How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel

β-lactam-induced OMV release promotes polymyxin tolerance in Salmonella enterica sv. Typhi

The rise of multidrug-resistant bacteria is a global concern, leading to a renewed reliance on older antibiotics like polymyxins as a last resort. Polymyxins, cationic cyclic peptides synthesized nonribosomally, feature a hydrophobic acyl tail and positively charged residues. Their antimicrobial mechanism involves initial interaction with Gram-negative bacterial outer-membrane components through polar and hydrophobic interactions. Outer membrane vesicles (OMVs), nano-sized proteoliposomes secreted from the outer membrane of Gram-negative bacteria, play a crucial role in tolerating harmful molecules, including cationic peptides such as polymyxins. Existing literature has documented environmental changes' impact on modulating OMV properties in Salmonella Typhimurium. However, less information exists regarding OMV production and characteristics in Salmonella Typhi. A previous study in our laboratory showed that S. Typhi ΔmrcB, a mutant associated with penicillin-binding protein (PBP, a β-lactam antibiotic target), exhibited hypervesiculation. Consequently, this study investigated the potential impact of β-lactam antibiotics on promoting polymyxin tolerance via OMVs in S. Typhi. Our results demonstrated that sub-lethal doses of β-lactams increased bacterial survival against polymyxin B in S. Typhi. This phenomenon stems from β-lactam antibiotics inducing hypervesiculation of OMVs with higher affinity for polymyxin B, capturing and diminishing its biologically effective concentration. These findings suggest that β-lactam antibiotic use may inadvertently contribute to decreased polymyxin effectivity against S. Typhi or other Gram-negative bacteria, complicating the effective treatment of infections caused by these pathogens. This study emphasizes the importance of evaluating the influence of β-lactam antibiotics on the interaction between OMVs and other antimicrobial agents.

Carbapenems versus β-lactam and β-lactamase inhibitors for treatment of nosocomial pneumonia: A systematic review and meta-analysis

Background

Carbapenems and β-lactam and β-lactamase inhibitors (BLBLIs) have been used empirically in nosocomial pneumonia, but their efficacy and safety are controversial.

Objective

We carried out a systematic review with meta-analysis to evaluate the efficacy and safety of carbapenems versus BLBLIs against nosocomial pneumonia.

Methods

PubMed, Embase, Cochrane Central Register of Controlled Trials, CNKI, Wangfang, VIP and Sinomed were searched systematically through April 29, 2023 for clinical trials comparing carbapenems with BLBLIs for treatment of nosocomial pneumonia. Random-effects models were used to evaluate the impact of treatment on the risk ratio (RR) of all-cause mortality, clinical response, microbiologic response, resistance by Pseudomonas aeruginosa, adverse effects (AEs), and serious adverse effects. The quality of the evidence was assessed with the Cochrane risk of bias tool. The review was registerted in the INPLASY (INPLASY202340113).

Results

Seven randomized controlled trials containing 3306 patients met our inclusion criteria Our meta-analysis showed no significant difference in all-cause mortality (RR = 0.88, 95% confidence interval [CI] = 0.75-1.03, I2 = 0%) or clinical cure (1.02, 0.96-1.09, 30%) or clinical failure (1.19, 0.97-1.47, 0%) or microbiologic clinical cure (0.98, 0.89-1.06, 40%) or Pseudomonas aeruginosa resistance (RR 2.43, CI 0.86-6.81, 49%, P = 0.09) or adverse events (0.98, 0.93-1.02, 0%) between carbapenems groups versus BLBLIs groups, but a significant difference was found for severe adverse events (RR 0.83, CI 0.73-0.94, 0%).

Conclusion

Differences in the prevalence of mortality, clinical cure, or clinical failure were not observed between carbapenems groups versus BLBLIs groups in terms of nosocomial pneumonia. The use of carbapenems was linked to a tendency towards the emergence of P. aeruginosa resistance, however, no statistically significant difference was observed.

Co-Circulation of SARS-CoV-2 and Other Respiratory Pathogens in Upper and Lower Respiratory Tracts during Influenza Season 2022-2023 in Lazio Region

Lower respiratory tract infections (LRTIs) occur when there is a lower airway tract infection. They are well-known for increasing the susceptibility of patients to bacterial/fungal co-infections and super-infections. In this study, we present the results of our investigation, which involved 381 consecutive patients admitted to our hospital during the Influenza season from October 2022 to April 2023. Among the 381 specimens, 75 were bronchoalveolar (BAL), and 306 were nasopharyngeal swabs (NPSs). Notably, 34.4% of the examined samples tested positive for SARS-CoV-2. Of these, we observed that 7.96% of NPSs showed positivity only for other respiratory viruses, while a substantial percentage (77%) of BAL specimens exhibited positive results only for bacterial co-infections. The results of our study not only confirm the importance of co-infections in COVID-19 but also emphasize the significance of utilizing rapid diagnostic tests (RDTs) for the timely diagnosis of LRTIs. In fact, RDTs allow for the identification of multiple pathogens, providing clinicians with useful and timely information to establish effective therapy.

The treatment of mild upper respiratory tract infections - a position paper with recommendations for best practice

Following the waning severity of COVID-19 due to vaccination and the development of immunity, the current variants of SARS-CoV-2 often lead to mild upper respiratory tract infections (MURTIs), suggesting it is an appropriate time to review the pathogenesis and treatment of such illnesses. The present article reviews the diverse causes of MURTIs and the mechanisms leading to symptomatic illness. Different symptoms of MURTIs develop in a staggered manner and require targeted symptomatic treatment. A wide variety of remedies for home treatment is available, including over-the-counter drugs and plant-derived substances. Recent pharmacological research has increased the understanding of molecular effects, and clinical studies have shown the efficacy of certain herbal remedies. However, the use of subjective endpoints in these clinical studies may suggest limited validity of the results. In this position paper, the importance of patient-centric outcomes, including a subjective perception of improved well-being, is emphasized. A best practice approach for the management of MURTIs, in which pharmacists and physicians create an improved multi-professional healthcare setting and provide healthcare education to patients, is proposed. Pharmacists act as first-line consultants and provide patients with remedies, considering the individual patient's preferences towards chemical or plant-derived drugs and providing advice for self-monitoring. Physicians act as second-line consultants if symptoms worsen and subsequently initiate appropriate therapies. In conclusion, general awareness of MURTIs should be increased amongst medical professionals and patients, thus improving their management.

Emerging soil contamination of antibiotics resistance bacteria (ARB) carrying genes (ARGs): New challenges for soil remediation and conservation

Soil plays a vital role as a nutrient source for microflora and plants in ecosystems. The accumulation and proliferation of antibiotics resistance bacteria (ARB) and antibiotics resistance genes (ARGs) causes emerging soil contamination and pollution, posing new challenges for soil remediation, recovery, and conservation. Fertilizer application in agriculture is one of the most important sources of ARB and ARGs contamination in soils. The recent existing techniques for the remediation of soil polluted with ARB and ARGs are very limited in terms of ARB and ARGs removal in soil. Bioelectrochemical remediation using bioelectrochemical systems such as microbial fuel cells and microbial electrolysis cells are promising technologies for the removal of ARB and ARGs in soil. Herein, diverse sources of ARB and ARGs in soil have been reviewed, their effects on soil microbial diversity have been analyzed, and the causes of ARB and ARGs rapid proliferation in soil are explained. Bioelectrochemical systems used for the remediation of soil contaminated with ARB and ARGs is still in its infancy stage and presents serious disadvantage and limits, therefore it needs to be well understood and implemented. In general, merging soil contamination of ARB and ARGs is an increasing concern threatening the soil ecosystem while the remediation technologies are still challenging. Efforts need to be made to develop new, effective, and efficient technologies for soil remediation and conservation to tackle the spread of ARB and ARGs and overcome the new challenges posed by ARB and ARGs contamination in soil.

Available evidence and potential for vaccines for reduction in antibiotic prescriptions

Bacterial antibiotic resistance is a public health issue. It means that drugs become ineffective, infections persist and have a huge impact on the health of patients and their spreading increases. To address a complex threat such as bacterial antibiotic resistance different and integrated approaches are needed including discovery of new antibiotics, improvement of diagnostics tools and improvement of antibiotic stewardship. Absolutely relevant are prevention of infections as well as decrease in the use of antibiotics. Vaccines are an important tool in the fight against bacterial antibiotic resistance and can help prevent it in several ways. Indeed, vaccines are highly effective in preventing diseases that might otherwise require the use of antibiotics to treat symptoms and associated complications. Preventing infections through vaccination helps reduce the need for and widespread and inappropriate use of antibiotics, including for secondary bacterial infections.

Relationships Between Diagnosis, Bacterial Isolation, and Antibiotic Prescription in Out Patients With Respiratory Tract Infection Symptoms in Rural Anhui, China

Objectives

This paper aims to explore the direct associations of antibiotics prescription with clinical diagnosis and bacterial detection. It also analyses the relations of clinical diagnosis with symptoms and bacterial detection, with a hope of revealing indirect links to antibiotic prescription.

Methods

The study was implemented in one village clinic and one township health center in each of four rural residential areas in Anhui Province, China. Observations were conducted to record clinical diagnosis and antibiotic prescription. A semi-structured questionnaire survey was used to collected patients' sociodemographic information and reported symptoms. Sputum and throat swabs were collected for bacterial culture.

Results

Among 1,068 patients presenting in the study settings who received a diagnosis of respiratory tract infection (RTI), 87.8% of prescriptions included an antibiotic and 35.8% included two or more antibiotics. Symptomatic RTI patients to the site clinics were diagnosed mainly as having upper respiratory tract infection (32.0%), bronchitis/tracheitis (23.4%), others (16.6%), pharyngitis (11.1%), common cold (8.0%), pneumonia/bronchopneumonia (4.6%) and tonsillitis (4.3%). These clinical diagnosis were associated with symptoms to a varied degree especially for upper respiratory tract infection and bronchitis/tracheitis. Prescription of any antibiotics was positively associated with diagnosis of bronchitis/tracheitis (OR: 5.00, 95% CI: 2.63–9.51), tonsillitis (OR: 4.63, 95% CI: 1.48–14.46), pneumonia/bronchopneumonia (OR: 4.28, 95% CI: 1.40–13.04), pharyngitis (OR: 3.22, 95% CI: 1.57–6.59) and upper respiratory tract infection (OR: 3.04, 95% CI: 1.75–5.27). Prescription of two or more antibiotics was statistically significant related to diagnosis of bronchitis/ tracheitis (OR: 2.20, 95% CI: 1.44–3.35) or tonsillitis (OR: 2.97, 95% CI: 1.47–6.00). About 30% of the patients were identified with some type of bacteria. Bacteria detection was linked with pharyngitis (OR: 0.50, 95% CI: 0.28–0.88) but not prescription of antibiotics.

Conclusions

Antibiotics prescription were found with a strong relation to diagnosis of RTIs given by the clinician but was not associated with the presence of bacteria in patient samples. Part of the diagnosis may have been given by the clinician to justify their antibiotics prescription. There is clear need to use additional measures (e.g., symptoms) in conjunction with diagnosis to supervise or audit excessive antibiotics use.

Insertion of a Clinical Pathway Pop-Up Window into a Computer-Based Prescription System: A Method to Promote Antibiotic Stewardship in Upper Respiratory Tract Infection

Outpatient antibiotics are most frequently prescribed for upper respiratory tract infection (URI); however, most such prescriptions are inappropriate. We aimed to determine the effect of an electronic clinical pathway on the rates of overall and rational prescription of antibiotics in patients with URI. A pilot quasi-experimental study was conducted in a university hospital and two of its nearby primary care units (PCU) in northeast Thailand from June to September 2020. Clinical pathway pop-up windows were inserted into the hospital’s computer-based prescription system. Care providers were required to check the appropriate boxes before they were able to prescribe amoxicillin or co-amoxiclav. We examined a total of 675 visits to the outpatient department due to URI at three points in time: pre-intervention, immediately post-intervention, and 6 weeks post-intervention. Patients in the latter group tended to be younger and visits were more likely to be general practitioner-related and to the student PCU than in the other two groups. In addition, the rate of antibiotic prescription was significantly lower at 6 weeks after intervention than at either of the other time periods (32.0% vs 53.8% pre-intervention and 46.2% immediately post-intervention; p < 0.001), and the proportion of rational antibiotic prescriptions increased significantly after implementation. Antibiotic prescription rates were lower at the community primary care unit and higher when the physician was a resident or a family doctor. The deployment of an electronic clinical pathway reduced the rate of unnecessary antibiotic prescriptions. The effect was greater at 6 weeks post-implementation. However, discrepancy of patients’ baseline characteristics may have skewed the findings.

Nontypeable Haemophilus influenzae newly released (NRel) from biofilms by antibody-mediated dispersal versus antibody-mediated disruption are phenotypically distinct

Biofilms contribute significantly to the chronicity and recurrence of bacterial diseases due to the fact that biofilm-resident bacteria are highly recalcitrant to killing by host immune effectors and antibiotics. Thus, antibody-mediated release of bacteria from biofilm residence into the surrounding milieu supports a powerful strategy to resolve otherwise difficult-to-treat biofilm-associated diseases. In our prior work, we revealed that antibodies directed against two unique determinants of nontypeable Haemophilus influenzae (NTHI) [e.g. the Type IV pilus (T4P) or a bacterial DNABII DNA-binding protein, a species-independent target that provides structural integrity to bacterial biofilms] release biofilm-resident bacteria via discrete mechanisms. Herein, we now show that the phenotype of the resultant newly released (or NRel) NTHI is dependent upon the specific mechanism of release. We used flow cytometry, proteomic profiles, and targeted transcriptomics to demonstrate that the two NRel populations were significantly different not only from planktonically grown NTHI, but importantly, from each other despite genetic identity. Moreover, each NRel population had a distinct, significantly increased susceptibility to killing by either a sulfonamide or β-lactam antibiotic compared to planktonic NTHI, an observation consistent with their individual proteomes and further supported by relative differences in targeted gene expression. The distinct phenotypes of NTHI released from biofilms by antibodies directed against specific epitopes of T4P or DNABII binding proteins provide new opportunities to develop targeted therapeutic strategies for biofilm eradication and disease resolution.

Outpatient antibiotic use associated with acute upper respiratory infections in China: a nationwide cross-sectional study

BACKGROUND

The assessment of antibiotic use for acute upper respiratory infections (AURIs) is important to promote the appropriateness of antibiotic prescribing. Evaluation of antibiotic prescriptions for AURIs at a national level is very limited in China.

OBJECTIVE

To investigate outpatient antibiotic prescriptions for AURIs in Chinese hospitals.

METHODS

This study used data from over 10 million outpatient and emergency department visits for AURIs, which contained information on drug prescription and diagnosis, from 94 cities and 28 provinces of mainland China. Antibiotic prescription rates for various subgroups and potential predictors of antibiotic use were estimated. Patterns of antibiotic prescriptions and proportions of individual antibiotics prescribed for different types of AURIs were analysed and reported.

RESULTS

In total, 10 770 219 outpatient visits for AURIs were included in this study. Of these, 40.8% (95% confidence interval 40.7-40.8%) resulted in antibiotic prescriptions. Patient characteristics, including age, gender, payment type, AURI type, department and season of visit, were significantly associated with antibiotic prescriptions for AURIs. In total, 4 984 744 antibiotic agents were prescribed, of which 87.9% were broad-spectrum antibiotics and only 36.8% were prescribed in line with the guideline recommendations. Azithromycin (13.2%), cefdinir (11.7%), cefixime (8.3%) and cefaclor (8.2%) were the most commonly prescribed antibiotics for AURIs in China.

CONCLUSIONS

Antibiotic prescribing for patients with AURIs in outpatient settings was prevalent nationwide in China. Antibiotic stewardship efforts targeting specific populations in outpatient settings are needed to reduce antibiotic use and promote appropriate antibiotic selection for AURIs in China.

Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020

PURPOSE OF REVIEW

The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.

RECENT FINDINGS

Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.

Antibiotic Resistance in Trinidad: A population-based survey of adults

Objectives: Antibiotic resistance (ABR) is a growing public health issue globally. This study aimed to ascertain the public’s knowledge of antibiotic resistance and to determine any associated demographic factors. Method: A cross-sectional survey was undertaken in Trinidad using a modified version of a World Health Organization questionnaire. Five hundred and fifty participants aged 16 years and older were interviewed. Data were analysed using SPSS Version-22. Results: The response rate was 91% (502/550). Most responders (53%) reported having taken antibiotics during the 6-month period prior to the survey. Almost 60% of responders believed that sore throat and colds/flu can be treated with antibiotics. Sixty-seven percent of responders believed that they had no individual role in combating the issue. Responders with a primary level education or older respondents were more likely than responders with a higher level of education or younger to agree that antibiotic resistance only affects those who use antibiotics frequently (p= 0.002 and p=0.017 respectively). Income level was also significantly associated with knowledge levels, the higher the income the more knowledgeable the responder. Conclusion: Our study found that public knowledge of antibiotic resistance is low. Age, income and educational levels were significantly associated with certain knowledge parameters. Much work needs to be done to change the attitudes of responders who believe they have no role to play in the fight against this national and global threat. These findings may be useful to health education professionals and government antimicrobial resistance programmes.

Photoinduced Antibacterial Activity of the Essential Oils from Eugenia brasiliensis Lam and Piper mosenii C. DC. by Blue Led Light

The objective of this work was to evaluate the phytochemical composition and the antibacterial and antibiotic-modulating activities of the essential oils of Eugenia brasiliensis Lam (OEEb) and Piper mosenii C. DC (OEPm) singly or in association with blue LED (Light-emitting diode) light. The antibacterial and antibiotic-modulatory activities of the essential oils on the activity of aminoglycosides were evaluated to determine the minimum inhibitory concentration (MIC, μg/mL) in the presence or absence of exposure to blue LED light. The chemical analysis showed α-pinene and bicyclogermacrene as major constituents of OEPm, whereas α-muurolol was the main compound of OEEb. Both OEEb and OEPm showed MIC ≥ 512 μg/mL against the strains under study. However, the association of these oils with the blue LED light enhanced the action of the aminoglycosides amikacin and gentamicin. In conclusion, the association of aminoglycosides with the blue LED light and essential oils was effective against resistant bacteria.

What drives inappropriate use of antibiotics? A mixed methods study from Bahawalpur, Pakistan

Purpose

This study investigates the knowledge, attitudes and practices of the general public regarding the use of antibiotics in community pharmacy, in Pakistan.

Methods

This is a mixed method study where data were collected through a validated questionnaire and semi-structured interviews. Convenience sampling techniques were used to recruit participants from the general public of Bahawalpur, Pakistan who visited pharmacies to purchase antibiotics between 1 June 2018 and 31 July 2018. Descriptive statistics and regression analyses were used to tabulate the results of quantitative data while inductive thematic analysis was used to identify themes and draw conclusions from the qualitative data.

Results

Over 60% of the 400 survey participants (n=246; 61.5%) had a moderate level of antibiotic knowledge; however, attitudes regarding antibiotics use were poor in half the sample (n=201; 50.3%). More than half (n=226; 56.6%) of the respondents stated that antibiotics could cure all types of infections. Just under one third (n=129; 32.3%) of respondents obtained the appropriate dosage regimen while the majority did not complete the course (n=369; 92.3%); stopping when they felt better. Inductive thematic analysis yielded four themes, 10 subthemes and 27 categories. Two subthemes were related to knowledge, one to attitude, three to practices and four subthemes were related to suggestions to improve the healthcare system. Inappropriate antibiotic practices included: lack of consultation with healthcare professionals, purchase of antibiotics without prescription or refilling of previous prescription, use of home supply of antibiotics, sharing of antibiotics with others, improper dosage regimens and early cessation of antibiotic therapy.

Conclusion

Level of education, low health literacy, high consultation fees of private practitioners, inadequate health facilities in government hospitals and patient overload, busy schedules of people, poor healthcare infrastructure in rural areas and unrestricted supply of antibiotics were key factors associated with inappropriate use of antibiotics in Pakistan.