Antimicrobial resistance: international control strategies, with a focus on limited-resource settings

Multicenter study to assess the use of BL-DetecTool for the detection of CTX-M-type ESBLs and carbapenemases directly from clinical specimens

Antimicrobial resistance (AMR) is one of the major public health problems worldwide. Multiple strategies have been put in place to address this problem. One of them is the rapid detection of the mechanisms of resistance, such as extended-spectrum beta-lactamases (ESBLs) and/or carbapenemases. We conducted a multicenter study that included nine European centers for the assessment of prototypes of a novel lateral flow immunoassay-based device (BL-DetecTool) for a rapid detection of ESBL (NG-Test CTX-M-MULTI DetecTool) and/or carbapenemases (NG-Test CARBA 5 DetecTool) from Enterobacterales and Pseudomonas aeruginosa in positive urine, positive blood cultures, and rectal swabs. We performed a prospective analysis between January 2021 and June 2022, including overall 22,010 samples. Based on each hospital information, the sensitivity to detect CTX-M was 84%-100%, 90.9%-100%, and 75%-100% for urine, positive blood cultures, and enriched rectal swabs, respectively. On the other hand, the sensitivity to detect carbapenemases was 42.8%-100%, 75%-100%, and 66.6%-100% for urine, positive blood cultures, and enriched rectal swab, respectively. BL-DetecTool allows a rapid and reliable detection of ESBL and carbapenemases directly from urine, positive blood cultures, or enriched rectal swabs, being an easy technique to implement in the workflow of clinical microbiology laboratories.

IMPORTANCE

The assessed rapid assay to detect CTX-M beta-lactamases and carbapenemases directly from clinical samples can favor in the rapid detection of these mechanisms of resistance and hence the administration of a more adequate antimicrobial treatment.

The Impact of an Antibiotic Stewardship Program on the Consumption of Specific Antimicrobials and Their Cost Burden: A Hospital-wide Intervention

Background

Inappropriate use of antimicrobials (AM) is a major concern worldwide that leads to the propagation of antimicrobial resistance (AMR). In addition to its clinical implications, AMR imposes an economic burden on communities, especially developing countries with more infectious diseases and less available resources. Antimicrobial stewardship programs (ASPs) have been found to be effective in reducing AMR. This study was designed to evaluate the effect of implementing an ASP in reducing AM consumption, its economic burden, and AMR as a consecutive result.

Materials and Methods

Consumption of caspofungin, amphotericin B, voriconazole, colistin, linezolid, vancomycin, and carbapenems was compared in a prospective cross-sectional study between two time periods introduced as pre- and post-ASP. Drug use density presented as anatomical therapeutic chemical (ATC)/defined daily doses (DDD) and normalized per 1000 bed days, cost savings, and AMR patterns were evaluated.

Results

A total of 9400 AM prescriptions were analyzed during a 2-year period. Consumption measured in DDD/1000 bed days dropped by 24.8, 25.0, 35.3, 47.0, 39.2, 10.5, and 23.2 percent for amphotericin B, caspofungin, colistin, voriconazole, meropenem, imipenem, and vancomycin, respectively. Linezolid consumption increased by 26.8% after implementing ASP. The expenditure of target AMs in the average value of USD decreased by 41.3% after the intervention compared to the time before using ASP (P-value=0.001). Implementing ASP also increased AM susceptibility of Pseudomonas aeruginosa, while the susceptibility of methicillin-resistant Staphylococcus aureus did not change significantly.

Conclusion

The results of this study suggest that establishment of ASP can lead to a reduction in improper administration of AMs and their expenditure resulting in economic benefit and lowering AMR at hospitals with minimum resources. Clinical pharmacists' role was critical to the success of this ASP and was uniquely empowered at our center.

Mechanistic Insight into the Photodynamic Effect Mediated by Neutral Red and a New Azine Compound in Staphylococcus aureus Cells

The photodynamic activity of Neutral Red and the new monobrominated Neutral Red was studied in suspensions of Staphylococcus aureus. The effect of mannitol and sodium azide in the presence of 25 μm photosensitizer on lethal photosensitization were investigated. The results of the mechanistic evaluation of Neutral Red showed that both mannitol and sodium azide produced a completed protective effect after irradiation without significant differences between them. The evaluation of monobrominated Neutral Red also showed a protective effect of microorganisms with the addition of mannitol. Although sodium azide produced a protective effect of the photoinactivation, it was incomplete and less than that exhibited by mannitol. The results indicate that the starting reagent, Neutral Red, is a producer of radical species, acting through a type I mechanism, whereas the halogenated derivative of Neutral Red produced reactive oxygen species and a contribution of singlet molecular oxygen cannot be discarded in the photoinactivation of Staphylococcus aureus cells. These results, analyzed together with the previously evaluated properties of the dyes, allow us to explain the differences observed in the photoinactivation of Staphylococcus aureus mediated by both azine photosensitizers.

Point prevalence survey of antimicrobial prescription in a tertiary hospital in South East Nigeria: A call for improved antibiotic stewardship

OBJECTIVES

Antimicrobial prescribing practices and use contribute to the growing threat of antimicrobial resistance (AMR) to global health. Information on antimicrobial prescribing and use are lacking in most developing countries, including Nigeria. This information is crucial for antimicrobial stewardship programmes, an effective tool in minimising AMR. This study was performed to gather baseline information on antimicrobial prescribing practices in Nigeria.

METHODS

A cross-sectional survey was conducted on all inpatients of a tertiary hospital in South East Nigeria. All patients on admission on the day of the survey formed the study population. A standardised questionnaire, web-based data entry and validation process designed by the University of Antwerp, Belgium, were adopted. Information on basic patient demographics, antimicrobial agents used, indication for treatment, laboratory data prior to treatment and stop/review date was collected.

RESULTS

Of 220 inpatients surveyed, 78.2% were receiving at least one antimicrobial agent. The highest prevalence of antimicrobial use was in the ICU (100%), adult surgical ward (82.9%) and paediatric medical ward (82.9%). Agents used were mainly third-generation cephalosporins (ceftriaxone 25.1%) and nitroimidazole (metronidazole 24.6%). Antimicrobial prescription was empirical (91.1% in medical wards, 96.8% in surgical wards and 100% in ICU). There was limited use of guidelines but clear documentation of stop/review dates and reasons for antimicrobial use.

CONCLUSION

Although a majority of antimicrobial prescriptions were made with indications, they were mostly prescribed empirically and the majority of prescriptions were parenteral formulations. There is a need to develop antibiotic guidelines, to educate prescribers on antimicrobial stewardship and to encourage targeted prescription.

Resistance Elasticity of Antibiotic Demand in Intensive Care

The emergence and spread of antimicrobial resistance (AMR) is still an unresolved problem worldwide. In intensive care units (ICUs), first-line antibiotic therapy is highly standardized and widely empiric while treatment failure because of AMR often has severe consequences. Simultaneously, there is a limited number of reserve antibiotics, whose prices and/or side effects are substantially higher than first-line therapy. This paper explores the implications of resistance-induced substitution effects in ICUs. The extent of such substitution effects is shown in a dynamic fixed effect regression analysis using a panel of 66 German ICUs with monthly antibiotic use and resistance data between 2001 and 2012. Our findings support the hypothesis that demand for reserve antibiotics substantially increases when resistance towards first-line agents rises. For some analyses the lagged effect of resistance is also significant, supporting the conjecture that part of the substitution effect is caused by physicians changing antibiotic choices in empiric treatment by adapting their resistance expectation to new information on resistance prevalence. The available information about resistance rates allows physicians to efficiently balance the trade-off between exacerbating resistance and ensuring treatment success. However, resistance-induced substitution effects are not free of charge. These effects should be considered an indirect burden of AMR. Copyright © 2016 John Wiley & Sons, Ltd.

Addressing Antimicrobial Resistance: An Overview of Priority Actions to Prevent Suboptimal Antimicrobial Use in Food-Animal Production

The growing concern regarding emergence of bacteria resistant to antimicrobials and their potential for transmission to humans via animal production has led various authorities worldwide to implement measures to decrease antimicrobial use (AMU) in livestock production. These measures are influenced by those implemented in human medicine, and emphasize the importance of antimicrobial stewardship, surveillance, infection prevention and control and research. In food producing animals, unlike human medicine, antimicrobials are used to control diseases which cause economic losses. This major difference may explain the failure of the public policies implemented to control antimicrobial usage. Here we first review the specific factors influencing AMU across the farm animal sector and highlighting the farmers' decision-making process of AMU. We then discuss the efficiency of existing regulations implemented by policy makers, and assess the need for alternative strategies, such as substitution between antimicrobials and other measures for infectious disease control. We also discuss the interests of regulating antimicrobial prices. Finally, we emphasize the value of optimizing antimicrobial regimens, and developing veterinary precision medicine to achieve clinical efficacy in animals while limiting negative impacts on public health. The fight against antimicrobial resistance requires both a reduction and an optimization of antimicrobial consumption. The set of actions currently implemented by policy makers does not adequately address the economic interests of farmers' use of antimicrobials.

Multidrug-resistant Gram-negative bacteria in solid organ transplant recipients with bacteremias

Bloodstream infections (BSIs) remain as life-threatening complications and are associated with significant morbidity and mortality among solid organ transplant (SOT) recipients. Multidrug-resistant (MDR) Gram-negative bacteria can cause serious bacteremias in these recipients. Reviews have aimed to investigate MDR Gram-negative bacteremias; however, they were lacking in SOT recipients in the past. To better understand the characteristics of bacteremias due to MDR Gram-negative bacteria, optimize preventive and therapeutic strategies, and improve the outcomes of SOT recipients, this review summarize the epidemiology, clinical and laboratory characteristics, and explores the mechanisms, prevention, and treatment of MDR Gram-negative bacteria.

Antimicrobial resistance (AMR) and plant-derived antimicrobials (PDAms) as an alternative drug line to control infections

Infectious diseases caused by antimicrobial-resistant microbes (ARMs) and the treatment are the serious problems in the field of medical science today world over. The development of alternative drug line to treat such infectious diseases is urgently required. Researches on ARMs revealed the presence of membrane proteins responsible for effusing the antibiotics from the bacterial cells. Such proteins have successfully been treated by plant-derived antimicrobials (PDAms) synergistically along with the commercially available antibiotics. Such synergistic action usually inhibits the efflux pump. The enhanced activity of plant-derived antimicrobials is being researched and is considered as the future treatment strategy to cure the incurable infections. The present paper reviews the advancement made in the researches on antimicrobial resistance along with the discovery and the development of more active PDAms.

Impact of treatment heterogeneity on drug resistance and supply chain costs

The efficacy of scarce drugs for many infectious diseases is threatened by the emergence and spread of resistance. Multiple studies show that available drugs should be used in a socially optimal way to contain drug resistance. This paper studies the tradeoff between risk of drug resistance and operational costs when using multiple drugs for a specific disease. Using a model for disease transmission and resistance spread, we show that treatment with multiple drugs, on a population level, results in better resistance-related health outcomes, but more interestingly, the marginal benefit decreases as the number of drugs used increases. We compare this benefit with the corresponding change in procurement and safety stock holding costs that result from higher drug variety in the supply chain. Using a large-scale simulation based on malaria transmission dynamics, we show that disease prevalence seems to be a less important factor when deciding the optimal width of drug assortment, compared to the duration of one episode of the disease and the price of the drug(s) used. Our analysis shows that under a wide variety of scenarios for disease prevalence and drug cost, it is optimal to simultaneously deploy multiple drugs in the population. If the drug price is high, large volume purchasing discounts are available, and disease prevalence is high, it may be optimal to use only one drug. Our model lends insights to policy makers into the socially optimal size of drug assortment for a given context.

The clinical impact of multidrug-resistant gram-negative bacilli in the management of septic shock

Multi-antibiotic drug-resistant (MDR) gram-negative bacilli are becoming a major threat to the standard care of septic patients. Empiric antimicrobial drug regimens to cover likely bacterial pathogens have to be altered in keeping with the spread of MDR pathogens in the health care setting and in the community. Reliable antibiotics for broad spectrum coverage for sepsis such as extended spectrum β-lactam antibiotics, carbapenems, and fluoroquinolones can no longer be counted upon to provide activity against a range of common, virulent pathogens that cause sepsis. In some regions of Asia, South America, and Eastern Europe in particular, MDR pathogens have become a major concern, necessitating the use of potentially toxic and costly antibiotic combinations as initial antibiotic therapy for septic shock. In this brief review, we will focus on the emergence of MDR gram-negative pathogens, resistance mechanisms, and suggest some management and prevention strategies against MDR pathogens.

Antimicrobial fibers: therapeutic possibilities and recent advances

The emergence of multi-drug-resistant bacteria such as methicillin-resistant strains of Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, Pseudomonas aeruginosa, Acinetobacter baumannii and extended-spectrum β-lactamase (carbapenemase)-producing Enterobacteriaceae is becoming a serious threat. New-generation antimicrobial agents need to be developed. This includes the design of novel antimicrobial compounds and drug-delivery systems. This review provides an introduction into different classes of antimicrobial materials. The main focus is on strategies for the introduction of antimicrobial properties in polymer materials. These can be roughly divided into surface modification, inclusion of antimicrobial compounds that can leach from the polymer, and the introduction of polymer-bound moieties that provide the polymer with antimicrobial properties. One of the main challenges in the development of antimicrobial polymers for the use in contact with human tissue is the concomitant demand of non-cytotoxicity. Current research is strongly focused on the latter aspect.

Photodynamic therapy based on 5-aminolevulinic acid and its use as an antimicrobial agent

Exogenous 5-aminolevulinic acid (ALA) is taken up directly by bacteria, yeasts, fungi, and some parasites, which then induces the accumulation of protoporphyrin IX (PPIX). Subsequent light irradiation of PPIX leads to the inactivation of these organisms via photodamage to their cellular structures. ALA uptake and light irradiation of PPIX produced by host cells leads to the inactivation of other parasites, along with some viruses, via the induction of an immune response. ALA-mediated PPIX production by host cells and light irradiation result in the inactivation of other viruses via either the induction of a host cell response or direct photodynamic attack on viral particles. This ALA-mediated production of light-activated PPIX has been extensively used as a form of photodynamic therapy (PDT) and has shown varying levels of efficacy in treating conditions that are associated with microbial infection, ranging from acne and verrucae to leishmaniasis and onychomycosis. However, for the treatment of some of these conditions by ALA-based PDT, the role of an antimicrobial effect has been disputed and in general, the mechanisms by which the technique inactivates microbes are not well understood. In this study, we review current understanding of the antimicrobial mechanisms used by ALA-based PDT and its role in the treatment of microbial infections along with its potential medical and nonmedical applications.

How to educate health care professionals in developing countries? A Brazilian experience

E-learning is an important tool to bring health care professionals updated information, especially in a large, developing country like Brazil, where teaching resources are limited. It allows the exchange of experiences between professionals, promotes simultaneous knowledge acquisition by a large number of participants, and reaches some remote areas.

Photodynamic inactivation of Escherichia coli and Streptococcus mitis by cationic zinc(II) phthalocyanines in media with blood derivatives

The photodynamic inactivation (PDI) of Escherichia coli and Streptococcus mitis sensitized by cationic phthalocyanines was studied in different media containing blood derivatives. First, the activity of zinc(II) tetramethyltetrapyridino[3,4-b:3',4'-g:3'',4''-l:3''',4'''-q]porphyrazinium (ZnAPc4+), zinc(II) 2,9,16,23-tetrakis[4-(N-methylpyridyloxy)]phthalocyanine (ZnPPc4+) and zinc(II) 2,9,16,23-tetrakis[2-(N,N,N-trimethylamino)ethoxy]phthalocyanine (ZnEPc4+) were compared to photoinactivate these bacteria in saline solutions. After visible light irradiation, a higher photoinactivation of E. coli cells was found for ZnPPc4+, while ZnEPc4+ was the more effective sensitizer to eradicate S. mitis cells. In the presence of human red blood (HRB) cells, two aspects were analyzed: the photohemolysis induced by these cationic phthalocyanines and the PDI of bacteria in medium containing erythrocytes. The highest photohemolytic damage was produced by ZnPPc4+, which can be avoided using azida ion as photoprotective quencher. In both bacteria, the photoinactivation is possible in presence of HRB cells. Mainly, ZnEPc4+ is effective to photoinactivate S. mitis with a low hemolysis of erythrocytes. However, inactivation of E. coli by ZnPPc4+ decreases in medium with HRB cells, further when azide ion is added to avoid hemolysis. The presence of plasma considerable reduces the photocytotoxic effect, which mainly affects the eradication of E. coli. However, the PDI of S. mitis by ZnEPc4+ is even possible in presence of blood derivatives.

Mechanistic insight of the photodynamic inactivation of Escherichia coli by a tetracationic zinc(II) phthalocyanine derivative

Photodynamic inactivation (PDI) of Escherichia coli has been studied in cultures treated with zinc(II) 2,9,16,23-tetrakis[4-(N-methylpyridyloxy)]phthalocyanine (ZnPPc(+4)) to obtain insight about the mechanism of damage. This phthalocyanine is rapidly bound to cells, reaching a value of approximately 0.8 nmol/10(6) cells when the cultures were incubated with 2 microM sensitizer. After 30 min of irradiation, a 4 log decrease of E. coli survival was observed. The photocytotoxic action was investigated in plasmid and genomic DNA by electrophoretic analysis. Absorption spectroscopic studies showed that this cationic phthalocyanine interacts strongly with DNA (K(DNA)=4.7 x 10(6)M(-1)). Photocleavage of calf thymus DNA sensitized by ZnPPc(+)4 was not found even after long irradiation periods. Similar results were also observed in genomic DNA extracted from E. coli cells after PDI treatment. Modifications of plasmid DNA isolated from bacteria were only observed after long irradiation periods. However, under these conditions transmission electron microscopy of the PDI bacteria revealed an aggregation of cytoplasmic macromolecules and irregularities in cell barriers. Also, scanning electron microscopy showed a shrunken appearance in cells after PDI. Even so, release of intracellular biopolymers was not detected by absorption. On the other hand, outer and inner membranes permeabilization assays showed an increase in the permeability. Consequently, alterations in the cell membrane functionality induced by ZnPPc(+4) appear to be the major cause of E. coli inactivation upon PDI.