The Slow-Motion Catastrophe of Antimicrobial Resistance and Practical Interventions for All Prescribers

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

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

New frontiers in CRISPR: Addressing antimicrobial resistance with Cas9, Cas12, Cas13, and Cas14

Background

The issue of antimicrobial resistance (AMR) poses a major challenge to global health, evidenced by alarming mortality predictions and the diminishing efficiency of conventional antimicrobial drugs. The CRISPR-Cas system has proven to be a powerful tool in addressing this challenge. It originated from bacterial adaptive immune mechanisms and has gained significant recognition in the scientific community.

Objectives

This review aims to explore the applications of CRISPR-Cas technologies in combating AMR, evaluating their effectiveness, challenges, and potential for integration into current antimicrobial strategies.

Methods

We conducted a comprehensive review of recent literature from databases such as PubMed and Web of Science, focusing on studies that employ CRISPR-Cas technologies against AMR.

Conclusions

CRISPR-Cas technologies offer a transformative approach to combat AMR, with potential applications that extend beyond traditional antimicrobial strategies. Integrating these technologies with existing methods could significantly enhance our ability to manage and potentially reverse the growing problem of antimicrobial resistance. Future research should address technical and ethical barriers to facilitate safe and effective clinical and environmental applications. This review underscores the necessity for interdisciplinary collaboration and international cooperation to harness the full potential of CRISPR-Cas technologies in the fight against superbugs.

Penicillin allergy as an instrumental variable for estimating antibiotic effects on resistance

Antibiotic resistance is influenced by prior antibiotic use, but precise causal estimates are limited. This study uses penicillin allergy as an instrumental variable (IV) to estimate the causal effect of antibiotics on resistance. A retrospective cohort of 36,351 individuals with E. coli positive urine cultures and prior outpatient antibiotic use, with outcomes assessed up to one year post-exposure, was analyzed using data from Maccabi Healthcare Services (MHS), the second-largest non-profit health fund in Israel. IV methods estimated risk differences (RD) and numbers needed to harm (NNH) for penicillin versus other antibiotics. The RD for resistance was 11.4% (95% CI: 7.6%, 15.4%) for amoxicillin/clavulanic acid, 14.1% (95% CI: 9.0%, 19.4%) for ampicillin, and 0.8% (95% CI: 0.2%, 1.4%) for piperacillin/tazobactam, with NNHs of 8.8, 7.1, and 122.0, respectively. Risks declined over time since exposure. Gentamicin, used as a negative control, showed no effect (95% CI: -2.4%, 1.8%). When directly comparing penicillin and quinolone effects on their respective AMR, penicillin use within 180 days increased resistance to amoxicillin/clavulanic acid by an RD of 17.8% (95% CI: 2.1%, 35.2%; NNH: 5.6), while quinolones raised ciprofloxacin resistance by 43.9% (95% CI: 29.9%, 59.4%; NNH: 2.3). These findings provide quantitative evidence of the impact of prior penicillin use on resistance, with implications for clinical practice and prescription policies.

The antibacterial and anti-biofilm effects of novel synthetized nitroimidazole compounds against methicillin-resistant Staphylococcus aureus and carbapenem-resistant Escherichia coli and Klebsiella pneumonia in vitro and in silico

The antibiotic resistance and biofilm formation by bacterial pathogens has led to failure in infections elimination. This study aimed to assess the antibacterial and anti-biofilm properties of novel synthesized nitroimidazole compounds (8a-8o). In this study, nitroimidazole compounds were synthesized via the A3 coupling reaction of sample substrates in the presence of copper-doped silica cuprous sulfate (CDSCS). Fifteen and two carbapenemase producing Escherichia coli and Klebsiella pneumonia (CP-E. coli and CP-K. pneumonia, respectively) and one methicillin-resistant Staphylococcus aureus (MRSA) and one methicillin-susceptible S. aureus (MSSA) plus standard strain of each isolate were included. The antibacterial effects of these compounds demonstrated that the lowest minimum inhibitory and bactericidal concentrations (MIC/MBC, respectively) levels corresponded to compound 8g against S. aureus (1/2 µg/mL) and K. pneumonia (8/32 µg/mL) standard and clinical strains and confirmed by in silico assessment. This was comparable to those of metronidazole being 32-128 µg/mL against K. pneumonia and 32-64 µg/mL against S. aureus. In comparison to metronidazole, against CP-E. coli, compounds 8i and 8m had significantly higher antibacterial effects (p < 0.001) and against CP-K. pneumonia, compounds 8a-8j and 8l-8o had significantly higher (p < 0.0001) antibacterial effects. Compound 8g exhibited significantly higher antibacterial effects against MSSA and compounds 8b (p < 0.001), 8c (p < 0.001), 8d (p < 0.001), 8e (p < 0.001) and 8g (p < 0.0001) exerted significantly higher antibacterial effects than metronidazole against MRSA. Moreover, potential anti-biofilm effects was corresponded to compounds 8a, 8b, 8c, 8e, 8f, 8g, 8i, 8k, 8m and 8n. Considering the antibacterial and anti-biofilm effects of novel synthesized compounds evaluated in this study, further assessments is warranted to verify their properties in vivo and clinical trials in the future.

Simultaneous optimization of production yield and sulfadiazine adsorption of MgFe2O4 loaded on prickly pear biochars using Box-Behnken design

A major challenge that humans facing is the uncontrolled discharge of antibiotic-containing wastewater into the environment, accompanying with huge threats to human community. The utilization of cost-effective biomass-based adsorbents is considered a potential solution for the treatment of antibiotic wastewater. This study aims to optimize the synthesis of MgFe2O4 nanoparticles loaded on prickly pear biochar (PPB) with outstanding sulfadiazine adsorbability using response surface methodology. Thirteen materials (MgFe2O4-PPB) produced based on Box-Behnken design were tested to evaluate the impact of the main factors on the material preparation process, including ratio of MgFe2O4:PPB precursors, calcination temperature and calcination time. Under optimized conditions, i.e., MgFe2O4:PPB ratio 0.5, temperature 600 °C and time 1 h, the production yield of 46.5% and sulfadiazine removal percentage of 85.4% were obtained. Characterization of optimized MgFe2O4-PPB indicated the good porosity and functionality suitable for the adsorption of sulfadiazine. Elovich model showed the best description of kinetic process. Temkin model was considered to be an accurate description of the isotherm adsorption. Proposed mechanism for antibiotic adsorption onto MgFe2O4-PPB was described. We clarify cost-benefit analysis to asses the importance of MgFe2O4-PPB as well as the economic and environmental impacts of biochar-based composites.

Evaluating the Effect of pH, Temperature and Concentration on Antioxidant and Antibacterial Potential of Spectroscopically, Spectrophotometrically and Microscopically Characterized Mentha Spicata Capped Silver Nanoparticles

The use of traditional plants has been tremendously increased due to their higher biological impact, minimal side effects, and comparatively low cost. Moreover, the emergence of antibacterial resistance is also shifting the scientific community to reconsider herbal remedies which provide relatively safer, cheap and biologically tolerable solutions. The present research was designed to fabricate the Mentha spicata conjugated silver nanoparticles (Me-AgNPs). Furthermore, the assessment of the bactericidal potential of Me-AgNPs against various bacterial strains was another motive behind this study. Fabricated NPs were characterized with the help of the UV-Visible spectrophotometric analysis, Fourier transform infrared spectroscopy (FTIR) and Scanning electron microscopy (SEM). Me-AgNPs showed a significant zone of inhibition (23 ± 0.2 mm) at 8 mg/mL against Staphylococcus aureus and a 4.0 ± 0.2 mm zone of growth inhibition at 2 mg/mL against Aeromonas veronii. The stability of Me-AgNPs was assessed at various pH (4, 7 and 11) and temperatures (25 °C, 4 °C, 37 °C, 75 °C). The significant zones of inhibition (11.3 ± 0.3 mm, 8.3 ± 0.3mm, 14.3 ± 0.3 mm, and 7.6 ± 0.2 mm) were observed at pH 11 against Escherichia coli, Staphylococcus aureus, Bacillus subtilis, and Klebsiella pneumoniae, respectively. Growth inhibition zones (14.0 ± 0.5 mm and 13.0 ± 0.5 mm) were also determined against B. subtilis and S. aureus at 25 °C. DPPH bioassay was conducted to find the antioxidant properties of Me-AgNPs. The highest (38.66 ± 0.2%) free radical scavenging activity was shown by Me-AgNPs at 4 mg/mL. Present study results concluded that biogenic Me-AgNPs have bactericidal as well as anti-oxidative potential. Moreover, these green synthesized Me-AgNPs could maintain their potency and stability at a wide range of pH and temperature.

Proteomic analysis of meropenem-induced outer membrane vesicles released by carbapenem-resistant Klebsiella pneumoniae

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an important multidrug resistance (MDR) pathogen that threatens human health and is the main source of hospital-acquired infection. Outer membrane vesicles (OMVs) are extracellular vesicles derived from Gram-negative bacteria and contain materials involved in bacterial survival and pathogenesis. They also contribute to cellular communication to nearby or distant recipient cells and influence their functions and phenotypes. In this study, we sought to understand the mechanism of bacterial response to meropenem pressure and explore the relationship between pathogenic proteins and the high pathogenicity of bacteria. We performed whole-genome PacBio sequencing on a clinical CRKP strain, and its OMVs were characterized using nanoparticle tracking analysis, transmission electron microscopy, and proteomic analysis. Thousands of vesicle proteins have been identified in mass spectrometry-based high-throughput proteomics analyses of K. pneumoniae OMVs. Protein functionality analysis showed that the OMVs were predominantly involved in metabolic, intracellular compartments, nucleic acid binding, survival, defense, and antibiotic resistance, such as Chromosome partition protein MukB, 3-methyl-2-oxobutanoate hydroxymethyltransferase, methionine-tRNA ligase, Heat shock protein 60 family chaperone GroEL, and Gamma-glutamyl phosphate reductase. Additionally, a protein-protein interaction network demonstrated that OMVs from meropenem-treated K. pneumoniae showed the highest connectivity in DNA polymerase I, phenylalanine-tRNA ligase beta subunit, DNA-directed RNA polymerase subunit beta, methionine-tRNA ligase, DNA-directed RNA polymerase subunit beta, and DNA-directed RNA polymerase subunit alpha. The OMVs proteome expression profile indicates increased secretion of stress proteins released from meropenem-treated K. pneumoniae, which provides clues for revealing the biogenesis and pathophysiological functions of Gram-negative bacteria OMVs. The significant differentially expressed proteins identified in this study are of great significance for exploring effective control strategies for CRKP infection.IMPORTANCEMeropenem is one of the main antibiotics used in the clinical treatment of carbapenem-resistant Klebsiella pneumoniae (CRKP). This study demonstrated that some important metabolic changes occurred in meropenem-induced CRKP-outer membrane vesicles (OMVs), The OMVs proteome expression profile indicates increased secretion of stress proteins released from meropenem-induced Klebsiella pneumoniae. Furthermore, this is the first study to discuss the protein-protein interaction network of the OMVs released by CRKP, especially under antibiotic stress.

Toward Clinical Applications: Transforming Nonantibiotic Antibacterials into Effective Next-Generation Supramolecular Therapeutics

Antibiotic resistance is a major driver of morbidity and mortality worldwide, necessitating alternatives. Due to their mechanism of action, bacteriophages, endolysins, and antimicrobial peptides (coined herein as nonantibiotic antibacterials, NAA) have risen to tackle this problem and led to paradigms in treating antibiotic-resistant bacterial infections. However, their clinical applications remain challenging and have been seriously hampered by cytotoxicity, instability, weak bioactivity, low on-target bioavailability, high pro-inflammatory responses, shorter half-life, and circulatory properties. Hence, to transit preclinical phases and beyond, it has become imperative to radically engineer these alternatives into innovative and revolutionary therapeutics to overcome recalcitrant infections. This perspective highlights the promise of these agents, their limitations, promising designs, nanotechnology, and delivery approaches that can be harnessed to transform these agents. Finally, I provide an outlook on the remaining challenges that need to be tackled for their widespread clinical administration.

Host Defense Peptide Piscidin and Yeast-Derived Glycolipid Exhibit Synergistic Antimicrobial Action through Concerted Interactions with Membranes

Developing new antimicrobials as alternatives to conventional antibiotics has become an urgent race to eradicate drug-resistant bacteria and to save human lives. Conventionally, antimicrobial molecules are studied independently even though they can be cosecreted in vivo. In this research, we investigate two classes of naturally derived antimicrobials: sophorolipid (SL) esters as modified yeast-derived glycolipid biosurfactants that feature high biocompatibility and low production cost; piscidins, which are host defense peptides (HDPs) from fish. While HDPs such as piscidins target the membrane of pathogens, and thus result in low incidence of resistance, SLs are not well understood on a mechanistic level. Here, we demonstrate that combining SL-hexyl ester (SL-HE) with subinhibitory concentration of piscidins 1 (P1) and 3 (P3) stimulates strong antimicrobial synergy, potentiating a promising therapeutic window. Permeabilization assays and biophysical studies employing circular dichroism, NMR, mass spectrometry, and X-ray diffraction are performed to investigate the mechanism underlying this powerful synergy. We reveal four key mechanistic features underlying the synergistic action: (1) P1/3 binds to SL-HE aggregates, becoming α-helical; (2) piscidin-glycolipid assemblies synergistically accumulate on membranes; (3) SL-HE used alone or bound to P1/3 associates with phospholipid bilayers where it induces defects; (4) piscidin-glycolipid complexes disrupt the bilayer structure more dramatically and differently than either compound alone, with phase separation occurring when both agents are present. Overall, dramatic enhancement in antimicrobial activity is associated with the use of two membrane-active agents, with the glycolipid playing the roles of prefolding the peptide, coordinating the delivery of both agents to bacterial surfaces, recruiting the peptide to the pathogenic membranes, and supporting membrane disruption by the peptide. Given that SLs are ubiquitously and safely used in consumer products, the SL/peptide formulation engineered and mechanistically characterized in this study could represent fertile ground to develop novel synergistic agents against drug-resistant bacteria.

Pushing the frontiers in the fight against antimicrobial resistance: the potential of fecal and maggot therapies

The escalating crisis of antimicrobial resistance (AMR) warrants innovative therapeutic strategies. Fecal microbiota transplantation (FMT) and maggot debridement therapy (MDT) represent paradigm-shifting approaches, leveraging biological systems to mitigate AMR. FMT restores a healthy gut microbiome, providing a biotherapeutic counter to pathogenic bacteria, thereby reducing reliance on traditional antibiotics. Conversely, MDT, a form of bio-debridement, utilizes the antimicrobial secretions of maggots to cleanse wounds and eliminate resistant bacteria. Despite the promise these therapies hold, their broader clinical adoption faces multifaceted challenges including the need for rigorous scientific substantiation, standardized protocols, deepened understanding of mechanisms of action, and surmounting regulatory and public acceptance barriers. However, their potential integration with precision medicine could revolutionize disease management, particularly with antibiotic-resistant infections.

Ceftiofur use and antimicrobial stewardship in the horse

Equine practitioners require recommendations that support antimicrobial stewardship and avoid generating resistance to medically important antibiotics. This review examines current inadequacies in antimicrobial stewardship standards within the veterinary community, related to antimicrobial categorisation and prescribing practices. Resistance to cephalosporin antibiotics in horses is also described. Properties of cephalosporin antibiotics are outlined and equine-specific studies of ceftiofur, a third-generation cephalosporin antibiotic with medical importance, are detailed. Readers are provided with recommendations that encourage appropriate use of ceftiofur, citing the evidence available in horses.

Structure-based drug discovery and antimicrobial activity of ciprofloxacin-grafted Ugi adducts

A new series of ciprofloxacin-derived Ugi adducts were rationally designed and synthesized. The synthesized molecules were explored for their potential antimicrobial activities against four pathogenic microorganisms. Among these derivatives, compound 7h with a 4-nitrophenyl substituent at R2 exhibited significant activity against two tested Gram-positive bacteria with a minimum inhibitory concentration value of 0.097 µg/mL while 7i bearing 4-chlorophenyl pendant demonstrated the best antimicrobial activities against Gram-negative bacteria. Furthermore, the analysis of the structure-activity relationships disclosed that types of substitutions differently affect the bacteria so the most potent derivative against Gram-negative infections was the least active one in Gram-positive microorganisms. Also, the molecular docking and molecular dynamic simulations were executed on 7i as the most potent Gram-negative anti-bacterial agent against ATP-binding sites of DNA gyrase B. Accordingly, our findings suggest that ciprofloxacin-based Ugi adducts are an interesting precursor for the design of potent antimicrobial agents.Communicated by Ramaswamy H. Sarma.

Does the Academy of Breastfeeding Medicine's Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary

BACKGROUND

In 2022 the Academy of Breastfeeding Medicine (ABM) published Clinical Protocol #36: The Mastitis Spectrum, which aims to update clinical approaches to management of benign lactation-related breast inflammation. The protocol has been timely because of the exponential increase in knowledge about the human milk microbiome over the past decade. This Commentary aims to continue respectful debate amongst clinicians and researchers within the Academy of Breastfeeding Medicine and more broadly, confident that we share a fundamental commitment to promote breastfeeding and support the well-being of lactating women, their infants and their families.

ANALYSIS

Although Clinical Protocol #36 offers advances, it does not fulfil the principles of best practice implementation science for translation of evidence into clinical guidelines. Clinical Protocol #36 inaccurately represents studies; misrepresents theoretical models as proven aetiologies; does not consistently attribute sources; does not reliably apply the SORT taxonomy; and relies upon single case reports. As a result, various recommendations in Clinical Protocol #36 lack an evidence-base or credible underlying theoretical model. This includes recommendations to use 'lymphatic drainage' massage, therapeutic ultrasound, and oral lecithin. Similarly, based on a contestable theoretical model which is presented as fact, Clinical Protocol #36 makes the recommendation to either reduce frequency of milk removal or to maintain current frequency of milk removal during an episode of breast inflammation. Although Clinical Protocol #36 limits this advice to cases of 'hyperlactation', the diagnosis 'hyperlactation' itself is undefinable. As a result, this recommendation may put breastfeeding women who present with breast inflammation at risk of worsened inflammation and decreased breast milk production.

CONCLUSION

Clinical Protocol #36 offers some advances in the management of breast inflammation. However, Clinical Protocol #36 also exposes clinicians to two international trends in healthcare which undermine health system sustainability: overdiagnosis, including by over-definition, which increases risk of overtreatment; and antibiotic over-use, which worsens the crisis of global antimicrobial resistance. Clinical Protocol #36 also recommends unnecessary or ineffective interventions which may be accessed by affluent patients within advanced economies but are difficult to access for the global majority. The Academy of Breastfeeding Medicine may benefit from a review of processes for development of Clinical Protocols.

A smart coating with integrated physical antimicrobial and strain-mapping functionalities for orthopedic implants

The prevalence of orthopedic implants is increasing with an aging population. These patients are vulnerable to risks from periprosthetic infections and instrument failures. Here, we present a dual-functional smart polymer foil coating compatible with commercial orthopedic implants to address both septic and aseptic failures. Its outer surface features optimum bioinspired mechano-bactericidal nanostructures, capable of killing a wide spectrum of attached pathogens through a physical process to reduce the risk of bacterial infection, without directly releasing any chemicals or harming mammalian cells. On its inner surface in contact with the implant, an array of strain gauges with multiplexing transistors, built on single-crystalline silicon nanomembranes, is incorporated to map the strain experienced by the implant with high sensitivity and spatial resolution, providing information about bone-implant biomechanics for early diagnosis to minimize the probability of catastrophic instrument failures. Their multimodal functionalities, performance, biocompatibility, and stability are authenticated in sheep posterolateral fusion model and rodent implant infection model.

An Ultrastable Self-Assembled Antibacterial Nanospears Made of Protein

Protein-based nanomaterials have broad applications in the biomedical and bionanotechnological sectors owing to their outstanding properties such as high biocompatibility and biodegradability, structural stability, sophisticated functional versatility, and being environmentally benign. They have gained considerable attention in drug delivery, cancer therapeutics, vaccines, immunotherapies, biosensing, and biocatalysis. However, so far, in the battle against the increasing reports of antibiotic resistance and emerging drug-resistant bacteria, unique nanostructures of this kind are lacking, hindering their potential next-generation antibacterial agents. Here, the discovery of a class of supramolecular nanostructures with well-defined shapes, geometries, or architectures (termed "protein nanospears") based on engineered proteins, exhibiting exceptional broad-spectrum antibacterial activities, is reported. The protein nanospears are engineered via spontaneous cleavage-dependent or precisely tunable self-assembly routes using mild metal salt-ions (Mg²⁺ , Ca²⁺ , Na⁺ ) as a molecular trigger. The nanospears' dimensions collectively range from entire nano- to micrometer scale. The protein nanospears display exceptional thermal and chemical stability yet rapidly disassemble upon exposure to high concentrations of chaotropes (>1 mm sodium dodecyl sulfate (SDS)). Using a combination of biological assays and electron microscopy imaging, it is revealed that the nanospears spontaneously induce rapid and irreparable damage to bacterial morphology via a unique action mechanism provided by their nanostructure and enzymatic action, a feat inaccessible to traditional antibiotics. These protein-based nanospears show promise as a potent tool to combat the growing threats of resistant bacteria, inspiring a new way to engineer other antibacterial protein nanomaterials with diverse structural and dimensional architectures and functional properties.

Long-term trend of antibiotic use at public health care institutions in northwest China, 2012-20 -- a case study of Gansu Province

BACKGROUND

Over the past 20 years, excessive antibiotic use has led to serious antimicrobial resistance (AMR) worldwide, and the phenomenon is particularly serious in China. To this end, the Chinese health sector took a series of measures to promote rational antibiotic use. In this study, to reveal the impact of policies on antibiotic use, we explored the long-term trend and patterns of antibiotic use at public health care institutions from 2012 to 2020 in northwest China, taking Gansu Province as an example.

METHODS

Antibiotic procurement data were obtained from the provincial centralized bidding procurement (CBP) platform between 2012 and 2020. Antibiotic use was quantified using the Anatomical Therapeutic Chemical (ATC)/defined daily doses (DDD) methodology and standardized using the DDD per 1000 inhabitants per day (DID). Twelve relevant quality indicators were calculated for comparison with the European Surveillance of Antimicrobial Consumption (ESAC) project monitoring results.

RESULTS

Total antibiotic use increased from 18.75 DID to 57.07 DID and then decreased to 19.11 DID, a turning point in 2014. The top three antibiotics used were J01C (beta-lactam antibacterials, penicillins), J01F (macrolides, lincosamides and streptogramins), and J01D (other beta-lactam antibacterials, cephalosporins), accounting for 45.15%, 31.40%, and 11.99% respectively. The oral antibiotics used were approximately 2.5 times the parenteral antibiotics, accounting for 71.81% and 28.19%, respectively. Different use preferences were shown in public hospitals and primary health care centres (PHCs), and the latter accounted for more than half of total use. The absolute use of all classes of antibiotics in Gansu is almost higher than any of the 31 European countries included in the ESAC, but the relative use of some focused antibiotics is lower than theirs.

CONCLUSIONS

The intervention policies of the health department reduced antibiotic use in Gansu Province, but the proportion of broad-spectrum and parenteral antibiotics was still high. It is necessary to further improve the quality of antibiotic prescriptions and pay more attention to the rationality of antibiotic use in PHCs.

Digital health for climate change mitigation and response: a scoping review

OBJECTIVE

Climate change poses a major threat to the operation of global health systems, triggering large scale health events, and disrupting normal system operation. Digital health may have a role in the management of such challenges and in greenhouse gas emission reduction. This scoping review explores recent work on digital health responses and mitigation approaches to climate change.

MATERIALS AND METHODS

We searched Medline up to February 11, 2022, using terms for digital health and climate change. Included articles were categorized into 3 application domains (mitigation, infectious disease, or environmental health risk management), and 6 technical tasks (data sensing, monitoring, electronic data capture, modeling, decision support, and communication). The review was PRISMA-ScR compliant.

RESULTS

The 142 included publications reported a wide variety of research designs. Publication numbers have grown substantially in recent years, but few come from low- and middle-income countries. Digital health has the potential to reduce health system greenhouse gas emissions, for example by shifting to virtual services. It can assist in managing changing patterns of infectious diseases as well as environmental health events by timely detection, reducing exposure to risk factors, and facilitating the delivery of care to under-resourced areas.

DISCUSSION

While digital health has real potential to help in managing climate change, research remains preliminary with little real-world evaluation.

CONCLUSION

Significant acceleration in the quality and quantity of digital health climate change research is urgently needed, given the enormity of the global challenge.

Green Biosynthesis of Selenium Nanoparticles Using Orange Peel Waste: Characterization, Antibacterial and Antibiofilm Activities against Multidrug-Resistant Bacteria

There is an increase of pathogenic multidrug-resistant bacteria globally due to the misuse of antibiotics. Recently, more scientists used metal nanoparticles to counteract antibacterial resistance. In this study, orange peel waste (OPW) was used for selenium nanoparticles’ (Se-NPs) biosynthesis through the green and ecofriendly method, and their applications as antibacterial and antibiofilm agents. Green biosynthesized Se-NPs were characterized using FTIR, XRD, SEM, EDAX, and TEM. Characterization results revealed that biosynthesized Se-NPs were highly crystalline, spherical, and polydisperse, and had sizes in the range of 16–95 nm. The biosynthesized Se-NPs were evaluated as antibacterial and antibiofilm activities against multidrug-resistant bacteria. Results illustrated that Se-NPs exhibited potential antibacterial activity against Gram-positive bacteria (S. aureus ATCC 29213 and biofilm-producing clinical isolates of S. aureus) and Gram-negative bacteria (Pseudomonas aeruginosa PAO1, MDR, biofilm, and quorum-sensing and producing clinical isolates of MDR P. aeruginosa, MDR E. coli, and K. pneumonia). Moreover, results illustrated that S. aureus ATCC 29213 was the most sensitive bacteria to Se-NPs at 1000 µg/mL, where the inhibition zone was 35 mm and MIC was 25 µg/mL. Furthermore, Se-NPs at 0.25 and 0.5 MIC decreased the biofilm significantly. The largest inhibition of biofilm was noticed in MDR K. pneumonia, which was 62% and 92% at 0.25 and 0.5 MIC, respectively. In conclusion, Se-NPs were successfully biosynthesized using OPW through the green method and had promising antibacterial and antibiofilm activity against multidrug-resistant bacteria, which can be used later in fighting resistant bacteria.

Infective endocarditis following invasive dental procedures: IDEA case-crossover study

BACKGROUND

Infective endocarditis is a heart infection with a first-year mortality rate of ≈ 30%. It has long been thought that infective endocarditis is causally associated with bloodstream seeding with oral bacteria in ≈ 40-45% of cases. This theorem led guideline committees to recommend that individuals at increased risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. However, to the best of our knowledge, there has never been a clinical trial to prove the efficacy of antibiotic prophylaxis and there is no good-quality evidence to link invasive dental procedures with infective endocarditis. Many contend that oral bacteria-related infective endocarditis is more likely to result from daily activities (e.g. tooth brushing, flossing and chewing), particularly in those with poor oral hygiene.

OBJECTIVE

The aim of this study was to determine if there is a temporal association between invasive dental procedures and subsequent infective endocarditis, particularly in those at high risk of infective endocarditis.

DESIGN

This was a self-controlled, case-crossover design study comparing the number of invasive dental procedures in the 3 months immediately before an infective endocarditis-related hospital admission with that in the preceding 12-month control period.

SETTING

The study took place in the English NHS.

PARTICIPANTS

All individuals admitted to hospital with infective endocarditis between 1 April 2010 and 31 March 2016 were eligible to participate.

INTERVENTIONS

This was an observational study; therefore, there was no intervention.

MAIN OUTCOME MEASURE

The outcome measure was the number of invasive and non-invasive dental procedures in the months before infective endocarditis-related hospital admission.

DATA SOURCES

NHS Digital provided infective endocarditis-related hospital admissions data and dental procedure data were obtained from the NHS Business Services Authority.

RESULTS

The incidence rate of invasive dental procedures decreased in the 3 months before infective endocarditis-related hospital admission (incidence rate ratio 1.34, 95% confidence interval 1.13 to 1.58). Further analysis showed that this was due to loss of dental procedure data in the 2-3 weeks before any infective endocarditis-related hospital admission.

LIMITATIONS

We found that urgent hospital admissions were a common cause of incomplete courses of dental treatment and, because there is no requirement to record dental procedure data for incomplete courses, this resulted in a significant loss of dental procedure data in the 2-3 weeks before infective endocarditis-related hospital admissions. The data set was also reduced because of the NHS Business Services Authority's 10-year data destruction policy, reducing the power of the study. The main consequence was a loss of dental procedure data in the critical 3-month case period of the case-crossover analysis (immediately before infective endocarditis-related hospital admission), which did not occur in earlier control periods. Part of the decline in the rate of invasive dental procedures may also be the result of the onset of illness prior to infective endocarditis-related hospital admission, and part may be due to other undefined causes.

CONCLUSIONS

The loss of dental procedure data in the critical case period immediately before infective endocarditis-related hospital admission makes interpretation of the data difficult and raises uncertainty over any conclusions that can be drawn from this study.

FUTURE WORK

We suggest repeating this study elsewhere using data that are unafflicted by loss of dental procedure data in the critical case period.

TRIAL REGISTRATION

This trial is registered as ISRCTN11684416.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 28. See the NIHR Journals Library website for further project information.

The Economic Impact of Carbapenem Resistant-Non Lactose Fermenter and Enterobacteriaceae Infections on Hospital Costs in Dr. Soetomo General Academic Hospital Surabaya, Indonesia

Background: Carbapenem resistant-non lactose fermenter (CR-NLF) and Carbapenem resistant-Enterobacteriaceae (CR-E) bacterial infections are likely to be a global threat to people’s health. However, studies on the economic impacts according to the hospital setting are very scarce. The study aimed to explore the impact of CR-NLF (Acinetobacter baumannii = CRAB) & Pseudomonas aeruginosa = CRPA) and CR-E (Escherichia coli = CREC) & Klebsiella pneumoniae = CRKP) infections on hospital costs from a payer perspective among patients admitted to Dr.Soetomo Hospital, Surabaya, Indonesia. Methods: In the retrospective case-control study, medical records of all included patients hospitalized during 2018−2021 were reviewed for CRAB, CRPA, CREC, CRKP, and carbapenem sensitive (CSAB, CSPA, CSEC, CSKP) were collected. We retrieved the data of age, gender, clinical specimen, dates of admission, and discharge status. The outcomes of interest were hospital length of stay and hospitalization cost. Results: The cost for CR-NLFs infections was higher than carbapenem sensitive, $3026.24 versus $1299.28 (p < 0.05). There was no significant difference between CR-E against carbapenem sensitive. It showed that the highest impact of the cost was CRAB, followed by CRPA, CRKP, and CREC. The bed, antibiotics, pharmacy, and diagnostic costs of CR-NLFIs were significantly higher than CR-E. Conclusion: This study showed that the hospital cost and expenditure of CR-NLFs per patient were higher than CS. The hospital cost per patient for CR-NLF was higher than CR-E.

Photodynamic inactivation (PDI) as a promising alternative to current pharmaceuticals for the treatment of resistant microorganisms

Although the whole world is currently observing the global battle against COVID-19, it should not be underestimated that in the next 30 years, approximately 10 million people per year could be exposed to infections caused by multi-drug resistant bacteria. As new antibiotics come under pressure from unpredictable resistance patterns and relegation to last-line therapy, immediate action is needed to establish a radically different approach to countering resistant microorganisms. Among the most widely explored alternative methods for combating bacterial infections are metal complexes and nanoparticles, often in combination with light, but strategies using monoclonal antibodies and bacteriophages are increasingly gaining acceptance. Photodynamic inactivation (PDI) uses light and a dye termed a photosensitizer (PS) in the presence of oxygen to generate reactive oxygen species (ROS) in the field of illumination that eventually kill microorganisms. Over the past few years, hundreds of photomaterials have been investigated, seeking ideal strategies based either on single molecules (e.g., tetrapyrroles, metal complexes) or in combination with various delivery systems. The present work describes some of the most recent advances of PDI, focusing on the design of suitable photosensitizers, their formulations, and their potential to inactivate bacteria, viruses, and fungi. Particular attention is focused on the compounds and materials developed in our laboratories that are capable of killing in the exponential growth phase (up to seven logarithmic units) of bacteria without loss of efficacy or resistance, while being completely safe for human cells. Prospectively, PDI using these photomaterials could potentially cure infected wounds and oral infections caused by various multidrug-resistant bacteria. It is also possible to treat the surfaces of medical equipment with the materials described, in order to disinfect them with light, and reduce the risk of nosocomial infections.

Re-thinking lactation-related nipple pain and damage

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple-areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple-areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

Revisiting Antibiotic Resistance: Mechanistic Foundations to Evolutionary Outlook

Antibiotics are the pivotal pillar of contemporary healthcare and have contributed towards its advancement over the decades. Antibiotic resistance emerged as a critical warning to public wellbeing because of unsuccessful management efforts. Resistance is a natural adaptive tool that offers selection pressure to bacteria, and hence cannot be stopped entirely but rather be slowed down. Antibiotic resistance mutations mostly diminish bacterial reproductive fitness in an environment without antibiotics; however, a fraction of resistant populations 'accidentally' emerge as the fittest and thrive in a specific environmental condition, thus favouring the origin of a successful resistant clone. Therefore, despite the time-to-time amendment of treatment regimens, antibiotic resistance has evolved relentlessly. According to the World Health Organization (WHO), we are rapidly approaching a 'post-antibiotic' era. The knowledge gap about antibiotic resistance and room for progress is evident and unified combating strategies to mitigate the inadvertent trends of resistance seem to be lacking. Hence, a comprehensive understanding of the genetic and evolutionary foundations of antibiotic resistance will be efficacious to implement policies to force-stop the emergence of resistant bacteria and treat already emerged ones. Prediction of possible evolutionary lineages of resistant bacteria could offer an unswerving impact in precision medicine. In this review, we will discuss the key molecular mechanisms of resistance development in clinical settings and their spontaneous evolution.

Synthesis, antimicrobial evaluation, and in silico studies of quinoline-1H-1,2,3-triazole molecular hybrids

Antimicrobial resistance has become a significant threat to global public health, thus precipitating an exigent need for new drugs with improved therapeutic efficacy. In this regard, molecular hybridization is deemed as a viable strategy to afford multi-target-based drug candidates. Herein, we report a library of quinoline-1H-1,2,3-triazole molecular hybrids synthesized via copper(I)-catalyzed azide-alkyne [3 + 2] dipolar cycloaddition reaction (CuAAC). Antimicrobial evaluation identified compound 16 as the most active hybrid in the library with a broad-spectrum antibacterial activity at an MIC80 value of 75.39 μM against methicillin-resistant S. aureus, E. coli, A. baumannii, and multidrug-resistant K. pneumoniae. The compound also showed interesting antifungal profile against C. albicans and C. neoformans at an MIC80 value of 37.69 and 2.36 μM, respectively, superior to fluconazole. In vitro toxicity profiling revealed non-hemolytic activity against human red blood cells (hRBC) but partial cytotoxicity to human embryonic kidney cells (HEK293). Additionally, in silico studies predicted excellent drug-like properties and the importance of triazole ring in stabilizing the complexation with target proteins. Overall, these results present compound 16 as a promising scaffold on which other molecules can be modeled to deliver new antimicrobial agents with improved potency.

Inappropriate use of antibiotics exacerbates inflammation through OMV-induced pyroptosis in MDR Klebsiella pneumoniae infection

The inappropriate use of antibiotics is a severe public health problem worldwide, contributing to the emergence of multidrug-resistant (MDR) bacteria. To explore the possible impacts of the inappropriate use of antibiotics on the immune system, we use Klebsiella pneumoniae (K. pneumoniae) infection as an example and show that imipenem increases the mortality of mice infected by MDR K. pneumoniae. Further studies demonstrate that imipenem enhances the secretion of outer membrane vesicles (OMVs) with significantly elevated presentation of GroEL, which promotes the phagocytosis of OMVs by macrophages that depends on the interaction between GroEL and its receptor, lectin-like oxidized low-density lipoprotein receptor-1 (LOX-1). OMVs cause the pyroptosis of macrophages and the release of proinflammatory cytokines, which contribute to exacerbated inflammatory responses. We propose that the inappropriate use of antibiotics in the cases of infection by MDR bacteria such as K. pneumoniae might cause damaging inflammatory responses, which underlines the pernicious effects of inappropriate use of antibiotics.

Trimethoprim-sulfamethoxazole as de-escalation in ventilator-associated pneumonia: a cohort study subanalysis

PURPOSE

This is a subanalysis of a previous study which compared the effectiveness of trimetoprim-sulfametoxazole (TMP-SMX) with all other regimens for treatment of ventilator-associated pneumonia (VAP). Aim of the current study was to focus on the effectiveness of a strategy based on TMP-SMX as de-escalation from β-lactam including regimens.

METHODS

Retrospective cohort study including patients who were hospitalized for VAP from 2011 to 2019. Patients were distributed in two groups: NO SWITCH TO TMP-SMX group, including patients who received β-lactams for all treatment duration, and SWITCH TO TMP-SMX group, which included patients who switched to TMP-SMX from a β-lactam including regimen after microbiology diagnosis. Three clinical outcomes were analyzed: mortality at 30 days from the start of the antibiotic treatment (T30), mortality at the end of treatment (EoT), and acquisition of multidrug-resistant bacteria during hospitalization in intensive care unit.

RESULTS

Overall, 70 patients were included in the current study, 32/70 (45.7%) in NO SWITCH TO TMP-SMX group and 38/70 (54.3%) in SWITCH TO TMP-SMX group, 37/70 (52.8%) had been already included in the previous study. No significant differences in clinical outcomes and patient's characteristics were found when the two groups were compared.

CONCLUSIONS

De-escalation to TMP-SMX for VAP treatment was not associated with higher mortality at EoT and T30 than standard treatment with β-lactam. Monotherapy with TMP-SMX as de-escalation from broad-spectrum empirical regimens is a β-lactam sparing strategy worthy to be further investigated in either multicenter cohort studies or randomized clinical trials.

Selenium Nanomaterials to Combat Antimicrobial Resistance

The rise of antimicrobial resistance to antibiotics (AMR) as a healthcare crisis has led to a tremendous social and economic impact, whose damage poses a significant threat to future generations. Current treatments either are less effective or result in further acquired resistance. At the same time, several new antimicrobial discovery approaches are expensive, slow, and relatively poorly equipped for translation into the clinical world. Therefore, the use of nanomaterials is presented as a suitable solution. In particular, this review discusses selenium nanoparticles (SeNPs) as one of the most promising therapeutic agents based in the nanoscale to treat infections effectively. This work summarizes the latest advances in the synthesis of SeNPs and their progress as antimicrobial agents using traditional and biogenic approaches. While physiochemical methods produce consistent nanostructures, along with shortened processing procedures and potential for functionalization of designs, green or biogenic synthesis represents a quick, inexpensive, efficient, and eco-friendly approach with more promise for tunability and versatility. In the end, the clinical translation of SeNPs faces various obstacles, including uncertain in vivo safety profiles and mechanisms of action and unclear regulatory frameworks. Nonetheless, the promise possessed by these metalloid nanostructures, along with other nanoparticles in treating bacterial infections and slowing down the AMR crisis, are worth exploring.

The rationale for including osteopathic manipulative treatment in the management of infections: a hermeneutic review

INTRODUCTION

As the prevalence of drug-resistant infections continues to outpace the development of new antibiotics, we must explore all reasonable options for enhancing the effectiveness of existing anti-infectives. The emergence of novel pathogens without initial drug treatments or vaccines, typified by the severe acute respiratory syndrome coronavirus-2 pandemic, further underscores the need for non-pharmacologic adjunctive measures for infection management. Osteopathic manipulative treatment (OMT) may represent such an adjunct.

AREAS COVERED

PubMed, CINAHL, Google Scholar, Cochrane databases and relevant chapters of major osteopathic texts were searched for animal experiments, case reports, observational studies, non-randomized, and randomized trials pertaining to infection, OMT, and the complications or safety of OMT. OMT was associated with one or more of the following: decreased bacterial colony counts in lung tissue; changes in immunologic profiles manifested by significant differences dendritic cells and levels of IL-8, MCP-1, MIP-1a, and G-CSF; shorter durations of IV antibiotics; decreased length of hospitalization; decreased rates of respiratory failure and death; decreased post-surgical lengths of stay; and enhanced patient satisfaction.

EXPERT OPINION

Preliminary, lower-grade evidence suggests that OMT can improve some infection-related outcomes, and is safe. The role of OMT in infection management should undergo further controlled trials without delay.

The Rationale for a Mandatory Antibiotic Stewardship Rotation During Residency: What Worked, What Needs More Work

Reports of antibiotic stewardship (AS) integration into the > 1000 United States internal medicine and family practice residency core curricula are scarce, but residents value such training. To help address this gap, and the projected shortage of physicians with training for establishing and leading an AS program (ASP), we describe the rationale for, and the output and shortcomings of, a dedicated AS rotation. Residents critically review, in real-time, inpatient antibiotic orders, provide feedback to the prescribers, learn the mechanics and requirements of an ASP, and complete a preliminary quality improvement project. Program evaluations are uniformly positive, noting limited opportunities otherwise to clarify optimal antibiotic choices or discuss antibiotics in depth. Nine posters at national conferences and 1 publication have roots in this rotation. Three alumni matriculated to accredited US infectious diseases fellowships. We invite others to join us in calling for more AS training opportunities during residency.

Nanomaterials arising amid antibiotic resistance

The rapid emergence of antibiotic resistance is recognized as a major public health threat. Nanomaterials have risen to tackle this problem through either improving the potency of existing antibiotics or generating entirely new antibacterial mechanisms.

An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda

Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% (10,402/45,160). The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines.

Animal Models of Phage Therapy

Amidst the rising tide of antibiotic resistance, phage therapy holds promise as an alternative to antibiotics. Most well-designed studies on phage therapy exist in animal models. In order to progress to human clinical trials, it is important to understand what these models have accomplished and determine how to improve upon them. Here we provide a review of the animal models of phage therapy in Western literature and outline what can be learned from them in order to bring phage therapy closer to becoming a feasible alternative to antibiotics in clinical practice.

Subtribe Hyptidinae (Lamiaceae): A promising source of bioactive metabolites

ETHNOPHARMACOLOGICAL RELEVANCE

The subtribe Hyptidinae contains approximately 400 accepted species distributed in 19 genera (Hyptis, Eriope, Condea, Cantinoa, Mesosphaerum, Cyanocephalus, Hypenia, Hyptidendron, Oocephalus, Medusantha, Gymneia, Marsypianthes, Leptohyptis, Martianthus, Asterohyptis, Eplingiella, Physominthe, Eriopidion and Rhaphiodon). This is the Lamiaceae clade with the largest number of species in Brazil and high rates of endemism. Some species have been used in different parts of the world mainly as insecticides/pest repellents, wound healing and pain-relief agents, as well as for the treatment of respiratory and gastrointestinal disorders.

AIM OF THE REVIEW

This review aims to discuss the current status concerning the taxonomy, ethnobotanical uses, phytochemistry and biological properties of species which compose the subtribe Hyptidinae.

MATERIALS AND METHODS

The available information was collected from scientific databases (ScienceDirect, Pubmed, Web of Science, Scopus, Google Scholar, ChemSpider, SciFinder ACS Publications, Wiley Online Library), as well as other literature sources (e.g. books, theses).

RESULTS

The phytochemical investigations of plants of this subtribe have led to the identification of almost 300 chemical constituents of different classes such as diterpenes, triterpenes, lignans, α-pyrones, flavonoids, phenolic acids and monoterpenes and sesquiterpenes, as components of essential oils. Extracts, essential oils and isolated compounds showed a series of biological activities such as insecticide/repellent, antimicrobial and antinociceptive, justifying some of the popular uses of the plants. In addition, a very relevant fact is that several species produce podophyllotoxin and related lignans.

CONCLUSION

Several species of Hyptidinae are used in folk medicine for treating many diseases but only a small fraction of the species has been explored and most of the traditional uses have not been validated by current investigations. In addition, the species of the subtribe appear to be very promising as alternative sources of podophyllotoxin-like lignans which are the lead compounds for the semi-synthesis of teniposide and etoposide, important antineoplastic agents. Thus, there is a wide-open door for future studies, both to support the popular uses of the plants and to find new biologically active compounds in this large number of species not yet explored.

Overdiagnosis and overtreatment of nipple and breast candidiasis: A review of the relationship between diagnoses of mammary candidiasis and Candida albicans in breastfeeding women

BACKGROUND

Breastfeeding mothers commonly experience nipple pain accompanied by radiating, stabbing or constant breast pain between feeds, sometimes associated with pink shiny nipple epithelium and white flakes of skin. Current guidelines diagnose these signs and symptoms as mammary candidiasis and stipulate antifungal medications.

AIM

This study reviews existing research into the relationship between Candida albicans and nipple and breast pain in breastfeeding women who have been diagnosed with mammary candidiasis; whether fluconazole is an effective treatment; and the presence of C. albicans in the human milk microbiome.

METHOD

The author conducted three searches to investigate (a) breastfeeding-related pain and C. albicans; (b) the efficacy of fluconazole in breastfeeding-related pain; and (c) composition of the human milk mycobiome. These findings are critiqued and integrated in a narrative review.

RESULTS

There is little evidence to support the hypothesis that Candida spp, including C. albicans, in maternal milk or on the nipple-areolar complex causes the signs and symptoms popularly diagnosed as mammary candidiasis. There is no evidence that antifungal treatments are any more effective than the passage of time in women with these symptoms. Candida spp including C. albicans are commonly identified in healthy human milk and nipple-areolar complex mycobiomes.

DISCUSSION

Clinical breastfeeding support remains a research frontier. The human milk microbiome, which includes a mycobiome, interacts with the microbiomes of the infant mouth and nipple-areolar complex, including their mycobiomes, to form protective ecosystems. Topical or oral antifungals may disrupt immunoprotective microbial homeostasis. Unnecessary use contributes to the serious global problem of antifungal resistance.

CONCLUSION

Antifungal treatment is rarely indicated and prolonged courses cannot be justified in breastfeeding women experiencing breast and nipple pain. Multiple strategies for stabilizing microbiome feedback loops when nipple and breast pain emerge are required, in order to avoid overtreatment of breastfeeding mothers and their infants with antifungal medications.

Antimicrobial use in wean to market pigs in the United States assessed via voluntary sharing of proprietary data

Data on antimicrobial use were collected for the 2016 and 2017 calendar years from swine producers in the United States. Nine large systems, collectively producing over 20 million market pigs annually, voluntarily provided data to advance understanding of antimicrobial use in the industry and to support antimicrobial stewardship initiatives. The scope of the study was limited to growing pigs, and the granularity of data varied across the systems. Data were summarized both qualitatively and quantitatively by antimicrobial class, active ingredient and route of administration (injection, water and feed). Data on the purpose of administration, doses and durations of administration were not available, but some information was provided by the responsible veterinarians. Aggregate data were similar both qualitatively and quantitatively in 2016 and 2017, although marked changes between years were evident within systems for some antimicrobials. Antimicrobial use (by weight) was dominated by the tetracycline class (approximately 60% of total use). Antimicrobials in classes categorized as critically important constituted 4.5% and 5.3% of total use in 2016 and 2017, respectively. In both years, fluoroquinolone (0.23%, 0.46%) and 3rd generation cephalosporin (0.15%, 0.11%) use collectively accounted for <1% of total use. Administration was predominantly oral in feed and water, and injection comprised approximately 2% of use overall, but around 12% for critically important antimicrobials. There was considerable variability among systems in patterns of antimicrobial use. This pilot project demonstrates the feasibility of acquiring antimicrobial use data via voluntary sharing. It is currently being expanded among larger swine production systems, and further efforts to enable confidential data sharing and benchmarking for smaller producers are being pursued by the swine industry. Recognized biases in the data caution against over-interpretation of these data as an index of national use.

Efflux pump inhibitors: new updates

The discovery of antibiotics ought to have ended the issue of bacterial infections, but this was not the case as it has led to the evolution of various mechanisms of bacterial resistance against various antibiotics. The efflux pump remains one of the mechanisms through which organisms develop resistance against antibiotics; this is because organisms can extrude most of the clinically relevant antibiotics from the interior cell environment to the exterior environment via the efflux pumps. Efflux pumps are thought to contribute significantly to biofilm formation as highlighted by various studies. Therefore, the inhibition of these efflux pumps can be a potential way of improving the activity of antibiotics, particularly now that the discovery of novel antibiotics is becoming tedious. Efflux pump inhibitors (EPIs) are molecules that can inhibit efflux pumps; they have been considered potential therapeutic agents for rejuvenating the activity of antibiotics that have already lost their activity against bacteria. However, studies are yet to determine the specific substrates for such pumps; the effect of altered efflux activity of these pumps on biofilm formation is still being investigated. A clear knowledge of the involvement of efflux pumps in biofilm development could aid in developing new agents that can interfere with their function and help to prevent biofilms formation; thereby, improving the outcome of treatment strategies. This review focuses on the novel update of EPIs and discusses the evidence of the roles of efflux pumps in biofilm formation; the potential approaches towards overcoming the increasing problem of biofilm-based infections are also discussed.

Transgingival photodynamic therapy (tg-aPDT) adjunctive to subgingival mechanical instrumentation in supportive periodontal therapy. A randomized controlled clinical study

BACKGROUND

Recent data from preclinical studies and case series suggest that transgingival irradiation with diode lasers may represent a novel modality for antimicrobial photodynamic therapy (aPDT). However, at present, there is lack of data from controlled clinical studies on the use of transgingival antimicrobial photodynamic therapy (tg-aPDT) in the treatment of periodontitis.

OBJECTIVE

To evaluate the clinical effects of tg-aPDT used in conjunction with nonsurgical mechanical instrumentation during supportive periodontal therapy (SPT).

MATERIALS AND METHODS

Forty stage II and III periodontitis patients enrolled in SPT were randomly assigned to two groups of equal size. At baseline, study sites had to show sites with pocket probing depth (PPD) of ≥ 5 mm and Bleeding on Probing (BOP). Full mouth and site-specific Plaque-Index scores (PI), BOP, PPD, and Clinical Attachment Level (CAL) were recorded at baseline (BL), three months (3 M), and 6 months (6 M), respectively. The primary outcome variable was the change in the number of sites with BOP. Treatment was performed under local anaesthesia after random allocation to one of the following groups 1) Subgingival scaling and root planing (SRP) + tg-aPDT (test) or 2) SRP alone (control).

RESULTS

Thirty-nine patients completed the study. Full mouth PI and BOP improved over six month, however without statistically significant difference between the groups. At 6 M, BOP-levels were statistically significantly lower in test sites (25.0 %) compared to the control sites (65.0 %), (p < 0.025). PPD improved in both groups with comparable mean values at 3 M (PPD test: 5.21 ± 0.92 mm; PPD control: 4.45 ± 1.36 mm) and 6 M (PPD test: 5.11 ± 1.10 mm; PPD control: 4.35 ± 1.14 mm). Additionally, CAL slightly improved in both groups with comparable mean values at 3 M (CAL test: 6.79 ± 1.72 mm; CAL control: 5.30 ± 2.43 mm) and 6 M (CAL test: 6.26 ± 1.70 mm; CAL control: 5.50 ± 2.33 mm).

CONCLUSIONS

Within its limits, the present results appear to indicate that the use of tg-aPDT adjunctive to SRP may represent a new modality for controlling inflammation and further bleeding in residual periodontal pockets.

Pre-operative conjunctival flora in patients with local and/or systemic risk factors for post cataract surgery infection in Northern Italy

PURPOSE

To investigate the pre-operative conjunctival flora in patients undergoing cataract surgery with major local and/or systemic risk factors for developing post-operative infection.

METHODS

A total of 83 patients underwent bacterial culture and sensitivity testing of conjunctival swabs obtained from both eyes because of local risk factors at the pre-operative visit (i.e. chronic blepharitis, conjunctivitis, or lacrimal system disease), and/or systemic risk factors (i.e. autoimmune or skin disorders) for developing post-operative infection. If the swab was found positive, an antimicrobial susceptibility test was performed, and a specific antibiotic therapy was administered. Surgery was performed when a repeat conjunctival swab (after antibiotic treatment) showed negative cultures.

RESULTS

Cultures were found positive in 25.3% of patients. Staphylococcus aureus (18%) and Staphylococcus epidermidis (15%) were the most frequently isolated microorganisms. Gram-negative bacteria, including Pseudomonas aeruginosa, were present in nine cases (8%).

CONCLUSION

Present results showed a low rate of swab positivity compared to previous published data, and slightly different microbial flora. The differences observed may be caused by geographical factors and/or to the specific characteristics of the subgroup of studied patients. Considering that the surface microbial flora is one of the major causes of endophthalmitis, this information may be useful in selecting antibacterial regimens to prevent serious ocular infections, and restrain the increasing problem of antibiotic resistance.

Impact of a Multiplex Polymerase Chain Reaction Assay on the Clinical Management of Adults Undergoing a Lumbar Puncture for Suspected Community-Onset Central Nervous System Infections

Patients admitted from the community with a suspected central nervous system (CNS) infection require prompt diagnostic evaluation and correct antimicrobial treatment. A retrospective, multicenter, pre/post intervention study was performed to evaluate the impact that the BioFire^® FilmArray^® meningitis/encephalitis (ME) panel run in-house had on the clinical management of adult patients admitted from the community with a lumbar puncture (LP) performed for a suspected CNS infection. The primary outcome was the effect that this intervention had on herpes simplex virus (HSV) polymerase chain reaction (PCR) turnaround time (TAT). Secondary outcomes included the effect that this intervention had on antiviral days of therapy (DOT), total antimicrobial DOT, and hospital length of stay (LOS). A total of 81 and 79 patients were included in the pre-intervention and post-intervention cohorts, respectively. The median HSV PCR TAT was significantly longer in the pre-intervention group (85 vs. 4.1 h, p < 0.001). Total antiviral DOT was significantly greater in the pre-intervention group (3 vs. 1, p < 0.001), as was total antimicrobial DOT (7 vs. 5, p < 0.001). Pre-intervention hospital LOS was also significantly longer (6.6 vs. 4.4 days, p = 0.02). Implementing the ME panel in-house for adults undergoing an LP for a suspected community-onset CNS infection significantly reduced the HSV PCR TAT, antiviral DOT, total antimicrobial DOT, and hospital LOS.

Crotamine and crotalicidin, membrane active peptides from Crotalus durissus terrificus rattlesnake venom, and their structurally-minimized fragments for applications in medicine and biotechnology

A global public health crisis has emerged with the extensive dissemination of multidrug-resistant microorganisms. Antimicrobial peptides (AMPs) from plants and animals have represented promising tools to counteract those resistant pathogens due to their multiple pharmacological properties such as antimicrobial, anticancer, immunomodulatory and cell-penetrating activities. In this review, we will focus on crotamine and crotalicidin, which are two interesting examples of membrane active peptides derived from the South America rattlesnake Crotalus durrisus terrificus venom. Their full-sequences and structurally-minimized fragments have potential applications, as anti-infective and anti-proliferative agents and diagnostics in medicine and in pharmaceutical biotechnology.

Facially Amphiphilic Cholic Acid-Lysine Conjugates as Promising Antimicrobials

The emergence of multidrug-resistant microbes is a significant health concern posing a constant need for new antimicrobials. Membrane-targeting antibiotics are promising candidates with reduced ability of microbes to develop resistance. In the present investigation, the principal reason behind choosing cholic acid as the crucial scaffold lies in the fact that it has a facially amphiphilic nature, which provides ample opportunity to refine the amphiphilicity by linking the amino acid lysine. A total of 16 novel amphipathic cholic acid derivatives were synthesized by sequentially linking lysine to C3-β-amino cholic acid methyl ester to maintain the hydrophobic/hydrophilic balance, which could be the essential requirement for the antimicrobial activity. Among the synthesized conjugates, a series with fluorenyl-9-methoxycarbonyl moiety attached to cholic acid via lysine linker showed promising antimicrobial activity against Staphylococcus aureus, Escherichia coli, and Candida albicans. A pronounced effect of increase in lysine residues was noted on the observed activity. The lead compounds were found to be active against drug-resistant bacterial and fungal clinical isolates and also improved the efficacy of antifungal agents amphotericin B and voriconazole. Membrane-permeability studies demonstrated the ability of these compounds to induce membrane damage in the tested microbes. The active conjugates did not show any hemolytic activity and were also found to be nontoxic to the normal cells as well as the examined cancer cell lines. The observed antimicrobial activity was attributed to the facial amphiphilic conformations, hydrophobic/hydrophilic balance, and the overall charge on the molecules.

Addressing the epidemic of antibiotic "allergy" over-diagnosis

OBJECTIVE

An epidemic of antibiotic allergy is occurring.

DATA SOURCES

Articles published since 2008.

STUDY SELECTIONS

Articles on antibiotic allergy and stewardship.

RESULTS

A number of overlapping factors contribute. The most important factor is antibiotic overuse. Antibiotics are commonly used in situations in which no antibiotics are indicated. Thirty percent to 50% of ambulatory antibiotic use may be inappropriate. The duration of indicated antibiotic use is often excessive, which leads to more side effects. All antibiotic use can result in adverse reactions, and a fraction of these will be dutifully recorded as an allergy in the electronic health record (EHR). Most EHRs are not well structured to accurately convey information on expected side effects that have occurred, metabolic or other contraindications, dose-related or situational toxicities, personal preferences, clinically significant immunologically mediated hypersensitivity, and other reasons a particular patient may not want or should not be given a specific drug or type of drug in the future. As populations age, their accumulated baggage of reported antibiotic allergies increase. Suspected antibiotic allergy is rarely confirmed with appropriate testing or rechallenge. Patients then receive suboptimal antibiotic therapy and experience more side effects, treatment failures, and serious antibiotic-resistant infections. Reporting an antibiotic allergy in the EHR is nominally done to improve patient safety, but unfortunately, this is often not the actual result.

CONCLUSION

Audit and feedback, to help ensure adherence to Choosing Wisely recommendations and good antibiotic stewardship practices, can help reduce inappropriate antibiotic use. Restructuring EHRs to facilitate correct drug intolerance reporting, along with active antibiotic allergy delabeling programs, can help stem this epidemic.

The second-hand effects of antibiotics: communicating the public health risks of drug resistance

Antimicrobial resistance (AMR) poses a threat to modern medicine, but there are challenges in communicating its urgency and scope and potential solutions to this growing problem. It is recognized that AMR has a 'language problem' and the way in which healthcare professionals communicate about AMR may not always resonate with patients. Many patients are unaware that antibiotics can have detrimental effects to those beyond the recipient, due to transmission of drug-resistant organisms. The overestimation of benefits and underestimation of risks helps to fuel demand for antibiotic use in situations where they may be of little or no benefit. To better communicate risks, clinicians may borrow the term 'second-hand' from efforts to reduce smoking cessation. We present several examples where antibiotics themselves have second-hand effects beyond the individual recipient in hospitals, long-term care homes and the community. Incorporation of the concept of the second-hand effects of antibiotics into patient counselling, mass messaging and future research may help facilitate a more balanced discussion about the benefits and risks of antibiotic use in order to use these agents more appropriately.