The threat of multidrug-resistant/extensively drug-resistant Gram-negative respiratory infections: another pandemic

Tenfold multiplex PCR method for simultaneous detection of mcr-1 to mcr-10 genes and application for retrospective investigations of Salmonella and Escherichia coli isolates in China

The increasing prevalence of antimicrobial resistance has raised significant concern globally. Colistin is currently considered a last resort for treating Gram-negative bacterial infections. However, the emergence of colistin resistance has led to a difficult situation against bacterial infections. Therefore, the monitoring of colistin resistance is of great importance for the control of bacterial infections. The mobile colistin resistance (mcr) gene has been identified as a colistin resistance gene, and ten mcr genes (mcr-1 to mcr-10) have been identified to date. Hence, the detection of mcr genes can help predict bacterial colistin resistance at the molecular level. However, there have not been reported multiplex PCR methods for simultaneously detecting mcr-1 to mcr-10 until now. In this study, we established a one-step multiplex PCR method for simultaneous detection of mcr-1 to mcr-10 for the first time. Furthermore, we retrospectively investigated the prevalence of the ten mcr genes in Escherichia coli (E. coli) and Salmonella isolates in China. The results showed that the mcr detection rate of Salmonella isolated during 2004-2019 was 4.73 % (16/338), and only mcr-9 was harbored. As well, the mcr detection rate of E. coli isolated during 2012-2015 was 20.42 % (49/240) and only mcr-1 was identified. Moreover, we also investigated the relationship between mcr harboring and colistin phenotype-resistance. The broth micro-dilution assay results showed that all mcr-1-positive E. coli isolates were colistin-resistant. However, all mcr-9-positive Salmonella isolates did not represent colistin-resistance. Our findings are beneficial for the monitoring and control of colistin resistance.

Multiplex PCR Pneumonia Panel in Critically Ill Patients Did Not Modify Mortality: A Cohort Study

In critically ill patients, identification of the pathogen may allow for the timely adjustment of antibiotics and improved outcomes. Background/Objectives: The aim of the study was to assess whether performing a multiplex PCR pneumonia panel (PN-panel) in patients with pneumonia in the intensive care unit (ICU) had any effect on mortality or other important clinical outcomes. Methods: A retrospective cohort study was conducted on adult patients with pneumonia who required ICU admission in four institutions in Bogotá between November 2019 and June 2023. Mortality at 30 days, the length of the hospital and ICU stay, the duration of antibiotics, and their association with the PN-panel performance were evaluated using an inverse probability of the treatment weighting to adjust for covariates and potential confounders. Results: A total of 304 patients were included, including 150 with PN-panel, with a mean age of 65.0 years (SD 14.6). SARS-CoV-2 was the primary etiologic agent in 186 (61.2%) patients, and 256 (84.2%) patients had community-acquired pneumonia. No association was found between 30-day mortality and the PN-panel, with a HR of 1.14 (CI 95% 0.76-1.70), although the assessment by an infectious disease specialist was associated with a lower mortality HR of 0.29 (CI 95% 0.19-0.45). There was no association between the PN-panel and antimicrobial therapy duration or other clinical outcomes. Conclusions: The use of the PN-panel was not associated with changes in mortality, the duration of antibiotics, or hospital and ICU stays. To acquire greater rational decision-making, microbiological data produced by this test should be interpreted with aid of an antimicrobial stewardship program oriented by an infectious disease team that could take the clinical data and integrate the information provided.

Economic burden of antimicrobial resistance on patients in Pakistan

Background

Antimicrobial resistance (AMR) occurs when microbes undergo changes that render antimicrobial drugs ineffective against them, resulting in limited, more expensive treatment options, longer hospital stays, and increased mortality rates. No study has estimated the costs related to AMR in hospitals in Pakistan. This study was conducted to determine the financial burden of antimicrobial resistance (AMR) in Pakistan and to compare it with the additional costs incurred by patients who respond well to antimicrobial treatments. The study also aimed to identify the most frequent types of microbes that cause bloodstream infections in Pakistan.

Methods

This quantitative study was conducted employing a prospective cohort study design. A sample of 193 patients was selected from two public sector tertiary care hospitals in the twin cities of Islamabad and Rawalpindi for a period of 7 months. The frequency trends of antimicrobial resistance against 12 blood pathogens were determined by analyzing culture sensitivity reports from patients who tested positive, as provided by pathology laboratories of the study hospitals. Direct and indirect costs were calculated using data from patients' medical records and through direct interactions with patients.

Results

This study estimated that treating cases of AMR resulted in approximately USD 33.97 [Pakistani Rupees (PKR) 9483.2] in additional costs compared to treating susceptible infections due to extended lengths of hospital stays. However, indirect costs such as spending on food, productivity loss, and accommodation are USD 55.84 (PKR 15588.3) higher in the non-infected control cohort compared to the cases. Direct costs (transport, pharmacy, and laboratory expenses) are directly related to AMR and add an additional burden of USD 12.30 (PKR 3435) for cases compared to non-infected controls. In comparison to susceptible controls, cases incur an additional cost of USD 32.9 (PKR 9185.9).

Conclusion

This study helped predict the economic burden of antimicrobial resistance in admitted patients with bloodstream infections (BSIs) in low- and middle-income countries, such as Pakistan, by different variable cost estimates. These findings will help in designing the most appropriate approach to combat AMR. Additionally, this study serves as a baseline tool that can be extrapolated to estimate the national economic burden because of AMR.

Aztreonam-avibactam versus meropenem for the treatment of serious infections caused by Gram-negative bacteria (REVISIT): a descriptive, multinational, open-label, phase 3, randomised trial

BACKGROUND

There is a need for additional therapeutic options for serious infections caused by Gram-negative pathogens. In the phase 3, descriptive REVISIT study, we investigated the safety and efficacy of aztreonam-avibactam in the treatment of complicated intra-abdominal infections or hospital-acquired pneumonia or ventilator-associated pneumonia (HAP-VAP) caused, or suspected to be caused, by Gram-negative bacteria.

METHODS

This prospective, multinational, open-label, central assessor-masked study enrolled adults who were hospitalised with a complicated intra-abdominal infection or HAP-VAP. Patients were randomly allocated via block randomisation using interactive response technology stratified by infection type in a 2:1 ratio to aztreonam-avibactam (with metronidazole for complicated intra-abdominal infection) or meropenem with or without colistin for 5-14 days for complicated intra-abdominal infection or 7-14 days for HAP-VAP. The primary endpoint was clinical cure at the test-of-cure visit (within 3 days before or after day 28) in the intention-to-treat (ITT) population. Secondary endpoints included 28-day mortality in the ITT population and safety in patients in the ITT population who received study drug (safety analysis set). No formal hypothesis testing was planned. The study was registered with ClinicalTrials.gov (NCT03329092) and EudraCT (2017-002742-68) and is complete.

FINDINGS

Between April 5, 2018, and Feb 23, 2023, we screened 461 patients. 422 patients were enrolled and randomly allocated (282 in the aztreonam-avibactam group and 140 in the meropenem group, forming the ITT analysis set), of whom ten patients (seven in the aztreonam-avibactam group and three in the meropenem group) were randomly allocated but did not receive study treatment. 271 (64%) of 422 patients had at least one Gram-negative pathogen from an adequate specimen identified at baseline. The most frequent baseline pathogens were Enterobacterales (252 [93%] of 271). Overall, 19 (24%) of 80 isolates tested for carbapenemases were carbapenemase-positive (serine, metallo-β-lactamase, or both). 193 (68·4%) of 282 patients in the aztreonam-avibactam group and 92 (65·7%) of 140 in the meropenem group had clinical cure at the test-of-cure visit (treatment difference 2·7% [95% CI -6·6 to 12·4]). For patients with complicated intra-abdominal infection, the adjudicated clinical cure rate was 76·4% (159 of 208) for the aztreonam-avibactam group and 74·0% (77 of 104) for the meropenem group. Cure rates in patients with HAP-VAP were 45·9% (34 of 74) for aztreonam-avibactam and 41·7% (15 of 36) for meropenem. 28-day all-cause mortality rates were 4% (12 of 282) for aztreonam-avibactam and 7% (ten of 140) for meropenem; in patients with complicated intra-abdominal infection, mortality was 2% (four of 208) and 3% (three of 104) for aztreonam-avibactam and meropenem, respectively, and in patients with HAP-VAP, mortality was 11% (eight of 74) and 19% (seven of 36), respectively. Aztreonam-avibactam was generally well tolerated, and safety findings were consistent with the known safety profile of aztreonam monotherapy. There were no treatment-related serious adverse events in the aztreonam-avibactam group.

INTERPRETATION

These phase 3 efficacy and safety data provide support for aztreonam-avibactam as a potential therapeutic option for complicated intra-abdominal infection or HAP-VAP caused by Gram-negative bacteria.

FUNDING

Pfizer.

Comparison of Multi-Drug Resistant Organisms Causing Early Ventilator-Associated Pneumonia in Three Geographically Distinct Trauma Intensive Care Units

Introduction: It is unclear why differences in patient location change organisms causing ventilator-associated pneumonia (VAP). We investigated VAP organisms in three geographically separate trauma intensive care units (TICUs). Patients and Methods: A retrospective review of organisms causing VAP (bronchoalveolar lavage [BAL] performed ≤7 d after admission and growing ≥105 cfu/mL) in three geographically separate TICUs was conducted. Patients were treated by similar multidisciplinary teams and protocolized pathways. The primary outcome was the incidence of multi-drug resistant (MDR) VAP. Secondary outcomes were the incidence of inappropriate empiric antimicrobial therapy (IEAT) and the determination of risk factors for MDR VAP. Chi-squared, Kruskal-Wallis, and multi-variable logistic regression analyses were used accordingly. Results: In total, 271 patients were included: 142 in TICU-1, 63 in TICU-2, and 66 in TICU-3. The incidence of MDR VAP was similar across TICUs at 33.8%, 47.6%, and 39.4%, respectively (p = 0.17). Gram-negative MDRs were more prevalent in TICU-1 (70.8%) versus TICU-2 (60.0%) or TICU-3 (26.9%) (p = 0.001). Gram-positive MDRs were identified more in TICU-3 (73.1%) versus TICU-2 (43.3%) or TICU-1 (35.4%). IEAT did not differ by unit overall but was significantly greater for MDR gram-positive organisms in TICU-3 (70.4%) versus TICU-2 (44.8%) or TICU-1 (37.5%) (p = 0.02) and highest for MDR gram-negative organisms in TICU-1 (64.6%) versus TICU-2 (62.1%) or TICU-3 (55.8%) (p = 0.02). Multi-variable regression analyses revealed antibiotic days before BAL and kidney replacement therapy (KRT) as significant predictors of MDR VAP. Conclusions: Different TICU locations did not influence the overall incidence of MDR VAP, but differences in MDR organisms were observed. IEAT rates for both gram-positive and gram-negative organisms in different units may necessitate changes in empiric therapy. Antibiotic days prior to the BAL and KRT significantly increased the odds of early MDR VAP.

Antibiotic resistance genotype, phenotype, and clinical outcomes in patients with Gram-negative infections at Rabin Medical Center in Israel

Antibiotic resistance is a major cause of morbidity and mortality. However, a better understanding of the relationship between bacterial genetic markers, phenotypic resistance, and clinical outcomes is needed. We performed whole-genome sequencing on five medically important pathogens (Acinetobacter baumannii, Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) to investigate how resistance genes impact patient outcomes. A total of 168 isolates from 162 patients with Gram-negative infections admitted to Beilinson Hospital at Rabin Medical Center in Israel were included for final analysis. Genomes were analyzed for resistance determinants and correlated with microbiologic and clinical data. Thirty-day mortality from time of culture was 26.5% (43/162). Twenty-nine patients had carbapenem-resistant isolates (29/168, 17.2%), while 63 patients had multidrug-resistant isolates (63/168, 37.5%). Albumin levels were inversely associated with mortality and length of stay, while arrival from a healthcare facility and cancer chemotherapy predicted having a multidrug-resistant isolate. Sequencing revealed possible patient-to-patient transmission events. blaCTX-M-15 was associated with multidrug-resistance in E. coli (OR = 3.888, P = 0.023) on multivariate analysis. Increased blaOXA-72 copy number was associated with carbapenem-resistance in A. baumannii (P = 0.003) and meropenem minimum inhibitory concentration (P = 0.005), yet carbapenem-resistant isolates retained sensitivity to cefiderocol and sulbactam-durlobactam. RJX84154 was associated with multidrug-resistance across all pathogens (P = 0.0018) and in E. coli (P = 0.0024). Low albumin levels were associated with mortality and length of stay in this sample population. blaCTX-M-15 was correlated with multidrug-resistance in E. coli, and blaOXA-72 depth predicted meropenem minimum inhibitory concentration in A. baumannii. RJX84154 may play a role in multidrug-resistance.

IMPORTANCE

While there have been several studies that attempt to find clinical predictors of outcomes in patients hospitalized with bacterial infections, less has been done to combine clinical data with genomic mechanisms of antibiotic resistance. This study focused on a hospitalized patient population in Israel with infections due to medically important bacterial pathogens as a way to build a framework that would unite clinical data with both bacterial antibiotic susceptibility and genomic data. Merging both clinical and genomic data allowed us to find both bacterial and clinical factors that impact certain clinical outcomes. As genome sequencing of bacteria becomes both rapid and commonplace, near real-time monitoring of resistance determinants could help to optimize clinical care and potentially improve outcomes in these patients.

Photodynamic Inactivation of Bacteria Using Nickel(II) Complexes with Catecholate and Phenanthroline Ligands

Metal complexes activated by light can combat infections by triggering the photodynamic inactivation of bacteria. Herein, we report six mixed-ligand nickel(II) complexes with the formulation [Ni(NN)2(L)] (1-6), where NN represents an N,N-donor phenanthroline ligand, specifically 1,10-phenanthroline (phen in 1, 2), dipyrido[3,2-d:2',3'-f]quinoxaline (dpq in 3, 4), and dipyrido[3,2-a:2',3'-c]phenazine (dppz in 5, 6), while L is an O,O donor bidentate ligand derived from catechol (cat2-, in 1, 3, 5) or esculetin (esc2-, in 2, 4, 6). The paramagnetic d8 octahedral complexes demonstrated good dark and photostability in the solution phase and exhibited significant light absorption in the visible (400-700 nm) region. When exposed to low-energy visible light, these complexes demonstrated significant photodynamic inactivation activity against both Gram-(+) Staphylococcus aureus (S. aureus) and Gram-(-) Escherichia coli (E. coli) bacteria. This resulted in minimum inhibitory concentration (MIC) values ranging from 0.31-9.49 μM. The activity was caused by the cell-damaging singlet oxygen species produced by the complexes under light exposure. Notably, the complexes showed no bacterial inhibition activity under dark conditions. This study marks the first examples of Ni(II) complexes designed for light-triggered antibacterial activity, illuminating the path for Ni(II)-based non-macrocyclic complexes for antibacterial PDT applications.

Fatty acid chain modification enhances the serum stability of antimicrobial peptide B1 and activities against Staphylococcus aureus and Klebsiella pneumoniae

Antimicrobial peptides (AMPs) possess broad-spectrum antibacterial properties and low resistance development, making them promising candidates for new antibacterial drugs. Incorporating fatty acid chains into AMPs can increase their hydrophobicity, strengthen membrane affinity, and improve their antibacterial effectiveness and stability. This study introduces fatty acid chains of varying lengths into the naturally derived antimicrobial peptide B1. These modified peptides were evaluated for their antibacterial activity, stability, and biocompatibility to identify the optimal chain length for analogues. The analogues B1-C6 and B1-C8 exhibited significantly enhanced antimicrobial activities against Staphylococcus aureus (S. aureus) and Klebsiella pneumoniae (K. pneumonia), demonstrating better stability and biocompatibility. Following acute toxicity and skin irritation tests on mice, further in vivo tests using a mouse skin inflammation model showed that these peptides significantly restrain bacterial growth and promote wound healing. The skin healing rate in the high-concentration group reached 95.92%, 97.35% 98.42% and 98.17%, respectively. These findings indicated that optimizing the hydrophobic-hydrophilic balance in AMPs is crucial for maximizing their therapeutic potential. This research offers a promising approach for designing effective AMPs to treat infections caused by S. aureus and K. pneumoniae.

Mechanisms of Polymyxin Resistance in Acid-Adapted Enteroinvasive Escherichia coli NCCP 13719 Revealed by Transcriptomics

Acid adaptation in Escherichia coli can induce antimicrobial resistance (AMR), posing challenges to global public health. We investigated the effects of acid adaptation on antimicrobial susceptibility, gene expression, zeta potential, and the outer membrane (OM) properties of Escherichia coli NCCP 13719. The acid-adapted (AA) strain exhibited increased resistance to multiple antimicrobials, with minimum inhibitory concentrations for colistin and polymyxin B increasing eight- and two-fold, respectively. Transcriptomic analysis identified 2225 differentially expressed genes, including upregulated genes associated with resistance to cationic antimicrobial peptides such as arnCTE, marA, and tolC. The upregulation of the arn operon suggests modifications in lipid A of lipopolysaccharides (LPS), reducing the negative charge of the OM and decreasing polymyxin binding affinity. Zeta potential measurements indicated a shift toward a less negative surface charge in the AA strain, which is consistent with LPS modifications. The AA strain also showed decreased OM permeability, which correlated with increased resistance to antimicrobials that penetrate the OM. These mechanisms collectively diminish the efficacy of polymyxins and highlight the potential for environmental factors to drive antimicrobial resistance. In conclusion, the acid adaptation of E. coli NCCP 13719 enhances AMR through changes in gene expression and OM modifications, highlighting the need for careful control of acidic environments during the treatment of medical devices and wastewater from food processing to prevent the emergence of resistant strains.

Association between 25-hydroxy vitamin D, interleukin-4, and interferon-γ levels and asthma in children with Mycoplasma pneumonia infection

To explore the association between 25-hydroxy vitamin D [25-(OH)-D], interleukin-4 (IL-4), and interferon-γ (IFN-γ) in children with Mycoplasma pneumoniae (MP) infection-related asthma. Logistic analysis was conducted to compare general data in MP asthma and MP non-asthma groups. The level of 25-(OH)-D, IL-4, and IFN-γ were detected and compared between groups. Moreover, the receiver operating characteristic curve (ROC) was applied to test the predictive value of each variable. The results of logistic regression analysis demonstrated that recurrent upper respiratory tract infections and collective living are related to the incidence of MP infection whether with asthma or without asthma. IL-4 and IFN-γ in MP asthma group were significantly higher than those in MP non-asthma group and control group (p < 0. 05), whilst 25-(OH)-D and IFN-γ/IL-4 in MP asthma group were significantly lower than those in MP non-asthma group and control group (p < 0. 05). ROC curves indicated that the area under the curve (AUC) of 25-(OH)-D, IL-4, IFN-γ, IFN-γ/IL-4, and joint detection are 0.765, 0.780, 0.853, 0.638, and 0.912 in diagnosis of MP infection-related asthma, and sensitivity and specificity of joint detection are both greater than 95%. For children with MP infection-related asthma, the level of IL-4 and IFN-γ is upregulated, while 25-(OH)-D is downregulated. The joint detection of 25-(OH)-D, IL-4, IFN-γ, and IFN-γ/IL-4 may improve diagnostic capabilities of MP infection-related asthma.

Antibacterial activity of a silver-incorporated vancomycin-modified mesoporous silica against methicillin-resistant Staphylococcus aureus

Since conventional antibiotics are almost ineffective on methicillin-resistant Staphylococcus aureus (MRSA) strains, designing their antibacterial alternatives is necessary. Besides, the use of vancomycin is applied for specific detection of the bacteria. Silver-incorporated vancomycin-modified mesoporous silica nanoparticles (MSNs@Van@Ag NPs) were designed for detection and treatment of MRSA bacteria. Mesoporous silica nanoparticles (MSNs) were synthesized through the template method, modified with vancomycin, and finally incorporated with silver nanoparticles (Ag NPs). The MSNs@Van@Ag NPs with a homogenously spherical shape, average size of 50-100 nm, surface area of 955.8 m2/g, and thermal stability up to 200°C were successfully characterized. The amount of Ag incorporated into the MSNs@Van@Ag was calculated at 3.9 ppm and the release amount of Ag was received at 2.92 ppm (75%) after 100 h. The in vitro antibacterial susceptibility test showed the MIC of 100 μg mL-1 for MSNs@Van and 50 μg mL-1 for MSNs@Van@Ag, showing in vitro enhanced effect of Ag and vancomycin in the bactericidal process. An in vivo acute pneumonia model was performed and biochemical assays and pathological studies confirmed the nanomedicine's short-term safety for in vivo application. Cytokine assay using ELISA showed that MSN@Van@Ag causes a reduction of pro-inflammatory cytokines and bacterial proliferation leading to alleviation of inflammatory response.

Assessment of Antibiotic Resistance in Pediatric Infections: A Romanian Case Study on Pathogen Prevalence and Effective Treatments

Antibiotic misuse in Romania has exacerbated the issue of antibiotic resistance, as patients often use antibiotics without proper medical consultation. This study aimed to assess the resistance of prevalent bacteria to different antibiotics. In this observational study conducted over six months, we analyzed 31 pediatric patients aged from 12 days to 13 years using the disk diffusion method. We identified 31 bacterial isolates, including 8 Gram-negative and 8 Gram-positive strains, with the most common being Pseudomonas aeruginosa, Escherichia coli, Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus, Streptococcus species, and Elizabethkingia meningoseptica. Our findings revealed that the most effective antibiotics were linezolid, ertapenem, and teicoplanin. In contrast, nearly all tested bacteria exhibited resistance to penicillin, followed by oxacillin and ampicillin. Resistance to cephalosporins varied with generation, showing higher resistance to lower-generation cephalosporins. The study highlights significant antibiotic resistance among common bacterial pathogens in Romanian pediatric patients, emphasizing the urgent need for controlled antibiotic use and alternative treatment strategies to combat this growing issue. Effective antibiotics such as linezolid and ertapenem offer potential solutions, whereas reliance on penicillin and lower-generation cephalosporins is increasingly futile.

Mechanism of antibacterial resistance, strategies and next-generation antimicrobials to contain antimicrobial resistance: a review

Antibacterial drug resistance poses a significant challenge to modern healthcare systems, threatening our ability to effectively treat bacterial infections. This review aims to provide a comprehensive overview of the types and mechanisms of antibacterial drug resistance. To achieve this aim, a thorough literature search was conducted to identify key studies and reviews on antibacterial resistance mechanisms, strategies and next-generation antimicrobials to contain antimicrobial resistance. In this review, types of resistance and major mechanisms of antibacterial resistance with examples including target site modifications, decreased influx, increased efflux pumps, and enzymatic inactivation of antibacterials has been discussed. Moreover, biofilm formation, and horizontal gene transfer methods has also been included. Furthermore, measures (interventions) taken to control antimicrobial resistance and next-generation antimicrobials have been discussed in detail. Overall, this review provides valuable insights into the diverse mechanisms employed by bacteria to resist the effects of antibacterial drugs, with the aim of informing future research and guiding antimicrobial stewardship efforts.

The diagnostic value of bronchoalveolar lavage fluid metagenomic next-generation sequencing in critically ill patients with respiratory tract infections

Metagenomic next-generation sequencing (mNGS) is an unbiased and rapid method for detecting pathogens. This study enrolled 145 suspected severe pneumonia patients who were admitted to the Affiliated Hospital of Jining Medical University. This study primarily aimed to determine the diagnostic performance of mNGS and conventional microbiological tests (CMTs) using bronchoalveolar lavage fluid samples for detecting pathogens. Our findings indicated that mNGS performed significantly higher sensitivity (97.54% vs 28.68%, P < 0.001), coincidence (90.34% vs 35.17%, P < 0.001), and negative predictive value (80.00% vs 13.21%, P < 0.001) but performed lower specificity than CMTs (52.17% vs 87.5%, P < 0.001). Streptococcus pneumoniae as the most common bacterial pathogen had the largest proportion (22.90%, 30/131) in this study. In addition to bacteria, fungi, and virus, mNGS can detect a variety of atypical pathogens such as Mycobacterium tuberculosis and non-tuberculous. Mixed infections were common in patients with severe pneumonia, and bacterial-fungal-viral-atypical pathogens were the most complicated infection. After adjustments of antibiotics based on mNGS and CMTs, the clinical manifestation improved in 139 (95.86%, 139/145) patients. Our data demonstrated that mNGS had significant advantage in diagnosing respiratory tract infections, especially atypical pathogens and fungal infections. Pathogens were detected timely and comprehensively, contributing to the adjustments of antibiotic treatments timely and accurately, improving patient prognosis and decreasing mortality potentially.IMPORTANCEMetagenomic next-generation sequencing using bronchoalveolar lavage fluid can provide more comprehensive and accurate pathogens for respiratory tract infections, especially when considering the previous usage of empirical antibiotics before admission or complicated clinical presentation. This technology is expected to play an important role in the precise application of antimicrobial drugs in the future.

An overview on pharmacological significance, phytochemical potential, traditional importance and conservation strategies of Dioscorea deltoidea: A high valued endangered medicinal plant

Dioscorea deltoidea Wall. ex Griseb. is an endangered species of the Dioscoreaceae family. It is the most commonly consumed wild species as a vegetable due to its high protein, vital amino acid, vitamin, and mineral content. There are approximately 613 species in the genus Dioscorea Plum. ex L., which is found in temperate and tropical climates. Dioscorea deltoidea, a plant species widespread across tropical and sub-tropical regions, called by different names in different languages. In English, it is commonly referred to as "Wild yam" or "Elephant foot". The Sanskrit name for this plant is "Varahikand," while in Hindi, it is known as "Gun" or "Singly-mingly." The Urdu language refers to it as "Qanis," and in Nepali, it is called "Tarul," "Bhyakur," or "Ghunar." Dioscorea deltoidea has been used to cure a wide range of human ailments for centuries. This plant has nutritional and therapeutic uses and also contains high amounts of steroidal saponins, allantoin, polyphenols, and most notably, polysaccharides and diosgenin. These bioactive chemicals have shown potential in providing protection against a wide spectrum of inflammatory conditions, including enteritis (inflammation of the intestines), arthritis (joint inflammation), dermatitis (skin inflammation), acute pancreatitis (inflammation of the pancreas), and neuro inflammation (inflammation in the nervous system). Furthermore, the valuable bioactive chemicals found in D. deltoidea have been associated with a range of beneficial biological activities, such as antibacterial, antioxidant, anti-inflammatory, immunomodulatory, hepatoprotective, and cytotoxic properties. Sapogenin steroidal chemicals are highly valued in the fields of medicine, manufacturing, and commerce. It has both expectorant and sedative properties. It is employed in the treatment of cardiovascular diseases, encompassing various ailments related to the heart and blood vessels, skin disease, cancer, immune deficiencies, and autoimmune diseases. Additionally, it finds application in managing disorders of the central nervous system and dysfunctional changes in the female reproductive system. Furthermore, it is valued for its role in treating bone and joint diseases. Metabolic disorders are also among the ailments for which D. deltoidea is employed. It has traditionally been used as a vermifuge, fish poison, and to kill lice. Diosgenin, a steroidal compound found in D. deltoidea, plays a crucial role as a precursor in the chemical synthesis of various hormones. Due to the presence of valuable bioactive molecule, like corticosterone and sigmasterol, D. deltoidea is cultivated specifically for the extraction of these beneficial phytochemicals. The current study aims to assess D. deltoidea's medicinal properties, ethnobotanical usage, phytochemicals, pharmacological properties, threats, and conservation techniques.

A comprehensive investigation of the medicinal efficacy of antimicrobial fusion peptides expressed in probiotic bacteria for the treatment of pan drug-resistant (PDR) infections

The present work aimed to examine the intracellular antibacterial efficacy of Recombinant Lactobacillus acidophilus/antimicrobial peptides (AMPs) Melittin and Alyteserin-1a, specifically targeting Gram-negative bacteria. The first assessment was to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of Recombinant L. acidophilus/AMPs versus Gram-negative and Gram-positive bacteria. In addition, the researchers examined the in vitro viability and safety of AMPs generated by L. acidophilus. The experiments included exposing the AMPs to elevated temperatures, proteases, cationic salts at physiological levels, and specific pH settings. The safety aspect was evaluated using hemolytic analysis utilizing sheep erythrocytes; cytotoxicity assays employing cell lines, and experiments on beneficial gut lactobacilli. An experiment was done using a time-kill method to assess the intracellular antibacterial efficacy of Recombinant L. acidophilus/AMPs compared to pathogenic varieties in HEp-2 cells. Previous investigations have shown that the MBC levels of recombinant L. acidophilus/AMPs were consistently two to four times higher than the equivalent MIC values when evaluated versus Gram-negative bacteria. Furthermore, the stability of the Recombinant L. acidophilus/AMPs showed variability when exposed to elevated temperatures (70 and 90 ℃), treated with protease enzymes (proteinase K, lysozyme), exposed to higher concentrations of physiological salts (150 mM NaCl and 2 mM MgCl2), and varying pH levels (ranging from 4.0 to 9.0). The recombinant L. acidophilus/AMPs are non-hemolytic towards sheep erythrocytes, exhibit little cytotoxicity in RAW 264.7 and HEp-2 cells, and are considered safe when compared to beneficial gut lactobacilli. The research examined the intracellular bacteriostatic effects of recombinant L. acidophilus/AMPs on Gram-negative bacteria inside HEp-2 cells. Nevertheless, no notable bactericidal impact was seen on Gram-positive bacteria (P > 0.05). The research shows that recombinant L. acidophilus/AMPs, namely (L. acidophilus/melittin/Alyteserin-1a) as the focus of the investigation, effectively eliminate Gram-negative bacteria. Therefore, more investigation is necessary to elaborate on these discoveries.

Multidrug antibiotic resistance in hospital wastewater as a reflection of antibiotic prescription and infection cases

Antimicrobial resistance (AMR) is an escalating issue that can render illnesses more difficult to treat if effective antibiotics become resistant. Many studies have explored antibiotic resistance in bacteria (ARB) in wastewater, comparing results with clinical data to ascertain the public health risk. However, few investigations have linked the prevalence of ARB in hospital wastewater (HWW) with these outcomes. This study aimed to bridge this gap by assessing the prevalence of ARB in HWW and its receiving waters. Among the 144 isolates examined, 24 were obtained from each of the six sites (untreated wastewater, aeration tank, sedimentation tank, effluent after disinfection, upstream canal, and downstream canal). A significant portion (87.5 %) belonged to the Enterobacteriaceae family, with Klebsiella pneumoniae as the predominant species (47.9 %). The antimicrobial sensitivity testing (AST) showed that 57.6 % of the isolates were resistant to amoxicillin/clavulanic acid (AMX), the most prevalent antibiotic used within the studied hospital. The total resistance rate before and after treatment was 27.7 % and 28.0 %, respectively, with an overall multi-drug resistance (MDR) rate of 33.3 %. The multiple antibiotic resistance index (MARI) range varied between 0.0 and 0.9. The outpatient ward's three-day mean bacterial infection cases showed a significant association (Spearman's rho = 0.98) with the MARI in the sedimentation tank. Moreover, a strong correlation (Spearman's rho = 0.88) was found between hospital effluent's MARI and the seven-day mean inpatient ward case. These findings indicate that applying wastewater-based epidemiology (WBE) to hospital wastewater could provide valuable insights into understanding ARB contamination across human domains and water cycles. Future studies, including more comprehensive collection data on symptomatic patients and asymptomatic carriers, will be crucial in fully unravelling the complexities between human health and environmental impacts related to AMR.

Molecular characterization of extended-spectrum β-lactamase-producing Escherichia coli isolated from lower respiratory tract samples between 2002 and 2019 in the Central Slovenia region

BACKGROUND

Antibiotic resistance is one of the most serious global health problems and threatens the effective treatment of bacterial infections. Of greatest concern are infections caused by extended-spectrum β-lactamase-producing Escherichia coli (ESBL-EC). The aim of our study was to evaluate the prevalence and molecular characteristics of ESBL-EC isolated over an 18-year pre-COVID period from lower respiratory tract (LRT) samples collected from selected Slovenian hospitals.

OBJECTIVES AND METHODS

All isolates were identified by MALDI-TOF and phenotypically confirmed as ESBLs by a disk diffusion assay. Using a PCR approach, 487 non-repetitive isolates were assigned to phylogroups, sequence type groups, and clonal groups. Isolates were also screened for virulence-associated genes (VAGs) and antimicrobial resistance genes.

RESULTS

The prevalence of ESBL-EC isolates from LRT in a large university hospital was low (1.4%) in 2005 and increased to 10.8% by 2019. The resistance profile of 487 non-repetitive isolates included in the study showed a high frequency of group 1 blaCTX-M (77.4%; n = 377), blaTEM (54.4%; n = 265) and aac(6')-Ib-cr (52%; n = 253) genes and a low proportion of blaSHV and qnr genes. Isolates were predominantly assigned to phylogroup B2 (73.1%; n = 356), which was significantly associated with clonal group ST131. The ST131 group accounted for 67.6% (n = 329) of all isolates and had a higher number of virulence factor genes than the non-ST131 group. The virulence gene profile of ST131 was consistent with that of other extraintestinal pathogenic E. coli (ExPEC) strains and was significantly associated with ten of sixteen virulence factor genes tested. Using ERIC-PCR fingerprinting, isolates with the same ERIC-profile in samples from different patients, and at different locations and sampling dates were confirmed, indicating the presence of "hospital-adapted" strains.

CONCLUSION

Our results suggest that the ESBL-EC isolates from LRT do not represent a specific pathotype, but rather resemble other ExPEC isolates, and may be adapted to the hospital environment. To our knowledge, this is the first study of ESBL-EC isolated from LRT samples collected over a long period of time.

New N-Terminal Fatty-Acid-Modified Melittin Analogs with Potent Biological Activity

Melittin, a natural antimicrobial peptide, has broad-spectrum antimicrobial activity. This has resulted in it gaining increasing attention as a potential antibiotic alternative; however, its practical use has been limited by its weak antimicrobial activity, high hemolytic activity, and low proteolytic stability. In this study, N-terminal fatty acid conjugation was used to develop new melittin-derived lipopeptides (MDLs) to improve the characteristics of melittin. Our results showed that compared with native melittin, the antimicrobial activity of MDLs was increased by 2 to 16 times, and the stability of these MDLs against trypsin and pepsin degradation was increased by 50 to 80%. However, the hemolytic activity of the MDLs decreased when the length of the carbon chain of fatty acids exceeded 10. Among the MDLs, the newly designed analog Mel-C8 showed optimal antimicrobial activity and protease stability. The antimicrobial mechanism studied revealed that the MDLs showed a rapid bactericidal effect by interacting with lipopolysaccharide (LPS) or lipoteichoic acid (LTA) and penetrating the bacterial cell membrane. In conclusion, we designed and synthesized a new class of MDLs with potent antimicrobial activity, high proteolytic stability, and low hemolytic activity through N-terminal fatty acid conjugation.

Antibiotic adjuvants: synergistic tool to combat multi-drug resistant pathogens

The rise of multi-drug resistant (MDR) pathogens poses a significant challenge to the field of infectious disease treatment. To overcome this problem, novel strategies are being explored to enhance the effectiveness of antibiotics. Antibiotic adjuvants have emerged as a promising approach to combat MDR pathogens by acting synergistically with antibiotics. This review focuses on the role of antibiotic adjuvants as a synergistic tool in the fight against MDR pathogens. Adjuvants refer to compounds or agents that enhance the activity of antibiotics, either by potentiating their effects or by targeting the mechanisms of antibiotic resistance. The utilization of antibiotic adjuvants offers several advantages. Firstly, they can restore the effectiveness of existing antibiotics against resistant strains. Adjuvants can inhibit the mechanisms that confer resistance, making the pathogens susceptible to the action of antibiotics. Secondly, adjuvants can enhance the activity of antibiotics by improving their penetration into bacterial cells, increasing their stability, or inhibiting efflux pumps that expel antibiotics from bacterial cells. Various types of antibiotic adjuvants have been investigated, including efflux pump inhibitors, resistance-modifying agents, and compounds that disrupt bacterial biofilms. These adjuvants can act synergistically with antibiotics, resulting in increased antibacterial activity and overcoming resistance mechanisms. In conclusion, antibiotic adjuvants have the potential to revolutionize the treatment of MDR pathogens. By enhancing the efficacy of antibiotics, adjuvants offer a promising strategy to combat the growing threat of antibiotic resistance. Further research and development in this field are crucial to harness the full potential of antibiotic adjuvants and bring them closer to clinical application.

Antimicrobial resistance in southeast Asian water environments: A systematic review of current evidence and future research directions

Antimicrobial resistance has been a serious and complex issue for over a decade. Although research on antimicrobial resistance (AMR) has mainly focused on clinical and animal samples as essential for treatment, the AMR situation in aquatic environments may vary and have complicated patterns according to geographical area. Therefore, this study aimed to examine recent literature on the current situation and identify gaps in the AMR research on freshwater, seawater, and wastewater in Southeast Asia. The PubMed, Scopus, and ScienceDirect databases were searched for relevant publications published from January 2013 to June 2023 that focused on antimicrobial resistance bacteria (ARB) and antimicrobial resistance genes (ARGs) among water sources. Based on the inclusion criteria, the final screening included 41 studies, with acceptable agreement assessed using Cohen's inter-examiner kappa equal to 0.866. This review found that 23 out of 41 included studies investigated ARGs and ARB reservoirs in freshwater rather than in seawater and wastewater, and it frequently found that Escherichia coli was a predominant indicator in AMR detection conducted by both phenotypic and genotypic methods. Different ARGs, such as blaTEM, sul1, and tetA genes, were found to be at a high prevalence in wastewater, freshwater, and seawater. Existing evidence highlights the importance of wastewater management and constant water monitoring in preventing AMR dissemination and strengthening effective mitigation strategies. This review may be beneficial for updating current evidence and providing a framework for spreading ARB and ARGs, particularly region-specific water sources. Future AMR research should include samples from various water systems, such as drinking water or seawater, to generate contextually appropriate results. Robust evidence regarding standard detection methods is required for prospective-era work to raise practical policies and alerts for developing microbial source tracking and identifying sources of contamination-specific indicators in aquatic environment markers.

A South African Perspective on the Microbiological and Chemical Quality of Meat: Plausible Public Health Implications

Meat comprises proteins, fats, vitamins, and trace elements, essential nutrients for the growth and development of the body. The increased demand for meat necessitates the use of antibiotics in intensive farming to sustain and raise productivity. However, the high water activity, the neutral pH, and the high protein content of meat create a favourable milieu for the growth and the persistence of bacteria. Meat serves as a portal for the spread of foodborne diseases. This occurs because of contamination. This review presents information on animal farming in South Africa, the microbial and chemical contamination of meat, and the consequential effects on public health. In South Africa, the sales of meat can be operated both formally and informally. Meat becomes exposed to contamination with different categories of microbes, originating from varying sources during preparation, processing, packaging, storage, and serving to consumers. Apparently, meat harbours diverse pathogenic microorganisms and antibiotic residues alongside the occurrence of drug resistance in zoonotic pathogens, due to the improper use of antibiotics during farming. Different findings obtained across the country showed variations in prevalence of bacteria and multidrug-resistant bacteria studied, which could be explained by the differences in the manufacturer practices, handling processes from producers to consumers, and the success of the hygienic measures employed during production. Furthermore, variation in the socioeconomic and political factors and differences in bacterial strains, geographical area, time, climatic factors, etc. could be responsible for the discrepancy in the level of antibiotic resistance between the provinces. Bacteria identified in meat including Escherichia coli, Listeria monocytogenes, Staphylococcus aureus, Campylobacter spp., Salmonella spp., etc. are incriminated as pathogenic agents causing serious infections in human and their drug-resistant counterparts can cause prolonged infection plus long hospital stays, increased mortality and morbidity as well as huge socioeconomic burden and even death. Therefore, uncooked meat or improperly cooked meat consumed by the population serves as a risk to human health.

Green Synthesis of MOF-Mediated pH-Sensitive Nanomaterial AgNPs@ZIF-8 and Its Application in Improving the Antibacterial Performance of AgNPs

Purpose

Herein, an emerging drug delivery system was constructed based on zeolite imidazole backbone (ZIF-8) to improve antibacterial defects of nanosilver (AgNPs), such as easily precipitated and highly cytotoxic.

Methods

The homogeneous dispersion of AgNPs on ZIF-8 was confirmed by UV-Vis spectroscopy, FTIR spectroscopy, particle size analysis, zeta potential analysis, and SEM. The appropriate AgNPs loading ratio on ZIF-8 was screened through the cell and antibacterial experiments based on biosafety and antibacterial performance. The optimal environment for AgNPs@ZIF-8 to exert antibacterial performance was probed in the context of bacterial communities under different acid-base conditions. The potential mechanism of AgNPs@ZIF-8 to inhibit the common clinical strains was investigated by observing the biofilm metabolic activity and the level of reactive oxygen species (ROS) in bacteria.

Results

The successful piggybacking of AgNPs by ZIF-8 was confirmed using UV-Vis spectroscopy, FTIR spectroscopy, particle size analysis, zeta potential analysis, and SEM characterization methods. Based on the bacterial growth curve (0-24 hours), the antibacterial ability of AgNPs@ZIF-8 was found to be superior to AgNPs. When the mass ratio of ZIF-8 and AgNPs was 1:0.25, the selection of AgNPs@ZIF-8 was based on its superior antimicrobial efficacy and enhanced biocompatibility. Notably, under weakly acidic bacterial microenvironments (pH=6.4), AgNPs@ZIF-8 demonstrated a more satisfactory antibacterial effect. In addition, experiments on biofilms showed that concentrations of AgNPs@ZIF-8 exceeding 1×MIC resulted in more than 50% biofilm removal. The nanomedicine was found to increase ROS levels upon detecting the ROS concentration in bacteria.

Conclusion

Novel nanocomposites consisting of low cytotoxicity drug carrier ZIF-8 loaded with AgNPs exhibited enhanced antimicrobial effects compared to AgNPs alone. The pH-responsive nano drug delivery system, AgNPs@ZIF-8, exhibited superior antimicrobial activity in a mildly acidic environment. Moreover, AgNPs@ZIF-8 effectively eradicated pathogenic bacterial biofilms and elevated the intracellular level of ROS.

An overview of gram-negative bacteria with difficult-to-treat resistance: definition, prevalence, and treatment options

INTRODUCTION

Difficult-to-treat resistance (DTR) is a newly proposed resistance phenotype characterized by resistance to all first-line drugs. The emergence of DTR as a new resistance phenotype has significant implications for clinical practice. This new concept has the potential to be widely used instead of traditional phenotypes.

AREAS COVERED

This study carried out a detailed analysis about the definition, application, and evolution of various resistance phenotypes. We collected all the research articles on Gram-negative bacteria with difficult-to-treat resistance (GNB-DTR), analyzed the DTR in each region and each bacterial species. The advantages and doubts of DTR, the dilemma of GNB-DTR infections and the potential therapeutic strategies are summarized in the review.

EXPERT OPINION

Available studies show that the prevalence of GNB-DTR is not optimistic. Unlike traditional resistance phenotypes, DTR is more closely aligned with the clinical treatment perspective and can help with the prompt selection of an appropriate treatment plan. Currently, potential treatment options for GNB-DTR include a number of second-line drugs and novel antibiotics. However, the definition of first-line drugs is inherently dynamic. Therefore, the DTR concept based on first-line drugs needs to be continuously updated and refined, considering the emergence of new antibiotics, resistance characteristics, and pathogen prevalence in different regions.

Cannabinoids as multifaceted compounds

Since ancient times, Cannabis and its preparations have found various applications such as for medical, recreational and industrial purposes. Subsequently the 1930s, legislation in many countries has restricted its use due to its psychotropic properties. More recently, the discovery of endocannabinoid system, including new receptors, ligands, and mediators, its role in maintaining the homeostasis of the human body and the possible implication in various physiological and pathophysiological processes has also been understood. Based on this evidence, researchers were able to develop new therapeutic targets for the treatment of various pathological disorders. For this purpose, Cannabis and cannabinoids were subjected for the evaluation of their pharmacological activities. The renewed interest in the medical use of cannabis for its potential therapeutic application has prompted legislators to take action to regulate the safe use of cannabis and products containing cannabinoids. However, each country has an enormous heterogeneity in the regulation of laws. Here, we are pleased to show a general and prevailing overview of the findings regarding cannabinoids and the multiple research fields such as chemistry, phytochemistry, pharmacology and analytics in which they are involved.

Multicenter Clinical Performance Evaluation of Omadacycline Susceptibility Testing of Enterobacterales on VITEK 2 Systems

We present the first performance evaluation results for omadacycline on the VITEK 2 and VITEK 2 Compact Systems (bioMérieux, Inc.). The trial was conducted at four external sites and one internal site. All sites were in the United States, geographically dispersed as follows: Indianapolis, IN; Schaumburg, IL; Wilsonville, OR; Cleveland, OH; and Hazelwood, MO. In this multisite study, omadacycline was tested against 858 Enterobacterales on the VITEK 2 antimicrobial susceptibility test (AST) Gram-negative (GN) card, and the results were compared to the Clinical and Laboratory Standards Institute broth microdilution (BMD) reference method. The results were analyzed and are presented as essential agreement (EA), category agreement (CA), minor error (mE) rates, major error (ME) rates, and very major error (VME) rates following the US Food and Drug Administration (FDA) and International Standards Organization (ISO) performance criteria requirements. Omadacycline has susceptibility testing interpretive criteria (breakpoints) established by the FDA only; nevertheless, the analysis was also performed using the ISO acceptance criteria to satisfy the registration needs of countries outside the United States. The analysis following FDA criteria (including only Klebsiella pneumoniae and Enterobacter cloacae) showed the following performance: EA = 97.9% (410/419), CA = 94.3% (395/419), VME = 2% (1/51), with no ME present. The performance following ISO criteria (including all Enterobacterales tested) after error resolutions was EA = 98.1% (842/858) and CA = 96.9% (831/858). No ME or VME were observed. The VITEK 2 test met the ISO and FDA criteria of ≥ 95% reproducibility, and ≥ 95% quality control (QC) results within acceptable ranges for QC organisms. In June 2022, the omadacycline VITEK 2 test received FDA 510(k) clearance (K213931) FDA as a diagnostic device to be used in the treatment of acute bacterial skin and skin-structure infections caused by E. cloacae and K. pneumoniae, and for treatment of community-acquired bacterial pneumonia caused by K. pneumoniae. The new VITEK 2 AST-GN omadacycline test provides an alternative to the BMD reference method testing and increases the range of automated diagnostic tools available for determining omadacycline MICs in Enterobacterales.

Antimicrobial Activity of an Fmoc-Plantaricin 149 Derivative Peptide against Multidrug-Resistant Bacteria

Antimicrobial resistance poses a major threat to public health. Given the paucity of novel antimicrobials to treat resistant infections, the emergence of multidrug-resistant bacteria renewed interest in antimicrobial peptides as potential therapeutics. This study designed a new analog of the antimicrobial peptide Plantaricin 149 (Pln149-PEP20) based on previous Fmoc-peptides. The minimal inhibitory concentrations of Pln149-PEP20 were determined for 60 bacteria of different species and resistance profiles, ranging from 1 mg/L to 128 mg/L for Gram-positive bacteria and 16 to 512 mg/L for Gram-negative. Furthermore, Pln149-PEP20 demonstrated excellent bactericidal activity within one hour. To determine the propensity to develop resistance to Pln149-PEP20, a directed-evolution in vitro experiment was performed. Whole-genome sequencing of selected mutants with increased MICs and wild-type isolates revealed that most mutations were concentrated in genes associated with membrane metabolism, indicating the most likely target of Pln149-PEP20. Synchrotron radiation circular dichroism showed how this molecule disturbs the membranes, suggesting a carpet mode of interaction. Membrane depolarization and transmission electron microscopy assays supported these two hypotheses, although a secondary intracellular mechanism of action is possible. The molecule studied in this research has the potential to be used as a novel antimicrobial therapy, although further modifications and optimization remain possible.

Traditional Chinese medicine for treatment of sepsis and related multi-organ injury

Sepsis is a common but critical illness in patients admitted to the intensive care unit and is associated with high mortality. Although there are many treatments for sepsis, specific and effective therapies are still lacking. For over 2,000 years, traditional Chinese medicine (TCM) has played a vital role in the treatment of infectious diseases in Eastern countries. Both anecdotal and scientific evidence show that diverse TCM preparations alleviate organ dysfunction caused by sepsis by inhibiting the inflammatory response, reducing oxidative stress, boosting immunity, and maintaining cellular homeostasis. This review reports on the efficacy and mechanism of action of various TCM compounds, herbal monomer extracts, and acupuncture, on the treatment of sepsis and related multi-organ injury. We hope that this information would be helpful to better understand the theoretical basis and empirical support for TCM in the treatment of sepsis.

Respiratory infections

Respiratory infections, whether acute or chronic, are extremely frequent in both adults and children, representing an increased economic burden on healthcare systems, morbidity and mortality. These infections can be either community- or hospital-acquired. Both non-immunosuppressed and immunosuppressed patients can develop such health issues, although prevalence is higher in the latter group. In terms of microbial aetiology, the causative pathogen can be viral, bacterial, fungal or parasitic. In this European Respiratory Review (ERR) series, the authors review some key issues relating to the aforementioned topics.

A new European Respiratory Review series explores respiratory infectionshttps://bit.ly/3A5eN3A