Chlamydia trachomatis infection and syphilis, and approximately 50% reduction in Neisseria gonorrhoeae infection. Doxycycline PEP was not demonstrated to be effective in reducing C. trachomatis and N. gonorrhoeae infection among Kenyan cisgender women. Although no worrisome trends in antimicrobial resistance (AMR) were observed in the trials, important concerns remain about doxycycline PEP and AMR development in STIs, other pathogens, commensals, and the microbiome. Tetracycline resistance in N. gonorrhoeae is already widespread in South Africa, but emergence of AMR in other STIs would be concerning. Larger sample sizes of doxycycline PEP users with longer follow-up time are needed to understand the impact that doxycycline PEP may have on AMR at individual and population level. In this opinion article, we weigh the benefits of doxycycline PEP for prevention of bacterial STIs against the existing AMR concerns and data gaps in the South African context. Based on the current evidence, we conclude that it would be reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis, provided that it is offered by experienced sexual health clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.South Africa has a large burden of bacterial sexually transmitted infections (STIs) with high rates among men who have sex with men (MSM). Randomised controlled trials have recently demonstrated high effectiveness of doxycycline post-exposure prophylaxis (PEP) for prevention of bacterial STIs in MSM, with 70% – 85% reductions in  What this study adds: This opinion article discusses doxycycline post-exposure prophylaxis (PEP) in the context of the South African healthcare system. Benefits and concerns of doxycycline PEP are discussed, and recommendation for implementation in controlled settings is provided.Chlamydia trachomatis, 2.2m new cases of Neisseria gonorrhoeae and 47 500 new cases of active syphilis infection occur in men in South Africa.1 In women, the estimated number of annual new cases is 1.9m of C. trachomatis, 2.3m of N. gonorrhoeae, and 23 175 of active syphilis.1 Men who have sex with men (MSM) are disproportionally affected. Prevalence estimates for C. trachomatis (12% – 26%), N. gonorrhoeae (8.1% – 28%) and active syphilis (5.2% – 17%) reported in research studies of MSM exceed that of the general male population   worldwide. Estimates of the World Health Organization (WHO) Spectrum STI model are that each year 3.9 million new cases of ctively) ; MycoplaInterventions are urgently needed to reduce the burden of STIs, associated morbidity and potential impact on HIV transmission. Recently, several randomised controlled trials (RCT) have reported on doxycycline prophylaxis as an effective, well-tolerated, and acceptable novel biomedical approach to prevent bacterial STIs among MSM. We discuss the effectiveness, concerns about antimicrobial resistance (AMR), and considerations for implementation of doxycycline prophylaxis for bacterial STIs in South Africa.7 Its liposolubility ensures high bioavailability and high tissue and fluid penetration. For STI post-exposure prophylaxis (PEP), a single dose of 200 mg doxycycline was used, ideally to be taken within 24 h (maximum 72 h) after condomless sex.9Doxycycline is a bacteriostatic antibiotic, a second-generation tetracycline with broad antibacterial spectrum that acts on the ribosomal protein synthesis unit.10Doxycycline (100 mg twice daily) is used for syphilis treatment of non-pregnant adults in the South African syndromic regimen for genital ulcer disease due to global benzathine benzylpenicillin shortage.C. trachomatis and M. genitalium in the syndromic regimen for genital discharge,10 in case of diagnostic test, the Southern African HIV Clinicians Society’s guidelines recommend doxycycline for first-line pathogen-directed treatment of C. trachomatis, and as part of the sequential therapy regimen for documented symptomatic M. genitalium infection.11 Doxycycline is not recommended for N. gonorrhoeae due to the high levels of antimicrobial resistance (AMR), with up to 90% of strains being resistant to tetracyclines.14Although azithromycin covers 15Other than STIs, doxycycline is used at the primary healthcare level for treatment of acne vulgaris, tick bite fever, in patients with an acute exacerbation of chronic obstructive pulmonary disease who have severe penicillin allergy, and as malaria prophylaxis.19 The IPERGAY trial from France reported a 47% reduction in STI incidence in the doxycycline PEP group of MSM taking HIV pre-exposure prophylaxis (PrEP).16 The relative reduction was almost 70% for C. trachomatis and syphilis, but there was no reduction in N. gonorrhoeae. The DOXYVAC trial by the same investigators observed similar reductions in STI in MSM taking HIV PrEP and with a history of STI treatment with an 84% reduction in C. trachomatis and syphilis and 51% reduction in N. gonorrhoeae.17Three RCTs have demonstrated the efficacy of doxycycline PEP for STI prevention in MSM and one in women .16,17,1818 Participants received three bottles of 30 doxycycline tablets and were counselled to take 200 mg of doxycycline, ideally within 24 h but no later than 72 h after condomless anogenital, vaginal, or oral sex, and not more than one dose every 24 h. In persons taking HIV PrEP, doxycycline PEP reduced syphilis by 87% and chlamydia by 88% while reductions of 77% in syphilis and 74% in chlamydia were observed for PLHIV. Unlike the IPERGAY trial, this study showed a reduction of N. gonorrhoeae incidence of 55% in PrEP users, and 57% among PLHIV. Some of the variability in the efficacy of doxycycline PEP against N. gonorrhoeae in the two French trials compared to the DoxyPEP trial in the US could be explained by the lower background level of doxycycline resistance in the US compared to France at the time of the trials, and that DoxyPEP trial participants were permitted to have more doses than in IPERGAY.20The DoxyPEP trial in the United States (US) of MSM and transgender women (TGW) with a history of STIs in the prior year also showed reductions in STI incidence among those using HIV PrEP  and in people living with HIV (PLHIV) .19 A nonsignificant decrease in C. trachomatis was observed, but the number of N. gonorrhoeae cases increased in the doxycycline PEP arm. Furthermore, only one case of syphilis occurred during the study period, making it impossible to draw conclusions on the effectiveness against syphilis. Various explanations for the lack of efficacy in these young women are under investigation; initial results indicate adherence is a major factor with approximately half of 50 randomly selected participants having a hair sample with detectable doxycycline.21Unlike the efficacy observed in the three trials among MSM, the dPEP Kenya trial did not show efficacy of doxycycline PEP in cisgender women (18–30 years).20 The IPERGAY and DoxyPEP trials did not observe a statistically significant increase in doxycycline resistance in N. gonorrhoeae strains although the sample sizes were small and with relatively short follow-up (median of 9 months).18 Similarly, oropharyngeal commensal Neisseria species, which may constitute a risk for AMR through horizontal gene transfer, did not significantly increase between baseline (63%) and follow-up (70%) in the doxycycline PEP arm in the DoxyPEP trial.22 However, the impact of doxycycline PEP on AMR in N. gonorrhoeae may be limited in South Africa as studies report that 74% – 89% of N. gonorrhoeae strains are already resistant to tetracyclines.14 Also, hypothetical concerns about co-selection of resistance to other classes of antibiotics may be limited given that most N. gonorrhoeae strains already have the putative tet(M) and rpsJ V57M mutations.23The main concern about doxycycline PEP is the effect it may have on AMR, other bacterial pathogens, and on the human microbiome.C. trachomatis and T. pallidum despite widespread use of doxycycline for these infections.20 Rare reports of treatment failure have been published.20 Resistance could theoretically emerge through single-point mutations or gene transfer, but this is generally considered unlikely.22M. genitalium has the potential to acquire tetracycline resistance given that this organism has a history of rapidly acquiring resistance mutations. Despite the low rate (< 2%) of resistance to azithromycin,25 previously as stand-alone treatment, sequential therapy of doxycycline followed by azithromycin or moxifloxacin is now recommended to avoid further emergence of AMR.11 The effects of doxycycline PEP on development of AMR in M. genitalium are unknown but warrant close monitoring.There is little evidence of AMR in 20 Data from a limited number of prospective studies suggest that treatment with oral tetracyclines for 2–18 weeks may increase resistance in the bacterial flora, although the effects may be modest and transient.26 The effects of doxycycline PEP on the microbiome may be different than when used daily for treatment; for example, the median number of pills taken in the DOXYVAC trial was 7 per month (interquartile range [IQR]: 4–11) and 4 per month (IQR: 1–10) in the DoxyPEP trial.18 Nevertheless, the DoxyPEP trial reported a decrease from 42% to 29% in nasopharyngeal carriage of S. aureus in a small sample of doxycycline PEP users, with an increase from 4% to 12% in the proportion of doxycycline-resistant strains between baseline and 1 year follow-up.22 The DoxyPEP study reported a persistently high (> 80%) prevalence of nasopharyngeal commensal Neisseria species in the doxycycline PEP arm, also with a nonsignificant increase in proportion of doxycycline-resistant isolates (63% to 70%).22 Studies with larger sample sizes and longer follow-up time are required to better understand impact of doxycycline PEP on STIs, other pathogens and the microbiome. This could be done by close monitoring and AMR surveillance of indiviudals using doxycycline PEP in health programmes.Treatment with tetracyclines has been associated with AMR in ‘bystander’ respiratory and gastrointestinal tract pathogens.7 Randomised controlled trials have shown efficacy of doxycycline PEP for STI prevention in MSM, but not in young cisgender women, while efficacy has not been evaluated in female sex workers and men who are not MSM.18 Therefore, consideration of doxycycline PEP for STI prevention should be limited to MSM at this stage.Doxycycline is a well-known, well-tolerated antibiotic that has been used for decades in the treatment of infectious diseases.18 The preventive effect would be predominantly to reduce C. trachomatis and T. pallidum infections due to the high rate of tetracycline resistance in N. gonorrhoeae.14 Given the high burden, associated morbidity and effects on HIV transmission, the efficacy of doxycycline PEP, and the limited alternative preventive options available, it would be reasonable to offer doxycycline PEP for primary STI prevention as part of a comprehensive sexual health package to high-risk MSM.Incidence of STIs in MSM in South Africa are higher than reported in the trials, suggesting that the number needed to treat to prevent one STI may be smaller than 4.7 in MSM on HIV PrEP and 5.3 in PLHIV, as reported in the DoxyPEP trial.C. trachomatis and N. gonorrhoeae infection as well as syphilis serology.11 Diagnostic tests for STIs are not routinely available in South Africa, but there are settings where access to diagnostic tests can be organised, for example in the private sector, research studies and implementation demonstration projects. Importantly, access to diagnostic STI testing and biomedical preventions for MSM are key objectives of the WHO’s Global Health Sector strategies on HIV, viral hepatitis and STIs,27 as well as the National Strategic Plan for HIV, tuberculosis and STIs 2023–2028.28Diagnostic STI testing should be performed before prescribing doxycycline PEP to avoid suboptimal treatment and potentially driving AMR of any undiagnosed prevalent infection. Resources permitting, diagnostic testing should include sensitive nucleic acid amplification tests for oropharyngeal, urethral, and anorectal 20 The impact of doxycycline PEP on AMR in N. gonorrhoeae may be relatively small given that most strains are resistant to tetracyclines.14 Emergence of doxycycline resistance in other STIs, especially M. genitalium, would be highly concerning given the limited treatment options available. Therefore, we recommend that doxycycline PEP is offered in well-controlled settings and with access to diagnostic testing (including AMR) by clinicians with expertise in STI management.There are many unanswered questions and genuine concerns about the long-term effects of doxycycline PEP on AMR in STIs, other pathogens and the microbiome.13 Furthermore, tetracyclines are used widespread as the primary antibiotic in agriculture;29 this may have more impact on driving population-level AMR than the effects of doxycycline PEP use by a small subgroup. On the other hand, intensive use of doxycycline in a small core group of users may select or induce AMR in pathogens that could subsequently spread to the general population.18 Although no worrisome trends in AMR were observed in the doxycycline PEP trials, further research is warranted to better understand the effects of doxycycline PEP on tetracycline resistance at both the individual and population level.The potential effects of doxycyline PEP on AMR in other pathogens and the microbiome should be considered in the South African context. Doxycycline has only a few indications, alternative treatment options are generally available and AMR development is unlikely .32 In the absence of long-term data regarding the impact of doxycycline PEP on AMR and the microbiome, the Centers for Disease Control and Prevention (CDC) provides considerations to healthcare providers to inform decision-making on a case-by-case basis, and additional guidelines are anticipated later in 2023.33 The Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine is planning to convene a forum in 2023 to provide evidence-based guidance and recommendations.9 The British Association for Sexual Health and HIV and the United Kingdom (UK) Health Security Agency do not endorse doxycycline for STI prophylaxis for lack of data about AMR, while other countries are waiting for further data before making formal recommendations.34 The WHO has not yet issued any statement.Globally, the balance between effectiveness of doxycycline PEP and AMR concerns is weighed differently. The San Francisco Public Health Unit, the California Department of Public Health and the Public Health Seattle & King Country in the US recommend doxycycline PEP use by MSM and TGW with a recent history of STI.35 However, at this stage, there is insufficient evidence to recommend daily doxycycline PrEP.Doxycycline PrEP (200 mg daily) is being evaluated as an alternative to PEP. One Canadian RCT comparing doxycycline PrEP and doxycycline PEP has started and an Australian study is giving MSM the option of doxycycline PEP or PrEP. These studies follow a pilot RCT that showed a 73% reduction in bacterial STIs in a sample of 30 MSM.Doxycyline PEP is a novel and effective preventive intervention that could substantially reduce the high STI burden and associated morbidity in MSM in South Africa. These STI prevention benefits should be weighed against the largely unknown risks and potential future harms of AMR. In the absence of current local doxycycline PEP data, it is essential that South Africa builds expertise in doxycycline PEP provision and improves STI and AMR surveillance. Based on current evidence, we think it is reasonable to offer doxycycline PEP to high-risk MSM on a case-by-case basis following comprehensive sexual health counselling by experienced clinicians in settings that have access to diagnostic STI testing and ongoing AMR surveillance.


The area under the ROC curve (AUC) value of the LUS on the fourth DOL was 0.94 (95% CI: 0.93–0.99) in predicting hsPDA. The LUS threshold at 33 achieved 89% sensitivity and 83% specificity, with the positive and negative predictive values (PPV and NPV) being 87 and 86%, respectively. The LUS can predict hsPDA in extremely preterm infants at an early stage.Lung ultrasound (LU) is increasingly used to diagnose and monitor neonatal pulmonary disorders; however, its role in hemodynamically significant patent ductus arteriosus (hsPDA) has not been elucidated. This prospective study investigated the predictive value of the LU score (LUS) for hsPDA in preterm infants with gestational age (GA) ≤ 25 weeks. Preterm infants with GA ≤ 25 weeks were enrolled in this study. LU was conducted on the fourth day of life (DOL). Six lung regions in every lung were scanned, with each region rated as 0–4 points. The performance of the LUS in predicting hsPDA among infants aged ≤25 weeks was analyzed by plotting the receiver operating characteristic (ROC) curve. A total of 81 infants were included in this study. GA, birth weight (BW), gender, Apgar score, delivery mode, antenatal steroids, meconium-stained amniotic fluid, premature rapture of membrane, and early-onset sepsis were not significantly different, but infants in the hsPDA group had increased LUS (38.2 ± 2.8 vs. 30.3 ± 4.3,  For fetuses, lungs that are filled with fluid show great vascular resistance, while their systemic circulation exhibits a low vascular resistance; as a result, the fetal circulation displays a right-to-left shunting feature. After birth, adaptation of the circulatory system is decided by closure of the ductus arteriosus (DA) in the early days of life (DOL). As for preterm infants, their DA may usually not close due to smooth muscle immaturity or biochemical oxygen-sensing mechanisms . The incThe maturation level is associated with the course of PDA closure. Hypoxia and immaturity of the ductal closure mechanism interfere with closure progress . PersistAt present, PDA is mainly assessed using echocardiography, which requires considerable expertise, and these skills cannot be acquired quickly. Lung ultrasound (LU) is used to diagnose and manage newborn diseases, and a guideline for LU has also been put forward for standardizing the approach . LU can This study was approved by the Ethics Committee of the hospital (No. SFYLS2019119). Immediate families or guardians of children provided informed consent before LU. All methods were performed in accordance with the Declaration of Helsinki.+6 weeks of GA who were admitted to the Department of Neonatology Intensive Care Units (NICU) after obtaining consent from their parents before and after delivery. The inclusion criteria were as follows: premature infants with a GA ≤ 25+6 weeks and those born in our hospital. Newborns with congenital heart disease (CHD) evidenced by cardiac ultrasound , those developing congenital abnormalities or additional chromosome abnormalities detected before delivery, and those showing pulmonary hemorrhage or pneumothorax were excluded from the present work. In addition, the potential causes of extravascular lung fluid increase were also considered, for example, hypoalbuminemia, premature rupture of membrane (PROM) > 18 h, early-onset sepsis (EOS), meconium-stained amniotic fluid (MSAF), mechanical ventilation (MV), acute kidney injury, and volume overload.This prospective observational study (July 2019–June 2022) was conducted at Shenzhen Maternity and Child Healthcare Hospital affiliated with Southern Medical University, a hospital with an annual number of deliveries of nearly 20,000. LU was conducted in preterm newborns born at ≤25Infants in the NICU underwent echocardiographic examinations on the fourth DOL by a sonographer, and echocardiographic examinations followed the LU scanning. The following examinations were performed: narrowest ductal diameter determined based on parasternal short axis view; ductal flow velocity determined according to ductal flow based on parasternal short axis view; ratio of left atrium-to-aortic root determined based on parasternal long axis; and descending aortic flow evaluated distal to DA origin . In this study, non-identifiable flow within the DA detected based on color Doppler was deemed as ductal closure .In our NICU, the preterm infant has an umbilical artery or peripheral artery catheter for invasive monitoring of blood pressure (BP) early postnatally, with the tip lying in the descending aorta near the DA insertion. Invasive BP was monitored following standard neonatal intensive care using a Dräger Vista 120 patient monitoring system . In addition, this study localized the BP transducer to the cardiac level. To guarantee a favorable quality signal, a visual assessment of the BP waveforms was performed on the monitor screen.Integrative echocardiographic examination includes the evaluation of ductal features, pulmonary over-circulation parameters, and systemic hypoperfusion signs. The hsPDA displays clinical characteristics of elevated oxygen demand and respiratory support, frequency and degree of apnea, tachypnea, tachycardia, feeding intolerance, abdominal distension, radiological findings showing pulmonary edema and cardiomegaly, oliguria, and diastolic/mean hypotension with or without metabolic acidosis that requires cardiotonic or vasopressor agents. A thorough echocardiographic assessment was conducted to eliminate pulmonary hypertension or possible congenital heart defects before any intervention to close the PDA ,17. ThisLU was scanned on the fourth DOL by an experienced sonographer, using a standardized protocol that was blinded to the clinicians. Two evaluators, who were blinded to the clinical details, were responsible for assessing each image. The hsPDA was determined by a neonatologist who was blinded to the LUS. Moreover, LU was performed using a commercial portable US device  with the “hockey stick” microlinear probe . Lung partition: This study scanned the anterior, lateral, and posterior regions of the chest wall. The hemithorax was divided into six areas , including the upper and lower anterior/lateral/posterior areas . The scaA 5-grade scale  was usedt-test, chi-square test, Mann–Whitney test, and Fisher’s exact test, were conducted between the hsPDA and non-hsPDA groups. The predictive performance of the LUS in hsPDA was analyzed by plotting the receiver operating characteristic (ROC) curve, and areas under the ROC curves (AUCs) and cutoff values were determined. Each test was two-sided, with p < 0.05 indicating statistical significance.SPSS23.0  was used for statistical analysis. Demographic information, clinical features, and echographic features were summarized. First, the Kolmogorov–Smirnov test was applied to test data normality, which was then represented as the mean  or median . Univariate analyses, including the Student’s ncss.com/software/pass).This study determined the sample size as follows. The incidence of hsPDA 1 year prior to this study was approximately 55% in the NICU, as indicated by our predetermined inclusion criteria. The sample size was calculated according to the simple random sampling formula, with α = 0.05 and δ = 0.12. A design effect of 1.2 yielded an effective sample size of 80, indicating that 80 newborns were required. Analyses were performed using power analysis and sample size (PASS) software . Ultimately, 81 infants were included in this study. During the study period, 92 eligible preterm infants with a GA ≤ 25p < 0.001) compared with the non-hsPDA group. The average time taken for LU scanning was four minutes, compared to six minutes for cardiac ultrasound examination. No prophylactic indomethacin or ibuprofen was administered. All infants in the hsPDA group received medical treatment, and 14 of them received surgical treatment.There were 35 cases in the non-hsPDA group, with a median GA of 25 weeks , mean BW of 718 ± 109 g, and mean LUS of 30.3 ± 4.3. There were 46 cases in the hsPDA group, with a median GA of 24.8 weeks , mean BW of 688 ± 110 g, and mean LUS of 38.2 ± 2.8. There were no cases of hydrops fetalis in this study. There were no significant intergroup differences in GA, BW, sex, Apgar score, delivery mode, antenatal steroids, premature rupture of membrane (PROM) > 18 h, EOS, or MSAF between the two groups, whereas the LUS was significantly different between the two groups. Infants in the hsPDA group had an increased LUS , while when the LUS threshold was set at 33, it achieved a sensitivity of 89%, specificity of 83%, and positive/negative predictive value (PPV/NPV) of 87% and 86%, respectively (ROC curve analysis was also performed to assess whether the LUS could predict hsPDA. The result revealed that the AUC was 0.94 (95% confidence interval [CI]: 0.89–0.99; ectively . FinallyPDA is the most frequently observed cardiac disease among newborns with GA ≤ 25 weeks. Accurate early prediction of hsPDA can assist clinicians in identifying high-risk newborns, possibly benefiting from targeted treatment. Echocardiography is the conventional evaluation method and requires considerable expertise and experience. In this prospective study, it was found that the LUS on the fourth DOL provided an excellent prediction of hsPDA in preterm newborns with GA ≤ 25 weeks. The LUS is clearly different in hsPDA than in non-hsPDA. To the best of our knowledge, the present study is the first to prospectively suggest that the LUS can help predict hsPDA in preterm infants with GA ≤ 25 weeks with a very high degree of precision.Lower GA and BW indicate higher incidence rates of PDA and hsPDA ,21. For LU is a convenient bedside imaging technique with high safety, non-invasiveness, ease of operation, and no ionizing radiation. In the last 10 years, LU has been widely adopted for the diagnosis and monitoring of neonatal pulmonary lesions. Moreover, LU has been used as a “functional” tool to quantify pulmonary pathological features and predict clinical treatment ,14,15,25Brat et al. first described the classic neonatal LUS strategy . Each luA previous study showed that the number of B-lines can reflect the pulmonary water content . The preThe LU scan was conducted on the fourth DOL. Owing to the rapidly declining pulmonary artery pressure following birth, it remained at a normal level at 72 h . In factIn this study, each hemithorax was classified into six regions. A 5-grade scale  was usedWill extended consolidations in a lung area delay ductus closure? There are still difficulties in reaching a conclusion. Firstly, the GA of infants was ≤25 weeks in this study, and in our experience, extensive consolidation is very common in these infants. In addition, extended consolidation is often a consequence of hsPDA rather than a cause of hsPDA. Finally, extended consolidation can cause hypoxemia, which may delay ductus closure. More research is needed in the future to investigate the impact of extended consolidation on ductus closure in clinical practice.Echocardiography is the conventional evaluation method for PDA. To properly utilize echocardiography results in clinical decisions, it is necessary to possess specific echocardiography expertise and substantially understand cardiovascular disease. Therefore, physicians involved in echocardiography research must possess extensive skills that cannot be acquired rapidly. Specifically, the physician in charge of echocardiography implementation and interpretation should focus on relevant techniques for evaluating data quality and making appropriate conclusions in diagnosis . The shuAccording to our study, the LUS allows for semi-quantitative evaluation of pulmonary edema levels, which can predict hsPDA at an early stage of life in extremely preterm infants. Some limitations of the present study should be noted. First, no consensus has been reached regarding the LUS strategy. There are variations in the LUS system for preterm infants among clinical units. Second, the present unicentric study had a low sample size. Multicenter studies with larger sample sizes are needed to validate our findings. Third, the LUS is a semi-quantitative evaluation of lung function, and the score may be impacted by the operator’s subjective factors.In conclusion, the LUS can predict hsPDA in extremely preterm neonates at an early stage.


In this research study, we developed hybrid resorbable three-dimensional (3D)-printed mesh/electrospun nanofibrous biomolecule-eluting mats for alveolar ridge preservation. The fabrication process involved the use of 3D printing and coaxial electrospinning technologies. Specifically, we utilized a lab-developed solution-extrusion 3D printer to fabricate polycaprolactone (PCL) meshes. Then, bi-layered poly(lactic-co-glycolic acid) (PLGA) nanofibrous membranes, which embedded ibuprofen and epidermal growth factor (EGF), were prepared utilizing electrospinning and coaxial electrospinning techniques, respectively. To ensure the quality of the produced mesh and spun nanofibers, we carried out a characterization process. Furthermore, we estimated the in vitro and in vivo release characteristics of ibuprofen and EGF, respectively, using high-performance liquid chromatography and enzyme-linked immunosorbent assays. In addition, we assessed the effectiveness of hybrid nanofibrous mats for preserving the alveolar ridge by adopting an animal model and conducting a histology examination. The study findings demonstrate that the nanofibrous mats provided a continuous discharge of ibuprofen and EGF for more than four weeks. Moreover, the animal test carried out in vivo showed that animals implanted with this combination of mesh and drug-eluting mats displayed considerably greater mobility than those without mats. The histological analysis revealed no unfavorable impacts from the drug-eluting mats. Our study demonstrated the successful fabrication of resorbable drug-eluting nanofibrous mats for alveolar ridge preservation by utilizing both 3D printing and coaxial electrospinning technologies. In our routine dental practice, alveolar ridge preservation (ARP) has been proposed as a post-extraction treatment to minimize the physiologic changes of the alveolar ridge surrounding the extraction socket, reduce the need for auxiliary ridge augmentation procedures, and enhance therapeutic predictability ,2,3. ThiThe evolution of modern technology has stimulated a keen interest in determining the most suitable materials and techniques for ARP . HoweverWe have engineered a novel approach for alveolar ridge preservation by the integration of three-dimensional (3D)-printing and electrospinning/coaxial electrospinning processes. Our solution involves the production of hybrid resorbable membranes that release biomolecules, utilizing polycaprolactone (PCL) meshes fabricated via a lab-developed solution extrusion 3D printer and bi-layered poly(lactic-co-glycolic acid) (PLGA) nanofibrous membranes that are loaded with ibuprofen and epidermal growth factor (EGF) through electrospinning and co-axial electrospinning techniques, respectively.Three-dimensional printing is widely recognized as an innovative technology that has the potential to address complex biomedical challenges . The verWith a melting temperature of 59–64 °C and a glass transition temperature of −60 °C, PCL is a semi-crystalline polymer that is widely used in the production of resorbable sutures, regenerative therapy scaffolds, and drug delivery systems because of its biocompatibility and non-toxic properties. The aliphatic ester linkage in PCL is subject to hydrolysis under physiological conditions, allowing for its absorption either through microorganisms or over an extended period of more than two years . PLGA isIbuprofen belongs to a class of nonsteroidal anti-inflammatory drugs (NSAIDs) commonly used to alleviate pain associated with a range of conditions, including but not limited to headaches, dental pain, menstrual cramps, muscle aches, and arthritis. In the field of dentistry, ibuprofen has been widely prescribed for post-operation analgesics ,23. Its Following fabrication, the printed mesh and spun nanofibers were subjected to comprehensive characterization of their properties. The in vitro and in vivo release kinetics of ibuprofen and EGF incorporated in the nanofibers were determined using high-performance liquid chromatography (HPLC) and enzyme-linked immunosorbent assays (ELISA), respectively. Furthermore, the efficacy of the hybrid nanofibrous mats in preserving the alveolar ridge was assessed on a rat model, and the activities of the implanted rats were evaluated. Additionally, a histological assay was conducted to further elucidate the results.In this study, PCL (molecular weight: 80 kDa) was used for the mesh material, and dichloromethane (DCM) was adopted as the solvent, both of which were purchased from Sigma-Aldrich . The nanofibers comprised PLGA with a molecular weight of 33,000 Da and a 50:50 ratio of lactic acid to glycolic acid, using hexafluoroisopropanol (HFIP) from Sigma-Aldrich as the solvent. Recombinant enhanced green fluorescent protein (reGFP) was acquired from Shanghai PrimeGene Bio-Tech, Shanghai, China. Ibuprofen and epidermal growth factor (EGF) were loaded into the nanofibers and were also obtained from Sigma-Aldrich.Drug and biomolecule-loaded bi-layered nanofibrous membranes were manufactured by creating a regular layer and a sheath-core structural layer. Several preliminary trials were conducted to determine the appropriate polymer and drug compositions necessary for the successful production of the nanofibrous membranes. The ordinary nanofiber layer was produced by mixing PLGA (1120 mg) and ibuprofen (280 mg) with 5 mL of HFIP and electrospinning them using a laboratory-developed spinning apparatus at a rate of 0.7 mL/h.Once the regular layer was electrospun, the sheath-core structural layer was created. PLGA (1400 mg) was blended with 5 mL of HFIP to serve as the material for the sheath layer, while the solution at the core was composed of 1 mL of EGF (20 μg) blended with 1 mL of phosphate-buffered saline (PBS). To spin the nanofibers, a dedicated coaxial spinning device that simultaneously delivers two solutions was used . The solThe outcome of the experiment yielded hybrid bi-layered nanofibrous membranes, with each layer having a thickness of about 0.1 mm and a total thickness of approximately 0.2 mm. To remove the solvent, all electrospun nanofibers were kept in a vacuum oven at 40 °C for three days and then stored at 4 °C till required.The tensile strength analysis of fabricated PCL meshes was conducted using a Lloyd tensile testing device manufactured by Ametek in the United States, with a load cell of 2500 N. The ultimate strengths were recorded while maintaining the extensional rate at 6 cm/min. Additionally, the ultimate load and deformation were acquired to evaluate the tensile properties of both pure PLGA and biomolecule-loaded PLGA using an elongational rate of 60 mm/min.N = 3), and an ImageJ code  was used.The morphological structure of the electrospun nanofibers was evaluated by means of scanning electron microscopy (SEM). To assess the nanofiber diameter distribution, 100 fibers were randomly selected (A JEOL Model JEM-2000EXII transmission electron microscope (TEM) from Tokyo, Japan, was used to confirm the sheath/core structure of coaxial electrospun nanofibers. To verify the presence of active biomolecules, PLGA was used as the sheath material and reGFP at the core in the electrospinning process. The resulting nanofibers were observed under a Leica TS SP8X laser scanning confocal microscope (LSCM) from Tokyo, Japan, at a wavelength of 487 nm.−1 resolution. A total of 32 scans were performed on the nanofibrous specimens, which were pressed into KBr discs and observed within the span of 400~4000 cm−1.To acquire the spectra of ibuprofen-loaded nanofibers, Fourier transform infrared (FTIR) spectroscopy was conducted using a Bruker Tensor 27spectrometer  with an absorption mode and 4 cmThe thermal characteristics of pristine PLGA and PLGA nanofibers embedded with ibuprofen were evaluated through differential scanning calorimetry (DSC), employing a DSC25 instrument manufactured by TA Instruments in New Castle, DE, USA. The temperature range employed was 30 to 250 °C, with a heating speed of 10 °C/min applied to the specimens.2 section of the nanofiber samples and subsequently measured (N = 3).To evaluate the hydrophilicity of the PLGA nanofibers, water contact angles of both pristine PLGA and drug and biomolecule-incorporated PLGA nanofibrous membranes were determined. A controlled amount of distilled water was applied to the surface of a 10 mmN = 3) holding 1 mL of PBS (Sigma-Aldrich) and kept at 37 °C for 24 h. The solution in the tubes was substituted by fresh PBS (1 mL) every 24 h for a period of 30 days.To investigate the release kinetics of ibuprofen from drug-eluting nanofibers, in vitro elution analysis was performed. 200 mg nanofibrous sample with a size of approximately 2 cm × 3 cm was put in assay tubes (N = 3). The assay employed a SunFire® C18 (25 cm × 4.6 mm × 5 μm), and the mobile phase for the ibuprofen was a mixture of acetonitrile:  . The assay wavelength was 280 nm, and the flow speed was 1.5 mL/min, with a retention time of 7 min.The Hitachi L-2200R HPLC system  was used to evaluate the drug concentrations in the gathered media (N = 3).Meanwhile, ELISA was used to measure EGF levels. 100 µL of eluents were put into the corresponding microtiter plate wells along with a biotin-conjugated antibody and incubated at 37 °C for 90 min. Each well of the microplate was treated with avidin that had been linked to horseradish peroxidase (HRP) and then allowed to incubate for a period of 30 min. The color change was measured spectrophotometrically at 450 nm after the addition of a sulfuric acid solution. The EGF level in the eluents was determined by comparing the optical density of the samples to a standard curve. The experiments were conducted in triplicate  approved the animal-related protocols.To mimic an extraction socket at the upper palate, the rats were initially anesthetized using Tiletamine + Zolazepam  and xylazine hydrochloride  through Intraperitoneal injection. ® Miltex®, Princeton, NJ, USA, and a #15c stainless steel scalpel were utilized to delicately remove the full-thickness gingival tissue using a sharp tissue elevator. Subsequently, a 3.0 mm round carbide bur  was used to create a 3.0 mm diameter and 1.5 mm deep socket after raising the mucoperiosteal flap.Initially, a 3.0 mm-diameter biopsy punch from IntegraN = 3), bilayer drug-embedded nanofibers were implanted in the alveolar socket. Subsequently, the 3D-printed PCL mesh was fixed over the socket wound with 6-0 polypropylene sutures . Conversely, rats in Group B (N = 3) received nanofibrous mats without embedded drugs, and the 3D-printed PCL mesh was immobilized as in Group A. In Group C (control group), the alveolar sockets of the rats were created similarly to the test groups, and natural secondary wound healing was performed without assistance. Another three animals that did not receive any surgery were employed as the healthy group.The rats were then randomly assigned to three groups: In Group A (N = 3 for each day). A #30 standardized sterile paper point (manufactured by DiaDent in the Republic of Korea) was used to extract tissue fluid from the palatal wound. The paper point was left in place for 30 s during each process to ensure adequate samples eluted with 0.1 mL of PBS immediately after being collected and stored at a temperature of −20 °C until analysis. The HPLC analysis was conducted to measure the drug levels at each time interval, using the same steps as that of the in vitro study. In addition, systemic drug concentration was determined by drawing blood specimens using syringes from the rats’ tails on days 1, 3, 7, and 14 (N = 3 for each day).Local tissue drug concentrations in rats from Group A were collected on postoperative days 1, 3, 7, and 14  staining were used to examine the epithelial and connective tissue characteristics.t-tests were utilized to statistically analyze two-group comparisons. Statistical significance was established at p-values lower than 0.05.In order to assess variances between groups, paired Using 3D printing and electrospinning methods, we created a degradable hybrid mesh consisting of PCL and drug-eluting PLGA nanofibrous membranes intended for alveolar ridge preservation. The printed mesh exhibited good flexibility, which would facilitate its implantation during surgery. Additionally, the morphological structures of the spun nanofibers are depicted in The image clearly displays green strings of reGFP, indicating that the bioactivity of the biomolecules in the core of the sheath-core-structured nanofibers has been effectively preserved. The EFG-loaded nanofibers also exhibited smaller dimensions than the pristine nanofibers.−1 indicated the presence of benzene from the added ibuprofen [3, C=O, and O-H bonds were also enhanced owing to the addition of ibuprofen. Furthermore, The results of the FTIR assay for pure PLGA nanofibers and ibuprofen-loaded PLGA nanofibers are shown in buprofen . The vibThe water contact angles of the pristine PLGA, ibuprofen-loaded PLGA, and EGF-incorporated PLGA nanofibers were estimated to be 131.74°, 107.5°, and 125.1°, respectively .While the pristine PLGA and EGF-incorporated sheath-core PLGA nanofibers displayed hydrophobic features, the water-soluble ibuprofen in the drug-loaded PLGA mats enhanced the hydrophilicity of the spun nanofibers.Despite the incorporation of drug and growth factor decreased the ultimate strength and elongation at the break of nanofibrous mats, the mats still exhibited excellent extensibility (with a strain of nearly 300%). This provides the advantage of coping with the extension/contraction during the healing process.The in vitro daily and cumulative profiles of ibuprofen released from the nanofibrous membranes are shown in The drug exhibited a peak release at day 1, accompanied by a stable and gradual diminishing drug discharge for 30 days. Further, data in Due to the shielding effect of the sheath PLGA material, no burst release was noted on day 1. Rather, a high release was found on days 9, 14, and 20, with gradually diminishing peaks.The nanofibrous mats could offer extended drug release for over 14 days. Meanwhile, the drug level in blood was not detectable (lower than the lowest detectable range of 0.01 μg/mL of HPLC), demonstrating the advantage of drug delivery via degradable nanofibers that achieve high drug levels to the target site with minimized systemic side effects.Additionally, the activity counts for each group over the 7-day post-surgery period are presented in p < 0.01). Rats that were implanted with drug-eluting mesh showed a higher trigger count than the group with no drugs  and a significantly higher number of triggered activities than the control group (p < 0.05). Furthermore, they exhibited activity levels similar to the healthy animals (p > 0.05). These outcomes indicate that drug-eluting nanofibrous mats are effective in restoring activity levels in the studied animals. This may have contributed to the analgesic effect of ibuprofen which is widely prescribed following oral surgery.The cumulative activity counts for the control (surgery only), healthy, mesh/nanofibers, and mesh/nanofibers/drugs groups were 4568 ± 1377, 9637 ± 596, 5815 ± 857, and 7945 ± 1266, respectively. As expected, the animals in the control (surgery only) exhibited significantly inferior activity to healthy animals (The results of the histological analysis are presented in Both groups displayed significant necrosis along with intense neutrophilic infiltration on days 1 and 3. On day 7, active fibrosis and the formation of granulation tissue were observed underneath the ulcerated surface in both groups. By day 14, the mucosal surfaces had completely healed in both groups. On day 14, foreign body-type giant cells were observed in the drug-embedded nanofibers with the PCL mesh group.The regeneration or reconstruction of bone to replace oral and maxillofacial defects in tissue engineering requires a porous scaffold. According to reports, nanofibrous membranes offer a distinct topography that enables therapeutic cells to be encapsulated for six weeks, leading to significant cellular infiltration of anti-inflammatory macrophages from the host ,33. SuccKumbar et al.  studied This study developed hybrid resorbable 3D-printed mesh/electrospun nanofibrous ibuprofen and EGF-eluting mats for alveolar ridge preservation. Ibuprofen is a nonsteroidal anti-inflammatory drug and blocks the action of cyclooxygenases, which are involved in the production of prostaglandins, to alleviate inflammation, pain, and fever. This mechanism acts peripherally, so ibuprofen can be delivered locally to the site of inflammation or pain ,37. In tThe drug-loaded nanofibers showed inferior fiber dimension to the pristine nanofibers. In a polymer/drug composite, the polymer plays as the component to withstand the external electrical force while performing electrospinning. The addition of the drug reduces the polymer in the composite matrix, making it easier to stretch. Sizes of spun nanofibers diminished accordingly. Additionally, the hollowed core structure of the sheath-core nanofibers possesses less strength to resist the exterior electric force, thus making the fibers prone to be elongated. Spun nanofibers thus have smaller diameter distribution.Drug elution from a degradable implant containing drugs can be divided into three phases: burst release, diffusion-dominated discharge, and degradation-controlled elution ,42. DuriCertain limitations were present in the current investigation, which used a rat model to evaluate mats containing drugs and EGF. The extent to which the current findings can be generalized to alveolar ridge preservation in humans remains unclear and warrants further research. We have made plans to pursue this avenue of investigation.We utilized 3D printing and electrospinning methods to manufacture resorbable mats that incorporate drugs and biomolecules for alveolar ridge preservation. In vitro testing of the nanofibrous mats revealed a sustained discharge of ibuprofen and EGF for over 4 weeks. In vivo animal testing demonstrated that animals implanted with the hybrid ibuprofen/EGF-eluting mats exhibited significantly greater mobility compared with animals without implants. The histological assay showed no negative effects of the drug/biomolecule-eluting implants. The degradable mats may eventually find use in humans for alveolar ridge preservation.


In addition, gelatin type A (GT)/alpha-tocopherol (α-TOC), PVA/olive oil (OO), PVA/orange essential oil (OEO), and PVA/anise oil (AO) emulsions were used. The experimental diameters of the nanofibers electrospun from the different tested systems were obtained using scanning electron microscopy (SEM) and ranged from 93.52 nm to 352.1 nm. Of the three studied ANNs, the one that displayed the best prediction results was the one with three hidden layers with the flow rate, voltage, viscosity, and conductivity variables. The calculation error between the experimental and calculated diameters was 3.79%. Additionally, the correlation coefficient (R2) was identified as a function of the ANN configuration, obtaining values of 0.96, 0.98, and 0.98 for one, two, and three hidden layer(s), respectively. It was found that an ANN configuration having more than three hidden layers did not improve the prediction of the experimental diameter of synthesized nanofibers.In the present work, different configurations of nt iartificial neural networks (ANNs) were analyzed in order to predict the experimental diameter of nanofibers produced by means of the electrospinning process and employing polyvinyl alcohol (PVA), PVA/chitosan (CS) and PVA/ Currently, the application of electrospun veils covers a wide range of uses in different industries such as pharmaceutical, food, and environmental due to the special physicochemical and microstructural characteristics displayed by these materials . In the 2) of 0.98, concluding that the parameters used in the design of the employed model significantly affected the average diameter of the electrospun nanofibers. Maurya et al. [−5. By employing two hidden layers, the minimal MMSE value was 8.5 × 10−5, which was obtained by using eight hidden neurons. Since the error values were minimal with two hidden layers, the configuration 4-8-8-1 was selected for maximal optimization, reporting R2 values of 0.79 and 0.94 for the training and testing data, respectively. Lakshmi Narayana et al. [2 value of 0.97 was obtained for the training data and 0.98 for the set of test data. Likewise, Premasudha et al. [This study reported a correlation coefficient . For the electrospinning process, a voltage interval ranging from 20 to 30 kV was selected; the apparatus was connected in series, and the injector–collector distance oscillated between 10 and 20 cm.The viscosity of the studied solutions/emulsions was determined by means of a RheolabQC Anton Paar rheometer at 25 ± 1 °C, employing the DG24 concentric cylinder configuration and the Star Rheoplus 3.0x software. The conductivity was measured with a Conductronic piece of equipment (model PC18) at 25 ± 1 °C.The viscosity and conductivity of the PVA emulsions incorporated with the EOs and GT/α-TOC emulsions and PVA/CS and PVA/Av solutions were established prior to the electrospinning process.The structures of the electrospun nanofibers were analyzed by means of scanning electron microscopy (SEM), employing a microscope (model JSM-6610LV). The images were processed with the ImageJ 1.51j8 software, and with it, the experimental diameter of the nanofibers was also determined, which corresponded to the arithmetic mean of 85 measurements of SEM carried out with different nanofibers .In the present work, the multilayer perceptron (MLP) neural network was employed with sigmoid activation (logsing) in the hidden layers, according to Equation (1), and linear in the output layer, as indicated in Equation (2) ,38:(1)f :(3)xn=x−The error percentage was calculated by means of Equation (4):The relative contribution of each input variable was calculated by means of the algorithm proposed by Olden et al. , accordiThe experimental diameters of the nanofibers, reported in the support material , are cloAs for the PVA/OEO nanofibers, a directly proportional relationship between the concentration and experimental diameter of the nanofibers was observed, as shown in On the other hand, a higher concentration of gelatin in the solution of the GT/α-TOC nanofibers allowed the production of thinner nanofibers, as observed in tic acid ,46,47.Regarding the PVA/CS nanofibers, a decrease in the experimental diameter of the nanofibers was observed as the CS concentration increased, as shown in On the other hand, the Av extract consists of aloine (polyhydroxylated anthraquinone glucoside), which is characterized by having a long alkyl structure that explains the high electrical conductivity of the electrospun solution .As observed in w/w), where it is evidenced that the PVA concentration plays a major role in the surface topography and distribution of the nanofiber experimental diameter. It is confirmed that at 10% PVA, larger diameters than those with 8% are produced; also, the presence of a branched microstructure is evidenced. The micrographs in 2 that relates the predicted diameter to the experimental one. For test 1, the R2 value was 0.71, and for test 2, it was 0.70, which indicated that the results of tests 1 and 2 were not satisfactory in the prediction of the experimental nanofiber diameter; for this reason, increasing the number of input variables to four was considered, as shown in The weighing of the input variables  and outpThe configuration with four ANN input variables consisted of one hidden layer with a variable number of neurons from two to fourteen, as shown in 2 of 0.96 and an error percentage of 4.44%; these results are in contrast with the rest of the proposed configurations for predicting the experimental nanofiber diameter, thus confirming that this configuration was the best approach to the experimental values of the nanofiber diameters obtained by SEM. Different configurations of ANN models featuring a single hidden layer have been employed in the prediction of experimental data [2 of 0.99.In order to avoid overparameterization, a variable number of neurons in a hidden layer from 2 to 14 was chosen for this study. Higher test MMSE values were observed in the ANN configurations consisting of 2, 4, 12, and 14 neurons, as observed in tal data ,56, whictal data , who emp2 ≤ 0.7, more training with the concomitant modification of both hidden layers and neurons is necessary [It has been reported that the use of a single hidden layer can favor the prediction of experimental data ; howeverecessary ,60.For this reason, the 8-neuron configuration allowed the establishment of the importance of the variables related to the characteristics of the polymeric solutions/emulsions and of those operation variables associated with the electrospinning process that are implied in the prediction of the experimental diameter of nanofibers. This type of sensitivity analysis was also proposed by Nasouri  and Kala2 closer to unity, which would imply an enhanced relationship between the experimental diameters and those predicted by the ANN. To this end, the 8-n configuration was proposed, which consisted of 8 neurons in the first hidden layer, whereas n  represented the variations of the neurons corresponding to the second hidden layer, with the following configurations shown in 2 of the output results corresponding to the training, test, and validation stages, it was observed that the configurations in 2 of 0.98 and average error percentage of 3.96%. Similar results were presented by Khatti [2 of 0.97. The prediction of the experimental nanofiber diameter by means of this ANN is complex and depends on the studied system and availability and quality of the input data.Once the response of one hidden layer predicting the diameter of nanofibers was analyzed, the study of the effect of two hidden layers was proposed in order to obtain an Ry Khatti , who emp2 through an additional configuration of three hidden layers of 8-16-n neurons, as shown in n varied from three to six. The results revealed that the 8-16-3  was to increase the Re 8-16-3  and 8-16e 8-16-3  presente2 of 0.98  were used for predicting the experimental diameter produced during the electrospinning process of nanofibers from PVA, PVA/CS, and PVA/Av solutions and GT/α-TOC, PVA/OO, PVA/OEO, and PVA/AO emulsions. In addition, the experimentation is related to the theory by means of an ANN model designed for understanding the nonlinear relationship among operative variables of the electrospinning process such as flow and voltage and physical properties of the biopolymer and essential oil solutions/emulsions.An enhanced prediction of the experimental nanofiber diameter was achieved by employing four input variables  in comparison with the use of three variables  in the ANN configuration.2 close to 0.98. Nevertheless, according to the MMSE, the best configuration for predicting the experimental nanofiber diameter with the test data was the one with three hidden layers, with an MMSE value of 0.03, which is in contrast with the MMSE value of 0.06 for two hidden layers (8-16).The ANN configurations that best predicted the experimental nanofiber diameter were those with two and three hidden layers, with an RThe computation error between the experimental nanofiber diameter obtained by SEM and the one predicted by the ANN was 3.79% for the configuration with three hidden layers, whereas for the one with two layers, it was 3.95%, which confirms the reliability of the ANN with three hidden layers, which will allow for narrowing down the combinations of polymers, solvents, and concentrations of solutions/emulsions in earlier stages in order to optimize the experimentation stage before proceeding to the electrospinning process.Additionally, it was confirmed that the most influential variable in the prediction of the experimental nanofiber diameter by employing a one-hidden-layer configuration with eight neurons was the viscosity of the solutions/emulsions to be electrospun.


Antimicrobial resistance (AMR) poses a significant threat to human health as 4.95 million deaths were associated with bacterial AMR in 2019 and is projected to reach 10 million by 2050. To mitigate AMR, surveillance is an essential tool for determining the burden of AMR and providing the necessary information for its control. However, the global AMR surveillance is inadequate and particularly limited among forcibly displaced persons (FDPs) despite having higher risks of harboring these pathogens. Predisposing factors among this group include poor living conditions, limited access to treatment and diagnostic tests, and inadequate trained health professionals in refugee camps. Strengthening AMR surveillance among FDPs would address the identified gaps and facilitate formulation and implementation of evidence-based policies on AMR control and prevention response. This article provides information on the growing population of FDPs, factors contributing to the AMR burden and AMR surveillance gaps in FDPs and highlighted recommendations for control. Antimicrobial Resistance is a condition where substances particularly drugs that are capable or killing or preventing the action of microorganisms are no longer active against them .Forcibly Displaced Persons- are people that are involuntarily displaced from their home country and they include refugees, asylum seekers and others who need international protection https://www.amnesty.org/en/what-we-do/refugees-asylum-seekers-and-migrants/#:~:text=An%20asylum%20seeker%20is%20a,asylum%20is%20a%20human%20right).Asylum seekers are people who leave their country of origin in search of protection from persecution and violation of human right in another country Refugees are people that are involuntarily displaced from their country by war, violence, conflict etc. and are in search of safety in another country .Migrants are people who move from one country to another especially in search for a better living condition  remains alarming, as 4.95 million deaths were associated with bacterial AMR in 2019 . This inhttps://guardian.ng/news/germany-records-almost-a-million-ukrainian-refugees/). Recent estimation shows that about 7.7 million people are internally displaced as a result of the conflict. Also, in Africa, an upward trend of forced displacement has been observed with over 32 million Africans displaced over the past decade largely due to repression of government against citizens, and extremist group violence (https://reliefweb.int/report/world/32-million-africans-forcibly-displaced-conflict-and-repression).According to the United Nations High Commissioner for Refugees (UNHCR), the number of FDPs is estimated at 90 million globally—the highest since World War II—propelled by the rising persecution, conflict, violence, human rights violations and other events actively disturbing public order, such as natural disasters. Internally-displaced people, refugees and asylum seekers account for about 57%, 29%, and 5% of the FDP population, respectively  . Also, limited international data available on undocumented immigrants suggest they are extremely vulnerable to lower self-reported health, accidents, injuries, psychosocial distress and unsafe water ), and the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) , making accurate data on FDPs available.Speedy addressing of factors preventing the implementation of NAPsIt is also worth noting that the WHO Global Actional Plan on AMR and Global AMR & Use Surveillance System (GLASS) do not have specific strategies for conducting AMR surveillance among FDPs, thereby necessitating the revision of these policy documents. Likewise, each country's AMR National Action Plans should clearly articulate the strategies to improve AMR surveillance among refugees and IDPs. Some of these strategies include, increasing AMR surveillance in countries of AMR prevalence, prioritizing AMR surveillance during transit, incorporating AMR surveillance on refugee camps, enforcing measures that prevent the spread of AMR in refugee camp where detected and provision of conducive environment and maximum resources for refugees.Also, factors hindering the adequate implementation of NAPs, as elucidated by Kariuki et al., such as lack of political commitment, inadequate funding, and inadequate capacity , need toTotal ban on unethical administration of antimicrobials will go a long a way in curbing the burden of AMR. This involve enforcing policies that allow only certified personnels to administer antimicrobials. Also, more sensitizations on the risk of antimicrobials should be carried out especially in sub-Sahara Africa countries where unethical administration and use of antimicrobials is more common.


Antimicrobial stewardship programmes (ASPs) facilitate appropriate antimicrobial use and require contextualization for optimal functioning. We aimed to investigate perceptions of and antimicrobial resistance (AMR) and ASPs among healthcare workers in academic and nonacademic hospitals.Cross-sectional survey.Three academic  and three nonacademic hospitals  in South Africa from January to June 2022.Doctors, nurses, and pharmacists.Voluntary questionnaire using Google Forms, encompassing AMR, ASPs, and selected discipline-specific components.p 0.004); 73.5% overall reported inappropriate antimicrobial use as a major contributor. Adequate education on antimicrobials occurred in only 36.4% overall. Microbiological testing guided therapy more often in nonacademic settings . In both settings, antimicrobial availability drove selection in 48.2%. Overall, ASPs improved patient care (89.8%) and reduced antimicrobial use (86.9%), although felt to override prescriber autonomy in academic settings , mainly among nurses. Only 50.2% reported successful local ASPs. A minority of pharmacists (20.0%) reported sufficient hospital support for ASPs. Education, involvement of infection control staff, and inclusion of nurses in ASPs were most impactful on AMR.Participants comprised 79 doctors (50 academic), 178 nurses (169 academic), and 21 pharmacists (18 academic) and were female predominant. AMR was a problem in academic hospitals (74.7% vs 51.2%, Selected healthcare worker perspectives differ by category and setting and can be targeted to improve ASPs. Further studies should target a higher number of clinical staff in both settings. The World Health Organization’s Global Action Plan on AMR lists improving awareness and understanding of AMR and strengthening the knowledge and evidence base as critical objectives. The South African National Strategy Framework on AMR aligns with this and emphasizes interdisciplinary efforts, infection prevention and control (IPC) and antimicrobial stewardship programmes (ASPs) as important enablers. However, much is dependent on behavioural change of practicing healthcare workers (HCW) and synergy between different sectors and disciplines.Antimicrobial resistance (AMR), one of the leading public health threats globally, has a significant impact in the sub-Saharan African region. Academic hospitals are tertiary/quaternary facilities located within the public sector which have onsite microbiology laboratories and onsite specialist microbiologists. Nonacademic public sector hospitals receive remote microbiology laboratory and specialist support.The delivery of healthcare in South Africa is mediated by both the public and private sectors, serving approximately 80% and 20% of the population, respectively. We aimed to evaluate the perceptions of AMR and ASPs among doctors, nurses and pharmacists at academic and nonacademic public sector hospitals in the three most populous South African provinces.Understanding the differences in HCW perceptions and experiences between academic and nonacademic facilities enables effective, pragmatic targeting of interventions. A recent study on South African HCW provided critical insights at a population level.Six public sector hospitals were surveyed in three provinces in South Africa. The academic facilities were Charlotte Maxeke Johannesurg Academic Hospital , Inkosi Albert Luthuli Central Hospital , and Tygerberg Hospital . The three nonacademic facilities were Leratong Hospital , Prince Mshiyeni Memorial Hospital , and Paarl Hospital . was distributed electronically and physically to staff members after piloting. Participation was voluntary and anonymous, and an informed consent statement was included.The self-administered web-based survey, adapted from a previous survey,The questionnaire encompassed basic demographic details, the scope of AMR and ASPs, and discipline-specific sections. Respondents also selected five interventions out of 11 options that would have the greatest impact on AMR. A free text section was offered for suggestions. Respondents could omit answers, and questions were grouped into themes for analysis.2 tests were used for comparison of proportions, using EpiCalc 2000 v1.02 . A two-tailed α of 0.05 was regarded as being statistically significant.Data were extracted from Google Forms into Microsoft Excel 2016 . Descriptive statistics were used (counts and proportions) to summarize the data. χThis study was approved by the University of the Witwatersrand’s Human Research Ethics Committee (reference number M200542), with the University of KwaZulu Natal’s Biomedical Research Ethics Committee and Stellenbosch University’s Health Research Ethics Committee providing reciprocal approval. Approval was granted from the provincial Departments of Health and hospital management at each site.1); key demographics are summarized below.Two hundred and eighty-three responses were collected between January 18 and June 30, 2022. Although the sample size target was 30% of the total staff employed, the respondents represented 3.9% of the target number of doctors (3.1% in academic and 7.3% in nonacademic settings), 2.4% of the target number of nurses (2.9% in academic and 0.6% in nonacademic settings), and 12.8% of the target number of pharmacists (19.1% in academic and 4.3% in nonacademic settings). The basic demographic data of the respondents are presented as supplementary material (Supplementary Table n = 242), 69.8% were nurses, 20.7% doctors, and 7.4% pharmacists. The respondents were female predominant . TBH contributed the largest number , dominated by nursing staff (n = 151) followed by doctors (n = 20). CMJAH contributed the highest number of doctors  and pharmacists .From academic sites (n = 41), mostly by doctors (70.7%). PMMH contributed 21 responses (51.2%).Survey responses at nonacademic sites were generally poorer (Doctorsn = 36) and medical officers (n = 26). The modal-age group for doctors was 31–40 years . Most (64.6%) were female.NursesRespondents were mostly specialists (n = 53). Most reported working at their current job for 6–10 years .PharmacistsMost respondents were female (88.8%). The modal age group was 51–60 years (n = 10). Pharmacists showed a variety of experience at their current hospitals, with seven reporting 11–20 years at their current facility (33.3%) and six reporting 0–1 year (28.6%).The majority of respondents were female (66.7%). The modal age group was 21–30 years (Survey responses by HCW category are summarized in Table Scope of AMRp 0.004), and correspondingly, 58.2% vs 41.5% reported AMR to be a problem in daily practice (p 0.071). Inappropriate antimicrobial use was a major contributor to AMR in 73.5% overall.Causes of/factors contributing to AMRStaff at academic sites felt that AMR was a problem in their respective hospitals to a greater extent than staff at nonacademic hospitals .Healthcare systemsInterruptions of therapy and poor IPC practices were important contributors to AMR in 62.4% and 57.6% overall, similar in both settings. Overall, 17.0% felt that inappropriate use of laboratory diagnostic tests frequently led to overuse of antimicrobials. The lack of rapid diagnostic test availability was identified as a contributor to antimicrobial overuse in 54.4% of all respondents, higher in nonacademic settings . Microbiological testing prompted appropriate changes in only 50.2% in academic settings compared with 80.0% in nonacademic settings (p <0.001).Overall, 68.4% reported adequate hospital surveillance for drug-resistant organisms. Only 36.4% felt that their hospital provided adequate education regarding antimicrobials, higher in nonacademic settings , driven by nurses  was felt to override prescriber autonomy in 29.4% of academic vs 7.5% of nonacademic respondents . In both settings, substantial support was noted for ASP improvement by the implementation of electronic medical recording (e.g. receiving results)  and implementation of electronic prescribing (72.4%).Staffing perspectivesOnly 50.2% of respondents reported that their hospital had implemented an effective ASP; this was higher in nonacademic settings . Feedback on antimicrobial selection was requested by 78.5% overall.Improvement strategiesIn academic settings, 73.0% felt that their individual contributions could impact AMR, compared with 84.6% in nonacademic settings .Comments by 45 respondents are included as supplementary material  did not agree that poor IPC practices contributed to AMR, a finding that has been noted amongst South African medical students and physicians and pharmacists in Ethiopia. Although national IPC recommendations are in place, successful implementation of these seemingly low-hanging fruit remains a challenge in overburdened and poorly resourced healthcare facilities. This cognitive dissonance is striking given that approximately one-third of respondents at academic facilities, mostly nurses, felt it very likely that a patient would develop an infection with a drug-resistant organism during their hospital stay similar to a study in Indonesia and lower than the 66.0% in Ethiopia. Only 53.0% of nurses overall would change their practice if a patient were known to be infected with a drug-resistant organism.AMR is widely perceived by HCW as a serious problem globally and nationally, Education and active involvement of the hospital IPC team were among the most frequently selected recommendations thought to have the greatest impact on tackling AMR, suggesting a lack of accountability or suboptimal knowledge on the importance of IPC. A comprehensive approach to understanding behavioral aspects and cognitive biases in AMR and AMS is needed.The tendency to underestimate the impact of individual actions in achieving a greater goal is a logical fallacy. This study showed that a significantly higher proportion of doctors felt that their individual contributions could impact AMR, emphasizing the need to empower nurses and pharmacists to counteract externalization of responsibility. This is highly relevant in both settings; in the academic setting, sample collection changed therapy in just 50.2% of patients, contributing to unnecessary resource consumption. In the nonacademic setting, the lack of availability of rapid diagnostic tests contributed to antimicrobial overuse in 64.1%, similar to the 64.4% of respondents at a tertiary center in Ethiopia but higher than the 52.8% reported in academic settings. Microbiology laboratories are traditionally located in academic settings outlining the need to optimize communication between the laboratory and clinicians, as highlighted previously.Diagnostic stewardship, including implementation of rapid diagnostic tests, can provide supplementary or quicker decision support for antimicrobial prescription and can guide microbiology result interpretation and inform appropriate collection of samples. Previous reports from Thailand and Indonesia found that doctors, rather than nurses or pharmacists, objected to interventions limiting prescribing decisions, while only 21.3% of physicians in Ethiopia reported that ASPs impacted decision autonomy.A greater proportion of staff in academic facilities, especially nurses, felt that ASPs override prescriber autonomy and can negatively affect patient care. These findings may be explained by the presence of more experienced personnel in South African academic settings and underscores the need for synergism between different professionals and education on the goals of AMS. Despite this, greater involvement of nursing staff in ASPs was selected among the top five interventions having an impact on AMR with adequate training reported by 31.0% of nursing staff overall. Significantly fewer nurses felt that ASPs reduce antimicrobial use and can save costs, improve quality of care, reduce AMR and duration of hospital stay, impact nosocomial infection rates, and are currently needed. The important role of nurses in AMS has been recognized, with education, optimization of interprofessional dynamics, and support of nursing leadership being strategic enablers.Exposure to effective ASPs was only reported by 50.2% of respondents in this study. Almost a third of nurses in academic settings did not have time to further invest in ASPs and felt that only clinicians needed to understand AMS; this may be reflective of different professional demands on their time or an alternative perspective on the role of nurses in successful ASPs. When indicated, it is imperative that the appropriate antimicrobials are accessible. Almost half of this survey’s respondents reported that availability drove selection compared with 68.9% in Ethiopia, 63.8% in the Democratic Republic of Congo, and 14.0% in Peru. Timely administration is also fundamental and reduces mortality in patients with sepsis; almost half of the nursing staff reported interruptions in therapy due to nonadministration of prescribed agents and delays between prescription and administration of longer than one hour. Staff shortages may play a role; utilization of technology to implement more rapid delivery of results or electronic prescribing garnered substantial support in this survey and may ease the effects of staffing challenges.Access to essential medicines of assured quality is a key component in optimizing antimicrobial use. Possible reasons include recall or performance bias or the fact that pharmacists and nurses have exposure to prescriptions written by a variety of doctors including those who were not survey participants. Prescription practices should be targeted as a quality improvement initiative as identified by doctors and nurses in Gabon, as 70.0% of pharmacists in this study often noted errors in antimicrobial prescriptions. Poor adherence to antimicrobial prescription guidelines (45.0%) has been previously reported in South Africa.Although the overwhelming majority of doctors reported routinely assessing for de-escalation and switching to oral formulations, in agreement with data from junior doctors in France, this was not corroborated by nursing staff nor pharmacists. These skilled personnel are, however, essential in enabling some of the interventions chosen as most impactful in the present and previous studies, such as education, multidisciplinary rounds (with prospective audit and feedback), and institutional guideline development. Pharmacists approach antimicrobial therapy from a systems perspective and are integral to successful ASPs; in this survey, 42.9% of all respondents did not feel that sufficiently trained pharmacists were available. The vast majority of pharmacists (80.0%) felt that they were not supported by their hospital to implement ASPs, while over 60% reported patient expectations as a contributor to antimicrobial overuse. The vital role of financial, information technology, and management support in effective ASPs was echoed in this survey.Additional pharmacists, infectious disease physicians, or clinical microbiologists were not viewed as having the greatest impact on AMR, contrary to previous studies. The small sample size overall prohibited firm conclusions with no category reaching the desired participant number; while poor response rates are a recognized limitation of surveys, stronger support from hospital management and unit managers may have improved participation and facilitated collection of more representative data.Limitations to this study include volunteer bias, which is difficult to mitigate in this type of research, and survey availability only in English. Lack of dedicated time, the absence of incentives, and restrictions in mobile data may have influenced participation; paper-based surveys were also distributed on request. The length of the survey may have dissuaded potential participants. There was a substantial female predominance; it is unclear whether this represents the total population of HCW. The modal age groups differed notably between professional groups. Generational differences, varying durations of working experience, and differing training/knowledge (reflective of undergraduate and postgraduate curriculum trends) may have influenced the responses as previously reported.Perceptions on AMR and ASPs differed somewhat between academic and nonacademic settings in this multicenter survey although many similarities were noted. AMR was of more concern in academic settings. In nonacademic settings, staff were willing to allocate more time to ASPs. Diagnostic stewardship, prescribing practices, and antimicrobial access must be optimized in both settings. IPC practices are underestimated as a contributor to AMR. Education, involvement of the hospital IPC team, and inclusion of nursing staff in ASPs were chosen as having the greatest impact on AMR. A multidisciplinary behavioral science-driven approach is needed to address the complex issue of AMS among HCW.Reddy et al. supplementary material


V. vulnificus-induced septicaemia and multiple organ failure syndrome after oyster consumption at a restaurant. We isolated and identified V. vulnificus vv16015 from the patient’s blood sample and antibiotic susceptibility tests indicated sensitivity to all 21 antibiotics. Oyster samples were subsequently collected from the restaurant’s supplier and three strains of V. vulnificus were isolated. Whole genome sequencing and analysis revealed vv16015 to be distantly related to these strains and confirmed that V. vulnificus contamination was present in the seafood of the restaurant and supplier. Using a Galleria mellonella larvae infection model, the virulence of vv16015 was determined to be higher than that of comparison strains isolated from a surviving patient (vv15018) and an oyster (vv220015). The human and environment distribution of V. vulnificus in Shenzhen is sporadic and heterogeneous, and vv16015 is highly virulent compared to other strains.We report a 36-year-old male patient died of The online version contains supplementary material available at 10.1186/s13099-023-00580-x. Vibrio vulnificus is a potentially deadly opportunistic and emergent human pathogen [V. vulnificus typically occurs through broken skin-contact with seawater or seafood consumption [V. vulnificus infection usually causes mild gastroenteritis, severe wound infection and sepsis [V. vulnificus infection is 16 h for wound infection and 26 h for sepsis, with mortality rates of up to 50% and 25%, respectively [V. vulnificus infections are rare, it disproportionately affects men, and patients with underlying health conditions, including liver disease (cirrhosis or hepatitis), diabetes mellitus and immune dysfunction, are at highest risk of mortality [V. vulnificus has the highest mortality rate of all foodborne pathogens, and accounts for 94% of Vibrio spp.-related deaths, with the exception of V. cholerae [pathogen . Infectisumption , though sumption . V. vulnd sepsis . The meaectively . AlthougV. vulnificus infection are likely underreported due to frequent mild symptoms, the majority of reports are from the United States of America (USA), Japan, South Korea, and China [V. vulnificus infection cases are predominantly reported in the south-eastern coastal region, including the regions of Guangdong, Taiwan, Zhejiang, and Fujian, corresponding with warm seawater conditions that are optimal for the pathogen [V. vulnificus infections [V. vulnificus-infected patients of 33 died (33.3%) in Guangdong Province between 2010 and 2020 [Vibrio spp. present in that water of local beaches [V. vulnificus infection have previously been reported.While cases of nd China . In Chinpathogen . In the fections . A highefections  and 34 cfections . In Chinand 2020 , and simand 2020  and Zhejand 2020 . Shenzhe beaches , howeverV. vulnificus infection from oyster consumption in Shenzhen, Guangdong Province, China, which led to a rapid deterioration of the patient’s condition and death on day two post-admission. We isolated V. vulnificus strains from the patient’s blood and oyster samples, tested antimicrobial susceptibility and modeled the virulence. The study provides insight into the variable virulence of the causative strain local seafood V. vulnificus contamination and variable virulence, which may be cause of concern.We report a case of foodborne V. vulnificus was isolated from the patient’s blood sample using a blood culture on modified cellobiose-polymyxin B-colistin (mCPC) agar medium and purified on blood plate agar medium. V. vulnificus was identified using Matrix-Assisted Laser Desorption/Ionization-Time Of Flight Mass Spectrometry (MALDI-TOF MS) and COMPACT VITEK2 and named vv16015.All animal experiments were approved by the Clinical and Research Ethics Committee of Shenzhen Centre for Diease Control and Prevention.E. coli ATCC25922 as the quality control strain, according to the recommendations of the Clinical and Laboratory Standards Institute document M100-S30 [Susceptibility of vv16015 to 21 antibiotics studied using the VITEK 2 AST-GN09 antimicrobial susceptibility board: amikacin, ampicillin, ampicillin/sulbactam, aztreonam, cefazolin, cefepime, cefotetan, ceftazidime, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, imipenem, levofloxacin, meropenem, nitrofurantoin, piperacillin, piperacillin/tazobactam, tobramycin, trimethoprim/sulfamethox, and tetracycline. The results were automatically interpreted by the VITEK 2-COMPACT fully automated microbiological analyser, using M100-S30 .de-novo genome assembly. Kraken2 (https://ccb.jhu.edu/software/kraken2/) was used to identify V. vulnificus, Prokka 1.14.6 [http://www.mgc.ac.cn/VFs/) and resistance genes identified through CARD online database (https://card.mcmaster.ca/).Genomic DNA was extracted using the QIAamp DNA Mini Kit and whole genome sequencing was performed by BGI . Raw data were filtered using Trimmomatic v0.39 , SPAdes a 1.14.6  was usedV. vulnificus strains isolated from eight countries between 1993 and 2022. To show the evolutionary relationships between vv16015 and the 133 other V. vulnificus strains, a maximum-likelihood phylogeny was constructed, with CMCP6 as the reference genome as it was considered to be the most complete and accurate of the published V. vulnificus clinical strain genomes. Snippy Pipeline v4.6.0 was used to identify core genomic single nucleotide polymorphisms (core-SNPs), then Maximum-likelihood phylogeny was constructed using fasttree and visualised and annotated in iTOL.From the National Center for Biotechnology Information (NCBI), we downloaded the genome sequences of 133 Galleria mellonella larvae model is widely used to study the pathogenic potential of Vibrio as it is easily survivable, simple, inexpensive and more ethically acceptable than mammalian infection models [G. mellonella larvae model to study the virulence of V. vulnificus vv16015, vv15018 and vv220015 were selected for experimental comparison and sourced from the Shenzhen Centre for Disease Control and Prevention strain bank. Vv15018 was isolated from a clinical patient with no specific disease history and discharged from hospital in good condition after an acute gastroenteritis caused by a poor diet. Vv22015 was isolated from an oysters and represents an environmental strain that was used as the experimental control because its virulence genes are approximately the same as those of vv16015 and vv15018.The n models . We estaG. mellonella larvae were 2-3 cm long with a mean weight of 0.33 g (Tianjin Huiyude Biotechnology Company Limited) and selected for vigour and absence of black spots. There were seven groups each with ten larvae. One group remained untreated controls (group C1) and six groups were injected with 10µL of control or bacterial suspension on the last right-side pair of hind feet. Group C2 received 0.9% sterile saline, T1 received 1 × 104 CFU/mL, T2 1 × 105 CFU/mL, T3 1 × 106 CFU/mL, T4 1 × 107 CFU/mL and T5 1 × 108 CFU/mL. After injection G. mellonella larvae were placed in separate sterile disposable petri dishes and incubated in a constant temperature incubator at 37 °C for 48 h and survival curves were plotted for G. mellonella larvae. Survivorship was recorded every 6 h.Sixth instar All statistical analyses were performed using GraphPad Prism 9.5.0 software. Larval survival were plotted by the Kaplan-Meier method. Log-rank (Mantel-Cox) test was used to compare the significance of differences in larval survival rates between groups. P < 0.05 was considered to indicate significant differences between groups.V. vulnificus-induced sepsis combined with multiple organ failure syndrome, rhabdomyolysis syndrome, active chronic viral hepatitis B, and post-hepatitis B cirrhosis. The person who had eaten at the restaurant with the patient reported diarrhoea symptoms on August 29-30th, though an anal swab was negative for pathogenic bacteria.A 36-year-old male patient with a history of liver cirrhosis and no traceable traumatic history consumed chilled oysters at a seafood restaurant in Shenzhen, China, on August 28, 2016. He felt unwell at approximately 16:00 on August 29th, 2016, and reported dizziness and a temperature of 39 °C. Symptoms progressed to include diarrhoea and abdominal pain at 19:00 on the 29th, and calf muscle pain at 4:00 on the 30th. He arrived at hospital at 5:00 on the 30th. We took treatment with ulinastatin for anti-shock, meropenem for anti-infection, continuous ventilator-assisted breathing, adenosylmethionine butanedisulfonate for hepatic protection, esomeprazole for acid suppression and gastric protection, human immunoglobulin for immune enhancement, plasma transfusion for improved oxygenation, bedside haemofiltration, and other treatments administered. Death was recorded on August 31, 2016 at 16:41 from V. vulnificus. 20 oyster samples were collected from the restaurant’s supplier and from which we isolated three strains of V. vulnificus: vv35, vv36, and vv37, which were sent with vv16015 to BGI  for whole genome sequencing.Antimicrobial susceptibility testing (AST) demonstrated susceptibility of vv16015 to all 21 antibiotics.We collected 13 oyster samples from the restaurant that the patient has eaten at and were unable to isolate tet (34). Pathogenesis-associated genes including vvhA, rtx gene cluster, and virulence genes associated with iron uptake in vv16015 suggests that the high pathogenicity of this strain is associated with a mixture of virulence factors. Maximum-likelihood phylogeny showed that vv16015 is distantly related to vv35, vv36, and vv37 in different branches . Vv16015 has a total of 126 virulence genes, approximately equivalent to vv35, vv36 and vv37, and 1 resistance gene, G. mellonella larvae were dependent on both inoculum size and V. vulnificus strain  was phylogenetically distinct from the three strains  isolated from oysters obtained from local restaurant suppliers in Shenzhen, and most similar to strain TW-06 isolated from oysters from Taiwan, Chinad , which encodes an oxytetracycline resistance phosphoribosyltransferase that mediates tetracycline resistance, AST demonstrated tetracycline sensitivity. Such sensitivity to this antibiotic which may be due to acetylation-mediated down-regulation of the gene tet (34) [V. vulnificus was demonstrated using the Galleria mellonella larvae model [The pathogenesis of  unknown . The vir studies , vv16015ae model ,and may V. vulnificus infection in Shenzhen, China. Although V. vulnificus infections are rare, due to the high mortality rate in patients with pre-existing conditions and unclear pathogenesis, we recommend systematic surveillance of seafood for V. vulnificus contamination. Furthermore, we suggest that clinicians provide health education to patients with underlying illnesses that place them at higher risk, recommending avoidance raw or undercooked seafood and contact with seawater with broken skin.This is the first reported case of death related to Below is the link to the electronic supplementary material.Supplementary Material 1


Molecular and genomic approaches have revolutionized medical microbiology by offering faster and more accurate diagnostic techniques for infectious diseases. Traditional methods, which include culturing microbes and biochemical testing, are time-consuming and may not detect antibiotic-resistant strains. In contrast, molecular and genomic methods, including polymerase chain reaction (PCR)-based techniques and whole-genome sequencing, provide rapid and precise detection of pathogens, early-stage diseases, and antibiotic-resistant strains. These approaches have advantages such as high sensitivity and specificity, the potential for targeted therapies, and personalized medicine. However, implementing molecular and genomic techniques faces challenges related to cost, equipment, expertise, and data analysis. Ethical and legal considerations regarding patient privacy and genetic data usage also arise. Nonetheless, the future of medical microbiology lies in the widespread adoption of molecular and genomic approaches, which can lead to improved patient outcomes and the identification of antibiotic-resistant strains. Continued advancements, education, and exploration of ethical implications are necessary to fully harness the potential of molecular and genomic techniques in medical microbiology. The healthcare system depends heavily on the science of diagnostics because it serves as the basis for medical judgment. Diagnostic tests provide crucial data that inform personalized cancer treatments, assist in choosing the best antibiotics to treat infections, and offer insightful information on every aspect of healthcare, including disease management, prevention, detection, diagnosis, and treatment . ClinicaSearch strategyWe used the PubMed and Scopus advanced search strategy to obtain articles from PubMed and Scopus employing the following terms: . We obtained the most pertinent research papers and used them in different arrangements using the Boolean operators “AND” and “OR.” Search outcomesAfter conducting the initial search, we identified a total of 965 articles across the searched databases. We then excluded duplicates (n=400) and conducted an initial screening of titles and abstracts, which excluded a further 565 articles. After the full-text screening of the remaining 360 articles, we excluded 149 articles for not meeting the inclusion criteria; the full free text was not available and was not written in English, leaving a total of 56 articles for the final review  was formed in 1995; the European Union (EU) allowed gene patents in 1998; and journals like The Journal of Medical Diagnostics started. Legal battles over gene patents occurred, including the 2013 United States Supreme Court ruling against patenting natural gene sequences. The history of molecular and genomic technique advancements is mentioned in Table Traditional diagnostic techniques versus molecular and genomic approachesTraditional diagnostic techniques for infectious diseases include culturing microbes on agar plates, biochemical testing, and microscopic examination of samples. These methods are slow, often taking days or weeks to yield results, and they may not be able to identify the causative agent of infection . AdditioIn contrast, molecular and genomic approaches offer faster and more accurate results and can detect antibiotic-resistant strains of bacteria . These mAdvantages of molecular and genomic approachesIn comparison to conventional diagnostic methods, molecular and genomic approaches have several advantages Table .These methods are quicker and more precise. While whole-genome sequencing can offer a thorough examination of all the bacteria present in a sample, PCR-based approaches can pinpoint the infection's primary cause in a matter of hours. Early and more focused treatment of infections is made possible by this speed and accuracy, which can improve patient outcomes ,20. TradAntibiotic-resistant bacterial strains can be found using molecular and genomic methods. These strains are spreading more widely, and conventional diagnostic methods might not be able to distinguish them. Antibiotic-resistant genes can be found using molecular and genomic methods, allowing for effective infection therapy ,24.Molecular and genomic techniques in the diagnosis of infectious diseasesMolecular and genomic techniques are being used in the diagnosis of a wide range of infectious diseases . PolymerNucleic acid amplification test The gold standard for amplification procedures in diagnostics is PCR. Since the method's initial publication in 1985 . In mediWhole-genome sequencingA potent technique for the diagnosis of infectious disorders is WGS. This technique entails sequencing every piece of DNA found in a sample of microorganisms, which can produce a thorough examination of every bacterium present. It allows for the high-resolution characterization of bacterial pathogens in terms of traits including pathogenicity, molecular epidemiology, and antibiotic resistance . When inIn bioinformatics and data analysis, molecular and genomic approaches and numerous data sets are produced by molecular and genomic techniques, and these data sets need to be evaluated and understood. Medical microbiology uses molecular and genomic techniques, while bioinformatics is the branch of science that deals with the processing and interpretation of biological data ,42. In bMatrix-assisted laser desorption ionization time-of-flight mass spectrometryThe 1980s saw the development of matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI-TOF) by Hillenkamp and Karas, which is essential for analyzing biomolecule masses. It ionizes molecules using a matrix and laser to create distinctive profiles for proteomics, biomolecule analysis, and microbiological identification. Their laser-ionization and time-of-flight detection methods are used in clinical diagnostics, drug development, and quality control because they provide quick, precise molecular insights. It quickly rose to prominence in clinical microbiology, revolutionizing the identification of microorganisms based on mass spectra, "fingerprints," and proteomics, detecting and characterizing proteins . It evolNext-generation sequencingThe field of genetic research has been completely changed by NGS, also known as massively parallel or deep sequencing. This technology makes it possible to quickly and affordably sequence complete genomes, opening the door for ground-breaking research in a variety of domains. Next-generation sequencing has ushered in a new era of genomics research by making it possible to sequence the human genome in just one day, enabling improvements in personalized medicine, evolutionary biology, microbiology, and other fields. This review examines the foundations, uses, and consequences of NGS, emphasizing its contribution to advancing knowledge and its potential to alter how we perceive the genetic universe . Next-geChallenges in implementing molecular and genomic approachesAlthough molecular and genomic approaches have several benefits over conventional diagnostic methods, there are also several practical obstacles . Some meFuture of molecular and genomic approachesMolecular and genomic methods are anticipated to influence the direction of medical microbiology in the future. With these methods, infectious illness diagnoses can be made more quickly and precisely, which can lead to better patient outcomes ,53. AddiFuture developments are projected to increase the accessibility and availability of molecular and genomic methods. It will be necessary to do this by creating new technology and educating medical personnel on how to use it . AdditioMedical microbiology is undergoing a revolution thanks to molecular and genomic techniques. Infectious disease diagnoses can now be made more quickly and precisely thanks to these methods, which can benefit patient outcomes. Additionally, molecular and genomic techniques can aid in the identification of bacterial strains that are resistant to antibiotics, which is becoming more crucial in light of the rise in antibiotic resistance. Molecular and genomic techniques are likely to be made more broadly available and accessible in the future, notwithstanding the difficulties involved in their implementation. This will necessitate continual study and development as well as instruction in the usage of these methods for medical practitioners. In the end, the application of molecular and genomic methods in medical microbiology can revolutionize how we identify and treat infectious diseases while also enhancing patient outcomes globally.