Other specific DSP article suggested by Editorial Board
Strategies to improve antimicrobial stewardship in surgery: insights from an ethnographic study.
Authors: Parker H, et al
Abstract
Background: There is an urgent need to improve surgical antimicrobial stewardship (AMS), to enhance individual care and reduce population-level antimicrobial resistance, but it is a complex issue.
Objectives: The aim was to conduct an ethnographic study asking what would work in practice to improve surgical antibiotic prescribing behaviour?
Methods: Adopting a socio-cultural-historical perspective,the authors undertook ethnographic observations of clinical practice (43.5 hours) and semistructured interviews (n=31) with surgical staff, AMS staff and patients at two English National Health Service hospitals. Interview transcripts and observational fieldnotes were analysed using the Framework Approach. Additionally, stakeholder engagement was integrated throughout to ensure the findings were meaningful. Results: The analysis of all fieldnotes (based on 43.5 hours of observation) and interview transcripts (n=31 from interviews with 31 different participants) identified that, while surgical staff were aware of antimicrobial resistance, they seldom considered AMS urgent or important in the acute setting where lack of time and the desire to mitigate perceived risk often prevailed. Other surgical issues were perceived to dominate senior decision-makers’ focus, thus perpetuating the status quo. Furthermore, attention to AMS was not always prioritised at the organisational level or by resource-limited AMS teams. Consequently, there was an absence of relationships and tools that foreground AMS. Electronic prescribing systems frequently hindered antimicrobial review and exacerbated patterns of siloed inter-disciplinary working, and feedback on antimicrobial prescribing and patient outcomes was largely absent. To improve AMS, surgical teams wanted sustainable improvements which effectively account for the hierarchical relationships, division of labour, rapid workflow and high staff turnover. Infection experts should better integrate into surgical teams to build relationships and trust, and to proactively contribute to patient care.
Conclusions: The data-driven, theoretically informed strategies have been offered to support change. Contextually appropriate improvements that address the status and visibility of AMS in surgery will be key. Further research is needed to assess the impact and sustainability of the suggested approaches.
Other specific DSP article suggested by Editorial Board
The rise of WHO-priority pathogens in central line associated bloodstream infection: Challenging the AWaRe paradigm in critical care.
Authors: Anand G, et al
Abstract
Central line-associated bloodstream infections (CLABSIs) pose a serious threat to critically ill patients, particularly in low- and middle-income countries facing rising antimicrobial resistance (AMR). Integrating WHO’s Priority Pathogen Lists (PPL) and AWaRe antibiotic classification into CLABSI surveillance provides a clinically meaningful framework to guide antimicrobial stewardship and infection control. An observational study was conducted in ICUs from 2021 to 2024. Patients with central lines in situ for ≥ 2 calendar days were evaluated using CDC-NHSN definitions. Isolates underwent antimicrobial susceptibility testing (CLSI M100). Pathogens were classified using WHO PPL 2024 and analysed as per AWaRe categories. Clinical outcomes were correlated with pathogen class and resistance profile. Among 5,398 ICU patients, 102 developed laboratory-confirmed CLABSIs. Of these, 76.5% were caused by WHO-priority pathogens-63 bacterial and 15 fungal. Carbapenem-resistant Klebsiella pneumoniae and Acinetobacter baumannii predominated, especially in trauma ICUs (88.6%, p = 0.0493). Over 95% of bacterial isolates were resistant to all Access and Watch antibiotics, necessitating the use of Reserve agents like colistin. Among fungal isolates, Candida auris emerged as the most resistant species, while C. tropicalis retained full susceptibility. Mortality was 100% in patients infected with high-priority bacterial pathogens and 85.7% with high-priority fungal pathogens. This study is the first to map CLABSIs against the WHO PPL and AWaRe frameworks, highlighting a convergence of high-risk infections, therapeutic exhaustion, and poor outcomes. The findings underscore the urgent need for targeted stewardship, enhanced surveillance, and policy-level AMR interventions in critical care settings.
Other specific DSP article suggested by Editorial Board
Enterococcus thailandicus: Genomic evidence of a potential new player in enterococcal virulence and antimicrobial resistance
Authors:Juan C. Vázquez-Ucha
Abstract
Background: Enterococcus thailandicus has been isolated from animals, fermented foods, wastewater, and humans, but its clinical relevance remains unclear. We investigated the pathogenic potential of E. thailandicus by phenotypic and genomic characterization of two human isolates from acute abdominal infections, complemented by a species-wide comparative genomic analysis of all publicly available E. thailandicus genomes.
Methods: Two E. thailandicus isolates were recovered from patients with acute cholecystitis and small bowel perforation. Species identification was performed by MALDI-TOF MS and ANI analysis, and antimicrobial susceptibility testing was conducted. Whole-genome sequencing (WGS) was performed, followed by in silico analysis of antimicrobial resistance genes, virulence factors, bacteriocins, and plasmid replicons. All available E. thailandicus genomes were included for phylogenetic comparison.
Results: Both clinical isolates were broadly susceptible to antimicrobials. WGS revealed the presence of the ptsD gene (linked to hospital-adapted E. faecium) and the bacteriocin gene enkB in both isolates. One isolate carried the tet(M) gene and a plasmid replicase associated with E. faecium plasmids. Among 46 genomes analyzed, 61% carried ptsD, all carried enkB, and 48% harbored acquired AMR genes, including functional optrA (n=12) and poxtA (n=5), both conferring linezolid resistance. Phylogenetic analysis showed wide genetic diversity with clustering by host or geography, consistent with ecological versatility.
Conclusions : This study reports the first genomic characterization of clinical E. thailandicus isolates, demonstrating its ecological adaptability, opportunistic pathogenic potential, and role as a reservoir of clinically relevant adaptive traits. Expanded genomic surveillance is warranted to clarify its evolutionary trajectory and potential impact on human health.
Other specific DSP article suggested by Editorial Board
Toll-like receptor 5 on monocyte as a biomarker of mortality risk in patients with sepsis.
Authors: Tan, H
Abstract
Objective: To evaluate the expression of Toll-like receptor 5 on monocyte at ICU admission as a potentially novel early screening biomarker to predict the mortality risk of sepsis.
Methods : Patients with sepsis (n = 107), ICU non-septic controls (n = 53) and healthy controls (n = 55) from May 2023 to December 2024 were enrolled. The expression of Toll-like receptor 5 on monocyte were detected by Flow cytometry within 4 h at ICU admission. The efficacy of Toll-like receptor 5 for predicting mortality risk of sepsis were analyzed by receiver operating characteristic curves. The Toll-like receptor 5 was categorized into higher and lower groups on the basis of the cutoff value, and Kaplan-Meier survival rates were analyzed to evaluate the relationship between Toll-like receptor 5 and the mortality risk of sepsis.
Results: Toll-like receptor 5 levels on monocyte at ICU admission in patients with sepsis were significantly higher than those in ICU non-septic patients and the healthy controls. The expression of Toll-like receptor 5 on monocyte in septic non-survivors were significantly higher than that in survivors. Moreover, the AUC of Toll-like receptor 5 (0.6983, P = 0.0006) for predicting mortality risk of sepsis were higher than PCT (0.5741, P = 0.2012) ,CRP (0.5820, P = 0.1582) and WBC (0.6381, P = 0.0172), but lower than APACHE II (0.7101, P = 0.0003) and SOFA score (0.7888, P < 0.0001). The AUC of Toll-like receptor 5 combined with SOFA score for estimating 28-day mortality in septic patients increased from 0.6983 to 0.8030 (P < 0.0001). Toll-like receptor 5, SOFA and APACHE II scores at ICU admission were found to be independent predictors of sepsis 28-day mortality. In addition, septic patients with higher Toll-like receptor 5 level (≥ 2.05) had poorer survival than those with lower levels (< 2.05) (P = 0.0002).
Conclusion: The expression of TLR5 on monocyte at ICU admission were valuable for predicting the mortality risk of sepsis. These findings can be used as a early screening biomarker to predict the mortality risk of sepsis.
Other specific DSP article suggested by Editorial Board
Dissemination of integrons and carbapenemase-encoding genes among multidrug resistant Proteus mirabilis isolated from urinary tract infections in Egypt.
Authors: Zaki, S
Abstract
Background: Proteus mirabilis (P. mirabilis) is an opportunistic pathogen responsible for various community-acquired and nosocomial infections, particularly urinary tract infections (UTIs). Rising resistance to broad-spectrum antibiotics, including carbapenems, is narrowing treatment options and poses a major public health concern. This study aimed to investigate the antimicrobial susceptibility patterns of P. mirabilis isolates obtained from UTI patients. Then, to assess the molecular determinants of carbapenem-resistant isolates with a focus on the role of integrons in resistance gene dissemination.
Methods: A total of 101 P. mirabilis isolates were recovered from 600 urine samples collected from both inpatients and outpatients at Minia University Hospitals, Egypt. The disc diffusion method was utilized for phenotypic identification and to determine the antimicrobial susceptibility profiles of carbapenem-resistant isolates. Subsequently, conventional PCR was performed to screen for eleven carbapenemase-encoding genes, AmpC β-lactamase genes, and integrons.
Results: Among the 101 isolates, 57 (56.4%) were resistant to imipenem, with the majority recovered from inpatients (80.7%) and catheterized patients (56.1%). Carbapenem-resistant isolates exhibited significantly higher resistance rates to ceftazidime (87.7% vs. 27.3%), aztreonam (50.9% vs. 18.2%), and gentamicin (15.8% vs. 0%) compared to carbapenem-sensitive isolates (p < 0.05). Multidrug resistance (MDR) was identified in 93% of the imipenem-resistant isolates. Molecular analysis revealed a predominance of class B metallo-β-lactamases, with, blaVIM−1 (78.9%) and blaNDM (24.6%) being the most common. Additionally, class A and class D carbapenemase genes were detected, although at comparatively lower frequencies. Out of 101 isolates, 39 (38.6%) were identified as ESBL producers, of which 13 (33%) were positive for either the blaTEM or blaSHV gene. AmpC β-lactamase gene (blaFOX) was identified in 7.9% of isolates. Integrons were widespread, with intI1 present in 91.2% and intI2 in 47.4% of resistant isolates. Notably, co-carriage of three or more carbapenemase genes was observed in 64.9% of resistant isolates, all of which exhibited MDR phenotypes.
Conclusion: Carbapenem resistance in P. mirabilis is highly prevalent and strongly linked to MDR, integron carriage. This reflects the ongoing evolution of antibiotic resistance and the key function of integrons in spreading resistance genes. The detection of isolates carrying several carbapenemase genes simultaneously is particularly worrisome. These findings highlight the importance of implementing antimicrobial stewardship alongside ongoing molecular surveillance to effectively track and control the spread of resistant strains.
Other specific DSP article suggested by Editorial Board
The effect of a 5-day course of azithromycin on Streptococcus pneumoniae carriage and antimicrobial resistance among Kenyan children discharged from hospital
Authors:Tanya E Libby
Abstract
Background: Mass azithromycin distribution reduces child mortality in some settings, potentially through reductions in nasopharyngeal carriage of Streptococcus pneumoniae, but has been associated with increased antimicrobial resistance. Individual-level data are lacking on the impact of azithromycin on antimicrobial resistance over time.
Methods: We analyzed data from a double-blind, randomized placebo-controlled trial (ClinicalTrials.gov; NCT02414399) which followed 1,398 hospitalized Kenyan children to evaluate the impact of a 5-day course of oral azithromycin at discharge from hospital on pneumococcal carriage and the proportion of isolates (among a random sample) resistant to azithromycin. Randomization to azithromycin or placebo (1:1) was stratified by enrollment county (Kisii or Homa Bay). Using generalized estimating equations, we calculated prevalence ratios (PRs) and 95% confidence intervals for the intervention, adjusting for enrollment site.
Results: Overall, 1,253/1398 (89.6%) enrolled children received antibiotics during their hospitalization. Pneumococcal carriage at discharge was similar among children randomized to the azithromycin group (158/702 [22.5%]) compared to the placebo group (171/696 [24.6%]; p = 0.4) and did not differ at month 3 (65.6% vs 67.0%; PR:0.98[0.90, 1.06]) or month 6 (66.7% vs 66.5%; PR:1.00[0.92, 1.08]). At discharge, 15.7% of isolates were resistant to azithromycin and there was no difference between azithromycin-treated and placebo groups at month 3 (35/266 [13.2%] vs 32/256 [12.5%]; PR:1.06[0.86, 1.66]) or month 6 (41/245 [16.7%] vs 43/243 [17.6%]; PR:1.01[0.69,1.49]).
Conclusions: Azithromycin treatment did not effect pneumococcal carriage or antimicrobial resistance 3- or 6-months post-randomization. High inpatient antibiotic use in this recently discharged population may have reduced any further impact of azithromycin.”