Antimicrobial Multidrug Resistance: Clinical Implications for Infection Management in Critically Ill Patients

Prolonged Beta-Lactam Infusions in Children: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess whether beta-lactam extended or continuous beta-lactam infusions (EI/CI) improve clinical outcomes in children with proven or suspected bacterial infections.

STUDY DESIGN

We included observational and interventional studies that compared beta-lactam EI or CI with standard infusions in children less than 18 years old, and reported on mortality, hospital or intensive care unit length of stay, microbiological cure, and/or clinical cure. Data sources included PubMed, Medline, EBM Reviews, EMBASE, and CINAHL and were searched from January 1, 1980, to November 3, 2023. Thirteen studies (2945 patients) were included: 5 randomized control trials and 8 observational studies. Indications for antimicrobial therapies and clinical severity varied, ranging from cystic fibrosis exacerbation to critically ill children with bacteriemia.

RESULTS

EI and CI were not associated with a reduction in mortality in randomized control trials (n = 1464; RR 0.93, 95% CI 0.71, 1.21), but were in observational studies (n = 833; RR 0.43, 95% CI 0.19, 0.96). We found no difference in hospital length of stay. Results for clinical and microbiological cures were heterogeneous and reported as narrative review. The included studies were highly heterogeneous, limiting the strength of our findings. The lack of shared definitions for clinical and microbiological cure outcomes precluded analysis.

CONCLUSIONS

EI and CI were not consistently associated with reduced mortality or length of stay in children. Results were conflicting regarding clinical and microbiological cures. More well-designed studies targeting high-risk populations are necessary to determine the efficacy of these alternative dosing strategies.

High prevalence and genomic features of multidrug-resistant Salmonella enterica isolated from chilled broiler chicken on retail sale in the United Arab Emirates

Non-typhoidal Salmonella represents a significant global concern for food safety and One Health. Despite the United Arab Emirates (UAE) being a leading consumer of chicken meat globally, there is a lack of comprehensive understanding regarding the prevalence and genomic characteristics of Salmonella within the country. This study aims to address this gap by conducting a thorough analysis of Salmonella prevalence, antimicrobial resistance, and genomic profiles of isolates obtained from whole broiler carcasses retailed under chilled conditions in the UAE. Our findings reveal that Salmonella was detected in 41.2 % (130/315) of the sampled chilled broiler carcasses, with notable variability observed among samples sourced from six different companies. Phenotypic antimicrobial resistance (AMR) testing, among 105 isolates, highlighted high resistance rates to tetracycline (97.1 %), nalidixic acid (93.3 %), ampicillin (92.4 %), azithromycin (75.2 %), ciprofloxacin (63.8 %), and ceftriaxone (54.3 %). Furthermore, a concerning 99 % (104/105) of the isolates exhibited multidrug resistance. Whole-genome sequencing (WGS) of 60 isolates identified five serovars, with S. infantis/Sequence Type (ST) 32 (55 %) and S. Minnesota/ST-458 (28.3 %) being the most prevalent. WGS analysis unveiled 34 genes associated with antimicrobial resistance, including mcr-1.1 (only in two isolates), conferring resistance to colistin. The two major serovars, Infantis and Minnesota, exhibited significant variation (P-values <0.001) in the distribution of major AMR genes (aadA1, blaCMY-2, blaSHV-12, qnrB19, qnrS1, sul1, and sul2). Notably, the gene qacEdelta, conferring resistance to quaternary ammonium compounds commonly found in disinfectants, was universally present in all S. Infantis isolates (n = 33), compared to only one S. Minnesota isolate. Additionally, all S. Infantis isolates harbored the IncFIB (pN55391) plasmid replicon type. Major serovars exhibited distinct distributions of antimicrobial resistance genes, underscoring the importance of serovar-specific surveillance. These findings emphasize the critical need for continuous surveillance and intervention measures to address Salmonella contamination risks in poultry products, providing valuable insights for public health and regulatory strategies not only in the UAE but also globally.

Preventive strategies in paediatric cardiovascular surgery: impact on surgical site infections and beyond

BACKGROUND

Surgical management of congenital heart disease (CHD) has increased worldwide, but healthcare-associated infections (HAIs) can threaten these efforts.

AIM

To analyse the incidence of HAI, the impact of preventive interventions, and microbiological profiles in a paediatric cardiovascular surgery programme.

METHODS

Cohort study including children aged <12 years with CHD who underwent cardiovascular surgery between 2010 and 2021 in Medellín, Colombia (a middle-income setting). Data were collected from medical and laboratory records and infection control programme databases. Impact of various preventive interventions was assessed using a Poisson model. P < 0.05 was considered statistically significant.

FINDINGS

A total of 2512 surgeries were analysed. Incidence of surgical site infection (SSI) was 5.9%, followed by central line-associated bloodstream infection (CLABSI; 4.7%), catheter-associated urinary tract infection (CAUTI; 2.2%), and ventilator-associated pneumonia (VAP; 1.4%). Most of the strategies focused on preventing SSI, resulting in a reduction from 9.5% in 2010 to 3.0% in 2021 (P = 0.030). Antibiotic prophylaxis based on patient weight and continuous infusion had an impact on reducing SSI (RR: 0.56; 95% CI: 0.32-0.99). Vacuum-assisted closure (VAC) in clean wounds reduced 100% of infections. No significant risk reduction was observed for other HAI with the implemented interventions.

CONCLUSION

Preventive strategies effectively reduced SSI but no other infections, emphasizing the need for targeted approaches to address a broader spectrum of HAI successfully.

Self-assembling short peptide amphiphiles as versatile delivery agents: a new frontier in antibacterial research

Self-assembling short peptide amphiphiles, crafted through a minimalistic approach, spontaneously generate well-ordered nanostructures, facilitating the creation of precise nanostructured biomaterials for diverse biomedical applications. The seamless integration of bioactive metal ions and nanoparticles endows them with the potential to serve as pioneering materials in combating bacterial infections. Nanomanipulation of these molecules' binary structures enables effective penetration of membranes, forming structured nanoarchitectures with antibacterial properties. Through a comprehensive exploration, we attempt to reveal the innovative potential of short peptide amphiphiles, particularly in conjugation with metal cations and nanoparticles, offering insights for future research trajectories.

Incidence of Carbapenem-Resistant Gram-Negative Bacterial Infections in Critically Ill Patients with COVID-19 as Compared to Non-COVID-19 Patients: A Prospective Case-Control Study

Introduction

Critically ill COVID-19 patients hospitalized in intensive care units (ICU) are immunosuppressed due to SARSCoV-2-related immunological effects and are administered immunomodulatory drugs. This study aimed to determine whether these patients carry an increased risk of multi-drug resistant (MDR) and especially carbapenem-resistant Gram-negative (CRGN) bacterial infections compared to other critically ill patients without COVID-19.

Materials and Methods

A prospective case-control study was conducted between January 2022 and August 2023. The ICU patients were divided into two groups (COVID-19 and non-COVID-19). Differences in the incidence of CRGN infections from Klebsiella pneumoniae, Acinetobacter spp., and Pseudomonas aeruginosa were investigated. In addition, an indicator of the infection rate of the patients during their ICU stay was calculated. Factors independently related to mortality risk were studied.

Results

Forty-two COVID-19 and 36 non-COVID-19 patients were analyzed. There was no statistically significant difference in the incidence of CRGN between COVID-19 and non-COVID-19 patients. The infection rate was similar in the two groups. Regarding the aetiological agents of CRGN infections, Pseudomonas aeruginosa was significantly more common in non-COVID-19 patients (p=0.007). COVID-19 patients had longer hospitalisation before ICU admission (p=0.003) and shorter ICU length of stay (LOS) (p=0.005). ICU COVID-19 patients had significantly higher mortality (p < 0.001) and sequential organ failure assessment (SOFA) score (p < 0.001) compared to non-COVID-19 patients. Μortality secondary to CRGN infections was also higher in COVID-19 patients compared to non-COVID-19 patients (p=0.033). Male gender, age, ICU LOS, and hospital LOS before ICU admission were independent risk factors for developing CRGN infections. Independent risk factors for patients' mortality were COVID-19 infection, obesity, SOFA score, total number of comorbidities, WBC count, and CRP, but not infection from CRGN pathogens.

Conclusions

The incidence of CRGN infections in critically ill COVID-19 patients is not different from that of non-COVID-19 ICU patients. The higher mortality of COVID-19 patients in the ICU is associated with higher disease severity scores, a higher incidence of obesity, and multiple underlying comorbidities, but not with CRGN infections.

Recent advances on anticancer and antimicrobial activities of directly-fluorinated five-membered heterocycles and their benzo-fused systems

Due to the importance of the fluorinated heterocycles as main components of marketed drugs where 20% of the anticancer and antibiotic drugs contain fluorine atoms, this review describes the reported five-membered heterocycles and their benzo-fused systems having directly connected fluorine atom(s). The in vivo and in vitro anticancer and antimicrobial activities of these fluorinated heterocycles are well reported. Some fluorinated heterocycles were found to be lead structures for drug design developments where their activities were almost equal to or exceeded the potency of the reference drugs. In most cases, the fluorine-containing heterocycles showed promising safety index via their reduced cytotoxicity in non-cancerous cell lines. SAR study assigned that fluorinated heterocycles having various electron-donating or electron-withdrawing substituents significantly affected the anticancer and antimicrobial activities.

The Impact of Reporting the Same-Day Identification and Antibiotic Susceptibility Test Results on the Treatment of Bloodstream Infections

Objective

The rise of antibiotic-resistant organisms necessitates the implementation of rapid identification (ID) and antibiotic susceptibility testing (AST) methods for patient management. We aimed to analyze how rapid ID and AST reporting influenced clinicians' treatment decisions.

Materials and Methods

Bacteria were identified directly from positive blood cultures (BC) using serum separator tubes and MALDI-TOF MS. EUCAST rapid antibiotic susceptibility testing (RAST) method was performed for AST. The impact of rapid ID and AST reports on clinician treatment decisions was evaluated through clinical documentation. The appropriateness of antimicrobial therapy and interventions was assessed according to institutional antimicrobial prescribing guidelines, AST results, and clinical data.

Results

A total of 128 BC bottles from 86 patients underwent processing. The rapid ID method was successful in 105 (82.1%) bottles obtained from 76 patients. The rapid ID results were reviewed by the Infectious Diseases Team on the same day for 55 (72.4%) of the 76 patients. Following the evaluation, new treatments or interventions were recommended for 28 (36.8%) patients. RAST results were available for 24 patients. The susceptibility profile of seven patients was assessed by the Infectious Diseases Team on the same day. Antimicrobial treatment was escalated in four cases, and de-escalation was made in two based on RAST results. If all rapid results had been assessed, adjustments could have been made for eight (10.5%) and eleven (14.5%) more patients, according to ID and RAST results, respectively.

Conclusion

Implementation of rapid ID and AST may contribute to patient management. Although rapid reporting was made, some results were not evaluated by the clinician on the same day, indicating that communication between the clinician and the laboratory needs to be strengthened.

Multidrug-Resistant Sepsis: A Critical Healthcare Challenge

Sepsis globally accounts for an alarming annual toll of 48.9 million cases, resulting in 11 million deaths, and inflicts an economic burden of approximately USD 38 billion on the United States healthcare system. The rise of multidrug-resistant organisms (MDROs) has elevated the urgency surrounding the management of multidrug-resistant (MDR) sepsis, evolving into a critical global health concern. This review aims to provide a comprehensive overview of the current epidemiology of (MDR) sepsis and its associated healthcare challenges, particularly in critically ill hospitalized patients. Highlighted findings demonstrated the complex nature of (MDR) sepsis pathophysiology and the resulting immune responses, which significantly hinder sepsis treatment. Studies also revealed that aging, antibiotic overuse or abuse, inadequate empiric antibiotic therapy, and underlying comorbidities contribute significantly to recurrent sepsis, thereby leading to septic shock, multi-organ failure, and ultimately immune paralysis, which all contribute to high mortality rates among sepsis patients. Moreover, studies confirmed a correlation between elevated readmission rates and an increased risk of cognitive and organ dysfunction among sepsis patients, amplifying hospital-associated costs. To mitigate the impact of sepsis burden, researchers have directed their efforts towards innovative diagnostic methods like point-of-care testing (POCT) devices for rapid, accurate, and particularly bedside detection of sepsis; however, these methods are currently limited to detecting only a few resistance biomarkers, thus warranting further exploration. Numerous interventions have also been introduced to treat MDR sepsis, including combination therapy with antibiotics from two different classes and precision therapy, which involves personalized treatment strategies tailored to individual needs. Finally, addressing MDR-associated healthcare challenges at regional levels based on local pathogen resistance patterns emerges as a critical strategy for effective sepsis treatment and minimizing adverse effects.