Other specific DSP article suggested by Editorial Board
Put your money where your mouth is: surveillance of antibiotic resistance within the commensal Neisseria.
Authors: Regan MR, et al
Abstract
Commensal Neisseria species are major reservoirs of adaptive genetic variation, including antimicrobial resistance, for their pathogenic relatives, yet they remain poorly characterized. This gap limits our ability to anticipate resistance mechanisms that may ultimately emerge in Neisseria gonorrhoeae and Neisseria meningitidis. Here, 166 novel commensal Neisseria isolates collected from 31 study participants were analyzed and minimum inhibitory concentrations (MICs) for seven antimicrobials: azithromycin, cefixime, ceftriaxone, ciprofloxacin, doxycycline, penicillin, and gentamicin was measured. Resistance, defined using the Clinical and Laboratory Standards Institute guidelines, was highly prevalent for azithromycin (76%) and doxycycline (52%), while no resistance to gentamicin was observed. High-level doxycycline resistance was always associated with the inheritance of tetM. Reduced susceptibility to azithromycin was linked to an MtrD K823E substitution, and reduced susceptibility to ciprofloxacin was associated with GyrA T91I (Neisseria subflava) or S91V (Neisseria mucosa). Across all antimicrobials, MICs varied widely, indicating the presence of additional modulating mutations. Finally, the genetic determinants underlying low-level doxycycline resistance and reduced penicillin susceptibility remain unresolved. Overall, here, the authors continue to build on the foundation of surveillance efforts in the commensal Neisseria and continue to flesh out what is known and unknown about this early warning system-or canary in the coal mine-for emerging resistance and clinically consequential evolution in pathogenic Neisseria. IMPORTANCE: Commensal Neisseria species constitute a vast and dynamic reservoir of genetic diversity that can be exchanged with pathogenic relatives, Neisseria gonorrhoeae and Neisseria meningitidis. However, these commensals remain substantially undercharacterized, limiting our ability to anticipate the evolutionary trajectories of antimicrobial resistance in clinically important species. By systematically analyzing commensal isolates and defining phenotypic resistance patterns alongside their genetic determinants, this study, and others like it, function as an early warning system for the emergence and spread of antimicrobial resistance. The high prevalence of azithromycin and doxycycline resistance, identification of specific mutations associated with reduced susceptibility, and evidence of additional unexplained contributors to minimum inhibitory concentration variation highlight both known and cryptic pathways of adaptation. These findings underscore the necessity of integrating commensal surveillance into resistance monitoring frameworks, improving our capacity to forecast clinically consequential evolution and to inform stewardship, diagnostics, and therapeutic development before resistance becomes entrenched in pathogenic Neisseria.
Other specific DSP article suggested by Editorial Board
Impact of a multiplex respiratory PCR panel on antibiotic stewardship in hospitalized pediatric pneumonia: a randomized clinical trial.
Authors: Chen J, et al
Abstract
The aim was to evaluate whether the FILMARRAY® Pneumonia Panel (FAPP) added to standard care could effectively guide antibiotic prescriptions in hospitalized pediatric patients with infectious pneumonia. In this single-center, open-label, parallel-group randomized controlled clinical trial, we enrolled hospitalized children (28 days to 18 years old) diagnosed with infectious pneumonia. Participants were randomized to standard care only (control) or to added FAPP (intervention group). The primary outcome was the proportion of patients with antibiotic change within 72 h. Between December 8, 2021, and February 16, 2023, we enrolled 315 patients (157 in the intervention group and 158 in the control group). Pathogens were detected in 86.6% (32.7% bacterial, 56.5% viral, and 10.9% atypical) via FAPP, which may encompass colonizing organisms due to its enhanced sensitivity. The primary outcome was comparable between the intervention and control groups (51.6%, 81/157, versus 49.4%, 78/158; P = 0.693). However, key exploratory secondary outcomes demonstrated significant improvements in the intervention group: total frequency of changes in antibiotic and antiviral agents based on pathogen results (47.8%, 75/157, versus 25.3%, 40/158; P < 0.001) and proportion of patients with antibiotic de-escalation within 72 h (14.6%, 23/157, versus 1.9%, 3/158; P < 0.001). Conclusion: Integrating FILMARRAY® into pediatric pneumonia clinical management did not significantly boost initial overall antibiotic modification rates. However, exploratory analysis showed it improved targeted antimicrobial adjustments and facilitated antibiotic de-escalation, suggesting FILMARRAY® may add value to antibiotic stewardship. Subsequent trials could substantiate this theoretical proposition.
Other specific DSP article suggested by Editorial Board
Giving Antibiotics a Second Chance: Evolutionary Trade-Offs and Phage-Driven Restoration of Antibiotic Susceptibility.
Authors: Wójcicki M, et al
Abstract
Antimicrobial resistance poses a critical and escalating threat to global public health, driven by the widespread and often unjustified use of antibiotics and the rapid dissemination of resistance determinants. With the antibiotic discovery pipeline largely depleted, alternative and complementary strategies are urgently needed to preserve the effectiveness of existing antimicrobials. Bacteriophages-viruses that specifically infect bacteria-have re-emerged as promising tools not only for direct bacterial eradication but also for reshaping bacterial evolutionary trajectories. This review examines the concept of phage-driven restoration of antibiotic susceptibility, focusing on evolutionary trade-offs that arise when bacteria adapt to phage pressure. Resistance to bacteriophages frequently involves modifications of surface structures, capsules, or efflux systems, changes that often incur fitness costs manifested as reduced virulence, impaired biofilm formation, or increased antibiotic sensitivity. Experimental studies and clinical case reports demonstrate that phage-antibiotic synergy can suppress bacterial growth more effectively than monotherapy, limit resistance emergence, and resensitize multidrug-resistant pathogens to previously ineffective antibiotics. Particular attention is given to mechanisms involving efflux pump targeting, capsule loss, biofilm disruption, and temperate phage-antibiotic interactions. In addition, emerging strategies that combine bacteriophages with CRISPR-Cas systems enable precise targeting and removal of resistance genes, offering a highly selective means to restore antibiotic efficacy and curb horizontal gene transfer. Together, these findings highlight bacteriophages as powerful evolutionary and therapeutic tools capable of giving antibiotics a “second chance”. Integrating phage-based approaches into antibiotic stewardship frameworks may represent a sustainable path forward in combating multidrug-resistant bacterial infections.
Other specific DSP article suggested by Editorial Board
Clinician perspectives on blood culture practice and diagnostic stewardship in regional emergency departments.
DOI: 10.1099/jmm.0.002171
Authors: Thomas E, et al
Abstract
Introduction: Bloodstream infection is a critical cause of morbidity and mortality, and high-quality blood culture practice is essential for accurate diagnosis and antimicrobial stewardship, particularly in regional and remote healthcare settings.
Gap Statement: Clinicians working in rural emergency departments (EDs) encounter unique systemic, workforce and logistical barriers to optimal blood culture practice, yet these challenges are not well characterized in the existing literature.
Aim: To explore clinician-reported barriers and enablers to high-quality blood culture collection across regional EDs in Western Australia.
Methodology: A qualitative study was conducted involving semi-structured interviews with doctors and nurses from three Western Australia Country Health Service EDs. Transcripts were analysed thematically to identify factors influencing blood culture ordering, collection technique, contamination and workflow integration.
Results: Twenty-four clinicians participated, describing substantial delays between sample collection and laboratory processing, difficulty obtaining two sets per episode and limited feedback on contamination or blood volume adequacy. Workforce turnover, variable training and inconsistent guideline use contributed to practice variation. Key enablers included strong team culture, leadership from clinical champions, structured induction, refresher training and the use of dual-set kits and visual dashboards to provide timely, non-punitive feedback.
Conclusion: High-quality blood culture practice in rural EDs is shaped by multifactorial systemic, workflow and workforce constraints and targeted, locally relevant interventions are essential to improve diagnostic yield and strengthen antimicrobial stewardship.
Other specific DSP article suggested by Editorial Board
Implementing portable, real-time 16S rRNA sequencing in the healthcare sector enhances antimicrobial stewardship.
Authors: Cunningham-Oakes E, et al.
Abstract
Background: Antimicrobial resistance (AMR) poses a significant global health challenge, resulting in over 1.27 million deaths in 2019 and is projected to cause up to 10 million deaths annually in the future. To address this issue, the healthcare sector requires rapid (24-72 h) and accurate (to genus or species-level) bacterial identification. 16S ribosomal RNA (rRNA) sequencing using Oxford Nanopore Technology (ONT) was implemented in an NHS setting to enhance diagnostic capabilities, reduce antibiotic misuse and improve patient outcomes.
Methods: ONT-based 16S rRNA sequencing was used on sterile site samples (pus, fluid, tissue) from seven NHS hospitals in Cheshire and Merseyside, England. The assay, validated against Sanger sequencing and MALDI-TOF, had a 24-72 h turnaround. Clinical impact was assessed by tracking antibiotic changes and patient outcomes over several months. Findings: ONT 16S sequencing informed antimicrobial stewardship in 56.9% of cases (124/218). It was mainly used when cultures failed (32.1%) or when patients were already on antibiotics (32.6%). Results often confirmed existing therapy (26.6%) or led to no change (28%) but still supported targeted prescribing. Streptococcus and Staphylococcus were most frequently detected genera, with Streptococcus common in ICU samples. The assay had the highest clinical impact in patients who are immunosuppressed, improving treatment precision.
Interpretation: The integration of ONT 16S sequencing into routine NHS diagnostics has enabled antimicrobial stewardship by offering a faster method with improved taxonomic resolution. Its earlier use in cases where routine cultures are likely to fail may contribute additional microbiological information for antimicrobial decision-making and may reduce diagnostic uncertainty.
Other specific DSP article suggested by Editorial Board
Volume control but structural imbalance: AWaRe-based assessment of antimicrobial stewardship in Shanghai, China (2016-2024).
Authors: Yu Q, et al
Abstract
Background: Recognizing irrational use as the key driver of antimicrobial resistance (AMR), the World Health Organization (WHO) introduced the AWaRe (Access, Watch, Reserve) classification to enhance prescribing structures. This study aims to comprehensively elucidate the long-term trends and structural evolution of antimicrobial use, providing evidence to inform the transition from volume-based control to structure-oriented optimization.
Methods: The Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) method and AWaRe classification were applied to assess the overall antimicrobial use and structural rationality across institutions, and further analyzed concentration indices to reveal clinical dependence on a limited set of agents.
Results: From 2016 to 2024, the overall antimicrobial usage and expenditure decreased by 57.94% and 22.07% with strong concordance. However, the prescribing structure severely deviated from the WHO’s target of ≥ 60.00% Access category. The proportion of Access category remained below 20.00%, while Watch category predominated but declined gradually, and Reserve category remained below 1.00% until a slight rebound after 2023, especially in secondary and tertiary hospitals. The annual top 10 agents consistently accounted for over 50.00%, exhibiting an initial decline in concentration followed by a slight rebound after 2021. In 2016, cefuroxime sodium injection constituted 63.50%, Herfindahl-Hirschman Index (HHI) was 0.41, later becoming more dispersed. Levofloxacin tablets have ranked first in utilization and remained high since 2022, contributing to a rebound in concentration (HHI = 0.06).
Conclusions: Antimicrobial stewardship (AMS) in Shanghai, China has achieved success in controlling volume, but still faces structural challenges. Insufficient Access, prolonged dominance of broad-spectrum Watch, and Reserve slightly rebound suggest potential AMR escalation. It is recommended to implement tiered, structure-oriented strategies and integrate pathogen surveillance with clinical data to assess prescriptions and guide targeted AMR control.