Antimicrobial Resistance in the Asia Pacific region: a meeting report

The challenge of antimicrobial resistance in the Asia-Pacific: a pediatric perspective

PURPOSE OF REVIEW

The densely populated Asia Pacific region is home to 600 million children, and suffers from a significant burden of morbidity and mortality due to infections associated with antimicrobial resistance (AMR). We aimed to identify the drivers, challenges and potential opportunities to alter the burden of AMR within the region.

RECENT FINDINGS

Despite the high AMR burden borne by the Asia Pacific region, there are limited (and geographically imbalanced) published data to delineate the contemporary epidemiology of serious multidrug-resistant bacterial infections in children. Furthermore, the region is impacted by overcrowded and poorly resourced healthcare facilities, insufficient microbiological resources, and widespread community and environmental antibiotic use leading to limited efficacy for frequently prescribed antibiotics. Vaccine coverage is also inadequate and inequitable, further driving the burden of infectious disease (and antibiotic overuse) in children.

SUMMARY OF IMPLICATIONS

There are many challenges in implementing antimicrobial stewardship and infection prevention and control programs to reduce the excessive AMR disease burden in children across the Asia Pacific region, yet locally-driven strategies have successfully reduced antibiotic overuse in some settings, and should be replicated. Reducing the AMR disease burden will require improved healthcare resourcing, including better access to microbiological diagnosis, and multidisciplinary approaches to enhance infection prevention and antibiotic prescribing.

Acceptability of Doxycycline Prophylaxis, Prior Antibiotic Use, and Knowledge of Antimicrobial Resistance Among Australian Gay and Bisexual Men and Nonbinary People

BACKGROUND

There is growing interest in novel sexually transmissible infection (STI) prevention strategies, including doxycycline postexposure prophylaxis (doxy-PEP). We assessed interest in doxy-PEP and other STI prevention strategies among gay and bisexual men and nonbinary people in Australia, as well as prior antibiotic use for STI prevention, and knowledge of antimicrobial resistance (AMR).

METHODS

We conducted a national, online survey in June to July 2023. Multivariable logistic regression was used to identify factors associated with the acceptability of doxy-PEP.

RESULTS

Of 2046 participants, 26.9% had been diagnosed with an STI in the previous year. Condoms were rated as an acceptable STI prevention strategy by 45.1% of the sample, STI preexposure prophylaxis by 54.0%, and doxy-PEP by 75.8%. Previous antibiotic use for STI prevention was reported by 7.5% of the sample, and 2.6% were currently using antibiotics for STI prevention. Over half the sample (62.1%) had some knowledge of AMR. Of those who knew something about AMR, 76.2% were concerned about it. Interest in using doxy-PEP was independently associated with previous use of antibiotics for STI prevention (adjusted odds ratio, 3.09; 95% confidence interval, 1.78-5.35; P < 0.001), whereas those who were concerned about AMR were less interested in it (adjusted odds ratio, 0.51; 95% confidence interval, 0.36-0.72; P < 0.001).

CONCLUSIONS

Doxycycline postexposure prophylaxis was highly acceptable to gay and bisexual men and nonbinary people in Australia, and few factors distinguished between interest in using it or not. We recommend community and professional discussion and education about the effective use of doxy-PEP, AMR, and who would most benefit from doxy-PEP.

Insights Into Antimicrobial Resistance From Dental Students in the Asia-Pacific Region

BACKGROUND

Dentists, as prominent prescribers, are key stakeholders in addressing the antimicrobial resistance (AMR) crisis. Dental students' perceptions about the topic have been underexplored in the Asia-Pacific region, a key location for the development and spread of AMR. Thus, the aim of this study was to evaluate the awareness and confidence to prescribe antimicrobials amongst dental students studying in the region.

METHODS

Students from 15 dental schools in 4 countries were invited to participate in a cross-sectional online survey during 2022-2023. A previously validated and standardised 14-item instrument was utilised.

RESULTS

In all, 1413 responses were collected from Australia (n = 165), Sri Lanka (n = 112), Japan (n = 173), and Vietnam (n = 963). Of those, 201 were from final-year students (14.2%). On a scale from 1 to 10, awareness on AMR was placed at a mean (SEM) priority of 8.09 (0.05). With regards to target areas to address for mitigation of the AMR crisis, participants placed general public awareness at the top (mean [SEM] 8.53 [0.05]). Final-year students presented a mean (SEM) level of confidence to prescribe antibiotics of 6.01 (0.14) on a scale from 1 to 10, whilst 59.7% and 56.8% indicated feeling pressured to prescribe by patients or when lacking time, respectively. Final-year students participating in research activities assigned a higher priority to AMR compared to their peers not involved in research (mean [SEM] 8.6 [0.19] vs 7.81 [0.16]; P = .01).

CONCLUSIONS

This study highlights a need for increased awareness and confidence to prescribe amongst dental students in the Asia-Pacific region, an understudied population thus far. To mitigate this issue, the implementation (followed by assessment) of local educational and antibiotic stewardship initiatives is warranted.

Quantitative distribution of antibiotic resistance genes and crAssphage in a tropical urbanized watershed

As antimicrobial resistance continues to pose a significant threat to global health, this study provided a focused examination of the prevalence and behavior of key antibiotic resistance genes in aquatic environments. We investigated the quantitative distribution of intI1, sul1, blaTEM, blaNDM, blaVIM, mcr-1, tetQ, and crAssphage within wastewater influents (n = 12), effluents (n = 12) and river water samples (n = 12), from three municipal wastewater treatment plants and three river locations in an urbanized watershed in Central Thailand over dry and wet seasons. The qPCR method demonstrated that intI1, sul1, blaTEM, and tetQ were the most abundant in all samples (2.71-7.89 mean log10 copies/100 mL), with all genes exhibiting consistently uniform levels across diverse locations, suggesting the potential for any site to act as a monitoring sentinel. Although there is a significant reduction of ARG concentrations by WWTPs (0.62 - >4.05 LRV), the persistence of these genes in effluents points to the limited effectiveness of existing treatment methodologies. Temporal data indicated stable ARG concentrations over time, but tetQ levels rose during the wet season, in alignment with the monsoonal climate in Thailand. Additionally, we identified crAssphage, a marker of human sewage contamination, exhibited strong correlations with the more abundant ARGs (rho 0.65 - 0.81), implying that human waste contributes significantly to the environmental burden of ARGs. The results of this research highlight the widespread nature of ARGs in water systems and the need for improved treatment and sanitation strategies to mitigate the public health threat posed by antimicrobial resistance.

Surveillance of carbapenem resistance in Asian countries: a systematic review and meta-analysis

INTRODUCTION

Carbapenems are used to treat multidrug-resistant organisms as last-resort antibiotics. Resistance to carbapenems is an emerging public health threat worldwide, with alarming reported rates in Asian countries. To minimise further spread of resistant strains and guide interventions, it is important to understand the prevalence rates and causative molecular determinants. Therefore, the systematic review and meta-analysis arising from this protocol will aim to comprehensively describe the available surveillance data on carbapenem resistance in Asian countries to provide an in-depth overview of the carbapenem resistance status in this region.

METHODOLOGY AND ANALYSIS

A systematic review and meta-analysis will be conducted via PubMed, ScienceDirect, Cochrane Library and Web of Science databases. Additional articles and grey literature will be searched in Google Scholar, OpenGrey and Google Chrome by manually searching the reference lists of selected studies. The review question was designed according to components in the ECLIPSE (E-expectations, C-client, L-location, I-impact, P-profile and S-service) framework. Studies conducted with samples other than clinical samples will be excluded. Only original articles published in the English language will be included. The Joanna Briggs Institute critical appraisal tool will be used to assess the quality of the included studies. A random-effects meta-analysis will be performed if the data are sufficiently homogenous. Heterogeneity between studies will be assessed via the I² statistic. The subgroup analysis will be performed considering the type of sample, pathogen type, region/country where the studies were conducted and genetic determinants.

ETHICS AND DISSEMINATION

As this study is conducted on the basis of published data, ethical approval is exempt. The findings of this study will be disseminated in a peer-reviewed journal with the intention of providing summarised data on the globally emerging threat of carbapenem resistance and emphasising the need to introduce alternative, more effective treatment options.

PROSPERO REGISTRATION NUMBER

CRD42024515806.

Global Epidemiology of Invasive Infections by Uncommon Candida Species: A Systematic Review

Emerging and uncommon Candida species have been reported as an increasing cause of invasive Candida infections (ICI). We aim to systematize the global epidemiology associated with emergent uncommon Candida species responsible for invasive infections in adult patients. A systematic review (from 1 January 2001 to 28 February 2023) regarding epidemiological, clinical, and microbiological data associated to invasive Candida infections by uncommon Candida spp. were collected. In total, 1567 publications were identified, and 36 were selected according to inclusion criteria (45 cases). The chosen studies covered: C. auris (n = 21), C. haemulonii (n = 6), C. fermentati (n = 4), C. kefyr (n = 4), C. norvegensis (n = 3), C. nivariensis (n = 3), C. bracarensis (n = 1), C. duobushaemulonii (n = 1), C. blankii (n = 1), and C. khanbhai (n = 1). Over the recent years, there has been an increase in the number of invasive infections caused by uncommon Candida spp. Asia and Europe are the continents with the most reported cases. The challenges in strain identification and antifungal susceptibility interpretation were significant. The absence of clinical breakpoints for the susceptibility profile determination for uncommon Candida spp. makes interpretation and treatment options a clinical challenge. It is crucial that we focus on new and accessible microbiology techniques to make fast and accurate diagnostics and treatments.

Surge in Ceftriaxone-Resistant Neisseria gonorrhoeae FC428-Like Strains, Asia-Pacific Region, 2015-2022

Ceftriaxone-resistant Neisseria gonorrhoeae FC428-like strains have disseminated across the Asia-Pacific region, with a continuous rise in prevalence during 2015-2022. To mitigate the effect of these strains, we advocate for enhanced molecular diagnostics, expanded surveillance networks, and a regionally coordinated effort to combat the global spread of FC428-like strains.

Could traces of fluoroquinolones in food induce ciprofloxacin resistance in Escherichia coli and Klebsiella pneumoniae? An in vivo study in Galleria mellonella with important implications for maximum residue limits in food

We hypothesized that the residual concentrations of fluoroquinolones allowed in food (acceptable daily intake-ADIs) could select for ciprofloxacin resistance in our resident microbiota. We developed models of chronic Escherichia coli and Klebsiella pneumoniae infection in Galleria mellonella larvae and exposed them to ADI doses of ciprofloxacin via single dosing and daily dosing regimens. The emergence of ciprofloxacin resistance was assessed via isolation of the target bacteria in selective agar plates. Exposure to as low as one-tenth of the ADI dose of the single and daily dosing regimens of ciprofloxacin resulted in the selection of ciprofloxacin resistance in K. pneumoniae but not E. coli. This resistance was associated with cross-resistance to doxycycline and ceftriaxone. Whole genome sequencing revealed inactivating mutations in the transcription repressors, ramR and rrf2, as well as mutations in gyrA and gyrB. We found that ciprofloxacin doses 10-fold lower than those classified as acceptable for daily intake could induce resistance to ciprofloxacin in K. pneumoniae. These results suggest that it would be prudent to include the induction of antimicrobial resistance as a significant criterion for determining ADIs and the associated maximum residue limits in food.IMPORTANCEThis study found that the concentrations of ciprofloxacin/enrofloxacin allowed in food can induce de novo ciprofloxacin resistance in Klebsiella pneumoniae. This suggests that it would be prudent to reconsider the criteria used to determine "safe" upper concentration limits in food.

Principles and practices of antimicrobial stewardship programs in Korea

This review addresses the escalating challenge posed by antibiotic resistance, highlighting its profound impact on global public health, including increased mortality rates and healthcare expenditures. The review focuses on the need to adopt the One Health approach to effectively manage antibiotic usage across human, animal, and environmental domains. Antimicrobial stewardship programs (ASPs) are considered as comprehensive strategies that encompass both core and supplementary initiatives aimed at enhancing prudent antibiotic use. The 2021 "Guidelines on Implementing ASP in Korea" introduced such strategies, with a strong emphasis on fostering multidisciplinary and collaborative efforts. Furthermore, the "Core Elements for Implementing ASPs in Korean General Hospitals," established in 2022, provide a structured framework for ASPs, delineating leadership responsibilities, the composition of interdisciplinary ASP teams, a range of interventions, and continuous monitoring and reporting mechanisms. In addition, this review examines patient-centric campaigns such as "Speak Up, Get Smart" and emphasizes the pivotal role of a multidisciplinary approach and international cooperation in addressing the multifaceted challenges associated with antibiotic resistance.

The Rapid Emergence of Hypervirulent Klebsiella Species and Burkholderia pseudomallei as Major Health Threats in Southeast Asia: The Urgent Need for Recognition as Neglected Tropical Diseases

The World Health Organization (WHO)'s list of neglected tropical diseases (NTDs) highlights conditions that are responsible for devastating health, social and economic consequences, and yet, they are overlooked and poorly resourced. The NTD list does not include conditions caused by Gram-negative bacilli (GNB). Infections due to GNB cause significant morbidity and mortality and are prevalent worldwide. Southeast Asia is a WHO region of low- and middle-income countries carrying the largest burden of NTDs. Two significant health threats in Southeast Asia are Burkholderia pseudomallei (causing melioidosis) and hypervirulent Klebsiella pneumoniae (HvKp). Both diseases have high mortality and increasing prevalence, yet both suffer from a lack of awareness, significant under-resourcing, incomplete epidemiological data, limited diagnostics, and a lack of evidence-based treatment. Emerging evidence shows that both melioidosis and HvKp are spreading globally, including in high-income countries, highlighting the potential future global threat they pose. In this article, we review both conditions, identifying current trends and challenges in Southeast Asia and areas for future research. We also argue that melioidosis and HvKp merit inclusion as NTDs, and that mandatory global surveillance and reporting systems should be established, and we make an urgent call for research to better understand, detect, and treat these neglected diseases.

Diagnostic and antibiotic use practices among COVID-19 and non-COVID-19 patients in the Indonesian National Referral Hospital

BACKGROUND

Little is known about diagnostic and antibiotic use practices in low and middle-income countries (LMICs) before and during COVID-19 pandemic. This information is crucial for monitoring and evaluation of diagnostic and antimicrobial stewardships in healthcare facilities.

METHODS

We linked and analyzed routine databases of hospital admission, microbiology laboratory and drug dispensing of Indonesian National Referral Hospital from 2019 to 2020. Patients were classified as COVID-19 cases if their SARS-CoV-2 RT-PCR result were positive. Blood culture (BC) practices and time to discontinuation of parenteral antibiotics among inpatients who received a parenteral antibiotic for at least four consecutive days were used to assess diagnostic and antibiotic use practices, respectively. Fine and Grey subdistribution hazard model was used.

RESULTS

Of 1,311 COVID-19 and 58,917 non-COVID-19 inpatients, 333 (25.4%) and 18,837 (32.0%) received a parenteral antibiotic for at least four consecutive days. Proportion of patients having BC taken within ±1 calendar day of parenteral antibiotics being started was higher in COVID-19 than in non-COVID-19 patients (21.0% [70/333] vs. 18.7% [3,529/18,837]; p<0.001). Cumulative incidence of having a BC taken within 28 days was higher in COVID-19 than in non-COVID-19 patients (44.7% [149/333] vs. 33.2% [6,254/18,837]; adjusted subdistribution-hazard ratio [aSHR] 1.71, 95% confidence interval [CI] 1.47-1.99, p<0.001). The median time to discontinuation of parenteral antibiotics was longer in COVID-19 than in non-COVID-19 patients (13 days vs. 8 days; aSHR 0.73, 95%Cl 0.65-0.83, p<0.001).

CONCLUSIONS

Routine electronic data could be used to inform diagnostic and antibiotic use practices in LMICs. In Indonesia, the proportion of timely blood culture is low in both COVID-19 and non-COVID-19 patients, and duration of parenteral antibiotics is longer in COVID-19 patients. Improving diagnostic and antimicrobial stewardship is critically needed.

Multi-platform whole genome sequencing for tuberculosis clinical and surveillance applications

Whole genome sequencing (WGS) of Mycobacterium tuberculosis offers valuable insights for tuberculosis (TB) control. High throughput platforms like Illumina and Oxford Nanopore Technology (ONT) are increasingly used globally, although ONT is known for higher error rates and is less established for genomic studies. Here we present a study comparing the sequencing outputs of both Illumina and ONT platforms, analysing DNA from 59 clinical isolates in highly endemic TB regions of Thailand. The resulting sequence data were used to profile the M. tuberculosis pairs for their lineage, drug resistance and presence in transmission chains, and were compared to publicly available WGS data from Thailand (n = 1456). Our results revealed isolates that are predominantly from lineages 1 and 2, with consistent drug resistance profiles, including six multidrug-resistant strains; however, analysis of ONT data showed longer phylogenetic branches, emphasising the technologies higher error rate. An analysis incorporating the larger dataset identified fifteen of our samples within six potential transmission clusters, including a significant clade of 41 multi-drug resistant isolates. ONT's extended sequences also revealed strain-specific structural variants in pe/ppe genes (e.g. ppe50), which are candidate loci for vaccine development. Despite some limitations, our results show that ONT sequencing is a promising approach for TB genomic research, supporting precision medicine and decision-making in areas with less developed infrastructure, which is crucial for tackling the disease's significant regional burden.

An extensively drug-resistant Pseudomonas aeruginosa isolate from Myanmar

OBJECTIVES

Antimicrobial resistance (AMR) including multidrug-resistant (MDR) and extensively drug-resistant (XDR) Pseudomonas aeruginosa has emerged as one of the serious public health threats across the globe. Southeast Asia is a 'hot spot' of antimicrobial-resistant bacteria, including MDR P. aeruginosa. Despite Myanmar being located in Southeast Asia and suffering from a high infectious disease burden, data on MDR and XDR P. aeruginosa from Myanmar are limited. In this communication, we report the draft genome of an XDR P. aeruginosa isolate, MMXDRPA001, that was identified during a routine diagnosis in Myanmar.

METHODS

An MMXDRPA001 isolate colonising a hospitalised patient was characterised by antibiotic resistance profiling following standard methods and whole-genome sequencing using an Illumina MiSeq platform. The generated reads were de novo assembled using SPAdes (v.3.9.1). Annotation was performed by Prokka (v.1.14.0). Sequence type, antimicrobial resistance and virulence-related genes were predicted from the sequence. The phylogenetic relationships of all P. aeruginosa isolates were determined using core genome single-nucleotide polymorphisms (SNPs) analysis utilising Snippy (v.4.6.0) and Gubbins (v.2.3.4).

RESULTS

P. aeruginosa MMXDRPA001 was resistant to most antipseudomonal β-lactams, aminoglycosides and quinolones. The assembly comprised 145 contigs totalling 6 808 493 bases of sequence and a total of 6183 coding sequences. The isolate belonged to sequence type (ST) 235, contained carbapenemase-encoding gene blaIMP-1 and was clonally related to a previously reported isolate from Thailand.

CONCLUSION

The identification of an international high-risk clone of ST235 XDR isolate in Myanmar, genomically relating to that from a neighbouring country underscores the need for coordinated AMR surveillance throughout healthcare settings in Myanmar and in the Southeast Asia region.

Detection of Methicillin-Resistant Staphylococcus Aureus using vancomycin conjugated silica-based fluorescent nanoprobe

Methicillin-Resistant Staphylococcus Aureus (MRSA) is a worldwide major pathogenic bacteria that has emerged over the past three decades as the leading cause of nosocomial and community-acquired infections. Biosensors can provide rapid, sensitive, and selective detection of the presence and number of bacteria in various environments. Herein, a novel fluorescence nanoprobe was designed as a biosensor for MRSA detection using dye-incorporated silica nanoparticles (FSiNP). Based on the results of specific surface area analysis using the Brauner Emmett-Teller (BET) method, the surface area of the nanoparticles was obtained at 377.127 m2/g, and the X-ray diffraction (XRD) analysis confirmed that it was in the amorphous phase. Vancomycin, as the bioreceptor, was immobilized on the silica surface through a hydrosilylation reaction, generating the biosensing platform FSiNP-Van. Each modification step was corroborated by the Fourier Transform Infra-Red (FTIR) spectroscopy. The sensing principle was based on the fluorescence-quenching mechanism of FSiNP-Van at 515 nm obtaining a rapid response time of 20 min. The FSiNP-Van nanoprobe provided a wide linear concentration range of 10-106 CFU/mL with a limit of MRSA detection calculated at 1 CFU/mL. The fluorescent nanoprobe demonstrated here is expected to find applications in point-of-care (POC) diagnostics to detect the presence of MRSA bacteria.

Assessment of antibiotic resistance patterns in Central Taiwan during the COVID-19 pandemic: A retrospective study

BACKGROUND

Antimicrobial resistance (AMR) is a growing worldwide public health issue due to the overuse and inappropriate use of antibiotics. AMR has been more prevalent during the coronavirus pandemic of 2019 (COVID-19) compared to previous periods. Therefore, this study was conducted to evaluate the AMR profile of common bacteria that were isolated for routine analysis during the pandemic of COVID-19 in Central Taiwan. The main goal of this study was to examine and analyze the AMR patterns both before and after the start of the COVID-19 pandemic.

METHODS

We conducted a retrospective analysis of clinical samples collected from two different time periods: the 1-year period before the onset of the COVID-19 pandemic (January 2019 to December 2019) and the 2-year period following the start of the pandemic (September 2020 to September 2022). The data for this study were obtained from clinical records, and both bacterial identification and antibiotic susceptibility testing were performed using the Phoenix identification system.

RESULTS

Among the 8152 bacterial isolates obtained during the study period from September 2020 to September 2022, 4022 (49.3%) were Escherichia coli, 1346 (16.5%) were Klebsiella pneumoniae, 1156 (14.2%) were Staphylococcus aureus, 887 (10.9%) were Pseudomonas aeruginosa, 376 (4.6%) were Enterococcus faecium, and 365 (4.5%) were Acinetobacter baumannii. The overall prevalence of resistant bacteria during the COVID-19 pandemic was as follows: vancomycin-resistant Enterococcus, 69%; carbapenem-resistant A. baumannii, 65%; methicillin-resistant S. aureus, 49%; carbapenem-resistant K. pneumoniae, 29%; carbapenem-resistant P. aeruginosa, 17%; and carbapenem-resistant E. coli, 2%. Carbapenem-resistant A. baumannii, vancomycin-resistant Enterococcus, carbapenem-resistant K. pneumoniae, and carbapenem-resistant E. coli increased by 19%, 10%, 2%, and 1%, respectively. On the other hand, carbapenem-resistant P. aeruginosa and methicillin-resistant S. aureus decreased by 6%, respectively.

CONCLUSION

This study provides a comprehensive assessment of AMR during the COVID-19 pandemic in Central Taiwan. Understanding the prevalence of AMR is crucial for preventing infection and formulating disease prevention policies. Further research is warranted to elucidate the correlation between AMR and the severity of infection in COVID-19 patients.

High Prevalence of Multidrug-Resistant Bacteria in the Trachea of Intensive Care Units Admitted Patients: Evidence from a Bangladeshi Hospital

Recent research has shown that antibiotic-resistant microorganisms are becoming more prevalent in intensive care units (ICUs) at an exponential rate. Patients in the ICU can get infected by pathogens due to invasive operation procedures and critical health conditions. This study primarily emphasized tracheal samples from ICU patients due to their reliance on ventilators, increasing their susceptibility to Ventilator-Associated Pneumonia (VAP). Moreover, the rise of multidrug-resistant (MDR) pathogens makes treatment strategies more challenging for these patients. In this study, we tested 200 tracheal specimens to determine the prevalence of microorganisms and analyzed the antibiotic susceptibility of these isolates against regular antibiotics, including 4th generation drugs. Among the 273 isolates, 81% were gram-negative bacteria, 10% were gram-positive bacteria, and 9% were fungi. The most prevalent gram-negative bacteria were Acinetobacter spp. (34%), Klebsiella spp. (22%), Pseudomonas spp. (14%), and Escherichia coli (9.2%). The most prevalent gram-positive bacteria were Staphylococcus aureus (5.9%), and the fungi were Candida spp. (7.3%). Among the most prevalent bacteria, except Staphylococcus aureus isolates, around 90% were resistant to multiple drugs, whereas 60% of Acinetobacter spp. and Pseudomonas spp. were extensively drug resistant. Sensitivity analysis against the gram-negative and gram-positive drug panel using a one-way ANOVA test followed by Tukey's post hoc test showed that in the in vitro assay, colistin was the most effective antibiotic against all gram-negative bacteria. In contrast, linezolid, vancomycin, and fusidic acid were most effective against all gram-positive bacteria. Regular monitoring of nosocomial infections and safe management of highly resistant bacteria can help prevent future pandemics.

Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia (CAPTURA)

BACKGROUND

In 2015, the UK government established the Fleming Fund with the aim to address critical gaps in surveillance of antimicrobial resistance (AMR) in low- and middle-income countries in Asia and Africa. Among a large portfolio of grants, the Capturing Data on Antimicrobial Resistance Patterns and Trends in Use in Regions of Asia (CAPTURA) project was awarded with the specific objective of expanding the volume of historical data on AMR, consumption (AMC), and use (AMU) in the human healthcare sector across 12 countries in South and Southeast Asia.

METHODS

Starting in early 2019, the CAPTURA consortium began working with local governments and >100 relevant data-holding facilities across the region to identify, assess for quality, prioritize, and subsequently retrieve data on AMR, AMC, and AMU. Relevant and shared data were collated and analyzed to provide local overviews for national stakeholders as well as regional context, wherever possible.

RESULTS

From the vast information resource generated on current surveillance capacity and data availability, the project has highlighted gaps and areas for quality improvement and supported comprehensive capacity-building activities to optimize local data-collection and -management practices.

CONCLUSIONS

The project has paved the way for expansion of surveillance networks to include both the academic and private sector in several countries and has actively engaged in discussions to promote data sharing at the local, national, and regional levels. This paper describes the overarching approach to, and emerging lessons from, the CAPTURA project, and how it contributes to other ongoing efforts to strengthen national AMR surveillance in the region and globally.

Leveraging collaborative research networks against antimicrobial resistance in Asia

Background

Antimicrobial resistance (AMR) is a global health security threat requiring research collaboration globally and regionally. Despite repeated calls for international research collaboration in Asia, literature analyzing the nature of collaborative AMR research in Asia has been sparse. This study aims to describe the characteristics of the AMR research network in Asia and investigate the factors influencing collaborative tie formation between organizations.

Methods

We carried out a mixed-methods study by combining social network analysis (SNA) and in-depth interviews. SNA was first conducted on primary data to describe the characteristics of the AMR research network in Asia. Exponential random graph models (ERGMs) were then used to examine the influence of factors such as organization type, country affluence levels, regional proximity and One Health research on collaborative tie formation among organizations. In-depth interviews were conducted with network participants to provide contextual insights to the quantitative data.

Results

The results reveal that the research network exhibits a core-periphery structure, where a minority of organizations have a significantly higher number of collaborations with others. The most influential organizations in the network are academic institutions from high-income countries within and outside Asia. The ERGM results demonstrate that organizations prefer to collaborate with others of similar organization types, country-based affluence levels and One Health domains of focus, but also with others across different World Health Organization regions. The qualitative analysis identified three main themes: the challenges that impede collaboration, the central role of academic institutions, and the nature of collaborations across One Health domains, giving rise to important empirical milestones in understanding AMR research in Asia.

Conclusion

We thus recommend leveraging academic institutions as "integrators" to bridge differences, increasing funds channelled towards research capacity building to alleviate structural barriers to collaboration, streamlining collaborative mechanisms to overcome cumbersome administrative hurdles, and increasing efforts to establish trust between all organizations.

Antibiotic Resistance among Patients with Urinary Tract Infections in Kandahar, Afghanistan

Background

Antimicrobial resistance is a global public health threat. Highest burden of resistance is reported from low- and middle-income countries.

Objectives

To investigate and report the current scenario of increased antibiotic resistance of uropathogens among symptomatic urinary tract infection patients in Kandahar, Afghanistan.

Methods

From January 2018 to December 2021, this retrospective study was carried out at two main hospitals in Kandahar City, Afghanistan. Here, culture and sensitivity profiles of uropathogens were studied among symptomatic Bacteriuria in the presence of genitourinary symptoms (i.e., dysuria, suprapubic pain or tenderness, frequency, or urgency) (UTI) patients.

Results

Among urine samples of 1589 patients, 1047 (65.9%) were culture positive and included in this study. Most of these patients (626/1047 [59.8%]) were females, with majority (818 [78.1%]) having age between 19 and 39 years. Gram-negative bacteria were the most prevalent (840/1047 [80.2%]), with E. coli (653/1047 [62.4%]) as the most common isolated uropathogen. Overall gram-negative bacteria had higher resistance against commonly used antibiotics of cotrimoxazole (62.8%), ciprofloxacin (56.0%), levofloxacin (47.5%), cefixime (44.5%), fosfomycin (41.5%), and even ceftriaxone (48.3%).

Conclusions

Kandahar province has higher resistance rates against commonly used empirical antibiotics like norfloxacin, ciprofloxacin, levofloxacin, and cefixime. Nitrofurantoin should be used as the first-line antibiotic in treating UTI patients. Public health authorities should make strict regulations and policies to reduce irrational use, inappropriate prescription, and over-the-counter availability of antibiotics in Kandahar.

Infection Prevention Control Strategies of New Delhi Metallo-β-lactamase Producing Klebsiella pneumoniae

The spread of multi-drug resistant organisms (MDROs) is increasing at an alarming rate worldwide. Among these, Carbapenemase-producing New Delhi Metallo-β-lactamase (NDM) poses a significant clinical threat, and appropriate measures must be taken to prevent or limit its penetration into still-free territories. The present report describes two independent cases of patients from Ukraine colonized by NDM-producing Klebsiella pneumoniae and admitted to two separate wards of an acute university hospital in a territory not yet affected by Carbapenemase producers of this class. Moreover, this report illustrates the infection prevention control (IPC) strategies promptly implemented by the IPC operational team to verify the possible spread of the microorganism in the ward and avoid any possible further contamination. The identification of genes coding for Carbapenemases, performed using real-time PCR, revealed no other cases within the wards involved. These cases emphasize the importance of early case recognition of multidrug-resistant bacteria, the necessity of effective inter-hospital communication, the need for effective antimicrobial stewardship protocol, and the importance of adequate IPC policies. Additionally, we highlight the need to improve screening procedures in the case of patients from countries with a high prevalence of MDRO, as essential measures to prevent potential nosocomial outbreaks and/or endemization.

Assessing the additional health burden of antibiotic resistant Enterobacteriaceae in surface waters through an integrated QMRA and DALY approach

Antibiotic resistant Enterobacteriaceae pose a significant threat to public health. However, limited studies have evaluated the health risks associated with exposure to antibiotic-resistant bacteria (ARB), especially in natural environments. While quantitative microbial risk assessment (QMRA) assesses microbial risks in terms of the probability of infection, it does not account for the severity of health outcomes. In this study, a QMRA-DALY model was developed to integrate QMRA with health burden (disability-adjusted life years (DALY)) from infections caused by ARB. The model considers uncertainties in probability of infection and health burden assessment using Monte Carlo simulations. The study collected antimicrobial resistance (AMR) surveillance data from surface waters with different land uses. Results revealed water bodies with agricultural land use to be the main AMR hotspots, with the highest additional health burden observed in infections caused by meropenem-resistant E. coli (∆DALY = 0.0105 DALY/event) compared to antibiotic-susceptible E. coli. The estimated ∆DALY for antibiotic-resistant K. pneumoniae was lower than for antibiotic-resistant E. coli (highest ∆DALY = 0.00048 DALY/event). The study highlights the need for better evaluation of AMR associated health burden, and effective measures to mitigate the risks associated with antibiotic-resistant bacteria in natural environments.

A Qualitative Study on the Policy Process and Development of the National Action Plan on Antimicrobial Resistance in Singapore

The global public health threat of antimicrobial resistance (AMR) has been accelerated by many interrelated factors spanning across One Health-human health, animal health, and the environment. Singapore launched its own National Strategic Action Plan (NSAP) on AMR in November 2017 with the aim of tackling the growing threat of AMR in Singapore through coordinated approaches. However, little is known about the policy process and development of the NSAP in Singapore. In this study, we analysed these aspects using an AMR governance framework. In-depth interviews were conducted with 20 participants across the One Health spectrum. The interviews were transcribed verbatim and analysed thematically. Areas that were well executed included (1) good coordination across various agencies, (2) a dedicated office to coordinate the work on the NSAP, and (3) a high level of governmental support. Areas that were lacking included (1) a lack of participation from certain sectors, (2) insufficient awareness around the AMR issue, (3) constraints in information sharing, and (4) a lack of ideal indicators to track the progress in addressing AMR. Improvements in these areas will provide a more holistic One Health engagement in support of the effective planning and implementation of the NSAP.

Social demographics determinants for resistome and microbiome variation of a multiethnic community in Southern Malaysia

The prevalence of antibiotic-resistant bacteria in Southeast Asia is a significant concern, yet there is limited research on the gut resistome and its correlation with lifestyle and environmental factors in the region. This study aimed to profile the gut resistome of 200 individuals in Malaysia using shotgun metagenomic sequencing and investigate its association with questionnaire data comprising demographic and lifestyle variables. A total of 1038 antibiotic resistance genes from 26 classes were detected with a mean carriage rate of 1.74 ± 1.18 gene copies per cell per person. Correlation analysis identified 14 environmental factors, including hygiene habits, health parameters, and intestinal colonization, that were significantly associated with the resistome (adjusted multivariate PERMANOVA, p < 0.05). Notably, individuals with positive yeast cultures exhibited a reduced copy number of 15 antibiotic resistance genes. Network analysis highlighted Escherichia coli as a major resistome network hub, with a positive correlation to 36 antibiotic-resistance genes. Our findings suggest that E. coli may play a pivotal role in shaping the resistome dynamics in Segamat, Malaysia, and its abundance is strongly associated with the community's health and lifestyle habits. Furthermore, the presence of yeast appears to be associated with the suppression of antibiotic-resistance genes.

Mobile Colistin Resistance (mcr) Gene-Containing Organisms in Poultry Sector in Low- and Middle-Income Countries: Epidemiology, Characteristics, and One Health Control Strategies

Mobile colistin resistance (mcr) genes (mcr-1 to mcr-10) are plasmid-encoded genes that threaten the clinical utility of colistin (COL), one of the highest-priority critically important antibiotics (HP-CIAs) used to treat infections caused by multidrug-resistant and extensively drug-resistant bacteria in humans and animals. For more than six decades, COL has been used largely unregulated in the poultry sector in low- and middle-income countries (LMICs), and this has led to the development/spread of mcr gene-containing bacteria (MGCB). The prevalence rates of mcr-positive organisms from the poultry sector in LMICs between January 1970 and May 2023 range between 0.51% and 58.8%. Through horizontal gene transfer, conjugative plasmids possessing insertion sequences (ISs) (especially ISApl1), transposons (predominantly Tn6330), and integrons have enhanced the spread of mcr-1, mcr-2, mcr-3, mcr-4, mcr-5, mcr-7, mcr-8, mcr-9, and mcr-10 in the poultry sector in LMICs. These genes are harboured by Escherichia, Klebsiella, Proteus, Salmonella, Cronobacter, Citrobacter, Enterobacter, Shigella, Providencia, Aeromonas, Raoultella, Pseudomonas, and Acinetobacter species, belonging to diverse clones. The mcr-1, mcr-3, and mcr-10 genes have also been integrated into the chromosomes of these bacteria and are mobilizable by ISs and integrative conjugative elements. These bacteria often coexpress mcr with virulence genes and other genes conferring resistance to HP-CIAs, such as extended-spectrum cephalosporins, carbapenems, fosfomycin, fluoroquinolone, and tigecycline. The transmission routes and dynamics of MGCB from the poultry sector in LMICs within the One Health triad include contact with poultry birds, feed/drinking water, manure, poultry farmers and their farm workwear, farming equipment, the consumption and sale of contaminated poultry meat/egg and associated products, etc. The use of pre/probiotics and other non-antimicrobial alternatives in the raising of birds, the judicious use of non-critically important antibiotics for therapy, the banning of nontherapeutic COL use, improved vaccination, biosecurity, hand hygiene and sanitization, the development of rapid diagnostic test kits, and the intensified surveillance of mcr genes, among others, could effectively control the spread of MGCB from the poultry sector in LMICs.

Evaluation of antibiotic appropriateness at an outpatient oncology centre

Current evidence supporting antimicrobial stewardship programs focused largely in inpatient setting. With the shift in cancer management from inpatient to ambulatory setting, it is crucial to examine the prevalence and predictors of inappropriate antibiotics prescribing. This is a retrospective cross-sectional study conducted at the National Cancer Centre Singapore (NCCS). Patients at least 21 years, with an active or past cancer diagnosis and prescribed with at least one oral antibiotic by a NCCS physician from 1st July to 30th September 2019 were included. Antibiotic appropriateness was assessed using institutional antibiotic guidelines or published clinical practice guidelines. For cases where antibiotics appropriateness cannot be ascertained using these guidelines, an independent three-member expert panel was consulted. A total of 815 patients were screened; 411 (59.4% females) were included with mean age of 62.4 years. The top three cancer diagnoses were breast (26.5%), lung (15.6%) and head and neck (13.6%). More than half (58.6%) received appropriate antibiotic choice. Of which, 235 (97.5%), 238 (98.8%) and 194 (80.5%) received appropriate dose, frequency and duration respectively. The presence of non-oncologic immunosuppressive comorbidities (OR 4.890, 95% CI 1.556-15.369, p-value = 0.007), antibiotic allergy (OR 2.352, 95% CI 1.178-4.698, p-value = 0.015) and skin and soft tissue infections (OR 2.004, 95% CI 1.276-3.146, p-value = 0.003) were associated with a higher incidence of inappropriate antibiotic choice. This study highlighted that inappropriate antibiotic prescribing is prevalent in the ambulatory oncology setting. Predicators identified can aid in the design of targeted strategies to optimise antibiotic use in ambulatory oncology patients.

Global incidence in hospital-associated infections resistant to antibiotics: An analysis of point prevalence surveys from 99 countries

BACKGROUND

Hospital-associated infections (HAIs) are an important cause of morbidity and mortality around the world. Many HAIs are caused by drug-resistant bacterial pathogens, but there are major gaps in our understanding of the number of hospital-associated drug-resistant infections (HARIs) worldwide. As such, we estimated trends in prevalence of HARIs caused by high priority pathogens (Escherichia coli, Acinetobacter spp., Klebsiella spp., Staphylococcus aureus, Enterobacter spp., and Pseudomonas spp.) in 195 countries.

METHODS AND FINDINGS

Resistance prevalence estimates were extracted from 474-point prevalence surveys (PPS) from 99 countries published between 2010 and 2020 coupled with country-level estimates of hospitalization rates and length of stay. Prevalence estimates were transformed in yearly incidence of HARIs per year by country and income group. We estimate the global number of HARIs per year to be 136 million (95% credible interval (CI) 26 to 246 million) per year, with the highest burden in China (52 million, 95% CI 10 to 95 million), Pakistan (10 million, 95% CI 2 to 18 million), and India (9 million, 95% CI 3 to 15 million). Among income groups, middle-income countries bore the highest burden of HARIs per year (119 million, 95% CI 23 to 215 million). Our analysis was constrained by the limited number of PPS for HARIs, lack of community-associated data on antibiotic-resistant infections, and our population level analysis.

CONCLUSIONS

In this study, we observe, in the absence of systematic surveillance systems for HARIs, a baseline overview of their rates. Our yearly estimates highlight the global threat of HARIs and may help define strategies to tackle resistance in hospital settings.

Integrative Digital Tools to Strengthen Data Management for Antimicrobial Resistance Surveillance in the "One Health" Domain in Nepal

Antimicrobial resistance (AMR) is increasing and represents one of the greatest public health challenges of our time, accounting for considerable morbidity and mortality globally. A "One Health" surveillance strategy, which integrates data concerning the resistant organisms circulating in humans, animals, and the environment, is required to monitor this issue and enable effective interventions. The timely collection, processing, analysis, and reporting of AMR surveillance data are necessary for the effective delivery of the information generated from such surveillance. Nepal has greatly improved its surveillance activities through a network of human and animal health laboratories; however, the data reported by sentinel laboratories are often inconsistent, incomplete, and delayed, causing challenges in terms of data cleaning, standardization, and visualization on a national level. To overcome these issues, innovative methods and procedures have been adopted in Nepal, with the development and customization of digital tools that reduce the human time and effort spent on data cleaning and standardization, with concomitant improvements in the accuracy of data. These standardized data can be uploaded to the district health information system 2 (DHIS2) One Health AMR surveillance portal, enabling the generation of reports that will help decision-makers and policy planners to combat the global problem of AMR.

Methicillin resistant Staphylococcus aureus isolated from surgical patients in Cambodia over a 10-year period

Methicillin-resistant Staphylococcus aureus (MRSA) related surgical infections are a global challenge. The burden of antimicrobial resistance is high throughout South-East Asia, and this is reflected in our local institution in Cambodia. Between 2011 and 2013, we analysed 251 wound swab samples at the Children's Surgical Centre, Phnom Penh; 52.5% of the Staphylococcus aureus isolates (n = 52/99) were MRSA positive. Ten years on, we have sought to investigate whether there is a difference in MRSA rates within our adult and paediatric patient population. Between 2020 and 2022, MRSA rates in our patient population have remained similar at 53.8% (n = 42/78). Resistance profiles of MRSA isolates have also remained similar with a significant proportion of MRSA still showing sensitivity to trimethoprim-sulfamethoxazole and tetracycline. We also find that patients presenting with wound infection secondary to trauma or orthopaedic implants had greater propensity to yield MRSA.

Impact of Multidisciplinary Collaborative Intervention on Isolation Implementation in Prevention and Control of Multi-drug Resistance Infection

OBJECTIVE

Contact precautions, especially the initiation of isolation, are important measures to prevent and control multidrug-resistant organisms (MDROs). However, the implementation in clinical practice remains weak. This study aimed to analyze the impact of multidisciplinary collaborative intervention on isolation implementation in multidrug-resistant infection, and determine the factors that affect the implementation of isolation measures.

METHODS

A multidisciplinary collaborative intervention related to isolation was conducted at a teaching tertiary hospital in central China on November 1, 2018. The information of 1338 patients with MDRO infection and colonization at 10 months before and after the intervention was collected. Then, the issuance of isolation orders was retrospectively analyzed. Univariate analysis and multivariate logistic regression analysis were performed to analyze the factors that affected the isolation implementation.

RESULTS

The overall issuance rate of isolation orders was 61.21%, which increased from 33.12% to 75.88% (P<0.001) after the implementation of the multidisciplinary collaborative intervention. The intervention (P<0.001, OR=0.166) was a promoting factor for the issuance of isolation orders, in addition to the length of stay (P=0.004, OR=0.991), department (P=0.004), and microorganism (P=0.038).

CONCLUSION

The isolation implementation remains far lower than policy standards. Multidisciplinary collaborative interventions can effectively improve the compliance to isolation measures implemented by doctors, thereby promoting the standardized management of MDROs, and providing reference for further improving the quality of hospital infection management.

Vancomycin Resistance in Enterococcus and Staphylococcus aureus

Enterococcus faecalis, Enterococcus faecium and Staphylococcus aureus are both common commensals and major opportunistic human pathogens. In recent decades, these bacteria have acquired broad resistance to several major classes of antibiotics, including commonly employed glycopeptides. Exemplified by resistance to vancomycin, glycopeptide resistance is mediated through intrinsic gene mutations, and/or transferrable van resistance gene cassette-carrying mobile genetic elements. Here, this review will discuss the epidemiology of vancomycin-resistant Enterococcus and S. aureus in healthcare, community, and agricultural settings, explore vancomycin resistance in the context of van and non-van mediated resistance development and provide insights into alternative therapeutic approaches aimed at treating drug-resistant Enterococcus and S. aureus infections.

Prevalence of methicillin-resistant Staphylococcus aureus in dairy farms: A systematic review and meta-analysis

Methicillin-resistant Staphylococcus aureus (MRSA) is an opportunistic bacterium that causes many human and animal infections worldwide. MRSA infections are classified as priority infections owing to their high morbidity and mortality, with a significant risk of zoonotic transmission. This study aimed to determine the pooled prevalence of MRSA in dairy cattle farms and its heterogeneity. Relevant studies were retrieved from three databases: PubMed, Web of Science, and Scopus. The pooled prevalence of MRSA in dairy farms was estimated using a random-effects model. Subgroup and meta-regression analyses were used to assess the probable sources of heterogeneity. Sensitivity and publication bias analyses were also performed. A total of 94 articles were eligible for inclusion in this meta-analysis. The pooled prevalence of MRSA was estimated to be 3.81% [95% confidence interval (95% CI) = 2.61-5.20] with significantly high heterogeneity (I ² = 96.6%, p = 0.00). For the subgroup analysis among continents, the prevalence was highest in Asia (4.89%; 95% CI = 2.88-7.35) and lowest in South America (1.33%, 95% CI = 0.00-5.49). As for the year of publication, MRSA prevalence was highest in reports published from 2015 to 2018 (4.36%, 95% CI = 2.41-6.80) and lowest in reports published before 2015 (2.65%, 95% CI = 0.75-5.52). As for sample type, the prevalence of MRSA in cattle milk (3.91%, 95% CI = 2.64-5.39) was higher than that in other sample types (1.19%, 95% CI = 0.05-3.24). These three factors were not significantly associated with the pooled prevalence of MRSA (p > 0.05). Therefore, the findings of this study indicate that the prevalence of MRSA has been minimal and consistent in dairy cattle farms over time.

Tracking the phage trends: A comprehensive review of applications in therapy and food production

In the present scenario, the challenge of emerging antimicrobial resistance is affecting human health globally. The increasing incidences of multidrug-resistant infections have become harder to treat, causing high morbidity, and mortality, and are posing extensive financial loss. Limited discovery of new antibiotic molecules has further complicated the situation and has forced researchers to think and explore alternatives to antibiotics. This has led to the resurgence of the bacteriophages as an effective alternative as they have a proven history in the Eastern world where lytic bacteriophages have been used since their first implementation over a century ago. To help researchers and clinicians towards strengthening bacteriophages as a more effective, safe, and economical therapeutic alternative, the present review provides an elaborate narrative about the important aspects of bacteriophages. It abridges the prerequisite essential requirements of phage therapy, the role of phage biobank, and the details of immune responses reported while using bacteriophages in the clinical trials/compassionate grounds by examining the up-to-date case reports and their effects on the human gut microbiome. This review also discusses the potential of bacteriophages as a biocontrol agent against food-borne diseases in the food industry and aquaculture, in addition to clinical therapy. It finishes with a discussion of the major challenges, as well as phage therapy and phage-mediated biocontrols future prospects.

The role of the clinical pharmacist in antimicrobial stewardship in Asia: A review

Clinical pharmacist-driven antimicrobial stewardship programs (ASPs) have been successfully implemented. Although relevant guidance and several studies suggest that clinical pharmacists be integrated into the current ASP team model, barriers still exist in Asia, primarily due to lack of dedicated personnel and lack of career advancement. We review the effectiveness and the ideal role of clinical pharmacist among ASPs in Asia. Several studies conducted in Asia have shown the effectiveness of pharmacist-led ASP interventions in hospitals and other healthcare settings. However, opportunities to expand the role of clinical pharmacists in ASPs in Asia exist in the implementation of rapid diagnostic test and drug allergies.

Epidemiology, Management, and Outcomes of Sepsis in ICUs among Countries of Differing National Wealth across Asia

Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).

Ciprofloxacin Concentrations 1/1000th the MIC Can Select for Antimicrobial Resistance in N. gonorrhoeae—Important Implications for Maximum Residue Limits in Food

Background: Concentrations of fluoroquinolones up to 200-fold lower than the minimal inhibitory concentration (MIC) have been shown to be able to select for antimicrobial resistance in E. coli and Salmonella spp. (the minimum selection concentration—MSC). We hypothesized that the low concentrations of quinolones found in meat may play a role in the genesis of quinolone resistance in Neisseria gonorrhoeae. We aimed to (i) establish the ciprofloxacin MSC for N. gonorrhoeae and (ii) assess if, at the ecological level, the prevalence of gonococcal ciprofloxacin resistance is associated with the concentration of quinolones used in food animal production, which is an important determinant of long-term low-dose exposure to ciprofloxacin in humans. Methods: (i) To assess if subinhibitory ciprofloxacin concentrations could select for de novo generated resistant mutants, a susceptible WHO-P N. gonorrhoeae isolate was serially passaged at 1, 1:10, 1:100 and 1:1000 of the ciprofloxacin MIC of WHO-P (0.004 mg/L) on GC agar plates. (ii) Spearman’s correlation was used to assess the association between the prevalence of ciprofloxacin resistance in N. gonorrhoeae and quinolone use for animals and quinolone consumption by humans. Results: Ciprofloxacin concentrations as low as 0.004 µg/L (1/1000 of the MIC of WHO-P) were able to select for ciprofloxacin resistance. The prevalence of ciprofloxacin resistance in N. gonorrhoeae was positively associated with quinolone use for food animals (ρ = 0.47; p = 0.004; N = 34). Conclusion: Further individual level research is required to assess if low doses of ciprofloxacin from ingested foodstuffs are able to select for ciprofloxacin resistance in bacteria colonizing humans and other species.

A Formative Assessment of Antibiotic Dispensing/Prescribing Practices and Knowledge and Perceptions of Antimicrobial Resistance (AMR) among Healthcare Workers in Lahore Pakistan

(1) Background: Antimicrobial resistance causes significant disease burden in low- and middle-income countries. The objective of this paper is to describe antibiotic dispensing/prescribing practices and underlying factors associated with these practices among community-based healthcare workers. (2) Methods: Cross-sectional survey data were collected from private and public health facilities in 14 union councils, Lahore Pakistan. Respondents included physicians, nurses, lady health workers/volunteers, midwives, pharmacy and medicine shop employees, and medical technicians. Descriptive and bivariate analysis are used to present the data; (3) Results: 177 respondents completed the survey. In terms of weekly dispensing of antibiotics, the most common were Amoxicillin/Augmentin (2.3 [SD 1.5]), Cefixine (2.4 [SD 1.6]), and Azithromycin (2.5 [SD 2.1]). For children, antibiotics were more likely to be prescribed/dispensed for sore throat (54.3%/95) and diarrhea (48.9%/86). For adults, antibiotics were more likely to be prescribed/dispensed for sore throat (67.0%/118), diarrhea (59.7%/105) and burning sensation when urinating (55.7%/176). In total, 55.4% of respondents stated that they have sold partial antibiotic courses to patients/customers. A total of 44.6% of respondents incorrectly answered that antibiotics could be used for viral infections; (4) Conclusions: Data from this study and similar research emphasize the urgent need to implement community-based stewardship programs for all healthcare workers.

Antimicrobial peptides: A promising tool to combat multidrug resistance in SARS CoV2 era

COVID-19 (Coronavirus Disease 2019), a life-threatening viral infection, is caused by a highly pathogenic virus named SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2). Currently, no treatment is available for COVID-19; hence there is an urgent need to find effective therapeutic drugs to combat COVID-19 pandemic. Considering the fact that the world is facing a major issue of antimicrobial drug resistance, naturally occurring compounds have the potential to achieve this goal. Antimicrobial peptides (AMPs) are naturally occurring antimicrobial agents which are effective against a wide variety of microbial infections. Therefore, the use of AMPs is an attractive therapeutic strategy for the treatment of SARS-CoV-2 infection. This review sheds light on the potential of antimicrobial peptides as antiviral agents followed by a comprehensive description of effective antiviral peptides derived from various natural sources found to be effective against SARS-CoV and other respiratory viruses. It also highlights the mechanisms of action of antiviral peptides with special emphasis on their effectiveness against SARS-CoV-2 infection.

Investigating forthcoming strategies to tackle deadly superbugs: current status and future vision

INTRODUCTION

Superbugs are microorganisms that cause disease and have increased resistance to the treatments typically used against infections. Recently, antibiotic resistance development has been more rapid than the pace at which antibiotics are manufactured, leading to refractory infections of pathogenic bacteria. Scientists are concerned that a particularly virulent and lethal "superbug" will one day join the ranks of existing bacteria that cause incurable diseases, resulting in a global health disaster on the scale of the Black Death.

AREAS COVERED

Therefore, this study highlights the current developments in the management of antibiotic-resistant bacteria and recommends strategies for further regulating antibiotic-resistant microorganisms associated with the healthcare system. This review also addresses the origins, prevalence, and pathogenicity of superbugs, and the design of antibacterial against these growing multidrug-resistant organisms from a medical perspective.

EXPERT OPINION

It is recommended that antimicrobial resistance (AMR) should be addressed by limiting human-to-human transmission of resistant strains, lowering the use of broad-spectrum antibiotics, and developing novel antimicrobials. Using the risk-factor domains framework from this study would assure that not only clinical but also community and hospital-specific factors are covered, lowering the chance of confounders. Extensive subjective research is necessary to fully understand the underlying factors and uncover previously unexplored areas.

Prevalence of Fungal Drug Resistance in COVID-19 Infection: a Global Meta-analysis

Purpose

Secondary bacterial or fungal infections are one of the most important medical complications among patients with Coronavirus Disease 2019 (COVID-19). The emergence of multidrug-resistant (MDR) candida can cause many problems such as treatment failure, adverse clinical outcomes, and even disease outbreaks. This systematic review and meta-analysis aims to investigate the prevalence and outcomes of fungal drug-resistant in COVID-19 patients.

Methods

PubMed, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for peer reviewed-articles published in English up to May 20, 2021. Heterogeneity across studies was evaluated using Cochrane’s Q test and the I² index. The pooled point prevalence and their corresponding 95% confidence intervals (CIs) were considered to estimate the prevalence of fungal drug resistance infection in COVID-19 patients.

Results

Eight eligible articles were included in our meta-analysis. The number of COVID-19 patients with fungal co-infection varied from 5 to 35 among selected studies. The overall pooled prevalence of fungal drug resistance among patients with co-infections of fungal and COVID-19 was 69% (95% CI: 37%, 94%) by using a random-effects model. In terms of specific species, the pooled meta-analysis for Candida Auris was estimated to be 100% (95%CI: 98%, 100%; I² = 0%), for Multi-Candida 59% (95%CI: 38%, 79%; I² = 12.5%), and for Aspergillus 15% (95%CI: 0%, 42%; I² = 0%).

Conclusion

Our study shows the high prevalence of fungal drug resistance in COVID-19 patients and emphasizes the need to strengthen antimicrobial stewardship programs, close monitoring for treatment failure, and the emergence of resistance upon treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12281-022-00439-9.

Mobile Tigecycline Resistance: An Emerging Health Catastrophe Requiring Urgent One Health Global Intervention

Mobile tigecycline resistance (MTR) threatens the clinical efficacy of the salvage antibiotic, tigecycline (TIG) used in treating deadly infections in humans caused by superbugs (multidrug-, extensively drug-, and pandrug-resistant bacteria), including carbapenem- and colistin-resistant bacteria. Currently, non-mobile tet(X) and mobile plasmid-mediated transmissible tet(X) and resistance-nodulation-division (RND) efflux pump tmexCD-toprJ genes, conferring high-level TIG (HLT) resistance have been detected in humans, animals, and environmental ecosystems. Given the increasing rate of development and spread of plasmid-mediated resistance against the two last-resort antibiotics, colistin (COL) and TIG, there is a need to alert the global community on the emergence and spread of plasmid-mediated HLT resistance and the need for nations, especially developing countries, to increase their antimicrobial stewardship. Justifiably, MTR spread projects One Health ramifications and portends a monumental threat to global public and animal health, which could lead to outrageous health and economic impact due to limited options for therapy. To delve more into this very important subject matter, this current work will discuss why MTR is an emerging health catastrophe requiring urgent One Health global intervention, which has been constructed as follows: (a) antimicrobial activity of TIG; (b) mechanism of TIG resistance; (c) distribution, reservoirs, and traits of MTR gene-harboring isolates; (d) causes of MTR development; (e) possible MTR gene transfer mode and One Health implication; and (f) MTR spread and mitigating strategies.

International travels and transmission of multidrug resistant Neisseria gonorrhoeae in Europe: A systematic review

BACKGROUND

The increase of gonococcal infection cases in Europe and rises in Neisseria gonorrhoeae antibiotic resistance (AMR) have become an urgent concern globally. In the last few years international tourism has increased, which might contribute to the spread of different strains of multiresistant gonococcal infections. This study aimed at assessing the effect of international travel on the transmission of multidrug resistant N. gonorrhoeae in the European Union and associated European countries.

METHOD

We conducted a systematic review and searched PubMed, Scopus, Embase and CENTRAL between January 1, 2010 and June 30, 2021 for gonococcal infection, antibiotic resistance and international travel. Articles were screened in title, abstract and keywords. The quality of the articles was assessed using a pre-designed tool. Individual, travel related and susceptibility to antimicrobials data were collected.

RESULTS

A total of 18 studies met our criteria, of which 88.9% concluded that international travel directly influences the transmission of multidrug resistant N. gonorrhoeae from the country of travel to the country of return. Travelers mainly visited South East Asian countries (66.7%) and returned to the UK (38.9%). Half of the included studies reported ciprofloxacin resistant strains and the most frequently prescribed drug used for treatment was ceftriaxone.

CONCLUSIONS

International travels might be an important factor in the spread of multi-resistant sexually transmitted infections (STIs). There is a need to strengthen AMR surveillance in international travelers for prompt investigation and notification of drug resistance in STIs.

Sepsis Management in Southeast Asia: A Review and Clinical Experience

Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia.

A Qualitative Study on the Design and Implementation of the National Action Plan on Antimicrobial Resistance in the Philippines

Antimicrobial resistance (AMR) is a global public health threat that warrants urgent attention. Countries developed their national action plans (NAPs) following the launch of the Global Action Plan on AMR in 2015. The development and implementation of NAPs are often complicated due to the multifaceted nature of AMR, and studies analyzing these aspects are lacking. We analyzed the development and implementation of the Philippine NAP on AMR with guidance from an AMR governance framework. We conducted in-depth interviews with 37 participants across the One Health spectrum. The interviews were transcribed verbatim and were analyzed thematically, adopting an interpretative approach. The enabling factors for NAP implementation include (1) a high level of governmental support and involvement of relevant stakeholders, (2) the development of policies to support improved responses in infection prevention and control and antimicrobial stewardship, and (3) better engagement and advocacy by professional associations and civil society groups. The challenges include (1) a lack of resources and regulatory capacity, (2) insufficient impetus for AMR research and surveillance, and (3) limited One Health engagement. Although there has been considerable progress for human health, strengthening the involvement and representation of the animal health and environment sectors in the AMR scene must be undertaken. Developing well-defined roles within policies will be paramount to the strong implementation of AMR strategies.

Antimicrobial Resistance Research Collaborations in Asia: Challenges and Opportunities to Equitable Partnerships

Antimicrobial Resistance is recognized as a major threat to global health security. The WHO Southeast Asia region is dubbed a “global hub for AMR emergence”, as it runs the highest risk for AMR emergence among all WHO regions in Asia. Hence, there is a need for Asia-centric, collaborative AMR research aligned with the true needs and priorities of the region. This study aimed to identify and understand the challenges and opportunities for such collaborative endeavors to enhance equitable partnerships. This qualitative study adopted an interpretative approach involving a thematic analysis of 15 semi-structured interviews with AMR experts conducting research in the region. The study identified several factors influencing research collaborations, such as the multi-dimensional nature of AMR, limited or lack of funds, different AMR research priorities in Asian countries, absence of Asia-centric AMR leadership, lack of trust and, unequal power relationships between researchers, and the negative impact of the COVID-19 pandemic in research collaborations. It also identified some opportunities, such as the willingness of researchers to collaborate, the formation of a few networks, and the prioritization by many academics of the One Health paradigm for framing AMR research. Participants reported that the initiation of stronger cross-discipline and cross-country networks, the development of Asia-centric AMR leadership, flexible research agendas with shared priorities, transparent and transferable funds, and support to enhance research capacity in LMICs could assist in developing more equitable collaborative research in Asia.

Antimicrobial Prescribing Confidence and Knowledge Regarding Drug Resistance: Perception of Medical Students in Malaysia and the Implications

Worldwide, microbes are becoming more challenging by acquiring virulent skills to adapt and develop antimicrobial resistance (AMR). This is a concern as AMR increases morbidity, mortality, and costs. Consequently, physicians need to be trained on appropriate antimicrobial prescribing, starting as medical students. Objective: To evaluate medical students’ confidence in antimicrobial prescribing and AMR. Methods: Cross-sectional study assessing medical students’ knowledge, perception, and confidence in prescribing antimicrobials and AMR in a Malaysian University. A universal sampling method was used. Results: Most responding students believed that educational input regarding overall prescribing was sufficient. Regarding the principle of appropriate and accurate prescriptions, female medical students had less knowledge (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.25–0.99; p = 0.050). Year-IV and Year-V medical students had more excellent knowledge than Year-III students regarding confidence in potential antibiotic prescribing once qualified. Year-V students also showed an appreciably higher confidence in the broad principles of prescribing, including antibiotics for infectious diseases, compared to those in other years. Conclusion: Overall, medical students gain more knowledge and confidence regarding the potential prescribing of antimicrobials as their academic careers progress. This is important given concerns with the current excessive use of antimicrobials in Malaysia.

International Travel as a Risk Factor for Carriage of Extended-Spectrum β-Lactamase-Producing Escherichia coli in a Large Sample of European Individuals—The AWARE Study

Antibiotic resistance (AR) is currently a major threat to global health, calling for a One Health approach to be properly understood, monitored, tackled, and managed. Potential risk factors for AR are often studied in specific high-risk populations, but are still poorly understood in the general population. Our aim was to explore, describe, and characterize potential risk factors for carriage of Extended-Spectrum Beta-Lactamase-resistant Escherichia coli (ESBL-EC) in a large sample of European individuals aged between 16 and 67 years recruited from the general population in Southern Germany, the Netherlands, and Romania. Questionnaire and stool sample collection for this cross-sectional study took place from September 2018 to March 2020. Selected cultures of participants’ stool samples were analyzed for detection of ESBL-EC. A total of 1183 participants were included in the analyses: 333 from Germany, 689 from the Netherlands, and 161 from Romania. Travels to Northern Africa (adjusted Odds Ratio, aOR 4.03, 95% Confidence Interval, CI 1.67–9.68), Sub-Saharan Africa (aOR 4.60, 95% CI 1.60–13.26), and Asia (aOR 4.08, 95% CI 1.97–8.43) were identified as independent risk factors for carriage of ESBL-EC. Therefore, travel to these regions should continue to be routinely asked about by clinical practitioners as possible risk factors when considering antibiotic therapy.

Concentrations of Ciprofloxacin in the World’s Rivers Are Associated with the Prevalence of Fluoroquinolone Resistance in Escherichia coli: A Global Ecological Analysis

Background: Extremely low concentrations of ciprofloxacin may select for antimicrobial resistance. A recent global survey found that ciprofloxacin concentrations exceeded safe levels at 64 sites. In this study, I assessed if national median ciprofloxacin concentrations in rivers were associated with fluoroquinolone resistance in Escherichia coli. Methods: Spearman’s regression was used to assess the country-level association between the national prevalence of fluoroquinolone resistance in E. coli and the median ciprofloxacin concentration in the country’s rivers. Results: The prevalence of fluoroquinolone resistance in E. coli was positively correlated with the concentration of ciprofloxacin in rivers (ρ = 0.36; p = 0.011; n = 48). Discussion: Steps to reducing the concentrations of fluoroquinolones in rivers may help prevent the emergence of resistance in E. coli and other bacterial species.

Novel Microfluidics Device for Rapid Antibiotics Susceptibility Screening

In recent years, excessive utilization of antibiotics has led to the emergence of antibiotic microbial resistance on a planetary scale. This recent phenomenon represents a serious threat to public health, as well as an enormous burden for healthcare systems’ budgets worldwide. Novel, rapid and cheap methods for antibiotic susceptibility screening are urgently needed for this obstacle to be overcome. In this paper, we present a microfluidic device for on-chip antibiotic resistance testing, which allows for antibiotic microbial resistance detection within 6 hours. The design, fabrication and experimental utilization of the device are thoroughly described and analyzed, as well as possibilities for future automation of the whole process. The accessibility of such a device for all people, regardless of economic status, was of utmost importance for us during the development of the project.

Prevalence of Vancomycin-Resistant Enterococcus (VRE) in Poultry in Malaysia: The First Meta-Analysis and Systematic Review

Databases such as PubMed, Scopus and Google Scholar were searched. Data extraction and assessment of study protocol was done by two independent reviewers and the results were reviewed by a third. OpenMeta analyst and comprehensive meta-analysis (CMA) were used for the meta-analysis. The random effect model was used, publication bias and between-study heterogeneity was assessed. Seventeen studies were added to the final meta-analysis. Studies were sampled from 2000–2018 and of the 8684 isolates tested, 2824 were VRE. The pooled prevalence of VRE among poultry in Malaysia was estimated at 24.0% (95% CI; 16.7–33.1%; I² = 98.14%; p < 0.001). Between-study variability was high (t² = 0.788; heterogeneity I² = 98.14% with heterogeneity chi-square (Q) = 858.379, degrees of freedom (df) = 16, and p < 0.001). The funnel plot showed bias which was confirmed by Egger’s test and estimates from the leave-one-out forest plot did not affect the pooled prevalence. Pooled prevalence of VRE in chickens and ducks were 29.2% (CI = 18.8–42.5%) and 11.2%, CI = 9.0–14.0%) respectively. Enterococcus faecalis was reported most with more studies being reported in Peninsular Malaysia Central region and used antibiotic disc diffusion as detection method. Increased surveillance of VRE in poultry in Malaysia is required.

Positive association between the use of macrolides in food-producing animals and pneumococcal macrolide resistance: a global ecological analysis

BACKGROUND

The reasons underpinning the large differences in the prevalence of resistance to macrolides in Streptococcus pneumoniae are imperfectly understood. We assessed if the volume of macrolides used in food-animals could play a role.

METHODS

Logistic regression was used to assess if the country-level prevalence of pneumococcal macrolide resistance was associated with country-level macrolide consumption in food animals and humans.

RESULTS

In both univariate and multivariate models, macrolide use in food-producing animals was significantly associated with pneumococcal macrolide resistance (coeff. = 339, 95% CI 21 - 658; P = 0.037).

CONCLUSIONS

In vitro and individual-level studies are required to verify or refute the hypothesis that macrolides used in food animals can promote the spread of macrolide resistance in humans.