, identifying factors influencing purchasing behaviors.

Methods

A cross-sectional survey of 385 antibiotic customers and structured observations of 1000 pharmacy dispensing events were conducted in four urban and rural areas in Bangladesh. Descriptive analysis defined antibiotic use, while Poisson regression examined how patients' demographics and health symptoms influenced prescription behaviors.

Results

Among 1000 observed medicine dispensing events, 25.9% were antibiotics. Commonly purchased antibiotics included macrolides (22.8%), third-generation-cephalosporins (20.8%), and second-generation-cephalosporins (16.9%). Following WHO-AWaRe classifications, 73.5% of antibiotics were categorized as Watch, and 23.1% as Access. From the survey, 56.6% antibiotics were purchased without a prescription from drug-sellers and informal healthcare providers, primarily for "non-severe" health-symptoms such as upper-respiratory-tract infections (37.4%), fever (31.7%), uncomplicated skin infections (20%), gastrointestinal-infections (11.2%), and urinary-tract infections (7.9%). The likelihood of presenting a prescription while purchasing antibiotics was 27% lower for individuals aged 6-59 compared to those ≤5 or ≥ 60. Lower-respiratory-tract infections and enteric-fever had higher prescription rates, with adjusted prevalence ratios of 1.78 (95% CI: 1.04, 3.03) and 1.87 (95% CI: 1.07, 3.29), respectively. After adjusting for confounders, sex, urban-rural locations, income, education, and number of health-symptoms exhibited no significant influence on prescription likelihood.

Conclusion

This study underscores unregulated antibiotic sales without prescriptions, urging tailored interventions considering prevailing health-seeking practices in diverse healthcare settings in LMICs. Enforcing prescription-only regulations is hindered by easy access through community pharmacies and conflicts of interest. Future strategies should consider how stewardship impacts the financial interests of pharmacy personnel in settings lacking clear authority to ensure optimal compliance.

Impacts of pharmacist-led multi-faceted antimicrobial stewardship on antibiotic use and clinical outcomes in urology department of a tertiary hospital in Guangzhou, China: an interrupted time-series study

BACKGROUND

Research on the effectiveness of pharmacist-led antimicrobial stewardship programmes (ASPs) in the urology department is limited.

AIM

To evaluate the impact of pharmacist-led multi-faceted ASPs on antibiotic use and clinical outcomes.

METHODS

A prescription review of inpatients receiving one or more antibiotics in the urology department of a large teaching hospital in Guangzhou, China, was conducted from April 2019 to March 2023. The pharmacist-led multi-faceted ASP intervention included guideline development, training, medication consultation, review of medical orders, indicator monitoring, and consultation. The primary outcome was antibiotic consumption. The data were analysed using interrupted time-series (ITS) analysis.

FINDINGS

Following the implementation of ASPs, an immediate decrease was observed in total antibiotic consumption, antibiotic use rate, second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones, and WHO Watch category antibiotics. No differences were observed in mortality rate before and after the intervention, and no significant short- or long-term effects were found on length of hospital stay (LOS) using ITS. However, there was a significant short-term effect on average antibiotic cost.

CONCLUSION

The implementation of pharmacist-led multi-faceted ASPs had positive impacts on reducing antimicrobial consumption without increasing LOS, antibiotic cost, or mortality rate.

Nature-based solutions for antibiotics and antimicrobial resistance removal in tertiary wastewater treatment: Microbiological composition and risk assessment

This field-scale study evaluates the seasonal effectiveness of employing nature-based solutions (NBSs), particularly surface flow and horizontal subsurface flow constructed wetland configurations, as tertiary treatment technologies for the removal of antibiotics (ABs) and antibiotic resistance genes (ARGs) compared to a conventional treatment involving UV and chlorination. Out of the 21 monitored ABs, 13 were detected in the influent of three tertiary wastewater treatments, with concentrations ranging from 2 to 1218 ng·L-1. The ARGs sul1 and dfrA1 exhibited concentrations ranging from 1 × 105 to 9 × 106 copies/100 mL. NBSs were better at reducing ABs (average 69 to 88 %) and ARGs (2-3 log units) compared to the conventional tertiary system (average 36 to 39 % and no removal to 2 log units) in both seasons. Taxonomic compositions in influent water samples shifted from wastewater-impacted communities (Actinomycetota and Firmicutes) to a combination of plant rhizosphere-associated and river communities in NBS effluents (Alphaproteobacteria). In contrast, the conventional technology showed no substantial differences in community composition. Moreover, NBSs substantially reduced the ecotoxicological risk assessment (cumulative RQs). Furthermore, NBSs reduced the ecotoxicological risk (cumulative RQs) by an average of over 70 % across seasons, whereas the benchmark technology only achieved a 6 % reduction. In conclusion, NBSs present a robust alternative for minimizing the discharge of ABs and ARGs into surface water bodies.

Assessing the removal of heavy metals and polycyclic aromatic hydrocarbons and occurrence of metal resistance genes and antibiotic resistance genes in a stormwater bioretention system

Bioretention basins are extensively used in urban areas to manage stormwater by reducing peak flows and pollution. This study evaluated the performance of a bioretention basin in removing heavy metals, polycyclic aromatic hydrocarbons (PAHs), and oil and grease. Using droplet digital PCR (ddPCR), the presence of metal resistance genes (MRGs) and antibiotic resistance genes (ARGs) in the basin's soil was analyzed. The results indicated effective removal of Zn (67%), but higher concentration of Mg was observed at the outlet. Cu, Fe and Pb showed no significant differences in the in- and outflow concentrations. The system successfully removed 82% of influent PAHs. Soil samples collected in summer and fall revealed higher MRG abundance in summer, with copA being the most prevalent MRG (1.2-4.8 log10 copies/g soil). Among the ARGs, sul1 was consistently found throughout the basin (2.5-6.7 log10 copies/g soil), while tetW was detected primarily at the basin's start and end in the topsoil layer. Rubellimicrobium and Geobacter were identified as potential carriers of ARGs/MRGs. Although the concentration of metals in soil was not measured in the current study, these findings emphasize the need to understand heavy metal distribution and the occurrence of MRGs and ARGs in stormwater control systems to improve their design and effectiveness.

Antibiotic resistance of heterotrophic bacteria from the sediments of adjoining high Arctic fjords, Svalbard

Antibiotic resistance bacteria (ARB) and antibiotic resistance genes (ARGs) are now considered major global threats. The Kongsfjorden and Krossfjorden are the interlinked fjords in the Arctic that are currently experiencing the effects of climate change and receiving input of pollutants from distant and regional sources. The present study focused on understanding the prevalence of antibiotic resistance of retrievable heterotrophic bacteria from the sediments of adjacent Arctic fjords Kongsfjorden and Krossfjorden. A total of 237 bacterial isolates were tested against 16 different antibiotics. The higher resistance observed towards Extended Spectrum β-lactam antibiotic (ESBL) includes ceftazidime (45.56%) followed by trimethoprim (27%) and sulphamethizole (24.05%). The extent of resistance was meagre against tetracycline (2.53%) and gentamycin (2.95%). The 16S rRNA sequencing analysis identified that Proteobacteria (56%) were the dominant antibiotic resistant phyla, followed by Firmicutes (35%), Actinobacteria (8%) and Bacteroidetes. The dominant resistant bacterial isolates are Bacillus cereus (10%), followed by Alcaligenes faecalis (6.47%), Cytobacillus firmus (5.75%) Salinibacterium sp. (5%) and Marinobacter antarcticus (5%). Our study reveals the prevalence of antibiotic resistance showed significant differences in both the inner and outer fjords of Kongsfjorden and Krossfjorden (p < 0.05). This may be the input of antibiotic resistance bacteria released into the fjords from the preserved permafrost due to the melting of glaciers, horizontal gene transfer, and human influence in the Arctic region act as a selection pressure for the development and dissemination of more antibiotic resistant bacteria in Arctic fjords.

Challenges and effective tracking down strategies of antibiotic contamination in aquatic ecosystem

A growing environmental concern revolves around the widespread use of medicines, particularly antibiotics, which adversely impact water quality and various life forms. The unregulated production and utilization of antibiotics not only affect non-targeted organisms but also exert significant evolutionary pressures, leading to the rapid development of antimicrobial resistance (AMR) in bacterial communities. To address this issue, global studies have been conducted to assess the prevalence and quantities of antibiotics in various environmental components including freshwater, ocean, local sewage, and fish. These studies aim to establish effective analytical methods for identifying and measuring antibiotic residues in environmental matrices that might enable authorities to establish norms for the containment and disposal of antibiotics. This article offers a comprehensive overview of methods used to extract antibiotics from environmental matrices exploring purification techniques such as liquid-liquid extraction, solid-phase extraction, green extraction techniques, and concentration methods like lyophilization and rotary evaporation. It further highlights qualitative and quantitative analysis methods, high-performance liquid chromatography, ultra-high-performance liquid chromatography, and liquid chromatography-tandem along with analytical methods such as UV-Vis and tandem mass spectrometry for detecting and measuring antibiotics. Urgency is underscored for proactive strategies to curb antibiotic contamination, safeguarding the integrity of aquatic ecosystems and public health on a global scale.

Comprehensive analysis and risk assessment of Antibiotic contaminants, antibiotic-resistant bacteria, and resistance genes: Patterns, drivers, and implications in the Songliao Basin

The pervasive use of antibiotics has raised substantial environmental concerns, especially regarding their temporal and spatial distribution across diverse water systems. This study addressed the gap in comprehensive research on antibiotic contamination during different hydrological periods, focusing on the Jilin section of the Songliao Basin in Northeast China, an area with severe winter ice cover. The study examined the occurrence, distribution, influencing factors, and potential ecological risks of prevalent antibiotic contaminants. Findings revealed antibiotic concentrations ranging from 239.64 to 965.81 ng/L, with antibiotic resistance genes (ARGs) at 5.22 × 10-2 16S rRNA-1 and antibiotic-resistant bacteria (ARB) up to 5.76 log10 CFU/mL. Ecological risk assessments identified significant risks to algae from oxytetracycline, erythromycin, and amoxicillin. Redundancy analysis and co-occurrence networks with ordinary least squares (OLS) demonstrated that the dispersion of ARGs and ARB is significantly influenced by environmental factors such as total organic carbon (TOC), total phosphorus (TP), total nitrogen (TN), fluoride (F⁻), and nitrate (NO₃⁻). These elements, along with mobile genetic elements (MGEs), play crucial roles in ARG patterns (R2 = 0.94, p ≤ 0.01). This investigation offers foundational insights into antibiotic pollution dynamics in cold climates, supporting the development of targeted mitigation strategies for aquatic systems.

MAPRS: An intelligent approach for post-prescription review based on multi-label learning

Antimicrobial resistance (AMR) is a major threat to public health worldwide. It is a promising way to improve appropriate prescription by the review and stewardship of antimicrobials, and Post-Prescription Review (PPR) is currently the main tool used in hospitals. Existing methods of PPR typically focus on the dichotomy of antimicrobial prescription based on binary classification which, however, is usually a multi-label classification problem. Moreover, previous research did not explain the causes beneath the inappropriate antimicrobial used in the clinical setting, which could be practically important for problem location and decision improvement. In this paper, we collected antimicrobial prescriptions and related data from clean surgery in a hospital in northeastern China, and proposed a Multi-label Antimicrobial Post-Prescription Review System (MAPRS). MAPRS first uses NLP techniques to process unstructured data in prescriptions and explores the value of clinical record text for solving medical problems. Then, Classifier Chains are used to deal with multi-label problems and fused with machine learning algorithms to construct a classifier. At last, a SHAP explanation module is introduced to explain the inappropriate prescriptions. The experimental results show that MAPRS could achieve great performance in a challenging six-category multi-label task, with a subset accuracy of 90.7 % and an average AUROC of 94.3 %. Our results can help hospitals to perform intelligent prescription review and improve the antimicrobial stewardship.

Detection of Extended-spectrum β-lactamase-producing Klebsiella pneumoniae and Escherichia coli in wastewaters of Madurai, India

The present study aimed to determine the presence of Klebsiella pneumoniae and Escherichia coli with extended-spectrum β-lactamase (ESBL)s property from treated wastewater effluents. Treated effluent samples were collected from two major water treatment plants which located at Avaniyapuram and Sakkimangalam, Madurai, Tamil Nadu, India. Among the 51 isolates, 56.86 % represented E. coli (18 from Avaniyapuram and 11 from Sakkimangalam) and 43.14 % were K. pneumoniae (7 from Avaniyapuram and 15 from Sakkimangalam). Based on the ESBL propensity, E. coli was overrepresented in the present study. All the isolates turned positive for ESBL, while 5.88 % of K. pneumoniae and 7.84 % of E. coli were positive for carbapenemases. Further, K. pneumoniae isolates from both sites showed 100 % resistance to beta-lactams, with resistance to other antibiotics such as tetracycline and meropenem. E. coli isolates were 100 % resistant to ceftazidime and cefuroxime, and 88.9 % were resistant to amoxicillin/clavulanate and ceftriaxone. The MAR indices observed in the present study for E. coli and K. pneumoniae were above the threshold value of 0.2 suggested a high risk of environmental contamination. These findings highlighted the need for routine surveillance at appropriate intervals for the presence of ESBL producing pathogens and other MDR pathogens in the environment to provide proper clinical management, develop various counter measures and policies to address and halt the spread of such potential threats.

Exploring drivers of self-treatment with antibiotics in three agricultural communities of northern Tanzania

BACKGROUND

Antimicrobial resistance (AMR) poses a significant global health threat, particularly in low- and middle-income countries (LMICs). Self-treatment with antibiotics, the practice of using antibiotics without professional guidance, is often considered an important contributor to the emergence and spread of AMR.

METHOD

This study investigated the drivers of self-treatment in three common types of agricultural communities in northern Tanzania. The research employed a comprehensive array of methods, including cross-sectional surveys (n = 790), interviews (n = 30) and observations (n = 178) targeting both antibiotic (human and animal) providers and users (patients and farmers). Qualitative interview data were analysed using a coding and association matrix, while descriptive analyses were performed on survey and observation data.

RESULTS

Self-treatment with antibiotics was highly prevalent in all communities. Between 41.0% (self-reported) and 60.3% (observed) of human antibiotics were obtained without a prescription and we observed that veterinary antibiotics were regularly purchased in retail shops without referral by a professional. Structural deficiencies in the healthcare system drove this practice: limited access to healthcare facilities, medication stockouts and prolonged waiting times were identified as key factors. The absence of safety nets like insurance schemes further contributed to self-medication. Retail shops offered a convenient and cost-effective alternative when antibiotics were inaccessible or unaffordable. Notably, informal networks comprising treatment vendors, friends or neighbours, as well as personal experiences played a crucial role in guiding individuals in their self-treatment decisions by providing advice on treatment choice and modalities.

CONCLUSIONS

Addressing self-treatment requires a multi-faceted approach. Improving the availability and accessibility of antibiotics, enhancing healthcare services and involving retail vendors in antibiotic stewardship are essential. Structural issues like access to diagnostics and medicines must be tackled, alongside reducing barriers and incentivising individuals to use professional healthcare services. Training retail vendors to sell specific first-line antibiotics over the counter with guidance on appropriate usage should be considered. Such bottom-up interventions will enable sustainable promotion of responsible antibiotic use, mitigating AMR emergence and securing a healthier future for all.

Occurrence, Source Apportionment, and Risk Assessment of Antibiotics in Mangrove Sediments from the Lianzhou Bay, China

In recent years, the widespread application of antibiotics has raised global concerns, posing a severe threat to ecological health. In this study, the occurrence, source, and ecological risks of 39 antibiotics belonging to 5 classes in mangrove sediments from Lianzhou Bay, China, were assessed. The total concentrations of the antibiotics (∑39 antibiotics) ranged from 65.45 to 202.24 ng/g dry weight (dw), with an average of 142.73 ± 36.76 ng/g dw. The concentrations of these five classes of antibiotics were as follows: Sulfonamides (SAs) > Tetracyclines (TCs) > Fluoroquinolones (QUs) > Penicillin (PCs) > Macrolides (MLs). The spatial distribution of antibiotics varied as high tidal zone > middle tidal zone > low tidal zone. The total organic carbon (TOC), pH, nitrate (NO3--N), and nitrite (NO2--N) of the sediment significantly influenced the distribution of antibiotics (p < 0.05). A source analysis identified untreated sewage from aquaculture as the primary source of antibiotics in the local mangrove. A risk assessment revealed that ciprofloxacin, norfloxacin, ofloxacin of QUs, and tetracycline of TCs exhibited medium risks to algae in certain sampling sites, while other antibiotics exhibited low or no risks to all organisms. Nevertheless, the total risk of all the detected antibiotics to algae was medium in 95% of the sites. The overall ecological risk level of antibiotics in the middle tidal zone was slightly lower than in the high tidal zone and the lowest in the low tidal zone. In summary, the experimental results provided insights into the fate and transport behaviors of antibiotics in mangrove sediments from Lianzhou Bay.

Impact of a package of point-of-care diagnostic tests, a clinical diagnostic algorithm and adherence training on antibiotic prescriptions for the management of non-severe acute febrile illness in primary health facilities during the COVID-19 pandemic in Burkina Faso

OBJECTIVE

To assess the impact of an intervention package on the prescription of antibiotic and subsequently the rate of clinical recovery for non-severe acute febrile illnesses at primary health centers.

METHODS

Patients over 6 months of age presenting to primary health care centres with fever or history of fever within the past 7 days were randomized to receive either the intervention package constituted of point-of-care tests including COVID-19 antigen tests, a diagnostic algorithm and training and communication packages, or the standard practice. The primary outcomes were antibiotic prescriptions at Day 0 (D0) and the clinical recovery at Day 7 (D7). Secondary outcomes were non-adherence of participants and parents/caregivers to prescriptions, health workers' non-adherence to the algorithm, and the safety of the intervention.

RESULTS

A total of 1098 patients were enrolled. 551 (50.2%) were randomized to receive the intervention versus 547 (49.8%) received standard care. 1054 (96.0%) completed follow-up and all of them recovered at D7 in both arms. The proportion of patients with antibiotic prescriptions at D0 were 33.2% (183/551) in the intervention arm versus 58.1% (318/547) under standard care, risk difference (RD) -24.9 (95% CI -30.6 to -19.2, p < 0.001), corresponding to one more antibiotic saved every four (95% CI: 3 to 5) consultations. This reduction was also statistically significant in children from 6 to 59 months (RD -34.5; 95% CI -41.7 to -27.3; p < 0.001), patients over 18 years (RD -35.9; 95%CI -58.5 to -13.4; p = 0.002), patients with negative malaria test (RD -46.9; 95% CI -53.9 to -39.8; p < 0.001), those with a respiratory diagnosis (RD -48.9; 95% CI -56.9 to -41.0, p < 0.001) and those not vaccinated against COVID-19 (-24.8% 95%CI -30.7 to -18.9, p-value: <0.001). A significant reduction in non-adherence to prescription by patients was reported (RD -7.1; 95% CI -10.9 to -3.3; p < 0.001).

CONCLUSION

The intervention was associated with significant reductions of antibiotic prescriptions and non-adherence, chiefly among patients with non-malaria fever, those with respiratory symptoms and children below 5 years of age. The addition of COVID-19 testing did not have a major impact on antibiotic use at primary health centers.

TRIAL REGISTRATION

Clinitrial.gov; NCT04081051 registered on 06/09/2019.

Screening canine sources for novel antimicrobials reveals the circular broad-spectrum bacteriocin, caledonicin, produced by Staphylococcus caledonicus

Introduction

Antimicrobial-resistant pathogens present an ongoing threat to human and animal health, with deaths linked to antimicrobial resistance (AMR) predicted to increase annually. While the misuse and overuse of antibiotics in humans undoubtedly contribute to this escalation, antibiotic use in the veterinary field, including companion animals, also plays a contributing role. Pet owners' desire to improve the quality of life of their pets is likely to support antibiotic use in this field. Consequently, there is a need for antibiotic alternatives to treat bacterial infections. This study set out to screen for antimicrobial peptides known as bacteriocins from bacterial isolates of aerobic/microaerophilic environments of canine sources and determine their potential as antibiotic alternatives against clinically relevant pathogens.

Methods

Following a laboratory-based protocol, 22 bacterial isolates were subjected to whole-genome sequencing (WGS), and a total of 14 putative novel bacteriocins were identified from both class I and II bacteriocin classes. One particular bacteriocin, herein named caledonicin, was identified via in silico analysis from a Staphylococcus caledonicus strain and partially purified for further in vitro evaluation.

Results

Caledonicin is a 64-amino acid (IAANLGVSSGTAYS MANALNNISNVATA LTIIGTFTGVGTIGSGIA ATILAILKKKGVAAAAAF) novel circular bacteriocin most closely related to enterocin_NKR-5-3B based on core peptide alignment (39.1%), with a molecular weight of 6077.1 Da. Caledonicin exhibits a broad-spectrum of activity against a range of pathogenic bacteria, including methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus pseudintermedius (MRSP), and Listeria monocytogenes; and the gut-related bacterium associated with Crohn's disease, Mediterraneibacter gnavus ATCC 29149 (previously Ruminococcus gnavus ATCC 29149).

Discussion

This represents the first bacteriocin screening study involving bacteria from canine sources and confirms this is a rich environment for bacteriocin-producing strains. This study also identifies and characterises the first novel bacteriocin from the staphylococcal species, Staphylococcus caledonicus.

Approachable Synthetic Methodologies for Second-Generation β-Lactamase Inhibitors: A Review

Some antibiotics that are frequently employed are β-lactams. In light of the hydrolytic process of β-lactamase, found in Gram-negative bacteria, inhibitors of β-lactamase (BLIs) have been produced. Examples of first-generation β-lactamase inhibitors include sulbactam, clavulanic acid, and tazobactam. Many kinds of bacteria immune to inhibitors have appeared, and none cover all the β-lactamase classes. Various methods have been utilized to develop second-generation β-lactamase inhibitors possessing new structures and facilitate the formation of diazabicyclooctane (DBO), cyclic boronate, metallo-, and dual-nature β-lactamase inhibitors. This review describes numerous promising second-generation β-lactamase inhibitors, including vaborbactam, avibactam, and cyclic boronate serine-β-lactamase inhibitors. Furthermore, it covers developments and methods for synthesizing MβL (metallo-β-lactamase inhibitors), which are clinically effective, as well as the various dual-nature-based inhibitors of β-lactamases that have been developed. Several combinations are still only used in preclinical or clinical research, although only a few are currently used in clinics. This review comprises materials on the research progress of BLIs over the last five years. It highlights the ongoing need to produce new and unique BLIs to counter the appearance of multidrug-resistant bacteria. At present, second-generation BLIs represent an efficient and successful strategy.

Toxicity of Moxifloxacin on the Growth, Photosynthesis, Antioxidant System, and Metabolism of Microcystis aeruginosa at Different Phosphorus Levels

Moxifloxacin (MOX), a widely used novel antibiotic, may pose ecological risks at its actual environmental concentrations, as has been detected in aquatic systems. However, its ecotoxicity to aquatic organisms and regulatory mechanisms of phosphorus in eutrophic aqueous environments are still limited. This study aimed to analyze its physiological and biochemical parameters, including cellular growth, chlorophyll fluorescence, photosynthetic pigments, oxidative stress biomarkers, and metabolomics to elucidate the toxicity induced by environmental concentrations of MOX in Microcystis aeruginosa at different phosphorus levels. The results revealed that the EC50 values of MOX on M. aeruginosa at different phosphorus concentrations were 8.03, 7.84, and 6.91 μg/L, respectively, indicating MOX toxicity was exacerbated with increasing phosphorus levels. High phosphorus intensified the suppression of chlorophyll fluorescence and photosynthetic pigments, while activating the antioxidant enzyme, indicating severe peroxidation damage. Metabolomic analysis showed MOX induced different discriminating metabolites under different phosphorus levels, and perturbed more biological pathways at higher phosphorus concentrations, such as starch and sucrose metabolism, pyrimidine metabolism, and glycerolipid metabolism. This indicates that phosphorus plays an important role in regulating metabolism in M. aeruginosa exposed to MOX. The findings provide valuable information on the mechanisms involved in cyanobacteria responses to antibiotic stress, and offer a theoretical basis for accurately assessing antibiotic toxicity in eutrophic aqueous environments.

Theoretical and experimental studies of cephalexin adsorption on aluminium as a new alternative of removal from wastewater

Cephalexin (CPX) is an antibiotic widely used to treat many infections. CPX has become an emerging pollutant present in wastewater. On the other hand, it is well known that organic compounds can be adsorbed over metal surfaces when the metal is in active state such as when it is rusting. This work proposes an alternative for the elimination of CPX from wastewater, applying electrochemical principles using a conventional and cheap substrate, aluminium. The first part consisted of obtaining the active states of aluminium electrodes carrying out voltametric curves at different pH (4, 7 and 9) to find the particular condition of interaction between CPX and metal surface. The potential was used in the potentiostatic tests to set the activation potential of metal at different times. After the treatment, electrolyte solutions were analysed using UV-vis spectra, and the aluminium surfaces were studied by optical micrographs and X-ray diffraction. In addition, aluminium-CPX interactions were corroborated by quantum-chemical calculations and adsorption isotherms. All results indicate that it was possible for the CPX removal at basic pH conditions, where the molecule adsorption on the aluminium substrate occurs due to a strong electrostatic interaction.

The global burden and trend of Clostridioides difficile and its association with world antibiotic consumption, 1990-2019

Background

To estimate the global trends and disease burden of Clostridioides difficile infection (CDI) and its correlation with worldwide antibiotic consumption.

Methods

Clostridioides difficile infection and antibiotic consumption data were retrieved from the Global Burden of Disease 2019, ResistanceMap-AntibiocUse, Food and Drug Administration (FDA) Adverse Event Reporting System, and Global Antimicrobial Resistance and Use Surveillance System. Jointpoint regression and age-period-cohort model were developed to show the global trends and burden of CDI. Correlation tests were calculated to explore the relationship between CDI and antibiotics.

Results

Globally, CDI is the most significant one with a high-rocketing burden increase rate among 13 pathogens causing diarrheal deaths and disability-adjusted life years (DALYs). The age-standardised death rate (ASDR) increased from 0.19 in 1990 to 0.43 in 2019, in which the elderly and females are at higher risk. A rapid increase in ASDR in high to middle sociodemographic index (SDI) regions such as North America (average annual percentage change (AAPC) = 7.71%), Andean (AAPC = 7.82%), and Southern Latin America (AAPC = 11.08%) was identified. Antibiotic consumption has a significant positive correlation with CDI with different risk stratifications.

Conclusions

The global burden of CDI has continuously increased for the past 30 years, especially in high to middle-SDI regions. World antibiotic consumption showed a strong positive correlation with CDI with different risk stratification. More effective prevention and control measures should be implemented in these critical regions, with a specific emphasis on vulnerable populations, to mitigate the spread of epidemics.

Degradation Efficiency and Mechanism of Tetracycline in Water by Activated Persulfate Using Biochar-Loaded Nano Zero-Valent Iron

Tetracycline (TC) contamination in water is one of the key issues in global environmental protection, and traditional water treatment methods are difficult to remove antibiotic pollutants.Therefore, efficient and environmentally friendly treatment technologies are urgently needed. In this study, activated persulfate (PS) using a biochar-loaded nano zero-valent iron (BC-nZVI) advanced oxidation system was used to investigate the degradation effect, influencing factors, and mechanism of TC. BC-nZVI was prepared using the liquid-phase reduction method, and its structure and properties were analyzed by various characterization means. The results showed that nZVI was uniformly distributed on the surface or in the pores of BC, forming a stable complex. Degradation experiments showed that the BC-nZVI/PS system could degrade TC up to 99.57% under optimal conditions. The experiments under different conditions revealed that the iron-carbon ratio, dosing amount, PS concentration, and pH value all affected the degradation efficiency. Free radical burst and electron paramagnetic resonance (EPR) experiments confirmed the dominant roles of hydroxyl and sulfate radicals in the degradation process, and LC-MS experiments revealed the multi-step reaction process of TC degradation. This study provides a scientific basis for the efficient treatment of TC pollution in water.