Global governance of antimicrobial resistance

Characterising proximal and distal drivers of antimicrobial resistance: An umbrella review

INTRODUCTION

Antimicrobial resistance (AMR) is a multifactorial challenge driven by a complex interplay of proximal drivers, such as the overuse and misuse of antimicrobials and the high burden of infectious diseases, and distal factors, encompassing broader societal conditions such as poverty, inadequate sanitation, and healthcare system deficiencies. However, distinguishing between proximal and distal drivers remains a conceptual challenge.

OBJECTIVES

We conducted an umbrella review, aiming to systematically map current evidence about proximal and distal drivers of AMR and to investigate their relationships.

METHODS

Forty-seven reviews were analysed, and unique causal links were retained to construct a causality network of AMR. To distinguish between proximal and distal drivers, we calculated a 'driver distalness index (Di)', defined as an average relative position of a driver in its causal pathways to AMR.

RESULTS

The primary emphasis of the literature remained on proximal drivers, with fragmented existing evidence about distal drivers. The network analysis showed that proximal drivers of AMR are associated with risks of resistance transmission (Di = 0.49, SD = 0.14) and antibiotic use (Di = 0.58, SD = 0.2), which are worsened by intermediate drivers linked with challenges of antibiotic discovery (Di = 0.62, SD = 0.07), infection prevention (Di = 0.67, SD = 0.14) and surveillance (Di = 0.69, SD = 0.16). Distal drivers, such as living conditions, access to sanitation infrastructure, population growth and urbanisation, and gaps in policy implementation were development and governance challenges, acting as deep leverage points in the system in addressing AMR.

CONCLUSIONS

Comprehensive AMR strategies aiming to address multiple chronic AMR challenges must take advantage of opportunities for upstream interventions that specifically address distal drivers.

Potential role of civil society organizations (CSOs) in antimicrobial resistance (AMR) mitigation efforts in low- and middle-income countries: A report from India

Antibiotic resistance (ABR) is a global health threat with the potential to cause mortality and morbidity on an unprecedented scale. In the past, civil society organizations (CSOs) have been successful in complementing the efforts of government health systems, thereby shaping the course of various public health programs, especially in low- and middle-income countries (LMICs). This article reports the outcomes of a CSO sensitization workshop held by one of the regional nodes of ReAct and highlights the perspectives of CSOs on their role in supporting the implementation of national and sub-national action plans for AMR mitigation. CSOs can contribute to (i) redefining the AMR narrative, (ii) generating the data for action and policy change, (iii) advocating for policy change, (iv) promoting research and influencing decisions pertaining to research in AMR, and (v) undertaking behavioral change communication for different target groups, among others. Governments in LMICs could leverage the expertise of CSOs by playing the role of facilitator while ensuring that the interventions align with national priorities and are sustainable. Efforts to ensure diverse funding and capacity building among CSOs should happen in parallel to ensure maximum impact on communities.

PLM-ARG: antibiotic resistance gene identification using a pretrained protein language model

MOTIVATION

Antibiotic resistance presents a formidable global challenge to public health and the environment. While considerable endeavors have been dedicated to identify antibiotic resistance genes (ARGs) for assessing the threat of antibiotic resistance, recent extensive investigations using metagenomic and metatranscriptomic approaches have unveiled a noteworthy concern. A significant fraction of proteins defies annotation through conventional sequence similarity-based methods, an issue that extends to ARGs, potentially leading to their under-recognition due to dissimilarities at the sequence level.

RESULTS

Herein, we proposed an Artificial Intelligence-powered ARG identification framework using a pretrained large protein language model, enabling ARG identification and resistance category classification simultaneously. The proposed PLM-ARG was developed based on the most comprehensive ARG and related resistance category information (>28K ARGs and associated 29 resistance categories), yielding Matthew's correlation coefficients (MCCs) of 0.983 ± 0.001 by using a 5-fold cross-validation strategy. Furthermore, the PLM-ARG model was verified using an independent validation set and achieved an MCC of 0.838, outperforming other publicly available ARG prediction tools with an improvement range of 51.8%-107.9%. Moreover, the utility of the proposed PLM-ARG model was demonstrated by annotating resistance in the UniProt database and evaluating the impact of ARGs on the Earth's environmental microbiota.

AVAILABILITY AND IMPLEMENTATION

PLM-ARG is available for academic purposes at https://github.com/Junwu302/PLM-ARG, and a user-friendly webserver (http://www.unimd.org/PLM-ARG) is also provided.

The Silent Threat: Antimicrobial-Resistant Pathogens in Food-Producing Animals and Their Impact on Public Health

The emergence of antimicrobial resistance (AMR) is a global health problem without geographic boundaries. This increases the risk of complications and, thus, makes it harder to treat infections, which can result in higher healthcare costs and a greater number of deaths. Antimicrobials are often used to treat infections from pathogens in food-producing animals, making them a potential source of AMR. Overuse and misuse of these drugs in animal agriculture can lead to the development of AMR bacteria, which can then be transmitted to humans through contaminated food or direct contact. It is therefore essential to take multifaceted, comprehensive, and integrated measures, following the One Health approach. To address this issue, many countries have implemented regulations to limit antimicrobial use. To our knowledge, there are previous studies based on AMR in food-producing animals; however, this paper adds novelty related to the AMR pathogens in livestock, as we include the recent publications of this field worldwide. In this work, we aim to describe the most critical and high-risk AMR pathogens among food-producing animals, as a worldwide health problem. We also focus on the dissemination of AMR genes in livestock, as well as its consequences in animals and humans, and future strategies to tackle this threat.

Antibiotic potentiation and inhibition of cross-resistance in pathogens associated with cystic fibrosis

Critical Gram-negative pathogens, like Pseudomonas, Stenotrophomonas and Burkholderia, have become resistant to most antibiotics. Complex resistance profiles together with synergistic interactions between these organisms increase the likelihood of treatment failure in distinct infection settings, for example in the lungs of cystic fibrosis patients. Here, we discover that cell envelope protein homeostasis pathways underpin both antibiotic resistance and cross-protection in CF-associated bacteria. We find that inhibition of oxidative protein folding inactivates multiple species-specific resistance proteins. Using this strategy, we sensitize multi-drug resistant Pseudomonas aeruginosa to β-lactam antibiotics and demonstrate promise of new treatment avenues for the recalcitrant pathogen Stenotrophomonas maltophilia. The same approach also inhibits cross-protection between resistant S. maltophilia and susceptible P. aeruginosa, allowing eradication of both commonly co-occurring CF-associated organisms. Our results provide the basis for the development of next-generation strategies that target antibiotic resistance, while also impairing specific interbacterial interactions that enhance the severity of polymicrobial infections.

The best laid plans?: international governance perspectives in AMR national action plans in Europe

BACKGROUND

There is a broad consensus in the European public health community that international collaboration and coordination are key in the fight against antimicrobial resistance (AMR). Yet, while experts typically testify the importance of cross-national learning and a coordinated effort to reduce the spread of multi-resistant bacteria, there are mixed views about how that is best realized in practice, particularly on the dichotomy between horizontal and vertical activities.

METHODS

National action plans (NAP) from all EU member states were systematically overviewed by two independent researchers. We followed a fixed procedure for locating a broad and comparable content on the international dimensions, and letting these vary on scales.

RESULTS

We find that countries adhere to four different strategies for international coordination, varying between 'high' and 'low' on values of vertical and horizontal activities. Most countries spend none or very little space to discuss international activities, while some countries use their NAPs to outline their aspiration for taking leading roles in the international struggle. Moreover, in line with previous research, we find that many countries directly mimic the Global Action Plan, but also that a large share of countries describe independent arrangements in their international strategies.

CONCLUSIONS

European countries recognize AMR and its inherent international governance challenge differently in their NAPs, which may have implications for coordinated action to address the issue.

Two-site study on performances of a commercially available MALDI-TOF MS-based assay for the detection of colistin resistance in Escherichia coli

Colistin is a last resort drug for the treatment of multiple drug-resistant (MDR) Gram-negative bacterial infections. Rapid methods to detect resistance are highly desirable. Here, we evaluated the performance of a commercially available MALDI-TOF MS-based assay for colistin resistance testing in Escherichia coli at two different sites. Ninety clinical E. coli isolates were provided by France and tested in Germany and UK using a MALDI-TOF MS-based colistin resistance assay. Lipid A molecules of the bacterial cell membrane were extracted using the MBT Lipid Xtract Kit™ (RUO; Bruker Daltonics, Germany). Spectra acquisition and evaluation were performed by the MBT HT LipidART Module of MBT Compass HT (RUO; Bruker Daltonics) on a MALDI Biotyper® sirius system (Bruker Daltonics) in negative ion mode. Phenotypic colistin resistance was determined by broth microdilution (MICRONAUT MIC-Strip Colistin, Bruker Daltonics) and used as a reference. Comparing the results of the MALDI-TOF MS-based colistin resistance assay with the data of the phenotypic reference method for the UK, sensitivity and specificity for the detection of colistin resistance were 97.1% (33/34) and 96.4% (53/55), respectively. Germany showed 97.1% (33/34) sensitivity and 100% (55/55) specificity for the detection of colistin resistance by MALDI-TOF MS. Applying the MBT Lipid Xtract™ Kit in combination with MALDI-TOF MS and dedicated software showed excellent performances for E. coli. Analytical and clinical validation studies must be performed to demonstrate the performance of the method as a diagnostic tool.

Exploring Models for an International Legal Agreement on the Global Antimicrobial Commons: Lessons from Climate Agreements

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change-both are common pool resource challenges that require massive, long-term political commitments-the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support.

SARS-CoV-2 caused a surge in antibiotic consumption causing a silent pandemic inside the pandemic. A retrospective analysis of Italian data in the first half of 2022

BACKGROUND

The phenomenon of antibiotic resistance shows no sign of stopping, despite global policies to combat it that have been in place for several years. The risk of forms of pathogenic microorganisms that are increasingly resistant to common antibiotics has led health authorities around the world to pay greater attention to the phenomenon. The worrying situation, has led to further recommendations from the World Health Organization (WHO) and national recommendations in Italy through the new National Plan against Antibiotic Resistance 2022-2025 (PNCAR 2022-2025).

AIM

This manuscript aims to raise the awareness of all health professionals to follow what is suggested by regulatory agencies and scientific societies.

METHOD

We conducted a retrospective study of antibiotic pharmacoutilization in Italy, in the Campania region at the Azienda Sanitaria Locale (ASL) Napoli 3 Sud, on consumption in the first half of 2022 in a population of more than 1 million people.

RESULT

The results indicate that consumption, based on defined daily doses (DDDs), is above the national average. Probably the COVID-19 pandemic has influenced this growth in prescriptions.

CONCLUSIONS

Our study suggests an informed and appropriate use of antibiotics, so as to embark on a virtuous path in the fight against antibiotic resistance.

Clearing an ESKAPE Pathogen in a Model Organism; A Polypyridyl Ruthenium(II) Complex Theranostic that Treats a Resistant Acinetobacter baumannii Infection in Galleria mellonella

In previous studies we have described the therapeutic action of luminescent dinuclear ruthenium(II) complexes based on the tetrapyridylphenazine, tpphz, bridging ligand on pathogenic strains of Escherichia coli and Enterococcus faecalis. Herein, the antimicrobial activity of the complex against pernicious Gram-negative ESKAPE pathogenic strains of Acinetobacter baumannii (AB12, AB16, AB184 and AB210) and Pseudomonas aeruginosa (PA2017, PA_ 007_ IMP and PA_ 004_ CRCN) are reported. Estimated minimum inhibitory concentrations and minimum bactericidal concentrations for the complexes revealed the complex shows potent activity against all A. baumannii strains, in both glucose defined minimal media and standard nutrient rich Mueller-Hinton-II. Although the activity was lower in P. aureginosa, a moderately high potency was observed and retained in carbapenem-resistant strains. Optical microscopy showed that the compound is rapidly internalized by A. baumannii. As previous reports had revealed the complex exhibited no toxicity in Galleria Mellonella up to concentrations of 80 mg/kg, the ability to clear pathogenic infection within this model was explored. The pathogenic concentrations to the larvae for each bacterium were determined to be≥105 for AB184 and≥103 CFU/mL for PA2017. It was found a single dose of the compound totally cleared a pathogenic A. baumannii infection from all treated G. mellonella within 96 h. Uniquely, in these conditions thanks to the imaging properties of the complex the clearance of the bacteria within the hemolymph of G. mellonella could be directly visualized through both optical and transmission electron microscopy.

Validation and Application of Long-Read Whole-Genome Sequencing for Antimicrobial Resistance Gene Detection and Antimicrobial Susceptibility Testing

Next-generation sequencing applications are increasingly used for detection and characterization of antimicrobial-resistant pathogens in clinical settings. Oxford Nanopore Technologies (ONT) sequencing offers advantages for clinical use compared with other sequencing methodologies because it enables real-time basecalling, produces long sequencing reads that increase the ability to correctly assemble DNA fragments, provides short turnaround times, and requires relatively uncomplicated sample preparation. A drawback of ONT sequencing, however, is its lower per-read accuracy than short-read sequencing. We sought to identify best practices in ONT sequencing protocols. As some variability in sequencing results may be introduced by the DNA extraction methodology, we tested three DNA extraction kits across three independent laboratories using a representative set of six bacterial isolates to investigate accuracy and reproducibility of ONT technology. All DNA extraction techniques showed comparable performance; however, the DNeasy PowerSoil Pro kit had the highest sequencing yield. This kit was subsequently applied to 42 sequentially collected bacterial isolates from blood cultures to assess Ares Genetics's pipelines for predictive whole-genome sequencing antimicrobial susceptibility testing (WGS-AST) performance compared to phenotypic triplicate broth microdilution results. WGS-AST results ranged across the organisms and resulted in an overall categorical agreement of 95% for penicillins, 82.4% for cephalosporins, 76.7% for carbapenems, 86.9% for fluoroquinolones, and 96.2% for aminoglycosides. Very major errors/major errors were 0%/16.7% (penicillins), 11.7%/3.6% (cephalosporins), 0%/24.4% (carbapenems), 2.5%/7.7% (fluoroquinolones), and 0%/4.1% (aminoglycosides), respectively. This work showed that, although additional refinements are necessary, ONT sequencing demonstrates potential as a method to perform WGS-AST on cultured isolates for patient care.

A whole cell-based Matrix-assisted laser desorption/ionization mass spectrometry lipidomic assay for the discovery of compounds that target lipid a modifications

Introduction

Matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) is a powerful analytical technique that has been applied to a wide variety of applications ranging from proteomics to clinical diagnostics. One such application is its use as a tool for discovery assays, such as monitoring the inhibition of purified proteins. With the global threat from antimicrobial-resistant (AMR) bacteria, new and innovative solutions are required to identify new molecules that could revert bacterial resistance and/or target virulence factors. Here, we used a whole cell-based MALDI-TOF lipidomic assay using a routine MALDI Biotyper Sirius system operating in linear negative ion mode combined with the MBT Lipid Xtract kit to discover molecules targeting bacteria that are resistant to polymyxins, which are considered last-resort antibiotics.

Methods

A library of 1200 natural compounds was tested against an E. coli strain expressing mcr-1, which is known to modify lipid A by adding phosphoethanolamine (pETN), making the strain resistant to colistin.

Results and Discussion

Using this approach, we identified 8 compounds that led to a decrease in this lipid A modification by MCR-1 and could potentially be employed to revert resistance. Taken together, as-proof-of-principle, the data we report here represent a new workflow based on the analysis of bacterial lipid A by routine MALDI-TOF for the discovery of inhibitors that could target bacterial viability and/or virulence.

An LC-MS/MS method for the simultaneous determination of 18 antibacterial drugs in human plasma and its application in therapeutic drug monitoring

Antimicrobial resistance (AMR) is a major threat to global health due to the wide use of antibacterial drugs. Multiple studies show that the pharmacokinetic/pharmacodynamic (PK/PD) studies of antibiotics are an approach to prevent/delay AMR. The pharmacokinetic parameters of antibiotics are the basis of PK/PD studies, and therapeutic drug monitoring (TDM) is the key method to obtain pharmacokinetic information. We developed an ultra-performance liquid chromatography–tandem mass spectrometry to determine 18 antibacterial drugs (piperacillin, cefazolin, cefuroxime, cefoperazone, ceftriaxone, cefepime, aztreonam, meropenem, imipenem, levofloxacin, moxifloxacin, azithromycin, clindamycin, tigecycline, linezolid, vancomycin, voriconazole and caspofungin) in human plasma for practical clinical usage. Samples were prepared using protein precipitation with methanol. Chromatographic separation was accomplished in 6 min on a BEH C₁₈ column (2.1 × 100 mm, 1.7 µm) using a gradient elution of acetonitrile and 0.1% formic acid in water at a flow rate of 0.3 ml/min. The electrospray ionization source interface was operated in the positive and negative ionization modes. Inter- and intra-day precision, accuracy, recovery, matrix effect, and stability were validated according to the Food and Drug Administration guidance. The correlation coefficients of calibration curves were all greater than 0.99. The accuracies of the 18 antibacterial drugs ranged from 89.1% to 112.4%. The intra-day precision of the analytes ranged from 1.4% to 9.3% and the inter-day precision from 2.1% to 7.2%. The matrix effects ranged from 93.1% to 105.8% and the extraction recoveries ranged between 90.1% and 109.2%. The stabilities of the 18 antibacterial drugs in plasma were evaluated by analyzing three different concentrations following storage at three storage conditions. All samples displayed variations less than 15.0%. The validated method was successfully applied to routine clinical TDM for 231 samples.

Automated antimicrobial susceptibility testing and antimicrobial resistance genotyping using Illumina and Oxford Nanopore Technologies sequencing data among Enterobacteriaceae

Whole-genome sequencing (WGS) enables the molecular characterization of bacterial pathogens. We compared the accuracy of the Illumina and Oxford Nanopore Technologies (ONT) sequencing platforms for the determination of AMR classes and antimicrobial susceptibility testing (AST) among 181 clinical Enterobacteriaceae isolates. Sequencing reads for each isolate were uploaded to AREScloud (Ares Genetics) to determine the presence of AMR markers and the predicted WGS-AST profile. The profiles of both sequencing platforms were compared to broth microdilution (BMD) AST. Isolates were delineated by resistance to third-generation cephalosporins and carbapenems as well as the presence of AMR markers to determine clinically relevant AMR classes. The overall categorical agreement (CA) was 90% (Illumina) and 88% (ONT) across all antimicrobials, 96% for the prediction of resistance to third-generation cephalosporins for both platforms, and 94% (Illumina) and 91% (ONT) for the prediction of resistance to carbapenems. Carbapenem resistance was overestimated on ONT with a major error of 16%. Sensitivity for the detection of carbapenemases, extended-spectrum β-lactamases, and plasmid-mediated ampC genes was 98, 95, and 70% by ONT compared to the Illumina dataset as the reference. Our results highlight the potential of the ONT platform’s use in clinical microbiology laboratories. When combined with robust bioinformatics methods, WGS-AST predictions may be a future approach to guide effective antimicrobial decision-making.

2D nanomaterial sensing array using machine learning for differential profiling of pathogenic microbial taxonomic identification

An integrated custom cross-response sensing array has been developed combining the algorithm module’s visible machine learning approach for rapid and accurate pathogenic microbial taxonomic identification. The diversified cross-response sensing array consists of two-dimensional nanomaterial (2D-n) with fluorescently labeled single-stranded DNA (ssDNA) as sensing elements to extract a set of differential response profiles for each pathogenic microorganism. By altering the 2D-n and different ssDNA with different sequences, we can form multiple sensing elements. While interacting with microorganisms, the competition between ssDNA and 2D-n leads to the release of ssDNA from 2D-n. The signals are generated from binding force driven by the exfoliation of either ssDNA or 2D-n from the microorganisms. Thus, the signal is distinguished from different ssDNA and 2D-n combinations, differentiating the extracted information and visualizing the recognition process. Fluorescent signals collected from each sensing element at the wavelength around 520 nm are applied to generate a fingerprint. As a proof of concept, we demonstrate that a six-sensing array enables rapid and accurate pathogenic microbial taxonomic identification, including the drug-resistant microorganisms, under a data size of n = 288. We precisely identify microbial with an overall accuracy of 97.9%, which overcomes the big data dependence for identifying recurrent patterns in conventional methods. For each microorganism, the detection concentration is 10⁵ ~ 10⁸ CFU/mL for Escherichia coli, 10² ~ 10⁷ CFU/mL for E. coli-β, 10³ ~ 10⁸ CFU/mL for Staphylococcus aureus, 10³ ~ 10⁷ CFU/mL for MRSA, 10² ~ 10⁸ CFU/mL for Pseudomonas aeruginosa, 10³ ~ 10⁸ CFU/mL for Enterococcus faecalis, 10² ~ 10⁸ CFU/mL for Klebsiella pneumoniae, and 10³ ~ 10⁸ CFU/mL for Candida albicans. Combining the visible machine learning approach, this sensing array provides strategies for precision pathogenic microbial taxonomic identification.

Breaking antimicrobial resistance by disrupting extracytoplasmic protein folding

Antimicrobial resistance in Gram-negative bacteria is one of the greatest threats to global health. New antibacterial strategies are urgently needed, and the development of antibiotic adjuvants that either neutralize resistance proteins or compromise the integrity of the cell envelope is of ever-growing interest. Most available adjuvants are only effective against specific resistance proteins. Here, we demonstrate that disruption of cell envelope protein homeostasis simultaneously compromises several classes of resistance determinants. In particular, we find that impairing DsbA-mediated disulfide bond formation incapacitates diverse β-lactamases and destabilizes mobile colistin resistance enzymes. Furthermore, we show that chemical inhibition of DsbA sensitizes multidrug-resistant clinical isolates to existing antibiotics and that the absence of DsbA, in combination with antibiotic treatment, substantially increases the survival of Galleria mellonella larvae infected with multidrug-resistant Pseudomonas aeruginosa. This work lays the foundation for the development of novel antibiotic adjuvants that function as broad-acting resistance breakers.

Antibiotics, like penicillin, are the foundation of modern medicine, but bacteria are evolving to resist their effects. Some of the most harmful pathogens belong to a group called the 'Gram-negative bacteria', which have an outer layer – called the cell envelope – that acts as a drug barrier. This envelope contains antibiotic resistance proteins that can deactivate or repel antibiotics or even pump them out of the cell once they get in. One way to tackle antibiotic resistance could be to stop these proteins from working.

Proteins are long chains of building blocks called amino acids that fold into specific shapes. In order for a protein to perform its role correctly, it must fold in the right way. In bacteria, a protein called DsbA helps other proteins fold correctly by holding them in place and inserting links called disulfide bonds. It was unclear whether DsbA plays a role in the folding of antibiotic resistance proteins, but if it did, it might open up new ways to treat antibiotic resistant infections.

To find out more, Furniss, Kaderabkova et al. collected the genes that code for several antibiotic resistance proteins and put them into Escherichia coli bacteria, which made the bacteria resistant to antibiotics. Furniss, Kaderabkova et al. then stopped the modified E. coli from making DsbA, which led to the antibiotic resistance proteins becoming unstable and breaking down because they could not fold correctly.

Further experiments showed that blocking DsbA with a chemical inhibitor in other pathogenic species of Gram-negative bacteria made these bacteria more sensitive to antibiotics that they would normally resist. To demonstrate that using this approach could work to stop infections by these bacteria, Furniss, Kaderabkova et al. used Gram-negative bacteria that produced antibiotic resistance proteins but could not make DsbA to infect insect larvae. The larvae were then treated with antibiotics, which increased their survival rate, indicating that blocking DsbA may be a good approach to tackling antibiotic resistant bacteria.

According to the World Health Organization, developing new treatments against Gram-negative bacteria is of critical importance, but the discovery of new drugs has ground to a halt. One way around this is to develop ways to make existing drugs work better. Making drugs that block DsbA could offer a way to treat resistant infections using existing antibiotics in the future.

Rapid Detection of blaKPC, blaNDM, blaOXA-48-like and blaIMP Carbapenemases in Enterobacterales Using Recombinase Polymerase Amplification Combined With Lateral Flow Strip

The emergence of carbapenemase-producing Enterobacterales (CPE) infections is a major global public health threat. Rapid and accurate detection of pathogenic bacteria is essential to optimize treatment and timely avoid further transmission of these bacteria. Here, we aimed to develop a rapid on site visualization detection method for CPE using improved recombinase polymerase amplification (RPA) combined with lateral flow strip (LFS) method, based on four most popular carbapenemase genes: bla_KPC, bla_NDM, bla_OXA-48-like, and bla_IMP. All available allelic variants of the above carbapenemases were downloaded from the β-lactamase database, and the conserved regions were used as targets for RPA assay. Five primer sets were designed targeting to each carbapenemase gene and the RPA amplification products were analyzed by agarose gel electrophoresis. FITC-labeled specific probes were selected, combined with the best performance primer set (Biotin-labeled on the reverse primer), and detected by RPA-LFS. Mismatches were made to exclude the false positive signals interference. This assay was evaluated in 207 clinically validated carbapenem-resistant Enterobacterales (CRE) isolates and made a comparison with conventional PCR. Results showed that the established RPA-LFS assay for CPE could be realized within 30 min at a constant temperature of 37°C and visually detected amplification products without the need for special equipment. This assay could specifically differentiate the four classes of carbapenemases without cross-reactivity and shared a minimum detection limit of 100 fg/reaction (for bla_KPC, bla_NDM, and bla_OXA-48-like) or 1000 fg/reaction (for bla_IMP), which is ten times more sensitive than PCR. Furthermore, the detection of 207 pre-validated clinically CRE strains using the RPA-LFS method resulted in 134 bla_KPC, 69 bla_NDM, 3 bla_OXA-48-like, and 1 bla_IMP. The results of the RPA-LFS assay were in consistent with PCR, indicating that this method shared high sensitivity and specificity. Therefore, the RPA-LFS method for CPE may be a simple, specific, and sensitive method for the rapid diagnosis of carbapenemase Enterobacterales.

Tales of treatment and new perspectives for global health research on antimicrobial resistance

Global health champions modernism and biomedical knowledge but tends to neglect knowledge, beliefs and identities of rural communities in low-income and middle-income countries. The topic of antimicrobial resistance represents these common challenges, wherein the growing emphasis on public engagement offers a yet underdeveloped opportunity to generate perspectives and forms of knowledge that are not typically incorporated into research and policy. The medical humanities as an interdisciplinary approach to illness and health behaviour play a central role in cultivating this potential-in particular, through the field's emphasis on phenomenological and intersubjective approaches to knowledge generation and its interest in dialogue between medicine, the humanities and the broader public.We present a case study of public engagement that incorporates three medical humanities methods: participatory co-production, photographic storytelling and dialogue between researchers and the public. Situated in the context of northern Thailand, we explore subcases on co-production workshops with villagers, tales of treatment shared by traditional healers and dialogue surrounding artistic display in an international photo exhibition. Our starting assumption for the case study analysis was that co-produced local inputs can (and should) broaden the understanding of the sociocultural context of antimicrobial resistance.Our case study illustrates the potential of medical humanities methods in public engagement to foreground cultural knowledge, personal experience and 'lay' sensemaking surrounding health systems and healing (including medicine use). Among others, the engagement activities enabled us to formulate and test locally grounded hypotheses, gain new insights into the social configuration of treatment seeking and reflect on the relationship between traditional healing and modern medicine in the context of antimicrobial resistance. We conclude that medical-humanities-informed forms of public engagement should become a standard component of global health research, but they require extensive evaluation to assess benefits and risks comprehensively.

Patterns of Antimicrobial Use in Hospitalized Children: A Repeated Point Prevalence Survey From Pakistan

Three repeated point prevalence surveys (PPSs) were conducted in pediatric wards of 5 hospitals using the methodology developed by Global-PPS to identify key targets for interventions and antibiotic stewardship programs. Out of the 916 hospitalized patients, 865 (94.6%) were treated with at least 1 antibiotic.

Children against antibiotics misuse and antimicrobial resistance: assessing effectiveness of storytelling and picture drawing as public engagement approaches

Background: Interventions delivered in schools have been found to be effective in improving knowledge of antibiotics and antimicrobial resistance (AMR) among school-aged children, particularly those in high-income countries, but the evidence is largely lacking in low- and middle-income countries. This study aimed to design, implement and assess storytelling in one school and picture drawing in another school as engagement approaches for improving knowledge, attitudes and beliefs about antibiotics and AMR among schoolchildren in Ghana.  Methods: Two schools with a total population of 375 schoolchildren ages 11-15 years in Tema, a city in Ghana, participated in public engagement interventions involving storytelling in one school and picture drawing in another school. The interventions included eight weeks of engagement led by science teachers and a competition held in each school. For quantitative outcome-based evaluation, schoolchildren were randomly sampled in each school (31 in the storytelling school and 32 in the picture-drawing school). Purposive sampling was also used to select 20 schoolchildren in each school for qualitative outcome-based evaluation. Respondents completed identical knowledge, attitudes and beliefs questionnaires and were interviewed at two time points (before and at most a week) after key interventions to assess changes in antibiotics and AMR knowledge, attitudes and beliefs. McNemar test was conducted to assess statistical significance between baseline and endline scores. Framework analysis was used for analysing the qualitative data. Results: Picture drawing had more significant effects (both positive and negative) on schoolchildren's AMR knowledge, attitudes and beliefs, whereas storytelling had a negative effect on children's AMR knowledge and no significant impact on beliefs and attitudes.  Conclusions: Our project's findings suggest that public engagement interventions that use picture drawing and storytelling may influence the knowledge, attitudes and beliefs of schoolchildren regarding antibiotic misuse and AMR. However, modifications are required to make them much more effective.

Preventing Biofilm Formation and Development on Ear, Nose and Throat Medical Devices

Otorhinolaryngology is a vast domain that requires the aid of many resources for optimal performance. The medical devices utilized in this branch share common problems, such as the formation of biofilms. These structured communities of microbes encased in a 3D matrix can develop antimicrobial resistance (AMR), thus making it a problem with challenging solutions. Therefore, it is of concern the introduction in the medical practice involving biomaterials for ear, nose and throat (ENT) devices, such as implants for the trachea (stents), ear (cochlear implants), and voice recovery (voice prosthetics). The surface of these materials must be biocompatible and limit the development of biofilm while still promoting regeneration. In this respect, several surface modification techniques and functionalization procedures can be utilized to facilitate the success of the implants and ensure a long time of use. On this note, this review provides information on the intricate underlying mechanisms of biofilm formation, the large specter of implants and prosthetics that are susceptible to microbial colonization and subsequently related infections. Specifically, the discussion is particularized on biofilm development on ENT devices, ways to reduce it, and recent approaches that have emerged in this field.

Children against antibiotics misuse and antimicrobial resistance: assessing effectiveness of storytelling and picture drawing as public engagement approaches

Background: Interventions delivered in schools have been found to be effective in improving knowledge of antibiotics and antimicrobial resistance (AMR) among school-aged children, particularly those in high-income countries, but the evidence is largely lacking in low- and middle-income countries. This study aimed to design, implement and assess storytelling and picture drawing as engagement approaches for improving knowledge, attitudes and beliefs about antibiotics and AMR among schoolchildren in Ghana. Methods: Two schools with a total population of 375 schoolchildren ages 11-15 years in Tema, a city in Ghana, participated in public engagement interventions involving storytelling in one school and picture drawing in another school. The interventions included eight weeks of engagement led by science teachers and a competition held in each school. For quantitative outcome-based evaluation, some schoolchildren were randomly sampled in each school. Purposive sampling was also used to select some schoolchildren in each school for qualitative outcome-based evaluation. Respondents completed identical knowledge, attitudes and beliefs questionnaires and were interviewed at two time points (before and at most a week) after key interventions to assess changes in antibiotics and AMR knowledge, attitudes and beliefs. Results: Picture drawing had more significant effects (both positive and negative) on schoolchildren's AMR knowledge, attitudes and beliefs, whereas storytelling had a negative effect on children's AMR knowledge and no significant impact on beliefs and attitudes. Conclusions: Our project's findings suggest that public engagement interventions that use picture drawing and storytelling may influence the knowledge, attitudes and beliefs of schoolchildren regarding antibiotic misuse and AMR. However, modifications are required to make them more effective. These include making the storytelling effective by turning it into drama or plays.

Culture-Free Detection of Antibiotic Resistance Markers from Native Patient Samples by Hybridization Capture Sequencing

The increasing incidence of antimicrobial resistance (AMR) is a major global challenge. Routine techniques for molecular AMR marker detection are largely based on low-plex PCR and detect dozens to hundreds of AMR markers. To allow for comprehensive and sensitive profiling of AMR markers, we developed a capture-based next generation sequencing (NGS) workflow featuring a novel AMR marker panel based on the curated AMR database ARESdb. Our primary objective was to compare the sensitivity of target enrichment-based AMR marker detection to metagenomics sequencing. Therefore, we determined the limit of detection (LOD) in synovial fluid and urine samples across four key pathogens. We further demonstrated proof-of-concept for AMR marker profiling from septic samples using a selection of urine samples with confirmed monoinfection. The results showed that the capture-based workflow is more sensitive and requires lower sequencing depth compared with metagenomics sequencing, allowing for comprehensive AMR marker detection with an LOD of 1000 CFU/mL. Combining the ARESdb AMR panel with 16S rRNA gene sequencing allowed for the culture-free detection of bacterial taxa and AMR markers directly from septic patient samples at an average sensitivity of 99%. Summarizing, the newly developed ARESdb AMR panel may serve as a valuable tool for comprehensive and sensitive AMR marker detection.

Attention to the Tripartite's one health measures in national action plans on antimicrobial resistance

The WHO, FAO, and OIE (the Tripartite) promote One Health (OH) as the guiding frame for national responses to antimicrobial resistance (AMR). Little is known, however, about how much national action plans (NAPs) on AMR actually rely on the OH measures outlined by the Tripartite. The paper investigates attention to OH through a systematic content analysis of 77 AMR NAPs to discern regional and income patterns in the integration of these OH measures. Our findings suggest that (1) AMR NAPs almost universally address the three key sectors of OH, namely, human, animal, and environmental health; (2) AMR NAPs primarily apply OH measures in policies related to human health care, food production, hygiene, and agriculture, whereas the level of attention to OH measures in sanitation, aquaculture, waste management, and water governance is generally low and mainly present in NAPs from low-income countries; (3) AMR NAPs of low-income and lower-middle-income countries' display greater congruence with OH measures than NAPs from upper-middle-income and high-income countries; and (4) the level of OH attention on paper appears to matter little for the extent of multisectoral collaboration in practice.

Towards Solving Health Inequities: A Method to Identify Ideological Operation in Global Health Programs

The function of ideology is to naturalize and maintain unequal relations of power. Making visible how ideology operates is necessary for solving health inequities grounded in inequities of resources and power. However, discerning ideology is difficult because it operates implicitly. It is not necessarily explicit in one’s stated aims or beliefs. Philosopher Slavoj Žižek conceptualizes ideology as a belief in overarching unity or harmony that obfuscates immanent tension within a system. Drawing from Žižek’s conceptualization of ideology, we identify what may be considered as ‘symptoms’ of ideological practice: (1) the recurrent nature of a problem, and (2) the implicit externalization of the cause. Our aim is to illustrate a method to identify ideological operation in health programs on the basis of its symptoms, using three case studies of persistent global health problems: inequitable access to vaccines, antimicrobial resistance, and health inequities across racialized communities. Our proposed approach for identifying ideology allows one to identify ideological practices that could not be identified by particular ideological contents. It also safeguards us from an illusory search for an emancipatory content. Critiquing ideology in general reveals possibilities that are otherwise kept invisible and unimaginable, and may help us solve recalcitrant problems such as health inequities.

The Effectiveness of an Educational Intervention on Knowledge, Attitudes and Reported Practices on Antibiotic Use in Humans and Pigs: A Quasi-Experimental Study in Twelve Villages in Shandong Province, China

Our aim was to evaluate the effectiveness of an intervention for residents in rural China on knowledge, attitudes and reported practices (KAP) on antibiotic use in humans and pigs. A quasi-experimental study was conducted in 12 villages in rural Shandong province, divided into intervention and control groups, covering a two-year period from July 2015 to June 2017. A package of health education-based interventions including training sessions, speakerphone messages, posters and handbooks for residents was developed and implemented over a one-year period to improve the use of antibiotics in humans and pigs. The intervention net effects were evaluated by Difference-in-Difference (DID) analysis based on responses to a questionnaire concerning KAP towards antibiotic use in humans and pigs. A total of 629 participants completed both baseline and post-trial questionnaires, including 127 participants with backyard pig farms. Significant improvements were found in KAP towards antibiotic use in humans, but changes related to antibiotic use for pigs were not significant. Participants who were in the intervention group (p < 0.001) were more likely to have improved their knowledge on antibiotic use in humans. Participants who had higher attitude scores were less likely to report self-medicating with stored antibiotics in the previous year (p < 0.001). Our results suggest that our health education-based intervention was effective in improving KAP on human antibiotic use, but it had little effect regarding antibiotic use for pigs.

[The problem of medical overuse : Finding a definition and solutions]

High-quality medical care including the concepts of "patient-centered medicine" and "precision medicine" imply medical awareness of measures that are "too much" and thus not appropriate for certain patients in a certain context. Physicians occupy a central role as stewards of limited social resources. Numerous influencing factors can cause a cascading into medical overuse. How to identify and avoid overuse? When is "less medicine" the better medicine for an individual patient?

Identification of Plant Soot as Novel Safe Feed Additive: Evaluation of 90-Day Oral Toxicity and Prenatal Developmental Toxicity in Rats

Plant soot, as a novel feed additive, could not only improve digestive function but also adsorb mycotoxins and inhibit bacterial infections. The subchronic toxicity and prenatal developmental effects of plant soot were studied for the first time. Our results indicated that there was no subchronic toxicity in the range of 2,000–50,000 mg/kg plant soot added in the feed, and there was no significant difference in reproductive function, embryo development, and teratogenicity between the pregnant rats exposed to 312.5, 1,250, and 5,000 mg/kg plant soot and the control group. The maximum no-observed effect level (NOEL) of supplemental dosage in feed could be set to 50,000 mg/kg, and the maximum intragastric NOEL could be set to 5,000 mg/kg, which preliminarily provided guidance on daily additive amount or clinical protocols for plant soot, as well as promoting the development and application of this harmless antibiotic substitutes.

Deep Learning Analysis of Vibrational Spectra of Bacterial Lysate for Rapid Antimicrobial Susceptibility Testing

Rapid antimicrobial susceptibility testing (AST) is an integral tool to mitigate the unnecessary use of powerful and broad-spectrum antibiotics that leads to the proliferation of multi-drug-resistant bacteria. Using a sensor platform composed of surface-enhanced Raman scattering (SERS) sensors with control of nanogap chemistry and machine learning algorithms for analysis of complex spectral data, bacteria metabolic profiles post antibiotic exposure are correlated with susceptibility. Deep neural network models are able to discriminate the responses of Escherichia coli and Pseudomonas aeruginosa to antibiotics from untreated cells in SERS data in 10 min after antibiotic exposure with greater than 99% accuracy. Deep learning analysis is also able to differentiate responses from untreated cells with antibiotic dosages up to 10-fold lower than the minimum inhibitory concentration observed in conventional growth assays. In addition, analysis of SERS data using a generative model, a variational autoencoder, identifies spectral features in the P. aeruginosa lysate data associated with antibiotic efficacy. From this insight, a combinatorial dataset of metabolites is selected to extend the latent space of the variational autoencoder. This culture-free dataset dramatically improves classification accuracy to select effective antibiotic treatment in 30 min. Unsupervised Bayesian Gaussian mixture analysis achieves 99.3% accuracy in discriminating between susceptible versus resistant to antibiotic cultures in SERS using the extended latent space. Discriminative and generative models rapidly provide high classification accuracy with small sets of labeled data, which enormously reduces the amount of time needed to validate phenotypic AST with conventional growth assays. Thus, this work outlines a promising approach toward practical rapid AST.

The global governance of antimicrobial resistance: a cross-country study of alignment between the global action plan and national action plans

BACKGROUND

Antimicrobial resistance (AMR) is a growing problem worldwide in need of global coordinated action. With the endorsement of the Global Action Plan (GAP) on AMR in 2015, the 194 member states of the World Health Organization committed to integrating the five objectives and corresponding actions of the GAP into national action plans (NAPs) on AMR. The article analyzes patterns of alignment between existing NAPs and the GAP, bringing to the fore new methodologies for exploring the relationship between globally driven health policies and activities at the national level, taking income, geography and governance factors into account.

METHODS

The article investigates the global governance of AMR. Concretely, two proxies are devised to measure vertical and horizontal alignment between the GAP and existing NAPs: (i) a syntactic indicator measuring the degree of verbatim overlap between the GAP and the NAPs; and (ii) a content indicator measuring the extent to which the objectives and corresponding actions outlined in the GAP are addressed in the NAPs. Vertical alignment is measured by the extent to which each NAP overlaps with the GAP. Horizontal alignment is explored by measuring the degree to which NAPs overlap with other NAPs across regions and income groups. In addition, NAP implementation is explored using the Global Database for Antimicrobial Resistance Country Self-Assessment.

FINDINGS

We find strong evidence of vertical alignment, particularly among low-income countries and lower-middle-income countries but weaker evidence of horizontal alignment within regions. In general, we find the NAPs in our sample to be mostly aligned with the GAP's five overarching objectives while only moderately aligned with the recommended corresponding actions. Furthermore, we see several cases of what can be termed 'isomorphic mimicry', characterized by strong alignment in the policies outlined but much lower levels of alignment in terms of actual implemented policies.

CONCLUSION

To strengthen the alignment of national AMR policies, we recommend global governance initiatives based on individualized responsibilities some of which should be legally binding. Our study provides limited evidence of horizontal alignment within regions, which implies that regional governance institutions (e.g., WHO regional offices) should primarily act as mediators between global and local demands to strengthen a global governance regime that minimizes policy fragmentation and mimicry behavior across member states.

Contribution of biofilm formation genetic locus, pgaABCD, to antibiotic resistance development in gut microbiome

The human gut microbiome is the presumed site in which the emergence and evolution of antibiotic-resistant organisms constantly take place. To delineate the genetic basis of resistance formation in gut microbiome strains, we investigated the changes in the subpopulation structure of Escherichia coli in rat intestine before and after antimicrobial treatment. We observed that antibiotic treatment was selected for an originally minor subpopulation E. coli carrying the biofilm-forming genetic locus pgaABCD and the toxin-antitoxin system HipAB. Such strains possessed dramatically enhanced ability to withstand the detrimental effects of antibiotics, becoming a dominant subspecies upon antibiotic treatment and eventually evolving into resistant mutants. In contrast, E. coli strains that did not carry pgaABCD and HipAB were eradicated upon antibiotic treatment. Our findings, therefore, suggested that genes encoding biofilm-forming ability played an important role in conferring specific gut E. coli strains the ability to evolve into resistant strains upon a prolonged antibiotic treatment, and that such strains may therefore be considered bacterial antibiotic resistance progenitor cells in the gut microbiome.

Governing antimicrobial resistance: a narrative review of global governance mechanisms

Antimicrobial resistance (AMR), a central health challenge of the twenty first century, poses substantial population health risks, with deaths currently estimated to be around 700,000 per year globally. The international community has signaled its commitment to exploring and implementing effective policy responses to AMR, with a Global Action Plan on AMR approved by the World Health Assembly in 2015. Major governance challenges could thwart collective efforts to address AMR, along with limited knowledge about how to design effective global governance mechanisms. To identify common ground for more coordinated global actions we conducted a narrative review to map dominant ideas and academic debates about AMR governance. We found two categories of global governance mechanisms: binding and non-binding and discuss advantages and drawbacks of each. We suggest that a combination of non-binding and binding governance mechanisms supported by leading antimicrobial use countries and important AMR stakeholders, and informed by One Health principles, may be best suited to tackle AMR.

Synthesis, insecticidal activity, resistance, photodegradation and toxicity of pyrethroids (A review)

Pyrethroids are a class of highly effective, broad-spectrum, less toxic, biodegradable synthetic pesticides. However, despite the extremely wide application of pyrethroids, there are many problems, such as insecticide resistance, lethal/sub-lethal toxicity to mammals, aquatic organisms or other beneficial organisms. The objectives of this review were to cover the main structures, synthesis, steroisomers, mechanisms of action, anti-mosquito activities, resistance, photodegradation and toxicities of pyrethroids. That was to provide a reference for synthesizing or screening novel pyrethroids with low insecticide resistance and low toxicity to beneficial organisms, evaluating the environmental pollution of pyrethroids and its metabolites. Besides, pyrethroids are mainly used for the control of vectors such as insects, and the non-target organisms are mammals, aquatic organisms etc. While maintaining the insecticidal activity is important, its toxic effects on non-target organisms should be also considered. Pyrethroid resistance is present not only in insect mosquitoes but also in environmental microorganisms, which results in anti-pyrethroids resistance (APR) strains. Besides, photodegradation product dibenzofurans is harmful to mammals and environment. Additionally, pyrethroid metabolites may have higher hormonal interference than the parents. Particularly, delivery of pyrethroids in nanoform can reduce the discharge of more toxic substances (such as organic solvents, etc.) to the environment.

Setting the standard: multidisciplinary hallmarks for structural, equitable and tracked antibiotic policy

There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an 'implementation gap'. At a policy level, the design of internationally salient solutions that are able to address AMR's interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise 'good' antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scales.

Strengthening the science of addressing antimicrobial resistance: a framework for planning, conducting and disseminating antimicrobial resistance intervention research

Antimicrobial resistance (AMR) has the potential to threaten tens of millions of lives and poses major global economic and development challenges. As the AMR threat grows, it is increasingly important to strengthen the scientific evidence base on AMR policy interventions, to learn from existing policies and programmes, and to integrate scientific evidence into the global AMR response.While rigorous evaluations of AMR policy interventions are the ideal, they are far from the current reality. To strengthen this evidence base, we describe a framework for planning, conducting and disseminating research on AMR policy interventions. The framework identifies challenges in AMR research, areas for enhanced coordination and cooperation with decision-makers, and best practices in the design of impact evaluations for AMR policies.This framework offers a path forward, enabling increased local and global cooperation, and overcoming common limitations in existing research on AMR policy interventions.

Governing the Global Antimicrobial Commons: Introduction to Special Issue

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons-the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches-one long-term and one short-term-for managing the antimicrobial commons. The first article explores the lessons for antimicrobial resistance that can be learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term.

Multidrug-resistant bacteria in ICU: fact or myth

PURPOSE OF REVIEW

Antimicrobial resistance (AMR) is increasing in ICUs around the world, but the prevalence is variable. We will review recent literature and try to answer the question whether this is a myth or a new reality, as well as discuss challenges and potential solutions.

RECENT FINDINGS

AMR is diverse, and currently Gram-negative multidrug-resistant organisms (MDROs) are the main challenge in ICUs worldwide. Geographical variation in prevalence of MDROs is substantial, and local epidemiology should be considered to assess the current threat of AMR. ICU patients are at a high risk of infection with MDRO because often multiple risk factors are present. Solutions should focus on reducing the risk of cross-transmission in the ICU through strict infection prevention and control practices and reducing exposure to antimicrobials as the major contributor to the development of AMR.

SUMMARY

AMR is a reality in most ICUs around the world, but the extent of the problem is clearly highly variable. Infection prevention and control as well as appropriate antimicrobial use are the cornerstones to turn the tide.

Preventing postpartum uterine disease in dairy cattle depends on avoiding, tolerating and resisting pathogenic bacteria

Up to forty percent of dairy cows develop metritis or endometritis when pathogenic bacteria infect the uterus after parturition. However, resilient cows remain healthy even when exposed to the same pathogens. Here, we provide a perspective on the mechanisms that dairy cows use to prevent postpartum uterine disease. We suggest that resilient cows prevent the development of uterine disease using the three complementary defensive strategies of avoiding, tolerating and resisting infection with pathogenic bacteria. Avoidance maintains health by limiting the exposure to pathogens. Avoidance mechanisms include intrinsic behaviors to reduce the risk of infection by avoiding pathogens or infected animals, perhaps signaled by the fetid odor of uterine disease. Tolerance improves health by limiting the tissue damage caused by the pathogens. Tolerance mechanisms include neutralizing bacterial toxins, protecting cells against damage, enhancing tissue repair, and reprogramming metabolism. Resistance improves health by limiting the pathogen burden. Resistance mechanisms include inflammation driven by innate immunity and adaptive immunity, with the aim of killing and eliminating pathogenic bacteria. Farmers can also help cows prevent the development of postpartum uterine disease by avoiding trauma to the genital tract, reducing stress, and feeding animals appropriately during the transition period. Understanding the mechanisms of avoidance, tolerance and resistance to pathogens will inform strategies to generate resilient animals and prevent uterine disease.

Introduction to Antimicrobial Resistance and the Maternal Sepsis Intervention

This chapter describes the threat to global health and security caused by the growing resistance of infectious organisms to antibiotics or antimicrobial resistance (AMR). Growing global connectivity ensures that AMR is a threat to us all wherever we are and with specific impacts on Low- and Middle-Income Countries (LMICs). The chapter outlines international responses to AMR including the Global Action Plan and the impact this has had on one LMIC; Uganda. It then introduces a recent UK funding call focused on improving the management of antibiotics or ‘Antimicrobial Stewardship’.

Detection of Colistin Resistance in Escherichia coli by Use of the MALDI Biotyper Sirius Mass Spectrometry System

Polymyxin antibiotics are a last-line treatment for multidrug-resistant Gram-negative bacteria. However, the emergence of colistin resistance, including the spread of mobile mcr genes, necessitates the development of improved diagnostics for the detection of colistin-resistant organisms in hospital settings. The recently developed MALDIxin test enables detection of colistin resistance by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) in less than 15 min but is not optimized for the mass spectrometers commonly found in clinical microbiology laboratories. In this study, we adapted the MALDIxin test for the MALDI Biotyper Sirius MALDI-TOF MS system (Bruker Daltonics). We optimized the sample preparation protocol by using a set of 6 mobile colistin resistance (MCR) protein-expressing Escherichia coli clones and validated the assay with a collection of 40 E. coli clinical isolates, including 19 confirmed MCR protein producers, 12 colistin-resistant isolates that tested negative for commonly encountered mcr genes (i.e., likely chromosomally resistant isolates), and 9 polymyxin-susceptible isolates. We calculated polymyxin resistance ratio (PRR) values from the acquired spectra; PRR values of 0, indicating polymyxin susceptibility, were obtained for all colistin-susceptible E. coli isolates, whereas positive PRR values, indicating resistance to polymyxins, were obtained for all resistant strains, independent of the genetic basis of resistance. Thus, we report a preliminary feasibility study showing that an optimized version of the MALDIxin test adapted for the routine MALDI Biotyper Sirius system provides an unbiased, fast, reliable, cost-effective, and high-throughput way of detecting colistin resistance in clinical E. coli isolates.

Synergistic Chemical and Photodynamic Antimicrobial Therapy for Enhanced Wound Healing Mediated by Multifunctional Light-Responsive Nanoparticles

Recently, rapid acquisition of antibiotic resistance, increased prevalence of antibiotic-resistant bacterial infections, and slow healing of infected wound have led to vast difficulties in developing innovative antimicrobial agents to obliterate pathogenic bacteria and simultaneously accelerate wound healing. To effectively solve this problem, we designed light-responsive multifunctional nanoparticles with conjugation of quaternary ammonium chitosan and photosensitizer chlorin e6 (Ce6) to merge chemical and photodynamic therapy to efficient antibacteria. The Mg/(-)-epigallocatechin-3-gallate (EGCG) complex rapidly responded to light irradiation under 660 nm with release of magnesium ions, which effectively accelerated wound healing without toxicity to mammalian cells. Notably, positively charged nanoparticles could efficiently adhere to the bacterial surface, and reactive oxygen species (ROS) produced under laser irradiation destroyed the membrane structure of the bacteria, which is irreversible, ultimately leading to bacteria death. Thus, multifunctional nanoparticles with a combination of chemical and photodynamic antimicrobial therapy would offer guidance to rational predicted and designed new effective antimicrobial nanomaterials. Most importantly, it may represent a promising class of antimicrobial strategy for potential clinical translation.

'LMICs as reservoirs of AMR': a comparative analysis of policy discourse on antimicrobial resistance with reference to Pakistan

Antimicrobial resistance (AMR) has recently emerged as a salient global issue, and policy formulation to address AMR has become a contested space, with various actors sharing competing-and sometimes contradictory-explanations of the problem and the range of possible solutions. To facilitate national policy setting and implementation around AMR, more needs to be done to effectively engage policymakers in low- and middle-income countries (LMICs). However, there is a dearth of research on differences in issue framing by external agencies and LMIC's national policymakers on the problem of AMR; such analyses are imperative to identify areas of conflict and/or potential convergence. We compared representations of AMR across nine policy documents produced by multilateral agencies, donor countries and an LMIC at the forefront of the global response to AMR-Pakistan. We analysed the texts in relation to five narratives that have been commonly used to frame health issues as requiring action: economic impact, stunting of human development, consequences for health equity, health security threats and relationship with food production. We found that AMR was most frequently framed as a threat to human health security and economic progress, with several US, UK and international documents depicting LMICs as 'hotspots' for AMR. Human development and equity dimensions of the problem were less frequently discussed as reasons to address the growing burden of AMR. It is clear that no single coherent narrative on AMR has emerged, with notable differences in framing in Pakistani and external agency led documents, as well as across stakeholders primarily working on human vs animal health. While framing AMR as a threat to economic growth and human security has achieved high-level political attention and catalysed action from governments in high-income countries, our analysis suggests that conflicting narratives relevant to policymakers in Pakistan may affect policy-making and impede the development and implementation of integrated initiatives needed to tackle AMR.

The state of social science research on antimicrobial resistance

This paper investigates the genealogy of social science research into antimicrobial resistance (AMR) by piecing together the bibliometric characteristics of this branch of research. Drawing on the Web of Science as the primary database, the analysis shows that while academic interest in AMR has increased substantially over the last few years, social science research continues to constitute a negligible share of total academic contributions. More in-depth network analysis of citations and bibliometric couplings suggests how the impact of social science research on the scientific discourse on AMR is both peripheral and spread thin. We conclude that this limited social science engagement is puzzling considering the clear academic and practical demand and the many existing interdisciplinary outlets.

A framework for improved one health governance and policy making for antimicrobial use

There is a need to develop an evaluation framework to identify intervention priorities to reduce antimicrobial use (AMU) across clinical, agricultural and environmental settings. Antimicrobial resistance (AMR) can be conceptualised and therefore potentially managed in the same way as an environmental pollution problem. That is, over-use of antimicrobial medicines as inputs to human and animal health leads to unintended leakage of resistance genes that further combine with natural or intrinsic resistance in the environment. The diffuse nature of this leakage means that the private use decision is typically neither cognisant, nor made responsible for the wider social cost, which is the depletion of wider antibiotic effectiveness, a common pool resource or public good. To address this so-called market failure, some authors have suggested a potential to learn from similar management challenges encountered in the sphere of global climate change, specifically, capping use of medically important drugs analogous to limits set on greenhouse gas emissions. Drawing on experience of the economics of greenhouse gas mitigation, this paper explores a potential framework to develop AMU budgets based on a systematic comparative appraisal of the technical, economic, behavioural and policy feasibility of AMU reduction interventions across the One Health domains. The suggested framework responds to a call for global efforts to develop multi-dimensional metrics and a transparent focus to motivate research and policy, and ultimately to inform national and global AMR governance.

The glocalization of antimicrobial stewardship

This brief commentary argues that glocal governance introduces a fruitful new perspective to the global governance debate of AMR, and cautions against too strict a focus on establishing globally binding governance regimes for curbing AMR.