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Ventilator-associated pneumonia: how long is long enough?
Authors:Koulenti D et al
Abstract
Purpose of review: To provide an updated overview of optimal antibiotic duration in ventilator-associated pneumonia (VAP), integrating guideline recommendations, clinical evidence, and expert opinion.
Recent findings: A randomized controlled trial, retrospective studies and meta-analyses support shorter (≤7-8-day) regimens for immunocompetent patients with VAP, reducing toxicity and, potentially, resistance development without compromising outcomes. However, while short-course regimens are increasingly supported, recent trials of newer agents often report durations >7 days, reflecting real-world challenges in resistant pathogens and trial design.
Summary: VAP remains the leading healthcare-associated infection in intensive care units (ICUs), related to worse outcomes and contributing substantially to antimicrobial use. Historically, prolonged antibiotic courses (≥10-14) were standard, particularly for cases involving multidrug-resistant (MDR) or extensively drug-resistant (XDR) organisms. This review synthesizes current evidence supporting shorter course therapy for VAP (≤7-8 days), emphasizing the importance of clinical response and individualization. While guideline convergence on 7-8 days has grown, exceptions apply for specific pathogens (e.g., nonfermenters, MDR or XDR organisms), bacteremia, slow response, or structural lung disease. Biomarkers like procalcitonin may assist in select cases but lack VAP-specific validation. Regular reassessment is essential to balance efficacy with stewardship. Evidence gaps remain for immunocompromised patients and ultra-short regimens.
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Cause and effect? A review of the impact of antibiotics on the gut microbiome in patients undergoing hematopoietic stem cell transplantation.
Authors: Nakagaki M et al
Abstract
Introduction: Patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) are at high risk of infection due to immunosuppression, prompting routine use of prophylactic and broad-spectrum antibiotics for treatment. However, emerging evidence suggests that gut microbiome disruption (dysbiosis), partly caused by antibiotic use, is associated with poorer transplant outcomes, including graft-versus-host disease (GVHD), infection, and mortality.
Areas covered: This narrative review discusses antibiotic use to prevent and treat febrile neutropenia in allo-HSCT recipients, including effectiveness, impacts on microbiome and GVHD, antimicrobial resistance and Clostridioides difficile infection (CDI). It also reviews available strategies to reduce unnecessary antibiotic use and proposes potential future interventions. A comprehensive PubMed search was conducted through 2024 using terms related to HSCT, antimicrobials, microbiome, resistance, and CDI.
Expert opinion: Improving outcomes while minimizing emergence of antibiotic resistance and CDI requires personalized, risk-adaptive antimicrobial stewardship (AMS). Tailored AMS approaches, including patient risk stratification and early de-escalation, could limit unnecessary antibiotic use and mitigate adverse effects. In the future, microbiome preservation and restoration may reduce transplant complications by maintaining colonization resistance and immune balance. Integrating these strategies into allo-HSCT care is essential for optimizing both clinical and microbiological outcomes.
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Recent insights into actinobacteria research in antimicrobial resistance: a review.
Authors:M KR et al
Abstract
Antimicrobial resistance (AMR) has emerged as a global health crisis, taking 4.71 million lives in the year 2021 and posing significant challenges to healthcare systems. Actinobacteria, particularly Streptomyces sp., are a well-established source of bioactive secondary metabolites, including antibiotics such as polyketides, aminoglycosides, and macrolides with activity against multidrug-resistant (MDR) bacteria. However, only 10% of the antibiotic genes are expressed, and others are silent in cryptic biosynthetic gene clusters (BGCs) that remain inactive under standard laboratory conditions. Advances in genome mining, bioinformatics tools like antiSMASH, and molecular techniques such as CRISPR-Cas have facilitated the identification of these clusters. Furthermore, innovative strategies such as co-culturing and HDAC inhibitors have shown promise in activating cryptic biosynthetic pathways to combat emerging antimicrobial resistance. Despite these advancements, the rapid evolution of resistance requires continuous research and global collaboration to ensure a sustainable pipeline of effective antibiotics. This review provides insight into actinobacteria-derived antibiotics, resistance mechanisms, and emerging biotechnological interventions to address the AMR crisis, underscoring the urgent need for multidisciplinary antibiotic discovery and stewardship efforts
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Antimicrobial stewardship in regional hospitals: a human factors evaluation of barriers and facilitators and the role of technology.
DOI: 10.1111/imj.70142
Authors: Van Dort BA et al
Abstract
Background: Antimicrobial stewardship (AMS) programmes aim to optimise antimicrobial prescribing. Regional hospitals have reduced access to resources that are essential for conducting AMS initiatives. Technology has the potential to reduce these challenges if implemented and used effectively. Objective: Identify the barriers and facilitators to successful AMS programmes in two regional hospitals in Australia and explore the role technology played in supporting AMS.
Methods: A contextual inquiry methodological approach was used, including observations and semi-structured interviews with AMS team members in two regional hospitals in Australia. Results: Observations were conducted for 27.5 h and interviews were performed with all AMS team members (n = 4). Electronic medication management and an antimicrobial dashboard were reported to make AMS processes efficient and information accessible. The use of multiple computerised systems and poor interoperability hindered AMS work processes. Executive support, resourcing and building rapport through in-person interactions were reported to influence the success of AMS programmes. Passionate and motivated infectious diseases (ID) consultants drove AMS programmes by building rapport with stakeholders and advocating for resources. COVID-19 was viewed as a facilitator of AMS as it increased the visibility of ID consultants, resulting in improved relationships and additional resources.
Conclusions: Using a small number of interoperable systems can enhance AMS, with tools such as an antimicrobial dashboard proving beneficial for remotely accessing information and reviewing antimicrobials in peripheral hospitals. Essential components for effective AMS programmes include supportive hospital executives and adequate staff resources. Sustaining AMS in regional settings relies on committed ID doctors and strong interdepartmental relationships.
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Antimicrobial resistance in chronic lung infection: the road to resistance.
Authors: Kwok WC et al
Abstract
Background: Antimicrobial resistance (AMR) is a growing global health crisis and is particularly relevant to people living with chronic lung diseases such as bronchiectasis, cystic fibrosis and chronic obstructive pulmonary disease. These conditions frequently involve acute and chronic bacterial infections, requiring increased antibiotic usage and risk of AMR. Understanding the dynamics of AMR and emerging diagnostic and therapeutic strategies is crucial for optimising patient outcomes in this setting.
Aims: This review explores the interplay between AMR and chronic bacterial lung infections, examining current understanding of pathogen epidemiology, diagnostic strategies, clinical implications of resistance and the impact of treatments. Future directions in research and therapeutic innovation are also outlined.
Narrative: Key pathogens in chronic lung infections, such as Pseudomonas aeruginosa, Haemophilus influenzae, Staphylococcus aureus and Moraxella catarrhalis, exhibit diverse resistance mechanisms and AMR is linked to increased disease severity, exacerbation frequency and mortality, particularly with multidrug-resistant strains. Long-term antibiotic therapies, such as macrolides and inhaled agents, improve clinical outcomes but may drive resistance, necessitating ongoing efforts to understand how they can best be employed. Traditional diagnostic methods, such as culture-based antimicrobial susceptibility testing, often fail to capture the complexity of polymicrobial infections and resistomes. Although advanced techniques like next-generation sequencing and metagenomics are able to identify clinically relevant resistotypes, their development toward clinical utility is still in progress.
Conclusions: AMR in chronic lung infections represents a dynamic and multifaceted challenge. Novel antibiotics, precision medicine approaches and alternative therapies such as bacteriophages show promise but require further validation. Improved stewardship and individualised treatment strategies are critical for mitigating AMR and enhancing patient outcomes. Collaborative efforts among researchers, clinicians and policy-makers are vital to advancing care and combating this global threat.
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Timing of Antibiotic Prophylaxis Prior to Abdominal Surgery Has No Impact on Infectious Complications: A Retrospective Matched Cohort Study.
Authors:Cira K et al
Abstract
Objective: To evaluate the impact of perioperative antibiotic prophylaxis (PAP) timing on postoperative infectious complications in abdominal surgery.
Summary background data: Current guidelines advocate strict adherence to predefined PAP timing, yet evidence on its optimal window remains inconclusive.
Methods: This single-center, retrospective matched cohort study, conducted at a high-volume university hospital in Germany (2013-2018), included 1,193 patients undergoing open elective CDC II-III abdominal surgeries. PAP timing was categorized as “on time” (OT: ≥30 m before incision) or “not on time” (NT:<30 m before incision). Propensity score matching (PSM) was applied to both the real-world (RW) cohort and optimized group (10-39 m NT, or 40-69 m OT, excluding infusion time). The primary outcome was the incidence of in-hospital postoperative infectious complications. Results: Of 1,193 patients, 750 (62.9%) received NT and 443 (37.1%) OT-PAP. Infectious complications occurred in 196 patients (16.4%; 229 events), with 41.9% of infection-causing organisms resistant to PAP. Despite matching, differences in ASA grade, malignancy, procedure type, and duration remained. Multivariable analysis identified procedure duration as independent predictor of surgical site infections. PAP timing did not significantly affect outcomes in RW, RW-PSM, or optimized-PSM cohorts, though fewer complications occurred with OT in procedures >200 minutes. Antimicrobial resistance did not alter observed associations.
Conclusion: PAP timing did not significantly affect in-hospital infectious complications following elective open abdominal surgery, and antimicrobial resistance did not confound this association. A rigid time-based approach may be less critical than assumed, warranting individualized strategies based on procedure length and resistance profiles.