Antimicrobial resistance in invasive strains of Escherichia coli from southern and eastern Mediterranean laboratories

Antimicrobial Resistance: Stewardship and One Health in the Eastern Mediterranean Region

Antimicrobial resistance (AMR) is a major threat in the Eastern Mediterranean region (EMR) due to factors such as the high prevalence of infectious diseases, weak health systems, and the misuse of antimicrobials. This paper aims to discuss how interdisciplinary action and collaboration, specifically through antimicrobial stewardship (AMS) and the One Health approach, can effectively address AMR in the EMR. The review focuses on successful AMS initiatives and the adoption of the One Health approach in countries within the EMR, including the Gulf Cooperation Countries (GCC), Egypt, Iran, Jordan, and Pakistan. The goal is to highlight the potential for progress in combating AMR and identify challenges and opportunities for strengthening interdisciplinary collaboration. The results showcase successful AMS programs and One Health initiatives in various EMR countries, demonstrating their potential to address AMR challenges. The paper also discusses the challenges faced by these nations, such as limited resources, fragmented health systems, and knowledge gaps. Additionally, opportunities for enhancing interdisciplinary action through regional cooperation, international partnerships, and research and innovation are outlined. In conclusion, this paper emphasizes the importance of a comprehensive and collaborative response to combat AMR in the EMR. It advocates for the One Health approach as a crucial framework to guide these efforts, promoting coordinated action, improved surveillance, responsible antimicrobial use, and enhanced interdisciplinary collaboration to effectively mitigate the threat of AMR.

Roles of host SUMOylation in bacterial pathogenesis

Bacteria frequently interfere with the post-translational modifications of host cells to facilitate their survival and growth after invasion. SUMOylation, a reversible post-translational modification process, plays an important role in biological life activities. In addition to being critical to host cell metabolism and survival, SUMOylation also regulates gene expression and cell signal transmission. Moreover, SUMOylation in eukaryotic cells can be used by a variety of bacterial pathogens to advance bacterial invasion. In this minireview, we focused on the role and mechanism of host SUMOylation in the pathogenesis of six important clinical bacterial pathogens (Listeria monocytogenes, Shigella flexneri, Salmonella Typhimurium, Klebsiella pneumoniae, Staphylococcus aureus, and Escherichia coli). Taken together, this review provided new insights for understanding the unique pathogen-host interaction based on host SUMOylation and provided a novel perspective on the development of new strategies to combat bacterial infections in the future.

Cefixime and cefixime-clavulanate for screening and confirmation of extended-spectrum beta-lactamases in Escherichia coli

Introduction

Detection of Extended-Spectrum Beta-Lactamases (ESBLs) depends on screening for resistance to certain cephalosporins, confirmation with selective ESBL inhibitors, and ESBL genes detection. New tests are required for accurate ESBL detection.

Aims

To test the ability of cefixime (CFM) and cefixime-amoxicillin/clavulanate (CFM-AMC) as a screening and confirmatory test for ESBL identification.

Methods

246 clinical isolates of Escherichia coli were tested by an ESBL screening test, a double-disk synergy test (DDST), a disk replacement test, the Vitek 2 ESBL test, and an ESBL genes test by PCR. CFM ESBL Screening was performed by disk diffusion, while CFM-AMC confirmation was performed by DDST and a disk replacement test.

Results

246 E. coli clinical isolates from two referral hospitals were collected over 2 years. The mean age ± standard deviation of patients was 43.8 ± 27.7 years and 76.8% were females. Resistance rates to penicillins, first, second, and third generation cephalosporins, and monobactams were very high at 97%, 84%, 100% and 97%, respectively. ESBL screening was positive in 81.3% of isolates, DDST was positive in 74.8%, disk replacement was positive in 79%, Vitek 2 ESBL test was positive in 67.3%, and ESBL genes were detected in 85.8% of isolates (CTX-M 75%, TEM 42.5%, SHV 4.6%). Compared to genotyping, screening with CFM achieved 87.7% sensitivity and 64.7% specificity. CFM-AMC DDST achieved 75.8% sensitivity and 75.4% specificity, and CFM-AMC disk replacement had 73% sensitivity and 70% specificity.

Conclusions

High prevalence of ESBLs was noted among E. coli isolates, dominated by CTX-M genotype. ESBL screening and confirmation using CFM and CFM-AMC is a new and accurate method for ESBLs detection.

Comparative in vitro activity of plazomicin and older aminoglyosides against Enterobacterales isolates; prevalence of aminoglycoside modifying enzymes and 16S rRNA methyltransferases

Comparative in vitro activity of plazomicin and 4 older aminoglycosides was evaluated with broth microdilution in 714 blood isolates from 14 hospitals in Turkey. Isolates included Escherichia coli (n=320), Klebsiella spp. (n=294), Enterobacter spp. (n=69), Serratia marcescens (n=20), and Citrobacter spp. (n=11). Isolates resistant to older aminoglycosides (n=240) were screened for aminoglycoside modifying enzyme genes: aac(6')-Ib, aac(3)-Ia, aac(3)-IIa, ant(2″)-Ia. Isolates with high MICs for plazomicin (n=41) were screened for 16S rRNA methyltransferase genes (armA, rmtA, rmtB, rmtC, rmtD, rmtE, rmtF, rmtG, rmtH, npmA) and 2 carbapenemase genes (blaOXA-48, blaNDM-1). Overall, resistance to plazomicin, amikacin, netilmicin, gentamicin, and tobramycin was 7.7%, 7.4%, 31.5%, 32.9%, and 34.7%, respectively. aac(6')-Ib and aac(3)-IIa were the most common AME genes. Co-occurrence of blaNDM-1 with armA and rmtC and blaOXA-48 with armA was striking. Enterobacter cloacae carrying rmtC+blaNDM-1, S. marcescens with armA+blaOXA-48, and rmtF+ blaOXA-48 in K. pneumoniae were reported for the first time.

Effective Oral Combination Treatment for Extended-Spectrum Beta-Lactamase-Producing Escherichia coli

Background: Extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) is increasing worldwide. The drugs of choice for treatment of ESBLs are parenteral carbapenems. The aim of this study was to evaluate the in vitro and in vivo efficacy of a new combination of oral cephalosporins and amoxicillin/clavulanate in treatment of ESBL-EC. Methods: A total of 150 ESBL-EC samples were collected over 1 year from two referral centers. Synergistic studies of cephalosporins and amoxicillin/clavulanate were performed in vitro using disk approximation and disk replacement methods. Combination treatment was assessed in vivo on 20 ESBL-EC urinary tract infection (UTI) patients. Results: ESBL-EC isolates were confirmed in 150 patients with a mean age of 46.67 years, 75.2% of them being women. Antibiotic susceptibility testing of isolates indicated high resistance rate to oral antibiotics. The frequency of positive synergy and mean distance of synergy between cephalosporins and amoxicillin/clavulanate was significantly higher with cefotaxime and cefixime compared with cefpodoxime, cefdinir, and ceftazidime using disk approximation and disk replacement methods (p < 0.05). Addition of amoxicillin/clavulanate enhanced the susceptibility rate with cefixime from 8.6% to 86.3%, significantly higher than with other cephalosporins (p < 0.0005). Cefixime and amoxicillin/clavulanate synergy was not affected by age, gender, hospital, department, sample type, or bacterial load. Eighteen of 20 ESBL-EC-positive UTI patients had a positive in vitro synergy test and complete clinical and microbiological resolution after completion of cefixime and amoxicillin/clavulanate oral treatment course. Conclusions: Cefixime and amoxicillin/clavulanate combination therapy could be an effective oral outpatient treatment option for ESBL-EC. In vitro synergistic testing is simple and predictive of successful treatment.

Surveillance and Control of Antibiotic Resistance in the Mediterranean Region

Antibiotic resistance is one of the most relevant problems in the healthcare: the growth of resistant microorganisms in healthcare settings is a worrisome threat, raising length to stay (LOS), morbidity and mortality in those patients. The importance of the antibiotic resistance and its spread around the world, gave rise to the activation of several surveillance systems, based especially on the collection of laboratory data to local or national level. The objective of this work is to carry out a review of the scientific literature existing on the topic and scientific activities related to surveillance of antibiotic resistance in the countries bordering the Mediterranean Sea. Recent Data from European Centre for Disease Prevention and Control (November 2015) show, for different combinations bacterium-drug, an increase of resistance from North to South and from West to East of Europe. It is of particular concern the phenomenon of resistance carried out by some gram-negative, specifically Klebsiella pneumoniae and Escherichia coli to third-generation cephalosporin, often combined in opposition to fluoroquinolones and aminoglycosides. Is particularly high the incidence of resistance to carbapenems by strains of Enterobacteriaceae (Klebsiella included). The resistance exerted by MRSA (Methicillin-resistant Staphylococcus aureus) continues to be relevant, albeit showing some decline in recent years. The incidence of resistance carried on by Streptococcus pneumoniae is stable and is mainly relevant to macrolides. Finally, a significant increase in recording relatively exercised by Enterococcus faecium to Vancomycin. Detecting, preventing, and controlling antibiotic resistance requires strategic, coordinated, and sustained efforts. It also depends on the engagement of governments, academia, industry, healthcare providers, the general public, and the agricultural community, as well as international partners. Committing to combating antibiotic-resistant microbes does support patient care, economic growth, agriculture, and economic and national security.

Resistance of Gram-Negative Bacilli in Lebanon

Several studies have reported the isolation of resistant Gram-Negative Bacilli in Lebanon. However, those studies are new and scarce as compared to worldwide data and mostly restricted to single center studies. In this review, we attempt to provide a reliable and comprehensive report describing the current situation and providing prospects for bacterial resistance in Lebanon. Several studies have shown that Extended Spectrum β-Lactamase-producing E. coli and K. pneumoniae strains are being increasingly reported. Moreover, 2.15% of E. coli and 7.84% of K. pneumoniae isolates have shown carbapenem resistance and up to 30% of isolated E. coli strains were found to be Multi-Drug Resistant. Molecular studies showed that the most widespread β-Lactamases in Lebanon are of the CTX-M-15 and SHV types. In addition, K. pneumoniae strains producing metallo-β-Lactamase and Klebsiella pneumoniae Carbapenemase have been reported. Resistant Pseudomonas aeruginosa and Acinetobacter baumannii caused several nosocomial infections and some Acinetobacter baumannii strains were found to produce OXA-58 type ESBL. The few data addressing the rate of antibiotic consumption in Lebanon show a high rate of antibiotic misuse and abuse. In conclusion, there is a need for antibiotic stewardship programs and additional studies that go beyond the scope of single-center studies in Lebanon.

What's New in the Management of Bacterial Septic Arthritis?

Septic arthritis is a common rheumatological emergency requiring prompt diagnosis and treatment, since delays in management can lead to high morbidity and mortality. In this review article, we discuss the epidemiology and recent advances in knowledge of the pathogenesis of septic arthritis, with a special emphasis on various bacterial and host factors involved in mediating the inflammatory process and the potential for targeted therapy to modulate the immune response. Recent advances in laboratory and imaging techniques are reviewed along with treatment and potential new therapies.

Descriptive study on parents' knowledge, attitudes and practices on antibiotic use and misuse in children with upper respiratory tract infections in Cyprus

Upper respiratory tract infections (URTIs) are common in children and represent a significant cause of antibiotic abuse which contributes to the development of antibiotic resistance. A survey was conducted in Cyprus in 2006 to assess parents’ and pediatricians’ Knowledge, Attitude and Practices (KAP) concerning the role of antibiotics in children with URTIs. A school-based stratified geographic clustering sampling was used and a pre-tested KAP questionnaire was distributed. A different questionnaire was distributed to paediatricians. Demographic factors associated with antibiotic misuse were identified by backward logistic regression analysis. The parental overall response rate was 69.3%. Parents (N = 1,462) follow pediatricians advice and rarely administer antibiotics acquired over the counter. Although a third expects an antibiotic prescription for URTI symptoms, most deny pressuring their doctors. Low parental education was the most important independent risk factor positively related to antibiotic misuse (OR = 2.88, 95%CI 2.02 to 4.12, p < 0.001). Pediatricians (N = 33) denied prescribing antibiotics after parental pressure but admit that parents ask for antibiotics and believe they expect antibiotic prescriptions even when not needed. In conclusion, Cypriotic parents trust their primary care providers. Although it appears that antibiotic misuse is not driven by parental pressure, the pediatricians’ view differs.

Co-infection of Influenza B and Streptococci causing severe pneumonia and septic shock in healthy women

Background

Since the Influenza A pandemic in 1819, the association between the influenza virus and Streptococcus pneumoniae has been well described in literature. While a leading role has been so far attributed solely to Influenza A as the primary infective pathogen, Influenza B is generally considered to be less pathogenic with little impact on morbidity and mortality of otherwise healthy adults. This report documents the severe synergistic pathogenesis of Influenza B infection and bacterial pneumonia in previously healthy persons not belonging to a special risk population and outlines therapeutic options in this clinical setting.

Case Presentation

During the seasonal influenza epidemic 2007/2008, three previously healthy women presented to our hospital with influenza-like symptoms and rapid clinical deterioration. Subsequent septic shock due to severe bilateral pneumonia necessitated intensive resuscitative measures including the use of an interventional lung assist device. Microbiological analysis identified severe dual infections of Influenza B with Streptococcus pyogenes in two cases and Streptococcus pneumoniae in one case. The patients presented with no evidence of underlying disease or other known risk factors for dual infection such as age (< one year, > 65 years), pregnancy or comorbidity.

Conclusions

Influenza B infection can pose a risk for severe secondary infection in previously healthy persons. As patients admitted to hospital due to severe pneumonia are rarely tested for Influenza B, the incidence of admission due to this virus might be greatly underestimated, therefore, a more aggressive search for influenza virus and empirical treatment might be warranted. While the use of an interventional lung assist device offers a potential treatment strategy for refractory respiratory acidosis in addition to protective lung ventilation, the combined empiric use of a neuraminidase-inhibitor and antibiotics in septic patients with pulmonary manifestations during an epidemic season should be considered.

Antibiotic consumption as a driver for resistance in Staphylococcus aureus and Escherichia coli within a developing region

BACKGROUND

This study aimed to provide insight into possible antibiotic drivers of methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli resistant to third-generation cephalosporins (3GCREC) in southern and eastern Mediterranean institutions.

METHODS

MRSA and 3GCREC susceptibility proportions from 19 regional hospitals, previously published by the ARMed project, were correlated with antibiotic use data from the same institutions.

RESULTS

Hospitals reporting below-median MRSA proportions had significantly lower total antibiotic use. MRSA proportions increased with greater use of carbapenems (P=.04). In multivariate analysis, a positive correlation was identified with the use of carbapenems (P=.002), combination penicillins (P=.018), and aminoglycosides (P=.014). No difference was ascertained between 3GCREC proportions and total antibiotic use. In multivariate linear regression, a correlation was identified only for 3GCREC (P=.005), but a negative association was evident for beta-lactamase-resistant penicillins (P=.010) and first-generation cephalosporins (P=.012).

CONCLUSIONS

The results suggest an association between resistance and antibiotic use, especially for carbapenems and third-generation cephalosporins. These data support the urgent implementation of antibiotic stewardship initiatives in hospitals in developing countries that focus on more judicious use of broad-spectrum formulations.

Bacterial septic arthritis in adults

Symptoms and signs of septic arthritis are an important medical emergency, with high morbidity and mortality. We review the changing epidemiology of septic arthritis of native joints in adults, encompassing the increasing frequency of the disorder and its evolving antibiotic resistance. We discuss various risk factors for development of septic arthritis and examine host factors (tumour necrosis factor alpha, interleukins 1 and 10) and bacterial proteins, toxins, and enzymes reported to be important determinants of pathogenesis in mouse models. Diagnosis of disease is largely clinical, guided by investigations and the opinion of skilled clinicians. We emphasise the need for timely medical and surgical intervention-most importantly, through diagnostic aspiration of relevant joints, choice of suitable antibiotic, and appropriate supportive measures. Management is growing in complexity with the advent of novel and antibiotic-resistant causative microorganisms and within the current climate of increased immunosuppression. Findings from animal models and patients are shedding light on disease pathogenesis and the possibility of novel adjunctive treatments, including systemic corticosteroids, cytokines and anticytokines, and bisphosphonates.

Self-medication with antibiotics in the ambulatory care setting within the Euro-Mediterranean region; results from the ARMed project

Anecdotal data from the southern and eastern Mediterranean region suggests that self-medication with antibiotics is commonly practiced in many countries. In order to provide proper information on the situation, we undertook short structured interviews in out-patients clinics or primary health centres in Cyprus, Egypt, Jordan, Lebanon, Libya, Tunisia and Turkey. A total of 2109 interviews were undertaken of which 1705 completed the full questionnaire. Self-medication was reported by 19.1% (<0.1% in Cyprus to 37% in Lebanon) of respondents. Intended self-medication ranged from 1.3% (95% CI 0%, 3%) in Cyprus to 70.7% (95% CI 64%, 77%) in Jordan. Upper respiratory tract symptoms were the most frequent reasons for which respondents indicated they would self-medicate. 48.4% of the whole group replied that they kept antibiotics at home, being highest in Lebanon (60%, 95% CI 51%, 69%). We found a significant association between antibiotic hoarders and intended users of antibiotics for self-medication. Our data confirms that non-prescribed antibiotic use is high within ambulatory care in southern and eastern Mediterranean countries, being almost twice that reported in a similar European study. Corrective efforts are clearly required in the region to ensure proper use of antimicrobials so as to reduce pressure for antimicrobial resistance.