Characteristics of and meningococcal disease prevention strategies for commercially insured persons receiving eculizumab in the United States

Emergence of high-level penicillin-resistant Neisseria meningitidis harboring ROB-1-type β-lactamase gene in Japan

While antimicrobial resistance in Neisseria meningitidis, the causative agent for invasive meningococcal disease (IMD), is rare, some meningococcal isolates in Japan were resistant to ciprofloxacin and penicillin (PCG). Among 290 meningococci isolated from 2003 to 2020 in Japan, four PCG resistant (PCGR) meningococci were found but showed the minimum inhibitory concentration (MIC) with 0.5 μg/mL at a maximum due to mutation in penA gene that encodes penicillin-binding protein 2. However, we herein report that PCGR meningococci harboring the ROB-1-type β-lactamase gene (blaROB-1) with PCG MIC of 32 μg/mL were isolated in Japan from 2 independent IMD patients at Tokyo in June, and at Shiga in December in 2024. The both isolates were also resistant to another β-lactams, ampicillin and amoxicillin. The PCGR meningococci with blaROB-1, which was genetically classified in sequence type (ST)-3587, was firstly identified in France in 2018 and isolated only in European and American countries until 2024. Phylogenetic analysis with whole genome sequencing revealed that the two Japanese N. meningitidis isolates were not genetically identical and that they were not identical to other ST-3057 meningococci isolated in western countries. The emergence of the blaROB-1 positive meningococci in Japan would warn medical risk that β-lactams such as PCG and amoxicillin are not always applicable to IMD treatment and prevention in Japan.

Progression of antibiotic resistance in Neisseria meningitidis

SUMMARYThe human pathogen Neisseria meningitidis (Nm) is the causative agent of invasive meningococcal disease (IMD), usually presenting as meningitis, bacteremia, or sepsis. Unlike Neisseria gonorrhoeae, antibiotic resistance in Nm has developed slowly. However, in the last two decades and with the reemergence of IMD following the COVID-19 pandemic, antibiotic-resistant Nm isolates, especially to penicillin and fluoroquinolones, have progressively increased. Recent worldwide studies of penicillin intermediate and resistant Nm isolates and the PubMLST global database reveal a notable increase in fully penicillin-resistant isolates since 2016, mediated by mosaic penA alleles or the β-lactamase genes blaROB-1 and blaTEM-1. Fluoroquinolone-resistant isolates, mediated by gyrA mutations, have increased since 2005. Also, while still exceptionally rare, four Nm isolates have been identified with third-generation cephalosporin-resistance since 2011. We review the emergence of antibiotic resistance determinants and lineages in Nm, the resistance to agents previously or currently used in treatment or chemoprophylaxis, and summarize updated treatment and prevention guidelines for IMD. Special populations (e.g., individuals on complement inhibitors) and antibiotic resistance in Nm urethritis isolates are also reviewed. The increasing number of resistant Nm isolates worldwide affects chemoprophylaxis and treatment options for IMD and emphasizes the need for enhanced global surveillance of antibiotic resistance in Nm.

Recommendations on NMOSD treatment in Latin America: Utilizing consensus-based RAND/UCLA methodology

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a serious condition affecting people worldwide, including Latin America (LATAM). Healthcare disparities and economic limitations make effective treatment access challenging. It is crucial to consider the best practice therapeutic decision-making, including emerging long-term preventive therapies, to ensure patients in LATAM and elsewhere can effectively manage their disease all over the world.

OBJECTIVES/AIMS

To establish evidence-based guidelines for treatment approaches in NMOSD patients in LATAM. A consensus process was conducted to develop validated statements.

METHODS

A group of NMOSD experts from LATAM utilized a 9-point Likert scale to vote on statements related to NMOSD management. The predetermined consensus threshold was set at a minimum expert agreement of 70 %. The RAND/UCLA methodology was employed to reach consensus recommendations.

RESULTS

Nineteen experts completed the consensus process between March and April 2023. In round 1, no statement failed to reach the predetermined consensus, resulting in 31 agreed statements. The statements were divided between general recommendations (14/31) and clinical scenarios (17/31). The scenarios were based on treatment-naïve NMOSD AQP4 positive patients (4/17); treatment-naive seronegative NMOSD patients (4/17); treatment switching (5/17) and safety (4/17).

CONCLUSIONS

Consensus recommendations were developed on the most important areas of NMOSD treatment by a panel of experts in LATAM. These statements are a valuable tool to guide decision-making and improve patient outcomes, serving as the foundation for developing standardized practice guidelines in our region.

Infection prevention in the immunocompromised traveler due to conditions other than transplantation: a review

This narrative review explores the risks related to infection in immunocompromised travelers due to conditions other than transplantation, and evaluates the evidence behind current prophylactic strategies, including immunizations, antimicrobials, and non-pharmacological interventions, to prevent various infection and how the current evidence applies to this special patient population, from the perspective of a US-based traveler.

An evaluation of ravulizumab for the treatment of neuromyelitis optica spectrum disorder

INTRODUCTION

Following the CHAMPION-NMOSD trial, the FDA recently granted approval for ravulizumab, a humanized monoclonal antibody against complement C5 protein in AQP-4 seropositive neuromyelitis optica spectrum disorder (NMOSD). Similar to eculizumab, ravulizumab offers near-complete prevention of NMOSD relapses, but has a longer half-life, providing decreased infusion frequency and increased convenience for patients. While targeting the complement pathway has clear advantages, patients are at risk for infection with encapsulated organisms, in particular Neisseria meningitidis.

AREAS COVERED

In this paper, we discuss the details of the CHAMPION-NMOSD trial and discuss challenges in meningitis prevention and strategies for switching therapies.

EXPERT OPINION

Ravulizumab improves on eculizumab's success as a highly effective NMOSD therapy by decreasing infusion frequency, thereby increasing patient convenience. We predict that ravulizumab will eventually replace eculizumab but may not have a similar impact on inebelizumab or satralizumab. Patients taking C5 complement inhibitors have an increased risk of serious meningococcal infections, such as invasive meningococcal disease (IMD), and have incomplete protection against IMD despite immunization. Thus, we recommend that in addition to standard pre-immunizations against Neisseria meningitidis, patients should also be assessed for starting on appropriate antibiotic prophylaxis against IMD, based on local resistance patterns.

Meningococcal Carriage in Children with Atypical Hemolytic Uremic Syndrome Receiving Eculizumab Therapy

BACKGROUND/OBJECTIVES

Eculizumab is a first-line treatment for atypical hemolytic uremic syndrome (aHUS), and patients undergoing eculizumab therapy may become more susceptible to infection caused by Neisseria meningitidis (Nm). While meningococcal vaccination is required for patients undergoing eculizumab therapy, there is limited knowledge about meningococcal carriage in children with aHUS. We aimed to evaluate (1) the prevalence of Nm carriage, (2) serogroup distribution, and (3) the immunization status of children undergoing eculizumab treatment for aHUS.

METHODS

The Meningo-aHUS study is a prospective, multi-center study evaluating meningococcal carriage in children and adolescents in Türkiye receiving eculizumab for aHUS. We noted the age, gender, daycare, school, or university attendance, passive smoking status, previous infection and antibiotic use, and previous immunization history, including meningococcal vaccines, from the medical records of those children with aHUS. We collected nasopharyngeal samples, tested them for Nm using real-time polymerase chain reaction, and performed a serogroup analysis on the positive samples.

RESULTS

We collected nasopharyngeal samples from 62 children with aHUS. Out of 62 children, 61 (98.4%) had received at least one dose of the meningococcal vaccine. The median time since the last meningococcal vaccine dose was 15 months (1-59 months). We detected meningococcal carriage in three (4.8%, 95% CI 1.0-13.5) children, and all three strains were non-groupable (NG). No other serogroups were detected.

CONCLUSIONS

Almost all the children received their risk-group meningococcal immunization, including booster doses. A 4.8% of children with aHUS carried NG meningococci and, no vaccine serogroups were detected. Patients treated with eculizumab remain profoundly susceptible to IMD due to these NG meningococcal strains. The occurrence of breakthrough cases and carriage of Nm, especially NG strains, highlights the significance of maintaining a state of constant alertness, promptly seeking medical attention, and swiftly treating any symptoms that align with IMD, regardless of their vaccination status or antibiotic prophylaxis.

Safety Profile of Monoclonal Antibodies and Subsequent Drug Developments in the Treatment of Paroxysmal Nocturnal Hemoglobinuria

Paroxysmal nocturnal hemoglobinuria (PNH) is a clonal stem cell disease characterized by intravascular hemolysis due to the targeting of affected red blood cells by the complement system. Eculizumab and ravulizumab are two monoclonal antibodies that inhibit the complement system's components and have been shown to significantly improve survival and quality of life. This review describes the role of these monoclonal antibodies in the treatment of PNH with an emphasis on their safety profile. The challenges in the use of these drugs and new drugs in various stages of drug development are also described, which may be helpful in addressing some of these challenges.

Myasthenia gravis: the changing treatment landscape in the era of molecular therapies

Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. MG is caused by antibodies against the acetylcholine receptor (AChR), the muscle-specific kinase (MuSK) or other AChR-related proteins that are expressed in the postsynaptic muscle membrane. The standard therapeutic approach for MG has relied on acetylcholinesterase inhibitors, corticosteroids and immunosuppressants, which have shown good efficacy in improving MG-related symptoms in most people with the disease; however, these therapies can carry a considerable burden of long-term adverse effects. Moreover, up to 15% of individuals with MG exhibit limited or no response to these standard therapies. The emergence of molecular therapies, including monoclonal antibodies, B cell-depleting agents and chimeric antigen receptor T cell-based therapies, has the potential to revolutionize the MG treatment landscape. This Review provides a comprehensive overview of the progress achieved in molecular therapies for MG associated with AChR antibodies and MuSK antibodies, elucidating both the challenges and the opportunities these therapies present to the field. The latest developments in MG treatment are described, exploring the potential for personalized medicine approaches.

Influence of factors commonly known to be associated with health inequalities on antibiotic use in high-income countries: a systematic scoping review

INTRODUCTION

Inappropriate antibiotic use contributes to antimicrobial resistance. High-income countries have high rates of antibiotic use, with a prevalence of health inequalities amongst populations.

OBJECTIVES

To understand the influence of factors commonly known to be associated with health inequalities on antibiotic use in high-income countries.

METHODS

Factors commonly known to be associated with health inequalities were defined as protected characteristics under UK's Equality Act (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race/ethnicity, religion or belief, sex, sexual orientation), socioeconomic characteristics (income, insurance, employment status, deprivation, education), geography (urban versus rural, region) and vulnerable groups. The study followed PRISMA-ScR and, PRISMA-E statements.

RESULTS

Fifty-eight of 402 identified studies met inclusion criteria. Fifty of those papers (86%) included one or more protected characteristics, 37 (64%) socioeconomic characteristics, 21 (36%) geography and 6 (10%) vulnerable groups. Adults in older age groups, especially those in residential care, had the highest antibiotic use. The influence of race or ethnicity and antibiotic use was particular to country context. Areas of high deprivation had higher antibiotic use compared with areas of no or low deprivation, and geographical variation existed within countries. When faced with health system barriers, migrants relied on alternative routes of antibiotic supply other than prescription.

RECOMMENDATIONS FOR FUTURE RESEARCH

To investigate how factors and wider social determinants of health interplay and impact antibiotic use, using frameworks/approaches to reduce health inequalities such as England's Core20PLUS approach. Antimicrobial stewardship initiatives should equip healthcare professionals to review patients at the highest risk of antibiotic use.

Complement Inhibition in Myasthenia Gravis and Neuromyelitis Optica Spectrum Disorder

The complement system is a tightly controlled signaling network that plays a role in innate immune surveillance. However, abnormal signaling through this pathway contributes to tissue damage in several inflammatory, autoimmune, and degenerative diseases. Myasthenia gravis (MG) and neuromyelitis optica spectrum disorders (NMOSD) have complement dysfunction at the core of pathogenesis, providing a strong rationale for therapeutic targeting of complement components. The purpose of this paper is to briefly review the role of complement activation in the pathogenesis of MG and NMOSD, to discuss the rationale and evidence for complement inhibition as a method to manage these diseases, and to provide a Canadian perspective on the use of complement inhibition therapy through real-world cases of MG and NMOSD.

Penicillin and Cefotaxime Resistance of Quinolone-Resistant Neisseria meningitidis Clonal Complex 4821, Shanghai, China, 1965-2020

Clonal complex 4821 (CC4821) Neisseria meningitidis, usually resistant to quinolones but susceptible to penicillin and third-generation cephalosporins, is increasing worldwide. To characterize the penicillin-nonsusceptible (PenNS) meningococci, we analyzed 491 meningococci and 724 commensal Neisseria isolates in Shanghai, China, during 1965-2020. The PenNS proportion increased from 0.3% in 1965-1985 to 7.0% in 2005-2014 and to 33.3% in 2015-2020. Of the 26 PenNS meningococci, 11 (42.3%) belonged to the CC4821 cluster; all possessed mutations in penicillin-binding protein 2, mostly from commensal Neisseria. Genetic analyses and transformation identified potential donors of 6 penA alleles. Three PenNS meningococci were resistant to cefotaxime, 2 within the CC4821 cluster. With 96% of the PenNS meningococci beyond the coverage of scheduled vaccination and the cefotaxime-resistant isolates all from toddlers, quinolone-resistant CC4821 has acquired penicillin and cefotaxime resistance closely related to the internationally disseminated ceftriaxone-resistant gonococcal FC428 clone, posing a greater threat especially to young children.

Bacterial and Viral Infection and Sepsis in Kidney Transplanted Patients

Kidney transplanted patients are a unique population with intrinsic susceptibility to viral and bacterial infections, mainly (but not exclusively) due to continuous immunosuppression. In this setting, infectious episodes remain among the most important causes of death, with different risks according to the degree of immunosuppression, time after transplantation, type of infection, and patient conditions. Prevention, early diagnosis, and appropriate therapy are the goals of infective management, taking into account that some specific characteristics of transplanted patients may cause a delay (the absence of fever or inflammatory symptoms, the negativity of serological tests commonly adopted for the general population, or the atypical anatomical presentation depending on the surgical site and graft implantation). This review considers the recent available findings of the most common viral and bacterial infection in kidney transplanted patients and explores risk factors and outcomes in septic evolution.

Acquisition of ciprofloxacin resistance among an expanding clade of β-lactamase positive, serogroup Y Neisseria meningitidis in the United States

BACKGROUND

Penicillin and ciprofloxacin are important for invasive meningococcal disease (IMD) management and prevention. IMD cases caused by penicillin- and ciprofloxacin-resistant Neisseria meningitidis containing a ROB-1 β-lactamase gene (blaROB-1) and a mutated DNA gyrase gene (gyrA), have been recently reported in the USA.

METHODS

We examined 2097 meningococcal genomes collected through US population-based surveillance from January 2011-February 2020 to identify IMD cases caused by strains with blaROB-1 or gyrA-mediated resistance. Antimicrobial resistance was confirmed phenotypically. The US isolate genomes were compared to non-US isolate genomes containing blaROB-1. Interspecies transfer of ciprofloxacin resistance was assessed by comparing gyrA among Neisseria species.

RESULTS

Eleven penicillin- and ciprofloxacin-resistant isolates were identified after December 2018; all were serogroup Y, sequence type 3587, clonal complex (CC) 23, and contained blaROB-1 and a T91I-containing gyrA allele. An additional 22 penicillin-resistant, blaROB-1-containing US isolates with wild-type gyrA were identified from 2013-2020. All 33 blaROB-1-containing isolates formed a single clade, along with 12 blaROB-1-containing isolates from six other countries. Two-thirds of blaROB-1-containing US isolates were from Hispanic individuals. Twelve additional ciprofloxacin-resistant isolates with gyrA T91 mutations were identified. Ciprofloxacin-resistant isolates belonged to six CCs and contained 10 unique gyrA alleles; seven were similar or identical to alleles from N. lactamica or N. gonorrhoeae.

CONCLUSIONS

Recent IMD cases caused by a dual resistant serogroup Y suggest changing antimicrobial resistance patterns in the USA. The emerging dual-resistance is due to acquisition of ciprofloxacin resistance by β-lactamase-containing N. meningitidis. Routine antimicrobial resistance surveillance will effectively monitor resistance changes and spread.